Tuesday, September 16, 2014

What Is the State of Small Practice USA

Are small practices improving, stagnant, or in decline? Articles debating the value of such practices are not of much value if the foundation of small practice is crumbling. Associations defending small practice in Washington DC may miss the point of fundamental changes required in training and in payment just to have small practice. Sadly the data is largely missing as studies have typically been about the largest and most centralized practices rather than those small and distributed where needed. Half the nation's population continues to be left behind as a side effect of Big Health focus.

There is no doubt that small practices can survive anywhere, even with dedicated efforts by large systems to move them away. This is about the ability of small practice clinicians to adapt and continue to serve their patients regardless of changes, but...

The Factors that Shape Small Practice Are Changing

Patient Changes
  • Demand is increasing in multiple dimensions as populations grow, age, and acquire more conditions needing care.
  • Patient complexity is increasing due to patient changes such as aging population increase and getting older and and patient conditions such as Alzheimer's as well as rising mental health and disease burdens in younger populations
  • As with the other factors, the changes are more dramatic where small practice is more likely
Changes in the Clinicians Needed for Small Practice 
  • The data does show that the proportions of clinicians in primary care arising from MD, DO, NP, and PA are decreasing - especially the family practice positions filled
  • But the massive increases in NP and PA graduates are difficult to evaluate
  • On the other hand the continued collapse of internal medicine primary care, the number 2 largest source of workforce, is an issue for care where needed, primary care, and the fast rising elderly - about 35,000 internists have been lost to hospitalist workforce (Hospitalist data)
  • And about 30,000 NP and PA graduates have been losto teaching hospitals to replace resident workforce lost due to many changes 
  • Data from the AMA Masterfile for 2013 as compared to 2005 demonstrates overall losses of general types of specialties, especially general surgery, general ob-gyn, general orthopedics, and other core surgical specialties remaining in core specialty. The data demonstrates greater losses where small practices are more common. 
  • MD, DO, NP, and PA clinicians are rapidly specializing to careers least associated with small practice and care where needed 
  • Physicians in small practices including core specialties and primary care are nearest retirement with those in most needed locations closest to retirement - replacements do not appear to be on the way.
  • Small practice ownership is threatened due to financial changes
  • About 6% of family physicians are found in urgent or emergent care (Graham Center) and rural/smaller hospitals are more likely to have FM docs as ER or hospitalist docs. This may also drain small practice FM docs from needed primary care. 
Changes in Payment Interacting with Training
  • Relatively less paid for primary care and basic services has shaped less primary care result from clinicians as well as fewer in the core specialties that do basic services. 
  • Clinicians that begin in primary care depart in a few years - taking their primary care experience with them (predominantly IM, NP, PA - less so for MPD, PD, FM)
  • Payment and training interact to prevent most desirable health access and small practice choices such as family medicine careers that are 90% permanent to primary care and family practice positions. Other graduates face a difficult choice to select and stay in primary care after training or entry. 
  • Shortages of clinicians have been shaped by decades of poor payment design
Payment Changes
  • Payment is stagnant, especially for small practice services
  • Small practices are paid less than larger or hospital based practices
  • Small practice owners are facing changes due to regulation and innovation, and must invest massive amounts or move out of small practice
  • Lesser pay and penalties are more likely where care is needed and there is less ability to pay for care in the populations served by small practices.
Systemic and National Changes
  • Forced mergers and consolidations
  • Bigger must be better mentality enacted as policy
  • Insurance reform has yet to address payment changes needed
  • Insurance issues more common where small practices are found
  • Declines in half of the American population with regard to income, education, jobs, local resources, and other spending areas 
Serious Issues with the Medical Literature and with Media Coverage
  • The bigger must be better mentality prevents understanding
  • There is a general lack of awareness regarding strengths, weaknesses, opportunities, threats of small practices
  • Research includes those smaller despite being different in many ways, failing the classic Apples to Oranges test of validity. This is seen in the most read and most prestigious journals. Small to large comparisons are too difficult to accomplish due to so much variation between and within groups in so many dimensions
  • Well orchestrated promotional efforts continue to push innovative workforce, innovative software, innovative reorganization, or other substitutes - instead of the workforce, training, and payment design changes needed. 


When the worst is emphasized and the best is underemphasized about small health care - most Americans suffer by design.

More attention could fuel more debate and some needed action. The real enemies are inaction and considering what has been done to be enough.


It is an impressive run of articles with some content regarding small health care, often negative but a few positive

9/16/14 AFP Community Blog The Demise of Small Practices Has Been Greatly Exaggerated

9/11/14 Commonwealth - All Health Care Is Local

9/10/14 Headlines - Small Hospital Closures Accelerate, Finances Weaker for Stand Alones

9/9/14 Commonwealth Do Health Care Costs Fuel Economic Inequality in the United States?




Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Reference Links

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.

Friday, September 12, 2014

Will Small Health Make the News Long Enough to Matter?

It is about time that Small Health Care received some attention as the small hospitals and small practices, but will this continue. Off and on over past decades, primary care has received much attention, but the attention has not resulted in changes in payment policy. In fact the increased cost of delivering care has made matters worse. 
Small Health Care is at least half made up of primary care and much of the remaining local care is basic services - services lowest paid by design. Small health does not have multiple lines of revenue with the top reimbursement in each line as seen in large health care. 

It is an impressive run of articles with some content regarding small health care, often negative but a few positive

9/11/14 Commonwealth - All Health Care Is Local

9/10/14 Headlines - Small Hospital Closures Accelerate, Finances Weaker for Stand Alones

9/9/14 Commonwealth Do Health Care Costs Fuel Economic Inequality in the United States?



Changes have not come
  • Primary care pay remains low and especially low compared to non-primary care specialized services
  • Disproportionate share funding is going away and across the board cuts have continued to reduce revenue.
  • Graduate medical education has not been reformed despite legislation and nearly a decade to observe the legislation going for naught.
  • Continued funding for Medicaid to remain at higher rates of pay has not passed. 
  • The government has not eased up on penalties that more commonly go to sites where small health is found.
  • The state governments have not reformed Medicaid criteria, eligibility, payment barriers, or low pay.

Can rural and small practice urban sites rally together to get more than just discussion?

Will federal facilities and funding supports contribute to care or undermine what remains of private small health care?

What will turn clinicians around to primary care and small health care when payment so obviously rewards specialized care and sites with concentrations of clinicians?

Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Reference Links

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.


Wednesday, September 10, 2014

More Reasons for Lesser Performance for Small Health

America is aging. With increases in age, Americans become more dependent and have more care needs in areas such as health, activities of daily living, finances, and more. Aging in America is not equitably distributed. States like Alaska and many of the locations associated with small health care have more rapid rates of aging growth and oldest American growth. Once again increasing demand for health and other services is occurring in locations that have lowest resources and fewest clinicians.

Unprecedented changes are being seen across America - particularly where small health care is dominant. Only a few years after penalties have been proposed and implemented for Pay for Performance or for Readmissions penalties, the landscape has changed. Economic declines, cuts in state and federal spending, failure to produce the specific clinicians needed, higher cost of delivery, and increasing patient complexities have proceeded and have even accelerated in some locations.

Why Do Payment Designs Persist in Penalizing Small Health Care Providers?

The situations are quite different from a few years ago and even worse is on the way.  Just when you think you have Summarized Small Health Complexities, new studies come out to contribute even more to our understanding of complexities - and the folly of attempting to link quality issues to lower payment. A new study highlights the rapid rise of care needs in seniors as reported in Healthjournalism.org from Millbank Quarterly.

Overall, researchers found:
  • Out of the 18 million older adults with some late-life disability, 19.6 percent had difficulty and 28.7 percent received help from another person with self-care, mobility or household activities.
  • Another 11.5 million adjusted for their limitations through assistive devices or reducing activity frequency.
  • About 20 percent of those under age 85 and more than 75 percent of those age 90 or older received some type of additional help
  • Women and widows made up a disproportionate share of those needing assistance, which is not unusual since women tend to outlive men. African-Americans and Hispanics were overrepresented in self-care and mobility assistance categories.
  • Those in the lowest-income quartile had significantly higher needs across all levels of assistance, especially those requiring help with three or more ADLs or IADLs.
  • Family caregivers continue to provide most of the assistance to older adults, particularly for those in lower income brackets.
  • Fifteen percent of older adults reported adverse consequences related to unmet needs in the month before the analysis.  Minorities, widows, or never-married, and those with the lowest income reported the greatest number of adverse consequences.
  • For those living at home or supportive care environments, 32 percent reported at least one adverse consequence in the previous month.
See New Millbank Report Highlights Seniors Unmet Care Needs

And our nation's politicians want to continue to cut needed areas of support?

There is nothing about this report that would indicate anything other than declines in local health outcomes where these scenarios are most likely to be found. We know from national payment distributions of nutrition funding, disability funding, Social Security, Medicare, and Medicaid that small health is where these populations are concentrated.

From what we understand about small health or the 2621 counties with lesser concentrations of clinicians, there are more elderly and they are more likely to be older and less healthy in a number of dimensions. Health literacy correlates with education level and age.

Slow steady worsening of rural hospital outcomes regarding Medicare patients (JAMA study) may actually reflect the slow steady worsening of patients and their situations as guided by aging and deterioration of local resources.
  • It is difficult to see how penalties and even lower revenue from Medicare or Medicaid or insurance would do anything other than worsen care and care outcomes.
  • It is difficult to see how forced closure of remaining small hospitals or small practices would do anything other than worsen local workforce, local revenue, and local social determinants of health 
Social determinants help shape health care outcomes and those with various deficits lack the resiliency to recover. Their communities are in the same shape. Social Determinants and Health Disparities

What happens in rural America has is often a prelude to what will happen in the rest of America. Adverse consequences and challenges often proceed from the smallest health care sites and smallest concentrations of workforce to somewhat larger and eventually even the largest:
  • Rapid aging
  • Increases in populations in need of care and resources
  • Poorly targeted programs
  • Programs that are targets for cost cutting
Rural hospitals  that escaped the closures of the 1980s due to overzealous cost cutting designers were given improved funding during the 1990s but in the last decade, increasing costs of delivery plus deteriorating conditions for local populations are once again difficult to address.

Current and even accelerated declines seen in rural and smaller hospitals may already represent what happens to health care redesigned by health designers who fail to understand the people, their situations, their health care, or their health outcomes.

Continue on to Open Season on Small Health By Big Media

Reference Links

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, September 9, 2014

Summary of Small Health Complexities

No small part of America is impacted by designs and information sources that disadvantage small health hospitals and practices and the people that depend upon small health care.

Small Practices 

  • Are perceived as impacting relatively few, but small practices of 5 or fewer physicians include 45% of primary care in America - essential for 40 - 50% of Americans in basic health needs
  • Are most commonly basic health need areas include mental health, basic surgical services, primary care, and dental health. If an area is in decline, it is associated with small health.
  • Receive few lines of revenue, have few basic services, are often paid less for the same service
  • Can have higher costs of supplies and other costs of delivering care
  • Can have the highest special cost increases such as recruitment, retention, and locums costs because of shortages of various health personnel at small practice sites.
  • Are hurt by rapid change - rapidly increasing costs of regulation, certification, software, revisions
  • Often have high complexities of patients and often deal with gaps in local social and health resources plus other factors that shape lesser outcomes
  • Can receive more penalties for care outcomes - making situations worse where care is needed
  • In the media and in the literature are often painted in a negative way and small health themes include rural, small, lower in volume, and generalist vs specialist controversies 
  • Articles in the media/literature often ignore small practice differences in many areas that shape outcomes such as patient populations and resources, assets and barriers - poor awareness contributes to misunderstanding 
  • Small health is an easy target for political and health designers bent on cost cutting. Small health is small, distant, poorly organized, attacked from so many directions that defense is difficult
  • Small health can lose out on federal funding because bigger entities are more organized. Sometimes funding (CHC funding) must be protected for the use of small or rural practices to keep from further inequitable distribution.

Small Hospitals

  • Include emergent or acute hospital services for 40% of the US population including nearly all rural hospitals and many single county urban hospitals
  • Have few lines of revenue, paid less, may have higher costs, not able to demand discounts from suppliers
  • Can suffer from higher costs in the same supplies needed for health care deliver and other costs can be higher including recruitment, retention, locums
  • Have rapidly increasing costs of regulation, certification, software, software revision
  • Are more dependent upon low pay (Medicare, Medicaid, lesser insurance, high deductible), and no pay (indigent)
  • Face declines in revenue due to declines in disproportionate share funding, limitations in Medicaid expansion, economic and other declines in the counties specific to small hospitals
  • Are in counties where population growth is higher 
  • Are in counties where complex populations are increasing faster (elderly), are higher in complexity, tend to have lesser outcomes
  • Are in counties with populations likely to result in readmission penalties for the hospital, based on care of patients oldest, poorest, least in health literacy, and with higher smoking, obesity, sedentary rates, attitudes and behaviors not conducive to best health outcomes   
  • Face media and academic articles predominantly negative, usually from authors not familiar with small health, and often compared to Big Hospitals with multiple more streams of revenue, higher reimbursements, different patient populations, different personnel, different relationships, and other differences - differences that should prevent publication or require as much explanation as the length of the article itself
  • Are an easy target for political or health care cuts
Is there any purpose for trashing small health other than closing small health?

Such attempts at closure are misguided, because small health is all that exists for much of America - suffering under Big Health design.

Health Professional Training Design Contributes to Inequities

Health professional training is concentrated in a few states where big health dominates and the focus is highly specialized career for MD, DO, NP, and PA - the design of health professional training is the opposite from the requirements of a small health workforce - a workforce that requires training distributed equitably among states (not stacked in 6), emphasis on primary care and basic specialists that remain in core specialties, and training in small health locations.

Instate in states of need, permanent primary care, and training influences specific to small health locations are required for recovery of basic health access and primary care. 

Rural and urban locations in need of clinicians are Small Health Care in America 
  • Areas in need of services, jobs, economics; 
  • Areas with lesser social determinants involving income, jobs, economics; populations subject to previous exploitation, outside land ownership, public lands that yield no tax revenues; 
  • Populations distant, different, less organized, and with less political clout; 
  • Locations disadvantaged by a number of government designs involving spending, making recovery even more difficult

Populations More Likely to Be Served By Small Health America

  • Small health is more likely for those in need of lower costs of living and lower costs of health care
  • Elderly, Medicare, Medicaid, Veterans, working poor, and less educated populations as well as others on fixed income or subject to lower income are about 43 - 50% found in areas of Small Health dominance where 40% of the Nation's Population can be found in 2621 counties with lowest concentrations of clinicians
  • Population growth in lowest concentration counties still remains 1% per year where Small Health is found. The rate of population growth in the 2621 lowest concentration counties has been three times greater as compared to the 79 counties with top physician concentrations each decade over the past three decades 
  • The populations increasing the most such as the elderly are also increasing most in demand for primary care and basic services. These services are supplied by the workforce facing the greatest challenges, especially where care is needed.
  • Increasing demand is specific to small health.
  • Stagnant/decreasing workforce production is specific to workforce needed by small health care
Small health location for a patient is the result of previous small health location or movement to a small health locations because of inability to live where Big Health dominates. Big health care is associated with big cost of living, higher property values, better financed schools or private schools, higher levels of college educated and professionals, and services that are more specialized across the gamut from health to home repair. Movement toward small health location is inevitable when lives reach a point where income no longer increases.

Big Health Physician Origins Are Increasing with Declines in Smaller Origins

Children raised "big" immersed in highest concentrations are 2 to 8 times more likely to become physicians and as physicians they are least likely to choose small practices or careers such as family medicine, primary care, or core specialties - specialties that are most needed by small health care. . 

About 23 - 27% of US born physicians were born in 79 top concentration counties where 12% of the population was found (2 to 1 ratio) as compared to lowest concentration origins that are 1 to 2 or about 19% arising from 38% of the population.

Big Concentration children have been even more likely to gain higher education and medical school admission in the past decade - and also can bypass US schools for Caribbean and international medical schools. Big Concentration children from other nations not surprisingly also concentrate where care is already concentrated

International medical school graduates from other countries are 82% found in 3400 zip codes with 75 or more physicians, leaving 18% for 40,000 zip codes where 68% of the US population is found - including even higher proportions of those needing more care (elderly, veterans). Only the most elite children from the most elite schools (allopathic private, top 20 MCAT schools, top research schools) reach 82% concentrated in higher concentrations. Only the schools with normal distributions of origins and schools with top family medicine proportions of graduates reach population based distribution or about 40% found where the 40% of the population in need is found.

Exclusive concentrated origins are further complicated by Big Health designs for training - a design that shapes physicians to locate in just a few states and among higher concentrations of physicians. This is rewarded by payment design that pays more for the services most commonly seen in Big Health ventures. Primary care and basic services are least important for Big Health and are most important for Small Health.

Population Based Spending Is More Important (State or Federal Government) 

Basic health, basic education, child development, basic nutrition, and other basics are more important for the places associated with Small Health.
  • Small health sites are associated with populations more dependent upon population based spending - spending distributed according to the population.
  • Many sources of spending, especially health spending, are concentrated in few locations
  • Child development, basic early education, basic nutrition, basic services and primary care, basic social services, and small health are more likely to be population based
Small health is more dependent upon retention of local market share - as more people go outside of local for shopping, primary care, or hospital care the local market share decreases. As people transport outside for health, they also shop outside. Since few are thinking about those small and in need, it is more important for small health and other small entities to work toward their own benefit.The Center for Rural Health Works is consistently working to help local small health to become better.

The Good, the Bad, and the Ugly involving National Designs for Dollar Distributions (millions) and Population Distributions (millions)


The basics often have population based distribution with regard to lowest concentration populations as demonstrated by ratios of population or spending relative to the 40% found in 2621 lowest concentration counties. With more specialized services or care comes greater concentration as is best seen in the 79 counties with 10% of the population and highest concentrations of physicians.

Numerous past, present, and potential future political plans include cuts 
in population based spending and other distributions. 

Counties with higher concentrations have advantages in health spending, more lines of revenue, more and highly specialized services as well as top jobs and education, Government spending of all types is centralized in such counties. Government cutbacks from the 1980s to the present typically involve jobs and services in outlying counties with lower to lowest concentrations. Setbacks in the economy may lag in impact for a short time, but small areas take more time to recover after setbacks.

Insurance coverage works well for higher concentrations, but less well for lower and lowest concentrations. Even with insurance reforms, small health locations still have barriers to care and barriers to the spending needed to expand care.

Lower and lowest concentration county populations also tend to have lesser insurance and high deductible plans. Poor competition between insurance companies translates to lesser value - higher cost of premium and less benefit. Populations already behind pay more of their income for health insurance coverage and get less value for their investment. A nation that has 30% waste of health care spending makes matters even worse for those already behind that have to spend relatively more.

General surgery as demonstrated in the table is the best distributed of the physician specialties (compared to 0.9 ratio for family medicine), but general surgery is still poorly distributed, is shrinking nationwide, and is shrinking even faster at 2 - 3 percentage points a year where care is most needed. Other general surgical specialties are shrinking at 2% per year where care is needed.

Two to three times as many graduates are needed to get 1 to distribute to 2621 counties with lowest concentrations. A design that requires too many specialists is insanity for care where needed result. Other specialties beyond family medicine and general surgery are generally 0.35 to 0.55 distributed in a population based fashion when it comes to lowest concentration counties. Nurse practitioners and physician assistants that are active clinicians are 0.62 distributed where most needed. Producing more of any specialty other than permanent family practice increases concentrations of MD, DO, NP, and PA clinicians.

Health spending that is population based is needed to support the broadest generalists and general specialties for small health. In fact, without more spending, there is no solution for small health as there will not be more workforce and more services where demand is increasing most.

Health spending designs
  • Concentrate spending where the most specialized are found
  • Concentrate MD, DO, NP, and PA where clinicians are concentrated
  • Pay less for primary care and basic services and care where needed
  • Convert MD, DO, NP, and PA to non-primary care specialties with losses of basic specialties and core specialties
  • Facilitate 11% growth of physician sub subspecialty positions and 4% growth of subspecialty fellowships for incredibly rapid growth of most specialized physicians at the cost of core specialties, basic services, and primary care (Jolly, Academic Medicine)
Big Health payment and training designs make it difficult to find and support the workforce needed for small health and in small health locations.


New Population Based Study in Annals of Family Medicine demonstrates 3 times greater disparity in hospitalization for those lowest in income compared to those highest. "In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care–sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor."

Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Reference Links

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.