Graham Center Forum Underscores Physician Supply, Distribution Challenges

January 26, 2011 04:55 pm James Arvantes Washington –

Family physicians and other primary care physicians have a direct impact on health care costs and hospitalization rates, and, according to speakers at a primary care forum here on Jan. 11, that makes it imperative that policymakers pay attention to the number and proportion of primary care physicians when addressing workforce issues.

The Patient Protection and Affordable Care Act will bring millions of previously uninsured patients into the health care system during the next few years, said speakers at the forum, which was held by the AAFP's Robert Graham Center and the American Board of Family Medicine, or ABFM.

According to Robert Phillips, M.D., M.P.H., executive director of the Graham Center, family physicians -- particularly those working with nurse practitioners, or NPs, and physician assistants, or PAs -- can have a sizeable impact on reducing health care costs and hospitalization rates when the patient-to-physician ratio is 1,500-2,000 patients for every one primary care physician. In addition, said Phillips, the ability of primary care physicians to reduce health care costs and hospitalization rates is even greater when the patient-to-physician ratio is smaller.

Phillips presented data from the Graham Center that showed about 205,000 primary care physicians provide direct patient care in the United States. The United States has an average patient population-to-primary care physician ratio of 1,500-to-one, said Phillips. But that rate varies, depending on areas of the country. "It ranges from 500-to-one to 5,000-to-one," said Phillips.

Most of the country has a shortage of primary care physicians, creating access-to-care problems and leading to higher health care costs and hospitalization rates, said Phillips. At the same time, the Affordable Care Act is expected to bring more than 30 million formerly uninsured patients into the health care system by 2014, creating an additional mismatch between the newly insured and primary care physicians. And, the newly insured tend to cluster in underserved areas where there are the fewest number of physicians and other health care providers, said Phillips.

"You have a distribution problem, first and foremost, and serving the newly insured will require some pretty potent policies for distribution and growth if you are really going to match up the primary care needs to the population for the suddenly insured," Phillips said.

He added that he did not know the appropriate patient-to-primary care physician ratio needed to achieve optimal outcomes. That depends on whether physicians locate where they are needed, said Phillips.

"We only need 9,000-11,000 more physicians to meet the needs of the currently uninsured -- if you get them to locate where they are most needed. But without strong incentives to encourage physicians to locate where their numbers are lowest, you'll need multiples of this number."

Physician Assistants and Nurse Practitioners

Phillips also presented data on PAs and NPs. He noted that there were about 62,771 PAs and 92,978 NPs in the country in 2008 based on Graham Center estimates. More than 43 percent of PAs and 52 percent of NPs practiced in primary care, according to those estimates.

Phillips also noted that the Graham Center found costs and avoidable hospitalizations jumped dramatically when the NP/PA-to-physician ratio was greater than one NP/PA for every physician. "If you have more NPs or PAs in an area, the costs start to go back up, which says the mixture of the team is important," said Phillips.

By the same token, family physicians who provide care without the help of NPs or PAs do not achieve the same outcomes as family physicians who provide care in concert with NPs or PAs, he added.

Falling Numbers in Primary Care

Phillips spoke as part of a panel that included James Puffer, M.D., of Lexington, Ky., president and CEO of the ABFM; Eric Holmboe, M.D., chief medical officer and senior VP of the American Board of Internal Medicine; and James Stockman III, M.D., president and CEO of the American Board of Pediatrics. Like the other speakers, Phillips decried the declining numbers of primary care physicians, telling audience members that "primary care is not replacing itself."

Primary care physicians represent 35 percent of the nation's workforce, but primary care students account for only 21 percent of graduate medical education programs, said Phillips. "We are losing primary care training slots. Some of them are going away, and some of them are turning into nonprimary care training slots."

Puffer pointed to income as a primary reason why medical students do not pursue primary care careers. "We have estimates that there is a $3.5-$3.7 million income difference between what a primary care physician will generate over the life of their career (and) what a subspecialist might generate," he said.

Puffer also said he was concerned about having enough primary care physicians to care for the increasing number of elderly patients. In 2011, 10,000 baby boomers a day will reach the age of 65. That trend is likely to continue for the next several decades, putting tremendous stress on the health care system.

"We will have to reasonably assume that it will be the generalists who primarily will be providing care to this population," said Puffer.

Meanwhile, he added, the number of family physicians who say they will continue to take care of children continues to decline, from 74 percent in 2005 to just more than 67 percent in 2009.