Heroes for a Few or For Tens of Millions

We no longer tolerate discrimination in research design. We still tolerate discrimination in the designs of payment and training.

Almost any day in the New York Times there is some death of someone's hero. A recent health care death stimulated some comment. A cardiologist who was one of few to expose the Tuskegee syphilis experiment died recently. For the past 65 years it has been a struggle to expose and address discrimination against vulnerable populations and other abuses of human subject research experimentation. Hundreds and sometimes thousands have died in each episode. Actually we are still only aware of the tip of the iceberg as prisoners, nursing students, medical students, people in other nations, and many others were subjected to abuses.

It can be difficult to find critique in health care where my way or the highway is far too common. Critique is too often missing when it comes to damage or death to vulnerable populations. Health systems fail, states fail, and federal designs fail with regard to the services, workforce, and support needed.

While we have improved in some areas involving small numbers in horrendous ways, we fail in being critical about the following...

Pay for performance and readmission penalties and a long line of payment designs continue to pay less where pay is already least and often is most complex.

Lesser pay (stagnant pay plus cuts) continues while regulation requires higher cost of delivery. This has long been a formula for disaster for small practices, small hospitals, primary care, and geriatrics due to higher complexity. Outside sources of funding to prop up these areas are drying up.

The design of GME fails to address inequities. About 55% of training in found in 1% of the land area with 10% of the US people. About 50% of medical education economic impact concentrates in a few dozen zip codes in just six states. Workforce remains concentrated in a few locations due to GME design as graduates tend to locate nearby or in locations similar to training. GME failure continues for primary care, basic services, mental health, and care for the elderly although some of the failure is shared payment failure. Payment failure can also be associated with academics.

COGME recommends specialties that GME cannot produce. More in general surgical specialties cannot result in more in general specialties because too few (and getting fewer) remain after graduation from first residency. More in internal medicine fails totally for primary care or for geriatrics. More in pediatrics has resulted in no increase in primary care pediatrics. Geriatric training fails to actually distribute geriatricians to the locations where the elderly in need of care are concentrated.

The current GME expansions of fellowship positions continue at 4% annually for subspecialty and 11% for subsubspecialty each year and this has continued for over a decade (Jolly AAMC) and likely over 15 years. Despite this continued expansion, institutions and associations scream for more Medicare money.

Teaching Community Health Centers are also too dilute by design with only a small portion with training specific to specialty (FM) and county of need and state of need.

The 4th Year of GME for FM is a worst possible result for vulnerable populations at the current time. This would require a change to fewer FM GME positions per class year shrinking FM production and FM workforce 12 - 20%.

New medical schools often promise greater primary care but their choice of sponsors, students, curricula, location, and other factors say otherwise. Any school not committed to 100% family medicine result will not achieve the optimal primary care and distribution required for a true health access focus. No medical school can control graduates driven away from primary care by primary care payment design (expansions of older schools fail too). An entire FM school beginning in locations of need in local high schools and continuing through 6 years of obligation also serving where needed is most specific to health access and most resistant to failure due to payment and training designs.

NP and PA are considered to be solutions for primary care but this also is not possible due to insufficient primary care payment and lack of support. Only the NP and PA family practice position result can address care where needed but this is the result that continues to shrink due to payment design plus the great flexibility of NP and PA training. Only the family practice result from MD, DO, NP, and PA is population based and equitable in distribution. The designs for all health professionals are too flexible and are not specific to the one outcome most important for health access.

Resident work hours restrictions seemed to be a good idea but have resulted in higher costs to run teaching hospitals with no gain in quality. There have been deteriorations in the training of residents such that longer training and even higher cost may be needed. There was also the national loss of 30,000 NP and PA plus hospitalists hired to fill this gap left by the the residency work hours restrictions. This has resulted in diversions away from primary care and an even greater concentration of NP, PA, and physician workforce.

Family medicine training continues in the wrong places with the wrong faculty and curricula to address the needs of family physicians, especially in the future. Being somewhat better about training location is not the same as optimal. There is also the GME failure to understand that primary care training is mostly about the decade after graduation because graduates have the specific context needed to learn best - the specific team, patient, community, and local relationships for optimal learning in the multiple dimensions required for health access.

Millions of dollars have been expended via FM Marketing focus from Keystone to Primary Care is Primary. This most important capital has not been focused upon top priority areas such as higher pay or more family physicians or a training design specific to 100% family medicine. Marketing is not needed for most family physicians who do not suffer from lack of marketing. Most family physicians are in locations where marketing is no help. These family physicians need student and resident support, colleagues, replacements, better payments, and a respite from constant change so that they can remain on the front lines.

Accelerating the exit of front line physicians is another serious consequence of the current chaos due to rapid change - the result of current designers and their innovative designs.

These represent discrimination 
as the consequences continue to impact tens of millions 
in health, economics, social determinants, and more. 

Also we remain distracted from real solutions, making matters worse.

It took 50 years to develop human research subject protections such as those for vulnerable populations. We cannot even get populations abused by current payment designs to be aware of how they are being abused such that they can organize and address the abuse.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr.

And those who think that they are representing equality and equity, yet are not, are seriously contributing to the substantial and growing problems.


Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


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

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