Primary Care Professionals
Recent Supply Trends, Projections, and Valuation of Services
Gao ID: GAO-08-472T February 12, 2008
Most of the funding for programs under title VII of the Public Health Service Act goes toward primary care medicine and dentistry training and increasing medical student diversity. Despite a longstanding objective of title VII to increase the total supply of primary care professionals, health care marketplace signals suggest an undervaluing of primary care medicine, creating a concern about the future supply of primary care professionals--physicians, physician assistants, nurse practitioners, and dentists. This concern comes at a time when there is growing recognition that greater use of primary care services and less reliance on specialty services can lead to better health outcomes at lower cost. GAO was asked to focus on (1) recent supply trends for primary care professionals, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals, including the factors underlying these projections; and (3) the influence of the health care system's financing mechanisms on the valuation of primary care services. GAO obtained data from the Health Resources and Services Administration (HRSA) and organizations representing primary care professionals. GAO also reviewed relevant literature and position statements of these organizations.
In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties. For the future, health professions workforce projections made by government and industry groups have focused on the likely supply of the physician workforce overall, including all specialties. Few projections have focused on the likely supply of primary care physician or other primary care professionals. Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation's financial support for primary care medicine. Ample research in recent years concludes that the nation's over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care--all hallmarks of primary care medicine--can achieve improved outcomes and cost savings. Conventional payment systems tend to undervalue primary care services relative to specialty services. Some physician organizations are proposing payment system refinements that place a new emphasis on primary care services.
GAO-08-472T, Primary Care Professionals: Recent Supply Trends, Projections, and Valuation of Services
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Testimony:
Before the Committee on Health, Education, Labor, and Pensions, U.S.
Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 2:30 p.m. EST:
Tuesday, February 12, 2008:
Primary Care Professionals:
Recent Supply Trends, Projections, and Valuation of Services:
Statement of A. Bruce Steinwald, Director:
Health Care:
GAO-08-472T:
GAO Highlights:
Highlights of GAO-08-472T, a testimony before the Committee on Health,
Education, Labor, and Pensions, U.S. Senate.
Why GAO Did This Study:
Most of the funding for programs under title VII of the Public Health
Service Act goes toward primary care medicine and dentistry training
and increasing medical student diversity. Despite a longstanding
objective of title VII to increase the total supply of primary care
professionals, health care marketplace signals suggest an undervaluing
of primary care medicine, creating a concern about the future supply of
primary care professionals”physicians, physician assistants, nurse
practitioners, and dentists. This concern comes at a time when there is
growing recognition that greater use of primary care services and less
reliance on specialty services can lead to better health outcomes at
lower cost.
GAO was asked to focus on
(1) recent supply trends for primary care professionals, including
information on training and demographic characteristics; (2)
projections of future supply for primary care professionals, including
the factors underlying these projections; and (3) the influence of the
health care system‘s financing mechanisms on the valuation of primary
care services.
GAO obtained data from the Health Resources and Services Administration
(HRSA) and organizations representing primary care professionals. GAO
also reviewed relevant literature and position statements of these
organizations.
What GAO Found:
In recent years, the supply of primary care professionals increased,
with the supply of nonphysicians increasing faster than physicians. The
numbers of primary care professionals in training programs also
increased. Little information was available on trends during this
period regarding minorities in training or actively practicing in
primary care specialties. For the future, health professions workforce
projections made by government and industry groups have focused on the
likely supply of the physician workforce overall, including all
specialties. Few projections have focused on the likely supply of
primary care physician or other primary care professionals.
Health professional workforce projections that are mostly silent on the
future supply of and demand for primary care services are symptomatic
of an ongoing decline in the nation‘s financial support for primary
care medicine. Ample research in recent years concludes that the
nation‘s over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care”all hallmarks of
primary care medicine”can achieve improved outcomes and cost savings.
Conventional payment systems tend to undervalue primary care services
relative to specialty services. Some physician organizations are
proposing payment system refinements that place a new emphasis on
primary care services.
Table: Supply of Primary Care Professionals:
Primary care physicians;
Number of primary care professionals: Base year: 208,187;
Number of primary care professionals: Recent year: 264,086;
Number of primary care professionals per 100,000 people: Base year: 80;
Number of primary care professionals per 100,000 people: Recent year:
90;
Average annual percentage change per capita: 1.17.
Physician assistants;
Number of primary care professionals: Base year: 12,819;
Number of primary care professionals: Recent year: 23,325;
Number of primary care professionals per 100,000 people: Base year: 5;
Number of primary care professionals per 100,000 people: Recent year:
8;
Average annual percentage change per capita: 3.89.
Nurse practitioners;
Number of primary care professionals: Base year: 44,200;
Number of primary care professionals: Recent year: 82,622;
Number of primary care professionals per 100,000 people: Base year: 16;
Number of primary care professionals per 100,000 people: Recent year:
28;
Average annual change per capita: 9.44.
Dentists;
Number of primary care professionals: Base year: 118,816;
Number of primary care professionals: Recent year: 138,754;
Number of primary care professionals per 100,000 people: Base year: 46;
Number of primary care professionals per 100,000 people: Recent year:
47;
Average annual percentage change per capita: 0.12.
Sources: GAO analysis of data from HRSA‘s Area Resource File and
organizations representing primary care professionals.
Notes: Data on primary care physicians are from 1995 and 2005. Data on
physician assistants are from 1995 and 2007. Data on nurse
practitioners are from 1999 and 2005. Data on dentists are from 1995
and 2007. Data for identical time periods were not available. The
average annual percentage change is not sensitive to these time period
differences.
[End of table]
What GAO Recommends:
GAO discussed the contents of this statement with HRSA officials and
incorporated their comments as appropriate.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-472T]. For more information, contact A.
Bruce Steinwald, (202) 512-7114, or steinwalda@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today as you prepare to consider the
reauthorization of health professions education programs established
under title VII of the Public Health Service Act.[Footnote 1] Most of
the funding for title VII programs goes toward primary care medicine
and dentistry training and increasing medical student diversity.
Despite a longstanding objective of title VII to increase the total
supply of primary care professionals, health care marketplace signals
suggest an undervaluing of primary care medicine, creating a concern
about the future supply of primary care professionals. As evidence,
health policy experts cite a growing income gap between primary care
physicians and specialists and a declining number of U.S. medical
students entering primary care specialties--internal medicine, family
medicine, general practice, and general pediatrics. Moreover, the
federal agency responsible for implementing title VII programs, the
Health Resources and Services Administration (HRSA), notes that
physician "extenders"--namely, physician assistants and nurse
practitioners--may also be choosing procedure-driven specialties, such
as surgery, cardiology, and oncology, in increasing numbers.[Footnote
2],[Footnote 3]
A paradox commonly cited about the U.S. health care system is that the
nation spends more per capita than all other industrialized nations but
ranks consistently low in such quality and access measures as life
expectancy, infant mortality, preventable deaths, and percentage of
population with health insurance. Moreover, experts have concluded that
not all of this spending is warranted, and overutilization of services
can, in fact, lead to harm.[Footnote 4] These findings come at a time
when there is growing recognition that greater use of primary care
services and less reliance on specialty services can lead to better
health outcomes at lower cost.
To examine the supply of primary care professionals in more detail, you
asked us to provide information related to the current and future
supply of these professionals. My remarks today will focus on (1)
recent supply trends for primary care professionals, including
information on training and demographic characteristics; (2)
projections of future supply for primary care professionals, including
the factors underlying these projections; and (3) the influence of the
health care system's financing mechanisms on the valuation of primary
care services.
To discuss the recent supply trends for primary care professionals--
including information on training and demographic characteristics--we
obtained data from HRSA's Area Resource File; the American Academy of
Physician Assistants (AAPA); and the American Academy of Nurse
Practitioners (AANP). In addition, we reviewed published data from AMA,
the American Association of Colleges of Nursing (AACN); and the
American Dental Education Association (ADEA).[Footnote 5] We also
obtained published annual estimates from the United States Census
Bureau on the noninstitutionalized, civilian population.
To obtain information about projections of future supply of primary
care professionals, we reviewed relevant literature and the position
statements of organizations representing primary care professionals,
including the American Academy of Family Physicians (AAFP) and the
American College of Physicians (ACP). We also interviewed officials
from HRSA, AAPA, AANP, the American Dental Association (ADA), and the
Association of American Medical Colleges (AAMC). In selecting workforce
supply projections for review, we focused on the projected estimates of
national supply for primary care professionals from the past decade.
To obtain information on the influence of the health care system's
financing mechanisms on the valuation of primary care services, we
reviewed relevant literature on Medicare's resource-based physician fee
schedule and the influence of primary care supply on costs and quality
of health care services.
We assessed the reliability of HRSA's Area Resource File data by
interviewing officials responsible for producing these data, reviewing
relevant documentation, and examining the data for obvious
errors.[Footnote 6] We assessed the reliability of the data provided by
the AAPA and the AANP by discussing with association officials the
validation procedures they use to ensure timely, complete, and accurate
data. We determined the data used in this testimony to be sufficiently
reliable for our purposes. We discussed a draft of this testimony with
HRSA officials. They provided technical comments, which we incorporated
as appropriate. We conducted this work from December 2007 through
February 2008, in accordance with generally accepted government
auditing standards.
In summary, in recent years, the supply of primary care professionals
increased, with the supply of nonphysicians increasing faster than
physicians. The numbers of primary care professionals in training
programs also increased. Little information was available on trends
during this period regarding minorities in training or actively
practicing in primary care specialties. For the future, health
professions workforce projections made by government and industry
groups have focused on the likely supply of the physician workforce
overall, including all specialties. Few projections have focused on the
likely supply of primary care physician or other primary care
professionals.
Health professional workforce projections that are mostly silent on the
future supply of and demand for primary care services are symptomatic
of an ongoing decline in the nation's financial support for primary
care medicine. Ample research in recent years concludes that the
nation's over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care--all hallmarks of
primary care medicine--can achieve improved outcomes and cost savings.
Conventional payment systems tend to undervalue primary care services
relative to specialty services. Some physician organizations are
developing payment system refinements that place a new emphasis on
primary care services.
Background:
Among other things, title VII programs support the education and
training of primary care providers, such as primary care physicians,
physician assistants, general dentists, pediatric dentists, and allied
health practitioners.[Footnote 7] HRSA includes in its definition of
primary care services, health services related to family medicine,
internal medicine, preventative medicine, osteopathic general practice,
and general pediatrics that are furnished by physicians or other types
of health professionals. Also, HRSA recognizes diagnostic services,
preventive services (including immunizations and preventive dental
care), and emergency medical services as primary care. Thus, in some
cases, nonprimary care practitioners provide primary care services to
populations that they serve.
Title VII programs support a wide variety of activities related to this
broad topic. For example, they provide grants to institutions that
train health professionals; offer direct assistance to students in the
form of scholarships, loans, or repayment of educational loans; and
provide funding for health workforce analyses, such as estimates of
supply and demand.[Footnote 8] In recent years, title VII programs have
focused on three specific areas of need--improving the distribution of
health professionals in underserved areas such as rural and inner-city
communities, increasing representation of minorities and individuals
from disadvantaged backgrounds in health professions, and increasing
the number of primary care providers. For example, the Scholarships for
Disadvantaged Students Program awards grants to health professions
schools to provide scholarships to full-time, financially needy
students from disadvantaged backgrounds, many of whom are minorities.
Primary Care Education and Training Programs:
After completing medical school, medical students enter a multiyear
training program called residency, during which they complete their
formal education as a physician. Because medical students must select
their area of practice specialty as part of the process of being
matched into a residency program, the number of physician residents
participating in primary care residency programs is used as an
indication of the likely future supply of primary care physicians.
Physician residents receive most of their training in teaching
hospitals, which are hospitals that operate one or more graduate
medical education programs. Completion of a physician residency program
can take from 3 to 7 years after graduation from medical school,
depending on the specialty or subspecialty chosen by the physician.
Most primary care specialties require a 3-year residency program. In
some cases, primary care physicians may choose to pursue additional
residency training and become a subspecialist--such as a pediatrician
who specializes in cardiology. In this case, the physician would no
longer be considered a primary care physician, but rather, a
cardiologist.
According to the AAPA, most physician assistant programs require
applicants to have some college education. The average physician
assistant program takes about 26 months, with classroom education
followed by clinical rotations in internal medicine, family medicine,
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and
geriatric medicine. Physician assistants practice in primary care
medicine, including family medicine, internal medicine, pediatrics, and
obstetrics and gynecology, as well in surgical specialties.
After completion of a bachelor's degree in nursing, a nurse may become
a nurse practitioner after completing a master's degree in nursing.
According to the AACN, full-time master's programs are generally 18 to
24 months in duration and include both classroom and clinical work.
Nurse practitioner programs generally include areas of specialization
such as acute care, adult health, child health, emergency care,
geriatric care, neonatal health, occupational health, and oncology.
Dentists typically complete 3 to 4 years of undergraduate university
education, followed by 4 years of professional education in dental
school. The 4 years of dental school are organized into 2 years of
basic science and pre-clinical instruction followed by 2 years of
clinical instruction. Unlike training programs for physicians, there is
no universal requirement for dental residency training. However, a
substantial proportion of dentists--about 65 percent of dental school
graduates--enroll in dental specialty or general dentistry residency
programs.
Supply of Primary Care Professionals Increased; Little Data Available
on Minority Representation:
In recent years, the supply of primary care professionals increased,
with the supply of nonphysicians increasing faster than physicians. The
numbers of primary care professionals in training programs also
increased. Little information was available on trends during this
period regarding minorities in training or actively practicing in
primary care specialties.
In Recent Years, Supply of Primary Care Professionals Increased:
In recent years, the number of primary care professionals nationwide
grew faster than the population, resulting in an increased supply of
primary care professionals on a per capita basis (expressed per 100,000
people). Table 1 shows that over roughly the last decade, per capita
supply of primary care physicians--internists, pediatricians, general
practice physicians, and family practitioners--rose an average of about
1 percent per year,[Footnote 9] while the per capita supply of
nonphysician primary care professionals--physician assistants and nurse
practitioners--rose faster, at an average of about 4 percent and 9
percent per year, respectively. Nurse practitioners accounted for most
of the increase in nonphysician primary care professionals. The per
capita supply of primary care dentists--general dentists and pediatric
dentists--remained relatively unchanged.
Table 1: Supply of Primary Care Professionals:
Primary care physicians[A];
Number of primary care professionals: Base year: 208,187;
Number of primary care professionals: Recent year: 264,086;
Number of primary care professionals per 100,000 people: Base year: 80;
Number of primary care professionals per 100,000 people: Recent year:
90;
Average annual percentage change per capita: 1.17.
Physician assistants[B];
Number of primary care professionals: Base year: 12,819;
Number of primary care professionals: Recent year: 23,325;
Number of primary care professionals per 100,000 people: Base year: 5;
Number of primary care professionals per 100,000 people: Recent year:
8;
Average annual percentage change per capita: 3.89.
Nurse practitioners[C];
Number of primary care professionals: Base year: 44,200;
Number of primary care professionals: Recent year: 82,622;
Number of primary care professionals per 100,000 people: Base year: 16;
Number of primary care professionals per 100,000 people: Recent year:
28;
Average annual percentage change per capita: 9.44.
Dentists[D];
Number of primary care professionals: Base year: 118,816;
Number of primary care professionals: Recent year: 138,754;
Number of primary care professionals per 100,000 people: Base year: 46;
Number of primary care professionals per 100,000 people: Recent year:
47;
Average annual percentage change per capita: 0.12.
Sources: GAO analysis of data from HRSA's Area Resource File, AAPA,
AANP, and the U.S. Census Bureau.
Notes: Data on primary care professionals for identical time periods
were not available. The average annual percentage change is not
sensitive to these time period differences.
[A] Data on primary care physicians include numbers for both MDs and
DOs. Data for MDs are from 1995 and 2005, and for DOs are from 1995 and
2004.
[B] Data on physician assistants are from 1995 and 2007. Data on the
total number of physician assistants were obtained from AAPA, then
weighted by using the percentage of physicians assistants who practiced
primary care according to the 1995 AAPA membership survey and the 2007
AAPA physician assistant census survey.
[C] Data on nurse practitioners are from 1999 and 2005. Data on the
total number of nurse practitioners were obtained from AANP, then
weighted by using the percentage of nurse practitioners who practiced
primary care according to the AANP.
[D] Data on dentists are from 1995 and 2007.
[End of table]
Growth in the per capita supply of primary care physicians outpaced
growth in the per capita supply of physician specialists by 7
percentage points in the 1995-2005 period. (See table 2.)
Table 2: Supply of Primary Care and Specialty Care Physicians, 1995 and
2005:
Primary care physicians;
Number of physicians: 1995: 208,187;
Number of physicians: 2005: 264,086;
Number of physicians per 100,000 people: 1995: 80;
Number of physicians per 100,000 people: 2005: 90;
Percentage change per capita: 12.
Specialty care physicians;
Number of physicians: 1995: 468,843;
Number of physicians: 2005: 553,451;
Number of physicians per 100,000 people: 1995: 181;
Number of physicians per 100,000 people: 2005: 189;
Percentage change per capita: 5.
All physicians;
Number of physicians: 1995: 677,030;
Number of physicians: 2005: 817,537;
Number of physicians per 100,000 people: 1995: 262;
Number of physicians per 100,000 people: 2005: 280;
Percentage change per capita: 7.
Source: GAO analysis of data from HRSA's Area Resource File.
Note: Numbers do not add to totals due to rounding.
[End of table]
By definition, aggregate supply figures do not show the distribution of
primary care professionals across geographic areas. Compared with
metropolitan areas, nonmetropolitan areas, which are more rural and
less populated, have substantially fewer primary care physicians per
100,000 people. In 2005, there were 93 primary care physicians per
100,000 people in metropolitan areas, compared with 55 primary care
physicians per 100,000 people in nonmetropolitan areas.[Footnote 10]
Data were not available on the distribution of physician assistants,
nurse practitioners, or dentists providing primary care in metropolitan
and nonmetropolitan areas.[Footnote 11]
Number of Primary Care Professionals in U.S. Training Programs
Increased from 1995 to 2006:
For two groups of primary care professionals--physicians and nurse
practitioners--the number in primary care training has increased in
recent years. Over the same period, the number of primary care training
programs for physicians declined, while programs for nurse
practitioners increased. Comparable information for physician
assistants and dentists was not available.
From 1995 to 2006, the number of physician residents in primary care
training programs increased 6 percent, as shown in table 3. Over this
same period, primary care residency programs declined, from 1,184
programs to 1,145 programs.
Table 3: Number of Physicians in Residency Programs, in the United
States, 1995 and 2006:
Primary care residents;
Number of resident physicians: 1995: 38,753;
Number of resident physicians: 2006: 40,982;
Percentage change: 6.
Specialty care residents;
Number of resident physicians: 1995: 59,282;
Number of resident physicians: 2006: 63,897;
Percentage change: 8.
All physician residents;
Number of resident physicians: 1995: 97,416;
Number of resident physicians: 2006: 104,526;
Percentage change: 7.
Sources: AMA, "Appendix II: Graduate Medical Education," Journal of the
American Medical Association (JAMA) vol. 276, no. 9 (September 1996)
and "Appendix II: Graduate Medical Education, 2006-2007," JAMA vol.
298, no. 9 (September 2007).
Notes: Primary care residencies include those for family medicine,
internal medicine, pediatrics, internal medicine/family practice, and
internal medicine/pediatrics.
[End of table]
The composition of primary care physician residents changed from 1995
to 2006. A decline in the number of allopathic U.S. medical school
graduates (known as USMD) selecting primary care residencies was more
than offset by increases in the numbers of international medical
graduates (IMG) and doctor of osteopathy (DO) graduates entering
primary care residencies.[Footnote 12] Specifically, from 1995 to 2006,
USMD graduates in primary care residencies dropped by 1,655 physicians,
while the number of IMGs and DOs in primary care residencies rose by
2,540 and 1,415 physicians respectively. (See table 4.)
Table 4: Number of Physicians in Residency Programs, by USMDs, IMGs,
and DOs, 1995 and 2006:
Primary care residents;
1995: USMDs: 23,801;
1995: IMGs: 13,025;
1995: DOs: 1,748;
2006: USMDs: 22,146;
2006: IMGs: 15,565;
2006: DOs: 3,163.
Specialty care residents;
1995: USMDs: 45,300;
1995: IMGs: 11,957;
1995: DOs: 1,585;
2006: USMDs: 47,575;
2006: IMGs: 12,611;
2006: DOs: 3,466.
All physician residents;
1995: USMDs: 69,101;
1995: IMGs: 24,982;
1995: DOs: 3,333;
2006: USMDs: 69,721;
2006: IMGs: 28,176;
2006: DOs: 6,629.
Total (USMDs + IMGs + DOs);
1995: USMDs: [Empty];
1995: IMGs: 97,416;
1995: DOs: [Empty];
2006: USMDs: [Empty];
2006: IMGs: 104,526;
2006: DOs: [Empty].
Sources: AMA, "Appendix II: Graduate Medical Education," JAMA vol. 276,
no. 9 (September 1996) and "Appendix II: Graduate Medical Education,
2006-2007," JAMA vol. 298, no. 9 (September 2007).
Note: Primary care residencies include those for family medicine,
internal medicine, pediatrics, internal medicine/family practice, and
internal medicine/pediatrics.
[End of table]
From 1994 to 2005, the number of primary care training programs for
nurse practitioners and the number of graduates from these programs
grew substantially. During this period, the number of nurse
practitioner training programs increased 61 percent, from 213 to 342
programs. The number of primary care graduates from these programs
increased 157 percent from 1,944 to 5,000.
Little Information Available Regarding Minorities in Training or
Actively Practicing In Primary Care Specialties:
Little information was available regarding participation of minority
health professionals in primary care training programs or with active
practices in primary care.[Footnote 13] Physicians were the only type
of primary care professional for whom we found information on minority
representation. We found information not specific to primary care for
physician assistants, nurse practitioners, and dentists identified as
minorities, which may be a reasonable substitute for information on
proportions of minorities in primary care.
For physicians, we used the proportion of minority primary care
residents as a proxy measure for minorities in the active primary care
physician workforce. From 1995 to 2006, the proportion of primary care
residents who were African-American increased from 5.1 percent to 6.3
percent; the proportion of primary care residents who were Hispanic
increased from 5.8 percent to 7.6 percent. Data on American Indian/
Alaska Natives were not collected in 1995, so this group could not be
compared over time; in 2006, 0.2 percent of primary care residents were
identified as American Indian/Alaska Natives.
Minority representation among each of the other health professional
types--overall, not by specialty--increased slightly. AAPA data show
that from 1995 to 2007, minority representation among physician
assistants increased from 7.8 percent to 8.4 percent. AANP data show
that from 2003 to 2005, minority representation among nurse
practitioners increased from 8.8 percent to 10.0 percent. ADEA data
show that from 2000 to 2005, the proportion of African-Americans among
graduating dental students rose slightly from 4.2 percent to 4.4
percent, while the proportion of Hispanics among graduating dental
students increased from 4.9 percent to 5.9 percent. The proportion of
Native American/Alaska Native among graduating dental students grew
from 0.6 percent to 0.9 percent.
Other demographic characteristics of the primary care workforce have
also changed in recent years. In two of the professions that were
traditionally dominated by men in previous years--physicians and
dentists--the proportion of women has grown or is growing. Between 1995
and 2006, the proportion of primary care residents who were women rose
from 41 percent to 51 percent. Growth of women in dentistry is more
recent. In 2005, 19 percent of professionally active dentists were
women,[Footnote 14] compared with almost 45 percent of graduating
dental school students who were women.
Uncertainties Exist in Projecting Future Supply of Health Care
Professionals; Few Projections Are Specifically for Primary Care:
Accurately projecting the future supply of primary care health
professionals is difficult, particularly over long time horizons, as
illustrated by substantial swings in physician workforce projections
during the past several decades. Few projections have focused on the
likely supply of primary care physician or nonphysician primary care
professionals.
History of Physician Workforce Supply Predictions Illustrates
Uncertainties in Forecasting:
Over a 50-year period, government and industry groups' projections of
physician shortfalls gave way to projections of surpluses, and now the
pendulum has swung back to projections of shortfalls again. From the
1950s through the early 1970s, concerns about physician shortages
prompted the federal and state governments to implement measures
designed to increase physician supply. By the 1980s and through the
1990s, however, the Graduate Medical Education National Advisory
Committee (GMENAC), the Council on Graduate Medical Education (COGME),
and HRSA's Bureau of Health Professions were forecasting a national
surplus of physicians. In large part, the projections made in the 1980s
and 1990s were based on assumptions that managed care plans--with an
emphasis on preventive care and reliance on primary care gatekeepers
exercising tight control over access to specialists--would continue to
grow as the typical health care delivery model. In fact, managed care
did not become as dominant as predicted and, in recent years, certain
researchers, such as Cooper,[Footnote 15] have begun to forecast
physician shortages. COGME's most recent report, issued in January
2005, also projects a likely shortage of physicians in the coming years
and,[Footnote 16] in June of 2006, the AAMC called for an expansion of
U.S. medical schools and federally supported residency training
positions.[Footnote 17] Other researchers have concluded that there are
enough practicing physicians and physicians in the pipeline to meet
current and future demand if properly deployed.[Footnote 18]
Few Projections Address Future Supply of Primary Care Professionals:
Despite interest in the future of the health care workforce, few
projections directly address the supply of primary care professionals.
Recent physician workforce projections focus instead on the supply of
physicians from all specialties combined. Specifically, the projections
recently released by COGME point to likely shortages in total physician
supply but do not include projections specific to primary care
physicians.[Footnote 19] Similarly, ADA's and AAPA's projections of the
future supply of dentists and physician assistants do not address
primary care practitioners separately from providers of specialty care.
AANP has not developed projections of future supply of nurse
practitioners.
We identified two sources--an October 2006 report by HRSA and a
September 2006 report by AAFP--that offer projections of primary care
supply and demand, but both are limited to physicians.[Footnote 20]
HRSA's projections indicate that the supply of primary care physicians
will be sufficient to meet anticipated demand through about 2018, but
may fall short of the number needed in 2020. AAFP projected that the
number of family practitioners in 2020 could fall short of the number
needed, depending on growth in family medicine residency programs.
HRSA based its workforce supply projections on the size and
demographics of the current physician workforce, expected number of new
entrants, and rate of attrition due to retirement, death, and
disability. Using these factors, HRSA calculated two estimates of
future workforce supply. One projected the expected number of primary
care physicians, while the other projected the expected supply of
primary care physicians expressed in full-time equivalent (FTE) units.
According to HRSA, the latter projection, because it adjusts for
physicians who work part-time, is more accurate.[Footnote 21] The
agency projected future need for primary care professionals based
largely on expected changes in U.S. demographics, trends in health
insurance coverage, and patterns of utilization. HRSA predicted that
the supply of primary care physicians will grow at about the same rate
as demand until about 2018, at which time demand will grow faster than
supply. Specifically, HRSA projected that by 2020, the nationwide
supply of primary care physicians expressed in FTEs will be 271,440,
compared with a need for 337,400 primary care physicians. HRSA notes
that this projection, based on a national model, masks the geographic
variation in physician supply. For example, the agency estimates that
as many as 7,000 additional primary care physicians are currently
needed in rural and inner-city areas and does not expect that physician
supply will improve in these underserved areas.
In a separate projection, AAFP reviewed the number of family
practitioners in the United States. AAFP's projections of future supply
were based on the number of active family practice physicians in the
workforce and the number of completed family practice residencies in
both allopathic and osteopathic medical schools. AAFP's projections of
need relied on utilization rates adjusted for mortality and
socioeconomic factors. Specifically, AAFP estimated that 139,531 family
physicians would be needed by 2020, representing about 42 family
physicians per 100,000 people in the United States. To meet this
physician-to-population ratio, AAFP estimated that family practice
residency programs in the aggregate would need to expand by 822
residents per year.
Both reports noted the difficulties inherent in making predictions
about future physician workforce supply and demand. Essentially, they
noted that projections based on historical data may not necessarily be
predictive of future trends. They cite as examples the unforeseen
changes in medical technology innovation and the multiple factors
influencing physician specialty choice. Additionally, HRSA noted that
projection models of supply and demand incorporate any inefficiencies
that may be present in the current health care system.
Move Toward Primary Care Medicine, A Key to Better Quality and Lower
Costs, Is Impeded by Health Care System's Current Financing Mechanisms:
Health professional workforce projections that are mostly silent on the
future supply of and demand for primary care services are symptomatic
of an ongoing decline in the nation's financial support for primary
care medicine. Ample research in recent years concludes that the
nation's over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care--all hallmarks of
primary care medicine--can achieve better health outcomes and cost
savings. Despite these findings, the nation's current financing
mechanisms result in an atomized and uncoordinated system of care that
rewards expensive procedure-based services while undervaluing primary
care services. However, some physician organizations--seeking to
reemphasize primary care services--are proposing a new model of
delivery.
Payment Systems That Undervalue Primary Care Appear to Be
Counterproductive:
Fee-for-service, the predominant method of paying physicians in the
U.S., encourages growth in specialty services. Under this structure, in
which physicians receive a fee for each service provided, a financial
incentive exists to provide as many services as possible, with little
accountability for quality or outcomes. Because of technological
innovation and improvements over time in performing procedures,
specialist physicians are able to increase the volume of services they
provide, thereby increasing revenue. In contrast, primary care
physicians, whose principal services are patient office visits, are not
similarly able to increase the volume of their services without
reducing the time spent with patients, thereby compromising quality.
The conventional pricing of physician services also disadvantages
primary care physicians. Most health care payers, including Medicare--
the nation's largest payer--use a method for reimbursing physician
services that is resource-based, resulting in higher fees for procedure-
based services than for office-visit "evaluation and management"
services.[Footnote 22] To illustrate, in one metropolitan area, Boston,
Massachusetts, Medicare's fee for a 25 to 30-minute office visit for an
established patient with a complex medical condition is
$103.42;[Footnote 23] in contrast, Medicare's fee for a diagnostic
colonoscopy--a procedural service of similar duration--is
$449.44.[Footnote 24]
Several findings on the benefits of primary care medicine raise
concerns about the prudence of a health care payment system that
undervalues primary care services. For example:
* Patients of primary care physicians are more likely to receive
preventive services, to receive better management of chronic illness
than other patients, and to be satisfied with their care.[Footnote 25]
* Areas with more specialists, or higher specialist-to-population
ratios, have no advantages in meeting population health needs and may
have ill effects when specialist care is unnecessary.[Footnote 26]
* States with more primary care physicians per capita have better
health outcomes--as measured by total and disease-specific mortality
rates and life expectancy--than states with fewer primary care
physicians (even after adjusting for other factors such as age and
income).[Footnote 27]
* States with a higher generalist-to-population ratio have lower per-
beneficiary Medicare expenditures and higher scores on 24 common
performance measures than states with fewer generalist physicians and
more specialists per capita.[Footnote 28]
* The hospitalization rates for diagnoses that could be addressed in
ambulatory care settings are higher in geographic areas where access to
primary care physicians is more limited.[Footnote 29]
Some Health Care Reform Proposals Seek to Reemphasize Primary Care
Medicine:
In recognition of primary care medicine's value with respect to health
care quality and efficiency, some physician organizations are proposing
a new model of health care delivery in which primary care plays a
central role. The model establishes a "medical home" for patients--in
which a single health professional serves as the coordinator for all of
a patient's needed services, including specialty care--and refines
payment systems to ensure that the work involved in coordinating a
patient's care is appropriately rewarded.
More specifically, the medical home model allows patients to select a
clinical setting--usually their primary care provider's practice--to
serve as the central coordinator of their care. The medical home is not
designed to serve as a "gatekeeper" function, in which patients are
required to get authorization for specialty care, but instead seeks to
ensure continuity of care and guide patients and their families through
the complex process of making decisions about optimal treatments and
providers. AAFP has proposed a medical home model designed to provide
patients with a basket of acute, chronic, and preventive medical care
services that are, among other things, accessible, comprehensive,
patient-centered, safe, and scientifically valid. It intends for the
medical home to rely on technologies, such as electronic medical
records, to help coordinate communication, diagnosis, and treatment.
Other organizations, including ACP, the American Academy of Pediatrics
(AAP), and AOA, have developed or endorsed similar models and have
jointly recommended principles to describe the characteristics of the
medical home.[Footnote 30]
Proposals for the medical home model include a key modification to
conventional physician payment systems--namely, that physicians receive
payment for the time spent coordinating care. These care coordination
payments could be added to existing fee schedule payments or they could
be included in a comprehensive, per-patient monthly fee. Some physician
groups have called for increases to the Medicare resource-based fee
schedule to account for time spent coordinating care for patients with
multiple chronic illnesses. Proponents of the medical home note that it
may be desirable to develop payment models that blend fee-for-service
payments with per-patient payments to ensure that the system is
appropriately reimbursing physicians for primary, specialty, episodic,
and acute care.
Concluding Observations:
In our view, payment system reforms that address the undervaluing of
primary care should not be strictly about raising fees but rather about
recalibrating the value of all services, both specialty and primary
care. Resource-based payment systems like those of most payers today do
not factor in health outcomes or quality metrics; as a consequence,
payments for services and their value to the patient are misaligned.
Ideally, new payment models would be designed that consider the
relative costs and benefits of a health care service in comparison with
all others so that methods of paying for health services are consistent
with society's desired goals for health care system quality and
efficiency.
Mr. Chairman, this concludes my prepared statement. I will be happy to
answer any questions that you or Members of the committee may have.
Contact and Acknowledgments:
For information regarding this testimony, please contact A. Bruce
Steinwald at 202-512-7114 or steinwalda@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Jenny Grover, Assistant Director;
Sarah Burton; Jessica Farb; Hannah Fein; Martha W. Kelly; and Sarabeth
Zemel made key contributions to this statement.
[End of section]
Footnotes:
[1] 42 U.S.C. §§ 292 - 295p.
[2] Physician assistants are health care professionals who practice
medicine under physician supervision. Physician assistants may perform
physical examinations, diagnose and treat illnesses, order and
interpret tests, advise patients on preventive health care, assist in
surgery, and write prescriptions. Unlike physician assistants, nurse
practitioners are licensed nurses who work with physicians and have
independent practice authority in many states. This authority allows
them to perform physical examinations, diagnose and treat acute
illnesses and injuries, administer immunizations, manage chronic
problems such as high blood pressure and diabetes, and order laboratory
services and x-rays with minimal physician involvement.
[3] For the purposes of this testimony, we considered primary care
physicians to be those practicing in family medicine, general practice,
general internal medicine, and general pediatrics. Some physician
groups, such as the American Medical Association (AMA), consider
physicians practicing in obstetrics/gynecology to also be primary care
physicians. In addition, we considered general dentists and pediatric
dentists to be primary care dentists. We defined primary care physician
assistants as those practicing in family practice, general practice,
general internal medicine, and general pediatrics. We defined primary
care nurse practitioners as those practicing in adult, family, and
pediatric medicine. Other types of health professionals, such as
registered nurses, can provide primary care services in a variety of
settings, but they were outside the scope of our review.
[4] For example, noted studies show that Medicare spending for
physician services varies widely by geographic areas and is unrelated
to beneficiary health status. Elliott S. Fisher and H. Gilbert Welch,
"Avoiding the Unintended Consequences of Growth in Medical Care: How
Might More Be Worse?" Journal of the American Medical Association, vol.
281, no. 5 (1999), 446-453; E.S. Fisher, et al., "The Implications of
Regional Variations in Medicare Spending. Part 1: The Content, Quality,
and Accessibility of Care," Annals of Internal Medicine, vol. 138, no.
4 (2003), 273-287; E.S. Fisher, et al., "The Implications of Regional
Variations in Medicare Spending. Part 2: Health Outcomes and
Satisfaction with Care," Annals of Internal Medicine, vol. 138, no. 4
(2003), 288-298; and Joseph P. Newhouse, Free for All? Lessons from the
RAND Health Insurance Experiment (Cambridge, Mass.: Harvard University
Press, 1993).
[5] We obtained the most recently available data on supply for each
professional group, the groups' training programs, and the groups'
demographic characteristics. We compared the most recent data to a
prior data point, in many cases 10 years earlier. For primary care
physicians, we obtained data on supply for 1995 and 2005 from the Area
Resource File and information on training and demographics from
published AMA data for 1995 and 2006. For physician assistants, we
obtained data on supply and demographic characteristics from AAPA for
1995 and 2007. For nurse practitioners, we obtained data on supply and
demographic characteristics from AANP for 1999, 2003, and 2005 and
information on training from published AACN data for 1994 and 2005. For
dentists, we obtained data on supply for 1995 and 2007 from the Area
Resource File and information on demographics from published ADEA data
for 2000 and 2005.
[6] Data from the AMA Masterfile and the American Osteopathic
Association (AOA) Masterfile--on which data on physicians in the Area
Resource File is based--are widely used in studies of physician supply
because they are a comprehensive list of U.S. physicians and their
characteristics.
[7] Allied health professionals include, for example, audiologists,
dental hygienists, clinical laboratory technicians, occupational
therapists, physical therapists, medical imaging technologists, and
speech pathologists.
[8] For fiscal year 2007, funding for the title VII health professions
programs was about $183 million. This excluded funding for student
loans, which did not receive funds through the annual appropriation
process.
[9] Allopathic medicine is the most common form of medical practice.
Graduates of allopathic medical schools receive doctor of medicine (MD)
degrees. Osteopathic medicine is a form of medical practice similar to
allopathic medicine that also incorporates manual manipulation of the
body as a therapy. Graduates of osteopathic medical schools receive
doctor of osteopathic (DO) medicine degrees. The number of primary care
physicians includes both MDs and DOs.
[10] Specialty care physicians are even more concentrated in
metropolitan areas. In 2005, there were 33 specialty care physicians
per 100,000 people in nonmetropolitan areas, compared with 200
specialty care physicians per 100,000 people in metropolitan areas. In
total, there were 87 physicians per 100,000 people in nonmetropolitan
areas and 293 physicians per 100,000 people in metropolitan areas in
2005.
[11] One researcher, analyzing HRSA data, reported that in 2007 more
than 30 million people were living in areas with too few dentists.
Shelly Gehshan, "Foundations' Role in Improving Oral Health: Nothing to
Smile About," Health Affairs, vol. 27, no. 1 (2008).
[12] Physicians who enter U.S. residency programs include graduates of
both U.S. medical schools and foreign medical schools. Physicians from
foreign medical schools--international medical graduates--can be
citizens of other countries or U.S. citizens who attended medical
school abroad.
[13] HRSA's Health Careers Opportunity Program defines underrepresented
minorities as racial and ethnic groups that are underrepresented in the
health professions relative to their numbers in the general population.
According to HRSA, African Americans, Hispanics, American Indians, and
Alaska Natives are underrepresented in the health professions. During
the period we examined, minority representation increased among the
general population. Specifically, from 1995 to 2006, the proportion of
African-Americans in the general population increased from 12.0 percent
to 12.3 percent; the proportion of Hispanics increased from 10.3
percent to 14.8 percent; and the proportion of American Indian/Alaska
Natives increased from 0.7 percent to 0.8 percent.
[14] American Dental Association, "Survey and Economic Research on
Dentistry: Frequently Asked Questions" (Chicago, Ill.: American Dental
Association), [hyperlink, http://www.ada.org/ada/prod/survey/faq.asp]
(accessed Jan. 7, 2008).
[15] Richard A. Cooper et al., "Economic and Demographic Trends Signal
an Impending Physician Shortage," Health Affairs, vol. 21, no. 1
(2002).
[16] OGME, "Sixteenth Report: Physician Workforce Policy Guidelines for
the United States, 2000-2020" (January 2005).
[17] AMC, "AAMC Statement on the Physician Workforce" (June 2006).
[18] David Goodman et al., "End-Of-Life Care At Academic Medical
Centers: Implications For Future Workforce Requirements," Health
Affairs, vol. 25 no. 2 (2006) and Jonathan P. Weiner, "Prepaid Group
Practice Staffing And U.S. Physician Supply: Lessons For Workforce
Policy," Health Affairs, Web Exclusive (Feb. 4, 2004).
[19] COGME does not currently hold a position on the appropriate ratio
of primary care physicians to specialty physicians. This is in contrast
to the position COGME held from 1992 through 2004, which recommended
that half of all physicians should be primary care physicians.
[20] U.S. Department of Health and Human Services, HRSA, Bureau of
Health Professions, "Physician Supply and Demand: Projections to 2020"
(October 2006) and AAFP, "Family Physician Workforce Reform (as
approved by the 2006 Congress of Delegates) Recommendations of the
AAFP" (September 2006).
[21] The FTE projection takes into account an expected decrease in the
number of hours worked by physicians due to demographic workforce
changes, including a greater share of female physicians and older
physicians, some of whom are likely to work less than full-time.
[22] Evaluation and management (E/M) services refer to office visits
and consultations furnished by physicians. To bill for their service,
physicians select a common procedural terminology (CPT) code that best
represents the level of E/M service performed based on three elements:
patient history, examination, and medical decision making. The
combination of these three elements can range from a very limited 10-
minute face-to-face encounter to a very detailed examination requiring
an hour of the physician's time.
[23] The fee for this service in Boston, Mass., is represented on the
fee schedule as CPT code 99214.
[24] The fee for this service in Boston, Mass., is represented on the
fee schedule as CPT code 45378.
[25] A.B Bindman et al., "Primary Care and Receipt of Preventive
Services," Journal of General Internal Medicine vol. 11, no. 5 (1996);
D.G. Safran et al., "Linking Primary Care Performance to Outcomes of
Care," Journal of Family Practice, vol. 47, no. 3 (1998); and A.C. Beal
et al., "Closing the Divide: How Medical Homes Promote Equity in Health
Care: Results From The Commonwealth Fund 2006 Health Care Quality
Survey" (The Commonwealth Fund, June 2007).
[26] B. Starfield et al., "The Effects Of Specialist Supply On
Populations' Health: Assessing The Evidence," Health Affairs web
exclusive (2005).
[27] B. Starfield et al., "Contribution of Primary Care to Health
Systems and Health," Milbank Quarterly, vol. 83, no. 3 (2005).
[28] K. Baicker and A. Chandra, "Medicare Spending, the Physician
Workforce, and Beneficiaries' Quality of Care," Health Affairs web
exclusive (2004).
[29] M. Parchman et al, "Primary Care Physicians and Avoidable
Hospitalizations," Journal of Family Practice, vol. 39, no. 2 (1994).
[30] AAFP, AAP, ACP, AOA, "Joint Principles of the Patient-Centered
Medical Home" (March 2007).
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