Training Cannot Overcome Deficits By Financial Design
The sad fact is that special training works for those associated with special training. Special training does not reduce the problem of inadequate access to care. The proof is in the concentrations of primary care where needed. These concentrations of primary care have remained the same - about half enough. Yes it is true that a special training program or school can have higher proportions serving in locations of need - but their success only results in displacement of others - FM for what was IM, and NP/PA for previous IM or FM. The specially trained replace the traditionally trained. This is a rearrangement of the deck chairs rather than an increase in concentration of workforce where needed.
One rural medical education design that may help a few locations. By moving faculty and other residency resources to rural settings, that particular rural setting can have some improvement in workforce. Indeed in Nebraska there were substantial faculty and resident contributions in the RTT and 2 month continuity rural rotation sites. In contrast, the short term medical student and resident rotations often represent a burden upon rural practices.
Beyond these very limited carefully coordinated contributions at a few sites across the nation, the evidence does not support resolution of workforce deficits via training as measured in physicians or clinicians per 100,000.
But we cannot claim that our efforts limited to training have contributed to deficit reductions with overall improvement of recruitment and retention to higher concentrations of workforce. More resulting from one program can only displace more from a different program or type of training. This was seen in Nebraska as the family physicians replaced internists and as NP and PA increased – but the local workforce contributions remained the same.
The Financial Design Remains Stronger than Training Influences
MD and DO have added more specialties with more added to each new specialty. Once NP and PA were widely accepted outside of underserved areas and primary care, they have been versatile workforce across a wide range of locations and specialties.
Internal medicine residency graduates have long had a wide range of specialty choices - and have taken them. Family medicine residency graduates were also limited in choices until recently, but the breakdown of primary care financing has resulted in great demand in urgent care and emergent care. Rural emergency room and rural hospitalist positions are filled by family physicians. More options with better financial backing translate to shorter stays in primary care.
Primary care physicians may be down to less than a 3 year stay with a cost now over $300,000 in losses and costs for each lost primary care physician. This is over $100,000 per year per FTE on top of $50,000 per year for digitalization, $100,000 per year for administration, over $40,000 a year for MACRA, and over $60,000 a year for Primary Care Medical Home.
If anything, the financial design changes prevent making any statements about training being able to address shortages. When primary care practices where needed have 8 billion fewer dollars a year to invest in primary care, a major consequence is reduced capacity to deliver primary care. The 38 billion for primary care in 2621 lowest primary care concentration counties is down to just 30 billion after HITECH to ACA to MACRA to PCMH. This 30 billion results in less primary care delivery capacity for all sources of graduates. The actual costs of innovation are each 50 - 100% higher for the practices where most needed. These primary care practices have lowest collection rates and their payments are 15% less - by design (Medicare 2011 data).
Claims of Being Able to Address Workforce Gaps Are Common and Distract Our Nation from the Necessary Changes Needed in the Financial Design
Deans, associations, schools, or program directors that make such statements represent a barrier to addressing the true cause of deficits – the financial design. The evidence of lack of improvement of workforce has been present for decades. Immersion in training appears to prevent objective review regarding the ability of training to address workforce deficits.
Rural Health, and Care Where Needed
Consider that there is only a fixed amount of funding going to primary care and to family practice positions. This is limited in counties with concentrations of the patients with the worst public and private plans.
There are fewer dollars to invest in rural primary care over the last decade of innovation, regulation, certification, and digitalization. In fact there are billions fewer as seen in lowest concentration counties that have lowest concentrations of MD DO NP and PA.
Primary care functions on only about 6% of health spending or about a steady 160 - 180 billion a year for a decade. Correcting for the proportion of primary care workforce or 25% serving this 40% of the population and correcting for lesser payments by 15% (Medicare 2011) and for 10% lower collections specific to lowest concentration counties, this indicates about 38 billion that was once available.
Some dollars can be injected by grant funding or special funding although this can be negated by losses of the small practices that do not have this better level of financial support. Small hospitals once could support local primary care but they also have faced worsening financial designs and many have closed. They are not able to bail out local primary care or other basic services.
About 25% of workforce where needed involves women's health and 4 basic surgical specialties. Each of these have been declining by 2 percentage points a year since 2005. Few pass up the chance to do one or more fellowships. The workforce where most needed in these specialties is the oldest - indicating the lack of replacement.
Declines in Family Practice Proportions and Retention
Another indication of failure to resolve deficits can be seen in family practice. Family practice positions filled by MD DO NP and PA are the only ones that demonstrate population based distribution. Unfortunately even those training in family practice and starting in family practice are now falling away in the years after graduation and the years after entry. Each source of workforce has declined to steadily lower proportions in primary care and especially in family practice positions.
But then the financial recession in primary care began. The Era of Cost Cutting took hold and the powerless and those providing care for them began to lose in the 1980s and steadily since that time.
Family medicine is down to 16% rural and the newest graduates have even lower levels. Hospital based FM is 26% rural – but this is once again about a different financial design involving ER, urgent, and hospitalist positions – the directions of rapid departure of family practice and other sources of primary care.
The Red Zone Specialties are those most likely to be burned out. They are most likely to plan to leave their current practice and are most likely tp plan to reduce hours of work a week. Generalists and general specialties - 75% of the workforce where needed, are Red Zone specialties. The decline of a specialty and the decline of the status of a specialty is about the financial design - especially when contrasted with the specialties doing much higher paid services and more concentrated in places most organized for highest payments and most lines of revenue.
A recent blog article in Health Affairs asks an important question. Social determinants are important in shaping outcomes, but is there something even more important shaping social determinants? If so those powerless are shaped poorly and the powerful do best. Those associated with the most powerful win and those most associated with most Americans most left behind lose.
Family medicine residency graduates can be considered casualties in the struggle for power - a struggle where the powerful win and the powerless lose. Family practice physicians and clinicians lose the most because they distribute the best in their family practice positions - the positions that most serve the powerless.
Some separate from the powerless. Others are hit hard by designs that hurt most Americans and those who serve them most.
Declines in primary care retention and departures from serving where needed indicate departure from the powerless and movement toward the powerful.
Consequences of Rapid Turnover of Primary Care and Family Practice
Family medicine residency graduates are also no longer reliable for retention in primary care. Less than half of recent graduates are expected to be found in primary care within 10 years of graduation. Steady declines from 90% to 65% a decade ago to less than 50% are the result of the financial design. Pediatrics remains only about 5 – 6% of the workforce in rural or in lower concentration counties.
Some NP and PA increases will cover the losses due to their massive expansions, but they will not stay long. This is one of many mechanisms moving primary care from most to least experienced in a span on less than a generation of workforce. NP and PA will also have to cover the declining family medicine yield as well.
The primary care workforce experience problem continues to worsen. This is made worse by those who leave after 5 or 10 or 15 years, taking their primary care experience with them.
- not to mention half enough basic workforce
- not to mention half enough local resources
- not to mention most rapid population growth decade after decade since the 1960s
- not to mention more counties added to the lowest concentration 2621 – likely 2800 by 2040 due to continued small practice and small hospital closures
- not to mention housing failure in higher concentration counties forcing millions of older, sicker, poorer, more vulnerable populations to move to lower concentration counties with housing available and more affordable
- not to mention the cuts in Medicare and Medicaid this year which have played out worse for those smaller, least organized, and most important for health access
- not to mention increases in administrative costs and practice complexities (instead of decreases this year as promised)
Powerless people are concentrated while those most concentrated do ever better. This appears to be the case across health care design as with education and economics.
The attempts to "improve" health care and education actually result in more stresses and less support for those who deliver health care or education.
The result of massive expansion during a time of fixed financial capacity in rural, lower concentration, primary care, and basic service settings can only be massive expansion of procedural, technical, subspecialty workforce in places that already have top concentrations.
Osteopathic graduates have been predominantly family practice as their primary care yield. Family practice choice has been cut in half with each doubling of osteopathic graduates - leaving no gain in primary care despite doublings as DO decreased from 70% to 35% to 18% family practice.
This is what happens to MD DO NP and PA graduates with massive expansion of workforce forced beyond the generalists and general specialties that provide 90% of rural services and services where most Americans most need care.
The designers that shape training and shape the financial design, do very well via the massive increase in highly specialized workforce paid best for their services. This shapes more specialized workforce and more concentrated workforce. Graduate medical education dollars also shape benefits for the designers. And even with deficits of GME dollars, the teaching hospitals find it beneficial to expand residency positions to improve revenue generation at lower cost of resident salaries and benefits.
The consequences are seen in runaway health care costs - impacting many facets of American life and premature death, including budgets adversely impacted at all levels from national to state to local to employer to personal.