Friday, July 18, 2014

Health Care Delivery Is No Laughing Matter

The Myth of Coverage Equals Care

Political cartoons lampoon one side or the other with ACA a common topic. A popular cartoon from Being Liberal depicts the Elephant in therapy after realizing the lack of failure of Obamacare, resulting in treatment for depression - a mental health condition which is covered under ACA. While intended for humor, the cartoon fails to raise the most important awareness:

More than coverage is required for needed care delivery.

The elements of the carton: 
  • Realizing - Those not able to gain awareness, will have a difficult time with therapy. Awareness of basic care needs has failed for Republics and Democrats for some time.
  • ACA isn't a failure, but it is not a success - especially in needed care areas
  • Depression may be "covered," but just try to find mental health care providers and services, or get approval for same from your "insurance" coverage.

Pay remains insufficient for primary care, for mental health, and for basic services (general surgical services) for the past three decades of payment designs

An entire generation of poor support has led to an entire generation of class years of MD, DO, NP, and PA graduates making other choices guided by highest health spending and better support for more specialized care, resulting in the current deficits where basic care is needed.

This is why the primary care delivery capacity, mental health delivery capacity, and basic service delivery capacity remains low - with shrinkage of the workforce despite rapidly increasing demand.

Stagnant health spending is bad enough. A pittance of funding increases go to pay for CEOs, administrators, management, innovations, consultants, billing personnel, health insurance companies, software companies, and technology - but not for more clinicians and teams to deliver the care. Shrinkage of care with higher or same cost is the opposite of value-based.

Disruptive innovation is a most appropriate term for what is going on, as basic services are being disrupted with innovation focus a reason. Distractive innovation is an appropriate term. Other common distractions are claims of being a solution, when no solution is possible because of designs for training and designs for payment. 

Returning Health and Life and Purpose to Health Care 

Health care delivery is mostly about people delivering health care to people - something that was taken out of health care design 3 decades ago. Poor awareness on the part of Republicans and Democrats and those who design health care will continue to prevent care where needed.

Cartoons are a good way to raise awareness, but the awareness that needs to be addressed is about failure in basic foundation types of care over decades of designs. 

Even the small proportion of spending for primary care in the United States would likely be enough, based on spending in other nations. However, the spending needs to be specific to the support of those that actually deliver the care - something avoided for decades.

Recent Works

Overcoming Barriers to Health Access Including ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

Best of Basic Health Access

Blogs indicate that primary care can be recovered and should be recovered, but it will take 30 consistent class years of improvement for actual recovery. We have to have at least one to begin.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

Thursday, July 17, 2014

Overcoming Hurdles to Health Access Including ACA

(And other 3 letter acronyms representing failure for the past three decades)

A nation divided continues to either promote ACA or protest it. Regardless of pro or con, many barriers to care remain as with health care designs 1983 to 2014 and beyond.

This post was stimulated by a recent family medicine piece reviewed situations facing practices in Sugar Land and Arlington in Texas. It is true that all practices face the challenge of patients who do not understand how insurance works. But there are substantial health access barriers that remain and ACA may actually complicate health access for those in need of care. Focus must be returned to the substantial health access failures with minimal distractions.

It is frustrating to see illustrations of practices in wealthier areas such as Sugar Land Texas. At these locations FM competes with a wide range of other providers for patients with insurance coverage better than ACA, Medicaid, and Medicare. It is not a surprise to see family medicine move steadily toward a focus on marketing – essential for competitive types of practices. But for those devoted to health access, the substantial resources involved in Primary Care Medical Home or other families of family medicine efforts could have been expended in ways that would have helped the half of family physicians where care is most needed.

Future of Family Medicine I, II, III… should be more about the incredible contributions of family physicians with regard to health access.

The great challenge of health care for our time is care for 40 – 50% of Americans who remain behind under state and national designs. Designs for the recovery of health access are the opposite of current US designs.

Family medicine leaders and various advocates of primary care, rural health, or care where needed may desire to praise the efforts of the current administration just like past administrations, but our primary responsibility is to the patients of family physicians and needed health improvements in our communities.

All family physicians should embrace a uniform approach to resolving health access involving improvements in who becomes a physician, how physicians are trained, and how they are supported – all specific to health access result.

Failure from Beginning to End

Factors important in distribution where needed are family medicine choice, residency in a state in need of physicians, medical school in a state in need of physicians, and physician origins associated with states and counties in need of care.

Linking up instate, permanent primary care FM, and training where care is needed is a solution. The chronological beginning step for improve health access is origin associated with counties in need of physicians.

When physicians arise from counties of need, they are more likely to be found in family medicine, primary care, and counties in need of care. Linear relationships exist from most to least.

Exclusive origins tend to fail for distribution.
Normal origins facilitate practice where needed.

Physician origins more closely associated with care where needed, primary care result, and family medicine result are about normal origins. Most exclusive physician origins are lowest yield for physicians to serve where needed. Solutions are about those multiple more times likely rather than those with reduced probability.

Texas is not different than other states in its failure to progress students arising from populations in most need of workforce. Physician origin failure is about most children left behind while fewer advantaged children progress to higher education and medical school. Widening gaps across the nation worsen this situation.

The US designs insure that advantaged children least like normal Americans have 2 – 8 times greater chance of admission and disadvantaged children (most children) have 2 to 4 times less (Birth Origins Studies). Widening gaps across income, education, health care, and other spending designs insure fewer doing well and more doing less well.

The probability of becoming a physician is made worse for children in states that have not invested as much at all levels from child development to early education to in higher education including medical education. Many medical schools have found ways to admit more students who are out of state in origin or otherwise least connected to the state. At Nebraska such students as well as those with Omaha or Lincoln origins have 2% family medicine choice – the opposite from the instate, family medicine, where needed solution for Nebraska.

American born children also have even lower probability of becoming a physician as 25% of entering US physicians are graduates of medical schools in other nations. International graduates also have limitations in distribution where needed and primary care result due to few choosing the only remaining permanent primary care source – family medicine.

Texas med schools (except for 1) fail for family medicine result - the only multiplier of care where needed. The medical schools that used to graduate family physicians in the 1990s across all states in need, now have substantially reduced FM production.

The US design for GME fails for primary care, for states in need of care, and for nearly all Texas counties in need of care.

A continuity design for preparation, medical school, and FM residency with pure FM result is increasingly the only solution – for the workforce component.

Workforce Design and Payment Design Solutions

The ACA design as with the past 30 years of designs has failed for the workforce needed and therefore fails for the care of populations in need of care. Solutions for health access recovery for most Americans must coordinate needed workforce with needed spending.

The ACA is a minimal benefit for payment for the services where needed. Medicaid expansion failure, return of Medicaid to lower reimbursement, cuts in disproportionate share, Medicare reimbursement too low for care where needed, and penalties for providers where needed represent continued failure by design.

The ACA remains in good company as with decades of failed designs.

The ACA designs, like SGR, DRG, national designs since 1980, still fail for support of primary care and workforce and spending where needed

Worsening Complexity and Numbers Where Care Is Needed

A 39% increase in the population since 1980 has been greater where care is needed, widening the care gap. The primary care design has failed for primary care delivery capacity increase, widening the care gap and preventing resolution of care where needed.

Now matters are worse.
  • Population growth – Population continues to increase faster where care is needed with lesser growth where clinicians are most concentrated.
  • Massive growth in demand for primary care is seen due to elderly populations and those rising to insurance.
  • There is no primary care response – due to fewer MD, DO, NP, and PA supported in primary care choices due to too little primary care spending and too much outside of primary care.
  • Basic services failure: the spending failure – pay for basic services, not the most specialized, is low. This results in declines in general surgeons and other general surgical workforce which are declining overall and especially in rural areas and counties with lower concentrations of clinicians.
  • Basic services failure: the workforce failure: Failures in basic services payment combine with fewer general surgeons, general ob-gyn physicians, fewer general orthopedists, and fewer core specialty trained physicians remaining in their general core specialty.

Generalists and general core specialties are the multiple times solution where care is most needed and where care demand is increasing at the most rapid rates.

This demand from the elderly, those rising to insurance, and those with more complex care needs will accelerate and will further overwhelm remaining providers where needed - where family docs are more likely to be found. The same factors that shape shortages of physicians and more family physicians also shape lesser health outcomes.

ACA penalties actually take away the payment support where care is needed due to value based, pay for performance, and readmission penalties.

ACA has not been helpful for rural hospitals and design changes have made matters worse. Already the nation is down one more rural hospital each month with the potential for hundreds more closed, as with DRGs and 1980s changes.

It is not possible to penalize providers where needed and move toward recovery of health access for greater than 40% of Americans behind by design.

The most specific health access solution is more family docs, trained instate in most states in need of workforce, arising from and trained in counties of greater need, and supported by a much better payment design. Maximal instate workforce for states in need, maximal primary care, and maximal workforce where needed – are about family medicine focus before, during, and after training.

Recent Works

Health Care Delivery Is No Laughing Matter

Will Teaching CHC Sites Deliver on the Promise of Health Access

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

Best of Basic Health Access

Robert C. Bowman, M.D. 

World of Rural Medical Education at

Monday, July 14, 2014

How Bad Health Design is Sweeping the Nation

Health care articles commonly indicate that health care has been taken out of the hands of physicians and others who provide care.

Not just the red states in this Bad Medicine map are suffering by design.  All states have been seeing red since 1983 (not just the 35 on the map). During the 1980s the cost cutting approach was established as the predominant modus operandi in US health policy. Most of the people in WA, OR, CA, NV, NM, CO, WY, IL, ME, MA, NY, NJ, NH, VT, and MD also suffer from the national and state cost cutting as seen in the states colored red. Bad Health Care Has Been Sweeping the Nation, not just Bad Medicine (see link below). My recent article Preventing Rural Workforce By Design reviews the many ways that our designs compromise health care where needed - and in more than just rural locations.

When did health care design and domestic policy get refocused on more for less for less result for the nation?

When did we depart designs for health care focused upon delivering health care, or focused upon delivery of education, or delivery of services to people in need of help? When did our designs defeat the ability of our servants to serve?

More for fewer has indeed been the defining trait dividing the nation into advantaged and disadvantaged across economics, business, politics, education, health, and other sectors.

It is indeed a tragedy that health care is becoming a major reason
for further divisions in the United States.

Multiple times greater health spending goes to 1% of the land area with top concentrations of physicians, clinicians, and health care services. Multiple times less health spending goes to 40,000 zip codes with 68% of Americans. Half of the economic impact of medical education (500 billion annually) goes to just 6 states and to just a few counties and a few dozen zip codes in these states. And we continue consolidations, mergers, closures of rural and smaller hospitals and practices, and produce the wrong workforce by design.

Instate, Primary Care, Where Needed = Health Access By Design

We need primary care that remains permanent to primary care. Primary care fails because our designs result in less than 30% yield for primary care from primary care training sources. Our designs for residency training fail for most states lower or lowest in physicians. Training more in a few states with top concentrations insures a continuation of this design. Even our reforms have failed to move training to primary care, to rural training, to counties in need of workforce, and to states in need of workforce (Chen, also analysis of Teaching CHCs)

And in a decade or two we shall finally realize that divisions shape health, education, and economic outcomes and vice versa. Meanwhile the task of repentance (going the opposite direction from failure) becomes more difficult.

It was the Reagan administration that shifted health care design in the 1980s. This ended the short period 1965 to 1978 when health care designs actually focused on delivering health care - especially health care delivery for Americans left behind by health care design. The period of 1965 to 1978 was restorative to primary care and to care for poor and elderly populations. (See graphic indicating the only real increase in primary care production

Other than a small bump of change in the 1990s, primary care production has flatlined in the face of a 39% increase in the population. We are still cruising upon designs set in place by 1980, designs unable to keep up after 33 class years. Even worse we are already experiencing the 2010 to 2040 doubling of the elderly and an even more rapid increase in demand for primary care and basic services. But we fail for primary care.

In our desperation we are grabbing at anything as a primary care solution and we are making matters worse.  We seem to be focusing upon everything other than direct support of the clinicians and teams delivering care where needing and adding to their support and their workforce.

Our core specialties most important for basic services where needed are also a failure by design as general surgical services lead the way in decline.

We act as if generic expansions of MD, DO, NP, and PA will work. Expansions fail because those produced are not the specialties required. We need permanent broadest generalists and core specialties that remain in their core specialty. This is about 70% of the workforce found where 40% of Americans need care. The demand is rising faster from the 65% of Americans outside of concentrations of workforce.

Our designs for training and payment fail most Americans and will continue to fail as populations in need of care increase faster than workforce and payment designs.

What Happens When Designs Are Specific to Delivery, not Cost Cutting?

Once upon a time we did have designs refocused upon delivery. After 1950s and 1960s, it was clear that America was neglecting the elderly, the poor, areas with concentrations of elderly and poor, and family practice. Rural areas and smaller urban settings benefited from the 1970s policies that focused upon spending where needed, workforce where needed, and support of health care providers and facilities where needed. The only lasting expansion of family medicine occurred 1970 to 1980 (re-creation to 3000 annual graduates) with family medicine suppressed since this time, a time with the other five sources falling steadily away from primary care retention.

What Happened in the 1980s to Reverse Health Access?

DRGs and Prospective Payment came into being and the payment was so low that hundreds of rural hospitals were taken down. After building up health care, local rural workforce, hospital services, and local economics for a brief time, this support where needed was lost.

DRGs and lower payment designs still kill rural hospitals and further cost cutting has taken out 20 more rural hospitals in the past 18 months. There are no eyes and ears in the field to guide which hospitals are lost, making the losses worse for areas in need of rural facilities and the greater levels of workforce around such facilities. The population increases in counties without a hospital are rapid with population growth and last hospital in the county closures adding more counties and counties with greater levels of population. My estimate is that zero hospital counties will increase from 25 million to over 40 million in the next 20 - 25 years. In these counties there will be lesser income, lesser concentrations of clinicians (MD, DO, NP, PA), and lesser social determinants and economic impact - in other words lesser health, lesser health status, and lesser health outcomes by design.

To make matters worse, more stresses are placed on care where needed. Top readmission penalties of 1 to 2% of all Medicare funds taken away for 2014 can be found in 9% of rural hospitals compared to 3% of urban hospitals. Taking care of people in need of care can be even more hazardous to your finances and survival as a provider.

Inequity in Payment By Design

Physician payment design rewards longer training and more specialized services. The 1980s design clearly supplied too little health spending with a rapid fall in primary care career entry. The “reform” SGR designs were temporarily better but still reward fewer and more expensive services. As the costs of delivery increased faster than reimbursement for services, primary care has had no choice other than to decline. Stagnant payment can be made worse, and has. In the last decade the even higher cost of delivery has compromised primary care teams and clinicians further, even while claims are made of improvements.

It is the revenue design inequity that is ruining primary care
as a workforce and as a career for MD, DO, NP, and PA graduates.

Flexible sources such as internal medicine, nurse practitioners, and physician assistants are most vulnerable and have mostly moved away due to flexible design and poor primary care support. 

We are entering a new permutation of cost cutting focus. Value based and Pay for Performance implies some increase in pay, but actually time after time these designs result only in penalty with little benefit. And also the way to better performance is to care for advantaged patients while avoiding those disadvantaged. We already know that value based and pay for performance designs for payment are designs that compromise revenue for providers serving where needed (Hong, others, county based studies, Pay for Performance Pounds Poverty Providers)

Veterans, rural populations, and most Americans need services to exist where they reside. Paying a fee for services rendered in primary care is reliable for getting the services performed. Paying for Performance and other designs actually shrink volume and health access – by design. They also result in more administration and management costs and fewer involved in health care delivery.

Now as the Veterans Administration "Pay for Performance" Bonus debacle extends from primary care to health access to disability payments – we truly see how bonuses work against the services needed. Bonuses can indeed be obtained when services and access are worsening. These bonuses are not going to the clinicians and obtaining bonuses is often not about clinician work. The bonuses often go to others for being more efficient - often due to the compromise of care. Will Congress bail out the VA debacle after failure to send enough money and failure of administration? Will Congress bail out 40% of Americans for their lack of access by design?

What About Fraud in the Era of Designer Dominance
As Compared to Provider Directed Care?

Administrative and management types committing fraud or worse just move to another similar or better job. Often the practices or facilities that are abused choose not to pursue charges. One reason is that they could be charged with massive penalties – because of fraud and billing abuses on a large scale. Even the penalty design works in favor of rewarding the guilty and punishing those who provide care. Accountability fails. Even at the corporate level, corporations are willing to invest in areas that profit while leaving individual patients behind. Corporate care or institutional care is quite different than clinician care.

The situation is different when physicians and clinicians cross the line. They can lose their jobs, licenses, and livelihood. Accountability remains.

Management is getting paid more and more and those who deliver services 
are getting more stress, less support, and more blame. 

One can easily guess how much worse we are with clinicians diminished and administrators in charge.

As we send more dollars for Primary Care Medical Homes, management of services or patients, Community Health Center sites, consultants, recruitment bonuses, Health Info Tech, retention bonuses, loan repayment, and those who manage such programs – are we really just adding to bureaucracy without adding to support for the team members and clinicians that deliver the care?

The VA debacle and others indicate failure by design.

In summary 
  • Numerous innovations indicate less volume, cost cutting, and poor support for delivery of services where needed.
  • Numerous innovations indicate that care quality differences, when they exist, are about the care of advantaged as compared to disadvantaged populations.
  • Innovation often results in compromise rather than focusing on delivery of health care and those who deliver health care.
  • Specific training designs and specific payment for services delivered where needed - this is what is required of a health care design.

True recovery of health access – and the United States – is about recovery of most Americans by designs for health, education, child well being, and early education.

Designers that sweep the bad news under the rug are not helping most of the nation with their designs. 

How Bad Medicine is Sweeping The Country.
Preventing Rural Workforce By Design
JAMA by Hong on Pay for Performance Inequities

Best of Basic Health Access

Robert C. Bowman, M.D. 

World of Rural Medical Education at

Friday, July 11, 2014

Will Teaching CHC Sites Deliver Health Access Result?

Teaching Community Health Center sites are a new innovation in graduate medical education (GME). Teaching CHCs have been set up to address failures in traditional GME in important health access areas - primary care needs, rural training, and the needs of states with fewer physicians. In general the states with highest concentrations of physicians have the most GME, the most specialized GME, the most clinicians of all types, and the highest spending on medical education and health care.

Teaching CHCs have been announced and it is possible to assess 65 sites with regard to future health access workforce impact. 

Will Teaching CHC Sites Deliver on their Promise of Needed Health Access Result?

Yes, but limited -The best answer is that the Teaching CHCs will have some small impact, but the full potential will not be realized. Changes should be specific to better site choices and greater focus upon graduates that will deliver health access where needed.

Local access improvement - All of the sites will add to care at the CHC sites and will have some influence regarding graduate choice of care where needed. Some sites are more likely to contribute care where needed for the United States due to the specialty trained, the county site of training, and the state location of training. 

Instate multiplier impact - Residency training has a profound impact upon instate practice location. Instate GME is a 20 to 40 times multiplier effect across US states when assessing 700,000 active physicians in databases controlling for origins (3 - 5 times instate effect) and medical school instate influences (4 - 6 times). Traditional GME concentrations in just a few states are a reason for failures in physician distribution for most states. Teaching CHC design should be specific to states (and counties) in need of workforce.

Residency Training Regional Impact - Research regarding residency training over the past 40 years has indicated that residency training location influences nearby practice. Training site graduates tend to fill up positions within a county and within nearby counties (within 60 miles). This effect may be stronger where no previous training exists and may be weaker when competing training exists. Traditional GME concentrates physicians where top concentrations exist. Teaching CHC training should be different. To accomplish this, Teaching CHCs should avoid locations where concentrations of physicians or clinicians are found. This is not the case for a substantial number of sites.

Specialty choice for training has significant impact. Only one source consistently and significantly multiplies care where needed. Family medicine training is the only training source with population based distribution. As other specialties melt away with lower local concentrations of physicians, family medicine remains about 30 per 100,000. With declining concentrations of physicians, family medicine becomes a greater proportion of local workforce. This translates to a 3 times multiplier for rural locations (RUCA), a 3 times multiplier for zip codes with fewer than 75 physicians (horizontal health access focus and outside of vertical concentrations), and a 3 times multiplier for counties lowest in physician workforce with less than 150 physicians per 100,000 or half of the national average or less. 

Population Based Distribution Is About Family Practice Positions Filled
by MD, DO, NP, or PA Only

No other source has population based distribution to locations in greater or greatest need. Population based can be determined by ratios of proportion of a specialty at a type of location compared to the population proportion. For example about 20.4% of active FM docs are found in rural locations with 19% of the US population for a ratio over 1.0 ratio. Because FM grads remain over 90% in FM and in primary care, their family practice positions filled influence population-based distribution for an entire career.

Only family practice positions filled by MD, DO, NP, and PA have population based distribution to locations where needed. Generic NP or PA graduates (just active clinicians with NPI) have lower concentrations or 0.62 ratios when considering counties in need of workforce - far less than the 1.0 population based ratio. Family practice positions filled by NP or PA have the family practice multiplier effect with twice or three times the distribution of sources not found in family practice. Unfortunately the NP or PA active family practice component is down to 25%. This is better than the 7% of MD or 17% of DO, but is far less than the 90% for family medicine trained physicians.

Teaching CHC designs should emphasize specialties found at Community Health Centers.

Generating a Ratio for CHC Distribution

A census of CHC workforce was assembled in 2004 and this can be compared to physicians in the 2005 American Medical Association Masterfile.

4.23 For All FM grads or 3084 out of 86,090 or 3.58% found in CHCs in 2004 (Rosenblatt census) compared to 0.85% of active US physicians in 2005 (Masterfile)

1.91 for PD training or 1247 out of 77,000 trained for 1.62%
1.64 for OB-Gyn or 525 out of 37,788 for 1.39%
1.09 for IM training or 1443 out of 156,761 trained for 0.92%
0.71 for Psychiatry or 197 out of 32,791 for 0.6%

Each of the 62 Teaching CHC sites was coded by county and by state location and by training specialty.
  • Top Rated - 11 sites were top rated due to the triple combination of FM training, training in a state in greatest need, and training in a county lower to lowest in clinician concentrations.
  • Higher Rated - 7 sites were higher rated with 2 out of 3 of a mix of FM training, county need, and state location need.
  • Marginal - 29 sites were marginal with the main factor being FM training as the county and state locations did not reflect greater need.
  • Lowest Rated - 18 sites were lowest rated as they were missing all 3. The sites were without FM training, without training in a state in greater need, and without training in a county of greatest need.
No Obligation - Since none of those trained at Teaching CHCs (or any program) acquire an obligation to serve where needed and none are required to stay instate or stay within their specialty of training, the results are limited. Again this translates to estimates based on specialty choice and training location influences. Specialty training choices other than FM are limited for reasons of primary care retention or poor distribution. 
  • IM training is limited due to less than 20% remaining in primary care and even the student types favorable for primary care retention only have 30 - 35% office primary care result. 
  • PD is down to 40% office primary care yield (COGME). 
  • Psychiatry and geriatric graduates are poorly distributed where care is needed (Masterfile).

Again all Teaching CHCs will contribute locally and will have some small influence upon choice of underserved settings - but some sites are more likely to contribute to greater need.

Anticipating Changes in States and Counties Regarding Need for Clinicians
Some situations are changing at the sites. For example increases in population and demographic changes in Texas or other states or certain counties will worsen their health access situation. 

In general the counties lower to lowest in workforce are increasing faster in population growth and have more elderly and more arising to insurance coverage. More with diabetes, obesity, smoking, poor health status, and preventable hospitalizations reside in counties short of workforce. Faster growth, higher complexity, and lesser workforce levels are likely to be associated for some time. Sadly penalties are also more likely with even lower reimbursement as Hong demonstrated in JAMA regarding CHC populations and Pay for Performance.

Stability of Recommendations

County deficits in the counties with lower to lowest concentrations and state deficits have been present for decades. Family medicine has been a consistent multiplier of distribution for its entire 44 year existence - but remains at 3000 annual graduates or the level first achieved 34 class years ago without much change since.

Will Training Interventions Improve Health Access?

For over 3 decades this answer has been an emphatic "NO!" 

Only from 1970 to 1980 has the United States improved health access workforce as seen with increases in primary care, workforce where needed, and distribution. The combination of specific training focus (FM, primary care) with funding for primary care training with increased Medicare and Medicaid spending illustrated the route to health access recovery. 
There is no guarantee that Teaching CHC contributions, even in family medicine, will increase FM graduates. The sites often have few graduates and some may not fill their residency positions. Expansions of residency positions outside of family medicine (generic expansion) may allow more medical students to bypass family medicine - another downside of Teaching CHC designs that are not specific to FM alone. Family medicine, internal medicine, and psychiatry are rather low on the priority list for medical students making career choices. Income and support and location advantages await those who specialize.

Some FM sites are found in states where FM programs have been terminated or downsized as traditional GME institutions find it to their advantage to convert FM GME positions to various other GME positions. The health access disadvantages of the current design are numerous.

Major design changes in FM could also decrease annual FM graduates and FM workforce. Some influential FM leaders have supported an increase in FM program length from 3 to 4 years. This can result in fewer slots offered and available in the match and fewer graduates. A program with 24 slots divided by 4 years would offer 6 slots rather than 24 divided by 3 years of GME for 8 slots. If FM goes to a 4 year training design this will effectively shrink FM annual graduates nationwide as 9000 divided by 3 is 3000 per year as compared to 9000 divided by 4 or 2250. Based on elective choices in some larger programs, about half of the residents have opted for 4 year training. This is still over 10% shrinkage of FM graduates. Other losses would be 3% fewer years in a career and lesser activity. Longer and more formal academic training for the past 50 years for FM, NP, and PA training has been associated with decreased distribution.

Shrinkage of the best source of primary care, primary care where needed, and workforce where needed would be a disaster for health access in the United States. It would seem that longer training, higher debt, lower income, and decreased life income would also be a disaster for medical students considering family medicine as well.

The Prospect for Health Access Recovery from Training Interventions
There is no guarantee that any training intervention will work because primary care spending support remains insufficient. Increases from 1300 to 16,000 annual NP graduates from 1980 to the present with increases from 1400 to 8000 annual PA graduates, two doublings of osteopathic graduates, numerous doublings of Caribbean graduates, and recent increases in MD graduates would be expected to have some impact. Unfortunately the health access impact has been limited and will remain limited due to limitations of primary care spending support. 

Expansions of graduates without more support have resulted in declines in the primary care result from training. The tripling of primary care capable graduates arising from six sources from 13,000 in 1980 to over 36,000 has been associated with a decline from over 60% serving in primary care to less than 30% - such is the serious consequence of payment inequities regarding primary care and basic services versus non-primary care and more specialized services. 

The expansions have involved the sources with the least primary care delivery (3 - 6 Standard Primary Care Years for NP, PA, IM) and have avoided the family medicine source with the most primary care delivery over a career (25 Standard Primary Care Years). Sources substantially not primary care in result over a career are not specific to health access recovery.

Spending specific to primary care continues to remain fixed and lower such that any training intervention for primary care may not result in greater primary care result. To deliver more care, the spending must be specific to the hiring and support of more clinicians and team members that deliver care. Spending diverted to non-primary care, administration, management of care, billing, dealing with insurance or government, consultants, health information technology, and personnel that do not deliver care results in less available for teams and clinicians that deliver care.

Recovery of health access requires payment and training interventions specific to health access – permanent family practice result, more spending on primary care delivery, more spending in counties in need of care, more core specialist result from core specialty training. In other words the US still needs broadest generalists and general specialties and better support for their work delivering basic services and primary care where most Americans have fallen behind by design.

Teaching Health Centers should bridge the gap that exists between the needs of most Americans and traditional training. Specific attention to this task is required.

Special funding for health access is scarce, and should be made most specific to interventions highest yield for health access. Hundreds of millions have been spent in recent years upon generic interventions that will result in less than one-third of graduates in primary care with even more limitations regarding service where needed.

Traditional GME funding must be made accountable and so must the funding of non-traditional health professional training. The accountability must be the same as for health access.

  • Instate for most states in need of workforce
  • Primary care result - permanent
  • Workforce where needed
Family medicine training in states in need of workforce in counties in need of workforce is the solution. Not only should graduates complete residency in such locations, they should have preparation and medical education in such locations. Specific designs in favor of health access shape all influences possible to instate, primary care, and where needed.

Teaching CHCS need specific health access design.

Best of Basic Health Access

Robert C. Bowman, M.D. 

World of Rural Medical Education at