Failing Primary Care Explained By Policy Failure

Graphics illustrate the changes across all types of primary care with permanent primary care career choices prevented by policy and flexible primary care sources driven away from primary care by choices of those not intending primary care, by situations during training, at graduation with poor entry to primary care, and each year after graduation as US policy shapes workforce steadily toward non-primary care and practices with top concentrations of existing workforce.

AMA and Masterfile data except as noted.

Each primary care source has declined in primary care entry and primary care retention except for the very limited policy periods when some improvements in primary care spending were noted.

The United States has increasingly favored the academic, subspecialty interests that are most likely to be found in top concentrations of existing workforce. This leaves behind primary care and populations most dependent upon primary care for their local health care, economics, jobs, and leadership - across 30,000 zip codes with 65% of the population, far more than just the designated underserved populations, and more than 65% of poor, near poor, rural, Community Health Center, elderly, and disadvantaged populations.

Over and over United States leaders in health and policy have been reminded of failing primary care and the reasons involving policy failure, training failure, and workforce failure. The failure of primary care is a consequence of a few people and a few associations and a few in government that have managed to set up designs that favor themselves rather than most in America. It has become easy for those with vast quantities of health spending by design, to resist any changes in the design. Witness 15 years to subvert the initial Medicare and Medicaid design and only 5 years to marginalize managed care changes and only a matter of months to defeat real health reforms 2010 to present that mattered for most Americans. 

The United States does not have a design that addresses health care for a majority of the American people. Despite various promises at the federal level, the local and state levels are likely to negate any gains. The reason is quite simple.

The US health care design works best for a few people
for a few years (or months) in their life
with care delivered in a few locations
at high cost
 and with limited outcome compared to the cost. 

Primary care is one of the best examples of health design failures. Government regulations impair primary care as shaped by panels dominated by academic, subspecialty, and association interests. Insurance company policies magnify the problems and both require increasing personnel and costs in primary care offices to address regulations. These additional costs and personnel are not associated with actual delivery of primary care services. Primary care failure is a failure for all Americans. Few understand that

Primary care is care needed by nearly all people nearly all years of their lives in nearly all locations delivered by those with the least support and the most complex tasks.

Substitutes for primary care deficits are costly and have consequences in areas such as morbidity and mortality - when too much or too little is done too late. Specialists Putting Mark On Strained Primary Care   With fewer PCPs, patients seek services from anyone, and that could raise utilization and costs   By Frank Diamond

Primary care costs are limited by lack of MD, DO, NP, PA, and RN workforce -limitations that will persist for at least the next 20 years - limitations that keep primary care workforce too small and less efficient and less effective. Primary care costs kept low are not a good idea. Contrast this with non-primary care costs that have consistently escaped any regulation, primarily because those doing well under US designs have fought any and all attempts to rein in costs. They have been successful non-primary care workforce has doubled each 15 years and now has Three Dimensions of Expansion that will continue to increase non-primary care. To Follow the Money, Follow the Workforce is a good way to understand the impacts of US policy preferences and consequences. 

Major journals, government reports, and associations contribute to the confusion by indicating primary care solutions that are not solutions, by indicating primary care numbers that are numbers of graduates and not numbers actually delivering primary care, and by indicating workforce solutions such as flexible primary care sources that are least likely to enter and remain in primary care. Permanent primary care solutions such as physician family practice have existed before, during, and after various reform attempts, but have actually been avoided as choices. When comparing sources of family practice, retention in family practice is what matters for career long health access contributions. Family medicine stays in family practice and US policy drives flexible NP and PA sources away from family practice and away from solutions for primary care and rural and underserved workforces.

Government that decides not to function is not helping to address basic health access. Goverment reduced to "no decision" will result in across the board cuts in Medicare and Medicaid at federal and state levels. No decision as the result of no undersanding will contribute even more to primary care failure.

Only two times in the last 50 years has the United States made policy changes that resulted in increases in decisions for primary care - both entry and retention. Only from 1965 - 1980 and during the 1990s has primary care workforce gained a boost. During 1965 - 1980 massive injections of cash basically doubled all workforce, including primary care. Five years after Five Periods of Health Policy and Physician Career Choice, this work is even more relevant today.

In the final analysis the 1965 - 1980 primary care workforce growth, basically the only significant growth in primary care workforce in a century, was predominantly about the first and only expansion of family medicine - moving from few hundred to 3000 annual graduates. The lack of improvement is also about policy designs that fail to favor health access, most Americans, and the family physicians most closely associated with both. Resistance is futile as flexible sources cannot resist US policy that drives them away.

Family physicians stay in family practice and in primary care because of the family medicine design that makes departure from family practice difficult (few options). But policy and training designs make it difficult to choose the permanent primary care source of family medicine - a career choices prevented, as is care for most Americans.  

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely


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