Primary Care Professionals: Recent Supply Trends, Projections,	 
and Valuation of Services (12-FEB-08, GAO-08-472T).		 
                                                                 
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.				 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-472T					        
    ACCNO:   A80691						        
  TITLE:     Primary Care Professionals: Recent Supply Trends,	      
Projections, and Valuation of Services				 
     DATE:   02/12/2008 
  SUBJECT:   Dentists						 
	     Federal funds					 
	     Funds management					 
	     Health care costs					 
	     Health care personnel				 
	     Health care planning				 
	     Health care policies				 
	     Health care reform 				 
	     Health care services				 
	     Medical education					 
	     Nurses						 
	     Physicians 					 

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GAO-08-472T

   

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Testimony: 

Before the Committee on Health, Education, Labor, and Pensions, U.S. 
Senate: 

United States Government Accountability Office: 

GAO: 

For Release on Delivery Expected at 2:30 p.m. EST: 

Tuesday, February 12, 2008: 

Primary Care Professionals: 

Recent Supply Trends, Projections, and Valuation of Services: 

Statement of A. Bruce Steinwald, Director: 

Health Care: 

GAO-08-472T: 

GAO Highlights: 

Highlights of GAO-08-472T, a testimony before the Committee on Health, 
Education, Labor, and Pensions, U.S. Senate. 

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 professionalsï¿½physicians, 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 systemï¿½s 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 nationï¿½s financial support for primary 
care medicine. Ample research in recent years concludes that the 
nationï¿½s 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 careï¿½all hallmarks of 
primary care medicineï¿½can 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. 

Table: Supply of Primary Care Professionals: 

Primary care physicians; 
Number of primary care professionals: Base year: 208,187; 
Number of primary care professionals: Recent year: 264,086; 
Number of primary care professionals per 100,000 people: Base year: 80; 
Number of primary care professionals per 100,000 people: Recent year: 
90; 
Average annual percentage change per capita: 1.17. 

Physician assistants; 
Number of primary care professionals: Base year: 12,819; 
Number of primary care professionals: Recent year: 23,325; 
Number of primary care professionals per 100,000 people: Base year: 5; 
Number of primary care professionals per 100,000 people: Recent year: 
8; 
Average annual percentage change per capita: 3.89. 

Nurse practitioners; 
Number of primary care professionals: Base year: 44,200; 
Number of primary care professionals: Recent year: 82,622; 
Number of primary care professionals per 100,000 people: Base year: 16; 
Number of primary care professionals per 100,000 people: Recent year: 
28; 
Average annual  change per capita: 9.44. 

Dentists; 
Number of primary care professionals: Base year: 118,816; 
Number of primary care professionals: Recent year: 138,754; 
Number of primary care professionals per 100,000 people: Base year: 46; 
Number of primary care professionals per 100,000 people: Recent year: 
47; 
Average annual percentage change per capita: 0.12. 

Sources: GAO analysis of data from HRSAï¿½s Area Resource File and 
organizations representing primary care professionals. 

Notes: Data on primary care physicians are from 1995 and 2005. Data on 
physician assistants are from 1995 and 2007. Data on nurse 
practitioners are from 1999 and 2005. Data on dentists are from 1995 
and 2007. Data for identical time periods were not available. The 
average annual percentage change is not sensitive to these time period 
differences. 

[End of table] 

What GAO Recommends: 

GAO discussed the contents of this statement with HRSA officials and 
incorporated their comments as appropriate. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-08-472T]. For more information, contact A. 
Bruce Steinwald, (202) 512-7114, or [email protected]. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you prepare to consider the 
reauthorization of health professions education programs established 
under title VII of the Public Health Service Act.[Footnote 1] Most of 
the funding for title VII programs 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. As evidence, 
health policy experts cite a growing income gap between primary care 
physicians and specialists and a declining number of U.S. medical 
students entering primary care specialties--internal medicine, family 
medicine, general practice, and general pediatrics. Moreover, the 
federal agency responsible for implementing title VII programs, the 
Health Resources and Services Administration (HRSA), notes that 
physician "extenders"--namely, physician assistants and nurse 
practitioners--may also be choosing procedure-driven specialties, such 
as surgery, cardiology, and oncology, in increasing numbers.[Footnote 
2],[Footnote 3] 

A paradox commonly cited about the U.S. health care system is that the 
nation spends more per capita than all other industrialized nations but 
ranks consistently low in such quality and access measures as life 
expectancy, infant mortality, preventable deaths, and percentage of 
population with health insurance. Moreover, experts have concluded that 
not all of this spending is warranted, and overutilization of services 
can, in fact, lead to harm.[Footnote 4] These findings come 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. 

To examine the supply of primary care professionals in more detail, you 
asked us to provide information related to the current and future 
supply of these professionals. My remarks today will 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. 

To discuss the recent supply trends for primary care professionals-- 
including information on training and demographic characteristics--we 
obtained data from HRSA's Area Resource File; the American Academy of 
Physician Assistants (AAPA); and the American Academy of Nurse 
Practitioners (AANP). In addition, we reviewed published data from AMA, 
the American Association of Colleges of Nursing (AACN); and the 
American Dental Education Association (ADEA).[Footnote 5] We also 
obtained published annual estimates from the United States Census 
Bureau on the noninstitutionalized, civilian population. 

To obtain information about projections of future supply of primary 
care professionals, we reviewed relevant literature and the position 
statements of organizations representing primary care professionals, 
including the American Academy of Family Physicians (AAFP) and the 
American College of Physicians (ACP). We also interviewed officials 
from HRSA, AAPA, AANP, the American Dental Association (ADA), and the 
Association of American Medical Colleges (AAMC). In selecting workforce 
supply projections for review, we focused on the projected estimates of 
national supply for primary care professionals from the past decade. 

To obtain information on the influence of the health care system's 
financing mechanisms on the valuation of primary care services, we 
reviewed relevant literature on Medicare's resource-based physician fee 
schedule and the influence of primary care supply on costs and quality 
of health care services. 

We assessed the reliability of HRSA's Area Resource File data by 
interviewing officials responsible for producing these data, reviewing 
relevant documentation, and examining the data for obvious 
errors.[Footnote 6] We assessed the reliability of the data provided by 
the AAPA and the AANP by discussing with association officials the 
validation procedures they use to ensure timely, complete, and accurate 
data. We determined the data used in this testimony to be sufficiently 
reliable for our purposes. We discussed a draft of this testimony with 
HRSA officials. They provided technical comments, which we incorporated 
as appropriate. We conducted this work from December 2007 through 
February 2008, in accordance with generally accepted government 
auditing standards. 

In summary, 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 
developing payment system refinements that place a new emphasis on 
primary care services. 

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.[Footnote 7] 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.[Footnote 8] 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,[Footnote 9] 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. 

Table 1: Supply of Primary Care Professionals: 

Primary care physicians[A]; 
Number of primary care professionals: Base year: 208,187; 
Number of primary care professionals: Recent year: 264,086; 
Number of primary care professionals per 100,000 people: Base year: 80; 
Number of primary care professionals per 100,000 people: Recent year: 
90; 
Average annual percentage change per capita: 1.17. 

Physician assistants[B]; 
Number of primary care professionals: Base year: 12,819; 
Number of primary care professionals: Recent year: 23,325; 
Number of primary care professionals per 100,000 people: Base year: 5; 
Number of primary care professionals per 100,000 people: Recent year: 
8; 
Average annual percentage change per capita: 3.89. 

Nurse practitioners[C]; 
Number of primary care professionals: Base year: 44,200; 
Number of primary care professionals: Recent year: 82,622; 
Number of primary care professionals per 100,000 people: Base year: 16; 
Number of primary care professionals per 100,000 people: Recent year: 
28; 
Average annual percentage change per capita: 9.44. 

Dentists[D]; 
Number of primary care professionals: Base year: 118,816; 
Number of primary care professionals: Recent year: 138,754; 
Number of primary care professionals per 100,000 people: Base year: 46; 
Number of primary care professionals per 100,000 people: Recent year: 
47; 
Average annual percentage change per capita: 0.12. 

Sources: GAO analysis of data from HRSA's Area Resource File, AAPA, 
AANP, and the U.S. Census Bureau. 

Notes: Data on primary care professionals for identical time periods 
were not available. The average annual percentage change is not 
sensitive to these time period differences. 

[A] Data on primary care physicians include numbers for both MDs and 
DOs. Data for MDs are from 1995 and 2005, and for DOs are from 1995 and 
2004. 

[B] Data on physician assistants are from 1995 and 2007. Data on the 
total number of physician assistants were obtained from AAPA, then 
weighted by using the percentage of physicians assistants who practiced 
primary care according to the 1995 AAPA membership survey and the 2007 
AAPA physician assistant census survey. 

[C] Data on nurse practitioners are from 1999 and 2005. Data on the 
total number of nurse practitioners were obtained from AANP, then 
weighted by using the percentage of nurse practitioners who practiced 
primary care according to the AANP. 

[D] Data on dentists are from 1995 and 2007. 

[End of table] 

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.) 

Table 2: Supply of Primary Care and Specialty Care Physicians, 1995 and 
2005: 

Primary care physicians; 
Number of physicians: 1995: 208,187; 
Number of physicians: 2005: 264,086; 
Number of physicians per 100,000 people: 1995: 80; 
Number of physicians per 100,000 people: 2005: 90; 
Percentage change per capita: 12. 

Specialty care physicians; 
Number of physicians: 1995: 468,843; 
Number of physicians: 2005: 553,451; 
Number of physicians per 100,000 people: 1995: 181; 
Number of physicians per 100,000 people: 2005: 189; 
Percentage change per capita: 5. 

All physicians; 
Number of physicians: 1995: 677,030; 
Number of physicians: 2005: 817,537; 
Number of physicians per 100,000 people: 1995: 262; 
Number of physicians per 100,000 people: 2005: 280; 
Percentage change per capita: 7. 

Source: GAO analysis of data from HRSA's Area Resource File. 

Note: Numbers do not add to totals due to rounding. 

[End of table] 

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.[Footnote 10] 
Data were not available on the distribution of physician assistants, 
nurse practitioners, or dentists providing primary care in metropolitan 
and nonmetropolitan areas.[Footnote 11] 

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. 

Table 3: Number of Physicians in Residency Programs, in the United 
States, 1995 and 2006: 

Primary care residents; 
Number of resident physicians: 1995: 38,753; 
Number of resident physicians: 2006: 40,982; 
Percentage change: 6. 

Specialty care residents; 
Number of resident physicians: 1995: 59,282; 
Number of resident physicians: 2006: 63,897; 
Percentage change: 8. 

All physician residents; 
Number of resident physicians: 1995: 97,416; 
Number of resident physicians: 2006: 104,526; 
Percentage change: 7. 

Sources: AMA, "Appendix II: Graduate Medical Education," Journal of the 
American Medical Association (JAMA) vol. 276, no. 9 (September 1996) 
and "Appendix II: Graduate Medical Education, 2006-2007," JAMA vol. 
298, no. 9 (September 2007). 

Notes: Primary care residencies include those for family medicine, 
internal medicine, pediatrics, internal medicine/family practice, and 
internal medicine/pediatrics. 

[End of table] 

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.[Footnote 12] 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.) 

Table 4: Number of Physicians in Residency Programs, by USMDs, IMGs, 
and DOs, 1995 and 2006: 

Primary care residents; 
1995: USMDs: 23,801; 
1995: IMGs: 13,025; 
1995: DOs: 1,748; 
2006: USMDs: 22,146; 
2006: IMGs: 15,565; 
2006: DOs: 3,163. 

Specialty care residents; 
1995: USMDs: 45,300; 
1995: IMGs: 11,957; 
1995: DOs: 1,585; 
2006: USMDs: 47,575; 
2006: IMGs: 12,611; 
2006: DOs: 3,466. 

All physician residents; 
1995: USMDs: 69,101; 
1995: IMGs: 24,982; 
1995: DOs: 3,333; 
2006: USMDs: 69,721; 
2006: IMGs: 28,176; 
2006: DOs: 6,629. 

Total (USMDs + IMGs + DOs); 
1995: USMDs: [Empty]; 
1995: IMGs: 97,416; 
1995: DOs: [Empty]; 
2006: USMDs: [Empty]; 
2006: IMGs: 104,526; 
2006: DOs: [Empty]. 

Sources: AMA, "Appendix II: Graduate Medical Education," JAMA vol. 276, 
no. 9 (September 1996) and "Appendix II: Graduate Medical Education, 
2006-2007," JAMA vol. 298, no. 9 (September 2007). 

Note: Primary care residencies include those for family medicine, 
internal medicine, pediatrics, internal medicine/family practice, and 
internal medicine/pediatrics. 

[End of table] 

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.[Footnote 13] 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,[Footnote 14] 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,[Footnote 15] 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,[Footnote 16] in June of 2006, the AAMC called for an expansion of 
U.S. medical schools and federally supported residency training 
positions.[Footnote 17] Other researchers have concluded that there are 
enough practicing physicians and physicians in the pipeline to meet 
current and future demand if properly deployed.[Footnote 18] 

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.[Footnote 19] 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.[Footnote 20] 
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.[Footnote 21] 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.[Footnote 22] 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;[Footnote 23] in contrast, Medicare's fee for a diagnostic 
colonoscopy--a procedural service of similar duration--is 
$449.44.[Footnote 24] 

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.[Footnote 25] 

* 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.[Footnote 26] 

* 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).[Footnote 27] 

* 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.[Footnote 28] 

* 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.[Footnote 29] 

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.[Footnote 30] 

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 [email protected]. 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. 

[End of section] 

Footnotes: 

[1] 42 U.S.C. ï¿½ï¿½ 292 - 295p. 

[2] Physician assistants are health care professionals who practice 
medicine under physician supervision. Physician assistants may perform 
physical examinations, diagnose and treat illnesses, order and 
interpret tests, advise patients on preventive health care, assist in 
surgery, and write prescriptions. Unlike physician assistants, nurse 
practitioners are licensed nurses who work with physicians and have 
independent practice authority in many states. This authority allows 
them to perform physical examinations, diagnose and treat acute 
illnesses and injuries, administer immunizations, manage chronic 
problems such as high blood pressure and diabetes, and order laboratory 
services and x-rays with minimal physician involvement. 

[3] For the purposes of this testimony, we considered primary care 
physicians to be those practicing in family medicine, general practice, 
general internal medicine, and general pediatrics. Some physician 
groups, such as the American Medical Association (AMA), consider 
physicians practicing in obstetrics/gynecology to also be primary care 
physicians. In addition, we considered general dentists and pediatric 
dentists to be primary care dentists. We defined primary care physician 
assistants as those practicing in family practice, general practice, 
general internal medicine, and general pediatrics. We defined primary 
care nurse practitioners as those practicing in adult, family, and 
pediatric medicine. Other types of health professionals, such as 
registered nurses, can provide primary care services in a variety of 
settings, but they were outside the scope of our review. 

[4] For example, noted studies show that Medicare spending for 
physician services varies widely by geographic areas and is unrelated 
to beneficiary health status. Elliott S. Fisher and H. Gilbert Welch, 
"Avoiding the Unintended Consequences of Growth in Medical Care: How 
Might More Be Worse?" Journal of the American Medical Association, vol. 
281, no. 5 (1999), 446-453; E.S. Fisher, et al., "The Implications of 
Regional Variations in Medicare Spending. Part 1: The Content, Quality, 
and Accessibility of Care," Annals of Internal Medicine, vol. 138, no. 
4 (2003), 273-287; E.S. Fisher, et al., "The Implications of Regional 
Variations in Medicare Spending. Part 2: Health Outcomes and 
Satisfaction with Care," Annals of Internal Medicine, vol. 138, no. 4 
(2003), 288-298; and Joseph P. Newhouse, Free for All? Lessons from the 
RAND Health Insurance Experiment (Cambridge, Mass.: Harvard University 
Press, 1993). 

[5] We obtained the most recently available data on supply for each 
professional group, the groups' training programs, and the groups' 
demographic characteristics. We compared the most recent data to a 
prior data point, in many cases 10 years earlier. For primary care 
physicians, we obtained data on supply for 1995 and 2005 from the Area 
Resource File and information on training and demographics from 
published AMA data for 1995 and 2006. For physician assistants, we 
obtained data on supply and demographic characteristics from AAPA for 
1995 and 2007. For nurse practitioners, we obtained data on supply and 
demographic characteristics from AANP for 1999, 2003, and 2005 and 
information on training from published AACN data for 1994 and 2005. For 
dentists, we obtained data on supply for 1995 and 2007 from the Area 
Resource File and information on demographics from published ADEA data 
for 2000 and 2005. 

[6] Data from the AMA Masterfile and the American Osteopathic 
Association (AOA) Masterfile--on which data on physicians in the Area 
Resource File is based--are widely used in studies of physician supply 
because they are a comprehensive list of U.S. physicians and their 
characteristics. 

[7] Allied health professionals include, for example, audiologists, 
dental hygienists, clinical laboratory technicians, occupational 
therapists, physical therapists, medical imaging technologists, and 
speech pathologists. 

[8] For fiscal year 2007, funding for the title VII health professions 
programs was about $183 million. This excluded funding for student 
loans, which did not receive funds through the annual appropriation 
process. 

[9] Allopathic medicine is the most common form of medical practice. 
Graduates of allopathic medical schools receive doctor of medicine (MD) 
degrees. Osteopathic medicine is a form of medical practice similar to 
allopathic medicine that also incorporates manual manipulation of the 
body as a therapy. Graduates of osteopathic medical schools receive 
doctor of osteopathic (DO) medicine degrees. The number of primary care 
physicians includes both MDs and DOs. 

[10] Specialty care physicians are even more concentrated in 
metropolitan areas. In 2005, there were 33 specialty care physicians 
per 100,000 people in nonmetropolitan areas, compared with 200 
specialty care physicians per 100,000 people in metropolitan areas. In 
total, there were 87 physicians per 100,000 people in nonmetropolitan 
areas and 293 physicians per 100,000 people in metropolitan areas in 
2005. 

[11] One researcher, analyzing HRSA data, reported that in 2007 more 
than 30 million people were living in areas with too few dentists. 
Shelly Gehshan, "Foundations' Role in Improving Oral Health: Nothing to 
Smile About," Health Affairs, vol. 27, no. 1 (2008). 

[12] Physicians who enter U.S. residency programs include graduates of 
both U.S. medical schools and foreign medical schools. Physicians from 
foreign medical schools--international medical graduates--can be 
citizens of other countries or U.S. citizens who attended medical 
school abroad. 

[13] HRSA's Health Careers Opportunity Program defines underrepresented 
minorities as racial and ethnic groups that are underrepresented in the 
health professions relative to their numbers in the general population. 
According to HRSA, African Americans, Hispanics, American Indians, and 
Alaska Natives are underrepresented in the health professions. During 
the period we examined, minority representation increased among the 
general population. Specifically, from 1995 to 2006, the proportion of 
African-Americans in the general population increased from 12.0 percent 
to 12.3 percent; the proportion of Hispanics increased from 10.3 
percent to 14.8 percent; and the proportion of American Indian/Alaska 
Natives increased from 0.7 percent to 0.8 percent. 

[14] American Dental Association, "Survey and Economic Research on 
Dentistry: Frequently Asked Questions" (Chicago, Ill.: American Dental 
Association), [hyperlink, http://www.ada.org/ada/prod/survey/faq.asp] 
(accessed Jan. 7, 2008). 

[15] Richard A. Cooper et al., "Economic and Demographic Trends Signal 
an Impending Physician Shortage," Health Affairs, vol. 21, no. 1 
(2002). 

[16] OGME, "Sixteenth Report: Physician Workforce Policy Guidelines for 
the United States, 2000-2020" (January 2005). 

[17] AMC, "AAMC Statement on the Physician Workforce" (June 2006). 

[18] David Goodman et al., "End-Of-Life Care At Academic Medical 
Centers: Implications For Future Workforce Requirements," Health 
Affairs, vol. 25 no. 2 (2006) and Jonathan P. Weiner, "Prepaid Group 
Practice Staffing And U.S. Physician Supply: Lessons For Workforce 
Policy," Health Affairs, Web Exclusive (Feb. 4, 2004). 

[19] COGME does not currently hold a position on the appropriate ratio 
of primary care physicians to specialty physicians. This is in contrast 
to the position COGME held from 1992 through 2004, which recommended 
that half of all physicians should be primary care physicians. 

[20] U.S. Department of Health and Human Services, HRSA, Bureau of 
Health Professions, "Physician Supply and Demand: Projections to 2020" 
(October 2006) and AAFP, "Family Physician Workforce Reform (as 
approved by the 2006 Congress of Delegates) Recommendations of the 
AAFP" (September 2006). 

[21] The FTE projection takes into account an expected decrease in the 
number of hours worked by physicians due to demographic workforce 
changes, including a greater share of female physicians and older 
physicians, some of whom are likely to work less than full-time. 

[22] Evaluation and management (E/M) services refer to office visits 
and consultations furnished by physicians. To bill for their service, 
physicians select a common procedural terminology (CPT) code that best 
represents the level of E/M service performed based on three elements: 
patient history, examination, and medical decision making. The 
combination of these three elements can range from a very limited 10- 
minute face-to-face encounter to a very detailed examination requiring 
an hour of the physician's time. 

[23] The fee for this service in Boston, Mass., is represented on the 
fee schedule as CPT code 99214. 

[24] The fee for this service in Boston, Mass., is represented on the 
fee schedule as CPT code 45378. 

[25] A.B Bindman et al., "Primary Care and Receipt of Preventive 
Services," Journal of General Internal Medicine vol. 11, no. 5 (1996); 
D.G. Safran et al., "Linking Primary Care Performance to Outcomes of 
Care," Journal of Family Practice, vol. 47, no. 3 (1998); and A.C. Beal 
et al., "Closing the Divide: How Medical Homes Promote Equity in Health 
Care: Results From The Commonwealth Fund 2006 Health Care Quality 
Survey" (The Commonwealth Fund, June 2007). 

[26] B. Starfield et al., "The Effects Of Specialist Supply On 
Populations' Health: Assessing The Evidence," Health Affairs web 
exclusive (2005). 

[27] B. Starfield et al., "Contribution of Primary Care to Health 
Systems and Health," Milbank Quarterly, vol. 83, no. 3 (2005). 

[28] K. Baicker and A. Chandra, "Medicare Spending, the Physician 
Workforce, and Beneficiaries' Quality of Care," Health Affairs web 
exclusive (2004). 

[29] M. Parchman et al, "Primary Care Physicians and Avoidable 
Hospitalizations," Journal of Family Practice, vol. 39, no. 2 (1994). 

[30] AAFP, AAP, ACP, AOA, "Joint Principles of the Patient-Centered 
Medical Home" (March 2007). 

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