Norman DePaul Brown, Ed.D., R.N.
Associate Professor and Chair
Department of Community Health Gerontological and Psychiatric Nursing
University of Arkansas for Medical Sciences
Peter C. Damiano, D.D.S., M.P.H.
Assistant Professor
Department of Preventive and Community Dentistry and
Public Policy Center, University of Iowa
Harry Douglas, III, D.P.A., M.P.A.
Vice President for Academic Affairs
College of Allied Health
Charles R. Drew University, Medicine and Science
Jeffrey R. Harris, M.D., M.P.H.
Associate Director for Program Development
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Suzanne El-Attar, M.D.
Nancy Ridenour, R.N., C., Ph.D., F.N.C.
Professor and Associate Dean for Graduate Programs
Texas Tech University Health Sciences Center
School of Nursing
Helen Rodriguez-Trias, M.D., F.A.A.P.
President
American Public Health Association
The traditional workforce discussion
There are many factors affecting the primary care workforce including the definition of who is a primary care practitioner, the lack of interdisciplinary and community based training of all primary care practitioners, the financial and lifestyle disincentives associated with selecting primary care practice, the lack of role modeling and status of primary care during the training process, and the priority of NIH for funding specialty related research and the impact on Academic Health Centers.
This paper examines a number of problems and possible approaches for dealing with issues regarding the expansion of the primary care workforce. Specifically, these recommendations are related to the expansion of the primary care workforce in underserved inner city and rural areas and our ultimate goal of integrating public health and prevention into the discussion of the primary care workforce including interdisciplinary community based training and the provision of care by teams of primary care providers based on the needs of a community.
Problem Statements
Access to primary care services needs to be improved, particularly in rural and inner city areas. Maldistributions in the primary care workforce is one of the factors limiting access to primary care in these areas.
- Last year, only 15% of residents went into primary care and only one-third of practicing physicians are in primary care.
- The oversupply of specialists is also encouraging an inappropriate increase in the use and cost of health care. Specialists are procedure-oriented in comparison to primary care physicians.
- Specialization has also been increasing for nurse practitioners and physician assistants.
- Limitations in state practice acts and reimbursements policies have been significant barriers to the most efficient utilization of nurse practitioners, physician assistants, and dental hygienists.
- Only 7% of practicing physicians and slightly greater than 10 percent of entering medical and dental students come from underrepresented minorities. The numbers may be higher for nurse practitioners and physician assistants but improvement remains necessary.
- A shortage currently exists of public health professionals, especially in the disciplines of epidemiology, biostatistics, environmental health, nutrition, health education, and public health nursing.
Recommendations
To address the problems identified above, we would like to suggest some specific recommendations for improvement:
- Reduce the number of physician residency positions supported by direct Medicare Graduate Medical Education (GME) funding from 135% of the number of graduating seniors to 110%. The COGME and PPRC reports and others have recommended that the ultimate goal should be a 50/50 ratio of specialists to primary care. However, this will take 30-50 years to achieve.
- Weight the direct and indirect funding for physician positions toward the training of and reimbursement for primary care residents. This would create a significant change in the Medicare GME from the support of educating physicians generally to support for primary care in particular.
- Increase Medicare and Medicaid reimbursement for primary care practitioners in relation to the reimbursement for specialists. This was attempted with the initial changes of the Resource Based Relative Value System (RBRVS) for physician payment reform under Medicare. The changes in reimbursement started by the change to a RBRVS should be adjusted even further toward primary care.
- Full support for primary care graduate training positions for nurse practitioners, physician assistants, nurse midwives, general dentistry and pediatric dentistry should be the goal in the same way that all primary care physician residency positions are fully funded. Currently because the Medicare GME money is used to support hospital based training, few of these programs receive any of this support. Money redirected from the reduction in the number of physician residency positions could be used to begin this process.
- To encourage a change in state acts to more accurately reflect the training and capabilities of nurse practitioners in particular, the National Advisory Council of Nursing Education and Practice could develop model language for practice acts and regulatory models for boards of nursing and other regulatory bodies. State legislators, often given the task of voting on practice act issues would benefit from the expertise that this group could provide without infringing on their states rights in this area.
- There is an added benefit from the training of nurse practitioners, physician assistants, nurse midwives, general dentists and pediatric dentists regarding the diversity added to the primary care team. These practitioners bring a different dimension to the primary care team that we believe is very positive. They will also help with the distribution problem of practitioners which is heavily skewed toward urban and suburban practices, leaving areas in the inner cities and in some rural areas chronically underserved.
- Increase the knowledge and understanding of primary care and the strengths of other disciplines by encouraging the interdisciplinary, community based training of all primary care students from all disciplines with an emphasis on prevention and public health principles.
- The Title VIII nursing education program currently requires outcome measures of the programs they fund regarding the selection of students from underserved areas and their placement back in those communities. This type of positive incentives could be used as a model for all programs funded by the Medicare GME and the Title VII medicine, PA and dentistry programs.
- Capitating direct Medicare GME and Title VII and Title VIII payment on a per graduate rather than a per student basis would also encourage better outcomes.
- We believe the primary care workforce should represent the multiculturalism found in the U.S., providing role models for students and recruits and ultimately improving the health of underserved populations in the U.S.
- Establish a set aside in the proposed global budget such that public health funding is increased from 3% of total expenditures to at least 6% of total health expenditures.
- Use part of this set aside to increase training support for the disciplines of epidemiology, biostatistics, environmental health, nutrition, health education and public health nursing.
Summary
In our opinion, an examination of primary care “workforce” issues goes beyond a discussion of certain types of practitioners and the designation of underserved areas. We believe the workforce discussions should include the training of practitioners in interdisciplinary, community-based setting for careers in primary care, the support for primary care practitioners once they get into practice, barriers to the utilization of practitioners in primary care settings, and the integration of public health and prevention into primary care.
The use of non-professionals from the community to improve access to primary care for many is an issue that fits in well with the concept of community oriented primary care. These local participants will have a better idea of the needs of the community and the unofficial barriers to primary care for the community’s residents. These unofficial practitioners should become an essential part of the primary care workforce of the future.