Primary Care Workforce Maldistribution into Shortage

1. Primary Care WorkforceMaldistribution into Shortage Robert Phillips, MD MSPH Stephen Petterson, PhD

2. Primary Care Physicians 30,600 rural Adjusted for retirements, deaths (JAMA) Adjusted for hospitalists, etc Work supported by ORHP/HRSA R04RH15123

3. NPs and PAs in Primary Care If you co-locate NPs, PAs and apportion FTE by physician specialty ratio at site How physicians organize by practice site 0 = No PC; 1 = Only primary care (National Provider Identifier File 2009)

4. Enough? Depends • Average PCP:population ratio is about 1500:1 (range 500:1 – 5000:1)

5. 30 million more insured: Massachusetts lessons for unleashing pent up demand for services without sufficient access to primary care

6. What is the right ratio? Between 1500:1 and 2000:1 (FP + NP+PA; 1000:1 with GIM) if costs and avoidable hospitalizations matter Costs and Avoidable hospitalizations begin rising rapidly with NP/PA:physician ratio >1.17. Difficulty demonstrating for General Internal Medicine

7. Need for more primary care providers is still largely a matter of population growth and aging The needs of the newly insured in 2015 will be about the same as for population growth, but are sudden and one-time The newly insured cluster in underserved areas--where the least number of providers are Serving newly insured will require potent policy for both distribution and growth

8. Medicare annual average expenditures by Hospital Referral Region Scope of Practice Rurl comprehensiveness reduces eligibility for proposed Medicare bonuses (MedPAC and reform bills)

9. Implications (ASPE question) • If we need more primary care providers to reduce costs and avoidable care • If we need them to practice a broader scope of team-based care • Our estimates of “need” are too low

10. Primary Care Not Replacing Itself • Between 2002 and 2006 • Residency positions grew +7.9% • Subspecialty positions grew +24.7% • (33% between 2001 and 2008) • However…the estimated number of graduates going on to practice primary care fell 15% (from 28.1% to 23.8%) Now about 22% E. Salsberg et al. US Residency Training Before and After the 1997 Balanced Budget Act. JAMA. 2008;300(10):1174-1180.

11. Income change adjusted for inflation 1998-2007 General IM loss = lost + preliminary + new subspecialty IM A Decade of GME Expansion Archives of Internal Medicine (JAMA) Feb, 2010

12. Income Disparity Pre-Medical School Factors Birth place Intent to serve state’s needs (e.g. primary care, rural) In-state students Age/Race of applicant Medical School Factors Targeted expansion strategies Community rotations and preceptorship Institutional mission to care for underserved, areas of need Public school Residency Factors Need-based training & tracks commitment to underserved Location (Rural, Community-based) Primary Care residency Placement and Retention Practice start-up subsidies Loan repayment Opportunity for continuing education Physician workforce: sufficient, composed & distributed to meet populations needs Need to alter incentives for distribution and production of primary care Create accountability across the pipeline