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Primary Care Workforce Challenges & the ACA
Analyses and Applications from the Robert Graham Center
Andrew Bazemore MD MPHNGA Meeting
April 2012
The Robert Graham Center Placed in Washington, DC 12 years ago by
AAFP To improve policy-making with better evidence
about primary care, family medicine Editorial independence Growing, but still a small staff
2 family physician researchers PhDs: Sociologist/statistician, Economist, Public Health Informaticist, Geographer 2 Masters-level Researchers Also: Project Mngr, GIS Trainer, Administrative Asst,
Fellow, Visiting Scholar
ACA & the Inadequacies of the Primary Care Workforce
Hlth Aff, 2008(Colwill): 44k short by 2025
Health Aff May 2008 vol. 27 no. 3w232-w241
Post ACA AAMC, 2010 – 46k short by 2025 Re-affirming reports from Mass Med
Society, Washington Post, others PC Workforce/Infrastructure not ready
for pent up demand of newly insured
ACA & the Inadequacies of the Primary Care Workforce
Reports highlight a problem of SupplyA problem, but perhaps less important than Distribution Composition Scope of Practice A workforce ready for New Models
of delivery, team-based care
Health Worker density by region
Physician Specialties to Population Ratio 1980-2006
(Physicians per 100,000 persons)
0
50
100
150
200
250
300
1980 1985 1991 1995 2000 2005 2006
Ph
ys
icia
ns
(M
D)
pe
r 1
00
,00
0 p
ers
on
s
All physicians Sub-Specialists Primary care physicians
U.S. Primary Care Workforce by Provider Type, 2010
Primary care provider Number
Physicians 208,807
Nurse practitioners 55,625
Physician assistants 30,402
Total 294,834
2010 AMA Masterfile, 2010 National Provider Identifier File
Primary Care : Population Ratio
1:1400 PC Physician: Population 1:1100 PC Providers: Population
What ratio matters?
Comparative review for AHRQ: Greater than Western European peers
Historical perspective: Largest, best trained PC Workforce in US History
13
What ratio matters?
Between 1500:1 and 2000:1 (FP + NP+PA; 1000:1 with other PCPs) if costs and avoidable hospitalizations matter
Difficulty demonstrating for General Internal Medicine
Distribution
Primary Care/Population ratios vary widely by most measures of geography State, County, Tract, or PCSA
US Primary Care Health Professional Shortage Areas By County (2006)
Legend
Data Source: HRSA (08/03/2006) Prepared by The Robert Graham Center
A Partial PC HPSA (n=667, 21.2%)A Full PC HPSA (n=1381, 44.0%)
Not A PC HPSA (n=1093, 34.8%)
Primary Care Physicians… Where aren’t they?
Geography
All Primary Care US
Population NP PA Physicians NP PA
Family Medicine
General Internal Medicine
General Pediatrics
Urban 84.3% 84.4% 91.0% 72.1% 75.1% 77.5% 89.8% 77.6% 80% Large Rural 8.9% 8.8% 6.5% 11.0% 11.6% 11.1% 6.7% 9.6%
10%
Small Rural 3.9% 3.7% 1.7% 7.7% 6.9% 7.2% 2.4% 7.3%
5%
Isolated Rural, Frontier 2.8% 3.0% 0.7% 9.1% 6.3% 4.2% 1.1% 5.5%
5%
Geographic Distribution of Primary Care Health Care Professionals,
2010
Consequences of Maldistribution
Scope of Practice: The Case of Family Medicine
2004 - Future of Family Medicine: Suggests our discipline is in part defined
by the ‘Basket of Services’ it delivers Using ABFM diplomate data 2003-
present, we discover: Wide variation in scope : Rural to Urban,
Regionally, by Age/Gender/ Years in practice
Declines in several key areas
What is Comprehensive Care?
Percent of FPs in Any Given Area of Scope
0 10 20 30 40 50 60 70
Hospital Medicine
Major Surgery
Post-op Care
Deliveries
Maternity Care
Palliative Care
Prenatal Care
Pre-op Care
ER
Urgent
Pain Management
Office Surgery
Newborn Care
Are
a o
f S
cop
e
Percent of FPs
Mean Percent Time Practicing in a Given Area
0 1 2 3 4 5 6 7
Major Surgery
Hospital Medicine
Post-op Care
Palliative Care
Pre-op Care
Maternity Care
Office Surgery
Pain Management
Urgent
ER
Mean Percent Time
Whence cries of shortage?
Colwill & AAMC report – Projected shortage of approximately 45,000 PCPs by 2025
Visits to Office Based Physicians
http://www.ahrq.gov/research/pcwork1.htm
IOM: Care without coverage: Too little, too late.
US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States
The Perfect Storm
PPACA PCMH Payment problems Paucity of student interest Parade of Boomers
Progress of the Physician Payment Gap
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
Year
An
nu
al I
nco
me
Diagnostic Radiology
Projection of Primary Care Physician Use
An era of Allopathic, Osteopathic, (and offshore)
expansion
How might we inform, direct or monitor expansion?World Health Organization - Social
Accountability
Education Research Community Service
Boelen C, Heck J. Defining and Measuring the Social Accountability of Medical Schools. Geneva: Division of Development of Human Resources for Health, World Health Organization; 1995. Document WHO/HRH/95.5.
% of Medical Graduates in Rural
0%0%0%0%
1%1%1%
0%1%
1%2%2%2%2%
4%6%
3%5%5%6%
5%5%
6%7%7%
5%3%3%
7%5%6%
3%8%
7%6%6%6%
5%10%
7%11%
13%15%
11%7%
23%15%
2.4%2.5%
3.7%4.0%
3.1%3.5%4.0%
4.9%5.0%
5.1%4.4%4.6%4.6%5.1%
3.7%2.0%
6.2%4.8%4.3%
3.9%4.9%5.1%
4.5%4.1%4.5%
6.0%8.8%
9.0%5.5%
7.2%6.9%
9.4%5.2%7.3%
8.4%9.7%10.3%
10.8%6.0%
9.5%6.4%
4.8%4.5%
11.6%17.4%
5.0%15.1%
0% 5% 10% 15% 20% 25% 30%
PRRI
MANJNYCACTDCMDFLIL
AZPAVATXHI
NVOHWIMI
LASCIN
NCGATN
WAUTALCOORMOMNNHNMMEIA
VTKSNEOKKYARWVNDMSSD
Sta
tes
% of Medical Graduates in Rural
% Retained in State and Rural % Out of State and Rural
US Rural Median = 10.8%
US Rural In State Median = 5.3%
Top 3:
1) South Dakota: 31%
2) Mississippi: 28%
3) North Dakota: 24%Bottom 3:
1) Puerto Rico: 2.4%
2) Rhode Island: 2.5%
3) Massachusetts: 3.7%
Some Workforce Resources of interest
http://www.ahrq.gov/research/pcwork1.htm
www.medschoolmapper.org
http://www.graham-center.org – Goto Tools & Resources
www.healthlandscape.org
