The Institutes of Medicine plays a key role as a designer of health care. Up and coming health care designers and those established as designers are a part of the infrastructure of IOM. Designers move around between associations, corporations, institutions, and foundations to gain credentials to reach the IOM and other positions of influence.
Is the reality of designs and designers gone awry finally taking hold at IOM? Can IOM move from academic focus to a population based focus with more academics focused upon population health?
IOM has just now established a Roundtable on Population Health
This is decades after some understanding of the impact of smoking cessation upon population health - an impact greater than cancer research regarding evaluation and treatment until about 15 years ago. Until that time, population health mattered more than all of the research and development, the new treatments, and the new evaluation methods.
Perhaps the designers are becoming aware of the flaws of their designs?
After jumping on the bandwagon to promote nursing as a substitute for physicians, perhaps the IOM can consider their influence.
IOM Made Poor Choices in Reporting Nurses as Substitutes for Physicians
The most important primary care impact of nursing is the 250,000 primary care nurses - ignored by IOM as an impact. The IOM could have chosen how nurses and physicians complimented one another. Instead they chose a small portion of just 50,000 nurse practitioners to illustrate for primary care - a most dilute source.
If IOM had examined how the designs of health care act to prevent primary care RNs from doing more before, during, and after encounters they would have contributed greatly as the 250,000 primary care RNs are the largest primary care workforce in the nation. Nurses forced to beg insurance companies for care for their patients in primary care offices is still a primary reason for ineffective primary care, for high cost of primary care delivery without more patients seen, and for high insurance company profits.
Message to IOM - Take on health insurance companies who have helped to design primary care into a difficult corner where primary care offices must hire employees to work for health insurance companies to save them money, reward hard working primary care nurses, and influence fewer nurses to leave primary care and RN jobs. Shortages of RNs are already a major problem for health care settings serving most Americans left behind. Lack of focus of nursing leaders upon basic nursing may be even more problematic for the nation's largest health workforce.
Message to IOM - After nurse practitioners have declined to 25% of total graduates as active direct care clinicians involved in primary care, you might at least mention the declining ability to substitute for primary care physicians. When a workforce adds new non-primary care specialties with more in each specialty added each year, primary care suffers and the primary care source most important for 200 million Americans behind by design suffers most (employed family practice).
Wrong Way Primary Care Designs Persist
Numerous foundations and the last 30 years of presidential administrations including the Obama Administration - have failed to support primary care recovery.
Most Primary Care Per Graduate
Failure of specific support of training that results in the most primary care per primary care graduate (FM) - instead the support is generic or goes to support the primary care sources resulting in the least primary care result. An example is the CMS Graduate Nursing innovation that claims primary care focus, but will result in just 2 Standard Primary Care Years per graduate or about 10 - 12 times less result than family medicine and 3 times less than the best nursing choice - family nurse practitioners. If primary care is the goal, then why not establish permanent family practice? Why support dilute nursing solutions sending funding to institutions that have demonstrated less support for primary care in the past?
Most Primary Care Delivered Where Needed
Failure of specific support of the specific primary care sources most likely to distribute - family medicine and the employed family practice components of NP and PA
More Primary Care Spending
Failure to increase primary care revenue to the level of 20 - 30% greater than the cost of delivering primary care by forcing more primary care personnel into tasks that do not deliver primary care (higher cost, less productivity), by forcing higher costs of health information technology in equipment and maintenance and personnel time/effort, and by forcing misguided quality focused efforts that cannot result in great quality (because quality is fixed in place by social determinants and patient situations) but will result in less volume and higher cost compared to revenue. Pay for Performance fails for practices serving the underserved and for practices serving most Americans left behind. Quality focus also fails because these take time and effort that are not likely to improve quality and will result in more millions with lower or no health access - a real decline in health care quality as quality cannot begin without the beginning of health access.
Note to IOM and other designers - Solving primary care recovery is required before quality can improve.
More Health Spending in Zip Codes with Multiple Times Less Health Spending
Failure to increase the health care dollars spent in 30,000 zip codes with lower to lowest health workforce - Over half of Americans are left behind by designs that fail for the workforce needed and the increased health spending per person needed to recover that workforce. Insurance coverage is nice, but fails without the primary care workforce. Until the rewards for non-primary care decrease and the support for primary care increases, the barriers to health access and health care quality will remain.
Additional failures are continued support of training that requires more and more dollars for less primary care workforce result. Training is supported that also requires more and more dollars in incentives to get less distribution
Note to Designers: Family medicine requires less dollars for more result in each.
Failure in Understanding Social Determinants and Patient Situations That Shape Health Outcomes
The IOM has done some good by highlighting physician errors. But the methods used result in too much blame placed on physicians and too much credit given. Proper studies must have the right variables included. When regression equations are loaded with physician variables, the studied blame or credit physicians too much. Any researcher familiar with regressions knows that adding the right variables results in decreased impact for the previous variables. The right variables can also result in the physician variable as knocked out of a significant contribution.
Studies of health care outcomes involving quality and cost must have
- Patient variables
- Patient situation variables
- System variables
- Health care team variables
- Physician or provider variables
On the other hand the American populations most left behind by design - most Americans - are impacted substantially by patient variables, patient situations (access, housing, transport, cannot get off work), system variables (coverage, provider situations), health care team variables (high turnover, too few, less support) with the physician less likely to have impact.
Many great health care "advances" fail to work for most Americans. For an example one can examine chemotherapy. Who has the family support to endure months of disabling treatment, or the finances, or the education or contacts to figure out puzzling instructions or the way to actually get best care? Who is least likely to receive the optimal doses, have the most side effects, or face the terrible choice between working or getting care? Who can get to rescue care in a timely fashion to avoid dying from side effects?
There has been IOM failure to understand that the controls used by many if not most health care studies involving populations - are not adequate. Studies supportive of this include studies by Hong in JAMA and by the Medicaid Randomization Studies in Oregon. Poor examples include the apples and oranges Critical Access Hospital study in JAMA where rural hospitals with different and lower funding, different and lower workforce, different and lower status populations had different and lower outcomes.
Perhaps the IOM has decided to get involved when teaching hospitals started seeing that their readmission rates were causing major problems for their cash flow - due to social determinants that result in lesser outcomes for the patients that they serve.
Or perhaps the IOM will figure out that a focus on residency work hours limitations will result in substantial harm and little real good.
- No improvements in teaching hospital quality due to social determinant limitations
- Losses of 30,000 nurse practitioners and physician assistants and other personnel from primary care and other settings to fill shortages of teaching hospital workforce resulting from residency work hours limitations
- An additional year or two required for some specialties during training with 4 - 10% loss of workforce for the graduates with such longer training - resulting in a less productive workforce and more cost of training and more graduates needed for the same result
Perhaps IOM has failed most because it allows distractions from the most effective treatments. Alternative or innovative treatments that distract patients from effective existing treatments have been areas of focus for IOM.
The IOM should exposed alternative solutions for primary care, health access, and rural health as less than the most effective. It should support permanent broadest generalists as a real solution for primary care and for rural health and for most Americans left behind by design.
Permanent broadest generalists exist (in FM) and have the most primary care delivery over a career, the most primary care delivery per graduate where needed, result in more spending upon primary care, and result in more spending in practice locations in need of health spending.
Other sources may be innovative or alternative, but they result in no increase in primary care workforce (flexible and depart primary care), far less primary care delivery over a career, far less primary care delivery per graduate where needed, and concentrations of workforce in the specialties and locations where top concentrations are already found.
True value in primary care is 90% retention in primary care, 90% retention in employed family practice, most primary care experience, lowest turnover, highest volume, longest career length, lowest training cost for the yield of primary care, best distribution, lowest cost of incentives for the distribution result.
IOM could expose government health access failures such as projections of 155,000 primary care internists by 2020 rather than the decline to less than 45,000 by 2030. IOM could point out that family medicine has reached its 90,000 maximum - all that can result from 3000 graduates a year for 30 class years. It could noted that the HRSA projection of 144,000 is impossible for 2020 or for any time - without an increase in annual graduates. IOM could expose the projection methods as fatally flawed and responsible for our yo-yo imbalances of workforce for decades.
IOM should play a role in examining entire careers of primary care capable graduates. It should find that the United States can spend 21 billion dollars a year on 14,000 annual graduate permanent broadest generalists and have sufficient primary care. Instead it tolerates six sources of primary care at a cost of 21 billion dollars for half enough primary care delivery result - because the primary care sources end up only 30% primary care in result.
There are few areas where the nation can spend less and get more and solve health access woes for nearly all Americans. IOM should figure this out.
Population Based Care is a beginning. How about figuring out how health care cost and health care quality are really about the first months and years of life of a child (child well being)? How about studies to figure out how physician origins are a mismatch for the care of most Americans and are getting worse? How about Basic Health Access for Most Americans?
If IOM can gain some awareness of most Americans, it could figure out solutions for these and other most pressing problems. But it faces the problem of its own designers who are most out of touch with most Americans and their daily lives. IOM cannot be fixed from insider efforts. As with most quality issues, the solution requires the perspective of outsiders.
Solutions specific to health access, long term investments in children from the earliest ages, shaping influences of outsiders who can best inform interventions - these represent the advances that IOM and other designers must seek.
Send your concerns to IOM, to Commonwealth, to Kellogg, to RWJ, or to your institution or association. Most Americans are counting on you for a different next 30 years for a needed change.
Robert C. Bowman, M.D.
SMART Basic Health Access