What You Will Not Hear in Workforce Reform Discussions

Workforce discussions, conferences, grants, and articles are reliable in one key area - lack of discussion of the requirements for true reform. The workforce blinders will be on and the focus will be on training interventions - interventions that cannot work because of the financial design. There will not even be discussion of the real reason for maldistribution. The big players have wiped this off of the table either by intention or by lack of awareness. There are so many other better options - for them. They prefer expansions of insurance or expansions of graduates or special innovative payments or special innovative training. Most Americans need and entirely different training design, an entirely different payment design, and most likely both for recovery of their basic access to health.

If you understand what is proposed, who proposes the solution, and why - there can be clarity

• If you understand how payment designs are crafted, those who benefit in top concentrations of workforce, and the concentrations of health care dollars by design, you can understand who opposes true reform.
• If you understand who benefits from more graduates trained, you can understand who supports expansions of graduates or more innovative training. Expansions fail and innovative training can be pointed to as a solution to indicate that something is being done - despite decades of continued access failure.
• If you understand that payment design prevents increases in the basics such as primary care, you understand that expansions of graduates are most specific to most specialized workforce - the workforce that concentrates in counties with higher to highest concentrations of physicians already.
• If you understand who benefits from measurement and digitalization focus, you can understand who supports innovative payment designs. The hi tech media also benefits from promotions of hi tech solutions despite the evidence basis to the contrary.
• If you understand how additional overutilization results from not having enough primary care, mental health, and basic services - you can understand why true reforms are opposed.
• If you understand the rapid increases in convenience, urgent, emergent, and alternative forms of basic care - you can understand worsening of the financial design for the basic care.
• If you understand 2 to 3 times greater utilization where workforce is most concentrated, you can understand why so much is paid out for few people to get care in few locations with most Americans left behind by design.
• If you understand that all specialties of MD DO NP and PA except family practice are more likely to concentrate in places where workforce is already concentrated, you can begin to understand the futility of more graduates for health access. It is imperative that no one points out that it requires 3 to 7 graduates going to top concentration counties to get just one to a lowest physician concentration county. One must avoid discussions that it takes 3 or 4 primary care trained physicians or nurse practitioners or physician assistants to get one for primary care for a career. Even when there is entry into family practice, the family practice result is fading to lower proportions of MD DO NP and PA.

The reason for all of the above plus higher turnover plus failure of special incentives is entirely about the financial design. What else can explain the global magnitude of the failure for decades with more to come.

True Reform to Address Primary Care, Basic Services, Mental Health Where Needed

...Sends more dollars to primary care, office, cognitive, basic, mental health services. These are over 90% of the services where care is most needed by most Americans. The key to distributing workforce is distributing dollars

• To basic services
• To places lowest in concentrations of MD DO NP and PA

As it turns out, the financial design that prevents distribution

• sends too little where lowest concentrations of workforce exist
• pays too little for generalist and general specialty services 
• pays so little for the basics compared to even slightly specialized services that workforce cannot be retained in the basics and support personnel follow the same gradient
• pays 10 - 15% less for the same basic services where lowest concentrations exist - and yet this inequity has not been address despite obvious cause and effect
• has become punitive with rapid acceleration of cost of delivery, with higher costs where care is needed, where care is already most complex. Any small change increase in payment is more than negated by the worsening financial design.

The last time enough dollars were injected

• locally, 
• annually, 
• dependably,
• where needed, 
• for any significant time period, 
• without adding costly requirements that negated the increased revenue,

was 1965 to 1978. Health access has been suffering even longer.

The improvement impact was quite dramatic during this time period, even as higher concentration counties benefited much more. In fact the multiple dimensions of increases of health care costs specific to higher concentration counties are the reasons for cost cutting designs

These are the insult to previous injury that have most hurt those most needed to provide care.

The impact of 1965 to 1978 increases:

• It was the one time increase in primary care production. 
• The original Medicare and Medicaid designs did boost revenue to lowest physician concentration counties as the basic services were supported at a much higher degree than now. 
• The costs of delivering care were much less and there were not more requirements for receiving more dollars
• The costs of delivery increases were less.

Distracting Appearances Because of a One Time Success Due to Financial Design

Critical review of "successful training interventions" traces the success back to this 1965 to 1978 period of time. Training interventions have multiplied - the more the merrier. This has been the outcry from the training institutions, schools, and programs. Hundreds if not thousands have been created for the purpose of improving care where needed. The lies have piled up endlessly as access has failed to improve. Even politicians have become suspicious regarding more training funds - for good reason.

The successes of 1965 - 1978 in medical education were widely trumpeted and there were many replications. This period of increasing revenue where care was most lacking was just long enough for the various WAMI and other training interventions to look like they worked. The social mission, rural pipeline, early intervention, and other advocates cried out for support. I should know, I was there with them. Decades of no resolution of the access problem made me suspicious and the evidence basis is clear. Timing during this one time expansion has allowed claims of training success for decades.

The 1970s decade was an ideal time for the expansion of family medicine from zero to 3000 annual graduates. But even the most specific workforce where needed (36% found where 40% reside in lowest concentration counties) cannot resolve the problem. This is because the financial design is the real reason for failure as seen in failure of increases in basic health access delivery capacity since 1980. Family medicine has fallen from 90% to less than 70% office family practice with worse to come from newer graduates. NP and PA have fallen below 25% family practice steadily and progressively. Internal medicine had the greatest disparity from basic to specialized and has collapsed.

Departments of FM, student interest groups, rural training, underserved training, diversity admissions, rural admissions, primary care schools, more schools, more programs, a 10 times expansion of NP grads, a 6 times expansion of NP grads, two doublings of DOs, and a 30% increase in MD grads have all failed - because of failed financial design.

Anyone connected with a school or program with even a small degree of success can publish glowing results, but the "success" is limited to their school or program with little change other than a rearrangement of the deck chairs. A school or program is effective only by displacing others.

The fact of the matter is that family medicine, NP, and PA expansions replaced the failing internal medicine primary care. Distribution continues to fail because of lack of distribution of dollars.

True Reform Is Required

• True reform improves access, especially where access is lacking for most Americans. 
• True reform sends dollars where most Americans reside in places most lacking in health care dollars. 
• True reform requires a major increase in revenue for primary care, mental health, and basic services that are 90% of services found in counties lowest in MD DO NP and PA concentrations. 

All but a few counties with higher and highest physician concentrations have lowest concentrations of physicians. These are counties with concentrations of populations with insurance plans that are worst paying and least supportive - Medicare, Medicaid, private, Veteran. These plans pay less for the same services because the practices are smaller, rural, independent, and less organized and thus are unable to negotiate with payers - who have taken advantage of them for decades.

The payers are fewer and the plans are least desirable for patients and providers. 

This is the unseen giant shaping maldistribution. 

The solution is to redirect revenue to cognitive, office, basic primary care, mental health and away from procedural, technical, subspecialty, administrative, management, micromanagement, regulation, innovation, and certification. The designers benefit from the current design and will not stand for true reform.

True Reform Is the Opposite of Policy Direction Since 1980

The innovation bandwagon has added insult to injury. Even greater innovations and reforms have progressed, skipping any testing and going right to implementation.

True Runaway Health Care Costs are the result of policy designs. You can trace the waves of runaway health care costs as seen

• in increased payments for procedural, technical, and subspecialty services predominantly in counties highest in physician concentrations
• in 2 - 3 times greater utilization of services in these counties
• in movements of NP and PA to more specialties with more added in each specialty
• in closures of small hospitals, rural hospitals, small practices  
• in new waves of increased spending resulted from increased numbers of administrative, management, micromanagement personnel
• in new record high levels of salary and benefits for CEOs and those who will be
• in accelerating costs derived from new regulation, innovation, and certification "solutions"
• in the destruction of local care where needed, primary care, mental health, basic surgical services

All policy changes have done is to add more institution, association, administration, corporation, consultant mouths to feed, leaving the basics and care where needed further behind.

Every wave of increase has resulted in higher concentrations of health spending with stagnant spending in lower concentration areas - plus billions more forced to be shipped out by administration, management, micromanagement, regulation, innovation, and certification "solutions."

The current times teach us that truth is elusive. The current times teach us that when solutions are not crafted, it is usually because the crafty are opposing the solutions.