Friday, August 29, 2014

Health Access Failure from the Start

Health Access Results Can Be Multiplied By Earliest Investments and Specific Health Access Focus. A Continuation of the Current Design Will Fail Most Americans.

A common mistake is believing that you can impact the end points (college tracks, medical school influences, loan repayments). When you are talking about national outcomes and improvements, the end points are far too late as they are dependent upon "the matrix of relationships" as Deming often noted. Previous life experiences shape subsequent encounters and situations. Health care is one of the ultimate examples of complexity - and even the best research fails to consider the numerous pre-existing influences that shape health outcomes.

Birth to Higher Education Pipeline Failure

Prevention of higher education and medical school from the start.
From a 2013 New York Times Article - Andreas Schleicher, who runs the O.E.C.D.’s international educational assessments, put it to me this way: “The bottom line is that the vast majority of O.E.C.D. countries either invest equally into every student or disproportionately more into disadvantaged students. The U.S. is one of the few countries doing the opposite.” The inequity of education finance in the United States is a feature of the system, not a bug, stemming from its great degree of decentralization and its reliance on local property taxes.      

Each of these results in disadvantage for most children as measured by lower probability of higher education and medical school admission as well as higher probability for children of advantage.

Dividing the Nation By Income in Medical School Admission
  • Over 60% of Medical Students arise from the top 20% in Parent Income (AAMC data) 
  • 20% arise from the second 20% - equity
  • Less than 20% arise from the bottom 60% of American children (AAMC data)
  • Lower income rural county origins and Mexican American populations have 5 times lower probability of admission
The problem is not necessarily with medical school admission as the same situations are found in higher education. College has been a prerequisite for medical school for 100 years. 

Dividing the Nation By Income in Higher Education
Highest Income Origin, Most Urban Origin, Children of Highest Educated/Professional Parents appear to benefit from a widening gap as compared to other origins as seen in data regarding US medical students.

Even when not gaining admission to a US MD school, the expanding osteopathic and Caribbean opportunities and other international schools (US born Asians going to Asian nations for medical school) offer more routes to becoming a physician.

Normal children in America have little chance with lesser opportunity shaped by design. Those most different and unlike most Americans in a number of dimensions are more likely to become US physicians.

Physicians with Origins Immersed in Top Concentrations from Birth to Graduation
  • Are least likely to choose primary care
  • Are least likely to remain in primary care when training in primary care
  • Are least likely to choose family medicine
  • Are least likely to remain in core specialties
  • Are least likely to distribute where needed
  • Often move state to state, failing to remain in states in need of workforce - reinforced by more specialized careers that dictate states, counties, zip codes, and practices
Origin changes, training changes, and policy changes all contribute to family medicine choice cut in half and internal medicine primary care retention cut from 60% to less than 20% in the past 18 years. Family medicine and internal medicine primary care

  • Represent 33 - 40% of physician workforce where workforce is needed
  • Are the most important sources of health care for the elderly populations that are doubling from 2010 to 2040
  • Are the most important sources where counties are growing the fastest in population growth and in primary care demand.
  • Since internal medicine primary care is steadily declining, the family practice sources are even more important.

The United States will continue to produce Too Many and Still the Wrong Physicians    


Solutions for Health Access Are the Opposite of the Designs for Training and Practice Support
  • Instate location for 30 states behind, not 6 - 10 states with top concentrations of physicians and graduate medical education 
  • Primary care - permanent over a career, not just during training
  • Workforce in counties and zip codes in need of workforce such as 2600 counties with lowest concentrations of clinicians and 40% of the United States population
State public medical schools have been admitting more highest income, most urban, children of professionals that move from state to state. These students have replaced students who are more average in income, normal to rural in geographic origin, and those from a wider range of parent education and occupation. 

In Nebraska the family medicine choice of those that dominate admissions is 2%. Those steadily being replaced over recent decades are those more connected to the state with a wider range of origins that have 15 - 30% family medicine choice, better primary care, and higher instate retention. Choice of family medicine at UNMC is associated with over 20 times more instate practice location in the 88 counties in need of workforce out of 93 in Nebraska. Family medicine more than triples distribution where needed, but it is more than just family medicine as the characteristics that result in family medicine also result in better distribution. This is why you cannot just influence health access or family medicine choice in medical school or late in the game. 

Real solutions focus upon the instate, permanent primary care, and workforce where needed very specifically across origins, preparation, all training, and practice support. 

In Kansas the family medicine choice is a 16 times multiplier of Kansas practice in 98 counties in need of workforce as compared to practice elsewhere out of state or in Kansas counties with top concentrations of clinicians. 

If we are to ever deal with health disparities, the patients and the clinicians must be addressed.

Most American patients need a better start. They also need a physician that is more like them in origins and one that is trained specifically for their needs. Our "one size fits none" medical education design is least specific for care where needed and Americans most in need of care.

We must deal with designs that are causative with regard to disparities. Some like to blame individuals for their plight, but these arguments go away when we are talking about designs, designs for education, and impacts on children who are dependent upon our designs. Our nation is dependent upon child development and early education for outcomes outcomes across education, economics, jobs, ideas, and health.

Designs that impact before birth, in the first months, and in the first years of life are important to understand. Our  has very little investment in education - less than 8% of school funding. The financial responsibility is at the state level - for adequate funding and to address inequitable funding due to local school districts that have little property value to tax. Some states do very little, and some states provide 60% or more of funding. States that invest more and less, would not surprise you as the same states that invest more do better in a number of outcomes.

Insufficient funding is bad, and property based taxation is even worse as lower property value schoolchildren face the worst discrimination. And when states fail in school funding distributions they are failing in jobs and economic impact for these school districts. And these areas of a state are even more dependent upon such spending in education, health, social security, and other areas for substantially more of their economics.

When Katrina hit, Houston Independent School District was able to absorb a substantial portion of the refugees into Houston schools - because it was in better financial shape, because the legislature required cash reserves, and because HISD accepted the challenge. The central metro areas have been losing out to suburbs, the legislature has slashed funding, and lawsuits have been required to attempt to address worsening situations for Texas schoolchildren statewide. How things have changed an in a short period of time. Now the deficits of funding impact the entire state, especially the school districts facing the greatest challenges. Even the higher property value school districts are feeling the effects. Within school districts there are also tough choices. 

Do the districts make the tough choices to attempt to meet the needs of most children, or do they shape their spending and programs to favor the children of advantage as their powerful parents continue to demand?

I see the same theme across education, health, primary care, economics, and health spending. With declines, those doing well cling more to what they have, sending more into a downward spiral and even those of advantage with them. 

Parents need to understand what happens in education. In the classroom, in the school, in the district, and in the state, the key measures are about the 50% left behind, not the few doing well. Those doing well have numerous advantages and will likely do well without investments in child development, early education, or catch up programming. For most American children, these recovery investments are essential. When the designers decide that cuts on costs are the only dictate, the powerful parents will direct the remaining funds to their children.

Most Americans will lose in this process of squeezes within squeezes, leaving an entire nation further behind.


Worsening disparities will continue to make matters worse

What we understand about social determinants indicates that declines in income, education, and other determinants will shape worsening health outcomes. Cash flow into an area can aid in development and recovery. Cash flow restrictions or requirements to send cash outside of an area can result in social determinant changes such as declines in jobs, income, and other areas. Rural and single county hospital closures are an example of such declines. An acceleration of closures of practices and hospitals where needed is the small scale example. State and national changes indicate massive changes in cash flow.
  • Federal and state funding cuts in child development, education, nutrition, Social Security, and health care where needed will worsen cash flow, jobs, economic impact, and situations where disparities exist as these are areas even more dependent upon these investments. 
  • Downsizing business changes, centralization of government positions (social services, extension), mergers of businesses and health care, and consolidations of schools all represent compromises of cash flow, jobs, income, 
  • Largest urban and rural systems take over those smaller. Some even proceed despite violations of the law. Local health care needs and local cash flow are compromised while centralized location benefit.
  • Mail order prescriptions took billions away from local pharmacies and economics while centralizing spending in just a few US locations. 
  • Requirements for health care providers to spend more for consultants, software, and other "advances" will send more dollars out of counties in need of spending. Practices will not be able to support local workforce as delivery personnel must decline to pay more for non-delivery budget items.

Unicef Report Card 11
Recent Works

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

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

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

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

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

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.



Tuesday, August 26, 2014

Comparative Primary Care Delivery By Medical School and Training Type

Physicians and other clinicians have been moving steadily away from primary care. Specific measuring tools can indicate sources better and worse in the production of primary care. Unlike "wait and see" or projections based on annual graduates, the Standard Primary Care Year (SPCYR) is a more specific measuring tool. The SPCYR estimates the future primary care delivery at the time of graduation. Data regarding years in a career, clinical activity, and adjustments for differences in volume between primary care sources are already known. 

Career Years x Primary Care Retention x Clinician Activity x Volume Adjust  =  SPCYR

The career years times how that career was spent with adjustments for activity and volume differences yields the Standard Primary Career Year estimate.

The most recent primary care retention figures can be inserted or the steady declines of recent decades of class years can be projected. Recent primary care retention was used rather than projections for this ranking. Even less primary care delivery would be expected from recent graduates, especially in sources declining the most rapidly.

Spreadsheet calculations can be used to estimate primary care deliver (in SPCYRs) for each type of training. For medical school calculations, the Standard Primary Care Year result for graduates choosing family medicine, internal medicine, and pediatric training can be estimated and the results summed for each type of school for 100 average graduates of that type of school. Results below.

Summary of Primary Care Delivery Contributions by Training Type

Substantial declines in primary care delivery have occurred in the past 20 years across physician, physician assistant, and nurse practitioner sources of clinicians. The major reasons include fewer graduates entering primary care careers and fewer staying in primary care careers. As rewarded by health policy payment design, more graduates have entered new specialties and more have been added to each new specialty. The most specific losses have been in family practice and in primary care position result. 

Declines in family medicine in certain schools simultaneously reduce primary care delivery and workforce where most needed by multiple times. This is because family medicine residency graduates deliver 2 to 6 times more primary care and because family physicians distribute at 2 to 4 times greater levels than other sources not in family practice positions. This location multiplier applies across all locations in need of workforce and applies to the graduates of over 95% of medical schools 

Since family practice is about one-fourth of workforce where needed and since primary care is half of workforce where needed, the declines noted in the past twenty years for MD, DO, NP, and PA graduates indicate declines in workforce where needed. 

Sources with predominantly internal medicine training as the source of primary care (international, lowest FM choice schools) have declined substantially because so few internists remain in primary care after training. The 60% primary care result of 1980 internal medicine entry has fallen to less than 20%. In general, types of schools with greater FM choice also tend to have graduates with slightly better internal medicine primary care retention.

Overall Primary Care Delivery Result in SPCYRs for Recent Graduates 
Estimated Over Their Careers 2010 to 2045
  • 12.1 Standard Primary Care Years per Graduate - Duluth medical school leads in primary care delivery per graduate due to 44% family medicine result for recent graduates and essentially 44% - 52% FM result for decades of class years.
  • 9.2 - Caribbean school graduates deliver the most primary care per graduate due to about 25% family medicine and 36% internal medicine (reduced to 12% actual primary care for IM)
  • 8.9 – Top osteopathic schools once led in primary care delivery with over 60% family practice result, but only the schools remaining at 30% family medicine continue this contribution.
  • 7.0 - Physician assistants have declined to only 20% family practice position result with less than 30% active as primary care clinicians, but PA graduates remain above the average US DO and US MD graduate.
  • 5.9 – International graduates other than from Caribbean schools have reduced primary care result due to only about 7% family medicine. The substantial internal medicine training choice of 45% is multiplied by only 30% retention in primary care to negate the primary care result.
  • 4.7 - Nurse practitioners have also had declines in primary care retention. Family nurse practitioner graduates likely have the highest contributions with
  • 4.4 - The US MD schools remain the major source of physicians for the United States. Declines in primary care delivery over the past two decades have been devastating for primary care result.
  • 2.4 - The schools considered the most exclusive by the top MCAT scores of matriculants, by NIH research dollars awarded per year, or by subspecialty production have the lowest primary care production. Fewest family physicians and least internal medicine and pediatric primary care retention reduce the primary care delivery result.

The SMART Family Medicine Medical School

Specific - Failures and successes shaped predominantly by family medicine choice indicate a Specific solution for primary care and for workforce where needed. Bypassing the barriers to family medicine result such as current medical school preparation, admission, and training makes sense.

Measurable - A family medicine only medical school is Measurable at 25 Standard Primary Care Years or 2 times the best school and 10 times the primary care delivery of the worst schools 

Achievable - Flexible sources of primary care cannot achieve primary care because so few stay in primary care over their careers. Primary care recovery is achievable based on the number of annual graduates needed times the family medicine SPCYR number. 

Specific designs for just 3 years of preparation and 3 years of medical (not 4) would result in 27 Standard Primary Care Years - a design that requires less graduates for more primary care result. 

Realistic - Expecting primary care from sources with nearly 20 class year declines in primary care result is not realistic. The overall primary care result from 6 primary care sources is only about 33% retention in primary care. When primary care delivery is the specific focus, the realistic solution is the 90% primary care result as seen only in family medicine. NP or PA graduates, if forced to remain permanent in family practice positions over a career, could be realistic sources but this would require a reversal of the past 50 years of training and policy in 50 states.

Timely - Actually it is already too late for primary care recovery. Workforce changes toward primary care would take at least 15 class years and more likely 25, but SMART expansions are the most timely in terms of the result for primary care, for 40% of the nation left behind where 36% of family physicians are found, for the populations increasing most in these locations such as the elderly, and for those previously without insurance coverage, 

Defeating SMART Family Medicine

An increase in family medicine residency from 3 to 4 years would result in 23 Standard Primary Care Years and fewer funded GME positions per class year would result in a 12 - 18% decline in the number of family medicine graduates a year - a disaster for primary care and workforce where needed.

A two year longer training for a doctoral NP degree similarly would reduce workforce result by 10% including primary care delivery with a likely further reduction in annual graduates due to shortages of faculty and other elements of training. 


Recent Works

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

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

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

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

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

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

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

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

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

How To Resolve Health Access for 40 States Behind By Design

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


The Worksheets

The first calculations involve an average 100 US MD graduates with typical activity, volume by specialty, and 35 career years in the 1990s 

US MD 1990s
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
83%
94%
100%
35
27.31
13%
359.99
IM
83%
60%
86%
35
14.99
25%
374.75
PD
83%
65%
95%
35
17.94
9%
161.45
8.91
891.18

Fewer in family medicine plus primary care retention cut by one-third for internal medicine cuts primary care delivery per graduate from 8.91 to 4.43 Standard Primary Care Years. Minor changes include declines in activity and years in a career.


The US MD figure of 4.43 Standard Primary Care Years for recent graduates (2010) basically sets a low bar for primary care production from the dominant US source of clinician workforce.

US MD Recent Grads
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
8%
196
IM
80%
20%
90%
34
4.90
25%
122
PD
80%
44%
95%
34
11.37
11%
125
4.43
443


Osteopathic medical schools have rapidly expanded with another doubling of graduates since the 1990s. Unfortunately the family medicine choice has been cut in half from 35% to 18%. Since family medicine is the predominant primary care source for US DO schools, the primary care result has also plummeted.

US DO
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
18%
441
IM
80%
28%
90%
34
6.85
14%
96
PD
80%
50%
95%
34
12.92
6%
78
6.14
614


Caribbean schools have been expanding annual graduates at some of the fastest rates. This has raised some controversy, but it has also raised primary care production. Caribbean graduates have some of the highest rates of family medicine choice. Internal medicine choice also makes a contribution at 36% of Caribbean graduates, but this is reduced to a reality check 12% because of only 33% primary care retention.

Caribbean
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
23%
563
IM
80%
33%
90%
34
8.08
36%
291
PD
80%
42%
95%
34
10.85
6%
65
9.19
919


International graduates are often considered a good source of primary care, but this may be because they are better than US MD graduates – slightly better. Graduates from schools in the Philippines stand out as superior in primary care and workforce where needed. This is somewhat limited to a few states. These figures do not correct for 20% - 25% that depart the United States after US residency training or lesser activity levels due to higher unemployment rates. These corrections would leave international graduates at the same low level as US MD graduates.

Inter-national
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
7%
171
IM
80%
30%
90%
34
7.34
45%
330
PD
80%
33%
95%
34
8.53
10%
85
5.87
587


Success as indicated by consistent top primary care delivery result from the 1970s to the present is found at Duluth.  Even with some slight decline to 44% family medicine, Duluth remains a star. These results are also shown per 100 graduates although Duluth is just 60 per year.

Duluth
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
44%
1077
IM
80%
30%
90%
34
7.34
8%
59
PD
80%
50%
95%
34
12.92
6%
78
12.13
1213


The top US DO schools continue with 30% family medicine choice. This is half of the level of all osteopathic schools before the 1970s, but the 30% level is still a mark to reach for any school to claim to be in the top echelon of primary care production. Schools in California (Western), West Virginia, and Texas lead. Newer schools such as Pacific Northwest and ATSU’s School of Osteopathic Medicine in Arizona have been consistent at 30% family medicine and should also rate at 8 – 9 Standard Primary Care Years per graduate.

Top US DO Schools
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
90%
100%
34
24.48
30%
734
IM
80%
20%
90%
34
4.90
16%
78
PD
80%
40%
95%
34
10.34
7%
72
8.85
885


The schools considered the most exclusive by the top MCAT scores of matriculants, by NIH research dollars awarded per year, or by subspecialty production have the lowest primary care production. 

Top MCAT/ Research
Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
% of Grads
SPCYRs per 100 Grads
FM
80%
85%
100%
34
23.12
3%
69
IM
80%
15%
90%
34
3.67
21%
77
PD
80%
33%
95%
34
8.53
11%
94
2.40
240

 This is the result of the lowest family medicine choice at less than 5%, slightly lower internal medicine choice at 21%, lowest internal medicine retention in primary care at less than 15%, and lowest pediatric retention in primary care at 33%.  Five times as many graduates of the most exclusive schools must be graduated to reach the primary care delivery of Duluth graduates. Most exclusive on physician origin, in selection, in training, and in graduate medical education choices (specialty, location) results in the least primary care delivery. Studies of 14 medical schools indicated only 2% of senior medical students planning internal medicine primary care. This translates to only about 8 – 10% of internal medicine trained graduates retained in primary care from these schools and not all are the most exclusive or have the worse primary care retention in physician databases.


Nurse practitioner and physician assistant primary care delivery can also be estimated. 

Activity
Primary Care Retention
Volume
Career Years
Standard Primary Care Years per Graduate
NP
60%
50%
70%
23
4.83
PA
75%
40%
75%
31
6.98


Nurse practitioner activity as a clinician is limited due to fewer who become clinicians (part time, inactive, nursing staff, and other non-clinician employment). The primary care retention figures were taken from AHRQ studies using NPI (procedural code) data. Previous comparison studies were summarize for the volume adjustment that was used in the Standard Primary Care Year publication in 2008. AAPA data indicates the 31 year career of PA graduates. The 23 year NP career is the result of late graduation about age 41 or 42 leaving 23 years before retirement.




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.