Piddle Twiddle and Resolve Not One Damn Thing Do They Solve

In the play 1776 there are any number of wonderful allusions to Congress then and now. Former President Nixon thought so too. He requested and received an edited version regarding Cool Cool Considerate Men as he felt they too closely resembled conservatives of the time. Cool Considerate (calm, calculating, conservative?) Men are still very evident, but do they still lead well or wisely or with sufficient understanding of the daily lives of most Americans?

Congress today is a divisive Congress just as presented in 1776. Is Congress today working together affirmatively for the nation. The most basic areas important to most Americans appear to be low priority. The current physician fee crisis is a great example of Piddle Twiddle and Resolve without a solution.

It has taken years for the Medicare Physician Payment Advisory Commission, stacked with landed gentry benefiting from the designs they set, to recognize its past errors and to recommend some protection of primary care fees as compared to non-primary care. Major protests were required to get just this small change. Reasonable increases in revenue that might keep up with the costs of delivering primary care are not even on the drawing board. Primary care workforce has followed the primary care spending design as noted in Accelerating Cycles of Decline.

Primary care workforce designs have doubled primary care numbers only from 1965 to 1985. Each 15 years since 1965 the non-primary care workforce has doubled and this will continue until 2025. The US is attempting to function from 2010 to 2025 on a design that was set in place in 1980.  Despite twice as many graduates and 3 times as many primary care sources, the primary care numbers of clinicians and the primary care delivery capacity continues to decline. Policy Failure Plagues Primary Care and Permanent Primary Care Choice through Five Policy Periods
indicate designs that work or fail.

Ever more resources are spent on non-primary care while primary care faces across the board cuts on top of inadequate reimbursement. The entire mess results in distrust of government and health insurance companies by those who provide care as well as the patients who receive care.

Even physicians realize that primary care reimbursement is too little (Leigh). More practices stream to types of payment (rural health clinic and FQHC) that have the ability to cover rising costs of care rather than fee for service under SGR that has been mired in the basement. Fixes in the 1960s to that restored some basic health care infrastructure failed as costs rose faster than revenue and as redesigns sent the spending to fewer locations with greater workforce concentrations. Fixes in the 1990s failed in just a few years. But Congress has little memory for failure and has little awareness as well.

Piddle Twiddle and Resolve

Delays are common responses when more spending is involved. There is no time for most Americans in need of care and the elderly are the major example. For 50 years the US has known about the need for more care beginning in 2010 and there has been no preparation for the workforce to deliver the care. In fact the workforce most needed is declining the most.

It is already too late for the elderly of today as they double from 2010 to 2030. During this period internal medicine will collapse from 90,000 to 40,000 in primary care as this is all that 1400 entering primary care a year can provide. Family medicine can no longer increase as it has been held hostage for 30 years at 3000 annual graduates - zero growth. Sadly government reports indicate increases when increases are not possible.  Journals also fail to present the truth or the consequences of failed policy. NP and PA workforce proportions have declined steadily in the needed primary care and in the locations where 65% of the elderly are found. This is mainly about fewer remaining in family practice - the predominant midlevel primary care, rural, and underserved response as well as service to those outside of concentrations.  Geriatric workforce is also concentrated 75 - 80% where only 30% of the elderly are found.

Health care most important for the elderly is held hostage by designs that defeat primary care as well as workforce in the zip codes outside of concentrations where 68% of the elderly are found. The elderly need two to three times more primary care and this workforce must match up to zip codes where the elderly are found - particularly as they lose mobility and transportability as they age. The damage of the last few months and the next months is specific to those remaining who care for the elderly. This is compounded by the past 15 years of decline. ew years of damage.

Piddle Twiddle and Resolve

The record is solid for health policy impact and primary care. Primary care numbers doubled from 1965 – 1980 with the initial health access plan before cost increases and cost cutting designs took over. The 1990s reforms boosted primary care and family medicine to peak levels with increased primary care revenue and decreased or stagnant non-primary care. The 2010 reforms that might have helped primary care have been compromised by cuts in Medicaid and those who care for patients most in need of care, in addition to innovation focus, and reorganization focus. As commented in 1776 - “Sweet Jesus” 

Momma Look Sharp To See If You Can Find the Remaining Front Line Workforce

The basic health services needed by nearly all Americans nearly all of the years of their lives are being compromised by insufficient primary care spending (widely recognized) and insufficient workforce retained in primary care due to insufficient primary care spending. To Follow the Workforce Follow the Spending. Matters are worse with substantially more paid to non-primary care, allowing experienced primary care personnel and professionals to be hired away from primary care employment.

Is Anybody There, Does Anybody Care?

As noted by 180 days of neglect after 30 years of neglect

Piddle Twiddle and Resolve 

There is of course only one response as indicated in the play

“Sit down Bob, Sit Down Bob, For God’s Sake Bob, Sit Down”

The reply is of course  "Never, Never"

May 2012 Be a Time When Congress and leaders across our nation, Despite Divisions, Will Resolve to Work Affirmatively for Most of Our Nation

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


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