The Real Crisis Facing Health Professionals Is Too Many Graduating and Worse to Come

It is getting hard to avoid the numerous media and social media promotions about the "crisis" of shortages of health professionals. These well funded promotional efforts indicate that health professional training can address these shortages. There is a specific intent such as increasing the billions spent on graduate medical education with some going to my institution or others like it. Others imply that more funding is needed. Nursing leaders claim that they can fix shortages with nurse practitioners. They are wrong as are all who claim that training can fix deficits.

This is not a crisis and training interventions cannot fix the shortages of half enough generalists and general specialists for half of the US population.

The fact of the matter is that the real crisis facing physicians, physician associates, and nurse practitioners is too many graduates - and not just by a small amount.

This is Not a Crisis. Deficits of Basic Health Access represent Discrimination, a Designed Disparity, and a Lack of Valuing Most Americans and What Remains of their Health Care

We Must End Discrimination By Design and Stop Exploitation of Those in Need for More Gains for those Doing Best

Workforce shortages are not a crisis because this is a chronic condition.

• There are two Americans - the fewer halves and most have nots. The haves are fewer over time and get more. The have nots are more than a majority and are increasing - and get less. Health care design facilitates disparities.
• And they are worsening the careers of health professionals with policies that help them and fail to help most Americans most behind.

The Good News of the Original Medicare and Medicaid Reforms then Bad, then Ugly

The fact of the matter is that only 1965 to 1978 did our nation and its designers pump more billions into these practices and hospitals where most needed. Cost overruns as those with the most lines of revenue and the highest levels or reimbursement reshaped health policy. The bigs abused the designs forcing cost cutting. Those not biggest suffer in this process.

Newer designs have not improved the health care dollars going to these 2621 counties lowest in workforce - BECAUSE THEY LACK THE DOLLARS AND THE WORKFORCE AS SHAPED BY THE FINANCIAL DESIGN.

Also this one time investment occurred during the same time as the creation and growth of primary care schools and family medicine residency programs and student interest groups and National Health Service Corps - such that many think that these work for primary care. But the real improvements were about the financial design that for this one time improved the capacity of these counties chronically left behind to build up workforce. This time has long passed them by.

Academic Leaders, Nursing Leaders, and Physician Leaders Have Worsened the Situation Facing All Health Professionals Not Near Retirement

The top problem for all health professionals that are not near retirement is the massive overproduction of US MD, DO, PA, and NP. This is a carefully guarded secret as academics control the numbers, the databases, the media, and the workforce research in ways that prevent discovery. Sadly many in academia assume that training more graduates or special training programs are the solution for deficits of workforce. They were taught this when they were in training and they continue to believe this assumption. This has set up the out of control accelerating cycles of decline that will continue until they stop or someone stops them.?

There is also no crisis in workforce as is widely promoted now as the academics and their associations move strongly across the media and into state level activities. The 2621 counties lowest in health care workforce have always had half enough generalists and general specialists and closures and compromises of practices and hospitals have always been about the financial design. Witness the failure despite new types of workforce and massive overexpansions.

Nurse Practitioners - Way Too Many Too Fast for them and for US

NP is the worst offender - increasing annual graduates regularly at 6% a year since the 1990s. Since then there have been two doublings from 10,000 annual graduates past 40,000 a year now. There are no signs of stopping this madness. This rate of growth is 10 times the annual population growth rate of 0.6% and is at least 5 times faster than demand for MD DO NP and PA jobs or dollars for health professionals.?

PA and DO graduates have been expanding at 5% a year for a doubling each 14 years for at least 3 generations of graduates - a rate 8 times faster than population growth. The financial design so compromises primary care such that the last doublings have resulted only in increases of workforce in two areas -?increases in non-primary care workforce and increases of workforce where it is already most concentrated.

The financial design continues to facilitate movements away from primary care and where most needed. For example the 2621 counties lowest in health care workforce have 40% of the population but get only 25% of primary care workforce supported by just 20% of primary care spending.

Other researchers have documented little addition of primary care in a recent doubling using PA entry into primary care at graduation numbers by class year. This is not rocket science. You compare the numbers entering primary care in the different class years. The numbers continue to rise slowly for primary care and massively for non-primary care. And the 20 - 30% more for primary care for the 100% increase in graduates - melts away within a decade due to departures as seen in other PA studies.

DO contributions in primary care - no increase with expansion increases in graduates.

DO primary care contributions have predominantly been about family practice which has declined from 70% in the 1960s to 35% in the 1990s and half of that in the 2010s - for no gain in primary care yield. Each doubling has been compromised for primary care by half as many entering primary care.

And with the combined match, there is no longer a forced choice of family practice as the opportunities for DO medical students have been expanded.??

US MD Joins the Annual Graduate Expansion Race

US MD was conservative in expansion holding at about 15,500 graduates from 1980 (after doubling) until 2003 but the expansion madness took hold and annual graduates are up 35% since 2003 and are increasing at 3 to 4% a year.?

Primary Care Workforce Flat By Design

NP expansions can be seen as adding some primary care numbers. Their leaders trumpet this regularly. But small number increases in primary care are small change compared to their non-primary care explosion. This primary care contribution is a rearrangement of the deck chairs. The fixed financial design for primary care assures no growth. This translates to NP filling positions as physician sources depart for no gain overall.

NP and PA are steadily moving away from family practice. Only family practice positions filled by MD DO NP and PA have 36% found in the 40% of the population lowest in health care workforce concentrations in 2621 counties. When they leave family practice positions, they are following the financial design to better supported specialties and more concentrated workforce counties. NP studies involving relicensure in WA and OR indicate about 25% primary care for active graduates - down considerably from the past.

So the summary is - NP adds minimal numbers in primary care. PA and DO fail to add primary care result with their expansions. US MD expansions are associated with declines in primary care result as so few enter and stay in these careers.?Primary care workforce is flat as is primary care spending as documented by the Graham Center.

Why is this hard to Understand?

Family Practice - Most Distributed and Most Departed

All sources of family practice, including MD and DO, are moving away from primary care such that it takes about 1.5 FM graduates in recent class years to equal the contribution of a single FM residency graduate in 1975. The small expansion of FM graduates at about 1% a year since 1980 is more than negated by declines in primary care yield per graduate.

See who contributes the most years of primary care in a career and who does not. The Standard Primary Care Year measuring tool is the product of primary care retention, years in a career, activity in practice, and a volume adjustment.

It takes more graduates in all sources to come close to the career primary care contribution of a 1975 family medicine residency graduate with maximal primary care retention, years in a career, activity in practice, and volume. FM, IM, and PD graduates were the best contributors but IM has tanked with FM and PD declining in primary care retention and primary care yield during a career. NP was never a good source with fewest years, lowest activity, lower volume, and higher turnover. PA was better with nearly 9 Standard Primary Care Years but has dropped to the 3 level common for NP and IM sources.

Internal medicine has essentially dissolved as so few entered primary care and as fewer have remained and 50,000 are in hospitalist positions. International graduate internal medicine has the same limitations with less than 3 years of primary care delivery on average over their careers. Note that internal medicine is most concentrated and least distributed.

See how the most promoted sources pan out as lowest contributors. See how the past contributions are still believed while the evidence changes. Clinging to the past is not good for the future of workforce planning.

New Opportunities Mean Departures from Primary Care for MD DO NP PA and Primary Care Trained Graduates

Hospitalist, urgent care, emergent care, retail care, and other careers attract more away from primary care and toward existing concentrations. Rural hospitals have often attracted family docs away from rural practices to become rural ER and hospitalist physicians. Hospital based FM is actually better distributed than office based, in the AMA Masterfile. The stronger financial design wins again.

Most Distributed Are Most Abused - By Design

See how family practice is more distributed as it has a higher proportion of the workforce in counties that other specialties avoid. This broadest generalist is a best source for all ages across basic presentations. This also exposes these family practice MD DO NP and PA to abuse where the payments are lower as are the health care workforce concentration. The worst Medicaid, Medicare, and private insurance plans are found in these counties - fixing shortages of workforce in stone. They face higher levels of complexity with lower levels of workforce and social supports and are paid less and this also forces fewer and lesser delivery team members to share the load. This is a specific formula for burnout and financial decline due to lesser productivity, higher turnover costs, and lesser revenue.

No design should pay less where shortages exist. No design such as value based should punish those with the worst financial design serving populations inherently lesser in outcomes - but such is the design now and worse in the future.

Insanity is Trying the Same Solution Over and Over and Over and Over

The DO and US MD expansions are quite ludicrous. There is only benefit for those doing the training. The graduates do have more opportunities to become physicians, but the graduates will likely face an entire career of compromise given

1. Massive overexpansions in these 4 sources
2. NP and PA lower paid and used to pad profits by health care employers
3. NP and PA moving to more new specialties with more added to each specialty and replacing all but the most procedural technical subspecialized services - resulting in fewer needed in these areas as well
4. Fewer and larger and more powerful and more dominant health care employers

Note that the massive overexpansions?hurt some very important areas

1. Distraction from a True Solution for Deficits of Workforce - The expansions have not fixed deficits and cannot fix deficits of generalists, general specialists, and workforce where most Americans face deficits - which are about the financial design not training
2. Overexpansions have facilitated non-primary care and higher health care costs and greater concentrations of workforce while increasing profits for those who already benefit the most from health care design
3. Overexpansions undermine independence and autonomy for all health professionals - especially in NP. Note that this decline in independence and autonomy in practice is the opposite of what NP leaders promise NP students. And yes, NP graduates are complaining already about job and job quality deficits. There will be more in entry level primary care, retail care, emergent care - only to move to better supported careers, specialties, and locations as soon as possible. But their choices will be continually compromised by overexpansion as with MD DO NP and PA.
4. Overexpansions have created the least experienced health care workforce in US history which will likely worsen in areas such as primary care with its bankrupt financial design.?

Again NP is the worst. About 40,000 NP graduate each year (42400 next year, 44,000 the year after) with no experience as an NP and enter a workforce of 350,000 for about 12% with no experience.

NP also has the shortest careers by 10 years, the lowest activity level at 60% (vs 80% for others, building less experience over time), and the highest turnover and departure from primary care and churn between specialties. The overall effect is even less experience in areas such as primary care. This is made worse because primary care is least supported financially. And the impact is magnified where the financial design for primary care is worst.

Retail, urgent, primary care, and ER may have the least experienced in these front line areas for not only NP but for MD DO and PA. Remember that those departing primary care after a few year (more common) take their primary care experience out of the remaining pool of workforce.

Graduates Can Go Where They Want and They Follow the Financial Design - More Freedom Results in Less for the Careers and Locations and Populations Least Supported. This Is a Very Specific Design for the Continued Compromise of Basic Health Access for Most Americans.

The justification for these massive expansions is always the ability to resolve deficits of workforce, but there is no law or regulation to force careers as generalists and general specialists where most Americans have half enough. In fact the moves toward independence and autonomy as well as increases in opportunities for new careers have defeated sources that once contributed to basic health access. Across recent history primary care, mental health, women's health, and basic surgical workforce has been largely missing in action. The counties most in need have the oldest physicians - an indication of lack of replacement. The general specialist physicians are the ones that go into practice after their residency, without taking a fellowship or two. Not only are they oldest in the counties - the nation is experiencing declines in physician workforce in these general specialty areas. This is seen when comparing Masterfile versions over the years.

Greater Autonomy and More Opportunities for NP and PA Translate to Declines in Basic Health Access

Initially NP and PA had to do underserved, rural, or primary care in regulation and due to few opportunities outside. But they have come a long way.?Notice how those promoting new types of workforce always push the relief of shortages as a reason for legislators or others to support this new kind. They also bring up sad stories of those denied a career in medicine such as those that graduated from medical school and did not get a residency, or others from other countries, or medics serving in the armed forces.

New Types of Assistant Physicians or Clinical Pharmacists Are Proposed

But remember that they are just another perpetuation of a chronic problem that will remain without addressing the root cause of shortages of workforce.

Greater Opportunities Exist for Osteopathic Graduates Resulting in Declines in Family Practice - Their Major Source of Primary Care and Distribution

Other than Michigan State residency programs, there were few opportunities for DO grads outside of family medicine. There has always been discrimination in the funding of GME for osteopathic graduates. But this has changed somewhat with the combined match allowing DO and MD to take any residency position offered in any specialty. DO Graduates have the opportunity to choose other specialties and are taking this opportunity.?But primary care and distribution will suffer as with other increases in opportunity, acceptance, autonomy, and independence.

Independence, autonomy, and opportunity combined with the insufficient financial design is particularly bad for primary care serving 40% of the population in 2621 counties lowest in health care workforce.

Primary care in these counties face 45% of complexity with just 25% of the primary care workforce and less than 20% of primary care spending. They have difficulties with integration and coordination as there are half enough general specialists and half enough social supports. Even worse the financial design results in fewer and lesser delivery team members - making higher functioning or patient centered primary care or medical homes or scribes more difficult.

Even worse, these 2621 counties lowest in primary care workforce are growing fastest in population numbers, demand, and complexity as their workforce is designed away.

Meanwhile the higher concentration counties enjoy the best revenue and the slowest growth and the greatest increases in health care dollars and workforce. They also tend to have the best health plans. The populations that they serve have inherently the best outcomes - for even better under value based designs.

The Degree of the Workforce Deficit Really Depends Upon Time - The Discriminations Are More Clear with More Passage of Time

The 32% in lowest concentration counties in the past has grown to 40%. The 40% in 2010 are on course to become 50% by 2060. Only those with major changes in local economics will escape as the better finances will shape better health plans and more and better local workforce. These counties are growing fastest and falling behind faster.

But back to the health professional workforce.

Dominant Health Policies and Health Employer Policies Shape Worse to Come

1. The Era of Cost Cutting from 1983 to at least 2030 and possibly beyond. Remember that cost cutting focus has dominated health policy since the 1980s. This micromanagement has been bad enough for those who need more funding at a time when funding cuts are more prominent. And the cuts high basic and most needed services hardest as those larger can often avoid cuts or make up the losses in other lines or revenue that do not exist where deficits are common. The assumption of overspending resulting in higher health care costs is not applicable where deficits of workforce.
2. Micromanagement of quality (HITECH to ACA to MACRA to value based) has added new complexities and higher costs of delivery that hurt delivery team members already suffering from burnout and fewer and lesser delivery team members by the financial design. They already have fewer and new duties are added. Plus outcomes are often fixed in place by the situations, conditions, behaviors, and other non-clinical factors.
3. Employer Profit Focus - Employers are doing all that they can to cut personnel costs to pad profits.

Cost cutting and higher micromanagement costs are making the financial design worse where America is growing fastest.

Academic leaders continue to exploit the shortages to aid in their expansion dreams - which fails to resolve deficits of workforce. The cycles continue and repeat and accelerate.

The Great and Growing Consequences of Overexpansion

There is a huge issue involved because the careers of all health professionals are impacted by the consequences.?Responsible academic leaders should never expand too fast as US MD and Nursing Leaders have discovered in the past. And when you cut back because you graduated too many, there is the risk of going down to too few. Workforce should match population growth and growth in demand - not massively exceed it.

The lesson of the past is consistent. Workforce in health care has always done best with better treatment when there has been a shortage or even a mild shortage relative to jobs available. There will be no such benefit. The opposite will be more and more true over time.

And of course, the schools and programs and academic entities benefit most from the training along with those who finance tuition and cost of living.?

I admit that it is hard to grasp this, as it took decades of research on my part to begin to question this.

My career in rural medical education was about rural training to fix deficits. I loved working with teens, rural health fairs, college efforts, medical student interest groups, student and resident rural rotations, visiting the rural communities, and working with them on projects for better health or for training. I worked in 5 states on these basic health access efforts.

I could point to the Nebraska efforts as a success, before and after I was there. Studies of UNMC graduates revealed that those who stayed in the pipeline all the way to choice of family medicine were 12 times more likely to be found in a Nebraska county of need compared to those who did not choose FM and UNMC.

But there was a nagging sense of futility over this time.

After tracking Nebraska health care workforce for nearly 20 years when Nebraska had an awesome pipeline to address workforce, there were essentially no improvements in the 70 counties shortest in workforce plus the 14 that never had workforce. It was clear that the expansions were only working for the 9 counties with concentrations of workforce and health care dollars and for those outside of Nebraska that were receiving more and more UNMC graduates as the graduates followed better financial designs outside.

It is important to question assumptions and beliefs and examine the data and evidence basis.

Few are willing to do so in workforce, so the problems remain while other problems multiply and grow - by design.