Wednesday, September 24, 2014

About GME - Insider Trading Is More than Just Wall Street

Insiders dominate the designs of health spending and the designs of health professional training. Not surprisingly these insiders shape workforce, services, and spending to just a few states and a few locations.

Resident training is even more stacked against care where needed. The determination of practice location is about origin influences, training influences, and specialty choice. Origins, training, and specialty influences are moving away from states in need, away from primary care, and away from care where needed locally.

Top Concentration States - Physician and GME - About 6 states receive 50% of the economic impact of US medical education which is 500 billion a year according to AAMC. Actually insider stacking is even more prevalent as only a few dozen counties receive this impact. Origin and training location facilitate concentrations of clinicians in a few states and in a few locations.

Top Concentration Zip Codes or Super Centers - About 55 - 60% of residents are trained in Super Center zip codes with 200 or more physicians or 1100 zip codes in 1% of the land area with only about 12% of pop, 45% of the physicians, and well over 50% of health spending - This may be the only practice location shaping experience of allopathic private graduates, graduates of exclusive/research/MCAT schools, and international graduates - which is why these cohorts have lowest distribution       Physician Distribution By Concentration

Major Centers are the sites of training for about 25% - 30% of residents. They are trained in zip codes with 75 - 199 physicians (Major Centers) in about 2.5% of the land area - this is a midrange between Super Centers and Outside

Together about 72% of physicians are found in about 3.5% of the land area in 3400 zip codes inside of super center and major center concentrations - leaving only about one-quarter of physicians remaining for care outside of concentrations. The highest concentrations of 82% of graduates inside of concentrations are seen in allo private, most exclusive US school grads, and international graduate cohorts. The best distribution at 50% inside and outside is seen in medical schools with 20 - 35% FM choice. This is also the result of family medicine choice as well as origins and training more normal with regard to state and location.

Experiential Place or Past Life Influences Help Explain Concentration and Distribution

Exclusive in origin and training and specialty results in concentration with poor distribution. More normal distributes.

Normal Origin and Training Facilitates More Normal in Distribution

Sadly less than 15% of residents are trained in 40,000 zip codes outside of concentrations of physicians. Outside zip codes have 68% of the population including higher proportions of the elderly as well as all who are increasing in population and in care demand. With declines in physician concentrations the health spending goes down, the complexity goes up, and the non-family practice workforce melts away.

The Family Medicine Multiplier

Family medicine is a three times multiplier of "outside" zip code practice location controlling for origin and training influences. FM multiplies needed result across medical schools and across types of locations outside of concentrations of physicians. All other specialties result in further concentration where physicians are already concentrated.

Generic expansions of graduates without FM predominating are only going to facilitate more concentration - especially with 11% annual increases in subsubspecialty fellowships and 4% annual increases in subspecialty fellowships (Jolly, Acad Med, 2001 - 2011) 

Expansions outside of FM allow more opportunities to escape FM or primary care. This is the opposite of the 1990s when massive declines in choice of hospital based residencies took FM over 3600 annual grads for a brief time. Specific is indicated - not generic.


Until there is an end to aberrant payment design and...
Until there is an end to all out assault upon core specialty result from training, there will not be care where most Americans need care. 

Insiders Dominate Inside with Highest Specialization, Academization, Centralization, and Concentration. 

More normal core specialties dominate care outside of concentrations - FM, primary care IM, primary care PD, general surgical specialties. All are stagnant or in decline by designs for training and payment. 

Designs for inside, shaped by insiders, fail for most Americans, fail for primary care where needed, and fail for most family physicians who are outside.

Nurse practitioners and physician assistants are also concentrated in the same zip codes and counties as physicians and physician specialists. Only the family practice result from NP or PA distributes above NP or PA averages - or reaches the 2 to 3 times multiplier of FM. This FP result continues to decline with each passing class year and year after graduation for NP and PA down to 25% and below.

Once you know how payment design fails for primary care and for distribution for all types of clinicians, you can understand how generic expansions continue to facilitate even more non-primary care and even greater concentrations of clinicians.

Insider trading and focus is found beyond Wall Street.

As Commonwealth recently speculated, the designs for health care may indeed shape America in ways not best for most Americans.

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...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


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, September 23, 2014

Primary Care Versus the Rest

Recent postings have defended primary care versus urgent care and other care venues. These posts tend to exaggerate the benefits of primary care while pointing out the flaws of urgent, retail, corporate, concierge, emergent, and other venues.

Primary care should take a realistic hard look at the competition and the many serious issues facing primary care. It is hard as a primary care and health access advocate to post this - but real change begins with Primary Care Versus the Rest across Specific Measurable Achievable Realistic and Timely.

It is common for primary care to defend itself for areas such as continuity and integration – but insurance companies, employer preferences, and other changes insure patient migrations, lack of continuity, and disintegration.

Access Issues Facing Primary Care More (and less for others)
  1. Primary care has largely refused to adapt to consumers (evening, weekend, phone, internet)
  2. has increasing delays until patients can be seen
  3. is moving from most experienced to least experienced workforce in the next decades
  4. has substantial clinicians near retirement or departing primary care in the next few years
  5. has shrinking proportions of all sources entering primary care
  6. may well be less responsive to part time or other emerging graduate preferences
  7. is forced by insurance contracts and habit patterns to see the most complex patients while the least complex and most profitable are stolen away


Finance Issues Facing Primary Care More
  1. Primary care has rapidly increased in cost of delivery with no end in sight - HIT, techs, MU, updates of software and hardware, ICD-10
  2. is forced to hire more personnel or consultants to save costs for someone else - government or insurance
  3. has payment too low where most Americans live and need care (and are more complex)
  4. may have cost issues locating a practice where best for revenue generation
  5. is being strung along with the hope of more pay by government and by insurance (and by associations), but for decades the costs and responsibilities go up more than the rare if any pay increase
  6. is also facing more funds extracted by associations (dues, certifications) and increasing requirements for certifications that also are more costly and cut into revenue

And paying dues and other costs and investments does not protect, preserve, profit, promote, or otherwise benefit the primary care clinician or practice

The Primary Care Priority remains far too low
  1. PC has not been spared the rigors of cost cutting
  2. has not been spared stagnation in revenue
  3. has not been spared sequestration cuts and other across the board cuts – cuts resulting from other parts of government and health care that spend too much
  4. PC associations have not been effective in improving revenue for decades
  5. PC association lobbying and political attention is actually higher for non-primary care, because the nurse practitioner, physician assistant, internal medicine, and pediatric graduates are more likely to be found outside of primary care and more members and higher pay shapes the political focus
  6. NP Associations are focused on independence as a top priority which is why retail, convenience, urgent, and emergent workforce increasingly arise from nurse practitioner graduates
  7. PC associations receive no negative attention for failing in primary care – they are allowed to claim primary care while benefiting from non-primary care to a much greater degree
  8. Family Medicine remains 90% primary care, but is dominated by academic interests and various favored projects – such as Primary Care Medical Home Nirvana - not attending to the failures of payment and more members who are dedicated lifelong to primary care (family medicine had devoted an entire floor and millions to PCMH - mainly benefiting consultants
  9. Public Primary Care, academic training, and other public supported venues can undercut private primary care - including some of the most profitable locations

Those most devoted to primary care receive little recognition or respect
  1. While their association leaders broadly proclaim the primary care benefits that only their small and dedicated proportion provides
  2. While all manner of primary care solutions or cures are proposed - other than the actual cure which is more support for them and for their kind and what they do
  3. While also forced to be subjugated as employees to employers that often do not understand or appreciate primary care, or to become a small portion of a large operation with little visibility or priority 

The actual cure for primary care remains funding specific to more clinicians who stay in primary care permanently and deliver more services to more Americans including those most rapidly increasing in numbers and in need of primary care

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...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


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, September 20, 2014

Another Fine CMS You Have Gotten Us Into

Perhaps we are indeed back to the time of Another Fine Mess (Laurel and Hardy). In a mad rush to implement innovation and to save all possible costs, CMS is creating complications for people that it is most responsible to protect.

As PBS and Ken Burns celebrate the legacy of The Roosevelts, it is tragic to see what has become of over a century of effort involving Social Security, Medicare, Medicaid, and health care equity.

The United States has one of the most complex health designs and clearly the various designers often know not what they are doing to others. More cartoons and comedians would find this a ripe area for material if not for the suffering involved.

Health and Human Services has a huge role across Social Security and US health care. CMS or the Centers for Medicare and Medicaid Services has a dominant role to play in the design of health care in the United States. 

CMS can be progressive or regressive. Interestingly CMS has chosen to appear to be progressive and innovative (or has been forced into this role) while often being regressive when there are consequences that must be addressed. Instead of a time honored role to help out those less able, CMS has implemented policies and programs that can disadvantage those most in need.

There is certainly an increasing awareness of CMS' inflexibility and poor attention to the consequences of its many actions and rapid changes. 

Since HHS has more money than all but a few nations and corporations, few appear willing to risk losing their small piece of this pie by attempting to press home their critique of this behemoth. Also the outright political attack upon "Obamacare" may make it easy for HHS to dismiss critique rather than giving proper attention to efforts to improve health care design and delivery.

Regardless of the reasons, CMS appears unwilling to ignore the advice of experts who have urged caution in the implementations of so many changes, many of them not completely ready for prime time as indicated by delays and a number of consequences. Requests for important changes are ignored or appear to result in a defensive posture - clearly not the collaborative approach required for improving health care at the local, state, or national level.

From the perspective of this author, small health and health access has suffered the most by rapid change and poor consideration of numerous consequences.

Regardless of the political administration over the past 33 years, dominant themes at CMS have made it harder to deliver health care.
  • Cost cutting above all - government should be about investment for optimal result. Cost cutting is essentially a focus upon a minimal investment for tolerable result. This is bad enough in business but should be in intolerable when this involves the health of people. Populations still behind in health should be intolerable, especially in a nation that spends by far the most on health care, but the very design fails to expose the designs that continue to leave substantial Americans behind.
  • There is too much focus on change for the sake of change and without the proper study of the consequences. Rarely are the interventions studied before full implementation in violation of human subjects protections that should apply to health care designers just as they apply to health care researchers.
  • CMS has a role to promote solutions that have worked for decades (like family practice) but instead promotes new and untried interventions, even when known to be dilute for the desired results such as primary care or care where needed. Simple payment designs are abandoned in favor of the increasingly complex.
  • Insurance companies, health associations, and others have been able to promote their own special interest needs shaping national designs favoring few with substantial Americans falling further behind.

CMS and HIT - Health Information Technology was not yet ready for prime time when billions were injected into software. The delay in spending "Bail Out" spending and the beneficiaries of such spending did not aid in the nation's economic recovery where needed. Obviously the software corporation sales force was willing to sell, but the pressures to sell and the relatively sudden opportunity may have actually delayed needed updates and developments. Clearly the implementations have been far too difficult and the interfaces haphazard.

Largest providers appear to be favored with such changes as their health information investments have often been ongoing. Smaller providers suddenly are faced with massive change and massive costs. 

The AMA says changes are needed in health information technology - but our nation plunges on with far less efficient HIT. The software still takes far too much time and effort.  Experts in HIT and those representing rural health care (National Rural Health Association) have encouraged more caution. AAFP experts also agree that the Meaningful Use regulations are ridiculously complex.

Numerous problems have been created in the most important and most forgotten area of health care delivery - the clinicians and teams that deliver the care. Distractions from their duties limit the services that can be provided at a time with too few clinicians and rapidly increasing demand.

In the 3 days spent preparing this, more continues to be added (5 paragraphs). CMS has a glitch just announced that will again cost physician practices millions more dollars. As has happened before, CMS will not be ready to fully service the physicians just added to the program in the past year. I would not be surprised to find that these will tend to be small health practices.

And there is more - While it might be considered important to add online personal access to medical records (considered important for digital innovation), people don't perceive the need to do so.

Stop the HIT Glitches and Delays for Better Care

We would never allow high tech to be suddenly practiced upon patients via high tech surgery or high tech medicines without substantial testing and development and careful application -

but we allow HIT to be implemented and promoted in a way 
that has resulted in complications and consequences in a
way not consistent with "Do No Harm." 

CMS and overzealous auditors and excessive delays in appeals/denials resolution - Those in charge of payment have not been efficient. They have paid many billions to those who have committed fraud. For many yearsOverzealous auditors have been paid according to how much they can save CMS - essentially Bounty Hunting. They have done what would be expected - caused problems for those attempting to deliver care. Major disruptions of care have resulted - so much for addressing the prime directive of health care - do no harm! The American Hospital Association and the American Medical Association and others have pleaded for CMS to address this problem.

Medicare Advantage Formulas - CMS was too cozy with insurance companies and ended up paying 12 billion in excess yearly for the past 6 years - because the insurance companies learned to manipulate severity of illness (Medicare Advantage Money Grab, Center for Public Integrity and CMS investigations). CMS makes headlines exposing fraud and waste of funding, but has somehow allowed overpayment by design. Sadly this overpayment generally goes for those already doing well - insurance, higher income patients, urban patients, patients where care is readily available. Too much for some means too little for many others.

Too much for few leaving too little for most others is an all too common CMS theme.

Small Health Payment Formulas - CMS has not been able to properly assess the revenue needs of small/rural hospitals as well as small/rural practices - perhaps because such locations are too far away from where CMS lives and breathes? The design is flawed. Small Hospital Closures Accelerate, Finances Weaker for Stand Alones Practices in the counties without a hospital demonstrate lesser pay, just as they demonstrate lesser concentrations of clinicians. Where care is dominated by hospital outpatient departments as in counties with top concentrations of physicians, pay is greater for the same service - by design. The primary care and basic services most prevalent in small health and where care is needed continues with lesser pay resulting in lesser support and care falling behind for most Americans.

Primary Care Payment - For Decades CMS designs have resulted in too little support for primary care and too much support for non-primary care - distorting US MD, DO, NP, and PA workforce away from primary care and family practice and care where needed. There can be no recovery of health access with current designs of payment and training - designs that appear set in stone.

Pay for Performance - Studies repeatedly show that providers rated "lower quality" under pay for performance are providers that are more likely to care for disadvantaged, complex, older, and sicker patients. The logical conclusion of Pay for Performance or Value Based payment is the elimination of care for patients in need and in locations where needed. CMS disagrees with the need for reform saying that to be fair it should continue the same payment design regardless of the consequences. Regarding the Flaws in Pay for Performance

Insurance Company Design - A major reason for costs too high and services provided too few is the current insurance company based payment design. This design appears to added only a small 5% paid to insurance companies for their work, but actually the design is far more costly. Insurance companies acting on their own or as intermediaries force health care providers to do their work. Employees in hospitals and practices must screen patients, bill patients, beg for prescriptions, beg for referrals, beg for hospitalization, beg for other services or goods, monitor high cost or high complexity patients, and other costly activities.

Preventing Rural Workforce - Prevention of Rural Workforce by Design is a review of many problems arising from designs and designers

CMS and Meaningful Use - Electronics experts and those representing small practice have cried out for delays in the rapid implementation of MU - to no avail. It is a primary reason why there is Open Season on Small Health Care

CMS and Disproportionate Share Rollbacks - Designs for more revenue for providers caring for patients where Medicare, Medicaid, low pay, and no pay patients were more likely. The Supreme Court did the most damage when allowing states to opt out of the national insurance reform plan, but CMS has not done enough to prevent declines in services, clinicians, and hospital facilities where care is needed arising from rollbacks in Disproprotionate Share.

CMS and Readmission Penalties - Readmission penalties at the top level of 1 to 2% are more likely for rural hospitals (9% vs 3% for urban) and 10% of hospitals in 2621 counties in most need of workforce.

CMS Failure in GME Design - Failures in the states in need, in primary care, and where clinicians are needed.


Health and Human Services has other limitations
  • Funding to boost primary care training that only results in 30% primary care result.
  • Funding distributed to locations that have higher concentrations of clinicians as those who can manipulate the system do manipulate the system
  • High administrative cost for Community Health Center programming
  • High administrative cost for low result from loan repayment programs. Loan repayment results in minimal changes in practice location. Generally those taking the loans are those who would have distributed (family physicians, prior commitment) or those that intend temporary benefit - not what helps long term. Loan repayment is another patch, not a fix such as more family physicians or others permanently committed to primary care for a career or permanently committed to locations of need. 
HHS must stop band-aid repairs and must have designs that truly result for primary care and care where needed.

HHS has made a number of mistakes and defensiveness and cover-ups have not helped. It might be nice to hide errors from politicians poised to exploit any error, but 

The design is such that it is not a surprise that Commonwealth has asked the question -  Do Health Care Costs Fuel Economic Inequality in the United States?

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...



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.

Stop the HIT Glitches and Delays for Better Care

Water is essential for life, but floods are destructive. Health information is essential for life, but floods of information, software, hardware, techs, consultants, and salespeople are too much -  too much for cost, too much for patients to comprehend, too much for physicians with established practices, too antiquated for new physicians/best business practice/best care.

This week is another announcement of another CMS delay/glitches that will impact physicians, their practices, and their patients. New physicians who are finally in a position to participate - may not gain the benefits. This is like the first round when some states were ill prepared to set up such a program. Delays in payment changes are no longer rare and cut into revenue - the lifeblood of health care delivery.

We would never allow high tech to be suddenly practiced upon patients via high tech surgery or high tech medicines without substantial testing, assessment, and development. Even then there would be careful observation during implementation.

But we allow HIT or Health Info Technology to be implemented and promoted in a way that has resulted in complications and consequences.

This is not consistent with "Do No Harm" - the high standard that must remain the top priority for health care. In fact, the word reckless comes to mind with regard to such implementation.

The Hypocrisy of Health Care Cost Outcry

We have numerous articles on a daily basis that blame physicians for running up the cost of health care - while somehow not seeing that we spend more and more billions for software, hardware, sales force, Health Info Techs, consultants and others that add substantially to the cost of health care - costs that steal funding and support from the clinicians and teams and their time to deliver care

When revenue is taken from practices to pay for HIT, it can cause "glitches" or delays in the health care that can be provided. Sadly these may be most apparent for patients in most need of care.

Any hope for better health care for most Americans absolutely requires a top priority focus upon spending specific to the teams and clinicians that actually deliver the care rather than so many other areas - no matter how innovative or exciting they may seem.

HIT Is Not Yet Ready for Prime Time

Much more development, standardization, and study of HIT is needed. Interfaces, databases, and other areas should be standardized. Platforms are still used that will be gone in just a few years. Updates of software and various changes in national standards (Meaningful Use, ICD-10, billing changes) are not coordinated and almost seem strung out for maximal cost and minimal benefit.

No one should doubt the potential of HIT, but the potential may actually be retarded by full scale promotion and implementation focus.

This week is another announcement of another CMS delay/glitch. These have been far too common and have gone on for far too long. 

Information Technology Cannot Heal - Time to Get Out of the Way of Healing and Those Who Can Help Remove Barriers to Healing 

Recent Works

Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...



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.




Thursday, September 18, 2014

All True GME Reforms Point to Family Medicine

The United States has 30 states in need of clinicians, needs primary care, and needs clinicians to locate practice where 40 - 50% of Americans are most in need of care. These same locations also are increasing most in population and have higher shares of populations growing faster in demand for primary care and basic services. All true reform for graduate medical education leads to family medicine specific expansions of GME positions. 

Primary Care Trained Graduates for Primary Care Result for a Career
  • Only family medicine training leads to 90% primary care result for a career.
  • Declines down below 15% primary care result for IM training and less than 40% for pediatric training represent failure for primary care. 
  • Less than 50% for primary care for nurse practitioners and less than 30% for physician assistant graduates is also failure for primary care

Clinician Workforce Where Needed
  • Only family physicians have population based distribution across their careers. This is a 1 to 1 distribution such as 20% of family physicians found in rural locations where 18% of the population is found. Family physicians are 36% found where 40% of Americans are found in the 2621 counties lowest in clinician concentrations.
  • 0.9 to 1.1 ratios are required for recovery of clinician services where needed and only family medicine reaches these ratios
  • 0.4 to 0.62 ratios or far less than 1.0 as in population based are not specific to services where needed. Far less is the result for all types of positions filled other than family practice

Training location also shapes clinician practice locations. Studies indicate that training locations where care is needed help to shape such locations in practice. Residency programs tend to fill up workforce in the 60 miles around the residency training program - especially in family medicine. For practical purposes, training in a certain county fills up graduates for a 2 or three surrounding county radius. 

Packing resident training into just a few counties that represent the centroid of top concentrations of physicians is the primary problem 
with regard to distribution of care where needed. 

Care where needed requires that training be established at sites in need of clinicians with nearby counties filling up with needed clinicians - by design.

The combination of poor retention in primary care plus poor distribution defeats all types of clinicians as sources of health access recovery other than family physicians. 

Clinicians for Thirty States in Need of Clinicians

The past decades of designs have favored 6 states with top concentrations of clinicians. Residency positions are not surprisingly concentrated in these states. Physicians that desire to remain in the 30 states in need of physicians often cannot do so because of aberrant GME design - they are forced to go to top concentration states and this shapes US physicians away from states in need and away from locations in need of physicians. The influence is particularly adverse with regard to international graduate physicians because their only influences are instate specific to states with top concentrations and in counties with top concentrations. 

The Instate Multiplier for States in Need - Across the 30 states in need of workforce, instate residency training is a 20 to 40 times multiplier of practice location using all active physicians (over 700,000) in the AMA Masterfile 2013 and controlling for state origins, state medical school, specialty, and other origin variables. 


In Conclusion, the Optimal Solution 
  1. Training in 30 states in need
  2. Training in family medicine
  3. All preparation and training in locations in need of workforce

This is also the solution for the following populations:
  • Elderly, oldest of the elderly, Medicare, Medicaid, Dual Eligible populations,  that are over 40% found in 2621 counties with 40% of the population
  • Veterans in need of care that are over 40% outside of lowest clinician concentration counties
  • Working poor, poor, rural, underserved, uninsured, underinsured, lesser employed, unemployed populations

So Why Do Our Leaders Promote the Following as Solutions

Generic expansions of MD, DO, NP, and PA
Generic expansions of physician primary care training
Generic advanced nursing

The Answer May Well Be That Generic Expansions Are Best for Employers, Institutions, Hospitals, Practices, and Facilities that 
  • already have higher concentrations of clinicians
  • already receive greater revenue by design

And those doing best want even more - from the generic workforce supplied to them, often with government and foundation dollars that are supposed to go for primary care and for workforce where needed. 

Will Teaching CHC Sites Deliver on the Promise of Health Access? - not if they do not remain specific to states in need, locations in need of workforce, and family medicine training (note, not all CHC sites are underserved or will result in distribution of family medicine residency graduates to surrounding counties lower in clinician concentrations)

Improving Graduate Medical Education - Especially in Family Medicine 

The best way to improve GME is to have a better medical student. 9 - 12 months in the third or fourth year spent in continuity sites where care is needed is the best of preparation for GME - especially for primary care and surgical careers as the Minnesota RPAP has demonstrated for decades. The third year dedicated to efficient and effective learning facilitates accelerated training. By the same process, all preparation and training immersed in communities in need of workforce is the optimal solution for health access recovery.

Avoiding the Distortion of Longer Graduate Medical Education Training (especially in FM)


Longer GME should be avoided. For example, a fourth year of FM GME 
  • Consumes more GME positions
  • Decreases the slots per year in a residency program by 12 - 20%
  • Decreases the number of family medicine graduates per year by 12 - 20%
  • Results in fewer years in a career (3% loss of workforce)
  • Delays and decreases income and increases debt at a time when family medicine residency graduates need increases in income, decreased debt and more income earning years
  • Is likely to result in declines in distribution (unless the 4th year of GME is specific to c-sections, surgery, and other procedural practices

More Evidence of GME Reform Failure


GME Changes in Academic Medicine by Jolly - 11% annual increases in sub subspecialty positions, 4% annual increases in subspecialty fellowship positions - translates to shrinkage of the physicians remaining in core specialties, the physicians most associated with basic services, primary care, and care where needed.

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings - Those least likely to gain admission are the most likely to choose family medicine, the most likely to be found in primary care, and the most likely to distribute to counties in most need of care. Why does our national design so distort physicians away from health access recovery.


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...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


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.