• Ensuring Primary Care Access in States with an Aging Family Physician Workforce

    One Pagers | Jun 15, 2019
    Elizabeth Wilkinson, BA; Emma Bazemore; and Yalda Jabbarpour, MD

    The United States depends on a robust primary care work- force to achieve the Institute for Healthcare Improvement Triple Aim goal of population health delivered at lower cost and with an improved patient care experience. With nearly 40% of U.S. family physicians older than 55 years, policymakers should support broad-spectrum training models that produce enough primary care physicians to meet state population needs.

    In 2018, the World Health Organization reaffirmed the critical role of primary care in driving efficiency, effective- ness, and equity in health systems.1 Access to primary care physicians has been shown to positively influence a range of health outcomes vital to a delivery system increasingly driven by paying for value and the health of populations.2,3 With the decreasing production of general internal medicine physicians because of increases in hospitalists and non–primary care subspecialization, family physicians play a critical role in ensuring a robust primary care workforce.4 However, an aging family physician workforce is a threat to primary care access.

    Using data from the 2018 American Medical Association (AMA) Physician Masterfile, we identified primary care physicians (i.e., family physicians, general internists, geriatricians, general pediatricians, and general practitioners) in direct patient care and used their geocoded addresses to map their distribution. We supplemented the total number of doctors of osteopathy in the AMA Physician Masterfile with 2016 Centers for Medicare and Medicaid Services’ National Plan and Provider Enumeration System data and Physician Compare data. We identified and excluded hospitalists using 2016 Medicare Provider Utilization and Payment data with methods by Kuo, et al., 2009, and accounted for retired physicians using a method by Petterson, et al., 2016.5,6

    We found that, on average, family physicians make up 40% of the primary care physician workforce. We designate “40-40 states” as those with at least 40% of their primary care physician workforce made up of family physicians.

    The information and opinions in this article do not necessarily reflect the views or the policy of the AAFP.

    Author disclosure: No relevant financial affiliations. June 15, 2019 ◆ Volume 99, Number 12

    40-40 states: disproportionate threat of family physician retirement in rural states. Shaded states are designated as 40-40. This designation means that at least 40% of the state’s primary care physician workforce is made up of family physicians and at least 40% of its family physicians are older than 55 years (includes only physicians in direct patient care).

    Data from the 2018 American Medical Association Physician Masterfile. Restricted using methods described in this article.


    1. World Health Organization. Declaration of Astana. Astana, Kazakh- stan; 2018. https://www.who.int/docs/default-source/primary-health/ declaration/gcphc-declaration.pdf. Accessed May 27, 2019.
    2. Starfield B, Shi L, Macinko J. Contribution of primary care to health sys- tems and health. Milbank Q. 2005;83(3):457-502.
    3. Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Asso- ciation of primary care physician supply and population mortality in the United States, 2005-2015. JAMA Intern Med. 2019;179(4):506-514.
    4. Dalen JE, Ryan KJ. United States medical school expansion: impact on primary care. Am J Med. 2016;129(12):1241-1243.
    5. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009; 360(11):1102-1112.
    6. Petterson SM, Rayburn WF, Liaw WR. When do primary care physicians retire? Ann Fam Med. 2016;14(4):344-349.

    The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.

    Published in American Family Physician, February 1, 2019. Am Fam Physician. 2019;99(3):153. This series is coordinated by Kenny Lin, MD, MPH, Deputy Editor for AFP.