The Glut of Health Workforce Exposed But Ignored

When you spend a decade or more preparing and training for a career as a physician or as a nurse practitioner, you expect that you life will improve with your new employment. This is no longer a reliable expectation. Decades of overproduction of NP, PA, DO, and MD graduates will have consequences for graduates as well as for our nation.

High debt from tuition, higher cost of living, the challenges of becoming a young health professional, and the difficulties dealing with employers that hold all the cards - will collaborate for worsening outcomes. The burnout, turnover, productivity, and suicide issues will intensify.

Slowing Population Growth Magnifies Overproduction

The new census figures indicate a slowing of population growth. This translates to a glut of health care workforce even worse than previously projected. Previous calculations of expansions used 0.72% as the annual growth rate from older census data. The newer figures are 0.62%. The decline will continue to 0.6% or lower. With growth of population down and health professional graduate expansions continuing, the glut will be far worse.

  • The new calculations indicate expansions of nurse practitioner graduates at 14 times annual population growth instead of 12 times as noted previously. The expansions are 8 to 10 times for expansions of MD, DO, and PA respectively.  
The one thing that overproduction cannot solve, is shortages of basic health access. 

This will not stop deans, associations, foundations, and journal articles from claiming that more graduates or special training can assess deficits. At best there is a rearrangement of the deck chairs as your favorite type of graduate or school or program produces graduates that occupy rural, shortage, underserved, or lower concentration positions. But the overall team members to deliver the care will remain compromised by the financial design. The claims of this or that graduate as a solution are ludicrous - and overproduction has long exposed the fallacy of more graduates to resolve deficits. Generalists, general specialists, women's health, mental health, primary care, cognitive, basic, and most needed workforce will remain behind by financial design.

Concentrations of Bad News for Most Americans Most Behind

The demographic stagnation of the population interacts with other societal areas for worst result for the places already most behind. Demographic stagnation combines with economic stagnation and health care design stagnation.

Lower population growth could help ratios of physicians to population where shortages exist, but this is not the case. Population growth has been highest decade after decade for the 2621 counties lowest in workforce. The growth in population, demand, and complexity already overwhelms the existing health workforce. The driving forces will continue to worsen the situation.

Populations are forced to move away from areas with workforce and toward areas with lower costs of housing and living - which have the lowest levels of workforce, public transportation, jobs, and social support. As people age or have worsening health and worsening finances, they must migrate away from places that have the resources that they need.

They will move from to areas that already have concentrations of the worst health insurance plans - a major reason for shortages of generalists and general specialists and even fewer of more specialized workforce. Primary care, women's health, and mental health workforce will have the worst impacts.

Irresponsible Expansion

Those training students promise them a better life and greater independence - but this will not be so. A better life for those in a workforce requires a reasonable production of graduates. Too many result in a glut with compromises for the workforce.

NP Annual graduates have blasted past 31,000. They continue to increase at over 2000 a year despite concerns regarding faculty shortages and shortages of patient material for training. PA graduates continue to increase in numbers. DO schools continue to increase in number and in class sizes. Since 2000 the US MD graduates have increased by 30% with new schools, new school sites, and more graduates added.

Employers Ratchet Down Salaries, Benefits, and Supports

Since the 1980s, health employers have focused more and more on the bottom line. Profits are about revenues minus costs of delivery. In health care, the personnel costs are the major area requiring dollars. Not surprisingly this is the area often targeted for cuts. Nursing has born the brunt of the hospital cost cutting for decades.

The glut of workforce changes the picture. MDs are already experiencing what nurses have long endured. Even worse,
  • employers can play off MD vs NP. This is already seen in media and academic articles. 
  • Employers already hire NP and PA to replace costly subspecialty physicians as much as possible, to save on personnel and maximize profits. Note how there is emphasis on team care and having physicians do less. The consequences of cost cutting and movements to least experienced and least trained personnel are not studied.
  • Bait and switch is common. Patients may go to a subspecialty practice, but may not see the subspecialist. In fact they may see an NP or PA that has less experience and far less training than the primary care physician that referred them to the practice. 
  • NP and PA are valuable for primary care to see patients, but they are even more valuable to save costs and to help generate other charges in the office. They can also do hospital rounds and keep physicians focused on highly paid procedures. The glut of workforce will move subspecialty physicians even farther from their patients. They will be fewer and in many places, they will be on call for more nights. Geisinger is a location with one of the highest levels of NP workforce in the nation and the physician component has been shrinking as noted 2005 to 2013.
The consequences to the current health care workforce less than age 55 are already being seen with worse to come. This is so tragic for the graduates who are not old enough to retire soon.

Bigger, Leaner, and Meaner Employers

The health system employers have been decreasing due to mergers and acquisitions. There will be fewer and they will dictate the professional and personal lives of their employees to a greater degree than ever. (See Rachetattat)  Overproduction makes this much worse.

The rule in health care is to be the biggest so you can be the baddest and gain the most in profits. You focus on increasing revenues and decreasing costs. Tragically in health care this means marginalizing the care and the health of those that do the caring. Certainly we have seen this in the largest health insurance entities, the largest health systems, and the largest health practices. Small and independent hospitals, pharmacies, practices, and systems have taken the most hits - by design.

Those smaller, doing basic services, least organized, and most needed will continue to lose out. In fact with continuing cuts, the most important practices, Emergency Rooms, and hospitals are likely to close at even greater rates. These are the ones most likely to serve the most Americans most behind. These providers are already paid 15 - 30% less for the same services - the lowest in the nation. They have had to endure the highest relative cost of delivery increases from HITECH, MACRA, and Primary Care Medical Home. They also have the highest costs with regard to turnover of key personnel - another huge disadvantage. Overproduction will continue to worsen the problem by increasing the rate of turnover and the costs of turnover.

Health Care Hates Lawsuits, But Expect More Directed at Health Professional Training

A recent decision forced an "education corporation" to cancel student debts because of their marketing techniques.  It is time to hold NP, PA, MD, and DO programs and schools responsible for overproduction. It is only a matter of time before new lawsuits are filed.

Shortages of Workforce, Deficits, and Access Barriers Will Not Be Resolved

Health care designers continue to hide their heads in the sand in key areas:

If shortages were resolved simply by producing more, this would have long ago been addressed. The fact of the matter is that the only time the US made headway vs shortages was 1965 to 1978 when major increases of funding via the new Medicare and Medicaid plans resulted in the support of more team members where there were concentrations of elderly and poor. These places benefited from the additional dollars added - and could expand care for the entire population of this area. 

The opposite is true for the current financial design. Situations are worse with revenue flat to declining and costs of delivery accelerated. The CMS Contribution to the Demise of Rural Health applies to 75% of the rural population and 32% of the urban population - the 40% of the population overall in 2621 counties already lowest in workforce. 

To reiterate, this massive expansion in four different types of graduates plus international graduates at 25% of physicians plus expansions of Caribbean graduates plus new types of workforce such as pharmacists and assistant physicians (Missouri demo failed) will not result in resolution of workforce deficits or access barriers. Shortages are shaped by the financial design that results in too few dollars to support generalists and general specialists where half of Americans reside. 

The Dean's Lie has long been made public. This is the lie of medical school deans saying that their school is able to make headway in primary care production. This lie has been exposed as expansions have failed, as internal medicine graduates fall below 10% remaining in primary care, and as family medicine graduates fall below 50%. 

The lies also apply to nurse practitioner claims. NP has continued to fall to new lower levels of graduates in primary care for the same reason. The dollars going to primary care are stagnant, the costs of delivery are increasing, and the team members are being compromised in numbers and in their ability to do the primary care delivery.

Foundations, associations, and journal articles promote the lies. These false claims delay the true reforms that could resolve access barriers - by addressing the financial design. 

  • There are claims that the independence of NP has contributed to expansion. Note that overexpansion hurts the independence of NP MD DO and PA. Independence is a myth in a time with mergers and acquisitions and other changes leaving fewer independent and more dependent upon employers.
  • There are claims that quality is the same for NP vs MD. This is actually what would be expected as outcomes are about the patient - not the provider. If the populations are same or similar, the outcomes will be similar. This is the finding of the journal articles. In contrast if the populations are different as in rural vs urban, the outcomes will be different. It is the sad state of the medical literature that gives false impressions magnified by the media and those who benefit from magnification.
  • Articles note massive increases in primary care numbers for NP. Would you expect anything else given the massive expansions? Family medicine graduates have been stuck at 3000 since 1980. IM is no longer a significant primary care contributor as so few stay in primary care. Pediatrics has also been stagnant with small increases in graduates negated by declines in those who remain active and in primary care. The studies actually show major increases in NP doing almost every specialty and subspecialty with a steady lowering of the proportion active and in primary care. NP are only 60% active (HRSA workforce) and were only half in primary care for a 30% active in primary care contribution. The addition of more specialties and subspecialties with more added to these areas comes at the cost of primary care. About half train in family practice but the proportion in family practice positions declines across graduation and each year in practice. 
You can count on higher primary care turnover, less primary care experience, steadily lower proportions remaining in primary care - for NP PA MD and DO - because of the financial design

Addressing the Financial Design

About 5 to 6% health spending for 55% of services has never been enough for primary care or for basic health access. Only four states are forcing private health insurers to increase to 8% going to primary care. This is too little and too late however. Primary care visit levels are shrinking.

And even worse, the increases in payments are tied to the onerous burden of value based funding - long exposed as worsening the financial design while not improving outcomes and burdening delivery team members unnecessarily. Sadly even foundations and associations stated as supportive of health access - support value based designs (Commonwealth, AAFP). Given 40 - 50% of family physicians with personal and professional lives made worse by the micromanagements and measurements, AAFP has no business supporting such designs. Does AAFP Truly Support Primary Care?     AAFP Initiatives Should All Be Focused on Triple Threat - worsening revenue, costs of delivery, complexity  The MACRA Test - Can You Survive this Discrimination?

In the 2621 Counties Already Lowest in MD DO NP and PA Concentrations

About half of the nation is adversely impacted by deficits of workforce. This is likely to continue to hit hardest in the 2621 counties lowest in workforce where 25% of the primary care workforce attempts to serve 40% of the most complex Americans. Designs have redirected 8 billion dollars away from the remaining primary care practices in the counties lowest in health care workforce with 40% of the population. This only leaves about 30 billion where there was once 38 billion in revenue invested in local primary care- for even fewer to serve more patients and increasingly complex patients. This is the toll of digitalization, innovation, and regulation since 2010. Lower collection rates and higher rates of key personnel turnover also defeat the financial designs important for Basic Health Access.

Micromanagements of cost and of quality have not helped costs or quality - yet they have hurt team members must - their time with patients and family. Costs continue to accelerate in the US and the administrative and micromanagement burdens are increasing factors.

Quality continues to deteriorate for this segment of the population because of deteriorations of social determinants, health funding, education funding, and social services support. As billions more are stolen from these counties, the outcomes will worsen along with economics, jobs, housing, education, nutrition, and other areas.

 It is not a surprise that the generalists and general specialists are most burnt out (see Red Zone Specialties graphic in addressing burnout) and the case can be made that this is most likely where most Americans most need care.

Also the 2621 counties lowest in health care workforce are also the counties growing most rapidly each decade since the 1960s. This is likely to continue - fueling greater numbers, demand, and complexity in the places already least in a number of designs. Affordable housing collapse will send even more millions to these counties along with the decline of American finances for most Americans - especially as they age.

These are already the counties with 40% of the population that have concentrations of veterans (over 50%), diabetics 47%, obesity, asthma, COPD, disability dollars, food stamp dollars, social security dollars, elderly, poor, poor children, and issues with worsening longevity, premature death, and mortality (infant, maternal). The demographic changes indicate worse to come as the most challenging populations are more concentrated in more of the US.

Much more than rural America is impacted as these counties have 40% of the population, 32% of the urban population, and 75% of the rural population. Yes, there is a 25% of the rural population that is doing well in health care workforce and in other areas. 

Americans behind in workforce are behind in so many areas. And they have been promised help for decades. But no training design can fix a broken financial design that dictates the numbers of health care team members. Too few for too many that are growing faster and more complex - that is the real problem. 

Sadly, the shortages are already fixed in place. It takes decades to fix workforce deficits. At least 20 years of a better financial design are needed. Sadly the situation has worsened since the "health reforms" of 2010. Expansions of the worst insurance for patients and providers cannot resolve the problem of cost of delivery higher than revenue generated. 


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