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Primary Care Workforce Maldistribution into Shortage. Robert Phillips, MD MSPH Stephen Petterson, PhD. Primary Care Physicians. 30,600 rural. Adjusted for retirements, deaths (JAMA). Adjusted for hospitalists, etc. Work supported by ORHP/HRSA R04RH15123. NPs and PAs in Primary Care.

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primary care workforce maldistribution into shortage

Primary Care WorkforceMaldistribution into Shortage

Robert Phillips, MD MSPH

Stephen Petterson, PhD

primary care physicians
Primary Care Physicians

30,600 rural

Adjusted for retirements, deaths (JAMA)

Adjusted for hospitalists, etc

Work supported by ORHP/HRSA R04RH15123

nps and pas in primary care
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)

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

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

what is the right ratio
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


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

scope of practice

Medicare annual average expenditures by Hospital Referral Region

Scope of Practice

Rurl comprehensiveness reduces eligibility for proposed Medicare bonuses (MedPAC and reform bills)

implications aspe question
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
primary care not replacing itself
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.

a decade of gme expansion

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


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






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