Medicine
Only the family practice associated MD, DO, NP, and PA components had reasonable cost of training for the primary care contribution.
Internal medicine has such low yield for primary care that the cost of training is prohibitive when the purpose is primary care workforce.
Pediatric training and medicine pediatric training is more costly for the yield of primary care compared to family medicine. Expansions of pediatric graduates over the past decades have resulted in little change in pediatric primary care workforce. More graduates over the past 10 years have merely replaced those departing.
The nurse practitioner training cost ratios will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed. Also the estimates used are generous - using 70% active. Reductions for part time, inactive, and turnover indicate about 60% active as clinicians over a career.
Family nurse practitioners are 50% of NP graduates, but only about 50% of FNP graduates remain in family practice employment. The NP family practice result is down to about 25% according to Advance for NP and PA.
There is a better decision for nursing leaders who intend primary care result from training. The appropriate move is to change the design of FNP training such that the most important outcome of family practice positions filled is made permanent. Without that move, nurse practitioner claims of primary care and workforce where needed are limited to only a small portion of NP graduates.
Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.
FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care.
Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center.
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Medicine
Cost of Training per Unit of Primary Care Delivery
The cost of primary care training can be compared to primary care delivery over a career.
The product of 4 factors is the SPCYR per Graduates specific to the time of graduation. With primary care retention declines, the overall result for all sources has declined - especially since 1998 graduates.
* The cost of multiple times more graduates to result in a nursing school graduate (some schools) was not considered. Costs of attrition were not considered. The cost of physician training is less when the revenue generated from residency is considered. Some studies consider residency training to pay for itself. This would reduce the cost of training for a physician to college and medical school costs. (see below)The Basic Calculations of the Standard Primary Care Year
% Primary Care | Years in Career | % Remain Active | % Volume | SPCYR Per Grad | |
NP not FNP | 15% | 24 | 70% | 70% | 1.76 |
FNP Trained | 54% | 24 | 70% | 75% | 6.8 |
PA not FP Start | 15% | 33 | 75% | 75% | 2.78 |
PA with FP Start | 60% | 33 | 75% | 80% | 11.88 |
FM Trained MD | 91% | 33 | 84% | 100% | 25.23 |
IM Trained MD | 15% | 32 | 82% | 86% | 3.38 |
PD Trained MD | 39% | 33 | 82% | 95% | 10.03 |
MPD Trained MD | 43% | 32 | 82% | 95% | 10.72 |
The product of 4 factors is the SPCYR per Graduates specific to the time of graduation. With primary care retention declines, the overall result for all sources has declined - especially since 1998 graduates.
The cost of training can be divided by the primary care delivery result in SPCYRs.
Cost of Training Relative to Primary Care Delivery over a Career
Cost of Training Post High School | Cost per SPCYr | |
NP not FNP | $380,000 | $215,420 |
FNP Trained | $380,000 | $55,850 |
PA not FP Start | $440,000 | $158,025 |
PA w/FP Start | $440,000 | $37,037 |
FM Trained | $950,000 | $37,661 |
IM Trained | $950,000 | $280,653 |
PD Trained | $950,000 | $94,756 |
MPD Trained | $1,050,000 | $97,957 |
Only the family practice associated MD, DO, NP, and PA components had reasonable cost of training for the primary care contribution.
Substantially more graduates are required for the same primary care delivery result over a career when sources remain in primary care at low levels, have fewer years in a career, have lesser activity as a clinician (part time, inactive, managerial, other non-clinician), and less volume per FTE.
Higher turnover is seen for NP and PA workforce with twice the annual turnover levels of primary care physicians. Higher turnover reduces productivity and experience.
Higher turnover is seen for NP and PA workforce with twice the annual turnover levels of primary care physicians. Higher turnover reduces productivity and experience.
Internal medicine has such low yield for primary care that the cost of training is prohibitive when the purpose is primary care workforce.
Pediatric training and medicine pediatric training is more costly for the yield of primary care compared to family medicine. Expansions of pediatric graduates over the past decades have resulted in little change in pediatric primary care workforce. More graduates over the past 10 years have merely replaced those departing.
The nurse practitioner training cost ratios will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed. Also the estimates used are generous - using 70% active. Reductions for part time, inactive, and turnover indicate about 60% active as clinicians over a career.
Family nurse practitioners are 50% of NP graduates, but only about 50% of FNP graduates remain in family practice employment. The NP family practice result is down to about 25% according to Advance for NP and PA.
There is a better decision for nursing leaders who intend primary care result from training. The appropriate move is to change the design of FNP training such that the most important outcome of family practice positions filled is made permanent. Without that move, nurse practitioner claims of primary care and workforce where needed are limited to only a small portion of NP graduates.
Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.
FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care.
Only the result of family practice is efficient for the purposes of health access and primary care. Family practice is the only population based workforce or the same proportion of workforce matched up to the same proportion of US population for 1.0 result (20% of FM found in rural zip codes with 20% of the US population).
Family medicine is efficient for the purpose of primary care delivery because 90% remain in family practice over a career. The NP and PA graduates entering and remaining in family practice positions are critical for health access, but this is down to 25% of recent graduates that will contribute in family practice. Movement steadily away from family practice positions filled simultaneously reduces primary care and workforce where needed.
Family medicine is efficient for the purpose of primary care delivery because 90% remain in family practice over a career. The NP and PA graduates entering and remaining in family practice positions are critical for health access, but this is down to 25% of recent graduates that will contribute in family practice. Movement steadily away from family practice positions filled simultaneously reduces primary care and workforce where needed.
Distribution By Location Type
Rural % | Under-served % | Outside % | |
NP not FNP | 10% | 12% | 35% |
FNP Trained | 28% | 15% | 55% |
PA not FP Start | 10% | 12% | 35% |
PA with FP Start | 30% | 18% | 55% |
FM Trained | 22% | 15% | 53% |
IM Trained | 10% | 9% | 28% |
PD Trained | 8% | 9% | 28% |
MPD Trained | 16% | 12% | 40% |
Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center.
Cost of Training Considerations
College | Health Prof | Graduate | Cost of Living | |
NP not FNP | $30,000 | $100,000 | $70,000 | $180,000 |
FNP Trained | $30,000 | $100,000 | $70,000 | $180,000 |
PA not FP Start | $120,000 | $125,000 | $195,000 | |
PA with FP Start | $120,000 | $125,000 | $195,000 | |
FM Trained | $120,000 | $200,000 | $300,000 | $330,000 |
IM Trained | $120,000 | $200,000 | $300,000 | $330,000 |
PD Trained | $120,000 | $200,000 | $300,000 | $330,000 |
MPD Trained | $120,000 | $200,000 | $400,000 | $330,000 |
Additional calculations can integrate the proportions of graduates found in certain locations to generate the contributions in rural primary care, underserved primary care, and primary care delivery outside of concentrations (in 30,000 zip codes with 65% of the US population left behind). The cost of training per unit of primary care is much less for family medicine. Other sources that yield less primary care per graduate are inefficient primary care sources.
Worsening Family Medicine Contributions
Worsening Family Medicine Contributions
The addition of a year of training to family medicine 3 year GME training would decrease career length by 4% and would add about $120,000 to training cost resulting in a $5000 increase to $43,000 per SPCYr. Even worse is that the 9000 annual training slots currently supported would need to be divided by 4 resulting in 2250 graduates per year for a 4 year GME design. This is a substantial reduction of FM workforce from 90,000 to 75,000 due to longer training.
More importantly millions of additional Americans would be left behind with a smaller FM workforce.
Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog
SMART Basic Health Access World of Rural Medical Education
Basic Health Access Blogspot 2011 - Summaries and Links for 2011
Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
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The United States has a health policy construct that actually prevents recovery of primary care. Primary care revenue support is insufficient to keep up with the increasing cost of delivering primary care. New types of costs burden primary care practices...
- Number One Two Three In Health Access
Solutions for health access primary care workforceEnter primary care practices at highest proportions after trainingStay in primary care practice at highest proportions in the years after graduationHave the longest health professional career lengthsRemain...
- Standard Primary Care Year Estimates 2012 Class Year
The Standard Primary Care Year is a common sense measuring tool. Graduates must meet all of 4 criteria to deliver primary care - train in primary care, remain in primary care, serve long careers, and deliver signficant volume. It is not enough just...
- Comparing Family Practice Sources
The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations...
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Achievable primary care is one of the weakest areas in the workforce literature. Enough annual graduate expansion of any primary care source will increase primary care, but steady declines in the proportion remaining in primary care in the years after...