Background

Among other things, title VII programs support the education and training  of primary care providers, such as primary care physicians, physician  assistants, general dentists, pediatric dentists, and allied health  practitioners. HRSA includes in its definition of primary care services,  health services related to family medicine, internal medicine, preventative  medicine, osteopathic general practice, and general pediatrics that are  furnished by physicians or other types of health professionals. Also, HRSA  recognizes diagnostic services, preventive services (including  immunizations and preventive dental care), and emergency medical  services as primary care. Thus, in some cases, nonprimary care  practitioners provide primary care services to populations that they serve.
Title VII programs support a wide variety of activities related to this broad  topic. For example, they provide grants to institutions that train health  professionals; offer direct assistance to students in the form of  scholarships, loans, or repayment of educational loans; and provide  funding for health workforce analyses, such as estimates of supply and  demand. In recent years, title VII programs have focused on three specific  areas of need—improving the distribution of health professionals in  underserved areas such as rural and inner-city communities, increasing  representation of minorities and individuals from disadvantaged  backgrounds in health professions, and increasing the number of primary  care providers. For example, the Scholarships for Disadvantaged Students  Program awards grants to health professions schools to provide  scholarships to full-time, financially needy students from disadvantaged  backgrounds, many of whom are minorities.

		Primary Care Education and Training Programs

After completing medical school, medical students enter a multiyear  training program called residency, during which they complete their  formal education as a physician. Because medical students must select  their area of practice specialty as part of the process of being matched into  a residency program, the number of physician residents participating in  primary care residency programs is used as an indication of the likely  future supply of primary care physicians. Physician residents receive most  of their training in teaching hospitals, which are hospitals that operate one  or more graduate medical education programs. Completion of a physician  residency program can take from 3 to 7 years after graduation from  medical school, depending on the specialty or subspecialty chosen by the  physician. Most primary care specialties require a 3-year residency  program. In some cases, primary care physicians may choose to pursue  additional residency training and become a subspecialist—such as a  pediatrician who specializes in cardiology. In this case, the physician  would no longer be considered a primary care physician, but rather, a  cardiologist.
According to the AAPA, most physician assistant programs require  applicants to have some college education. The average physician  assistant program takes about 26 months, with classroom education  followed by clinical rotations in internal medicine, family medicine,  surgery, pediatrics, obstetrics and gynecology, emergency medicine, and  geriatric medicine. Physician assistants practice in primary care medicine,  including family medicine, internal medicine, pediatrics, and obstetrics  and gynecology, as well in surgical specialties.
After completion of a bachelor’s degree in nursing, a nurse may become a  nurse practitioner after completing a master’s degree in nursing.  According to the AACN, full-time master’s programs are generally 18 to   24 months in duration and include both classroom and clinical work.  Nurse practitioner programs generally include areas of specialization such  as acute care, adult health, child health, emergency care, geriatric care,  neonatal health, occupational health, and oncology.
Dentists typically complete 3 to 4 years of undergraduate university  education, followed by 4 years of professional education in dental school.  The 4 years of dental school are organized into 2 years of basic science  and pre-clinical instruction followed by 2 years of clinical instruction.  Unlike training programs for physicians, there is no universal requirement  for dental residency training. However, a substantial proportion of  dentists—about 65 percent of dental school graduates—enroll in dental  specialty or general dentistry residency programs.

	Supply of Primary Care Professionals Increased; Little Data Available on Minority Representation

In recent years, the supply of primary care professionals increased, with  the supply of nonphysicians increasing faster than physicians. The  numbers of primary care professionals in training programs also  increased. Little information was available on trends during this period  regarding minorities in training or actively practicing in primary care  specialties.

		In Recent Years, Supply of Primary Care Professionals Increased

In recent years, the number of primary care professionals nationwide grew  faster than the population, resulting in an increased supply of primary care  professionals on a per capita basis (expressed per 100,000 people). Table 1  shows that over roughly the last decade, per capita supply of primary care  physicians—internists, pediatricians, general practice physicians, and  family practitioners—rose an average of about 1 percent per year, while  the per capita supply of nonphysician primary care professionals— physician assistants and nurse practitioners—rose faster, at an average of  about 4 percent and 9 percent per year, respectively. Nurse practitioners  accounted for most of the increase in nonphysician primary care  professionals. The per capita supply of primary care dentists—general  dentists and pediatric dentists—remained relatively unchanged.
Growth in the per capita supply of primary care physicians outpaced  growth in the per capita supply of physician specialists by 7 percentage  points in the 1995-2005 period. (See table 2.)
By definition, aggregate supply figures do not show the distribution of  primary care professionals across geographic areas. Compared with  metropolitan areas, nonmetropolitan areas, which are more rural and less  populated, have substantially fewer primary care physicians per 100,000  people. In 2005, there were 93 primary care physicians per 100,000 people  in metropolitan areas, compared with 55 primary care physicians per  100,000 people in nonmetropolitan areas. Data were not available on the  distribution of physician assistants, nurse practitioners, or dentists  providing primary care in metropolitan and nonmetropolitan areas.

		Number of Primary Care Professionals in U.S. Training Programs Increased from 1995 to 2006

For two groups of primary care professionals—physicians and nurse  practitioners—the number in primary care training has increased in recent  years. Over the same period, the number of primary care training  programs for physicians declined, while programs for nurse practitioners  increased. Comparable information for physician assistants and dentists  was not available.
From 1995 to 2006, the number of physician residents in primary care  training programs increased 6 percent, as shown in table 3. Over this same  period, primary care residency programs declined, from 1,184 programs to  1,145 programs.
The composition of primary care physician residents changed from 1995 to  2006. A decline in the number of allopathic U.S. medical school graduates  (known as USMD) selecting primary care residencies was more than offset  by increases in the numbers of international medical graduates (IMG) and  doctor of osteopathy (DO) graduates entering primary care residencies.  Specifically, from 1995 to 2006, USMD graduates in primary care  residencies dropped by 1,655 physicians, while the number of IMGs and  DOs in primary care residencies rose by 2,540 and 1,415 physicians  respectively. (See table 4.)
From 1994 to 2005, the number of primary care training programs for  nurse practitioners and the number of graduates from these programs  grew substantially. During this period, the number of nurse practitioner  training programs increased 61 percent, from 213 to 342 programs. The  number of primary care graduates from these programs increased   157 percent from 1,944 to 5,000.

		Little Information Available Regarding Minorities in Training or Actively Practicing In Primary Care Specialties

Little information was available regarding participation of minority health  professionals in primary care training programs or with active practices in  primary care. Physicians were the only type of primary care professional  for whom we found information on minority representation. We found  information not specific to primary care for physician assistants, nurse  practitioners, and dentists identified as minorities, which may be a  reasonable substitute for information on proportions of minorities in  primary care.
For physicians, we used the proportion of minority primary care residents  as a proxy measure for minorities in the active primary care physician  workforce. From 1995 to 2006, the proportion of primary care residents  who were African-American increased from 5.1 percent to 6.3 percent; the  proportion of primary care residents who were Hispanic increased from  5.8 percent to 7.6 percent. Data on American Indian/Alaska Natives were  not collected in 1995, so this group could not be compared over time; in  2006, 0.2 percent of primary care residents were identified as American  Indian/Alaska Natives.
Minority representation among each of the other health professional  types—overall, not by specialty—increased slightly. AAPA data show that  from 1995 to 2007, minority representation among physician assistants  increased from 7.8 percent to 8.4 percent. AANP data show that from 2003  to 2005, minority representation among nurse practitioners increased from  8.8 percent to 10.0 percent. ADEA data show that from 2000 to 2005, the  proportion of African-Americans among graduating dental students rose  slightly from 4.2 percent to 4.4 percent, while the proportion of Hispanics  among graduating dental students increased from 4.9 percent to   5.9 percent. The proportion of Native American/Alaska Native among  graduating dental students grew from 0.6 percent to 0.9 percent.
Other demographic characteristics of the primary care workforce have  also changed in recent years. In two of the professions that were  traditionally dominated by men in previous years—physicians and  dentists—the proportion of women has grown or is growing. Between  1995 and 2006, the proportion of primary care residents who were women  rose from 41 percent to 51 percent. Growth of women in dentistry is more  recent. In 2005, 19 percent of professionally active dentists were women,  compared with almost 45 percent of graduating dental school students  who were women.

	Uncertainties Exist in Projecting Future Supply of Health Care Professionals; Few Projections Are Specifically for Primary Care

Accurately projecting the future supply of primary care health  professionals is difficult, particularly over long time horizons, as  illustrated by substantial swings in physician workforce projections during  the past several decades. Few projections have focused on the likely  supply of primary care physician or nonphysician primary care  professionals.

		History of Physician Workforce Supply Predictions Illustrates Uncertainties in Forecasting

Over a 50-year period, government and industry groups’ projections of  physician shortfalls gave way to projections of surpluses, and now the  pendulum has swung back to projections of shortfalls again. From the  1950s through the early 1970s, concerns about physician shortages  prompted the federal and state governments to implement measures  designed to increase physician supply. By the 1980s and through the 1990s,  however, the Graduate Medical Education National Advisory Committee  (GMENAC), the Council on Graduate Medical Education (COGME), and  HRSA’s Bureau of Health Professions were forecasting a national surplus  of physicians. In large part, the projections made in the 1980s and 1990s  were based on assumptions that managed care plans—with an emphasis  on preventive care and reliance on primary care gatekeepers exercising  tight control over access to specialists—would continue to grow as the  typical health care delivery model. In fact, managed care did not become  as dominant as predicted and, in recent years, certain researchers, such as  Cooper, have begun to forecast physician shortages. COGME’s most  recent report, issued in January 2005, also projects a likely shortage of  physicians in the coming years and, in June of 2006, the AAMC called for  an expansion of U.S. medical schools and federally supported residency  training positions. Other researchers have concluded that there are  enough practicing physicians and physicians in the pipeline to meet  current and future demand if properly deployed.

		Few Projections Address Future Supply of Primary Care Professionals

Despite interest in the future of the health care workforce, few projections  directly address the supply of primary care professionals. Recent  physician workforce projections focus instead on the supply of physicians  from all specialties combined. Specifically, the projections recently  released by COGME point to likely shortages in total physician supply but  do not include projections specific to primary care physicians. Similarly,  ADA’s and AAPA’s projections of the future supply of dentists and  physician assistants do not address primary care practitioners separately  from providers of specialty care. AANP has not developed projections of  future supply of nurse practitioners.
We identified two sources—an October 2006 report by HRSA and a  September 2006 report by AAFP—that offer projections of primary care  supply and demand, but both are limited to physicians. HRSA’s  projections indicate that the supply of primary care physicians will be  sufficient to meet anticipated demand through about 2018, but may fall  short of the number needed in 2020. AAFP projected that the number of  family practitioners in 2020 could fall short of the number needed,  depending on growth in family medicine residency programs.
HRSA based its workforce supply projections on the size and  demographics of the current physician workforce, expected number of  new entrants, and rate of attrition due to retirement, death, and disability.  Using these factors, HRSA calculated two estimates of future workforce  supply. One projected the expected number of primary care physicians,  while the other projected the expected supply of primary care physicians  expressed in full-time equivalent (FTE) units. According to HRSA, the  latter projection, because it adjusts for physicians who work part-time, is  more accurate. The agency projected future need for primary care  professionals based largely on expected changes in U.S. demographics,  trends in health insurance coverage, and patterns of utilization. HRSA  predicted that the supply of primary care physicians will grow at about the  same rate as demand until about 2018, at which time demand will grow  faster than supply. Specifically, HRSA projected that by 2020, the  nationwide supply of primary care physicians expressed in FTEs will be  271,440, compared with a need for 337,400 primary care physicians. HRSA  notes that this projection, based on a national model, masks the  geographic variation in physician supply. For example, the agency  estimates that as many as 7,000 additional primary care physicians are  currently needed in rural and inner-city areas and does not expect that  physician supply will improve in these underserved areas.
In a separate projection, AAFP reviewed the number of family  practitioners in the United States. AAFP’s projections of future supply  were based on the number of active family practice physicians in the  workforce and the number of completed family practice residencies in  both allopathic and osteopathic medical schools. AAFP’s projections of  need relied on utilization rates adjusted for mortality and socioeconomic  factors. Specifically, AAFP estimated that 139,531 family physicians would  be needed by 2020, representing about 42 family physicians per 100,000  people in the United States. To meet this physician-to-population ratio,  AAFP estimated that family practice residency programs in the aggregate  would need to expand by 822 residents per year.
Both reports noted the difficulties inherent in making predictions about  future physician workforce supply and demand. Essentially, they noted  that projections based on historical data may not necessarily be predictive  of future trends. They cite as examples the unforeseen changes in medical  technology innovation and the multiple factors influencing physician  specialty choice. Additionally, HRSA noted that projection models of  supply and demand incorporate any inefficiencies that may be present in  the current health care system.

	Move Toward Primary Care Medicine, A Key to Better Quality and Lower Costs, Is Impeded by Health Care System’s Current Financing Mechanisms

Health professional workforce projections that are mostly silent on the  future supply of and demand for primary care services are symptomatic of  an ongoing decline in the nation’s financial support for primary care  medicine. Ample research in recent years concludes that the nation’s over  reliance on specialty care services at the expense of primary care leads to  a health care system that is less efficient. At the same time, research  shows that preventive care, care coordination for the chronically ill, and  continuity of care—all hallmarks of primary care medicine—can achieve  better health outcomes and cost savings. Despite these findings, the  nation’s current financing mechanisms result in an atomized and  uncoordinated system of care that rewards expensive procedure-based  services while undervaluing primary care services. However, some  physician organizations—seeking to reemphasize primary care services— are proposing a new model of delivery.

		Payment Systems That Undervalue Primary Care Appear to Be Counterproductive

Fee-for-service, the predominant method of paying physicians in the U.S.,  encourages growth in specialty services. Under this structure, in which  physicians receive a fee for each service provided, a financial incentive  exists to provide as many services as possible, with little accountability for  quality or outcomes. Because of technological innovation and  improvements over time in performing procedures, specialist physicians  are able to increase the volume of services they provide, thereby  increasing revenue. In contrast, primary care physicians, whose principal  services are patient office visits, are not similarly able to increase the  volume of their services without reducing the time spent with patients,  thereby compromising quality. The conventional pricing of physician  services also disadvantages primary care physicians. Most health care  payers, including Medicare—the nation’s largest payer—use a method for  reimbursing physician services that is resource-based, resulting in higher  fees for procedure-based services than for office-visit “evaluation and  management” services. To illustrate, in one metropolitan area, Boston,  Massachusetts, Medicare’s fee for a 25 to 30-minute office visit for an  established patient with a complex medical condition is $103.42; in  contrast, Medicare’s fee for a diagnostic colonoscopy—a procedural  service of similar duration—is $449.44.
Several findings on the benefits of primary care medicine raise concerns  about the prudence of a health care payment system that undervalues  primary care services. For example:    Patients of primary care physicians are more likely to receive preventive  services, to receive better management of chronic illness than other  patients, and to be satisfied with their care.
Areas with more specialists, or higher specialist-to-population ratios, have  no advantages in meeting population health needs and may have ill effects  when specialist care is unnecessary.
States with more primary care physicians per capita have better health  outcomes—as measured by total and disease-specific mortality rates and  life expectancy—than states with fewer primary care physicians (even  after adjusting for other factors such as age and income).
States with a higher generalist-to-population ratio have lower per- beneficiary Medicare expenditures and higher scores on 24 common  performance measures than states with fewer generalist physicians and  more specialists per capita.
The hospitalization rates for diagnoses that could be addressed in  ambulatory care settings are higher in geographic areas where access to  primary care physicians is more limited.

		Some Health Care Reform Proposals Seek to Reemphasize Primary Care Medicine

In recognition of primary care medicine’s value with respect to health care  quality and efficiency, some physician organizations are proposing a new  model of health care delivery in which primary care plays a central role.  The model establishes a “medical home” for patients—in which a single  health professional serves as the coordinator for all of a patient’s needed  services, including specialty care—and refines payment systems to ensure  that the work involved in coordinating a patient’s care is appropriately  rewarded.
More specifically, the medical home model allows patients to select a  clinical setting—usually their primary care provider’s practice—to serve as  the central coordinator of their care. The medical home is not designed to  serve as a “gatekeeper” function, in which patients are required to get  authorization for specialty care, but instead seeks to ensure continuity of  care and guide patients and their families through the complex process of  making decisions about optimal treatments and providers. AAFP has  proposed a medical home model designed to provide patients with a  basket of acute, chronic, and preventive medical care services that are,  among other things, accessible, comprehensive, patient-centered, safe, and  scientifically valid. It intends for the medical home to rely on technologies,  such as electronic medical records, to help coordinate communication,  diagnosis, and treatment. Other organizations, including ACP, the  American Academy of Pediatrics (AAP), and AOA, have developed or  endorsed similar models and have jointly recommended principles to  describe the characteristics of the medical home.
Proposals for the medical home model include a key modification to  conventional physician payment systems—namely, that physicians receive  payment for the time spent coordinating care. These care coordination  payments could be added to existing fee schedule payments or they could  be included in a comprehensive, per-patient monthly fee. Some physician  groups have called for increases to the Medicare resource-based fee  schedule to account for time spent coordinating care for patients with  multiple chronic illnesses. Proponents of the medical home note that it  may be desirable to develop payment models that blend fee-for-service  payments with per-patient payments to ensure that the system is  appropriately reimbursing physicians for primary, specialty, episodic, and  acute care.

	Concluding Observations

In our view, payment system reforms that address the undervaluing of  primary care should not be strictly about raising fees but rather about  recalibrating the value of all services, both specialty and primary care.  Resource-based payment systems like those of most payers today do not  factor in health outcomes or quality metrics; as a consequence, payments  for services and their value to the patient are misaligned. Ideally, new  payment models would be designed that consider the relative costs and  benefits of a health care service in comparison with all others so that  methods of paying for health services are consistent with society’s desired  goals for health care system quality and efficiency.
Mr. Chairman, this concludes my prepared statement. I will be happy to  answer any questions that you or Members of the committee may have.

	Contact and Acknowledgments

For information regarding this testimony, please contact A. Bruce  Steinwald at 202-512-7114 or steinwalda@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Jenny Grover, Assistant Director; Sarah  Burton; Jessica Farb; Hannah Fein; Martha W. Kelly; and Sarabeth Zemel  made key contributions to this statement.
This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.

Summary:
Why GAO Did This Study

Most of the funding for programs under title VII of the Public Health Service Act goes toward primary care medicine and dentistry training and increasing medical student diversity. Despite a longstanding objective of title VII to increase the total supply of primary care professionals, health care marketplace signals suggest an undervaluing of primary care medicine, creating a concern about the future supply of primary care professionals--physicians, physician assistants, nurse practitioners, and dentists. This concern comes at a time when there is growing recognition that greater use of primary care services and less reliance on specialty services can lead to better health outcomes at lower cost. GAO was asked to focus on (1) recent supply trends for primary care professionals, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals, including the factors underlying these projections; and (3) the influence of the health care system's financing mechanisms on the valuation of primary care services. GAO obtained data from the Health Resources and Services Administration (HRSA) and organizations representing primary care professionals. GAO also reviewed relevant literature and position statements of these organizations.

What GAO Found

In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties. For the future, health professions workforce projections made by government and industry groups have focused on the likely supply of the physician workforce overall, including all specialties. Few projections have focused on the likely supply of primary care physician or other primary care professionals. Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation's financial support for primary care medicine. Ample research in recent years concludes that the nation's over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care--all hallmarks of primary care medicine--can achieve improved outcomes and cost savings. Conventional payment systems tend to undervalue primary care services relative to specialty services. Some physician organizations are proposing payment system refinements that place a new emphasis on primary care services.