Fifty Years of Failed Primary Care Workforce Innovation

For fifty years nurse practitioners and physician assistants have been promoted as primary care solutions, but the primary care result has been negated by a movement from 65% primary care to over 65% non-primary care.
The promises of the past have not been realized in the primary care of today. Declines across fifteen class years of recent graduates indicate even less primary care delivery per graduate in the future.
NP and PA graduates were few prior to 1980. Since 1980 the NP and PA annual graduates have doubled in number each 6 to 12 years. After 50 years of development, after 50 years of promises and after 30 years of massive expansion, where is the health access workforce?
Such writing is never fun. This is not the way to win friends and influence people. Sadly the United States has demonstrated an impressive ability to continue to promote solutions that do not work, innovations that fail, and reorganizations that delay primary care recovery. Perhaps by pointing out innovations that have failed, more will begin to objectively review recent innovations and reorganizations - and the US policy reasons why they all fail. 
Why do health professional associations, nursing workforce leaders, physician associations, government reports (all the way to the highest levels such as the Institutes of Medicine), entire issues of journals, and various foundations persist in the myth?
Why continue to promote NP and PA graduates as primary care solutions?
Any flexible workforce that can go either direction cannot be called a primary care solution. Too little primary care spending and much more health spending for non-primary care assures the final non-primary care result.
It is time to call the midlevel effort in the United States a failure for basic health access result - a most commonly stated reason for the creation of NP and PA.
This is no disrespect to dedicated NP and PA graduates that remain in primary care. The US result is entirely the fault of US health policy. Versatile NP and PA graduates have found great favor in non-primary care workforce.
How much smaller does the result need to be after decades of diminishing return on investment? The United States can expect less than 25% of the recent NP and PA graduating classes to serve in primary care during their careers with even lower proportions serving in primary care where needed.
The US designs insure NP and PA primary care to be the least experienced in primary care delivery. Departures from primary care during training, at graduation, and each year after graduation assure least experience and least years in primary care from NP and PA graduates. Lowest activity levels, one or more year breaks away from any health care delivery, lowest volume, and increased pay for movements to different primary care practices assure least experience and least continuity.
Why is this evidence ignored decade after decade?
This is not about the quality of care, which is more about the patient than the provider for well over half of American patients. This is about experienced primary care RN, NP, PA, MD, and DO workforce as well as health care team members. When those in primary care benefit from departing continuity practices (4% salary gain) and benefit even more (10%) by departing primary care, lower primary care experience is the result.
Because of US policies, it is simply not possible to extract much primary care out of midlevel graduates or any flexible workforce source that can go both ways – to primary care or to non-primary care. Even during the 1990s, physician assistants were tracked by Larsen and Hart as departing steadily over a 10 year period during arguably the most favorable primary care policy in the past 30 years.
The evidence is clear. NP and PA workforce in the United States has followed US policy designs from basic health access beginnings to become non-primary care workforce most commonly found in zip codes with the top concentrations of physicians in the United States. The pathways for NP, PA, MD, and DO workforce indicate steady departures from basic health access for the past 50 class years of graduates and across the years after graduation from training.
The departures include fewer and fewer entering and remaining in primary care as well as fewer and fewer entering and remaining in family practice – the source most important for 200 million people and the source most commonly found where health spending is lowest by United States designs.


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