Friday, April 17, 2015

The History of Good Deal Bad Deal Payment Designs

The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent.

Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially for primary care and all physicians paid on the lower end of the payment scale.
  • Good Deal Start Bad Deal End Number 1  was the original Medicare and Medicaid falling behind in about a decade
  • Good Deal Start Bad Deal End Number 2 - 1990s "reforms" - falling behind in about 5 years
  • Good Deal Start Bad Deal End Number 3 - MACRA - few if any years ahead (but better than a 21% cut?)
The AMA actually rented out the auditorium where Kennedy announced what would become Medicare and Medicaid to lodge its protest. Fifty years ago there were at least some leaders raising concerns regarding what would happen. Now with Medicare and Medicaid so much of the payment design, matters are worse.
  • By the 1980s, primary care payment was insufficient to the cost (rampant inflation, liability cost, lower pay going up lower), primary care choice was going down fast, and primary care retention dropped.
The 1990s reforms did initially adjust primary care pay higher, but set it lower than non-primary care. Managed care threats scared more students into primary care. Primary care choice rose and internal medicine grads returned from 44% to 54% in office primary care - for a short time.
  • By the late 1990s, internal medicine office primary care retention was dropping 3 to 4 percentage points a year down to below 20% where it has stayed. 
  • Family medicine had a few years over 3000 annual graduates before dipping back below 3000, the level that it has remained essentially since 1980. The lack of family medicine expansion is an overall measure of payment design failure and failure of payment where care is needed - since 1980. 
  • The internal medicine retention in office primary care also tracks the same failure as does physician assistant primary care. The doubling of PA annual graduates (100% more from 1998 to 2008) resulted in over 200% increase in entry into non-primary care with just a small (and disappearing) 30% gain in entry to primary care. 
  • More specialties are added with more added to each new specialty for NP and PA - by payment design. Over 30,000 were added to teaching hospitals due to better pay and also resident work hours restrictions (higher cost, no increase in quality, bad value change).
The 2015 MACRA deal, is another bad deal that fails to acknowledge the cost of health care delivery rising much faster than inflation.
  • The fact that the CMS Actuary actually states this is quite interesting. Someone doing his job and away from political gain!
Steadily Shorter Time Periods Before Payment Failure

For primary care/basic services paid by Medicare and Medicaid since 1965, the period of time before any design has resulted in insolvency has been shrinking (10 years to 5 years to 1 year).

Payment Failure is Most Evident Where Workforce Fails - By Design

Sadly most Americans and the small practice and small hospital providers that they need the most are falling steadily behind by design.

Insurance reform fails when payment design fails, and payment design that costs providers even more and can pay small providers even less - fails to an even greater degree and where most needed - by design.
Buck Up Leaders

When our physician leaders fail to acknowledge these failures, they fail at leadership. They have failed with bad assessments of payment and bad assessments of workforce due to bad assessments of payment plus bad assumptions. It may be tough to inform political leaders and the public, but that is the job of physician leaders.

In the past few years it has become more difficult to critique health care delivery design. Political polarization has made this worse. It is possible to be highly critical of ACA and be appropriate. Complicating the problem is research failure. As Science pointed out, few studies of health care delivery are randomized. This allows too many assumptions, too many consequences, and implementation of new policy too fast and too dangerous while claiming success.

One main failure of ACA has been financial instability in the design:
  • Cost of delivery increased too high
  • Decreases in productivity due to ACA and rapid change
  • Distractions from care delivery due to ACA and rapid change
  • Confusion of public and providers due to ACA and rapid change
  • Revenue increasing less than inflation and far less than cost of delivery
Delays and mistakes by CMS and Congress have also caused problems - holding up payment.

Who cares how payment occurs if it supports health care delivery, avoids needless distractions, and supports care delivery where care is needed? Why change if you really do not know the consequences and you do know that change and rapid change are harmful?

Payment Design Failure Due to Failure to Support Care Delivery

Frankly since 1980 the new payment designs have abandoned all resemblance to payment for the support of health care delivery. The payment designs have been based upon cost cutting. The carnage has been seen in small hospital closures and small practice deficits with more and more territory and higher proportions of the population found where concentrations of clinicians are lowest. About 40% of Americans reside in 2621 counties lower to lowest in concentrations of  clinicians where 41 - 45% of older Americans, poor Americans, Medicare and Medicaid populations, diabetics, smokers, and those with poor to fair health are found. These populations:
  • Are being left behind by design and 
  • Their providers are paid less by design and 
  • They will be paid less by new design including penalties
Bonuses and Penalties, Quality or Not, Are About Populations not Providers

It is ludicrous to think that payment can be adjusted for the incredible complexity range of the American population - particularly those elderly or poor. Hong in JAMA demonstrated the discrimination of pay for performance.

For decades, the payment designs have continued to pay more where care is concentrated and less where care is needed. Another decade of this design will continue.
  • More lines of revenue and higher pay rates continue where care is concentrated
  • Fewest lines of revenue, few codes, and lowest pay rates continue where clinicians are least concentrated
  • Bonuses are only for those caring for the advantaged or Medicare Advantaged.
  • Penalties are for those taking care of populations behind by design.
Primary Care Investment Pays and Saves

The evidence builds for investment in primary care as a solution for better quality of primary care, better organization, and same cost of delivery. There can be no resolution of primary care without 20 - 30% more in payment support. Michigan recently had a demonstration project that fit these criteria with enough payment to cover increased costs of delivery and this resulted in overall savings of 1% regarding overall costs.
  • If you can pay primary care more to deliver better primary care and hold costs the same over years of time and not require a change to a more complicated and confusing payment design - why delay implementation?
Primary care delivery capacity is a function of primary care revenue minus the cost of delivery minus distractions from productivity.

Five Periods of Primary Care Payment Consequences           Individual Graphics

Internal medicine once contributed 65% of graduates into primary care. This resulted in internal medicine as the most important source with steadily over 3000 per class year added - for over 110,000 at one point. Sadly the consistent level of over 3000 in primary care per class year has become 1400 for primary care a year under the past decades of payment design.

Numerous distractions continue. Hospitalist workforce has claimed over 37,000 internal medicine graduates. Subspecialty fellowship positions increase by 4% per year and subsubspecialty fellowships by 11% a year (AAMC, Jolly). And our leaders still claim internal medicine as primary care training? And our researchers claim that internal medicine will contribute 90,000 for primary care. Try a maximum level of 40,000 for active office primary care by 2030 which is about all that 1400 per class year for 30 class years can provide.

Frozen family medicine, frozen pediatrics, and declining internal medicine translate to gaps in care and care where needed. Massive expansions of NP and PA have barely kept up with the declining internal medicine because fewer and fewer enter and remain in primary care. Expansions fail for primary care because of payment design. Failure in payment design also means more cost of delivery in areas such as primary care where needed. Locums costs, recruitment and retention bonuses, payment to brokers and headhunters, advertising costs, and administrative costs increase at federal, state, and local levels.

As usual, the graduates fail for locations of need - also due to poor support. Even worse,
populations are increasing fastest (twice as fast) where care is needed and where family medicine is most in demand. NP and PA are leaving family practice and primary care for better support and pay in non-primary care areas.

Marketing Has Become the Focus; Failure to Understand the Market Continues

The market interpretation is quite obvious. Pay is insufficient for primary care and for care where needed. The data is extensive and dates back for decades of class years.

Frustrated leaders appear to have turned to marketing. Marketing is needed where physicians try to crowd into locations with too many physicians. This is of course driven by payment design and better paying patients that also are easier to care for.

Marketing is not needed where care is needed. What is needed where people need care is higher payment, better support, lower cost of delivery, permanent family practice and permanent general surgical specialties (surgery, orthopedics, ob-gyn) - all falling further behind by payment and training design.

Primary care leaders, true to primary care, must have one major focus - pay for primary care consistently above the rising cost of care delivery.

Primary care leaders were able to take the debacle of the 1950s and 1960s and recover some level of primary care by 1980. The failures have been steady for primary care and for health access since that time.


Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

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

Wednesday, April 15, 2015

Oops We Did It Again for Too Little Payment By Design

The one major problem that has faced primary care for the past three decades has been cost of delivery rising faster than payment. Each "fix" has not really been a fix as steadily fewer enter and remain in primary care from all six sources. 

MACRA is the new design and CMS has already projected the impact for decades. Here is what the Chief CMS Actuary says in his April 9, 2015 report:


"While H.R.2 avoids the significant short-range physician payment issues resulting from the current SGR system approach, it nevertheless raises important long-range concerns that would  almost certainly need to be addressed by future legislation. In particular, additional updates totaling  $500 million per year and a 5 percent annual bonus are scheduled to expire in 2025, resulting in a payment reduction for most physicians. In addition, this bill specifies the physician payment update amounts for all years in the future, and these amounts do not vary based on underlying economic conditions, nor are they expected to keep pace with the average rate of physician cost increases. The specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large. We anticipate that physician payment rates under H.R.2 would be lower than scheduled under the current SGR formula by 2048 and would continue to worsen thereafter.  Absent a change in the method or level of update by subsequent legislation, we expect access to Medicare-participating physicians to become a significant issue in the long term under H.R. 2."  

Temporary Fixes
  • The initial Medicare and Medicaid design initially was a great boost to primary care and care where needed. In a few years the design proved insufficient to keep up with staggering inflation, malpractice, personnel, and other costs in the 1980s. 
  • The RBRVS fix in the 1990s was also short lived. 
  • SGR left all physicians hanging under the Sword of Damocles - so much so that anything seemed tolerable. 
  • The MACRA gets away from SGR, but whether it is a fix is questionable.
  • Note that the actual payment process has yet to be determined and this could be powerful in who survives and who thrives, but much will happen in the next ten years and MACRA does not have the flexibility.
MACRA Appears To Be Just What the Doctor Ordered

That is for those doing well in the largest and most organized practices that have the most advantaged patients.

For the smallest practices where care is most needed, MACRA will pay less.

Discrimination By Design

Readmission penalties and Pay for Performance cannot help but pay less where care is more complex and most needed. The same social determinants, situations, and conditions that have shaped shortages of clinicians and access barriers also shape lesser outcomes. Lesser pay will add insult to injury. 

It is most likely that MACRA will join Medicare Advantage as paying more for the care of populations that have advantages. Populations in need of care are left behind by MACRA and populations in smaller and less organized settings cannot access the favored payment plan - Medicare Advantage. The new designs do not work well for small hospitals, small practices, and care where needed. Lack of awareness continues to add consequences by design.

Accelerating Recruitment and Retention Costs

Where care is needed, there are more storm clouds. Even if patchwork programs survive, primary care delivery faces more problems. Insufficient payment is a primary reason for the rapidly rising cost of recruitment and retention bonuses, locums payments, broker fees, consultant costs, and other special programs.

A major consequence of insufficient payment is greater turnover of the teams and clinicians to deliver the care. The costs of turnover now include learning new software and other applications. There is little encouraging about the most important determinants of primary care at the current time.

SGR has been defeated. Congress did get a payment plan through. But more than two miracles are needed to recover primary care delivery capacity.


Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

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.

Tuesday, April 14, 2015

The Impact of Maldistribution of Awareness

Health designs in the United States work for few people in a few locations at high cost. This health design spends so much on administrative and highly specialized services that basic services and basic health access are insufficient for most Americans. A major reason for decades of failure is the maldistribution of health information.

The scientific process begins with awareness of the problem. Those who design health care are raised and trained and constantly immersed in top concentrations far away from most Americans - and far away from the awareness needed to lead the nation in health access, basic services, primary care, and care where needed. 

Medical Group Management Association statements have consistently acknowledged the information arising from the largest and most organized practices. When very little arises from the smallest and least organized, awareness is maldistributed.

Where funding is missing, facilities and practices and workforce are missing. This also results in insufficient access and encounters. The recent insurance expansion can accomplish little without the accessible workforce to do services. Expansions also fail with fees too low and the need to entirely retrain many if not most Americans - who have been trained that access is not around, payment is missing, and usual care is emergent or worse.

The following graphic from Where Americans Get Health Care indicates the ecology of health care. Where most Americans are aware of changes in their health, there is little awareness and little data. Where few receive care there is the most data and the most awareness. These most organized entities also dominate health care design while those least organized and most distant are left out in payment, in workforce outcomes, in health outcomes, in economic benefit, and in growing disparities.

The smallest practices are the most basic, are 45% of primary care (Graham Center), are the least organized, and are falling behind the most under ACA as with previous designs. Despite the challenges, studies indicate advantages for small practices although the new designs are clearly trying to eliminate them. Where practices are smaller there are some advantages to more personal for clinicians, teams, staff, community, and individuals. Again this awareness is common knowledge for rural physicians and the family physicians that most often remain long term locally, but awareness is lacking for those designing payment and penalties.

Health information technology gurus are having a fit when there is any delay to Meaningful Use - which has been implemented as Fire, Ready, Aim. This not quite ready for prime time "advance" and those promoting MU do not have the awareness of clinicians, especially those in the smaller practices and those most threatened.

Even worse, the next ten years will be essentially no pay increase. Meaningful Use change is costly, requires adjustment, and can decrease productivity and revenue. About 10,000 family physicians are within 3 years of retirement and about 36% are providing primary care in 2621 counties lower to lowest in physician workforce concentrations. It is very likely that those not aware will continue to drive more away from needed practices or any practice - by their designs shaped by poor awareness.

From 1950 - 1980 the United States attempted to focus on a health care design that was specific to delivering health care including the wide range of age, income level, and geographic locations. Since 1980 the direction has been more for fewer in fewer locations with ever higher concentrations of workforce. Since 1983 the health care design has had the top priority of cost cutting without attention to preserving the basic services or primary care which have fallen into decline. Lack of awareness killed off 400 rural hospitals in the 1980s and early 1990s and lack of awareness has returned such that another 300 will soon be gone. 

Awareness can improve care and lack of awareness can kill tens of thousands due to declines in basic access.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

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.

Saturday, March 14, 2015

Should HHS Take from the Poor and Give to the Rich?

I find it interesting that CMS overpays for high risk or complex patients, even when there is overcoding and fraud via Medicare Advantage. Yet CMS will not pay more for truly complex patients across rural and underserved areas. The largest do well and the smallest struggle to survive. This is the payment design, the administration design, and the enforcement design. Behind each design and designer is a serious lack of awareness of the consequences for Americans most in need of care.

From NPR by Schulte - "Instead of winnowing out abusive corporations, all insurance participants were punished: The study said that a number of large Medicare health plans, which were not named, raised risk scores far above their peers. But the agency chose not to ferret out the worst offenders to discipline them. Instead CMS cut rates industrywide in 2010 by 3.41 percent to offset the jump in risk scores."

As noted in the NPR article, the Obama plan has cuts planned for Medicare Advantage, but history is on the side of no cuts and even some increases - and 53 Senators have signed on. Drug companies and insurance companies have both turned potential cuts into substantial gains.

CMS has done little about Medicare Advantage despite 12 billion in overbilling a year. The close relationship between CMS and insurance payers appears to have facilitated the abuses (Center for Public Integrity).

For some perspective regarding the massive dollar amounts, the waste in Medicare alone, a 604 billion program in 2013, was 50 billion. According to GAO, the contracted payment vendors share responsibility. GAO has listed Medicare as a high risk program for 20 years and has listed Medicaid for 12 years. The interventions to address fraud and waste have resulted in small change, usually promoted as great success by CMS. Fraud and waste continues to rise at 5 billion a year for Medicare or 10%.In December 2011, OIG found that CMS had not resolved or taken significant action toresolve 48 of 62 vulnerabilities reported in 2009 by CMS contractors specifically charged with addressing fraud.

CMS may not even be able to do much. It appears that highly organized corporations can find their way to more of the treasury with or without Congress. Constant attention to introduce legislation, prevent unwanted legislation, shape away harmful portions, and encourage the best interpretations - these are the actions that profit the biggest and most organized while leaving the rest behind.

Medicare Advantage since 2003 has not been equitable in distribution. MA tends to attract patients of advantage - the more urban, higher income, and higher cost of living areas have competitive plans rich with benefits - due to the substantial dollars shaped to insurance payers by their own process. The Medicare Advantage plans dwindle to few, or one less competitive, or none as population and income decline. It is an important principle of profit for insurers to insure those who do well and avoid those who are more costly or less healthy. Medicare Advantage has been a fine design for this purpose.

Experts continue to have a limited awareness of these important demographic differences in seniors and Medicare populations. Fixed income seniors must live in areas lower to average in costs - usually away from exclusive plans and facilities that concentrate where people, income, and health payments are concentrated.

The Office of Inspector General does not understand elderly or Medicaid demographics and may not understand where fraud and waste are more likely. Somehow OIG wants to save small change - 1 billion from Critical Access rural hospital payments. They were persuasive enough to gain the Obama budget recognition - more evidence of poor understanding of rural people, health access, and aberrant payment designs at the root of the problem. Critical Access payments are a small portion of total Medicare or hospital spending. These are payments that have clearly stopped widespread rural hospital closures for the past two decades (too late for a few hundred 1983 - 1992). The program is even more important with worsening payments and higher costs of delivery under new designs as modified by the Supreme Court (once or perhaps twice).

OIG should investigate where there is real money to be saved. Taking on the bigger and biggest would appear to be more rewarding. HHS should also perform duties in ways that do not further impair basic health access. After 30 years of declining health access, substantial changes are still needed.

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

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.

Wednesday, March 11, 2015

The Primary Care Medical Home School

Home school is most local by design. Primary Care Medical School is only about primary care without the option to leave primary care after graduation. The Primary Care Medical Home School is local, primary care, where needed by design.

The current health professional training designs for MD, DO, NP, and PA all fail for primary care workforce result. Recovery of primary care is about all influences lined up most specific for recovery.

Medical education is not the only higher education in need of redesign. College is too expensive, fails in relevance to career, and often forces students to leave locations where care is needed to go to exclusive settings attending college with exclusive students. Local, normal, and relevant can go hand in hand with online and other modes of advanced education. 

The best model for health access recovery is specific to primary care across preparation/college, medical school,  and residency training. A specific design is not difficult to visualize as such a design is the opposite of the current health education design. In the current flawed design, the wrong students from the wrong places are admitted, they are trained in the wrong places with the wrong faculty and the wrong curricula. There is little emphasis upon primary care, local care, and integration of care within the community.

Recovery of Health Access is about:
  • Instate Training - Training must be specific to states in need of primary care. All influences of instate origin, instate preparation, instate medical school, and instate residency should all be combined for maximal instate result. Graduate training instate is a 20 - 40 times instate multiplier and the other factors all add 3 - 6 times multipliers specific to instate practice result as measured over a career.
  • Primary Care Result - The outcome of the training school or program must be 90% or above primary care as measured over an entire career. Training designs that allow departures during and after training represent hemorrhages that must be stopped to hope to recover primary care and to have the most experienced primary care workforce.
  • Practice Location Where Needed - Training in locations of need and training with practitioners and teams serving such populations is specific to building up workforce where needed as well as the training most specific to the practice of the graduate. An obligation for the first six years after graduation is a continuation of local preparation and training. This obligation further shapes future practice locations of need in local or adjacent counties. Primary care specific training in counties of need as demonstrated with family medicine training has filled up workforce in local and adjacent counties across studies from the 1980s to the most recent graduates.
Beginning to End Design

The Primary Care Medical Home/School must begin with students connected to places in need of primary care, and these students remain connected to these places during training as their online college courses will supplement their local learning in Primary Care Medical Homes/Schools. Their careers will be spent entirely in primary care and all of their preparation, training, and obligation is spent locally. Such a design is specific to instate, primary care, where needed - the only specific formula for primary care recovery. 

Current designs prepare and train with the opposite influences, result in less than 30% primary care, and result in far less primary care where needed.

Instate workforce where needed is a result that can be measured. The US medical school outcomes are abysmal in this area, about 2 to 12% of graduates are found with instate care where needed result using the most recent decades of graduates. Instate is defined as instate relative to medical school of graduation and "where needed" is defined as a county with less than 150 physicians per 100,000 as the practice location in 2013. 

In the Great Plains states of Kansas and Nebraska, family medicine choice (U of KS, UNMC) is associated with a 12 and 22 times greater instate practice location of need as compared to those not choosing family medicine. Origins, tendencies for instate residency, family medicine, and family medicine distribution all contribute to this stellar outcome. 

So why not design even more specific? 

Preparation can begin in middle school and high school with community-based preparation, community projects, college and medical school courses delivered to the community-based students (age 14 and up), and increasing health care contributions for the trainees based on their progress.

Instate, Permanent Primary Care, Where Needed is specific. Anything not specific is driven away by payment policies that do not support instate, that do not support primary care, that do not support care where needed. 

Training design that is not specific and payment design that is not specific has defeated primary care recovery for decades. These design barriers are the major reason why family medicine, the most specific to recovery, is still just 3000 annual FM graduates as reached first in the class of 1980. The barriers drive all of the more flexible forms away from primary care during and after training. Higher pay outside of primary care drives flexible primary care forms (IM, MPD, NP, PA, PD) away from primary care even for those few that enter primary care after primary care training. Family medicine also cannot maintain 90% remaining in active primary care family practice at the adverse payment policies no longer support such careers. 

All routes point to very specific solutions for health access recovery. As long as other agendas dominate primary care training and payment, health access recovery will fail regardless of floods of new generic, flexible graduates.

College for a New Age

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

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.