Does Academia Compromise Health Care for Most Americans?

Academic leaders truly believe that they are excelling in their exclusive areas of education, research, and patient care. This may be a matter of their exclusive perspective as they lay their claims regarding

Educating the next generation of physicians
Conducting cutting-edge research
Offering world-class patient care (AAMC Exec Darrell Kirch, MD)

Exclusive is an appropriate descriptive term. The exclusive origins and exclusive training experiences of the academic leaders are matched by decades of immersions in exclusive academic environments. The pathway to academic leadership flows through institutions, foundations, corporations, and associations - each with their own exclusive designs. There is a filtering process that selects for exclusive and results in exclusive.

Exclusive perspectives cloud a more global perspective - necessary for evaluation and treatment of the health care needs of an entire nation - the exclusive doing well and most of the nation not doing well.

Academic health education clearly works well for academics and associated associations, corporations, and foundations. The exclusive designs contribute to most Americans not doing as well.

A review of the big 3 academic areas from the perspective of basic health access may yield different results.

Educating the next generation of physicians

Exclusive origins are difficult to overcome. Not surprisingly American physicians are considered weak in areas such as empathy, service orientation, and communication skills. About 30 - 35% of US physicians were not born in the United States. Those that do come to the United States for medical school or graduate medical education arose from the most concentrated origins in their home nation and have had most concentrated experiences when training in the United States when inside and outside of the walls of academia.

There are many different routes to graduate medical education and US practice for exclusive origin children from the US and from other nations. Those of normal to lesser SES have 2 to 5 times lower probability of capturing the US medical school positions - diluted even lower by those entering from other nations. Origins including race and ethnicity also impact admissions as well as distribution (Birth Origins and US Physicians). Once again those most exclusive have 3 to 8 times greater probability of admission and have the least distribution.

According to the AAMC, about 60% of American children most left behind in the bottom 3 income quintiles have a shot at just 20% of admissions positions. Those born in the US that become physicians arise 60 - 70% from the top 20 - 25% in Socioeconomic Status. They have the same exclusive origins of 71% from the top quartile as seen in the top 146 colleges (Carnevale, Rose). The same exclusive colleges populate medical schools, law schools, business schools, engineering schools, and more. US Born physicians are multiple times more likely to come from the areas most concentrated in people, property values, income, education, and other exclusive terms.

Modern academic medicine was shaped over 100 years ago and has in turn shaped medical education, research, practice, and physicians. The efforts have been the steady long term work of academic leaders organized to prosper academic institutions over many decades. One hundred years ago physicians were distributed according to the population. They were shaped by that population in their life experiences and also by their physician experiences. Great differences were seen in only a few generations of physicians.

The pathway to admissions and across training and practice has been changed by designs impacting medical education, research, practice, and health care. The MCAT has been a vehicle to help decrease medical school attrition rates, but the scores are shaped by the students taking the test - the once that set the standard for exclusive scores. There appears little obstacle to physicians becoming less and less like their patients. As far as the MCAT predicting physician quality - the inability to do this has been known for over 80 years. The skills and abilities and behaviors of physicians are far too complex to hope to have any predictive value. Much the same is true about predicting patient outcomes, but this has not stopped academia either.

Now physicians have most exclusive origins, scores, and training. They are found in the most exclusive settings. About 45% of physicians are found in 1100 zip codes in 1% of the land area where only 10% of the population (and shrinking) is found. Those who desire access to care have six differences in payment plans to overcome. All lines of revenue and the top reimbursement in each line goes to the most concentrated settings - usually via designs that they helped to shape.

As with the generalists of 100 years ago, only family physicians have population based distribution. FM prospered during only the 1970s when payment designs supported the team members to deliver the care. Since the 1980s and the Era of Cost Cutting, FM has been stuck at 3000 annual graduates for 37 class years with more to come. Even family medicine is shrinking away from the broadest generalist positions most associated with population based care and most important for access. Interestingly only family physicians have population based origins. All other physicians are more likely to arise from counties higher in income, education, and concentrations of physicians. The most exclusive specialties are 6 times more likely to arise from the most concentrated origins as compared to the least. The specialties and subspecialties are increasingly populated by those most exclusive in origins, colleges, and medical schools.

Nurse practitioner and physician assistants are not necessarily a workforce solution. They have followed the same payment distortions. Only the family practice positions filled by NP or PA matching population based distribution or at least 36% found where 40% of Americans are most left behind in lowest workforce concentration counties. Across MD, DO, NP, and PA graduates the remainder found in family practice positions continues to decline as more new specialties are added with more added to each new specialty.

The next generations of physicians could benefit most from origins, training sites, and practices connected to most Americans in most need of care such as 2621 lowest physician concentration counties. This 40% of the population only has 6.5% of residents in training. Residents are found 50 - 60% in just 1100 zip codes in 1% of the land area and the medical education experiences are not far from this exclusive level as well.

Origins, training, practices, and payments more population based would be good for the nation, but this is not likely given the magnitude of changes needed.

The payment design supported by the major medical associations and institutions prevents any training design from resulting in more workforce in these areas - which I learned via 30 years of academic experiences attempting to address this goal. It is possible to change the names in the counties of need or even the initials behind the name, but the same inadequate workforce

Conducting cutting-edge research

Like the payment design, the research design has been focused in ways that have substantially increased the cost of health care. Exclusive drugs, technological developments, equipment, and more have worked out well for drug corporations, corporations formed by academic institutions, and others who have benefited from the billions sent to medical education and to research.

But Do Most Americans Benefit?...One area that cannot be documented is whether these amazing and most expensive clinical interventions actually work on most Americans most behind. Treatments for cancer, arthritis, and major disabilities require months or years of being disabled - far beyond the ability of most Americans to stay employed or care for other dependents, or be cared for.

Cutting-edge research clearly works for those with the best insurance coverage who live in or near places with concentrations of physicians - who can and do access care. They are also most able to get sick time and support through their disabled time.

Cutting edge fails for those that lack the basics to identify the need for cutting edge and lack the ability to take the treatment or survive the treatment.

Research supported by those who benefit from CT scanning supports lung cancer screening, but does this work for those with numerous factors against their best outcome after intervention?

In a time of value based care, the nation appears to lack any values with regard to most Americans and their care

New areas of cutting-edge research include health policy research. For over twenty years this research has demonstrated numerous solutions to health care quality. The various policies, regulations, managements, and other clinical interventions have yet to demonstrate significant improvements in outcomes. What is most evident is more cost without quality improvement - the opposite of value.

Even Worse... The additional trillions added to health care costs for more care for fewer in even fewer locations and added for the purpose of better "quality" have compromised local spending on the real determinants of health - police, fire, sanitation, housing, nutrition, public health, economic development, environments, situations, behaviors, and social determinants.

Offering world-class patient care

As noted previously, the health care design shapes 45% of physicians and well over 50% of health spending to occupy 1100 zip codes in 1% of the land area with just 10% of the population. The 40% of people living in lower income, lower cost of living, lower housing areas havelowest concentrations of physicians (just 21%) because of payment designs largely shaped by academics that have consistently paid least for office, cognitive, basic, primary care, mental health, basic specialties, small practices, small hospitals, rural health, and care where needed.

Generalists are 46% of local workforce where needed and general specialties are another 30%. Their efforts represent 90% of the services provided in 2621 lowest concentration counties.

It is hard for academics to claim world-class patient care when most of the nation suffers from deficits in basic care.

This does not prevent AMA and AAMC from touting the economic impact of physicians at 2.2 million dollars per year that the physician is active.

Regions of the country are divided into top physician concentration counties with 10% of the population, Higher concentration counties with 20% of the population, a Middle 30% region, and a Bottom 40% lowest in concentrations of physicians, physician assistants, nurse practitioners, mental health providers, and a number of determinants of health.

Population %	Top 10%	Higher 20%	Middle 30%	Lowest 40%
Counties in Category	79	152	286	2621
Population Numbers	31.5 million	63 million	94 million	126 million
Active Physicians per 100,000 in 2013 Masterfile	468.9	305.0	222.5	114.6
Residents in Training per 100,000 as of 2013	154.39	58.75	29.90	6.43
Raw Economic Impact from Physicians per Person	$10,298.72	$6,704.83	$4,885.26	$2,487.15
Adjusted Economic Impact from Health Spending per Person	$14,043.71	$7,619.13	$4,441.14	$1,921.89
Raw Total Health Spending per Person	$21,655.14	$14,098.26	$10,272.23	$5,229.74
Adjusted Total Spending per Person	$29,460.32	$15,746.03	$8,804.23	$3,555.56
Index Comparison to Bottom 40%	8.3 times	4.4 times	2.5 times	1.0

Figures include 700,000 active physicians for 2013 from the AMA Masterfile, 2.2 million for the economic impact per physician from the AMA, adjusted using 3 million for top concentration physicians to 1.7 million for lowest concentration due to differences in payments and specialty types, 3.2 trillion used for total spending, adjusted for additional spending lines in top concentrations (21% to 29% of health spending).

The resident concentration of 154 per 100,000 people is greater than the total active physician workforce in lowest concentration counties at 114.6 per 100,000. Combining active physicians, residents, and faculty results in even greater disparities as the comparison is over 650 to less than 130 from highest to lowest. The lowest concentration counties are essentially the red counties in the recent election plus the predominantly minority blue counties (Black Belt, southwest border counties)

The academic publications or reports avoid discussing the exclusive origins or the divisions created from so many jobs, services, and dollars in few places and the few jobs, services, and dollars where most Americans are found.

Academics claim that workforce can be addressed by just funding more residency positions. This is a solution that works for academia, but not for others. More primary care graduates have failed for primary care for decades. More general surgeons and other general surgical graduates cannot result in more general surgical care. This is also because the payment design pays so little for generalist, general specialty, and mental health care that there can be no more team members to deliver the care.

Academics choose the concepts to promote including higher volume superior to lower, procedural over cognitive, longer training rewarded much greater than physicians shaped by more patient experiences, urban better than rural, more subspecialized over basic, and more complicated over simple. Most apparent in academia is that formal learning, even when learners are overwhelmed or are not motivated, is much more important than the learning that occurs patient to patient over the decades after formal training.

Those doing best with the most lines of revenue and the highest reimbursement by designs that they shape should have world-class health care but often fail to do so. One way that some academic institutions have done this is to do two-tier care - exclusive care for the exclusive patients and less exclusive for the less exclusive patients. So-called quality failures can also be present in academia because changes are so difficult to accomplish. Another reason for poor outcomes is because some patients have what used to be called "piss poor protoplasm." This quite inappropriate term is appropriate to consider. The poor people or those with any number of deficits do have poor outcomes. The poor outcomes are about the patient and their situations, environments, behaviors, and life experiences dating back to birth and earlier.

A final reason for poor outcomes is that the academics have made poor decisions and have undermined their financial construct in ways that compromise the nurses, clinicians, physicians, and other team members who deliver the care.

Sadly few see that the same payments too low, administrative costs too high, regulatory costs too high, and increasing patient complexity also undermines primary care, mental health, basic services, and care for most Americans.

Rural Practice - Learning for a Lifetime

I do not want to seem unappreciative after 3 decades of academic support (65 - 70 hours a week for teaching, research, and patient care paid at 35 hours a week), but I should have learned the lessons taught me in rural practice in the 1980s. The following are just a few.

1. Supportive Medicare and Medicaid rebuilt access in the 1970s in ways that allowed me to practice but unsupportive payment prevents access, workforce, and care where needed. The supportive designs that we grew up in during the 1970s no longer existed. I desired to help produce more rural family physicians and to help supply workforce for areas in need of access. Unfortunately the designs for payment would never (so far) allow this 1980 to 2020 and likely beyond. The designs that looked so good in the 1970s such as WAMI and others were ones that gained attention in the 1970s. The impressive early results were really about supportive designs. Initial family physicians had 30% rural distribution sinking to less than 20% in the less supportive designs. Initial 95% retention of FM grads within family medicine positions has declined below 75% or lower with more decline to come. Designs shaped for cost cutting are quite different from payment designs that support the team members to deliver the care, especially where care is most needed.

2. Locally supportive state and federal policies with a decent economy made rural health care and other community functions a joy 1983 - 1985 while the opposite was true 1986 to the present and beyond. Practice where needed since 2010 has become much worse from too many directions to count with more to come.

3. Veteran plans are a poor fit for veterans and drive many to suicide even after a recovery with the help of local care and community. I watched my practice, my church, and my community come together to support Veterans. When the Veteran went back to VA facilities, they came back disillusioned, depressed, and suicidal.

This makes it easy to identify the waste of 200 million more for rural located veterans. The dollars are spent through layers of administration and are spent on brick and mortar new startups - designs least efficient and most wasteful, particularly for most Veterans and most Americans left behind by payment designs. How many more costly special clinics serving special populations will it take to see that designs divide and decline local access?

4. Organized medicine was never going to be a solution for health care for most Americans. I turned to organized medicine for help as I could see the writing on the wall for my practice and many others. I spent weeks and lost thousands of dollars becoming the first Delegate to the AMA from the Young Physicians Section. It was clear that the AMA had lost touch with most physicians, especially those younger.

Perhaps if I had spent my efforts with family medicine organizations, I would have found the same neglect earlier. I never thought that primary care and family medicine leadership would support the efforts that have compromised delivery of primary care, especially most members of AAFP. I dropped membership for a time but then decided I would need to be a member to hope to change AAFP. Resistance has been futile so far.

The Academic Origins of Obamacare

Managed care butted heads with academicare in the 1990s. Since that time, those desiring to micromanage physicians and patients have teamed up.

The academic origins of Obamacare have been captured by video and also by Kip Sullivan in The Health Care Blog in his Open Letter to Present Obama Series.
The inability of the ACA to MACRA design to do as claimed has also been described.
The academic stamp of approval was considered most important for ACA.
ACA to MACRA has clearly worked for those that already had the information systems, organization, size, and highest payments already. Those smaller and less organized have faced the most chaos and change and costs leaving them further behind.

There appears to be more benefit for academia and associated associations with designs that contribute to rapid chaotic change and more benefits that accrue from promoting such change and profiting of the training and certifications.

Benefits of Academia

Medical education is a fit for few in few locations and fails for care where needed due to designs largely shaped by academics.
Research is a fit for few in few locations at much higher cost.
Practice is a fit for few with few conditions with care delivered in few locations.

Few academics seem to realize that there cannot be world class health care when the basic generalists and general specialty physicians and team members who provide 70% of the nation's services receive a tiny portion of health spending - grossly insufficient to provide services, especially where most Americans are found. Just 6% of health spending for 55% of services in primary care is why the US is 23rd of 26 developed nations in generalists - and lower than 50th among all nations where most Americans attempt to access care.

I do not buy in to all of the arguments that increasing the levels of generalists or of primary care workforce will result in higher quality and lower costs. There is a better argument that states and nations that invest in people and social fabric have lower costs, better outcomes, and also recognize the importance of primary care, public health, child development, and other spending that shapes a better society.

Communities, states, and nations that invest in the people that can best shape behaviors, situations, environments, and social determinants from the earliest ages will reap the rewards of better education, health, economic, and societal outcomes. Academic health care must work to stay out of the way. The United States clearly can no longer tolerate out of control health spending as dollars go more and more for care for the few in few places, for accelerating regulation and administrative costs, and for increasing fraud, abuse, and waste.

Designs that were a poor fit for most Americans have certainly contributed to changes in elections. We will see if this makes distributions of spending worse or not as designs change once again.

Flaws in the Readmission Improvement Claims

Six Degrees of Payment Discrimination Shapes Disparities By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care.

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior - the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care

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

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

The blogs represent the opinion of the blogger alone.

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

Copyright 2016

Search This Blog

Basic Health Access