How To Resolve Health Access for 40 States Behind By Design

Wisconsin family physicians intended a summit meeting focused upon workforce. Numerous connections were made. There have been improvements in primary care training support, but is Wisconsin closer to a specific solution for inadequate health access?

Sticking with a specific intent is very important, as are state and local organized 

efforts to resolve health access. 

The continued summit efforts in Wisconsin have resulted in grants for family medicine residencies and generic funding for primary care training. Whether these are targeted specifically for Wisconsin (with obligations), for permanent primary care where needed (family medicine or legislated family practice arising from NP and PA), or for optimal health access focus of training remains to be seen. 

In a nation where generic primary care training only result in 20 – 30% primary care, most of the so-called primary care funding goes to create non-primary care clinicians. States have funded more family practice positions only to watch as institutions within the state have converted family practice positions to other specialties.

A review of the various speakers and topics at initial meetings indicates a rounding up of the usual suspects – those least familiar with Wisconsin populations in need of care. Not surprisingly the summit intended for workforce ended up promoting primary care medical home, team care, recruitment issues, interprofessional care, and legislative initiatives - agendas common to national associations and others who are responsible for the current lack of access. Payment reform was mentioned. Since greater spending specific to primary care and specific to Wisconsin counties of need is a requirement for any resolution of health access woes. This would seem to be priority 1 through 5 with training specifics next on the priority list. 

Specific must win out against other distracting agendas.

Success in health access is measured in payment specific to needed care – payment specific to clinicians and teams who deliver care (not administrative costs, technology costs, or costs of personnel used to save insurance or government costs). Success in health access is not about generic “payment reforms” or innovative rearrangements of practice or personnel or information.

A Summit focus often tends to the global rather than the local. The focus tends to be distorted toward reorganization because this is what the barrage of media indicates as a solution for primary care. This, of course, is not a focus specific to more primary care encounters per clinician multiplied by increased numbers of clinicians and teams serving in Wisconsin locations in greater or greatest need of clinicians. Of course there is also the chance that the reporting did not capture what has transpired as reporters often emphasize what works best for them or for their employers.

Those actually delivering care where needed understand the real needs - more clinicians 

and team members with better support. 

Did the summit connect those who deliver care where needed to those who can accomplish the necessary changes? Did the summit build a solid coalition of those specific to primary care and care where needed? Did the summit avoid those with alternative agendas to gain funding for themselves, regardless of low relevance for care where needed?

Wisconsin, like all but about 6 states, needs to focus very specifically upon the workforce that it needs and how to best support that needed workforce - not traditional designs and innovations failing for decades due to poor specificity.

A workforce summit specific to health access barriers should involve those dedicated to resolving health access woes. The invitations should be specific to those dedicated to filling Wisconsin's family practice positions with MD, DO, NP, and PA clinicians - the ones found where care is needed past, present, and future.

The discussion should center around continuity longitudinal integrated curricula with the predominant training locations provided by Wisconsin sites with lower to lowest concentrations of clinicians - specific preparation, specific training, and specific obligation with specific support for training and practice. To the west and north (RPAP is SMART,   Northern Ontario School of Medicine), Wisconsin has optimal examples of such training and the benefits. Again most relevant can be successes close at hand rather than national or distant. Sadly in the case of RPAP, it is a solution avoided for 40 years just like family medicine specific result. Long term results specific to health access should receive the top priority considerations for any health access training focus.

No direct route to Wisconsin practice or to permanent primary care or to long term care where needed exists. Flexible choices allow graduates to exit states in need of workforce. Flexible choices allow MD students to not choose primary care 80% of the time. NP and PA active clinician result is not much better at only 30% active clinician primary care result over a career with only about 20 – 25% filling family practice positions over a career – the only ones that multiply care where needed. Only family practice result is a 2 to 4 times multiplier of care where needed. Other results perpetuate more care where care is already concentrated.

Over and over the health access solution must be instate for 40 states, must be primary care training that is permanent for primary care result, and must be specific to workforce where needed. Permanent family practice result from MD, DO, NP, and PA plus instate origins plus instate training plus instate practice requirements would appear to be most specific.

Accountability is not a part of the current design. The doubling or tripling of primary care delivery per graduate is also not the intent of the current design. 

But new designs specific to health access recovery would force a change. 

When the few states doing well can no longer steal what they need from 40 states, they actually will have to craft their own solutions – and pay for them. Theft of workforce from communities with less care must be limited and care where needed must be protected and supported. Until that time, most states, most locations (40,000 of 43400 zip codes, 2600 – 2800 counties out of 3132), and most Americans will fall further behind by design. Stacking 45% of clinicians into 1% of the land area is difficult to change, but this change is necessary to hope to address health access.

Most forget that the primary problem in primary care is lack of primary care clinicians. Lack of primary care clinicians is about insufficient funding specific to practicing primary care clinicians and lack of a training design specific to primary care clinician result. Summits focused on design changes for training and design changes for payment are required.

Those not willing to focus the training and the payment will not solve primary care, team care, rapidly increasing cost of delivery (technology, recruitment, retention, locums costs), or Wisconsin's health access barriers.

Delays in appropriate diagnosis and treatment will allow more tens of thousands to die each year.  

WAFP Wisconsin White Paper

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Blogs indicate that primary care can be recovered and should be recovered.

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

Basic Health Access Web    Basic Health Access Blog   World of Rural Medical Education

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.