Primary Care Physician Supply for Missouri

Abstract

Primary Care Supply is not at a level to support needs for the U.S. public now or in the future. Missouri is deteriorating to an extreme shortage of primary care clinicians. With a present supply that is stagnant and not meeting patient needs, new opportunities to select and educate the next generation of physicians will be necessary to meet the predicted health care needs for our citizens. Examining the pipeline, process of medical education, practice transformation, and payment reform are important for the future.¹ We should encourage our training institutions to provide resources for increasing the types of physicians we need for the next generation. Local and national leadership will need to heed the advice of forecasts and provide new methods and solutions for the needs of society. Academic institutions should be held to achieving a true output of physicians for the needs of society.

Knowns and Importance: Primary Care Physician Supply

Missouri physician workforce is now lacking adequate primary care physicians and is declining toward a larger shortage for the next 20 years.² By 2035, the United States is going to need an additional 44,000 primary care physicians. Missouri will need an additional 687 primary care physicians (18% increase of current workforce) by 2030 to maintain the status quo. The status quo is that Missouri is presently 363 primary care physicians short of overcoming the current Health Professional Shortage Areas.³ By the year 2035, the current supply of our training programs, we will be short by 33,000 primary care physicians and would require an additional 1,700 primary care slots per year to meet this need.⁴

Definition of Primary Care

First Contact, Continuous, Comprehensive and Coordinated to populations undifferentiated by sex, disease or organ systems.⁵ Health care systems that have more primary care, have better quality, better population health, greater health equity at lower costs.⁶

Family Medicine best meets the definition of primary care. The recently approved Entrustable Professional Activities (EPAs) for Family Medicine by the eight family medicine national organizations include the diversity of care across the spectrum for FM. These EPAs clearly defined the broad spectrum skills of first contact medical care that graduates of family medicine programs achieve.⁷ (See Figure 1.)

Figure 1.

EPAs for Family Medicine End of Residency Training

Family physicians are in virtually every type of community, whether that is rural, urban, suburban, or underserved.

How Did We Get Here?

Currently practicing primary care physicians make up only a quarter of the physicians in the U.S. and this number has been on a decline for the past 30 years.⁸

Why Has This Happened?

Like so many complex systems, we have arrived at where we are because of market forces that are shaping physician output. From the 1990s, DRGs were introduced that decreased value of the outpatient visits and led to favoring procedural billing codes. The RUC (Relative Value Scale Update Committee) was introduced to pay physicians on RVUs and as the RUC was dominated by specialist physicians, procedures continued to be higher valued over outpatient and cognitive care visits as new procedures continued to take value from outpatient billing codes.⁹

Over time, primary care salaries have declined with inflation and specialty salaries have significantly outpaced inflation, and over time the spread of these salaries among physicians. Primary care as an option for many medical students is seen as a less than viable option for their impending medical school debt.¹⁰ Although the majority of patient visits are in outpatient clinics, the majority of medical education is in large academic tertiary care centers where only 1/1,000 people per population visit in a year versus 113/1,000 visit a primary care clinician.¹¹ Medical reports have concluded we should work toward a balanced workforce of near 50% primary care in the U.S. The more recent COGME (Council on Graduate Medical Education report to HRSA in 2013 recommended GME slots be adjusted to meet the workforce of more than 40% primary care.¹² (See Figure 2.)

Figure 2.

Note: All numbers refer to discrete individual persons and whether or not they received care in each setting in a typical month

From: Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344:2021–2025.48

Reprinted with permission from the Massachusetts Medical Society.

The U.S. population has been growing, and our population has an impending large group of baby boomers in the retirement age that are increasing their needs for primary care medicine access. The number of PCP supply has not kept up and has actually fallen behind. Family Medicine supply has been stagnant; general internal medicine supply, general pediatric supply and general surgery have also continued to decrease during this time period. During this time, the number of general internal medicine graduates entering primary care has declined to 10%, only half of pediatricians enter primary care pediatrics on graduation from residency, and only about 10% of surgery residents enter general surgery upon graduation.¹³ Only Family Medicine has continued to have almost all of their graduates providing primary care.

Many medical schools declare that their graduating classes have nearly half of their graduates that are going to be primary care doctors. This is sometimes referred to as the “Deans Lie.” What really is demonstrated is many of those graduates in internal medicine and pediatrics proceed into subspecialties after their primary certification residency. These doctors are not going to be providing primary care. It has been proposed that the true measure of primary care output of a medical school, should be measured five years out from medical school graduation to count those actually doing primary care and this would give a more accurate presentation at what percentage are actually providing primary care for their career.¹⁴ It may very well be that family medicine is the true indicator on how well a medical school does in preparing doctors for the future needs of the country and meeting the needs for a diverse population and decreasing health disparities.

Of all types of physicians and advanced practitioners, only Family Medicine tends to locate where the population is. They tend to locate in rural areas per capita more than any other type of medical providers (physicians, nurse practitioners, or physician assistants).¹⁵

Why Is This Important?

High performing health care systems in the world have one commonality. These countries have a rather larger proportion of primary care physicians compared to specialty care. Almost all of these high performing health systems have a proportion of 50% or greater of the physicians in primary care.¹⁶ From that data, an increase in the PCP supply for society meets the Triple AIM of lower costs, better quality, and better outcomes.¹⁷

There are also Economics: for every one family physician entering a community, there is 1.4 million dollars added to the annual local economy.¹⁸ There continues to be a shortage of primary care physicians in rural areas. Family Medicine is the second largest specialty and family doctors have been the number one recruited specialty nationally for nine years running and the number of available positions is almost double that of the next most recruited specialty, general internal medicine.¹⁹

Where is Missouri?

Missouri is one state that has a sizable rural population and struggles to maintain an adequate supply of medical providers. Pending demographic shifts also increase the concern for further shortages. Health care in Missouri plays a significant role in the economy. Nearly 10% of Missouri’s workforce is employed in the health care sector. Missouri ranks eleventh in the nation (8.7%) for number employed in health care. Missouri is a national leader in medical school graduates (twelfth with 517 annual allopathic graduates and 330 osteopathic graduates.)²⁰ With 2.7% of the medical school graduates in the U.S. yet only 1.9% of the population. There are six medical schools in the state supplying these graduates. Missouri has the third highest per capita medical student graduates, yet the eighth lowest for all types of residency slots.² Recent data has ranked Missouri near the bottom four states in the country for the past decade in retaining graduates entering family medicine. Missouri is the number two state for exporters of medical graduates. Missouri has fewer physicians (all specialties and primary care physicians) per 100,000 population than the U.S. as a whole. The state also has less physician assistants and dentists.² Missouri will need an additional 1,000 primary care physicians by 2025. That would be an additional 100 graduates every year from our programs all staying in Missouri. Currently Missouri is only producing 75 per year in our Family Medicine programs and with the pediatricians and general internists practicing primary care, that number is estimated at 150 graduates actually initially providing primary care, assuming they all stay in Missouri to practice. Missouri would have to double the output to meet this need in the next few years and every year through 2025. There are no known current plans to significantly increase the primary supply at any of the teaching centers in the state.

Missouri also has significant Health Professional Shortage Areas (HPSAs) which may be urban or rural. HPSAs are defined as having fewer than 3,500:1 population to practitioner. Almost 19% of Missourians live in a primary care HPSA compared to 12% nationally. Missouri has 200 primary care HPSAs (sixth most in U.S.) and is now short 363 primary care physicians (seventh most need in the U.S.) and is meeting only 39% of its need ranking it fifty-first in the U.S. for meeting its primary care needs. The types of physicians needed in rural Missouri the most are: primary care doctors, general surgeons, and psychiatrists.²

Over 60% of Family Medicine residency graduates stay within 100 miles of where they are trained.²¹ However, Missouri is the number two exporter of medical school graduates in the country. Missouri has one of the lowest retention of our medical school graduates remaining in the state to complete their training in Family Medicine according to the AAFP. There are limited primary care residency training slots to increase this number for the state’s needs. There has been no increase in the training funding from Medicare since 1997 in the form of Medicare training slots. As medical student graduates leave to complete their training in other states, they most likely will not be coming back to Missouri to practice medicine.

What Needs to Happen?

There has been a 10% increase of U.S. medical student graduates over the past 10 years. However, the PCP supply has stayed stable and the number of U.S. graduates entering primary care as a percentage has actually fallen compared to other specialties and is now around 8% of allopathic graduates.²² There is not a need for increased medical students, or schools, in Missouri as shown in the data above-there needs to be an increase in the number entering primary care and staying in Missouri upon graduation. Medical schools and training programs should be held accountable for their graduates entering practice for the needs of society. (See Figure 3²³.)

Figure 3.

There is really not a need for an increased number of Medicare cap slots-we need a redistribution of the slots to a primary focus. Despite incorrect assumptions about the match and number of Medicare cap slots in the U.S. being stable since 1997, there are over 6,000 foreign medical graduates entering our training programs every year.²² Most specialties have seen an increase in numbers of residents being trained despite no increase in the cap. Academic centers have continued to grow despite no increase in cap, and most large academic centers are double and triple digits of the number of residents over the Medicare cap. Many institutions increase specialty slots based on the needs of the hospital, not on the needs of the surrounding community or the country as a whole. In reality, there is an adequate supply of residency slots for graduates of U.S. allopathic and osteopathic schools, just not the right mix of what those slots are for the current or future needs of the population.

“Emphasis on coordinated and ongoing care leads to better health outcomes, and saving money. Cost savings is not the only benefit. Having a regular access to a particular physician is associated with earlier and more accurate access, fewer ER visits, fewer hospitalizations, lower costs, and better care,” said Dick Durbin, Senator Illinois. Dis-coordinated care leads to the opposite of what Senator Durbin stated.¹⁶ Having an ongoing relationship with a regular family physician is associated with lower costs, fewer hospitalizations, better outcomes and better patient satisfaction.²⁴

“Expert Research has found nations where the primary care physician supply is 50% or greater than of physician workforce, there are better outcomes and lower costs,” attributed to Jeff Harris, MD, ACP President.²⁵

Our Current Physician Supply

The state of Kansas will be used as a comparison. Kansas has one medical school with three campuses. Kansas graduates about 170 medical students per year and there are four Family Medicine residency programs in Kansas with approximately 42 graduates per year. At 19%, Kansas University ranks as the second highest allopathic medical school in the country for percentage of graduates entering family medicine (32 entered family medicine in 2015).²⁶

Missouri has six medical schools. In 2015, 850 medical students graduated. Only 103 (12%) entered Family Medicine. Forty-five of those 103 were from one of the six medical schools, Kansas City University (osteopathic school). Only 34 of those graduates of the 103 total entered Family Medicine training programs in the state. There are six allopathic and three osteopathic family medicine training programs in the state. The allopathic have the most consistent amount of graduates producing about 61 graduates per year and the osteopathic programs graduate about 14 per year total. There has been the closure of three family medicine training programs in the last 15 years in Missouri and the opening of a new one in 2012 with a net loss of 10 graduates per year in those past 15 years. With a population more than double that of Kansas (2.9 million), Missouri (six million residents) is only producing 75 graduates per year versus Kansas at 42. Missouri produces 1/80,000 residents-per year and Kansas produces 1/69,000 residents per year. At that rate Missouri will be looking at more of a gap in primary care physicians in the future. Although there is no statewide data source on an exact clear picture of the primary care workforce, the University of Missouri, and more recently the State of Missouri, is progressing toward state workforce numbers to show this need. Present data is derived from the Graham center and population based statistics for the federal registries.²⁷

Only 12% of Missouri medical school graduates entered Family Medicine and only 4% of the total graduates stayed in Missouri to complete their training in Missouri Family Medicine programs. Missouri has been in the bottom five states in the country for retaining primary care graduates from its medical schools for the past decade. It is an established fact that the majority of residency graduates stay within a 100-mile radius of where they did their training.²¹ Therefore, it is very important to look at increasing the number of primary care training slots in Missouri to allow graduates to complete their training and progress into practice within our state borders.

Options for Solutions

New incentives and policies for distributing primary care physicians to areas of greatest need, as well as a larger absolute number of primary care physicians that will be needed. Since many medical students graduate with an average education debt of $250,000, students often make their specialty choice on financial reasons and paying back these loans is one of those acute financial factors. One effective way to encourage students to enter primary care is to have loan repayment programs for primary care physicians with payback being time practicing in those states underserved areas. Both Missouri and Kansas have such plans.

Kansas loan repayment programs actually outnumber those available in Missouri quite significantly. As many as 20 graduating residents per year enter practice in underserved areas of Kansas with loan repayment programs provided through various state agencies. There are many opportunities to receive this funding through the Kansas Medical Student Loan (KMSL) and Kansas State plans, and they continue to be funded at this time. The Kansas Department of Rural Health Education also administers the Kansas Bridging Plan. Since its inception, the program has had 313 physician participants and 84% are currently practicing in Kansas.

Keeping Talent in Missouri

On the other hand, the Missouri loan repayment programs is not as abundant as the Kansas Program. PRIMO (Primary Care Resource Initiative for Missouri) is the only statewide program that pays back student loans for service to Missouri needed populations. The Missouri governor has removed most of its funding every year since 2010. It has only been able to support 1–2 primary care residents per year since 2010. The PRIMO program began in 1995 and has numerous success stories of primary care physicians remaining in Missouri after loan payback. The author of this article is one such recipient’s of the PRIMO program and continues to practice and train primary care physicians for Missouri.

National Solutions

There is a consideration to rebalance the GME dollars to influence the country’s population needs for medical physicians. More dollars directed at primary care will lead to desired increase, improving outcomes, improving student interest in primary care and balancing the widening pay gap between PCPs and specialties. A recent study in Academic Medicine drew a sharp conclusion of the lack of accountability among publicly funded graduate medical education (GME) institutions. GME institutions receive about $13 billion in public funds annually through Medicare and Medicaid yet they produce PCPs at an abysmal rate. Currently, there is no accountability for GME-funded academic institutions to produce the type of doctors needed for efficient, high quality health care delivery for society needs. Institutions should be held accountable for the public dollars that are entrusted to them to meet needs of society.

There is a consideration for GME reform where the system for payment of education for resident physicians that will allow dollars go to initial certification residencies only, and not to secondary certificate programs (fellowships). With the saved money, there could be an increase in the number of physicians that are training in primary certificate training programs. Many of the secondary certificates are finding alternative payment models currently, as mentioned above, and are increasing the number of specialty trained residents above the 1997 cap. We should also look beyond the historic training sites in large urban centers and train more residents in the community where most patient visits and practices are located.

Improving the Image of Primary Care as a Career Path

This summer the “Health is Primary” national marketing campaign to Kansas City. This is a five-year, $20-million-dollar campaign funded by the national organizations of family medicine. The five-year campaign began in 2015 and is doing “City Tours” across the U.S. Kansas and Missouri will be featured with the Kansas City tour during July and August of 2016 in conjunction with the annual National Conference of Family Medicine Resident and Student Conference at Bartle Hall in Kansas City, Mo. The conference, held July 28–30, 2016, in Kansas City, had record-breaking attendance with almost 4,500 students, residents, and educators at the meeting, which is reported as the largest national gathering of residents and students in the country. Family Medicine already has a great image when asking patients, health care agencies and employers and this message is being marketed to increase the perceived nature of Family Medicine across the country.²⁸

Patient-Centered Medical Homes and Team-Based Care

Patient-Center Medical Homes (PCMH) with physician leaders have been affiliated with meeting the Triple AIM. Physicians leading teams of other providers leads to timely care and better outcomes. Although some might believe that advanced NPs and PAs can provide primary care unsupervised, this is not how they are trained. Family Medicine physicians receive over 22,000 hours of supervised training before they enter practice while APRNs receive about 4,000–6,000 hours and PAs even less.²⁹ Advanced providers are trained to augment physicians and delivery of care but not to lead the care independently. Only physicians, at the completion of residency training, receive written approval to practice independently per their final program letter as required by the ACGME. APRNs and PAs receive no such declaration at graduation. APRNs and PAs are vital team members in PCMHs as they provide for more care providers in the team based system.

The UMKC Family Medicine residency program has done several things to help improve the short supply. First of all, it is currently the fourth largest Family Medicine program in the country. Doximity ranked the UMKC Family Medicine program as one of the top in the Midwest. As of 2016, it has graduated 375 Family Medicine graduates with another 93 graduates in the primary care fellowships of sports medicine, geriatrics, and surgical obstetrics. The UMKC program has taken great pride in training full spectrum family physicians with concentration in geriatrics and advanced training in maternity care for the needs of our communities. With these 468 UMKC graduates, 48% of them serve in rural America. One hundred and seventy-eight residency graduates practice across Missouri and 69 practice in Kansas. There are 160 practicing in the Kansas City Metropolitan area. UMKC was awarded a 3.8 million dollar grant from HRSA in 2011 (1.9 Million each in Family Medicine and general internal medicine) through the federal health care law that increased the size of the UMKC general internal medicine and Family Medicine programs each by two per year. The UMKC Family Medicine program was a rural designated program with three quality indicators to gauge its success. HRSA required that all the positions were in primary care and that the graduates would go into primary care. The local indicators of success were that the residents graduating would do rural Family Medicine and a third level was that they practice in Missouri. Of the six graduates from the UMKC Family Medicine rural program, all of them are practicing rural medicine and five out of six are practicing in rural Missouri. Of the last four residents yet to graduate, they all have intentions of practicing in Missouri and believe they are committing to rural practice. This is great success to a program costing $1.9 million federal dollars supporting 10 graduates of which all are doing rural medicine and nine out of ten remaining in Missouri. Economic outcomes would tell us Family Medicine doctors in rural communities stimulate about $1.4 million to their local economies per year.¹⁸ This will be $13 million to the Missouri state economy per year and additions to local rural communities. Over a typical 37-year career, that is $481 million added to the rural economy of Missouri. This shows a great return on investment for years to come. Unfortunately, this federal grant is expiring and Truman Medical Centers is unable to support the continuation of these spots secondary to financial reasons since the core institution is well over the Medicare cap. Therefore, UMKC and Missouri will have a net of decreasing primary care output by four PCPs per year in 2018. This is not the direction our state needs to be going.

The UMKC Family Medicine program continues to matriculate many Kansas students that have Kansas Medical Student Loan (KMSL) and Kansas Bridging Plan (KBL) scholarships. UMKC FMRP has consistently one to two in every residency class that will return to practice in Kansas rural communities and will be leaving to fulfill their obligations to Kansas further widening the gap of primary care physician output between Kansas and Missouri.

Conclusions and Relevance

There needs to be some action on several levels. First, there must be more support for matriculating students in our medical schools that have a high predilection to go into primary care. Diversity, rural background, and women are all known factors in the success of this.²⁶ We must have community support for the recruitment and retention of primary care doctors. Creating clinics and opportunities where primary care doctors excel in settings like patient centered medical homes with teams of providers ready for the needs of society. Residency programs and hospitals must expand to meet the need of the primary physician supply beyond the large academic centers needs, whether that is locally or garnering state and national support to expand these training programs like the PRIMO and HRSA grants have. There must be support at each state level to support loan repayment and opportunities to match primary care students and residents to locations where they are needed. There must be a coordinated effort to improve the viability of primary care practice and payment reform to balance the widening gap of primary care/specialty pay. There also needs to be national level GME reform to pay for what our country and society needs, not the needs of the established medical urban teaching centers and to create accountability for the types of physicians they graduate. Real payment reform could be initiated to influence the changes we need in the future for our physician supply.

Biography

Todd Shaffer, MD, MBA, FAAFP, Professor and Program Director Family Medicine Residency, University of Missouri - Kansas City, Department of Community and Family Medicine and Truman Medical Center-Lakewood.

Contact: shaffert@umkc.edu