6
The Primary Care Workforce

This chapter focuses on the principal types of primary care clinicians—physicians, physician assistants (PAs), and nurse practitioners (NPs). They are the personnel most likely, under state practice acts, hospital or health plan credentialing, or customary practice, to have significant patient care authority. The chapter reviews trends in the supply of these components of the health workforce (noting the extreme difficulties of producing reliable and valid estimates of supply and, especially, requirements for clinicians or clinicians' services); it also briefly comments on the education and training infrastructure for such personnel (a topic taken up in greater detail in Chapter 7). The chapter then advances four recommendations concerning important directions that, in the committee's view, the production and use of primary care clinicians ought to take.

The committee's definition of primary care draws attention to the concept of a primary care clinician, where clinician is defined by the committee as "an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients" (see Chapter 2). This individual might or might not be a physician;1 that is, the committee view is that primary care clinicians as likely to include at least physicians, PAs, and Nps;

1  

For purposes of this chapter, the term physician refers to individuals trained in schools of allopathic medicine (who have received an M.D.) and those trained in schools of osteopathic medicine (who have received a D.O.), and no distinction is made between the two categories of physicians (or schools) unless it is explicitly noted.



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--> 6 The Primary Care Workforce This chapter focuses on the principal types of primary care clinicians—physicians, physician assistants (PAs), and nurse practitioners (NPs). They are the personnel most likely, under state practice acts, hospital or health plan credentialing, or customary practice, to have significant patient care authority. The chapter reviews trends in the supply of these components of the health workforce (noting the extreme difficulties of producing reliable and valid estimates of supply and, especially, requirements for clinicians or clinicians' services); it also briefly comments on the education and training infrastructure for such personnel (a topic taken up in greater detail in Chapter 7). The chapter then advances four recommendations concerning important directions that, in the committee's view, the production and use of primary care clinicians ought to take. The committee's definition of primary care draws attention to the concept of a primary care clinician, where clinician is defined by the committee as "an individual who uses a recognized scientific knowledge base and has the authority to direct the delivery of personal health services to patients" (see Chapter 2). This individual might or might not be a physician;1 that is, the committee view is that primary care clinicians as likely to include at least physicians, PAs, and Nps; 1   For purposes of this chapter, the term physician refers to individuals trained in schools of allopathic medicine (who have received an M.D.) and those trained in schools of osteopathic medicine (who have received a D.O.), and no distinction is made between the two categories of physicians (or schools) unless it is explicitly noted.

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--> that is how the term is used in, for instance, Chapter 5. The committee recognizes that the broader primary care team will include various other health care personnel, such as therapists, nutritionists, social workers, allied health personnel, and office staff. This range of professionals is reflected, for example, in the vignettes used in Chapter 3 to illustrate the scope of primary care. Finally, yet other health professionals, such as dentists, deliver primary care within their own fields and disciplines (IOM, 1995a), but as they are not likely to be responsible for the large majority of health care needs of all people, they are not discussed further here. Workforce Trends And Supply Projections: Physicians Overall Levels of Supply An extremely contentious set of issues in the United States in recent years has involved the numbers of physicians and their distribution by geographic area and specialty. Today, essentially all experts agree that the overall levels of physicians in the country point to a surplus; some in fact would characterize the level as a significant oversupply. These issues were explored in a recent report by an Institute of Medicine committee on aggregate physician supply (IOM, 1996a, pp. 3–4). The report concluded that the nation, at present, clearly has an abundant supply of physicians—which some members of the committee were prepared to label a surplus; judgments about the implications of those numbers must be made in the context of the overall U.S. health care system and the components of that system of greatest concern—the quality and costs of health care and access to services; the increase in the numbers of physicians in training and entering practice each year is sufficient to cause concern that supply in the future will be excessive, regardless of the assumptions made about the structure of the health care system; and the steady growth in numbers of physicians coming into practice is attributable primarily to ever-increasing numbers of IMGs [international medical graduates], about which the committee is very concerned. Other very recent publications are divided. For example, a minority viewpoint has been laid out by Cooper (1995), who argues that projections of the demand for and supply of physicians using more up-to-date assumptions show "no evidence of a major impending national surplus" (p. 1534). Cooper also draws attention to more than twofold differences across the states in the physician-to-population ratios; to the rapid growth of a wide array of nonphysician clinicians (including NPs and PAs); and to the need to develop policies that take

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--> into account the full range of practitioners (not just physicians) who will be delivering services to patients in the next century. In rebuttal, Tarlov (1995) notes the near unanimity of projections of substantial physician surpluses in analyses since 1980 and draws attention to the considerable uncertainties that surround the Cooper assumptions. Tarlov also calls for more creative actions on the part of many parties to deal not only with workforce supply issues but also to achieve other health goals as well, including reducing the disparities in access for underserved populations and increasing the representation of minorities in the medical profession. The most recent publication of the Pew Health Professions Commission comes down forcefully on the side of surplus, using language such as "a large oversupply" that will result in a "dislocation of crisis proportions" (Pew Health Professions Commission, 1995, p. 42). By and large, the IOM committee reporting here subscribes to the majority view; namely, that the nation does face a meaningful oversupply of physicians, in the aggregate, in coming years. Figure 6-1 provides some basic data on the growth in physicians in this country over the past nearly 50 years. According to federal statistics, the number of active nonfederal M.D. physicians per 100,000 population in 1950, for example, was 126.6; the figure rose to 127.4 in 1960 and 137.4 in 1970 (DHHS, 1993). In effect, for 35 years or so since the end of World War II, the nation believed it had a considerable shortage of physicians. Steps were taken in the 1960s and 1970s both to expand the production of physicians within the country and to liberalize the rules by which foreign (now international) medical graduates could enter the United States for training and remain to practice. The change in U.S. physician supply was dramatic.2 Between 1970–1971 and 1991–1992 the annual number of medical school graduates increased from approximately 9,000 to more than 15,000 (for allopathic schools, or M.D.s) and from 500 to more than 1,500 (for osteopathic schools, or D.O.s). As a result of these increases and federal policies that allowed more IMGs to practice in the United States, the number of physicians per 100,000 population increased dramatically between 1970 and 1990. Active physicians numbered 151.4 per 100,000 population in 1970 and 267.5 per 100,000 in 1992 (IOM, 1996a). Put another way, the nation had 1 active physician for every 584 persons in the country in the mid-1970s (DHEW, 1977) and 1 for every 398 persons by the early 1990s. For active nonfederal M.D.s, the physician-to-population figures were 137.4 M.D.s per 100,000 population in 1970 and 219.5 in 1991, a rise of 60 percent. The percentage increase in the ratio of active nonfederal D.O.s was 104 percent (on a considerably smaller base), from 5.7 D.O.s per 100,000 persons in 1970 to 11.6 in 1991. 2   Reporting of these figures differs somewhat across the period and by sources, depending on who is included in the various categories. Sources include DHEW (1977), NCHS (1983), and DHHS (1993).

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--> FIGURE 6-1 Numbers of physicians (M.D.s and D.O.s) and physicians per 100,000 population, selected years 1950–2020. SOURCE: IOM, 1996a. Reprinted with permission. Original source: Unpublished data from the Bureau of Health Professions (BHP) provided November 1, 1995. Data for 1950 through 1990 adjusted by BHP from American Medical Association Physician Masterfile and unpublished American Osteopathic Association data. Basic format of figure adapted from Rivo and Satcher (1993, p. 1077). Table 6-1 provides further information on the U.S. physician supply (both M.D.s and D.O.s) according to various activity categories (e.g., active patient care, research, teaching) for selected years. Of interest is that, in the nearly quarter-century covered by these data, the total numbers of active physicians in patient care and the total numbers in residency training essentially doubled, whereas those in other professional activities rose only a fraction. Table 6-2a shows that, counting all physicians (including those who were inactive or had unknown addresses), the total numbers of federal and nonfederal physicians were 334,028 in 1970; 615,421 in 1990; and 670,336 in 1993.

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--> TABLE 6-1 Supply of Physicians in the United States, 1970, 1980, 1992, by Type of Activity Type of Activity Number of Physiciansa Number of Physicians per 100,000 populationa   1970 1980 1992 1970 1980 1992 TOTAL 328,020 462,276 685,291 160.9 203.5 267.5               Total Active Physiciansb 308,487 436,667 627,723 151.4 192.2 245.0 Total active physicians in patient carec 222,657 310,533 461,405 109.2 136.7 180.1 Total active physicians in other professional activity 31,582 38,009 39,816 15.5 16.7 15.5 teaching NA NA 8,293 NA NA 3.2 research NA NA 16,398 NA NA 6.4 administration NA NA 15,125 NA NA 5.9 Total physicians in training providing patient cared 50,687 61,450 99,138 24.9 27.1 38.7 Not classifiede 3,561 26,675 27,364 1.7 11.7 10.7 Total Inactive Physicians 19,533 25,609 57,568 9.6 11.3 22.5 NOTE: NA=not available. a Data for 1970 and 1980 are for allopathic physicians (M.D.s) only; data for 1992 include both allopathic and osteopathic physicians. b Includes all physicians and physicians in training except those specifically identified as "inactive." c Although physicians in training clearly provide considerable patient care, they are not included in this total; see their separate line item, below. d "Physicians in training" is defined for 1970 and 1980 as "interns and residents, all years"; for 1992 the term is defined as "residents and fellows." e "Not classified'' includes, for 1970 and 1980, those physicians for whom an address is not known. SOURCES: IOM, 1996a, Table 2-1. Reprinted with permission. Data for 1970 and 1980 adapted from NCHS, 1983, Tables 1 and 55. Data for 1992 adapted from Kindig 1994, Table 1 and text.

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--> TABLE 6-2a Number of Active Federal and Nonfederal Physicians (M.D.s Only) by Specialty, Selected Years Specialty 1970 1980 1990 1994 Primary Care Specialties General practice 57,948 32,519 22,841 18,454 Family practice NAa 27,530 47,639 54,709 General internal medicine 39,924 58,462 76,295 84,951 General pediatrics 17,950 27,582 36,519 41,906           Total primary care specialties 115,822 146,093 183,294 200,020           Other Specialties           Obstetrics-gynecology 18,876 26,305 33,697 36,649 Internal medicine subspecialtiesb 1,948 13,069 22,054 26,476 Pediatrics subspecialtiesc 869 1,880 5,380 7,451 All other specialties 173,414 227,569 302,885 334,752           Total other specialtiesd 195,107 268,823 364,016 405,328 Not classified physicians NAe 20,629 12,678 14,283 Total active physiciansf 310,929 435,545 559,988 619,751           Total Physiciansg 334,028 467,679 615,421 684,414 NOTE: Data for 1990 and after are as of January 1. Data prior to 1990 are as of December 31. a Data on family practice were not available before 1975. b Internal medicine subspecialties include diabetes; endocrinology, diabetes, and metabolism; hematology; hepatology; cardiac electrophysiology; infectious diseases; clinical and laboratory immunology; geriatric medicine; sports medicine; nephrology; nutrition; medical oncology; and rheumatology. c Pediatric subspecialties include adolescent medicine; pediatric critical care medicine; neonatalperinatal medicine; pediatric allergy; pediatric cardiology; pediatric endocrinology; pediatric pulmonology; pediatric emergency medicine; pediatric gastroenterology; pediatric hematology/oncology; clinical and laboratory immunology; pediatric nephrology; pediatric rheumatology; and sports medicine. d Does not include, for 1994, 120 family practice subspecialty practitioners. Data on family practice subspecialties were not available before 1992. e Data not available before 1972. f Excludes those who are inactive and those for whom the address is unknown. g Includes those who are active, inactive, and those for whom the address is unknown. SOURCE: AMA, 1996.

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--> Primary Care Physicians Who Is Included A major part of the physician workforce debate has centered on whether the supply of primary care physicians is sufficient. Although the committee wishes to underscore its view that primary care needs to be considered as a function and that the core of primary care delivery is a team of clinicians (and others), for the purposes of this chapter some denomination of the kinds of physicians typically considered as belonging to the area of primary care is necessary. Thus, to be able to show some numbers relating to supply and to trends over time, the committee focused on the primary care physicians practicing or trained in general practice, family practice, general internal medicine, and general pediatrics. For purposes of counting practitioners, the committee did not bring obstetricians-gynecologists (OB-GYNs) into its primary care category. It did recognize that many women use OB-GYN specialists as their main, or even sole, health care providers, and the committee agreed that some regular use of this specialty is essential, if only to ensure that women see a physician at least yearly. As discussed in Chapters 2 and 5, however, the committee did not believe that OB-GYNs in general are likely to take on responsibility for "the large majority of health care needs" of their patients (and clearly they are not a source of primary care for men); thus, as a general proposition the practice of OB-GYN does not dovetail with the committee's definition of primary care. Some researchers and others in the workforce policy area, however, do include them in the primary care category, and some elements of the OB-GYN community have successfully argued that they are a part of the primary care workforce. In general, other specialists and subspecialists are not, for workforce planning purposes, considered primary care physicians. The committee acknowledges that many other types of physicians may render what is recognizably primary care, for at least some of their patients or at least some of the time. No current estimates are available, however, to indicate what proportion of the practices of these other types of specialists is primary care. Thus, for purposes of understanding or influencing workforce policy, the committee is not considering physician specialties beyond those specified above. Trends in Supply The supply of primary care clinicians has been studied for many years. The IOM report on primary care in 1978 (IOM, 1978), the report of the Graduate Medical Education National Advisory Committee (GMENAC, 1981), and more recent studies by the Physician Payment Review Commission (PPRC, 1992, 1995) and numerous statements of the Committee on Graduate Medical Education (COGME, especially the fourth and seventh reports [1994, 1995]) have all

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--> expressed concern about the adequacy of the supply of primary care physicians. This issue was also addressed in several of the proposals for health care reform, most extensively in the Health Security Act (CCH, 1993). The prevailing view is that the nation has had, and still does, an imbalance between generalists and specialists—too few of the former and too many of the latter. Specifically, as already noted, the United States has experienced a dramatic change in the composition of its physician workforce. In the early 1930s, 87 percent of private practice physicians were in general practice; 30 years later, only about 50 percent were generalists. Since then, the proportion of primary care physicians has continued to decline—leveling off at about one-third of all active physicians. Tables 6-2a, 6-2b, and 6-2c provide information on specialty distribution for allopathic physicians for several years beginning with 1970; this information pertains only to M.D.s and takes only active physicians into account. Counting generalist M.D.s to be those in general and family practice, general internal medicine, and general pediatrics, the numbers in primary care increased from about 116,000 (in 1970) to 200,020 (in 1994); the total of all other specialties rose TABLE 6-2b Physicians (M.D.s only) by Specialty Category as a Percentage of Total Active Physicians, Selected Years Category 1970 1980 1990 1994 Primary care specialties 37.3 33.5 32.7 32.3 Other specialties 62.8 61.7 65.0 65.4 Not classified NA 4.7 2.3 2.3 Total active physicians 100.1 99.9 100.0 100.0 NOTE: NA = not available; percentages do not sum to 100.0 because of rounding. SOURCE: Based on data from AMA, 1996 (see Table 6-2). TABLE 6-2c Percentage Changes in Numbers of Physicians (M.D.s only) in Primary Care During Selected Periods Category 1970–1990 1990–1994 1970–1994 All primary care 58.3 8.7 72.7 General/family practice 21.6 3.8 26.3 General internal medicine 91.1 11.4 112.8 General pediatrics 103.4 14.8 133.5   SOURCE: Based on data from AMA, 1996 (see Table 6-2a).

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--> from about 195,000 to more than 405,328 in the same period. In percentage terms (see Table 6-2b), primary care doctors as a percentage of total active physicians went from about 37 percent in 1970 to just over 32 percent in 1994; other specialties were about 63 and 65 percent of all active physicians in those years. Said another way, in the nearly quarter-century from 1970 to 1994 the total number of M.D.s in the United States more than doubled (from 334,000 to 684,414), and the total of active physicians nearly doubled (about 311,000 to almost 620,000). Most of the growth in the number of allopathic physicians was in specialty medicine—a rise of 108 percent over the period. The primary care workforce (general and family practice, general internal medicine, and general pediatrics) increased by about 73 percent (see Table 6-2c). The percentage increases during 1970–1994 were about 133 percent for general pediatrics, about 113 percent for general internal medicine, and about 26 percent for general and family medicine combined; if just family medicine is considered, the percentage increase from 1980 (the first year of family practice data noted in Table 6-2a) to 1994 was 99 percent. By 1994, of all primary care M.D.s in the United States, 43 percent were in internal medicine, 36 percent in general and family practice (mostly the latter), and 21 percent in pediatrics. More recently, various expert groups and researchers have concluded that the future demand for physician services including primary care physicians may be attenuated by the rapid growth of managed care plans, which use fewer physicians per enrollee than are used by the rest of the population (Kindig et al., 1993; COGME, 1995; Davis et al., 1995; Gamliel et al., 1995; PPRC, 1995; ProPAC, 1995; Scheffler, Appendix E). Other factors also suggest that the aggregate supply of primary care clinicians may be adequate in the near future. These include the rapid growth in the supply of primary care professionals other than physicians; the provision of primary care by specialist physicians (probably a significant number, although recent data are not available); and a recent turnaround in the numbers of medical students choosing primary care (perhaps a delayed response to market signals that are increasing the incomes of generalists both absolutely and in relationship to specialists incomes). As COGME (1996) notes in its eighth report, however, although projections of the numbers of generalist physicians may suggest that supply will be adequate, there is no guarantee of appropriate geographic distribution of those practitioners. Education, Training, and Licensure Today, the United States has a total of 125 schools of allopathic medicine3 and another 16 schools of osteopathic medicine; up to four new osteopathic 3   Until very recently, the United States had 126 allopathic schools, a number that had remained stable for years. A merger between two schools in Philadelphia changed the figure to 125.

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--> schools are in various stages of planning. Together they currently graduate approximately 17,500 physicians a year—a figure that has been fairly constant for about 15 years. Specifically, the number of M.D. graduates in 1994 was 15,579 (Barzansky et al., 1995), and the number of D.O. graduates that year was 1,775 (Singer, 1994). Graduates from allopathic schools alone are projected to number about 16,400 for the academic years through 1998–1999 (Jonas et al., 1994). Information on enrollments in allopathic schools is instructive. Total enrollment in 1993–1994 was nearly 66,500; of these, about 40 percent were women. With respect to race and ethnic background, 15.6 percent were Asian and Pacific Islander; nearly 8 percent were Mexican American, Puerto Rican, or of other Hispanic background; 7.2 percent were non-Hispanic African American; 0.6 percent were Native American or Alaskan Native; all other students (white but not of Hispanic origin, and non-U.S. foreign students of any race or ethnicity) made up nearly 70 percent of all students. Of interest is that the ratio of students applying to U.S. medical schools to those accepted is about 2.5 to 1. With respect to the primary care workforce, it is evident from the small proportion of minority students enrolled in medical schools that achieving significant representation of minorities who are trained and practicing in primary care will be difficult, at least in the near term. Newly graduated physicians take graduate medical education (GME) training in a highly developed graduate training system in this country. Accredited single-specialty and combined-specialty GME programs numbered 7,277 in 1993 (JAMA, 1994), with a total of 97,370 resident physicians. 4 Of these programs, 407 are in family practice, 416 in nonsubspecialty internal medicine, and 215 in nonsubspecialty pediatrics; respectively, the total numbers of positions in these programs were on the order of 8,500 (family medicine), 21,300 (internal medicine), and 7,750 (pediatrics).5 According to Whitcomb (1994), most GME programs (more than 90 percent) are affiliated with a medical school (or a closely related entity). Groups in both the public and private sectors have sought, over the years, to increase the production of primary care physicians (see also Chapter 7). In the public sector, these steps have included support under Title VII of the Public Health Service Act for the training of primary care physicians. Several state governments have also pressed the medical schools within the state to increase 4   See JAMA, 1994. "Straight" residency programs (in generalist or subspecialist disciplines) number just over 7,100 programs; "combined" programs (about 160 in all) are blends such as internal medicine and another specialty (e.g., pediatrics, emergency medicine). 5   The numbers of programs or positions in "nonsubspecialty" internal medicine or pediatrics may be misleading, however, because historically a majority of those internal medicine residents and a large minority of those in general pediatrics went on to subspecialty training. By contrast, over 90 percent of family practice residents enter family practice.

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--> production of primary care physicians (including Arizona and California). Several private foundations also support programs to increase the training of generalists. Geographic Distribution of Primary Care Physicians Of considerable importance is the continuing lack of sufficient primary care clinicians in some geographic areas, particularly rural and some poor urban areas. By and large, problems of geographic maldistribution are set out in terms of aggregate physician presence, not the availability of primary care physicians (or primary care clinicians). For example, in 1993 metropolitan areas had an average ratio of physicians to population of 226 per 100,000 persons, whereas for non-metropolitan areas the ratio was 118 per 100,000 persons (Cooper, 1995). More telling is Cooper's analysis of physician-to-population ratios across the states, which shows a high of 294 in Maryland and the District of Columbia and a low of 118 in Mississippi. Cooper argues that the nation can be characterized as having five regions as follows (physician-to-population ratios are given in parentheses): the Boston-Washington corridor (227 to 294 per 100,000 persons); east and west "arms" including Florida (190 to 212); the central zone (147 to 181); the northern Rockies and Alaska (132 to 143); and Mississippi (118). Workforce developments in the past 25 years provide ample evidence that increases in aggregate supply, by themselves, are not adequate to correct the problem of shortages in some areas of the country. Although physicians have been moving to smaller or more rural areas since the early 1980s (Schwartz et al., 1980; Williams et al., 1981; Newhouse et al., 1982a, 1982b), the fact that rural areas and inner cities continue to face access problems cannot be gainsaid. Geographic maldistribution in rural areas (e.g., for counties of fewer than 50,000 residents) is worsening, not improving, according to recent data from COGME (1995), a pattern consistent with the data reported by Cooper (1995). The committee returns to the geographic maldistribution issue later in this Chapter 7. Workforce Trends And Supply Projections: Nurse Practitioners According to a recent report on nurse staffing in hospitals and nursing homes (IOM, 1996b), the largest group of health care providers in the United States is registered nurses (RNs); in 1992, more than 2.2 million individuals were licensed to practice as RNs, or about 750 RNs per 100,000 population. RNs are prepared in one of three different educational tracks that can take two, three, or four years. 6 In 1993, there were 129 diploma programs, 857 associated degree programs, 6   More information on nursing education can be found in IOM, 1995c.

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--> in favor of state options for health care block grants. The rise in the number of persons underinsured or uninsured in any one year will also affect demand for health care services. So, too, will increases in mandatory out-of-pocket costs, such as higher health care premiums, higher deductibles and copayment requirements, and cutbacks in coverage of certain services such as those for mental health. Economic demand for health care services is not equivalent to potential need for such services. As Tarlov (1995, p. 1559) notes: [A]lso affecting requirements are the emergence of new diseases, sharp changes in demographic composition and the different needs of special populations including the poor, immigrants, some minority groups, children, military personnel, veterans, retirees, elders, and people in underserved rural and urban areas. … The committee is under no illusions: Developing a national consensus about service requirements—i.e., the human need for health care services—is, and will remain, a profound challenge. Changes on the supply side can be expected to help eliminate shortages in the future. Among these changes are the probable increase in the number of specialists and subspecialists who expand their delivery of primary care services, a rising interest in primary care careers on the part of medical students, and continued rapid growth in training of NPs and PAs. In general, the committee supports these trends, but it remains unconvinced that the supply of well-prepared primary care clinicians will be sufficient to meet the demand for their services, at least in the short term. In the longer term, of course, these steps may well suffice, but the committee is not persuaded that, collectively, they will produce adequate numbers of appropriately competent personnel able to function in the model of a primary care team and to provide adequate quality of care. To address these concerns, the committee has two points it wishes to emphasize concerning the future of programs that produce primary care physicians, PAs, and NPs. Recommendation 6.1 Programs Regarding the Primary Care Workforce The committee recommends (a) that the current level of effort to increase the supply of primary care clinicians be continued and (b) that these primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care.

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--> General Issues of Access and Quality of Care In the committee's judgment, the nation does still have an imbalance in the supply of primary care clinicians relative to clinicians (chiefly physicians) in specialty and subspecialty disciplines. Recommendation 6.1 is intended to help right that balance, without tipping the scale toward a future excess of primary care clinicians of any type. Its language about the output of current training programs is, therefore, chosen advisedly. That is, the committee believes that the present levels of production of primary care physicians, NPs, and PAs should be maintained—not accelerated, but also not diminished. The committee does not recommend the introduction of major new initiatives aimed at increasing the aggregate supply of primary care clinicians. Rather, as noted just below, the aim is to improve access to primary care for all Americans, taking into account expertise, geographic distribution, ethnic and cultural representation within the primary care workforce, or other factors important to the delivery of high-quality primary care. The committee's further focus with respect to primary care training programs is on improving primary care competencies. These issues are explored more fully in Chapter 7 on training and education and are touched on in Chapter 8 with respect to accountability for quality of care. This committee, like others at the IOM, endorses the IOM's stated position about universal access to health care coverage for all Americans (IOM, 1993) and has explicitly offered its own recommendation in this area (Recommendation 5.1). Fulfilling this aim is regarded as especially pertinent for primary care, because of the centrality of primary care to well-rounded, integrated health care, access to appropriate specialists, and better patient outcomes. It is even more important for those populations that do not now receive adequate primary care. Thus, the committee is especially concerned that training programs be configured so as to prepare students for careers in the full range of settings needed to serve all the American people. These points are also addressed more fully in Chapter 7 in discussions of undergraduate medical education in primary care sites (see Recommendation 7.1) and graduate medical education in nonhospital sites such as HMOs, community clinics, physician offices, and extended care facilities (see Recommendation 7.6). Minority Participation in Primary Care Training and Practice The committee also wishes to go on record as supporting special initiatives that will increase the percentage of underrepresented minorities in the health professions, including primary care. This is in keeping with recent recommendations of other IOM committees, especially one on minority representation in the health professions (IOM, 1994) and another on aggregate physician supply (IOM,

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--> 1996a); it is also consistent with the "3000 by 2000" goals of the Association of American Medical Colleges. Specifically, the committee would like to see the ethnic and cultural mix of the present and future supply of primary care clinicians be modified over time by an increase in the proportion of minorities. In this regard, the committee draws attention not only to the problems of underrepresentation among practitioners (i.e., physicians, NPs, or PAs) but also among the health professions faculty and researchers. Consistent with the sentiment of the IOM report Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions (IOM, 1994), the committee is sensitive to the need for health professions schools to develop programs that reflect genuine appreciation and respect for students' various backgrounds, values, and perspectives. It also underscores the need for health professions schools and professional organizations to engage in more outreach to prospective students at the university (indeed, at the high school) level. This view dovetails with the discussion in the next chapter about the need for training programs, professional organizations, and similar groups to emphasize cultural sensitivity and appropriate communication skills (see Recommendation 7.4). Monitoring Supply And Requirements Recommendation 6.2 Monitoring the Primary Care Workforce The committee recommends that state and federal agencies carefully monitor the supply of and requirements for primary care clinicians. In keeping with the increasingly interdisciplinary nature of primary care, the committee urges that state and federal agencies compile a composite database of primary care clinicians—including physicians, NPs, and PAs providing primary care services. This would help analysts, policymakers, educators, and others understand the changing requirements for primary care clinicians and monitor utilization patterns of employment, geographic distribution, and insurance status of patients served. Market forces may be able in the future to correct the modest shortage of primary care clinicians. The restructuring presently taking place, however, remains fluid so that the committee cannot be certain that market forces will induce and maintain appropriate responses in training and practice choices. Moreover, the committee remains concerned about the rapid changes taking place in the health care sector as a whole. It concludes that ongoing monitoring of supply and requirements is essential to ensure that appropriate public policy and private career decisions can be made. Currently, the Bureau of the Health Professions (of the Health Resources and Services Administration [BHP/HRSA]), the Council on Graduate Medical Education

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--> (COGME), and the National Committee on Nursing Education and Practice have responsibility for monitoring primary care clinician supply and requirements. The committee endorses their efforts and notes the recommendations from a parallel IOM committee (IOM, 1996a) on the same point. Specifically, that panel advocated (p. 90) that the Department of Health and Human Services, chiefly through the Health Resources and Services Administration, regularly make information on physician supply and requirements and the status of career opportunities in medicine available to policymakers, educators, professional associations, and the public … [and that] the American Medical Association, the Association of American Medical Colleges, the Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and other professional associations cooperate with the federal government in widely disseminating such information to students indicating an interest in careers in medicine. Clearly, those recommendations pertain to physicians (and to all physicians, not just those in primary care). This committee would extend that advice to include nurses (especially advanced practice nurses or NPs) and PAs (see IOM, 1996b, for a detailed discussion of the needs for better data on the nurse workforce). Nurses and PAs are health care practitioners of direct interest to BHP/HRSA. The analogous collaboration and cooperation would be sought with a wide array of professional associations, including but not limited to the American Academy of Physician Assistants, American Association of Colleges of Nursing, the American Association of Physician Assistants, American Nurses Association, the National League for Nurses, and the National Organization of Nurse Practitioner Faculties. Apart from general monitoring of the several professions relevant to primary care (e.g., in terms of current size and composition and future projections of supply and requirements), efforts should also be made to obtain current information on the use of primary care clinicians by managed care plans and integrated health delivery systems. Of particular interest are patterns of substitution across physicians, NPs, and PAs and the impact of the complex interactions of these practitioners on health care costs, access, and quality of care. These points are revisited in Chapter 8 with respect to a primary care research agenda. Geographic Maldistribution of the Primary Care Workforce The committee is concerned by the continuing geographic maldistribution of the primary care workforce; there are too few clinicians in inner cities and rural areas. Despite many attempts to address this shortage, the nation simply has not adequately improved access to primary care services in these underserved areas.11 Although programs such as the National Health Service Corps have filled 11   The history of formally identifying areas that are underserved by health care providers is more than a quarter-century old, beginning with the development of the Index of Medical Underservice in the early 1970s and continuing with Critical Health Manpower Shortage Areas, Nurse Shortage Areas, Health Manpower Shortage Areas, and now Health Professional Shortage Areas (HPSAs). The last are identified on the basis of several variables, including low physician-to-population ratios, high rates of adverse health events such as infant deaths, and poor access to care. According to the Bureau of Primary Health Care (BPHC, 1995), in 1994 almost 2,740 HPSAs had been designated (of which about two-thirds were rural) covering a population of nearly 48 million individuals. More information on HPSAs and on the entire effort to designate underserved areas and to address their health care professional needs can be found in Lee (1991), Desmarais (1995), and Mullan, (1995).

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--> the gap to some extent (especially for rural areas) (Mullan, 1995), significant disparities remain. The latest, dramatic evidence of this for physicians was presented by Cooper (1995), cited earlier; equivalently detailed information for NPs and PAs is not available. The incompatibility between articulated public policy goals and objectives and the financing mechanisms put in place to support them have created an expansion of the physician supply without actually achieving an adequate workforce supply in underserved areas. Neither ''trickle-down" physician workforce policy nor market forces to date have been notably successful in alleviating the problems of inequitable distribution of primary care services and clinicians, across the nation. The committee has dealt—essentially throughout this report—with the widely recognized issues of maldistribution of physicians by generalist or specialty training and practice. The problem of maldistribution by geographic location is another, and troubling, matter. The committee regards the goal of overcoming imbalances in the geographic distribution of primary care clinicians as an especially significant one. It also believes that, with the rapid changes now taking place in the private sector, managed care organizations and integrated health delivery systems have a significant duty to address this question head-on. Recommendation 6.3 Addressing Issues of Geographic Maldistribution The committee recommends that federal and state governments and private foundations fund research projects to explore ways in which managed care and integrated health care systems can be used to alleviate the geographic maldistribution of primary care clinicians. For purposes of this recommendation, the committee regards rural and inner city jurisdictions as appropriate targets for such projects and for specific attempts to redress the shortage of primary care clinicians in these areas. Clearly, as between rural areas and the core metropolitan areas, the problems, the likely solutions, and the types of personnel and configurations of primary care teams are all likely to differ. In fact, rural areas themselves will vary along these dimensions, as will inner cities.

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--> The committee believes that managed care organizations may be able to deal with some maldistribution problems where earlier efforts have not worked. For instance, integrated delivery systems that wish to expand their businesses into previously uncovered catchment areas, whether rural or inner city, can provide financial incentives, collegial relationships, and telecommunications capabilities that will attract physicians (as well as NPs and PAs) into those areas. Academic health centers may also operate community or school clinics or other types of ambulatory care networks, especially in poor sections of metropolitan areas, that essentially also represent good business and expanded catchment opportunities. The inducements may include acceptable practice sites, competitive salaries, hospital privileges, professional relationships and backup, and appropriate referral networks, but the growing scarcity of practice openings in more affluent areas should not be discounted. The precise combinations of fiscal and professional incentives that might work best for particular types of underserved areas are clearly not known today. Thus, demonstration and evaluation of current efforts would be particularly useful, in the committee's view. The committee did not call for testing or evaluation of specific approaches that managed care and integrated systems might use to address the geographic maldistribution problems of these areas. Consistent with the principles laid out in Chapter 2, however, the committee notes that it would not subscribe to solutions that were based solely on one type of primary care clinician; it believes that innovative programs involving physicians, NPs, and PAs are more desirable, and indeed it would advocate that strategies involving the entire primary care team be investigated. Finally, this recommendation is couched in terms of research projects and thus should be considered in conjunction with the broad research agenda laid out in Chapter 8. The committee advances it here to underscore the policy issues—specifically, a very uneven presence of primary care clinicians across the states that severely hinders any efforts to bring greater parity in access to health care services to large portions of the U.S. population. Because managed care organizations and integrated systems are gaining such a prominent role in the whole restructuring of the nation's health care system, it was felt that demonstration and evaluation projects conducted by them or under their auspices would shed the most light on how best to address this access issue. In short, the committee believes that as managed care plans and approaches expand, they bring opportunities to improve access to primary care in rural and inner city areas; that efforts to encourage that possibility are called for; and that the successes and failures of such efforts should be thoroughly understood. Impediments to the Use of Nurse Practitioners and Physician Assistants "Scope of practice" laws, established by the states, govern what NPs and

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--> PAs are permitted to do. Collectively, these laws constitute a crazy quilt of permitted or disallowed practices and activities. Thus, the legal restrictions on the scope of practice for NPs and PAs in some states seriously impede the involvement of these types of personnel in primary care in some settings and circumstances. This fact has a number of health care policy and delivery implications. For example, for managed care enterprises that operate in more than one state, the configurations they can use to organize their primary care teams may be different, depending on the state in question. It is not clear to this committee why different structures for the delivery of high-quality primary care ought to turn on what may be quite idiosyncratic or outmoded state practice acts. Recommendation 6.4 State Practice Acts for Nurse Practitioners and Physician Assistants The committee recommends that state governments review current restrictions on the scope of practice of primary care nurse practitioners and physician assistants and eliminate or modify those restrictions that impede collaborative practice and reduce access to quality primary care. The committee is concerned that state statutes presently on the books create obstacles to innovative collaboration among members of primary care teams and that those ordinances by default hinder the provision of effective and efficient health care. These limitations may involve the degree and nature of supervision (such as the requirement in some states for on-site supervision of PAs), the ability to prescribe pharmaceuticals, or the ability to order other services needed by the patient without a physician's case-by-case approval. A recent analysis of the practicing environment in 10 states for NPs and PAs assigned weighted scores regarding scope of practice, requirements for physician supervision, prescriptive and dispensing authority, reimbursement, and so forth. It found total average scores of 63.9 in these 10 states with scores ranging from 0 in Illinois and Ohio where NPs are not recognized at all, to scores over 90 in Maryland, Montana, New Hampshire, and Oregon. Similarly, PAs scores in the same states averaged 60.5 with a range from 0 in Mississippi to over 90 in Iowa, Massachusetts, and Montana (RTI, 1995). The committee believes that more freedom to structure the divisions of duties and responsibilities should be given to the primary care team. Clearly, reconsideration by the states of these practice acts might also enable some to address their shortage-area problems (discussed earlier) more creatively as well, in part by enabling managed care organizations and integrated delivery systems to develop efficient models of primary care practice that work within their own

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--> corporate structures and yet are adaptable to the particular needs of specific frontier, rural, or inner city populations. Summary This chapter has reviewed trends in the supply of the principal types of primary care clinicians—physicians, NPs, and PAs—taking care to observe the great difficulties of developing reliable and valid estimates of supply and, especially, requirements for clinicians or clinicians' services. It also briefly comments on the education and training infrastructure for such personnel, which leads into the next chapter. The present chapter then advances four recommendations concerning important directions that, in the committee's view, the production and use of primary care clinicians ought to take. These involve (1) continuing the current level of effort to increase the supply of primary care clinicians but ensuring that primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care; (2) encouraging state and federal agencies to carefully monitor the supply of and requirements for primary care clinicians; and (3) exploring ways in which managed care and integrated health care systems might be used to alleviate the geographic maldistribution of primary care clinicians; and (4) examining how state practice acts for NPs and PAs might be amended to eliminate outmoded restrictions on practices that currently impede efficient and effective functioning of primary care teams and that reduce access to needed health care. References AAPA (American Academy of Physician Assistants). 1995 AAPA Membership Census Mid-Year Report, September 1995. Alexandria, Va.: AAPA, 1995. AACN (American Association of Colleges of Nursing). 1994–1995. Special Report on: Master's and Post-Master's Nurse Practitioner Programs, Faculty Clinical Practice, Faculty Age Profiles, and Undergraduate Curriculum Expansion In Baccalaureate and Graduate Programs in Nursing . Publ. No. 94-95-4. Washington, D.C.: AACN, 1995. AMA (American Medical Association). Physician Characteristics and Distribution in the US. 1995/1996 Edition. Chicago: AMA, 1996. Barzansky, B., Jonas, H.S., and Etzel, S.I. Educational Programs in U.S. Medical Schools, 1994–95. Journal of the American Medical Association 274:716–722, 1995. Birkholz, G., and Walker, D. Strategies for State Statutory Language Changes Granting Fully Independent Nurse Practitioner Practice. Nurse Practitioner 19:54–58, 1994. BPHC (Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services). Health Professional Shortage Area (HPSA) Designations: 1978–1994. Unpublished material from the Division of Shortage Designation, March, 1995. CCH (Commerce Clearing House). Health Security Act (President Clinton's Health Care Reform Proposal and Health Security Act). Presented to Congress on October 27, 1993. Chicago, Ill.: Commerce Clearing House, 1993.

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