Primary care shortage/new schools

[pagirl82]

I just saw this article that states the primary care shortage has been overestimated. I've always suspected this, although I'm not sure I agree with the author's reasoning. He suggests that patient centered medical homes, EHR, and using non-physician providers will increase efficiency. He cited a study from Kaiser where primary care visits decreased 25% after EHR implementation, which allowed for more phone interactions. I assume there were more phone interactions because their EHR allows online scheduling and frees up phone lines, but he doesn't say this.

 

 

He also brings population growth into his argument. This is my main concern. There was a study by the AAMC that showed the "supply of nurse practitioners has outpaced population growth".

 

The issue of new schools was brought up last year with the AAPA elections. Has there since been any discussion or an investigation to determine if new schools are truly necessary? Oversaturating medicine should be a real concern. Of course PA's make up

a small percentage of health care providers, but MD/DO/PA/NP education all seem to be on a similar path. All continue to increase the number of new schools and class sizes. Job advertisements are nowhere near as plentiful as they used to be. It's not just the economy.

 

This already happened to pharmacy. They were predicting huge shortages 15-20 years ago. There was a lot of hype and it was made to seem as if they couldn't possibly meet demand unless drastic measures were taken. Many new schools opened and existing schools increased class size. Supply has now met demand. I've seen mention of older, higher salaried pharmacists who've been fired (for petty reasons) so a younger, cheaper pharmacist can take their place. New grads are having a hard time finding jobs in recent years. It'll only get worse because new school are still opening! Pharmacy does have a unique problem that's decreasing demand: mail order pharmacy and automated dispensing.

 

There's no reason why the healthcare provider field can't/won't become oversaturated. Would the respective MD/DO/PA/NP education associations have the authority to reduce the number of schools or class size if need be? Schools would fight tooth and nail to prevent this since they're big money makers. There doesn't seem to be any turning back once the number of grads outpaces demand. If there were, there wouldn't be so many healthcare fields complaining of oversaturation.

[Gordon, PA-C]

I just saw this article that states the primary care shortage has been overestimated. I've always suspected this, although I'm not sure I agree with the author's reasoning. He suggests that patient centered medical homes, EHR, and using non-physician providers will increase efficiency. He cited a study from Kaiser where primary care visits decreased 25% after EHR implementation, which allowed for more phone interactions. I assume there were more phone interactions because their EHR allows online scheduling and frees up phone lines, but he doesn't say this.

 

 

He also brings population growth into his argument. This is my main concern. There was a study by the AAMC that showed the "supply of nurse practitioners has outpaced population growth".

 

The issue of new schools was brought up last year with the AAPA elections. Has there since been any discussion or an investigation to determine if new schools are truly necessary? Oversaturating medicine should be a real concern. Of course PA's make up

a small percentage of health care providers, but MD/DO/PA/NP education all seem to be on a similar path. All continue to increase the number of new schools and class sizes. Job advertisements are nowhere near as plentiful as they used to be. It's not just the economy.

 

This already happened to pharmacy. They were predicting huge shortages 15-20 years ago. There was a lot of hype and it was made to seem as if they couldn't possibly meet demand unless drastic measures were taken. Many new schools opened and existing schools increased class size. Supply has now met demand. I've seen mention of older, higher salaried pharmacists who've been fired (for petty reasons) so a younger, cheaper pharmacist can take their place. New grads are having a hard time finding jobs in recent years. It'll only get worse because new school are still opening! Pharmacy does have a unique problem that's decreasing demand: mail order pharmacy and automated dispensing.

 

There's no reason why the healthcare provider field can't/won't become oversaturated. Would the respective MD/DO/PA/NP education associations have the authority to reduce the number of schools or class size if need be? Schools would fight tooth and nail to prevent this since they're big money makers. There doesn't seem to be any turning back once the number of grads outpaces demand. If there were, there wouldn't be so many healthcare fields complaining of oversaturation.

 

 

Good post. The big issue that everybody is ignoring is that the baby boomer surge is TEMPORARY. After all the baby boomers die off, there is going to be a huge surplus of providers. All the workforce studies ignore projections beyond the next 20 years.

[CAdamsPAC]

Good post. The big issue that everybody is ignoring is that the baby boomer surge is TEMPORARY. After all the baby boomers die off, there is going to be a huge surplus of providers. All the workforce studies ignore projections beyond the next 20 years.

 

 

 

Wrong! We Boomers are never going to die!

[physasst]

Good post. The big issue that everybody is ignoring is that the baby boomer surge is TEMPORARY. After all the baby boomers die off, there is going to be a huge surplus of providers. All the workforce studies ignore projections beyond the next 20 years.

 

A few thoughts. First off the study is very well done. OR/SE folks are going to inherit the earth, or at least change healthcare delivery....It's hard to know with this. I'd like to see this data validated through replication, and/or piloting. In fact, this has to be piloted. Simulation models are nice, but on a national level, they can be difficult at best. She could very well be right, but right now it's theoretical. It needs to be proven experimentally, that is that the efficiencies she is using as her assumptive variables actually work in practice as she assumes. I took some OR classes in school, mainly focused on decision analysis and decision science.....and we are re-engineering health care delivery here with a very, very robust OR/SE group here. In fact, it seems most of the recent research positions, and funding initiatives have been directed into OR/SE projects. The engineers will dominate healthcare...Also, there are some limitations which she acknowledges as well. One thing that my doctoral mentor would always hit on was the concentration of physicians and providers in urban and suburban areas, when there were very few providers in 30,000 zip codes with 65% of the population. Actually, 72% of primary care physicians are located in clustered zip codes (large cities) where there are 75 or more physicians in the same zip code. How does that affect the access? I think it's great to take the OR/SE approach.....

 

As far as the baby boomers, my only thought would be...okay......we have a looming (already here really, but will worsen) obesity epidemic.....in 10-20 years, we are going to have a lot of 35-40 year olds with chronic illnesses and physical problems of people in their 60's. There will still be work.....that is if the whole health care system doesn't collapse by then....

 

Lastly, I would only add that you cannot restrict workforce by limiting entry to the profession, that may drive up salaries, but will lead to shortages and over corrections. This will correct itself through the market. As a profession over saturates, fewer people will enter it, and saturation levels will settle out.

[Just Steve]

I don't see mention within this thread of the several million newly insured patients....is this because there is doubt that they will actually get the insurance? Or...?

[physasst]

I don't see mention within this thread of the several million newly insured patients....is this because there is doubt that they will actually get the insurance? Or...?

 

Well, that's only one of several problems with this study Just Steve....in addition to the lack of an understanding of distribution....they are using outdated data and no use of annual data. I like MEPS a lot but it isn't really granular enough for this type of projecting.

 

If you analyze 10 years of MGMA data you will find that family medicine annual productivity did not change much over that 10 years. The 2500 patient panel is a bit ambitious as well, although I understand that the AAFP reports 2496 as the average patient panel (2008 figure). Aging population requires more visits and changing lifestyle of physicians means less annual visits. Add to that you have physicians drifting into concierge medicine and decreasing the provider pool and increasing demand outside the practice.

 

It's a good study and simulation because it is thinking outside of the box, but they make some rather daring assumptions...The trend is more demand annually and I only see more demand ahead. Excess demand in PC is the consensus and not some naive use of PA/NPs and EHR to fill in the gaps. I like simulation models but prefer conservative assumptions.....

 

Still, the paper is thought provoking and stimulative, which is never a bad thing...

[pagirl82]

Good post. The big issue that everybody is ignoring is that the baby boomer surge is TEMPORARY. After all the baby boomers die off, there is going to be a huge surplus of providers. All the workforce studies ignore projections beyond the next 20 years.

 

Good point. I've always had a problem with the "aging baby boomers are going to flood the healthcare system" hysteria. They're already in the system! Yes, aging people need more care, but that would be a slow increase in utilization and a need geriatrics and nursing home care. I haven't heard much encouragement to increase the number of geriatricians, just a lot of hype about the primary care shortage, which is really more of a maldistribution than a shortage, at least for now.

[pagirl82]

Lastly, I would only add that you cannot restrict workforce by limiting entry to the profession, that may drive up salaries, but will lead to shortages and over corrections. This will correct itself through the market. As a profession over saturates, fewer people will enter it, and saturation levels will settle out.

 

I don't agree with this at all. If you look at other health professions that are oversaturated (or nearly saturated) or law, students continue to enter these programs, programs expand, and new schools continue to open (I'm not sure if that's happening with law schools). Students still choose these careers because it's very attractive to have a degree with a specific career/job attached to it. Some students/grads will say that didn't know the job outlook was so bad until it was too late. Some hope they'll get lucky and be the one to find a job.

 

Schools have no incentive to close or decrease class numbers. If you talk to students or grads struggling to find jobs in oversaturated field, a lot of them will tell you that school exaggerated or lied about expected job opportunities and a bright future.

 

A lot of young lawyers aren't practicing law because there aren't enough job opportunities and enrollment continues at record numbers. Pharmacists and other allied health professions are already experiencing saturation. Enrollment continues. You end up with a lot of unhappy grads with education debt and no jobs. There's no reason to think it can't happen to us, too. We're not immune. It's reasonable to think expect the market to correct itself, but that doesn't happen in this country. People will always flock to professional schools when the economy is poor and schools will always be happy to take their money.

 

If control measures are not in place, this could be a disaster. There are no control measures, as far as I can see. I believe the respective education associations or accreditation bodies have the authority to require schools to decrease class size. I'm not sure if they can close schools just because of saturation. None of this is happening in the already troubled fields and they continue to open new schools. No school is going to voluntarily decrease class size and lose out on tuition. I know each profession is separate and have different regulations, but they probably have a lot of similarities, so what happens in other professions can happen to us.

 

This is something to take seriously. Morale among healthcare providers has been dropping in recent years. Imagine how it'll be when you can't find a job in the specialty you desire or near your family, or you're constantly worried about getting fired and replaced by a cheaper younger PA, or can't get a job at all. It's bad for us, bad for patient care, and bad for the economy. I'm sure this topic is somewhat taboo because the public would be outraged that we'd talk about controlling the output of new healthcare providers, but we need to be realistic and talk about it. It's the responsible thing to do.

 

I'm not sure if this is true, but some people claim that in addition to controlling quality and streamlining medical education, the Flexner Report also had a "hidden agenda" aimed to balance supply and demand. There's nothing wrong with doing that. It's actually a very good idea.

[BroncoPAS]

I don't agree with this at all. If you look at other health professions that are oversaturated (or nearly saturated) or law, students continue to enter these programs, programs expand, and new schools continue to open (I'm not sure if that's happening with law schools). Students still choose these careers because it's very attractive to have a degree with a specific career/job attached to it. Some students/grads will say that didn't know the job outlook was so bad until it was too late. Some hope they'll get lucky and be the one to find a job.

 

Schools have no incentive to close or decrease class numbers. If you talk to students or grads struggling to find jobs in oversaturated field, a lot of them will tell you that school exaggerated or lied about expected job opportunities and a bright future.

 

A lot of young lawyers aren't practicing law because there aren't enough job opportunities and enrollment continues at record numbers. Pharmacists and other allied health professions are already experiencing saturation. Enrollment continues. You end up with a lot of unhappy grads with education debt and no jobs. There's no reason to think it can't happen to us, too. We're not immune. It's reasonable to think expect the market to correct itself, but that doesn't happen in this country. People will always flock to professional schools when the economy is poor and schools will always be happy to take their money.

 

If control measures are not in place, this could be a disaster. There are no control measures, as far as I can see. I believe the respective education associations or accreditation bodies have the authority to require schools to decrease class size. I'm not sure if they can close schools just because of saturation. None of this is happening in the already troubled fields and they continue to open new schools. No school is going to voluntarily decrease class size and lose out on tuition. I know each profession is separate and have different regulations, but they probably have a lot of similarities, so what happens in other professions can happen to us.

 

This is something to take seriously. Morale among healthcare providers has been dropping in recent years. Imagine how it'll be when you can't find a job in the specialty you desire or near your family, or you're constantly worried about getting fired and replaced by a cheaper younger PA, or can't get a job at all. It's bad for us, bad for patient care, and bad for the economy. I'm sure this topic is somewhat taboo because the public would be outraged that we'd talk about controlling the output of new healthcare providers, but we need to be realistic and talk about it. It's the responsible thing to do.

 

I'm not sure if this is true, but some people claim that in addition to controlling quality and streamlining medical education, the Flexner Report also had a "hidden agenda" aimed to balance supply and demand. There's nothing wrong with doing that. It's actually a very good idea.

 

Very well written, I was going to add to it but you said it all.

[Guest JMPA]

While a MD/PA goes to school to enter the profession, NP are essentially limitless. There is no lpn, rn, starting point equivalent for an MD/PA. Any RN has not only the potential but also the means to become a NP and practice dependently. When compared to MD/PA whom first has to be fortunate enough to get accepted, NP seems like the easier and more sensible route. Why would a RN not want to move up and become a NP? So yes, there is potential for not just saturation but over saturation. And with the record numbers of abortions the demand for health care practicioners will be exponentially changed in a short period of time.

[pagirl82]

There will still be work.....that is if the whole health care system doesn't collapse by then....

 

I don't see mention within this thread of the several million newly insured patients....is this because there is doubt that they will actually get the insurance? Or...?

 

I realize I've completely left out some very important factors in my discussion. Partly because I didn't want to start a political debate and partly because I have no idea how to factor the ACA in. I just wanted to begin this discussion and throw around some ideas or find out if it has been already been discussed.

 

The ACA does not seem sustainable. I don't know where to go with that.

 

But let's imagine it is sustainable...

 

Even with all the newly insured patients and increased demand for primary care in the first few years, it's still worth considering whether this country is on target to produce an excess of providers. The real problem will always be getting people to go into primary care and getting those primary care providers into the right locations. It will always be hard to convince students to enter a field that pays less than others and has a lot of unique responsibilities to fulfill. It will always be hard to attract providers to rural areas, undesirable locations, or locations far from family and friends.

 

I like to look at Massachusetts' health care, even though they already had a very low uninsured population and a high physician per capita ratio, so it's hard to generalize to the rest of the country. There are a lot of reports of primary care shortages there, but they had "shortages" before Romneycare began. I'm sure overall it is more difficult or takes longer to find a pcp in MA since Romneycare, but I think it's important to realize that what they consider a shortage of pcp's was not new problem. Romneycare didn't collapse primary care, it just made it a little less accessible. I've heard some of the anecdotal difficulties finding a pcp have to do with physicians not accepting certain insurance plans. I don't live in Mass., so I welcome corrections.

 

Where I live, more than half the physicians have closed panels and it can take months to get an appointment as a new patient in primary care. I don't see that as a problem. You establish with primary care for the long haul. If there's a dire problem in the mean time, you can go to urgent care or the ER, if appropriate. That's not a shortage of pcp's. That might be near ideal supply/demand. If you don't live in an area where population is expanding or have a large turnover, having an open panel and the ability to schedule a new patient with minimal wait might mean you don't have enough patients. That arrangement sounds ideal to patients and the media, even better if all physicians were that accessible so you could have your pick, but obviously physicians with half empty panels is a problem... a problem that will come eventually IF too many grads are produced. This needs to be considered.

 

Yet, that situation, in the media, would be portrayed as a shortage. If already established patients can't get timely appointments, that's usually a scheduling problem. With the trend toward open access scheduling over the past few years, hopefully not too many people can say "I have to wait 3 weeks to see my pcp". Again, that would be portrayed in the media as a primary care shortage when in reality it might not be.

[pagirl82]

While a MD/PA goes to school to enter the profession, NP are essentially limitless. There is no lpn, rn, starting point equivalent for an MD/PA. Any RN has not only the potential but also the means to become a NP and practice dependently. When compared to MD/PA whom first has to be fortunate enough to get accepted, NP seems like the easier and more sensible route. Why would a RN not want to move up and become a NP? So yes, there is potential for not just saturation but over saturation. And with the record numbers of abortions the demand for health care practicioners will be exponentially changed in a short period of time.

 

Why can't you limit NP's? You need to be accepted into a program eventually to gain a master's or doctorate, right? I know there are online for profit programs, like Kaplan, but there is an admission process. That could be limited.

[physasst]

Of course we could over saturate, but there is no indication in the workforce data currently that that is even close to a remote problem in the next 30 years. We generally only run projections on 5, 10, or 15 year cycles, because beyond that the variables become way too muddy and the projections become useless. In the next 15 years, there is nothing to worry about.

 

The only alternative, and one which I support, would be centralized workforce planning, ala the UK, but very few US providers would be happy with that, as you essentially would be told what specialty you could practice in. By controlling the number of openings per specialty, some become so competitive that most applicants would not be able to practice in them. How would that go over here?

 

We only produce 6,900 PA graduates annually....compared with over 9,000 NP graduates and 26,000 physicians entering residency annually, we don't produce enough PAs currently to meet any of the demand models over the next 15 years. And we have factored the ACA into many of our projection models.

 

The paper is decent, but you have to be careful when you have business school leaders using rather outlandish assumptions to try and explain away a complex problem.

 

Bottom line is, for anyone on this forum currently, student or practicing PA, there is little to worry about on a national level. There may be increased saturations in certain markets, but that is to be expected. PA students 25 years from now may face a different forecast, but hell, we don't even know how we'll be practicing in 25 years...

 

Maybe we'll all have tricorders and you won't even need very many practitioners......There's already some hints that advanced computer algorithms and the continuing advancement into AI may mean that in 25-30 years many of us may not be needed, if you believe in Moore's Law that is. Who knows what the future holds that far into the future.

 

I know I just ordered the Leap so that I can use my computer with just my hands in mid air......Can't wait for the holographic 3D imaging....which is being tested at places now......Tony Stark, eat your heart out....

 

OH, and it's not just being portrayed in the media. If you are truly interested in this field PAGirl, I would suggest that you attend the annual AAMC Physician Workforce Research Meeting in DC.....Some incredible, incredible presentations every year, and there are usually about 8 or so of us PAs in attendance..The top workforce researchers in the country are there and they are the one's making these projections.....It's the sine non qua of workforce research meetings. We need more work in this area, and we need bright, motivated people with different ideas....so if you are truly interested in this, it might be good for you to attend.

 

https://members.aamc.org/eweb/DynamicPage.aspx?webcode=MeetingProfile&evt_key=94506c4f-4662-4311-b059-287fb6358b33

[Timon]

I just want to throw it out there in regards to comparing law students with over saturation. In regards to law practice there is a misconception that one will graduate and find work for a law firm. Most often those who pass the bar exam have to take the approach of opening their own practice which is a daunting task. Knowing several people from college who went this route (I myself considered this route at one point) fail to realize that initially you'll be working for free and often times have to find your own clients. If one does not have an entrepreneur mindset they often times set themselves up for failure.

 

I think a better scenario to compare are those who are going into teaching. Lots of people want to become teachers and cannot open their own schools. Often times they have to wait for someone to retire or relocate after hoping to get any scraps from the table as a substitute. I think this is a more likely scenario as it is based off of the allocation of private and public funds per population versus the need for products and services at ones discretion based off of the needs of businesses and individuals as well as being independent from government and private funding dictating reimbursement.

[pagirl82]

Thanks for all that info physasst! I'll take a look at that link.

 

A lot of my concern relates to the fact that I was planning to go to pharmacy school before I became a PA. I read pharmacy journals from a family friend in high school (late 90s). They described a slight current shortage in pharmacy and warned of a huge insurmountable shortage in the next decade due to the aging baby boomers.

 

My family's pharmacist friend used to get frequent calls from recruiters offering outrageous salaries. Protocol was for him to inform his boss. Boss would ask what was offered, say OK, and the next pay period all the pharmacists' salaries were adjusted to the extremely high "going rate".

 

I went to many information sessions at pharmacy schools throughout high school to my senior year in undergrad. The attitude was: We can never catch up no matter how many seats or schools are added. There will always be a shortage. You'll always be in high demand. They'd tell stories about the abundance of jobs, amazing benefits, and glorious future. There were mentions of new sports cars, houses, and expensive vacations being given as signing bonuses. The stories were less dramatic in the later sessions I attended, but still extremely positive.

 

I worked as a pharm tech the summer before senior year in undergrad. Some pharmacists discouraged me from pharmacy because admissions were so competitive and told me to go to med school instead. Some discouraged me because of the long shifts and thankless tasks. Some said it wasn't a glamorous job, but well worth the money and lifestyle. They were brutally honest. There was never any mention of the possibility that jobs might be hard to find in just a few years.

 

Pharmacists are smart people and good with numbers. Their projections were soo far off. It would seem as if they never stopped to adjust along the way but just kept approving more seats/schools without reason. Over a period of 15 years they went from being extremely in demand and optimistic, predicting huge shortages to reaching near saturation. Grads are having a hard time finding jobs and it gets worse each year. I've heard starting salaries are dropping. Pharmacists aren't treated as well anymore, demanded to fill more and more scripts faster, regardless of safety. There's no bargaining power when you're easily replaced with unemployed new grads with high loans. It's like no one saw it coming or those who did didn't have the power to stop it.

 

The pharmacy story sounds almost identical to the predicted "doctor shortage" due to baby boomers and subsequent never ending increase in MD/DO/PA/NP seats/schools. We're on an identical path. This is why I'm worried! I don't trust that anyone is looking out for us. By us, I mean MD/DO/PA/NP. I realize PA's are a small percentage. My concern isn't that PA grads are increasing, it's that the number of all healthcare provider grads are increasing and I'm not convinced that it's due to necessity.

[rpackelly]

I actually believe that the Health Affairs Study was overly conservative; there is opportunity for PAs/NPs to take up much more slack than their simulation visualized. Their major model used three MDs/1 PA/NP seeing approx.20% of the practice load......we all know of settings where there are more PAs/NPs than docs, sometimes 2:1. And that is not wrong or bad in a good setting with excellent support. So I think that by 2030 there might be a surplus of midlevels if our schools keep multiplying. The baby boomer bulge will be smaller in terms of patients. But there will always be a place for excellent providers; it will just return to the demographics of the 1980s for a time, where relocation for a job and frequent specialty change (and relatively low salary) were the rule rather than the exception. We will cycle just like teachers and nurses, and even physicians of various specialties. Our cycles will likely be longer and less acute in both directions.