Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
The Primary Care Workforce
The Primary Care Workforce
Pages 148-178
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 148... ...
. They are the personnel most likely, under state practice acts, hospital or health plan credentialing, or customary practice, to have significant patient care authority.
|
From page 149... ...
This range of professionals is reflected, for example, in the vignettes used in Chapter 3 to illustrate the scope of primary care. Finally, yet other health professionals, such as dentists, deliver primary care within their own fields and disciplines (IOM, 1995a)
|
From page 150... ...
Tarlov also calls for more creative actions on the part of many parties to deal not only with workforce supply issues but also to achieve other health goals as well, including reducing the disparities in access for underserved populations and increasing the representation of minorities in the medical profession. The most recent publication of the Pew Health Professions Commission comes down forcefully on the side of surplus, using language such as "a large oversupply" that will result in a "dislocation of crisis proportions" (Pew Health Professions Commission, 1995, p.
|
From page 151... ...
for selected years. Of interest is that, in the nearly quarter-century covered by these data, the total numbers of active physicians in patient care and the total numbers in residency training essentially doubled, whereas those in other professional activities rose only a fraction.
|
From page 152... ...
152 no ¢ o am Ed Cal no To Cq an an .= as Cq ·_4 C)
|
From page 153... ...
bInternal medicine subspecialties include diabetes; endocrinology, diabetes, and metabolism; hematology; hepatology; cardiac electrophysiology; infectious diseases; clinical and laboratory immunology; geriatric medicine; sports medicine; nephrology; nutrition; medical oncology; and rheumatology. CPediatric subspecialties include adolescent medicine; pediatric critical care medicine; neonatalperinatal medicine; pediatric allergy; pediatric cardiology; pediatric endocrinology; pediatric pulmonology; pediatric emergency medicine; pediatric gastroenterology; pediatric hematology/oncology; clinical and laboratory immunology; pediatric nephrology; pediatric rheumatology; and sports medi c~ne.
|
From page 154... ...
, for the purposes of this chapter some denomination of the kinds of physicians typically considered as belonging to the area of primary care is necessary. Thus, to be able to show some numbers relating to supply and to trends over time, the committee focused on the primary care physicians practicing or trained in general practice, family practice, general internal medicine, and general pediatrics.
|
From page 155... ...
In the early 1930s, 87 percent of private practice physicians were in general practice; 30 years later, only about 50 percent were generalists. Since then, the proportion of primary care physicians has continued to decline leveling off at about one-third of all active physicians.
|
From page 156... ...
, and 21 percent in pediatrics. More recently, various expert groups and researchers have concluded that the future demand for physician services including primary care physicians may be attenuated by the rapid growth of managed care plans, which use fewer physicians per enrollee than are used by the rest of the population (Kindig et al.,1993; COGME, 1995; Davis et al., 1995; Gamliel et al., 1995; PPRC, 1995; ProPAC, 1995; Scheffler, Appendix E)
|
From page 157... ...
With respect to the primary care workforce, it is evident from the small proportion of minority students enrolled in medical schools that achieving significant representation of minorities who are trained and practicing in primary care will be difficult, at least in the near term. Newly graduated physicians take graduate medical education (GME)
|
From page 158... ...
Geographic Distribution of Primary Care Physicians Of considerable importance is the continuing lack of sufficient primary care clinicians in some geographic areas, particularly rural and some poor urban areas. By and large, problems of geographic maldistribution are set out in terms of aggregate physician presence, not the availability of primary care physicians (or primary care clinicians)
|
From page 159... ...
; thus a count of currently 7Other types of advanced practice nurses, of which NPs are a part, include certified nurse midwives, certified nurse anesthetists, and clinical nurse specialists. Like their physician counterparts, some of these clinical personnel may well deliver primary care as an element of their practices, but primary care is not their main task or type of training, and for that reason they are not considered further in this report.
|
From page 160... ...
Primary Care Nurse Practitioners The National Nursing Sample Surveys do not specifically break out NPs who are practicing primary care, but the large majority of NPs are thought to be doing so. Table 6-4 shows the number of NP graduates in 1992 by their area of specialization.
|
From page 161... ...
; an additional 3 percent of this entire student body were in combined NP and clinical nurse specialist (CNS) programs (1,023 in traditional and 59 in generic programs)
|
From page 162... ...
About 1 in 10 NPs have hospital admitting privileges, and 1 in 3 have hospital discharge privileges (Washington Consulting Group, 1994~. WORKFORCE TRENDS AND SUPPLY PROJECTIONS: PHYSICIAN ASSISTANTS Physician assistants are health personnel who are typically trained in two or more years to render basic health care services that in earlier decades were performed only by physicians (Scheffler and Gillings, 1982; Jones and Cawley, 1994~.
|
From page 163... ...
Accurate counts of the number of PAs being graduated in this country date only to about 1967, and figures for the aggregate supply of PAs only to about 1970. The data are collected by the American Academy of Physician Assistants (AAPA)
|
From page 164... ...
PAs in primary care practice with and are supervised by primary care physicians, although in some practices in rural areas the link is electronic and periodic rather than comprising a traditional team practice with shared office space. Primary Care Physician Assistants According to a 1995 AAPA report, 5,922 of 12,534 PAs responding to the survey were practicing in federally defined primary care specialties internal medicine, general pediatrics, and family medicine (Table 6-6~.
|
From page 165... ...
in the West. OTHER FIRST-CONTACT PROVIDERS First-contact providers such as dentists, optometrists, and pharmacists play an important role in the provision of basic health care services.
|
From page 166... ...
Among the trends that complicate forecasting today are the following (Fell et al., 1993~: the rate of growth of managed care plans; innovations in the patterns of use of primary care professionals in the future, including the wider use of teams; the rate of spread of those innovations; the acceptance of new patterns of primary care providers by patients as they choose among competing health plans; the degree to which specialists seek to expand their provision of primary care as the pending surplus of specialists cuts back on the opportunities within specialties; the ability of academic health centers and other health organizations to support training of primary care clinicians when the financial viability of the training programs is threatened by the competitive health care market seeking to avoid training costs; and the probable reductions in federal and state budgets for health professional education, including support for GME and nursing training under the Medicare program. In the committee's view, drawing inferences about the expected adequacy of supply relative to requirements must be done with considerable caution, especially for the more distant future, and especially for NPs.
|
From page 167... ...
Market-driven changes will affect the effective economic demand for primary care clinicians. These changes include the growth of managed care, the development by some managed care organizations of innovative models of personnel substitution, and the increased use of primary care teams.
|
From page 168... ...
To address these concerns, the committee has two points it wishes to emphasize concerning the future of programs that produce primary care physicians, PAs, and NPs. Recommendation 6.1 Programs Regarding the Primary Care Workforce The committee recommends (a)
|
From page 169... ...
These points are also addressed more fully in Chapter 7 in discussions of undergraduate medical education in primary care sites (see Recommendation 7.1) and graduate medical education in nonhospital sites such as HMOs, community clinics, physician offices, and extended care facilities (see Recommendation 7.6~.
|
From page 170... ...
Monitoring Supply And Requirements Recommendation 6.2 Monitoring the Primary Care Workforce The committee recommends that state and federal agencies carefully monitor the supply of and requirements for primary care clinicians. In keeping with the increasingly interdisciplinary nature of primary care, the committee urges that state and federal agencies compile a composite database of primary care clinicians including physicians, NPs, and PAs providing primary care services.
|
From page 171... ...
The analogous collaboration and cooperation would be sought with a wide array of professional associations, including but not limited to the American Academy of Physician Assistants, American Association of Colleges of Nursing, the American Association of Physician Assistants, American Nurses Association, the National League for Nurses, and the National Organization of Nurse Practitioner Faculties. Apart from general monitoring of the several professions relevant to primary care (e.g., in terms of current size and composition and future projections of supply and requirements)
|
From page 172... ...
It also believes that, with the rapid changes now taking place in the private sector, managed care organizations and integrated health delivery systems have a significant duty to address this question head-on. Recommendation 6.3 Addressing Issues of Geographic Maldistr~but~on The committee recommends that federal and state governments and private foundations fund research projects to explore ways in which managed care and integrated health care systems can be used to alleviate the geographic maldistribution of primary care clinicians.
|
From page 173... ...
Impediments to the Use of Nurse Practitioners and Physician Assistants "Scope of practice" laws, established by the states, govern what NPs and
|
From page 174... ...
Recommendation 6.4 State Practice Acts for Nurse Practitioners and Physician Assistants The committee recommends that state governments review current restrictions on the scope of practice of primary care nurse practitioners and physician assistants and eliminate or modify those restrictions that impede collaborative practice and reduce access to quality primary care. The committee is concerned that state statutes presently on the books create obstacles to innovative collaboration among members of primary care teams and that those ordinances by default hinder the provision of effective and efficient health care.
|
From page 175... ...
examining how state practice acts for NPs and PAs might be amended to eliminate outmoded restrictions on practices that currently impede efficient and effective functioning of pnmary care teams and that reduce access to needed health care. REFERENCES AAPA (American Academy of Physician Assistants)
|
From page 176... ...
Patient Care Physician Supply and Requirements: Testing COGME Recommendations. Rockville, Md.: Health Resources and Services Administration, Department of Health and Human Services, 1996.
|
From page 177... ...
San Francisco: Pew Health Professions Commission, 1995. PPRC (Physician Payment Review Commission)
|
From page 178... ...
Survey of Certified Nurse Practitioners and Clinical Nurse Specialists: December 1992 Final Report to the Bureau of Health Professions. Washington, D.C.: U.S.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.