We Are Not Growing Primary Care, We Are Shrinking It

The Reality of Primary Care is quite different than what is presented by various associations, institutions, and foundations. We are not growing primary care. We are shrinking it.

AAFP has had its usual promotions of successes in the match as there are incremental increases in the number choosing family medicine. There is nothing to cheer about. FM graduates have had an annual growth rate barely keeping up with the annual population growth rate since 1980 when 3000 graduates were first reached. Given that only half of the 2018 graduates will serve careers in primary care, the actual primary care contributions have decreased much faster.

To save time you may want to review this compilation of the primary care delivery capacity estimates over time for 1970 to 2030 graduates. Each source is melting away from primary care contributions with declines in retention, activity, volume, and years in a career. 

The Standard Primary Care Year estimates the career contribution in primary care by estimating the years in a career, the retention in primary care over a career, and the activity in practice over a career as well as adjusting for the lower volume of NP and PA (Rural Health Clinic data, others)

As a start, note that my estimates are wrong. In fact, they are too rosy. The retention stated for FM in primary care was too high. So here are some revised figures and some estimates for the future. For decades these figures have all been in decline. What is missing is a cumulative review and compilation of the damage being done.

We will start with the current assumptions

The Deans Lie or the Big Lie - This has long been the assumption that Match into primary care training equals primary care result. These reports use inflated figures tend to ignore lower retention levels. There is also the lack of consideration of activity, differences in volume, productivity, or other factors

Appearance of Primary Care (Grads) Total Grads Retention Believed Activity Assumed Volume Assumed
IM 3600 9000 40% 100% 100%
PD 1800 3000 60% 100% 100%
FM 2800 3500 80% 100% 100%
NP 16500 33000 50% 100% 100%
PA 2250 9000 25% 100% 100%

The lack of critical review is what has allowed sources of primary care to make exaggerated claims about their primary care contributions. Deans and associations still consider internal medicine to be important to primary care even though the contributions have been shrinking for some time with worse to come. The 3600 for primary care is a gross overestimate

NP can claim 16500 or half in primary care and even more from some sources, but there are no corrections for lower activity, volume, or years in a career.

In my study publication on the Standard Primary Care Year, the FM contribution estimate was higher - because there was little consideration of lower retention in primary care. The data has been updated as steady departures have been seen.

More Recent Graduates and Their Contributions

Realistic Class Yr Contribution Grads Retention in Primary Care Activity in Practice Volume Adjustor
IM 684 9000 10% 80% 95%
PD 1012 3000 45% 75% 100%
FM 1400 3500 50% 80% 100%
NP 5197 33000 35% 60% 75%
PA 1265 9000 25% 75% 75%

Instead of 3600, IM is actually good for 684 per class year for primary care contribution - 700 x 30 class years is only 21,000 for an active office based IM primary care workforce (30 years in a generation of IM) IM has long been producing only about 1000 - 1200 per class year for a very limited result, not the 140,000 in office based internal medicine that once existed.

PD is down from 1800 to a figure more like 1000 for about 30,000 as an active office based workforce. The actual figure would be much lower with continued declines in retention, activity, volume.

FM is down from 2800 to 1400 for about 50,000 as an office based workforce in FM - half of previous. Consider how little influence this component will have on the nation, or even on AAFP.

NP programs graduate 33000 but only about 5000 is the result, certainly not 16000

To obtain the Standard Primary Care Year estimate, multiply years in a career, activity, retention, and a volume adjuster using the estimates above and the years in a career below. 

SPC Years Years in Career
IM 2.3 30
PD 10.1 30
FM 12.0 30
NP 3.2 20
PA 4.2 30

IM contributions are lowest due to lowest retention. The 60% retention is down to 10% for a primary care contribution.

NP contributions are lower due to lower retention plus least activity, least volume, and fewest years in a career. Studies have long documented 60% activity levels for RN and NP (HRSA Nursing workforce), late entry age 40 - 41 on average, fewest years in a career (late entry), and lowest volume 

The Situation Has Become Worse

My new estimates consider
  • Lower Activity
  • Lower Primary Care Retention as in past decades
  • Fewer Years in a Career
  • Lower volume as productivity has declined 
The Massive Glut of Workforce will contribute to fewer in practice, fewer in primary care, fewer years in a career. The worsening financial design will result in fewer years in a career, lower retention, and lower volume - especially due to meaningless use and abuse.

Realistic Estimate of Standard Primary Care Years of primary care contribution over a career
IM 1.6  
PD 6.6
FM 7.1
NP 2.7
PA 3.7

No source is immune. Family medicine retention declines are clearly present. No source is efficient or effective for primary care yield.

Which is the best value for primary care production? 

The best answer is none of the above. FM is a much better source compared to IM and NP, but is more costly than NP or PA, but NP and PA have lower yield and less experienced primary care practitioners.

As a comparison this is what the 1970s grads did

SPCYrs Retention Activity Volume Years
IM 16.0 60% 85% 95% 33
PD 21.0 75% 85% 100% 33
FM 25.2 90% 85% 100% 33
NP 4.5 50% 60% 75% 20
PA 7.7 55% 75% 75% 25

  • Internal medicine graduates have declined in primary care from 16 to 1.6 Standard Primary Care Yrs
  • Pediatric grads from 21 to 6.6
  • FM grads from 25 to 7 - best source (dubious honor given low contributions for all) due to highest activity, retention, volume, and years - but fading
  • NP from 3.2 to 2.7 - NP has never been a good source due to lowest activity, volume, and years in a career
  • PA from 7.7 to 3.7 - PA is also not a good source due to lower retention, lower volume

The PA data indicates a decline from 54% family practice to less than 25% from the 1980s to the present. Studies confirm essentially no added primary care despite a doubling of PA annual graduates. The same is seen in DO expansions.

When you look at numbers of graduates and do not consider years in a career, activity, volume, and retention - you completely miss the mark. Expansions of Family Medicine Residency Graduates will not fix the problem and could help lower primary care contributions per primary care graduates.  

When you believe that your kind is right and others are wrong - you miss the mark.'

When you focus on expansion if insurance, particularly with expansions of the worse insurance plans that do not support primary care, you miss the mark.

Rural Standard Primary Care Contributions

The insertion of the proportion of primary care graduates found in rural locations can estimate the rural SPCYr contribution of a class year.

Then when you consider the Rural Standard Primary Care Year, the internal medicine contributions vanish, particularly for international medical graduates. IMG workforce is the lowest for contributions to the US physician workforce as about  20 - 40% depart from the US after graduation for no US workforce contribution for this component. They also have lowest distribution in real time studies of physician databases over time, not just the first few years after graduation shaped by obligations. Publications have been in error as pointed out by myself and the Robert Graham Center researchers. 

Rural Standard Primary Care Years
  • FM 16% rural for newest graduates for 4.0 Rural Standard Primary Care Years.  FM once had 7.6 Rural Standard Primary Care years per graduate for the 1970s graduates with 30% rural distribution.
  • PD 8% rural for 1.7     PD 2.5  Rural Standard Primary Care Years per 1970s graduate for 12% rural (likely overestimate)
  • PA 18% rural for 1.4   PA previously contributed 2.3 - boosted by the regulatory restrictions of the time forcing primary care and rural
  • IM 8% rural for 1.3 IM 1.9 Rural Standard Primary Care Years per 1970s graduate for 12% rural (likely overestimate)
  • NP 20% rural (likely overestimate) for 0.9 Rural SPCYrs    NP 1.4 - boosted by the regulatory restrictions of the time forcing primary care and also rural at 30%
  • IMG IM with with 0.4 Rural SPCYrs given reductions for losses overseas without US Practice and lower retention. Perhaps the studies were biased by those who had a vested interest in filling US internal medicine residency programs that had difficulty filling with residents. 

Regulatory and Legislative Changes

The NP and PA lobby has been very effective. The restrictions have been lifted. The regulatory boosts to primary care and to rural/underserved have long gone away. Acceptance is seen across the locations and career choices. New specialties and more added to each new specialty has been present for decades. Academic centers have been some of the biggest adopters - clearly moving NP and PA away from primary care and from where needed.

Regulatory and Financial Design Changes Hurt Basic Health Access

Only the family practice component matters for distribution where needed with a consistent multiplier of 2 x for urban and 3 x or greater for rural, lower concentration county, frontier (regression studies, controlling for type of training and origins)

The family practice proportions are declining and the distribution proportions are declining. We have discussed these exhaustively.

Reflection reveals that there is no way to resolve primary care, rural, underserved, or lower concentration county deficits. The glut of workforce from overproduction will not fix primary care deficits and will make the situation worse.

In fact, the declines in all parameters important to primary care delivery capacity confirm the financial design as the problem. This also indicates too many graduates.

Now consider $120,000 cost or more per residency year for primary care training at $500,000 to $700,000 per resident not considering losses and those leaving the nation - and it really gets ridiculous when you divide the cost by the primary care yield. 

For even more fun folly, consider 4 years of primary care training for substantially higher cost per primary care year result. This is one of the focus areas of family medicine in the not too distant past - way off target for Basic Health  Access.

A Final Warning

Until there is some demonstration of improved primary care retention, these figures should be considered overestimates as the last figures have demonstrated.

Standard Primary Care Year
Primary Care retention decline
Physician Distribution by Concentration

Standard Primary Care Year Atlas

Consider that the past decade has resulted in worsening retention when reviewing these, but it is hard to figure out how low the primary care contributions can go

Bob Bowman
Basic Health Access

For Burnout Relief, Focus on the Financial


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