Friday, March 5, 2010

Top Ten Reasons for Future Subspecialist Physicians To Be Concerned


This guest piece, by Robert Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, AZ, can be considered to be a sequel to his guest blog from January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future. In that piece, Dr. Bowman discussed how, of the five primary care training “forms” (General Pediatrics, General Internal Medicine, Family Medicine, Nurse Practitioners and Physician assistant) only family physician provided enough “Standard Primary Care Years” per graduate, and distributed to the areas in which people live, to provide sufficient primary care. In this piece, he presents information on how the change in the workforce is likely to have an even greater impact on subspecialists.
I think that this is very timely. The idea that family physicians, or primary care doctors in general, will be “replaced” by nurse practitioners and/or physician’s assistants keeps rearing its ugly head despite evidence to the contrary. Dr. Bowman demonstrates that reimbursement policies that pay far more for “partialism” encourage both physicians and non-physicians to enter subspecialist practice. We still do and will need more primary care and it is not going to happen by magic. It is going to happen by changing reimbursement policies. (See, for example, Mary Carmichael's "
The Doctor Won't See You Now", in Newsweek, Feb 26, 2010).
The first two graphics demonstrate trends in the number of primary care providers by "form" if there were not movement into subspecialism, and what the real trend will be.
The final graphic compares the retention in primary care, over time, for the different "forms" based on whether they are more "permanent choice" primary care (e.g., family medicine) or "flexible choice" (e.g., internal medicine).

10. “Midlevel” Growth: Nursing leaders have promised to deliver health access where it was most needed and received numerous concessions to move beyond nursing but have largely left health access behind along with basic nursing. Nursing leaders continue to promise primary care while nurse practitioners steadily depart primary care to become specialty workforce and appear poised to become “nurse doctors” (DNPs). There is every reason to believe that DNPs will be no more – and probably less – likely to practice in underserved or rural areas at greater rates than current NPs. Physician assistant leaders are likely to follow the independent "successes" of nursing. Future subspecialist physicians will face competition no other physician subspecialists have ever had to face.

9. Increasing NP, IM, Ped entry into subspecialties. About 40% more nurse practitioner, 50% more internal medicine, and 60% more pediatric graduates are entering specialty workforce compared to a 10 - 15 years ago, and specialization rates have continued to increase. In addition, more internists and nurse practitioners convert from primary care to specialty care in the years after graduation.

8. Increasing PA production, also entering subspecialties. Over 220% more new physician assistant graduates are entering the sub-specialty workforce, increasing from fewer than 1500 in 1998 to over 4600 in 2008. The percentages in emergency care, orthopedic, and surgical subspecialties are now greater than those in primary care. Physician assistants also are converting from primary care to specialty care after graduation. Only 28% of 2008 graduates entered primary care in AAPA surveys.

7. Postive Cost-Benefit ratio for “midlevel subspecialists. Nurse practitioner and physician assistant graduates have lower employment costs than subspecialist physicians. It is possible for 2 or 3 NP or PA subspecialists to generate more revenue than one subspecialist physician for less cost of salary, benefits, and other physician perks.

6. Increased “midlevels” in subspecialties decrease need for more subspecialist physicians. More and better nurses, assistants, and other health care team members are recruited to subspecialty workforce because the higher reimbursement for subspecialty services as compared to primary care allows these subspecialists to pay them more. Physician assistants and nurse practitioners are on track to increase to 450,000 that are more than 70% subspecialty care. The US is moving to a specialty workforce that can deliver more specialty care with fewer specialty physicians.

5.Increasing US graduates likely will further increase subspecialist production. US graduates deliver twice the workforce of non-citizen international medical graduates due to delays in entry and departures from the US workforce after graduation. Expansions of US medical schools are likely to replace more non-citizens with US origin graduates. This replacement results in twice the specialty workforce for each position transitioned from a non-citizen to a US origin graduate.

4. Increasing subspecialist production of US Medical Schools. The United States produces 40 - 50% more subspecialist workforce from each type of medical school compared to a decade ago. Currently no one can estimate just how much specialty workforce will be produced as the annual graduates entering the workforce continue to increase with higher percentages found entering specialty care in physicians and in non-physicians.

3. Threats to very high subspecialist reimbursement. To the extent that there is any decrease in subspecialist reimbursement, these physicians will face the possibility of longer hours, more services, less vacation, and more years of work per subspecialist physician.

2.Supply, demand, and cost of care. All physicians will be blamed for continued health care cost increases as all levels of government and all businesses and all of the US people pick up the tab. There is potential for even more costs with subspecialists increasing services to compensate for an oversupply of subspecialists.

1. And, finally, when the United States finally invests in sufficient primary care substantially fewer visits will be needed in specialty offices.

Add to this
· the steadily increasing disconnect between subspecialist physicians separated from their patients by additional assistants
· the admission patterns of medical schools favoring upper-income students leading to subspecialists with ever more exclusive origins who are less and less like lower and middle income Americans .
In other words, our medical education leaders and medical association leaders and subspecialists...
...will probably never see it coming

Robert C. Bowman, M.D.,

Only those unable, those unaware, or those with another agenda fail to understand that solutions for basic health access have worked for over one hundred years.



tschmitt2002 said...

Excellent piece. I agree! As an NP who as continued to work in a rural NP owned clinic, because my patients need more access to care, I am disturbed by the number of my colleagues that specialize upon graduation. However, the turf battles over who should provide a primary care home, and the large amount of bureaucratic red tape to own a rural NP practice where no other provider will go, the lack of physicians who can collaborate outside of their own health system contracts (as they are owned by hospitals), is hindering access in rural areas. Likewise, such practices have become targets of groups looking to prove that NP's and PA's cannot provide primary care homes.
The reality is, as is so eloquently pointed out in the post, that there are not enough primary care providers to go around. The bulk of public health, prevention, and intervention happens at the primary care level. Ideas, besides reimbursement, to help entice everyone to primary care and rural practice?

Bob Bowman said...

Did some more analysis. There will be a 29% increase in non-primary care workforce from 2010 to 2020. This is only the beginning as the 2010 to 2040 changes are a doubling of non-primary care from 480,000 to 900,000 but actually higher if the rate of expansion continues and there are more declines in primary care than anticipated (more conversions from primary care to non-primary care).

The expansions will not distribute equitably. They will follow the current US designs that have led to the same concentrations of physicians as set by policy. There will be about a 32% increase in non-primary care physicians in 3400 zip codes inside of concentrations of physicians in 4% of the land area. These are locations where 75 - 92% of non-primary care physicians are already found. Talk of rural programming for distribution of subspecialists is unfounded assumption.

Overproduction in the US and in Japan and in other nations has not distributed physicians outside of concentrations. Even family physicians remain in a 50:50 inside and outside equilibrium despite periods of increased or decreased production. For the subspecialty and hospital workforce it will be pack em, stack em, and rack em up in the top zip codes that already get over 80% of the health care dollar attributable to physician services and hospital services.

In the US there are policy, funding, physician origin, and training factors that will prevent distribution to 30,000 zip codes with 65% of the US population and all of the US populations growing the most in population.

By the way, without health care coverage expansions for those left out, even more stacking up will occur. Established non-primary care types may make it, but the new additions will face an increasingly challenging scenario, if health care costs do not take the design down before this time.

After some subspecialty shortages are addressed in the first few years, the side effects will be greater. Few understand that it takes 30 years for the design level to be reached. The last 20 years of this design will once again overshoot health demand since there is no coordinated 50 - 60 year planning and no consideration of population needs. Of course the 75% of physicians and 90% of physician leadership fails to see the needs of the 65% of the population outside of concentration.

Overutilization and excessive competition are guaranteed with non-primary care and primary care shortages remaining in most states and in locations outside of concentrations.

Then one must consider 500,000 for the NP and PA workforce age 30 - 65 with 75% in non-primary care. The NP and PA non-primary care workforce is also most likely to be found in the larger and largest groups as noted by The Lewin Group in areas such as cardiology.

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