Stop the Insanity of Massive Overexpansions of Health Workforce

We should send a clear message to the "experts" and the media and associations and health professional training institutions: Please stop the insanity of doing the same thing over and over again expecting a different result. 

• New innovative types of workforce have failed to resolve workforce deficits despite massive expansions
• More new types and more expansions have failed.
• More new types and more expansions are proposed.

It is the financial foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed.

It Is Not the Initials or the Expansion, It is the Financial Design

It is not about who is a better health professional or the type of training. Expansions are not the solution for any domination or perceived domination of health care.

Texas has another new medical school planned but a family physician dean will not be able to keep the promise of more doctors where needed.

Associations, journalists, social media sites, and others constantly promote expansions as solutions. They will not work.

STATnews just had another workforce article about the need for expansions.

• It starts with a Boston example. Massachusetts is the state with the highest concentrations of health care workforce and Boston is the peak health workforce location in Massachusetts. Then it goes rural. 
• Rural and underserved areas are then noted. While this may be an extreme, the shortages are more than just small portions of the population. 
• Those left behind total over 50% and this proportion is increasing due to system design. 

The shortages inside and outside of highest concentration counties are about Triple Threat.

It is the Triple Threat that defines and shapes shortages:

• worsening revenue, 
• worsening costs of delivery, 
• worsening complexity. 

These also shape burnout, turnover, lower productivity, and an even worse financial situation.

Triple Threat wins and half of Americans lose - by financial design.

Numerous articles demonstrate Triple Threat. New ones are finally being added. Sadly the primary care leadership has been distracted by alternative payment models and false hopes of added revenue through innovation. These have not added significant revenue and have added substantial costs of delivery and complexity in ways that decrease revenue. In other words, our health access leadership has been worsening access by design.

Commonwealth has a mission for health access and has a president with a career built on digitalization and innovation - demonstrated enemies of health access. Commonwealth often equates insurance coverage with access - another common myth.

How can you expect the worst private and public plans 

to increase workforce where needed 

when the plans pay less than cost of delivery? 

JAMAnetwork has an new article demonstrating the high costs of administration in primary care. Once again the higher costs are found for those smallest who are the ones dominating care where care is most needed by most Americans.

The financial equation fails for primary care where needed.

• $100,000 a year for administrative costs
• $100,000 a year for turnover costs for each FTE primary care physician and this may be more because the retention is less than 3 years.
• $100,000 less a year due to 15% less paid for office services (Medicare 2011)
• $50,000 a year due to MACRA
• $80,000 a year for the few attempting primary care medical home
• $50,000 to $80,000 a year for digitalization
• Highest costs of supplies and other accounts payable

The dollars do not add up. More billions are designed away from primary care practices.

Expansions of NP PA DO and MD graduates have proceeded at 6 to 12 times the annual growth rate of the US population at 0.7% for the past 16 years and even longer than that for NP PA and DO.

The financial design assures that deficits continue in primary care, rural health, and care where lowest concentrations of MD DO NP and PA already exist. The basic workforce such as primary care is flat while subspecialties increase in workforce at even higher rates.

The primary care teams are led by the least experienced workforce in the history of the United States and they will be moving to fewer years and fewer experiences a year.

The excess graduates go to more subspecialties with more added in each - MD DO NP and PA. This leads to more profits and higher health care costs as well as more cost for little gain in outcomes - the True American health care design.

The market is being flooded by excessive graduates

• Often by those who profit by training more and more. 
• Their services result in even more profit those who profit most. 
• The excessive graduates keep costs of personnel down and also result in less benefits and insufficient support for those who deliver care.
• Excessive graduates make clinicians and physicians fearful of losing jobs and this can prevent professionals from standing firm against policies that pad corporate or institution profits - policies that can harm patients and their families.

Too little revenue and the higher costs of delivery hurt the basics. The damage can be seen in the innovative new designs and the regulations to enforce this.

Shortages are entirely about the financial designs

... the designs specific to the shortage areas - generalists and general specialties, primary care, women's health, mental health, small practices, small hospitals, 75% of rural American (not 25% doing well), 2621 counties lowest in concentrations of MD DO NP and PA (75% of rural pop and 32% of the urban pop) because of 15% lower payments, worst collections, and most penalties - by design. This does not include the populations in higher concentration counties that cannot access care due to worst public and private insurance plans (10 - 20% of the US).

Triple Threat is the cause of disparities in workforce - revenue too low where needed, costs of delivery accelerated especially where workforce is most needed, complexity increasing in multiple dimensions specific to the places and populations and practices most left behind.

A Better Design Is Required

By 2010 the deficits were already set in motion. The solution required a better financial design to maintain 2010 until 2040 to result in sufficient basic services by 2040. An entire generation of new workforce must be supported and this requires sufficient finances for sufficient workforce. Instead we lost ground.

For example the 2621 counties lowest in primary care with half enough (40 - 50 per 100,000) had 38 billion invested in primary care practices (20% of the national 160 - 180 billion) but HITECH to MACRA to Primary Care Medical Home extracted 8 billion leaving only 30 billion. Turnover cost have increased and have subtracted another 3 billion not counting administration of various programs to decrease turnover. Going over 10 billion the wrong way defeats any solution.

These counties with half enough across the basics (generalists and general specialties) need over 80 billion a year in revenue for sufficient primary care plus whatever is forced on them in higher costs.

Even then the complexity would not be fully addressed in these counties with 40% of the population and higher concentrations (over 45%) of diabetics, smokers, COPD, obesity, Veterans, poor children, mentally ill, premature deaths, and more. They have the worst social determinants, local supports, turnover frequency, and turnover costs. These all combine for many dimensions of complexity - and worsening shortages.

The growth to 50% of the population is already set in motion and there is no indication that there is any greater movement of dollars to these counties that will increase to 2800 counties lowest in primary care - by design.

How can the US increase spending upon primary care when hundreds of billions are being cut and when regulations cripple the remaining funds?

Expansions will make situations much worse and cannot make them better - by financial design.