Primary Care Is Not Built Up By Tearing It Down

A secondary title would be the problem of poor support for mental health and primary care where substantial portions of Americans reside. Primary care is not improved when "my form" is supported and "other primary care" is not.

Numerous interventions are being attempted in health care. Various media and foundation postings appear to promote "jump on the bandwagon." Sometimes in their haste to promote PCMH or integration or their own intervention, there is damage done to primary care in areas such as reputation.

A recent post at the Robert Wood Johnson site discussed Improving Primary Care, One Patient at a Time. It was hard to follow this or understand how this related to primary care. The major point highlighted was negative about primary care in the mental health area - noting how depression was under-recognized.

As with many such clips, the point of view of resourced health care was advanced (often supplemented by special funds or grants) and there was poor understanding of under-resourced health care (where funding is least by design). When you have more funding, much is possible. When you have less funding, there is more responsibility with more challenge. As seen, foundations have a vested interest to make their interventions look good, but these may not necessarily be applicable for most Americans behind by design.

The major health access factors to consider in mental health as in primary care involve workforce, health spending, poor distributions of providers, and poor support of needed care.

Because of major deficits in mental health care, about 40% of mental health care is provided by primary care. Of course primary care involves any number of various types of services, especially when scope is broadest.

This is a reason why numerous interventions involve integration of mental health care with primary care - CHC, military, other. Another reason is that mental health is so poorly distributed.

The major problem with mental health is gross underspending. Compromised spending has compromised workforce and mental health approaches. Insurance coverage and the distorted application of such coverage have been major reasons. It remains to be seen whether insurance will actually perform as new laws guide, or whether it will be business through cost cutting as usual - delay, deny, etc. These tactics are particularly successful in mental health where patients can change their minds or situations during delays - thus "relieving" the need for care.

Because mental health provider concentrations are lower in the same counties and populations that have primary care deficits, primary care where needed has additional burdens. Primary care where needed takes on numerous roles that people with an urban perspective or high resourced perspective or top concentration perspective do not "get". Mental health, STDs, various surgical skills, ER, hospital, public health, medical examiner, and other roles are common where local resources are less. This occurs where social determinants and lack of resources help shape lesser health, health status, and health outcomes. Since poor outcomes gain publication and headlines, we will see more of these.

Any researcher or major foundation or government report or office of inspector general investigation can make certain providers look bad - rural hospitals, rural clinicians, or those that provide services for people in about 2000 counties where gaps exist. This is because of the overall situation due to health care and other designs in the United States. Lack of awareness of authors, editors, and reviewers results in less than critical treatment in journals or in the press.

Over-resourced Versus Under-resourced

Examples of lack of awareness include misguided JAMA articles about Critical Access hospitals that continue to attempt to compare apples to oranges or over-resourced versus under-resourced facilities or facilities caring for entirely different populations with different and lower funding and different personnel and services. A recent study indicating counties with general practitioners as lesser in health outcomes. If you understand GP docs and their distribution, you can understand this situation. GP docs are over 83% near retirement, are in counties with least social determinants, are the oldest, and may not actually be practicing or are likely to be part time. You have to understand these issues much better to be able to publish and not do harm.

Populations where mental health care is needed (40% of the US) are not as amenable to standard mental health practices. Psychiatrists from major urban origins or from international origins may struggle to understand populations in need of care - just as they struggle with the choice to distribute to positions involving such care. Different attitudes, different cultures, different beliefs, and other differences exist.

Distribution is a major difference for psychiatry. Only about 20% of psychiatrists are found where 68% of the population is found - one of the worst distributions of any specialty.

Overburdened psychiatry (stressful if full day, too few, poor funding, fewer remaining in general psychiatry) has adopted overreliance upon medications, less face to face time with patients, and more administrative or supervisory or research (drugs) work. Child and geriatric psychiatry are in great need and geriatric psychiatry needs are rapidly increasing.

There remains a tendency to promote more intensive work with certain patients. The Congressional Budget Office evaluated managed cost or managing intensive need patients and concluded that the additional costs of management negated cost savings. Readmission interventions have also been limited due to high cost and low yield. In a moment of reflection you can see how highly resourced can spend more to "manage" while low resourced are just trying to deliver care.

It is sad to see US populations blamed for their poor outcomes, or blame placed on their primary care providers, or blame placed on the last remaining facilities - particularly those providing care where care is most needed, most complex, and least supported - by national design.

The fact is that all specialties concentrate where clinicians are most concentrated except for family practice. This means that broadest generalists will always be filling in the gaps when all other specialties have fallen away - where social determinants and spending are least and complexities are most.

What Can Work

Interventions that seem to work in areas such as mental health that may well decrease health spending include putting the homeless into housing. Improvements in housing help shape cost savings across health care and other societal components.

Community based efforts such as Southcentral Foundation and Grand Junction Colorado are beyond simple integration.

The Oregon studies of Medicaid Randomization indicated much improvement in financial security for those with Medicaid coverage and improvements in health status ratings with a decrease in ratings of depression. Others are left with insecurity, decreased finances, and poor access.

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Robert C. Bowman, M.D.
www.basichealthaccess.blogspot.com 
SMART Basic Health Access
www.ruralmedicaleducation.org

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