Primary Care Workforce Challenges & the ACA Analyses and Applications from the Robert Graham Center Andrew Bazemore MD MPH NGA Meeting April 2012

The Robert Graham Center Placed in Washington, DC 12 years ago by AAFP Placed in Washington, DC 12 years ago by AAFP To improve policy-making with better evidence about primary care, family medicine To improve policy-making with better evidence about primary care, family medicine Editorial independence Editorial independence Growing, but still a small staff Growing, but still a small staff 2 family physician researchers 2 family physician researchers PhDs: Sociologist/statistician, Economist, PhDs: Sociologist/statistician, Economist, Public Health Informaticist, Geographer 2 Masters-level Researchers 2 Masters-level Researchers Also: Project Mngr, GIS Trainer, Administrative Asst, Fellow, Visiting Scholar Also: Project Mngr, GIS Trainer, Administrative Asst, Fellow, Visiting Scholar

Agenda In this session, we will review analyses and online applications that result from recent Robert Graham Center primary care workforce projects funded by the Macy and Kresge Foundations, HRSA and AHRQ.

Agenda We will also direct attendees towards freely available online resources that may inform planning and advocacy conversations at their home departments and institutions related to the current and future primary care workforce.

ACA & the Inadequacies of the Primary Care Workforce Hlth Aff, 2008(Colwill): 44k short by 2025 Hlth Aff, 2008(Colwill): 44k short by 2025 Health Aff Health Aff May 2008 vol. 27 no. 3w232-w241 Post ACA Post ACA AAMC, 2010 – 46k short by 2025 AAMC, 2010 – 46k short by 2025 Re-affirming reports from Mass Med Society, Washington Post, others Re-affirming reports from Mass Med Society, Washington Post, others PC Workforce/Infrastructure not ready for pent up demand of newly insured PC Workforce/Infrastructure not ready for pent up demand of newly insured

ACA & the Inadequacies of the Primary Care Workforce Reports highlight a problem of Supply Supply A problem, but perhaps less important than Distribution Distribution Composition Composition Scope of Practice Scope of Practice A workforce ready for New Models of delivery, team-based care A workforce ready for New Models of delivery, team-based care

Health Worker density by region

Physician Specialties to Population Ratio (Physicians per 100,000 persons)

U.S. Primary Care Workforce by Provider Type, 2010 Primary care providerNumber Physicians208,807 Nurse practitioners55,625 Physician assistants30,402 Total294, AMA Masterfile, 2010 National Provider Identifier File

Primary Care : Population Ratio 1:1400 PC Physician: Population 1:1400 PC Physician: Population 1:1100 PC Providers: Population 1:1100 PC Providers: Population

What ratio matters? Comparative review for AHRQ: Greater than Western European peers Comparative review for AHRQ: Greater than Western European peers Historical perspective: Largest, best trained PC Workforce in US History Historical perspective: Largest, best trained PC Workforce in US History

13 What ratio matters? Between 1500:1 and 2000:1 (FP + NP+PA; 1000:1 with other PCPs) if costs and avoidable hospitalizations matter Difficulty demonstrating for General Internal Medicine

Distribution Primary Care/Population ratios vary widely by most measures of geography Primary Care/Population ratios vary widely by most measures of geography State, County, Tract, or PCSA State, County, Tract, or PCSA

Primary Care Physicians… Where aren’t they?

Geographic Distribution of Primary Care Health Care Professionals, 2010

Consequences of Maldistribution

Scope of Practice: The Case of Family Medicine Future of Family Medicine: Future of Family Medicine: Suggests our discipline is in part defined by the ‘Basket of Services’ it delivers Suggests our discipline is in part defined by the ‘Basket of Services’ it delivers Using ABFM diplomate data 2003-present, we discover: Using ABFM diplomate data 2003-present, we discover: Wide variation in scope : Rural to Urban, Regionally, by Age/Gender/ Years in practice Wide variation in scope : Rural to Urban, Regionally, by Age/Gender/ Years in practice Declines in several key areas Declines in several key areas

What is Comprehensive Care?

Whence cries of shortage? Colwill & AAMC report – Projected shortage of approximately 45,000 PCPs by 2025 Colwill & AAMC report – Projected shortage of approximately 45,000 PCPs by 2025

Visits to Office Based Physicians

IOM: Care without coverage: Too little, too late. US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States The Perfect Storm PPACA PPACA PCMH PCMH Payment problems Payment problems Paucity of student interest Paucity of student interest Parade of Boomers Parade of Boomers

Projection of Primary Care Physician Use

An era of Allopathic, Osteopathic, (and offshore) expansion

How might we inform, direct or monitor expansion? World Health Organization World Health Organization - Social Accountability EducationResearchCommunity Service Boelen C, Heck J. Defining and Measuring the Social Accountability of Medical Schools. Geneva: Division of Development of Human Resources for Health, World Health Organization; Document WHO/HRH/95.5.

Top 3: 1) South Dakota: 31% 2) Mississippi: 28% 3) North Dakota: 24% Bottom 3: 1) Puerto Rico: 2.4% 2) Rhode Island: 2.5% 3) Massachusetts: 3.7%

Measuring Accountability to State’s Interest and ROI

Some Workforce Resources of interest – Goto Tools & Resources