Basic Health Access

Flexible Fails and Permanent Primary Care Prevented

2011-12-31T23:04:00.001-07:00

The United States has a health policy construct that actually prevents recovery of primary care. Primary care revenue support is insufficient to keep up with the increasing cost of delivering primary care. New types of costs burden primary care practices further. Meanwhile the rewards for non-primary care choices have increased. The rewards are greater for primary care graduates that depart primary care. The rewards are greater for employers who receive more revenue when graduates convert from primary care.

Prevention of Primary Care Recovery By Design

Accelerating cycles of primary care deficits are the result of US policy.

The cycle starts with primary care deficits.
Innovative academicians create new sources of primary care. The designs are generic to workforce needs and are not specific to primary care or most needed primary care.
Despite more sources and increased graduates in each source, there is less primary care result per primary care graduate. Studies contribute to the confusion as they only measure first career choices which fail to capture steady departures from primary care in the years after graduation. Only about 30% of US primary care training results in primary care delivery.
Innovators propose to fix primary care with more types of primary care and further expansions of annual graduates. Others say that primary care can be fixed with reorganzation (continuity home) or innovative payment designs. No such proposal can work without changes in the US policy construct that increase primary care retention in professionals and other personnel - this requires more primary care spending, especially in 30,000 zip codes with lowest spending by design.
US policy does not change and this results in less retention of primary care graduates within primary care careers with flexible primary care graduates departing primary care during training, at graduation, and each year after graduation.
The result is ever more non-primary care with continued deficits of primary care.

The 1980 primary care class year including six primary care sources with 14,000 graduates at 18 Standard Primary Care Years per graduate for 250,000 Standard Primary Care Years for the 1980 class year. The 2012 graduates of six sources will be 28,000 in number but the yield will be only 7 SPCYrs per graduate for a result of 195,000 SPCYrs. Standard Primary Care Year 2012

Since 1980 the United States has had substantial growth of population and primary care demand but the response has not been Specific, Measurable, Achievable, Realistic, or Timely with regard to primary care or the health access needs of most Americans. Tragically the needs are greatest in locations where the elderly, poor, near poor, rural, and underserved populations are found - in 30,000 zip codes that have lower than average to lowest primary care concentrations.

Permanent primary care family medicine is a real solution for primary care and for 200 million Americans in 30,000 zip codes, but permanent primary care choice is actually prevented by policy. Only medical students can choose permanent primary care as nurse practitioner and physician assistant primary care is flexible by design. Only medical students can choose family medicine residency training. Nurse practitioner and physician assistant family practice employed components make the same substantial contributions where needed, but only when remaining in family practice. NP and PA graduates found in family practice employment have decreased to 25% of total graduates. Even when entering family practice with its substantial primary care, rural, and underserved outcomes; the retention is not permanent. Family medicine retains primary care and rural and underserved components because of permanent family practice result.

If the United States only had permanent primary care as the source of primary care, it would know exactly how many graduates were needed each year to supply sufficient primary care. Meeting Primary Care Needs in the Latter Half of the 21st Century

Even with a permanent source, insufficient primary care support will result in a permanent source converted to flexible. Workforce cannot remain where it is not supported. Family medicine has had greater primary care retention in the past. It is possible that this final permanent primary care source could be defeated to flexible and non-primary care. This is quite easy to accomplish as all that is required is for the current design to continue to keep revenue paid below the rapidly increasing cost of delivering primary care.

United States Policy Prevents Permanent Choice as Graduates Prefer Flexible Primary Care Training Sources To Keep Their Options Open or Outright Choose Non-Primary Care

It is not possible to recovery primary care with flexible sources. The US primary care training design is 90% flexible and only 10% permanent. Also the flexible training outcomes have steadily decreased in primary care result per graduate. Ever more graduates are required and even with expansions, the primary care deficit is not erased. A permanent primary care source has different outcomes by design.

The current US design facilitates Three Dimensions of Non-Primary Care Growth with Zero Growth in Primary Care

Permanent Solutions for Primary Care Are SMART

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Shared Savings Equals Cost Cutting By Design

2011-12-30T15:51:00.002-07:00

Medicare needs to cut costs. It has chosen methods to cut costs that will damage the basic health care services needed by most Medicare patients. And instead of calling this cost cutting, it uses terms such as "shared savings." Even worse, the “shared savings” will result in even less health spending in United States locations that already have lowest health spending. Innovative designs are not the problem. The problem is that Medicare designers need to understand the basic health needs of most Medicare patients left behind by design.

Medicare and Medicaid face significant challenges.

Spending will continue to rise with more patients covered such as the doubling of the elderly from 2010 to 2030. The United States has continued to add more drugs, treatments, drug coverage, reasons for hospitalization, and technologies that are most costly. Politicians shout Death Squad rhetoric for any attempt to limit services. Meanwhile those needing basic services such as primary care are left behind. Medicare, Medicaid, and other patients are also left behind in 30,000 zip codes with lower or lowest health workforce.

Not surprisingly the Centers for Medicare & Medicaid Services (CMS) wants to cut costs just as in the 1990s and just as in the 1980s. In fact, the real designs since the 1980s have all been cost cutting in focus.

CMS Design Distortions

Surprisingly few realize that the CMS design is not focused on health or health care delivery for improved health. More and more studies are indicating the failure of a design that allows more and more spent on fewer Americans with little or less result. The real Medicare design favors those nearest death rather than better health and better health care. This is the design that works best for those receiving the most spending. They also influence designs and designers the most.

Designs Fail for Most Americans Forgotten By Designers

About 30,000 zip codes with 200 million Americans are dependent upon Medicare and Medicaid for substantial amounts of health spending. Another top down cost cutting (shared savings) design will result in even less spent in 30,000 zip codes. This will result in fewer primary care personnel and professionals in 30,000 zip codes. Medicare makes this worse by failing to increase primary care revenue as each year bring double digit increases in the cost of delivering primary care. Accelerating Cycles of Primary Care Decline are accelerated.

The CMS changes will make it even harder for Medicare patients (and those not on Medicare) to access primary care in 30,000 zip codes. Already practices are making changes such as limiting Medicare patient access. In states that have experienced Medicaid cuts substantial problems result for many practices dependent on Medicare and Medicaid for half of revenue. Practices that can avoid lowest revenue Medicare and Medicaid patients as well as those on little or no insurance will do so. Closures of practices, fewer personnel to deliver the care, and less volume per primary care professional will result in increasing access problems for most Americans.

What Medicare Was Before 1980 and After Redesign

Medicare has only acted to improve primary care only from 1965 to 1980 when it led the nation to a doubling of the primary care graduate design. This was the only time the primary care workforce production design was increased. Since 1980 only non-primary care has doubled and it has done so each 15 years. The Medicare design fails to reign in non-primary care with massive overspending. The Medicare design fails to pay for basic services even 2010 to 2030 when the elderly are doubling and they need local zip code care or adjacent zip code care as the elderly become more limited in mobility and transportability and need 2 to 3 times more primary care.

Cost cutting designs may be difficult to avoid, but they will not help most of the elderly or most people in the United States – by design.

How Can Primary Care Infrastructure Be Restored with Even Less Spending?

The goals of "promoting accountability for the care of Medicare Fee-For-Service (FFS) beneficiaries; requiring coordinated care for all services provided under Medicare FFS; and encouraging investment in infrastructure and redesigned care processes” are impossible goals with a cost cutting design.

The United States has not demonstrated the ability to prioritize horizontal health access needs under designs that reward vertical tertiary and quaternary services. Also the horizontal health access providers have remained true to health access service on the front lines. Those dominating US health care are the most organized subspecialty and academic interests. Accountable Care does not offer opportunities to separate out primary care in ways that allow it to survive, much less become the foundation of a viable health care system.

The Motivations for Infrastructure Investments Are Poor.

Cost cutting designs such as shared savings will make it even more difficult for necessary infrastructure reinvestments in primary care delivery. Too little spending on primary care has already resulted in over a decade of larger multi-specialty and academic practices less likely to bail out underfunded primary care.

A better choice is to fund primary care separately and directly. A separate primary care design is also an important check and balance upon appropriate care. Primary care too connected to subspecialty and hospital care can be subjected to compromise. A population based or cost based design would be best for primary care. Cost cutting is appropriate for hospital and non-primary care services that have resulted in runaway US health care costs for decades.

Benefits for the Bigger and Badder

Another concern is that only those most organized and sophisticated with top number-crunching ability would benefit. They can select the partners that they want and the populations that they want. They can even bundle services in ways that cherry pick services. Accountable Care is already a bundling of services and the failure to recognize this is also another concern with regard to the designers.

New reforms plus failure in accountability are problematic.

The Obama administration has allowed states the flexibility to have plans with a wide range of services. Also states that have not met deadlines or basic needs have not been disciplined. When the federal government sets up a program to allow financial incentives for those that make investments such as electronic records and then fails to force states to meet federal deadlines, the result is distrust of providers in federal and state designs. States have had such bad plans that lawsuits are required – and more flexibility is being given?

Even optimal states such as Oregon that are far ahead in developing state plans, those in charge cannot tell how much spending will be invested and there is a vague mention of three different types of plans. As a physician delivering care, I can tell you that a major problem is variation in health care plans. Even if people can access care, there is great uncertainty with regard to getting basic medications, referrals, or hospitalization.

At some point people who promise more for less should be held accountable. Innovations and reorganizations are spectacularly unsuccessful, especially in areas such as basic health access where the United States has failed to invest in many dimensions.

Integration Dysfunction

For decades the US has never figured out how to integrate various private, public, and grant providers. It has actually created more designs that make coordination even more difficult. Coordinated care could result from the new reforms. Unfortunately the cost cutting portion is the deal killer.

Instead of starting "population based" for a more integrated and equitable design, a shared savings payment model is required first. There are other increasing costs not considered in a cost cutting design or any design. These include rapid increases in routine costs, increases in the cost of finding and keeping trained personnel in areas such as primary care, and new costs such as electronics and software.

Without an integrated and simplified design such as single payer with universal access and standardized record keeping, the real benefits of integration and coordination are minimal. The same fragmentations result in too much cost required just to get paid such as screening patients, multiple fee scales in multiple locations for multiple services with multiple types of billing and multiple types of record keeping, etc.

Grassroots Up Versus Top Down

Accountable Care follows the same failed designs of past decades and for the same basic reason – the designers. Cost saving has been documented in models that have focused on basic personal, cultural, social, and family needs. Southcentral Foundation is such a model. Southcentral also had quality improvements and greater retention of health personnel, essential for better quality and better patient satisfaction and better health care in Alaska on complex patients.

Time and talent and treasure are three different approaches. The US design has resulted in a focus on treasure and highly specialized talent. What is also required is time spent with people and talent in people skills areas.

What If Our Nation Had a Different Design for Entry to Medical School?

Medical students before and during school are not known for substantial time availability, but what they have can be spent working with patients part time in their homes to save substantial costs. it is interesting to see energy invested in a grassroots human being effort rather a focus on research. Medical students at the School of Osteopathic Medicine Arizona have one of the most intense first years of training, yet several have found the time to devote to a home care prevention of readmission. This is a partnership between the students, the hospital, and dieticians. The results in the first two years have been outstanding. Also this was accomplished with little treasure or specialized talent. The model reinforces being there in a caring way helping patients to maximize their health - rather than more and more health care services required.

Imaging 50,000 applicants pursuing medical school based on grassroots service efforts rather than devoting hundreds of hours for research (or 250,000 applying for health professional school positions). Imagine tens of thousands working with patients, families, and neighborhoods on better health outcomes in more than just readmission.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Number One Two Three in Health Access

2011-12-27T22:45:00.000-07:00

Solutions for health access primary care workforce

Enter primary care practices at highest proportions after training
Stay in primary care practice at highest proportions in the years after graduation
Have the longest health professional career lengths
Remain active in practice during a career at the highest percentages
Deliver the highest volume of primary care when active in primary care delivery.
Are most likely to be found in 30,000 zip codes with 200 million Americans and only 25% of total workforce (Practice Locations Outside of Concentrations) and
Are least likely to be found in 1000 zip codes with only 11% of the population and 50% of the workforce (Super Center Concentrations).

Only family medicine residency graduates meet all of these criteria for graduates past, present, and future. Only family medicine residents have not been increased beyond the 3000 annual graduates first reached in 1980. The US primary care design has also not changed for primary care numbers since 1980 while the non-primary care design has doubled each 15 years since 1965.

Only a broadest generalist primary care source can best meet the needs of over 65% of elderly, poor, near poor, rural, underserved, lower income, middle income, disadvantaged, children in need of health care workforce, and shortage area populations.

Number 1 is United States Origin Family Medicine from a US Medical School	25 Standard Primary Care Years	Estimated Range of 23 – 30 Standard Primary Care Years depending upon age at workforce entry, gender, retention in primary care
Number 2 is United States Origin Family Medicine from a non-US Medical School	22 - 25 Standard Primary Care Years	A slight delay in entry to practice is likely to result in the potential for lesser workforce, but there may be no difference
Number 3 is non-US Origin Family Medicine from a non-US Medical School	20 – 22 Standard Primary Care Years (but broad range)	Medical education in other nations commonly results in younger age but those working toward US training and practice face delays that result in older age entry to US workforce

Standard Primary Care Years Estimates for 2012
First career and practice location choices are simply insufficient to assess primary care sources. The Standard Primary Care Year is an important estimate of future primary care delivery assigned to the class year of graduation.

Pediatric and Medicine Pediatrics	10 – 14 SPCYrs	Less than half and likely less than 40% will remain in primary care.
Physician Assistant Beginning Family Practice	12 SPCYrs	Steady departures over the years after graduation limit outcomes.
Nurse Practitioners Trained as Family Nurse Practitioners	6 – 8 SPCYrs	Half will be active as direct care clinicians in family practice employ. Fewest years and lowest volume result in substantially fewer SPCYrs.
Internal Medicine	3 – 5 SPCYrs	Few enter primary care and departures continue after graduation.
Physician Assistant not Starting in Family Practice	1 - 3 SPCYrs	Family practice is the predominant PA primary care vehicle
Nurse Practitioners not FNP trained	1 – 2 SPCYrs	Family nurse practitioners are the predominant NP primary care vehicle

Nurse practitioner and physician assistant contributions to rural or underserved locations in need of workforce are multiple times greater when employed in family practice as compared to NP and PA not family practice employed. NP and PA graduates not employed in family practice remain below average in needed practice locations. About 25% of NP and PA workforce are found active as family practice clinicians although declines could result in fewer.

Comments by any number of “workforce experts” about family medicine from any US origin or non-citizen source should be supportive about expansion, about selection specific to family practice, and about training specific to family practice. This entire blog was posted because non-citizen family medicine has received comments and even testimony to Congress that has not been flattering. What matters is health access delivery where needed. Even if only 7% of non-citizens average family medicine choice, this choice is an important one for 200 million Americans left behind and about to have even more difficulty.

Generic expansions of health professional training not specific to permanent family practice (MD, DO, NP, and PA) should be understood as solutions for non-primary care and practice locations that already have top concentrations. Flexible designs fail for primary care and for 200 million Americans. Flexible designs are represented by NP, PA, and IM training that can result in any number of non-primary care careers. For nurse practitioner or physician assistant training to be SMART Basic Health Access Solutions, they would have to find a way to permanent family practice by a permanent design change. Generic and flexible is failed health access.

Specific family practice is the SMART solution for health access for 200 million Americans left behind and falling further behind by design.

Physician Distribution By Concentration Zip Code Practice Locations Inside and Outside of Concentrations

More about the Standard Primary Care Year

Three Dimensions of Non-Primary Care Expansion and Zero Growth in Primary Care Design

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Rural Rearrangements of the Deck Chairs

2011-12-24T10:24:00.000-07:00

Comprehensive Rural Programs Are Not Enough to Overcome US Maldistribution By Design

There is no evidence that Rural Programs in Medical Schools actually increase rural workforce when considering the outcomes of the parent schools. Even with expansions of annual graduates in the parent schools, there has been no improvement. There is nothing wrong with rural programming. It is possible that health access outcomes could decline without rural programming or it might be possible to demonstrate problems resulting from inadequate preparation for the demands of rural practice. The fact is that rural programming has not been able to overcome overall changes in the US health design. Rural programming has not been able to keep up with population changes that increase demand such as increases in elderly, poor, and lower income patients. Lack of health spending for rural populations is the likely reason why rural programming or generic expansions are unable to improve rural access to care. In some ways rural programming can be seen as preventing solutions for health access that require increased spending in primary care, in rural locations, and in locations underserved for workforce.

New Rounds of Publications Emerge

Comprehensive Rural Programs have been promoted as health access solutions in new publications. Unfortunately the efforts of Duluth, the Rural Physician Associates Program, the Rockford program, and the Physician Shortages Area Program have not improved the rural, primary care, or family medicine outcomes when considering the parent schools of these programs - the University of Minnesota, the University of Illinois, or Jefferson.

Defeat of Rural Programming Due to Individual School Family Medicine Collapse or Decline

Declines in family medicine for Mercer from 32% to 3% will take Mercer from a top ranking proportion of graduates found in rural, found in underserved, and found in rural underserved areas to less than the national average.

The WWAMI program has long been promoted as a solution for states in need of workforce, even as states such as Alaska spend 1 million more dollars a year on primary care recruitment, retention, and locums costs alone. WWAMI has the same problem as all rural models - it leaks. The graduates have not been required to stay instate or in needed careers. The graduates are not admitted with a commitment instate or to family medicine or to rural practice or to underserved practice. The major WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) state needs remain the same - family physicians. With inadequate family physicians, locations in need of workforce are forced to pay more and more to get the same or less workforce.

Marginal and underserved rural proportions have certainly not improved for the University of Washington in the AMA Masterfile. There was an 11% proportion prior to WAMI and down to the 8 - 9% level for 1994 - 2000 graduates. The 20 - 30% family medicine level is now down to one-third this level. The rural contribution of the University of Washington have not improved at best and there are indications of steady declines.

The main reason for success and failure appears to be the same reason. During 1965 to 1980 the United States poured billions into health care and much of this went to marginal and underserved locations with high proportions of Medicare and Medicaid patients. The 1980s cost cutting designs with increasing costs of delivering care and less revenue resulted in declines. Then the 1990s again injected funding specific to rural locations and primary care where needed for a few years before returning to cost cutting and major declines across all graduating classes of MD, DO, NP, and PA.

The University of Washington and the University of North Carolina have also been used as examples of medical schools that can accomplish dual roles of research and health access. Together all of the parent schools with rural programming actually barely keep above the US average regarding needed rural outcomes.

Medical schools that do much better for rural outcomes are medical schools in rural locations.
Osteopathic public medical schools have also been outstanding sources of rural physicians, instate physicians, and family medicine.
Medical schools in the South also contribute more rural physicians, but this has to do with higher levels of rural population
Medical schools in the Midwest also contribute more rural physicians for the same reasons - a state with a higher proportion of rural workforce.

What is most evident is little change at all - before or after rural programming.

Thirty Years of Health Access Workforce Prevention

The creation of osteopathic public medical schools was only 1970 to 1980 and further osteopathic public schools have been prevented for 30 years. At the heart of the successes of all the medical schools associated with rural workforce is family medicine, also prevented from expansion for 30 years by the US design. This remaining permanent primary care choice is difficult when primary care is marginalized, when the practice locations most common to family physicians receive the least health spending, and when many of the locations preferred by medical students are locations that have lowest percentages of workforce in family medicine. Family physicians can be tracked as steadily moving away

The University of Nebraska is another example of declines in instate, primary care, and rural workforce due to changes in family medicine and admission. The University of Nebraska has established a number of different rural programs involving 8^th grade to retention in rural practice. Unfortunately a decline to 2 - 3% family medicine choice for the great majority entering from major metro origins defeats the overall rural programming (last 4 matches at UNMC). The proportion entering from out of state and instate metro areas continues to increase (40% to 50% to 60%) and this proportion has 4 to 5 times lower choice of family medicine than in recent decades. It is difficult to fill graduate programs that do address Nebraska’s health access needs without family medicine choice. As more UNMC graduates depart the state for training and for practice, UNMC will no longer be able to keep up its contribution of half of Nebraska workforce - particularly as seniors double from 2010 to 2030.

Chen in Academic Medicine suggested that rural training tracks triple rural location in the graduates of a family medicine residency. Actually this is not specific to rural programming. simple choice of family medicine is enough to triple rural location, even when controlling for physician origins, type of medical school, and state practice location type.

Rural programs and tracks are small. Rural efforts are dependent upon sources of students that are declining (lower and middle income origin, lower and middle population density origin, children not of professional parents, rural interested, family medicine interested, first generation to college). Graduate medical education rural efforts can only exist when programs fill their residency positions (more difficult, not the best fit types chosen). Also the higher proportions of health access workforce in existing rural programs is easily overcome by the much lower and declining health access outcomes of much larger non-rural or traditional components.

The existence of such rural programming within a state or school appears to rearrange who chooses such programming without actually increasing desired outcomes. The outcomes are worse when considering entire careers of contribution due to lack of instate retention, declining primary care retention in the years after graduation from primary care training programs, and declining retention in rural locations.

Only complete school designs have made top contributions to rural workforce including rural located medical schools and osteopathic public schools. Only the family medicine proportion can be consistently demonstrated to have top health access contributions. Except in a few states (states that tend to have top workforce concentrations that drive FM out), family medicine is also associated with top instate retention. This is noted in University of Kansas graduates choosing family medicine that have 16 times greater instate rural location compared to U of KS grads not choosing family medicine. Family medicine has been the result of admission of students with factors contributing to instate most needed health access and family medicine contributes to instate most needed health access.

Graham Center Policy One-Pager Comprehensive Medical School Rural Programs Produce Rural Family Physicians While the title is true, the parent institutions do not have overall rural workforce gains. Also the parent institutions have barely above average rural contributions.

Which Medical Schools Produce Rural Physicians - a 15 year update

This is Blog Number 50 for Basic Health Access Blog begun in 2011.

Rural Medical Education Specific Blogs and Links

Rural Workforce 2000 to 2010 Uncle Sam says "I want you" to serve in rural locations. Uncle Sam's design says "I don't want you" to serve in rural locations. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans.

Atlas of Basic Health Access at the World of Rural Medical Education

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many (non-health access interested parties) determining training curricula, and very few focused on basic health access

Pounding Poverty Providers with Pay for Performance Designs that send even less dollars to those who care for most Americans are the reason for health access problems. Pay for Performance designs make matters worse resulting for gains in revenue for those that care for patients who naturally have better outcomes and no gain for those who care for the more complex patients.

Speak Your Piece: Measuring Rural Health Care Rural health care providers are paid less to provide treatment to a population that is more likely to be poor than those in the cities. Now medical researchers are saying rural hospitals don't provide the same quality of care as those city institutions that have more money and richer patients. Well......Which is it, JAMA? Where is your consistency in articles regarding quality of care? If you choose some authors that consider social determinants and other important limitations but ignore these factors in other publications, this causes confusion.

Rural Primary Care: Stark Realities All primary care sources have declined in primary care per graduate and in rural primary care delivery per graduate. The rural Standard Primary Care Year contributions over the class years illustrate the declines in rural primary care delivery.

Non-Specific Rural Pipelines or Specific Long Term Obligations Voluntary choice allows potential rural physicians to steadily leak away with each year of training and practice. Only very specific shaping is most likely to result in early, middle, and late career rural contributions.

Preparing for Health Care Cuts This is not good news for rural workforce. No administration in the past 30 years has really understood the problems that result in insufficient rural workforce and matters may be even worse in 2012 and beyond.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Piddle Twiddle and Resolve Not One Damn Thing Do They Solve

2011-12-23T12:07:00.001-07:00

In the play 1776 there are any number of wonderful allusions to Congress then and now. Former President Nixon thought so too. He requested and received an edited version regarding Cool Cool Considerate Men as he felt they too closely resembled conservatives of the time. Cool Considerate (calm, calculating, conservative?) Men are still very evident, but do they still lead well or wisely or with sufficient understanding of the daily lives of most Americans?

Congress today is a divisive Congress just as presented in 1776. Is Congress today working together affirmatively for the nation. The most basic areas important to most Americans appear to be low priority. The current physician fee crisis is a great example of Piddle Twiddle and Resolve without a solution.

It has taken years for the Medicare Physician Payment Advisory Commission, stacked with landed gentry benefiting from the designs they set, to recognize its past errors and to recommend some protection of primary care fees as compared to non-primary care. Major protests were required to get just this small change. Reasonable increases in revenue that might keep up with the costs of delivering primary care are not even on the drawing board. Primary care workforce has followed the primary care spending design as noted in Accelerating Cycles of Decline.

Primary care workforce designs have doubled primary care numbers only from 1965 to 1985. Each 15 years since 1965 the non-primary care workforce has doubled and this will continue until 2025. The US is attempting to function from 2010 to 2025 on a design that was set in place in 1980. Despite twice as many graduates and 3 times as many primary care sources, the primary care numbers of clinicians and the primary care delivery capacity continues to decline. Policy Failure Plagues Primary Care and Permanent Primary Care Choice through Five Policy Periods
indicate designs that work or fail.

Ever more resources are spent on non-primary care while primary care faces across the board cuts on top of inadequate reimbursement. The entire mess results in distrust of government and health insurance companies by those who provide care as well as the patients who receive care.

Even physicians realize that primary care reimbursement is too little (Leigh). More practices stream to types of payment (rural health clinic and FQHC) that have the ability to cover rising costs of care rather than fee for service under SGR that has been mired in the basement. Fixes in the 1960s to that restored some basic health care infrastructure failed as costs rose faster than revenue and as redesigns sent the spending to fewer locations with greater workforce concentrations. Fixes in the 1990s failed in just a few years. But Congress has little memory for failure and has little awareness as well.

Piddle Twiddle and Resolve

Delays are common responses when more spending is involved. There is no time for most Americans in need of care and the elderly are the major example. For 50 years the US has known about the need for more care beginning in 2010 and there has been no preparation for the workforce to deliver the care. In fact the workforce most needed is declining the most.

It is already too late for the elderly of today as they double from 2010 to 2030. During this period internal medicine will collapse from 90,000 to 40,000 in primary care as this is all that 1400 entering primary care a year can provide. Family medicine can no longer increase as it has been held hostage for 30 years at 3000 annual graduates - zero growth. Sadly government reports indicate increases when increases are not possible. Journals also fail to present the truth or the consequences of failed policy. NP and PA workforce proportions have declined steadily in the needed primary care and in the locations where 65% of the elderly are found. This is mainly about fewer remaining in family practice - the predominant midlevel primary care, rural, and underserved response as well as service to those outside of concentrations. Geriatric workforce is also concentrated 75 - 80% where only 30% of the elderly are found.

Health care most important for the elderly is held hostage by designs that defeat primary care as well as workforce in the zip codes outside of concentrations where 68% of the elderly are found. The elderly need two to three times more primary care and this workforce must match up to zip codes where the elderly are found - particularly as they lose mobility and transportability as they age. The damage of the last few months and the next months is specific to those remaining who care for the elderly. This is compounded by the past 15 years of decline. ew years of damage.

Piddle Twiddle and Resolve

The record is solid for health policy impact and primary care. Primary care numbers doubled from 1965 – 1980 with the initial health access plan before cost increases and cost cutting designs took over. The 1990s reforms boosted primary care and family medicine to peak levels with increased primary care revenue and decreased or stagnant non-primary care. The 2010 reforms that might have helped primary care have been compromised by cuts in Medicaid and those who care for patients most in need of care, in addition to innovation focus, and reorganization focus. As commented in 1776 - “Sweet Jesus”

Momma Look Sharp To See If You Can Find the Remaining Front Line Workforce

The basic health services needed by nearly all Americans nearly all of the years of their lives are being compromised by insufficient primary care spending (widely recognized) and insufficient workforce retained in primary care due to insufficient primary care spending. To Follow the Workforce Follow the Spending. Matters are worse with substantially more paid to non-primary care, allowing experienced primary care personnel and professionals to be hired away from primary care employment.

Is Anybody There, Does Anybody Care?

As noted by 180 days of neglect after 30 years of neglect

Piddle Twiddle and Resolve

There is of course only one response as indicated in the play

“Sit down Bob, Sit Down Bob, For God’s Sake Bob, Sit Down”

The reply is of course "Never, Never"

May 2012 Be a Time When Congress and leaders across our nation, Despite Divisions, Will Resolve to Work Affirmatively for Most of Our Nation

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Leigh JP, Tancredi D, Jerant A, Kravitz RL. Physician wages across specialties: informing the physician reimbursement debate. Arch Intern Med. Oct 25 2010;170(19):1728-1734.

1776 is a musical with music and lyrics by Sherman Edwards and a book by Peter Stone. The story is based on the events surrounding the signing of the Declaration of Independence. It focuses on, and partly fictionalizes, the efforts of John Adams to persuade his colleagues to vote for American independence and to sign the document.

Link to the "Cool Considerate Men" sequence from the restored version of the film. "This sequence was cut out of the original release upon complaint by President Richard Nixon, for the song allegedly drew many parallels between the opponents of American Independence in 1776 to the modern conservative right." – forever to the right… Dialogue Hancock – “Fortunately there are not enough men of property in American to dictate policy.” Response - "Most men with nothing would rather protect the possibility of becoming rich than face the reality of being poor." A comment about the Republican Party is worth a read. YouTube

Graphic Primary Care Graduate Increases, Decreasing Primary Care Delivery

Pounding Poverty Providers with Pay for Performance

2011-12-21T09:23:00.000-07:00

United States designs for health spending consistently result in less for those who already have the lowest health spending. This is accomplished by designs that send less to those that attempt the responsibility of their care. Design changes and even reforms that are supposed to send more spending to those who care for most Americans left behind can also fail.

Because more Americans are joining those at or below poverty, particularly children, the nation should spend far more time understanding the inequities of the current and future designs.

Proposals for bonus funds were supposed to send more funding to those who care for underserved patients, family medicine and rural associations had to exert additional time and energy and research to insure that the programs actually send funding to those who deliver the needed care. Studies from North Carolina indicated that previous bonus program funding were commonly accessed by those that were not supposed to receive the funding.

Hong in JAMA demonstrated that Pay for Performance punished practitioners caring for the underserved. See comment in AFP Community Blog.

Pediatrics just published an article about the value of a continuity medical home – an article that actually demonstrated that continuity was really about advantage and discontinuity was about disadvantage. The real driver of better quality was social determinants, not the medical home concept in this study that did not really even study outcomes of actual certified medical homes.

Now Kaiser indicates much the same for Hospitals that care for those left behind. Readmission rates are much higher for lower income Americans. This is of course a function of any number of social determinant and similar demographic characteristics that add up to difficulties that lead to hospitalization and difficulties that are far more likely after hospitalization.

It is hardly possible to keep up with all the ways that funding is diverted to care of those with easier care and naturally better outcomes.

Not much comment is needed other than indicating that until designers understand most Americans and their basic needs, the designs will continue to favor few. Design changes also may insure even greater divisions.

Potential Impact of Pay-for-Performance on the Financial Health of Critical Access Hospitals (Policy Brief)    Author(s): Robert Town, Ira Moscovice Sponsoring organization: Flex Monitoring Team
Pay-for-performance (P4P) incentives likely reduce the financial status of CAHs already in financial stress. However, P4P incentives are likely to have only a modest impact on the financial stability of CAHs. Date: 02 / 2010

Providing Underserved Patients with Medical Homes: Assessing the Readiness of Safety-Net Health Centers  Author(s): Katie Coleman, Kathryn Phillips
Sponsoring organization: Commonwealth Fund
Surveys safety-net health centers (public hospitals and clinics, federally qualified health centers, rural health centers, and free clinics for the medically underserved) to determine their potential to become patient-centered medical homes (PCMHs). Date: 05 / 2010    A summary would be that those caring for Americans left behind have an uphill battle to qualify as medical homes. They have a major battle just trying to keep up with increasing demand.

Basically even to become eligible for increased pay, there is substantially more investment required to get where needed. Also the outcomes will be less not due to lack of effort, but due to care of underserved patients. Government designers and reformers do not understand the people most in need of care or the type of care they need or the funding required to meet their needs.

A true approach to build quality requires far more understanding and awareness and substantial time and effort to process a real design. Cost cutting focus results in rapid implementation and designers are most familiar with what works for a few rather than what would work for most.

Arizona has delayed six months beyond the required July 1 2011 federal deadline to set up their electronic verification site so that Medicaid providers can recoup their tens of thousands invested in patient management software and hardware and consultants in the past 2 years. There are only 10 days left in the year. It appears likely in at least one state that investments required to gain incentives will not even be paid as indicated. Other states short on funds and Medicaid funds may also play the delay game. This is a catastrophic event signaling to those who care for patients in need that they need to stop caring for Medicaid patients or leave the state. This is another way to Pound Poverty Providers.

One thing is certain. Taking the "safety-net" for granted is guaranteed to result in greater divisions between Americans in income, health, employment, productivity, and other measures.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

What Do Medical Home Studies Indicate?

2011-12-19T21:10:00.002-07:00

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.

In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.

What Do Medical Home Studies Indicate?

Associations and researchers are willing to use data sources that are not from “official medical homes” to indicate medical home value.
Concepts are considered more important than the primary care people who deliver the care. Of course those who cut primary care funding fail to understand they are cutting the experienced people needed to deliver primary care. Primary care is about people – repeat often, especially when examining studies about primary care.
Methods that select patients with better social determinants will have better outcomes. Methods tha select patients with higher levels of continuity will have better social determinants and better outcomes as well as better access to care. Substantially more is also invested in health care for those who have greater access and higher social determinant levels. One would also have to ask how many criteria were needed by researchers to demonstrate a difference.
In the study, those of advantage were more likely to have continuity home experiences. In almost every instance of lower probability of preventive visits (age less than 1, single mom, lower income, lack of health insurance, less educated parents), those that preserved continuity had greater proportional improvement (close to 2 to 1). In other words those that somehow bucked social determinants had better care. The continuity home definition did little for those with social determinant advantages and did the most for those that managed to have a continuity home despite odds against.
In the study the differences are significant, but the differences are so small as not to be relevant.
Children with a medical home were more likely to receive higher health ratings (excellent or very good) as compared to those without that were lower rated (good, fair or poor). Many would consider the noted outcomes as a matter of differences in health status.
As with other pediatric studies, the experts consider near universal access to pediatric care. They have of course overlooked the problem of maldistribution and limited access for over half of children due to workforce limitations in 30,000 zip codes with low or lower health workforce concentrations.
Then the study considers a 30% decreased ER utilization discussed in association with a continuity home.

At this point I just have to stop looking. This is a poor study by any number of measures. These are good people that are well intentioned. Some if not most have delivered care where needed. Sadly there is a loss of perspective.

There are significant investments of time and effort by associations and this is a likely reason why such studies are published. What is obvious from this and other studies is that changes in social determinants are required as a top priority with reorganizations of care way down the list.

The current pediatric study does not prove the value of the Medical Home as headlines indicate in Medscape – proof is almost impossible to prove in medical studies. What the Medscape headlines do indicate is poor understanding of medical studies by the medical media (or at least dramatization that is deceptive).

The investment in medical home terminology is so high that family medicine leaders have protested when studies fail to show the expected benefit. After devoting substantial funding to this area, perhaps objectivity is lost. Does Family Medicine Need New Leaders?

I am certainly for the concepts of team care, continuity of care, integration of information, and other aspects that are considered medical home concepts. These are obvious to those who have experienced the great pleasure of delivering challenging care with a supportive team. Who would be against such a design?

The problem remains that continuity home interventions are not going to solve primary care woes or the associated social determinant maldistributions.

Diverting a Nation from Real Solutions

The continuity home has been touted as a solution for the primary care woes of the nation. In fact, the Continuity Home will not improve the major health access problems of the nation. When providers present “cures” that do not work and distract patients from treatments that do work, this is considered a serious offense.

Offensive Literature and Offensive to Dedicated Primary Care Practices

It is hard not to find much of the literature developing around the medical home concept to be “offensive.”

I will continue to assert first that social determinants are far more important and that any primary care practice that has dedicated health professionals that function together as a team to provide health care, that stay together as a team, that keep the same patients, that keep the same location for care, and that have sufficient funding to accomplish the above – will have the optimal care with or without medical home designation.

If the cost of a medical home designation impedes care, medical home designation will not improve the care and may damage care.

If the medical home designation comes with more funding, the care may improve but this is likely the result of the additional funding rather than a medical home focus (beware government promises of more funding as this may not materialize).

If sites receive continuity home grants, then they will have better care because the additional funding is likely to give them an advantage in recruiting and retaining the best primary care personnel. Continuity care is clearly more likely with those that are easiest to care for, as demonstrated in the study.

Of course a real design for the care of all Americans provides sufficient primary care spending across the nation, not just for those who have grants or cost-based reimbursement.

Quality Arises from People and Relationships from the Ground Up, Not from Concepts Thrust on People from Above

Quality is the result of reflective process by dedicated team members with objective consideration of all relevant aspects of care – especially very basic awarenesses and understandings of the patients served. This process does not require certain terms such as continuity home, stroke center, chest pain centers, etc. Continuity home focus can improve care and can raise awareness of methods that can improve care, but a continuity home itself will not be the reason for change.

But if you desire a nice name or certification there are numerous places to contact, meetings to attend, and others willing to take money away from delivery of primary care. Your choice of the following or dozens of others.

On-Site Certification. The Mark of Quality that Sets Your Medical Home Above the Rest. The Joint Commission: Primary Care Medical Home 2011 StandardsAccess and Continuity in the Medical Home SettingBlueprints for Building a Medical Home

The Problem Facing Primary Care

The problem facing primary care remains the same. The problem is that revenue derived from primary care services is insufficient to keep up with rapidly rising costs. When the cost of delivering care is insufficient, the result is cuts in personnel, less experienced personnel, fewer personnel, and decrease in the ability to deliver more care and better care.

When the costs of delivering care are increased due to various innovations and reorganizations without increasing the revenue, it is possible to also result in less primary care delivery.

If a national focus on higher quality (by less volume, more costly technology, fewer personnel) results in less primary care delivered per primary care provider, the nation will have much greater problems with cost, quality, and access because the missing link is primary care personnel of all types.

The Problem of Social Determinants Ignored

If primary care experts ignore social determinants, then they do not understand the most important variables regarding cost, quality, and access. If Pay for Performance pays more for “quality,” relatively less will be paid to practices that have lower and middle income patients. This is because practices that are more likely to care for those in need of care will have lower quality ratings because of the patients that they care for. Higher quality ratings and greater pay will go to those who have better quality because of who they are.

The authors of this Pediatrics article have built another very good case for social determinants yet they have claimed that the reason is the continuity home. This is a quite serious problem for Pediatrics, for primary care, and for most Americans in need of real solutions for health access.

Better Ratings with Better Pay, or Care Delivered Where Needed?

To get lower quality ratings and less pay, continue to care for underserved, poor, near poor, rural, disadvantaged, and lower income patients.

To get better quality ratings and better pay, be sure you care for less complex people. The nation will overall have lower health care quality, higher costs, and declining access to care – but you and your practice will do better.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Basic Health Access Blogspot 2011

2011-12-13T08:23:00.000-07:00

My desire for you for 2012 is for you to progress toward becoming a true leader, for you to benefit from the leadership of a true leader, and for you to select true leaders to lead our nation.

A leader will find it difficult to articulate a coherent vision unless it expresses his core values, his basic identity…. one must first embark on the formidable journey of self-discovery in order to create a vision with authentic soul.

Mihaly Csikszentmihalyi

May the new year of 2012 be a continued journey of self-discovery for you and for our nation. I have been blessed with opportunities at East Tennessee, Nebraska, and A T Still to continue the self-discovery begun in rural family practice in Nowata OK.

Fifty Blogs in Order of Viewing Popularity

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

The Clinician Specific Medical Education Blog was also begun as a complement to SMART Basic Health Access with the most recent posting Longitudinal Clinical Experience Rating Scale and others such as Are We Short Changing Those Who Desire to Become Clinicians? , What They Don't Teach Medical Students: Doctoring , and Real Excellence in Medical Education

These join http://www.basichealthaccess.org/ and http://www.ruralmedicaleducation.org/ and http://www.physicianworkforcestudies.org/

Major Journals Fail Primary Care Once Again - Major journals have slipped in another article that apparently was designed for controversy and for widespread distribution to media outlets. The title of this Health Affairs article is not original - "Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services as Compared to Other Countries." Health Affairs published the bait. Media outlets such as the NY Times were hooked.

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 1980 - 2010 – Too much is the rule for US health care costs with three dimensions of rapid growth of non-primary care – the care that cannot be regulated except through limitations of workforce.

Meeting Primary Care Needs in the Last Half of the 21st Century - Really! – A SMART plan actually indicates how the US can meet primary care needs. All that is required is a focus upon specific primary care result rather than primary care that is 70% not primary care in result.

One Million Hearts Saved or 160 Million Lives Improved - The Million Hearts Campaign has been shaped by those leading health care – government, associations, business, and insurance. Million Hearts is not a poor choice in itself. It is what Million Hearts represents that is the problem. Million Hearts represents numerous choices past, present, and future that have not worked for most Americans. These continued choices distract and divert attention from what works. A focus upon diseases and risk factors is quite different when compared to specific focus upon the basic needs of most Americans.

To Follow the Money, Follow the Workforce – With half of workforce guided to 1% of the land area by over half of annual health spending and with substantial funding expended by 1% of the land area to get ever more dollars from any number of treasuries, there will be no interruption of every more expended for fewer Americans in fewer locations with less overall result.

Why Do Primary Care Myths and Misinformations Persist? – The evidence indicates ever less primary care from primary care trained graduates. Why are these poor sources getting worse promoted as solutions?

RPAP Is SMART and Has Been for Forty Years – The longest running rural, primary care, and health access intervention remains the best for any number of areas – especially communities in need of health access.

Countdown to the 2012 Primary Care Armageddon - There are about 132 112 99 62 18 7 days until January 1, 2012 when Medicare will be forced to cut fees to physicians by nearly 30%. These cuts have already been enacted by Congress. To prevent this action, the current Congress would need to take action – a major problem with this Congress. Over 114 days have been wasted and Congress is nearing recess.

What is Killing US is Not Four Diseases Focus - The Myth for the Cure and others in the Disease Focused Crowd Are Now Selling Four Diseases to the United States and to the World Health Organization. What is Killing US is greed, stress, ignoring the needs of children, and ignoring the development of human infrastructure.

Pounding Poverty Providers with Pay for Performance United States designs for health spending consistently result in less for those who already have the lowest health spending. This is accomplished by designs that send less to those that attempt the responsibility of their care. Design changes and even reforms that are supposed to send more spending to those who care for most Americans left behind can also fail.

Accelerating Cycles of Primary Care Decline – When factors intersect progressively, the primary care result is much greater decline. With less revenue on the way and more distortions of primary care trained graduates away from primary care, more cycles of decline are coming.

Disease Focused Disorder Mentality or Sentimentality – After 100 years of socialization of health care leaders regarding disease focus, will we understand the consequences of too much focus on disease and ever less understanding of people and the context of care?

Why are 2008 Government Projections of Primary Care Workforce in Error? Four years later and after ignoring 10 years of evidence, this HRSA site continues to deceive. Internal medicine is heading to 40,000 by 2030, not 155,000 in primary care by 2020. Family medicine is fixed in place by 3000 annual graduates for over 30 years and cannot increase - by design. Projecting more with steadily less is a serious distortion by those supposed to leader health access for our nation.

What Do Medical Home Studies Indicate? Those positive about the medical home are promotions that indicate the value of the continuity medical home when the real determinants of better health care are social determinants. The fact is that health care access, cost, and quality are fixed in place by designs. To understand what works, it is important to understand the designs and the designers.

The Black Hole of US Subspecialization spells Workforce Concentration, continued higher costs for health care, and Lack of Access for Most Americans

Fifty Years of Failed Primary Care Workforce Innovation – Innovation lunacy has taken on new heights, even in areas with fifty years of failed primary care workforce innovation.

Finance-me-cratic Constants in the Bureaucratic Universe - America has come to a standstill in many important areas - health, education, leadership, and more. Recessions have always found ways to blame any number of individuals or types of people. In fact, recessions have a common cause involving the relationship between finance-me-crats, aristocrats, and bureaucrats.

What can a zip code 10032 study indicate about nurse practitioner versus physicians with data a dozen years old, providers that predominantly did not understand the language and culture of the patients, a location representative of very few zip codes in America, and the lowest aim of indicating no difference. As we understand more and more about social determinants, it should be surprising that any differences will be found in populations with the most social determinant limitations, such as those in this study.

This Will Be Brief As Will Primary Care - Anyone with any understanding at all regarding primary care understands that primary care is about people. Primary care is people delivering primary care services to people. Primary care involves the most basic health services, those needed by nearly all Americans nearly all the years of their lives in nearly all locations. The year 2012 is likely to be most challenging. There appears to be little hope for addressing the most important problem – insufficient revenue to keep up with double digit increases in the cost of delivering primary care.

Comparing Family Practice Sources - The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations of workforce or health spending. It is also important to understand that not all sources remain in family practice in the years after graduation. NP and PA sources continue 40 years of steady movement away from family practice - the result of flexible design.

Rural Rearrangements of the Deck Chairs - Merry Christmas December 24, 2011 Comprehensive Rural Programs Are Not Enough to Overcome US Maldistribution By Design There is no evidence that Rural Programs in Medical Schools actually increase rural workforce when considering the outcomes of the parent schools. Even with expansions of annual graduates in the parent schools, there has been no improvement. There is nothing wrong with rural programming. It is possible that health access outcomes could decline without rural programming or it might be possible to demonstrate problems resulting from inadequate preparation for the demands of rural practice. The fact is that rural programming has not been able to overcome overall changes in the US health design.

Failing Primary Care Explained By Policy Failure – Koch’s postulates are satisfied – US Health Policy can rebuild or destroy primary care as illustrated a number of policy periods across 1960 – 2010.

Generic Expansions Are Not SMART – Generic expansions of annual graduates absolutely fail for the purpose of health access. Too few enter and too few remain, even when the training program is a primary care program.

Rural Primary Care: Stark Realities – With the exception of family practice sources that remain in family practice (family medicine), the reality is that rural primary care delivery per primary care graduate has been rapidly declining for some time.

SMART Primary Care : Family Practice Contributions – Only family practice (MD, DO, NP, PA) works for the purpose of health access for 200 million Americans and over 65% of the elderly as well as all populations in need of health access. Only family practice that stays in family practice for a career (family medicine) is efficient and effective.

FInd New Family Medicine Leaders? – The best of the best are often those that ask the best questions rather than regurgitating the expected responses. When family medicine leaders question good works in family medicine journals, it is time to raise a question about family medicine leaders and where family medicine dollars have been invested, other than in more family physicians (exactly what the nation needs for the next 30 years and more).

The Squeeze Play that Fails - Medicare is supposed to be a design that facilitates health care for the elderly. But the overall US design for health care insures that most of the elderly fail in access to basic health services.

Does Primary Care Experience Matter? Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature. One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices.

Still the Health Access Solution for Most Americans - Health access workforce solutions have always been and will always be the broadest scope generalists. Other workforce even with slightly greater specialization or limitation in age range or limitation in scope will remain limited in distribution. Other sources fail to remain in primary care and fail to distribute outside of locations where workforce is already saturated at top concentrations

Myth for the Cure: Essential for Disease Focus - Do no harm is difficult when the focus is eliminating disease. Nearly all of the disease-focused treatments cause harm and some cause substantial harm to people, to groups, or to entire nations. Harm can be direct to patients or indirect within health care. At ever more spent on health care, disease focus can wreck and entire nation and impact the world.

How the Disease Focused Abuse Health Access - At number 6 on the listing was the Clinton Health Access Initiative. I thought perhaps this might be a good source to contact. But the site explained that it is really about access to drugs and treatments.

Deifying Disease By Design - In a recent video released to the world, top experts have revealed their agenda for making progress with regard to disease focus. Local and state have not been enough. National is not enough. They want the entire world to focus on just a few, or one.

Cost of Training per Unit of Primary Care Delivery – At about $30,000 - $40,000 per Standard Primary Care Year of primary care delivery over a career, family medicine stands on top. Pediatric and physician assistant graduates have twice this cost. Nurse practitioners are moving to three times greater and internal medicine has a 5 times greater cost of training per unit of primary care delivery. Sources that do not remain in family practice and that do not result in family practice have the highest cost of training per unit of primary care delivered where the nation needs primary care most - in zip codes with 200 million Americans (65%).

Who Really Benefits? Claims of benefit to health access have been pointed out as promotions and promises, impractical, deceptive, or insignificant. Over and over the design deficits do not allow health access recovery. To understand primary care failure, one must understand who benefits from designs that fail for primary care result.

Can We Have Our Billions Back Please? Why would an advocate for basic health access keep hammering on disease focus? The answer is simple. For decades we have more different researchers and subspecialists creating more reasons to spend dollars anywhere but on basic health care services, especially services needed by over half of Americans.

Exploring the Health Consequencs of Disease Focus - The past 30 years have been cost cutting designs in the US. Past leaders have shaped health care focused ever more on disease, subspecialty, and academic interests. A previous Congress reacted with an at

Piddle Twiddle and Resolve Not One Damn Thing Do They Solve - In the play 1776 there are any number of wonderful allusions to Congress then and now. Former President Nixon thought so too. He requested and received an edited version regarding Cool Cool Considerate Men as he felt they too closely resembled conservatives of the time. Cool Considerate (calm, calculating, conservative?) Men are still very evident, but do they still lead well or wisely or with sufficient understanding of the daily lives of most Americans?

Addressing the Primary Care Crisis – The right questions must be asked and the answers must be specific to the needs of most Americans or the US will have another 30 years of primary care failure by design.

Part I: Limitations of Awareness – Those shaping the designs have low awareness of the basic needs of most Americans. National plans and planners that fail in awareness regarding most Americans fail America.

Lets Take a Stand for Most Americans Instead of Against – This is a response for most Americans, unlike the popular emails that are really not for most Americans. Outgoing director of Medicare and Medicaid Donald Berwick indicated much the same.

Standard Primary Care Year Estimates – Only primary care training that results in graduates that enter and stay in primary care and have the longest careers and have the most activity as direct care clinicians and have the top volume delivery and remain where needed at highest levels can help with primary care recovery. Lowest retention, shortest career, lowest volume, and fewest active requires far too many graduates to even maintain primary care levels, much less address primary care for 200 million left behind.

Rural Pipelines Versus Long Term Obligations – Rural pipelines in the US are a failure and have been for the last 30 years because of US health policy. At each of 7 or more segments in the pipeline from before admission to retirement, US health policy drives workforce away from rural locations, primary care needed in rural areas, and underserved areas common to rural settings. While academic associated entities would like greater state and federal and foundation spending at each level of the pipeline, there are solutions that are SMART and have been for 40 years.

Uncovering Cover Ups Involving the Front Lines – A British report in WWII indicated the horrific failures of the early years regarding bombing runs. The US needs an objective approach to deal with the failed front lines of primary care.

To Be SMART or Not to Have Health Access – Specific, Measurable, Achievable, Realistic, and Timely is what is required to recover health access. Generic, primary care training not primary care in result, assumption, promotion, delay, and other priorities higher than primary care (even in primary care training) are not going to recover health access.

Rural Workforce 2000 to 2010 - Uncle Sam says "I want you" to serve in rural locations. Uncle Sam's design says "I don't want you" to serve in rural locations where lowest health spending goes to lower population density, lower income density, lower employment density, lower workforce density locations that are most dependent upon lowest paid primary care and lowest paid general careers. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans. Millions hungry for health care cannot be fed by small change programs.

Critique of Commonwealth Fund Report on Ensuring Equity - A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access or the great possibilities of innovation and reorganization or technology, to have primary care or health access someone must be there to deliver the care.

Revisiting Physician Distribution by Concentration – Methods that categorize workforce by concentrations of physicians are a much better measure of too much or too little. Too much is 1% of the land area with 50% of physicians and just 10% of the US population. Too little is 30,000 zip codes with 200 million Americans (65%) left behind with lower or lowest workforce concentrations and primary care concentrations. If you understand concentrations of workforce, you can understand concentrations of health spending and how few benefit despite the claims by health professional associations that health spending is good for the nation.

Rearranging the Deck Chairs: Death Displacement– A focus on deaths prevented or lives saved is only possible with distorted thinking. We all will die. Our overall quality of life is about how our lives are impacted by our efforts and by our national desig

Choices for Higher Priority Areas That Could Make a Difference – Nations must make their best choices to put nations in a better position. The United States makes decisions that impact future generations in ways that have placed the United States in a position that has deteriorated steadily. We have also failed to learn that misguided attempts to rescue can actually make matters worse even more rapidly.

It has not been a good year for primary care or health access after 15 years of rapid decline and after 30 years of decline with only a few 1990s years of interruption.

Blogs indicate that primary care can be recovered and should be recovered, but it will take 30 consistent years of improvement for actual recovery. We have to have at least one to begin.

Accelerating Cycles of Primary Care Decline

2011-12-05T08:27:00.001-07:00

Disruptive innovation was created as an attractive term, but innovation that is disruptive fits primary care best at the present time in the United States. Innovation is actually distracting and distorting primary care away from solutions. The last three innovative primary care training forms (NP, PA, MPD) are 60 – 75% not primary care in contributions over a career. This is a contrast with 60 – 75% primary care at their beginnings decades ago. Such rapid declines are not the result of a single cause and effect. Multiple factors accelerate the cycles of primary care decline.

Some of these changes actually accelerate primary care decline on their own. Others work to decrease primary care workforce capacity and cascade to result in another downward cycle.

This is an outline page indicating the first few factors involved in primary care decline by design.

The United States Design includes

Ever Higher Costs of Primary Care Delivery - force cuts in personnel, less support, less volume, repeat cycle of decline - a 12% annual cost increase for 6 years doubles the cost of delivering primary care. Coupled with a freeze in primary care fees or a minimal increase, the cost of delivering primary care will continue to kill off primary care delivery and workforce.
More Primary Care Cost Types - More types of personnel or equipment often not specific to primary care delivery, less budget remaining for primary care specific personnel, cuts, declines in primary care fees and delivery, repeat cycle of decline
Flexible Primary Care Training + US Policy + Voluntary Choice - This is a policy driven equation for the United States that by its very nature has resulted in ever less primary care per graduate arising from primary care graduates. Tracking class years over time the US primary care per graduate level has declined to one-third the 1980 graduate level or from 18 SPCYrs down to 7 for recent graduates. Graphic Listed
Dysfunctional Primary Care Training – drives residents and medical students away from primary care (Keirns, Academic Medicine) - situations played out right in front of medical students are not a good idea for primary care career selection or retention
Hamstrung Primary Care Workforce – Top priorities of insurance and government have been cost cutting for 30 years with worsening in the past 15 and worsening in most recent years. The primary care nurse is a primary example of a primary care professional that cannot participate as actively in direct patient care delivery due to the design. The design forces nurses to contact insurance companies just to get needed prescriptions, referrals, hospitalizations, goods, and services. Also they must collect information needed for care from our fragmented system. New jobs and duties such as risk management also are about cost cutting, not care delivery. What helps fail primary care is primary care professionals that are forced to do other activities other than delivering primary care - by the US designs that have been cost cutting in nature for 30 years. SMART designs are specific to enhance primary care delivery - not defeat it before it can arise.
Training of Primary Care Is Not Primary Care Specific – Training has never been SMART or primary care specific for RN, MD, DO, NP, and PA. For 100 years the focus has moved ever more hospital and academic and subspecialty. The models that are different and are primary care specific are few and small in number, in numbers of graduates, and in national impact. The training in any training program will be shaped by the outcomes of the graduates. With fewer entering primary care and even fewer remaining in primary care, the training changes to fit graduate needs. If this is not so, the program dies for lack of graduates as graduates are interested in preparing for the jobs that exist and that allow them to do well. When programs send a minority in primary care and those attracted desire non-primary care careers, the program composition will change to fit non-primary care. Only a permanent primary care source can withstand this. Of course this is why family medicine has been a lower priority choice - due to its permanent primary care outcomes.

This is just a beginning of cycles of decline. Anyone trying to tell you that the US has more primary care or that primary care is doing well

- is selling something.

Cost of Training per Unit of Primary Care Delivery

Policy Protected Primary Care is Permanent - Family Medicine

Why Do Primary Care Myths and Misinformations Persist?

Fifty Years of Failed Primary Care Workforce Innovation

To Follow the Money, Follow the Workforce

Failing Primary Care Explained By Policy Failure

Three Dimensions of Non-Primary Care Increase vs Zero Growth in Primary Care

The Black Hole of US Subspecialization

2011-12-01T07:07:00.001-07:00

Subspecialization and Academization and Hospitalization and Centralization:

Spells Workforce Concentration and Lack of Access for Most Americans

Various health corporations and health professional associations want government and everyone else to stay away from regulating health care. The reason is clear. The design is near perfect for academic, subspecialty, and hospital interests. The corporations and associations and their stockholders and members stand to gain from more and more health spending diverted to non-primary care areas. Health insurance companies benefit from ever greater spending. More non-primary care workforce results in even more non-primary care spending and more non-primary care workforce. Total health spending captures more and more of the Gross Domestic Product. More invest in health care and share in the profits, resulting in subtractions from health care delivery.

Divisions of the United States into rich and poor are facilitated by the health design that sends so much to so few for so little benefit. Inefficient government at all levels from loss of government personnel (due to health care cost increases), inefficient business (current and past health care costs cripple), and cuts of teachers by school districts as well as poor support for basic education and basic health access are just a few consequences attributable to the US designers.

Subspecialization, Academization, Hospitalization, and Centralization are a means to an end - bad for US and good for a few. This of course is what more and more are realizing as the real United States design that impacts not only health but finances, government bailouts, and more.

The Conversion of NP and PA By Subspecialization and Academization

Nurse practitioner and physician assistant associations are also dominated by academic and subspecialty interests. More dollars per hour results in more found in non-primary care and also more ability to pay for dues, attend meetings, and participate in leadership positions. The health access workforce is busy delivering health access, has fewer other than office direct clinician care, and does not have the employer, benefit, and salary support to allow association participation. This is the same as has been found in physician associations for decades. How many more interviews devoted to the importance of primary care will be given by subspecialty nurse practitioners, even in states like Alaska that need pure strains of permanent family practice NP and PA workforce?

Nurse practitioner associations have strong connections to health insurance foundations such as United Health Care. They have testified together (for Congress) and have even implicated the best health access sources to be impaired. Those promoting the primary care source with lowest primary care delivery over a career have chosen to spread misinformation about the best source. Nurse practitioner associations, health insurance corporations, and non-for profit foundations are not the only ones who are pointing fingers at the international medical graduate component of family medicine. The NP and United testimony was a prime example of half truth and innuendo. The truth is that international graduate non-citizens choosing family medicine are number 3 or third highest as a primary care source and one of only 3 permanent sources.

The family physician from US origins delivers 25 Standard Primary Care Years as compared to about 4 for a nurse practitioner graduate.
The Caribbean graduate of US origin also delivers about 25 SPCYrs as a family physician.
The non-citizen international graduate delivers about 20 – 22 Standard Primary Care Years during a career.

It takes 6 NP grads to equal the primary care delivery of a US MD or DO school family physician or one from a Caribbean school. It takes 5 NP graduates to reach the primary care delivery of a non-citizen family physician.

It is not quite deception as few understand the limitations of fewest years, least activity, low primary care retention, and lower volume.

Doctoral Degrees Dictate Decline

In the controversy about the NP doctoral movement, the really important information about workforce capacity has been lost. While various people argue quality or academic points, the facts about health care delivery during a career are lost. After 2015 it will take 10% more NP graduates to accomplish the same workforce as doctoral requirements will kill off two more years of a career (8 – 10% loss). The change will result in fewer in primary care, fewer active as direct care clinicians, and fewer serving where needed.

Readers can judge for themselves why a source that is in last place in primary care delivery should compare themselves with the number 1, number 2, and number 3 best sources of US primary care when they are number 8 and only the smaller family practice component does the real primary care and health access work of NP.

Academization, Subspecialization, Hospitalization, and Centralization Marginalize Health Access

Global directions are clear over the last century, the last 40 years, and especially the last 15. Various foundations continue to promote NP and PA workforce – in some ways contrary to their health access missions. Foundations also continue to promote innovation and reorganization when the major need for the next 20 years will remain enough entering primary care and remaining in primary care – something that flexible primary care sources cannot supply. When you present solutions that cannot work because of failure to address primary care workforce, you are clearly delaying health access recovery.

Policy Impact Forces Replicating the Subspecialty Dominant Design

Physician subspecialization dominated medicine for decades with more new specialties and more in each new specialty. Nurse practitioners and physician assistants have followed suit in the past 20 years. With the demise of managed care in the 1990s, the subspecialty avalanche accelerated. NP and PA graduates keep finding their way to a wider range of specialties and more are entering these new specialties.

NP and PA academization also continues to longer and more formal and more expensive training. This is exactly the design followed by physicians over the last 50 years as well.

The NP and PA subspecialty workforce is ideal for keeping subspecialty offices and office equipment going longer with more services and with more lab and other revenue generations.

All the above is evidence that the real designers of US health care involve academic institutions, health professional associations, health insurance corporations, those who sell medical equipment and technology, Wall Street and other investors, and representatives of these groups serving in foundations and government.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Why Do Primary Care Myths and Misinformations Persist?

2011-11-30T17:23:00.000-07:00

As noted previously, all primary care RN, MD, DO, NP, and PA are greatly needed. But the probability of actually being in primary care over a career of contribution is small for new graduates in RN (10%), MD (20%), DO (30%), NP (25%), and PA (25%). Steady departures from primary care are seen for all except the small part of MD and DO that is family physicians. Family physicians are the only remaining primary care result that is relatively permanent but are only 7 – 8% of US MD and Non-Citizen IMG choose FM along with about 16 – 18% of DO and 25% of Caribbean US Origin.

The NP and PA primary care effort has stagnated because fewer have remained in primary care. The case can be made that unless more health spending is injected into primary care, the NP, PA, IM, and PD contributions will actually shrink. Family medicine is stagnated by 30 years of no increase in annual graduates from the 1980 level of 3000 per year.

One would think that common sense observations would reveal the myth of NP or PA or any flexible workforce increasing in primary care delivery - given fixed low primary care spending with double digit increases in the cost of delivering primary care.

But common sense appears to be the one quality lacking in the US health care design. Only a permanent primary care source by training (FM) or by obligation or by restriction can result in primary care graduates actually delivering the primary care indicated by graduation from a primary care program. NP and PA graduates are not permanent primary care by training or by obligation and they are no longer restricted to primary care or underserved locations.

Generic expansions fail for MD, DO, NP, and PA with such low and falling proportions of primary care in the years after graduation. Questions should be raised.

Why Does the United States Persist in Myths such as

Midlevel Primary Care as solutions for primary care with fewer and fewer remaining in primary care over time.
Generic expansions as solutions for primary care - expansions that cannot work because of US policy for 30 years (same for NP, PA, MD, and DO).
Innovation and reorganization as solutions for primary care - innovations that also cannot work because of policy for 30 years.
Generic expansions of internal medicine as solutions for primary care where it takes 8 graduates to result in 1 FTE of primary care.
Any expansion of pediatrics - Pediatric expansions for 15 years have demonstrated the futility of expansion for primary care and cannot increase primary care delivery. It would take two major changes. Graduates would have to decide to change their location preferences away from saturated locations and the US would need to inject more spending into primary care for children above the rapidly increasing cost of delivering primary care (not cuts or freezes in reimbursement).

Given US policies bad since the 1980s and worsening, only specific designs (SMART) work such as family physician specific or long term obligations or restrictive legislation forcing permanent primary care. These are the only Specific, Measurable, Achievable, Realistic, and Timely interventions given the fact that US policies drive all but permanent sources away from primary care, especially in the last 15 class years.

Why Do Myths Persist?

An obvious reason is that major players have much to gain. Perhaps it has to do with substantial gains for those that benefit by the US policy design. After capturing what will be 80% of physicians, the designers benefit with over 70% of NP and PA graduates as non-primary care workforce. NP and PA leaders benefit by being able to claim primary care.

Those benefitting can be tracked by substantial movements to teaching hospitals, academic institutions, hospitals, surgical workforce, emergency rooms, and the largest subspecialty practices. Flexible workforce such as NP and PA are valuable in a variety of specialty, hospital, and academic roles individually or together at the same time.

Those in the US that do not understand the difference between flexible or temporary primary care and permanent career choices or first career choices compared to an entire career contribution help contribute to the problem as seen in government and foundation reports, media postings, major journals, and statements of various deans and workforce experts.

Perhaps the midlevel emphasis is also a reaction to physician domination. Association with male domination may bother females and there is the feminist movement to consider. Government personnel, those in non-physician health professions, and a variety of lobbyists (when not working for medicine) may have an axe to grind. Physician leaders, associations, and lobbyists do have a way of getting other health professionals and their associations stirred up. Others believe that their own type of health care is superior. A number of alliances exist with for-profit corporations and others who may help the cause of advanced nursing. Some have consequences.

Poor Understanding of the Mechanisms of Midlevel Departure from Basic Health Access

A common problem is that few understand how much benefit there is for NP and PA that depart primary care and basic health access settings. The benefits accrue to the individuals converting, to the employers that facilitate conversion, and to the hospital and teaching hospital and subspecialty physicians in the largest group practices. Movement away from primary care and from the more underserved locations is assured with lowest health spending in multiple dimensions. Movement is assured toward the highest concentrations of workforce joining others that already receive the most lines of revenue and the highest reimbursement in each line.

NP and PA Benefit - Basically all health personnel receive higher to highest salaries when departing primary care. Nurses, physician assistants and nurse practitioners in particular are documented as paid the least in school health, primary care, and community health arenas. The most experienced follow the designs to hospital and subspecialty settings. This is where health spending is the highest and where all lines of revenue are found with the highest reimbursement in each line. This is set in place by the academic, hospital, and subspecialty designers. Primary care appears increasingly to be a job for those new, those part time, and those transitioning. The best opportunities are subspecialty and hospital where NP and PA graduates can enjoy significant flexibility, autonomy, variety, and financial reward. This contrasts with primary care where working harder matters little as there is less funding available even if those in charge of primary care clinics wanted to reward their major contributors. Pay increases usually do not cover the rising cost of health insurance and other deductions from paychecks.

Employer Benefit - Major health care employers shape designs for health workforce and health spending. Health care employers receive greater revenue from subspecialty PA and NP services and lesser revenue from primary care efforts. Flexible workforce can fit a number of situations from the most office based to intensive care settings and from multiple physicians and other team members to few.

Subspecialist Benefit - Subspecialty physician practices receive more revenue by adding NP and PA subspecialists. The subspecialty physicians in the practice do not lose revenue when adding NP or PA professionals. When a subspecialty physician is added to the group, the other established subspecialists decline in revenue generation. In other words NP and PA provide services that complement and do not compete. Guess which type of addition is likely to be preferred? (Cardiology example from The Lewin Group). The study indicated that the largest groups benefited the most – those that are most likely to be in the top concentrations of workforce. This sends NP and PA not only away from primary care but also to the top concentration locations.

Subspecialty physicians can generate more revenue with NP and PA additions for other reasons. The NP or PA at the clinic can see patients while the subspecialists are making more money doing more procedures and more expensive procedures. Hospital NPs and PAs can do much of the rounding, also preserving physician time for high revenue generation areas.

NP and PA expansions can “throw out a net” to gather ever more referrals and ever more procedures sent to colleague subspecialty physicians. Each contribution generates more revenue more than one way. Such a net can also suppress competing practices and corner the market – an increasingly successful tactic in health care used by health care insurers, large systems, academic institutions, and practically all except those attempting to deliver basic health access services. Those backlogged with more patients to see than subspecialists can get things updated with a PA or NP professional – and quicker to be seen can result in difficulties for others who remain backlogged. This is an important consideration when there is so much demand for subspecialty workforce (even though some of this is too much done for too little result and also more is due to the decline of primary care and the decline of managed care).

While it appears that there are benefits, the NP and PA changes over the years include less and less primary care and fewer remaining where needed. Only the family practice employed NP or PA can be demonstrated to consistently serve the 65% of the population in 30,000 zip codes in need of primary care and the family practice employed proportion has declined the most over the past 30 years.

The next post is about The Black Hole of United States Subspecialization that also has impacted MD, DO, NP, and PA workforce and that effectively prevents recovery of primary care and recovery of the US economy.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Disclaimer: Dedicated primary care MD, DO, NP, PA, and RN professionals are quite remarkable. All that separates them from non-primary care careers is their dedication, their commitment, and their desire to serve. Every other influence via policy and training sends them away from primary care. Those departing primary care for non-primary care are also not to blame as this is what the designs favor. Those who are dedicated and those who are herded away from primary care and toward existing top concentrations of workforce deserve better designs, better representation, and an accurate depiction of the United States health workforce situation. When only a few shape the designs and decisions, most health professionals and most Americans are left out by design.

Disease Focused Disorders

2011-11-28T14:23:00.000-07:00

A study just published in NEJM indicates some of the consequences of specific heart disease and diabetes treatments.

“The study, by researchers from the US Centers for Disease Control and Prevention (CDC), singles out 4 drugs and drug classes — warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Alone or together, they account for 67% of emergency ADE hospitalizations of adults 65 years and older. Warfarin was implicated in 33%, lead author Daniel Budnitz, MD, MPH, director of the CDC's Medication Safety Program, and coauthors write.”

Via Medscape Article at http://www.nejm.org/doi/full/10.1056/NEJMsa1103053#figure=t1

Hospital interventions will not work well to address these situations.

Physician interventions have not worked well.

Patient interventions are not likely to work mainly because we often understand so little about patients and even fail to include patient factors in most such studies. Health literacy rates are lower in the elderly, caregivers are important factors, living conditions vary and change because of hospitalizations, etc. Also we are finding out that readmissions to hospitals can greatly be reduced when someone actually visits the home of the patient - what a novel and innovative idea only centuries old.

If the focus continues to be stamping out disease or evidence of disease, people in the United States and worldwide (Myth for the Cure) will have even more problems with warfarin, oral antiplatelet medications, insulins, and oral hypoglycemic agents. Chemotherapy reactions, infections resulting from treatments, and reactions resulting from antibiotics used in treatment are also problem areas.

Note that “High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations.” Those inside of hospitals making up the definitions of high risk can be off target.

This is only the tip of the iceberg regarding too much done for too few with too little result. Consequences such as these insure even more done for much greater cost and ever greater potential for adverse outcomes. This also results in less and less remaining for important basic health care services that keep getting bypassed in funding priorities – so not surprisingly one factor that could improve the outcomes is compromised.

The outlook for 2012 is a worsening of primary care, particularly for the elderly who need 2 to 3 more times primary care due to age. Matters will be even worse for those who need the most care. Good luck finding primary care for Medicare patients that have not established care somewhere. At some point the lawyer advertisements will note “Did your hospital send you home too soon? Did your hospital physician send you home on Coumadin, insulin, Plavix, or metformin? Call 555-SUEBYME” and add to the Four Diseases problem of the US - especially greed. Obviously the lawsuit interventions have also not done much to improve care despite trial lawyer claims.

What will work?

Doctors must be more aware of patients, patient situations, and patient limitations before training, during training, and after training. If they are not aware before training, they are not likely to improve after training. They will do too much for patients that will consequently have more adverse events.

Physicians who are more likely to know their patients are may also be less aggressive in treatment – a policy that is good for some patients and not as good for some, but is less likely to result in emergency hospitalizations and adverse events. Being ridiculed or rated lower in quality is a consequence of being aware of your patients. But the best care for patients is about the patient and situation rather than being guideline perfect.

Treating patients all the same with the same guidelines appears to be contraindicated for best results.

This is why guidelines regarding aspirin, beta blockers, anticoagulants, and measures of diabetes outcomes must be processed by the primary care nurses, physicians, and practitioners that know the patients and their situations rather than prosecuted as in Pay for Performance, system requirements, other insurance company measures, or other guidelines.

The One Million Hearts Campaign going on now champions more done despite not enough understanding, awareness, and primary care workforce. How many more adverse events will arise?

Note that patients are often placed on aspirin, beta blockers, anticoagulants, hypertensive medications, heart medications, and diabetes medications during a hospitalization BUT THOSE WHO BEGAN THE MEDICATIONS ARE OFTEN NO LONGER PART OF THE CARE.

Insurance companies force the primary care doctors and nurses to pick up the responsibility even though the patient was sent out before stabilization, before the side effects were known, and before adequate follow up was assured – a nice result of the US hospital and hospitalist design and the US design that defeats enough primary care workforce and overloads primary care nurses. By shifting the workload and responsibility, this was another indication of irresponsibility in health care design and implementation.

“With an estimated 21,010 hospitalizations for warfarin-related hemorrhages, the cost for this one type of adverse drug event is probably hundreds of millions of dollars annually.24” Actually a better estimate would be over 1 billion to as much as 5 billion. These are not cheap hospitalizations when brains, lungs, and other organs are involved. Low cost hemorrhages do not get hospitalized. These costs do not include rehab of brains, lungs, joints, etc. or costs to caregivers and the nation in productivity.

Consider the cost of 250,000 annual ER visits ranging from $500 – 2000 per visit then there are urgent care, office visits, hospitalizations, placements in long term care, and deaths.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

The consistent theme is too much done for too few with too little result. Consequences insure even more done for much greater cost with ever greater potential for adverse outcomes. Basic health care services are also compromised by this design that sends ever more dollars to more different diseases resulting in few remaining to collaborate with patients, families, caregivers, specialists, and health care teams to optimize care and minimize consequences.

The Squeeze Play That Fails

How the Disease Focused Abuse Health Access

Deifying Disease By Design

Can We Have Our Billions Back Please?

Exploring the Health Consequences of Disease Focus...

What Is Killing US Is Not Four Deadly Diseases

This Will Be Brief As Will Primary Care

Fifty Years of Failed Primary Care Workforce Innovation

2011-11-28T00:26:00.000-07:00

For fifty years nurse practitioners and physician assistants have been promoted as primary care solutions, but the primary care result has been negated by a movement from 65% primary care to over 65% non-primary care.

The promises of the past have not been realized in the primary care of today. Declines across fifteen class years of recent graduates indicate even less primary care delivery per graduate in the future.

NP and PA graduates were few prior to 1980. Since 1980 the NP and PA annual graduates have doubled in number each 6 to 12 years. After 50 years of development, after 50 years of promises and after 30 years of massive expansion, where is the health access workforce?

Such writing is never fun. This is not the way to win friends and influence people. Sadly the United States has demonstrated an impressive ability to continue to promote solutions that do not work, innovations that fail, and reorganizations that delay primary care recovery. Perhaps by pointing out innovations that have failed, more will begin to objectively review recent innovations and reorganizations - and the US policy reasons why they all fail.

Why do health professional associations, nursing workforce leaders, physician associations, government reports (all the way to the highest levels such as the Institutes of Medicine), entire issues of journals, and various foundations persist in the myth?

Why continue to promote NP and PA graduates as primary care solutions?

Any flexible workforce that can go either direction cannot be called a primary care solution. Too little primary care spending and much more health spending for non-primary care assures the final non-primary care result.

It is time to call the midlevel effort in the United States a failure for basic health access result - a most commonly stated reason for the creation of NP and PA.

This is no disrespect to dedicated NP and PA graduates that remain in primary care. The US result is entirely the fault of US health policy. Versatile NP and PA graduates have found great favor in non-primary care workforce.

How much smaller does the result need to be after decades of diminishing return on investment? The United States can expect less than 25% of the recent NP and PA graduating classes to serve in primary care during their careers with even lower proportions serving in primary care where needed.

The US designs insure NP and PA primary care to be the least experienced in primary care delivery. Departures from primary care during training, at graduation, and each year after graduation assure least experience and least years in primary care from NP and PA graduates. Lowest activity levels, one or more year breaks away from any health care delivery, lowest volume, and increased pay for movements to different primary care practices assure least experience and least continuity.

Why is this evidence ignored decade after decade?

This is not about the quality of care, which is more about the patient than the provider for well over half of American patients. This is about experienced primary care RN, NP, PA, MD, and DO workforce as well as health care team members. When those in primary care benefit from departing continuity practices (4% salary gain) and benefit even more (10%) by departing primary care, lower primary care experience is the result.

Because of US policies, it is simply not possible to extract much primary care out of midlevel graduates or any flexible workforce source that can go both ways – to primary care or to non-primary care. Even during the 1990s, physician assistants were tracked by Larsen and Hart as departing steadily over a 10 year period during arguably the most favorable primary care policy in the past 30 years.

The evidence is clear. NP and PA workforce in the United States has followed US policy designs from basic health access beginnings to become non-primary care workforce most commonly found in zip codes with the top concentrations of physicians in the United States. The pathways for NP, PA, MD, and DO workforce indicate steady departures from basic health access for the past 50 class years of graduates and across the years after graduation from training.

The departures include fewer and fewer entering and remaining in primary care as well as fewer and fewer entering and remaining in family practice – the source most important for 200 million people and the source most commonly found where health spending is lowest by United States designs.

Generic Expansions Are Not Smart

SMART Primary Care : Family Practice Contributions...

Still the Health Access Solution for Most American...

To Follow the Money, Follow the Workforce

Failing Primary Care Explained By Policy Failure

Cost of Training per Unit of Primary Care Delivery

2011-11-27T01:26:00.000-07:00

The cost of primary care training can be compared to primary care delivery over a career. Additional calculations can integrate the proportions of graduates found in certain locations to generate the contributions in rural primary care, underserved primary care, and primary care delivery outside of concentrations (in 30,000 zip codes with 65% of the US population left behind). The cost of training per unit of primary care is much less for family medicine. Other sources that yield less primary care per graduate are inefficient primary care sources.

Real Measures of Efficient and Effective Primary Care

The United States does not require more primary care in 3400 zip codes where primary care is saturated. The United States must have primary care that has demonstrated the ability to locate outside of concentrations. This must be kept in mind. Internal medicine, adult NP, pediatricians, and pediatric NP sources all result in lesser primary care delivery and lower proportions compared to the best primary care sources.

The categories for NP and PA divided into family practice or not family practice as the family practice component contributes the lion’s share of the midlevel primary care, rural, and underserved contributions. The physician figures involve those attending United States or Caribbean medical schools. Graduate medical education does deliver some primary care and does contribute to revenue generation and these items were not included.

Cost of Training Relative to Primary Care Delivery over a Career

	Cost of Training	Cost per SPCYr	Cost per Rural SPCYr	Cost per Under-served SPCYr	Cost per Outside SPCYr
NP not FNP	$380,000	$215,420	$2,154,195	$1,795,163	$615,484
FNP Trained	$380,000	$55,850	$199,463	$372,330	$101,545
PA not FP Start	$440,000	$158,025	$1,580,247	$1,316,872	$451,499
PA w/FP Start	$440,000	$37,037	$123,457	$205,761	$67,340
FM Trained	$950,000	$37,661	$171,185	$251,072	$71,058
IM Trained	$950,000	$280,653	$2,806,532	$3,118,369	$1,002,333
PD Trained	$950,000	$94,756	$1,184,452	$1,052,847	$338,415
MPD Trained	$1,050,000	$97,957	$612,228	$816,304	$244,891

When the focus is primary care delivery from primary care training, substantially more graduates are required when sources remain in primary care at low levels.

Recent cost of training figures are listed at the table at the end of the blog and include cost of living and cost of all higher education and training (post high school). These are also figures that are appearing optimistic due to ever higher cost of higher education and even more problems that will drive primary care to lower retention and less primary care delivered over a career. Family medicine would also decline but not to the same degree as the more flexible sources.

Only family medicine is efficient for the purpose of primary care delivery. If a few family medicine leaders succeed in adding a year to FM training, this would decrease career length by 4% and would add about $120,000 to training cost resulting in a $5000 increase to $43,000 per SPCYr. More importantly millions of additional Americans would be left behind with a smaller FM workforce.

Pediatric expansions are unable to increase the primary care result. More graduates over the past 10 years have merely replaced those departing. There simply are not the openings for PD primary care where PD primary care is willing to locate. Internal medicine appears to be much the same with more moving away from primary care. For all practical purposes, any expansions for the purpose of primary care physician production must be specific to family medicine. Only permanent primary care obligations could improve flexible IM, PD, MPD, NP, and PA results.

The nurse practitioner training cost will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed.

Family nurse practitioners are 50% of NP graduates, but only 50% of FNP graduates remain in family practice employment.

There is a better decision for nursing leaders who desire to be truthful and maintain their assertion of primary care delivery from nurse practitioners. The appropriate move is to permanent primary care family practice rather than permanent doctorates. Without that move, nurse practitioner claims of primary care contributions must be qualified to only a small portion of NP graduates.

Currently nursing workforce leaders and various foundations that promote NP training as solutions for primary care are greatly exaggerating the benefits and are minimizing the cost.

Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.

The Basic Calculations of the Standard Primary Care Year

	% Primary Care	Years in Career	% Remain Active	% Volume	SPC Years Per Grad
NP not FNP	15%	24	70%	70%	1.76
FNP Trained	54%	24	70%	75%	6.8
PA not FP Start	15%	33	75%	75%	2.78
PA with FP Start	60%	33	75%	80%	11.88
FM Trained	91%	33	84%	100%	25.23
IM Trained	15%	32	82%	86%	3.38
PD Trained	39%	33	82%	95%	10.03
MPD Trained	43%	32	82%	95%	10.72

FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care.

Distribution By Location Type

	Rural %	Under-served %	Outside %
NP not FNP	10%	12%	35%
FNP Trained	28%	15%	55%
PA not FP Start	10%	12%	35%
PA with FP Start	30%	18%	55%
FM Trained	22%	15%	53%
IM Trained	10%	9%	28%
PD Trained	8%	9%	28%
MPD Trained	16%	12%	40%

Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center.

Cost of Training Considerations

	College	Health Prof	Graduate	Cost of Living
NP not FNP	$30,000	$100,000	$70,000	$180,000
FNP Trained	$30,000	$100,000	$70,000	$180,000
PA not FP Start	$120,000	$125,000		$195,000
PA with FP Start	$120,000	$125,000		$195,000
FM Trained	$120,000	$200,000	$300,000	$330,000
IM Trained	$120,000	$200,000	$300,000	$330,000
PD Trained	$120,000	$200,000	$300,000	$330,000
MPD Trained	$120,000	$200,000	$400,000	$330,000

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!.

Generic Expansions Are Not Smart

SMART Primary Care : Family Practice Contributions...

Still the Health Access Solution for Most American...

Revisiting Physician Distribution by Concentration...

Rural Primary Care: Stark Realities

To Follow the Money, Follow the Workforce

Why are 2008 Government Projections of Primary Care Workforce in Error?

Standard Primary Care Year Estimates

Failing Primary Care Explained By Policy Failure

Uncovering Cover Ups Involving the Front Lines

2011-11-27T01:01:00.001-07:00

Why Do Bad Policies and Practices Continue or ....

Find New Primary Care Leaders that Represent Primary Care Truthfully

At the start of World War II, the RAF Bomber Command effort was failing. This was not what air command indicated. The British public at large was kept in the dark especially when German bombs were raining down and killing British citizens. This could have continued for years.

Eventually the truth had to be told. More British Airmen were dying than Germans on the ground. The Butt Report indicated the sobering truth. The most important industrial targets such as the Ruhr were missed 9 out of 10 times. Over Germany as a whole the rate was 1 in 4 on target. Flying at night often in bad weather without reliable guidance systems and under attack, the methods of the time simply failed. Over in the US the vaunted Norden Bombsight was also great in theory, but woeful in actual battle performance. Air crews were sacrificed with 5 - 10% lost each mission and their efforts were inconsequential.

Once there was understanding of the errors and assumptions, the way was cleared for real improvements in performance - by design changes.

The reality of primary care in the United States is also quite different compared to government indications. Primary care is widely recognized as a neglected area, even by non-primary care physicians. All seem to understand the difficulty of choosing and remaining in primary care, except those who have vested interests. Looking like primary care is important even when primary care yield is actually lower or lowest.

Primary care needs a Butt Report. Primary care needs less theory and more emphasis on practice. Numbers in secondary databases and association reports and government reports do not fit with the reality of shrinking primary care delivery capacity. The war for health access is won by enough front line personnel and experienced front line personnel. The war is not won by pretend primary care, theoretical innovations, or deceptive reorganizations.

No war is won with steadily fewer front line troops remaining leaving rookies and the least experienced. This is the legacy of poor support for primary care resulting in few committing to permanent primary care and ever more departing after graduation. Only sources permanent in primary care result have the most experience and the best primary care delivery result.

A Butt report regarding primary care would emphasize entire careers of workforce contribution rather than the first career and location choices. A proper report would include steady losses from primary care during training, at graduation, and each year after graduation. Studies indicate that dysfunctional primary care training drives medical students and residents away from primary care (Keirns, Academic Medicine). Indeed US policy has been toxic to primary care since 1980. Only from 1965 - 1980 has the US actually increased primary care and the policies that accomplished these were changed over 30 years ago.

A decent report would reveal the truth of one out of three primary care graduates found serving in primary care workforce in the years after graduation with only one out of six sources reliable in primary care result. The reality of failure in primary care delivery from five out of six sources is too important to cover up.

Such a report would not allow those using the name of primary care for training that resulted in a minority of graduates found in primary care. This training is properly termed non-primary care training.

Such a report would recommend that funding for primary care training be specific for primary care result, especially in a nation desperate for primary care. Such a primary care report would question the ability of flexible primary care sources to deliver primary care with so few total graduates entering primary care and even fewer remaining in primary care over the years after graduation – a guarantee of workforce too small and least experienced. Does Primary Care Experience Matter? With short term primary care stays, one could argue that the training was largely wasted with little chance for continuity, little chance to understand patients or populations, and little chance to become a part of the health care team.

Such a report would clearly indicate failed US health policy regarding primary care. Such a report years ago would have led to redesigns of training and support long before the major recessions and cuts of the current time period. Delays in this understanding make it most difficult for the necessary redesign with substantially more spend on primary care – during a time when any increased expenditures seems unlikely.

Such a report specific to the needs of 65% of Americans would have led to understanding that the best answer for the most Americans left behind in health access is permanent, broadest generalist, family practice. Such a report would have prioritized permanent family practice and would have forced any entities planning to deliver health access to permanent family practice outcomes – especially NP and PA where only 1 in 4 is employed in family practice. Generic fails, specific works. Generic funding fails also.

Reports during the age of science commonly indicate technology as great in theory but poor in practice, particularly in people intensive front lines areas – as in soldiers during battle, as in leaders great in theory but failing when faced with actual battle, as in the innovations in torpedoes and bombs that failed during the start of the war.

The US still fails to understand how it fails teachers delivering education, nurses delivering health care, and primary care clinicians delivering primary care. There is always a two way interaction. It is patients that shape the time and place of encounters. It is support that shapes the workforce and the availability. It is personnel at the primary care clinic that shape outcomes before, during, and after the encounter. Too many barriers, too few personnel, too little support, and not enough primary care professionals are all limitations far greater than HIT, software, electronic prescribing, paperless, primary care medical home, pay for performance, and all the other distractions. What matters is too many barriers, too few personnel, too little experience, and too few dedicated front line primary care professionals.

Even with such a report, five sources with 25,000 of 28,000 primary care graduates would not agree because the report would place them in a bad light. Five sources screaming would appear to be more valid, but this would not change the truth of too few remaining in primary care.

The truth is that so much support for non-primary care and so little support for primary care translates to too few entering primary care and too few remaining in primary care.

Family physicians with just 10% of the primary care graduates will deliver nearly 40% of the primary care arising from the six training types. This is entirely about staying in primary care, staying active at highest levels, highest volume, and most years in a career. The gap between family physicians and other primary care sources widens with each passing year as other sources decline more rapidly in primary care delivery.

Permanent stays and flexible flees under US health policies that favor non-primary care.

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!.

Generic Expansions Are Not Smart

SMART Primary Care : Family Practice Contributions...

Still the Health Access Solution for Most American...

Revisiting Physician Distribution by Concentration...

Rural Primary Care: Stark Realities

To Follow the Money, Follow the Workforce

Why are 2008 Government Projections of Primary Care Workforce in Error?

Standard Primary Care Year Estimates

Failing Primary Care Explained By Policy Failure

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

FInd New Family Medicine Leaders?

2011-11-25T12:47:00.001-07:00

Message to Family Medicine: Return Leaders to Family Medicine Focus

Annals of Family Medicine published an article about the Primary Care Medical Home that was not flattering. In many ways Annals has been cutting edge with regard to basic health care delivery and this article is no exception. Annals is also not alone in their critique. As with articles in other journals there was little difference demonstrated in Minnesota primary care practices with or without PCMH.

Current family medicine leaders have groused about the methods and findings. Instead of complaints, they should understand why the Primary Care Medical Home or any innovation or reorganization is not likely to work, especially in a state with top health care quality already because of best starts for the children of the state. They should be leading Americans to understand the real reasons for health care quality and providers of any type are largely not a reason.

A number of innovations and reorganizations and certifications have resulted in substantially more cost for primary care practices. Should family physicians pay more and more when primary care reimbursement is being cut? One can assert that any design that sends more money into primary care practices can result in more and better primary care personnel - essential for at least more primary care delivery and at least maintaining the level of care.

Patients, patient decisions, and social determinants shape health outcomes before, during, and after health care encounters. Providers may well shape outcomes the least in the half of Americans left behind by US designs. Social determinants clearly shape health care outcomes the most, as noted by Hong in JAMA and others. Health outcomes are not shaped by innovations and reorganizations, even when academics design the innovations and reorganizations.

Family medicine has always taught that health is about what happens outside of academic settings most of all. Do family medicine leaders remember these sentinel basic health care lessons taught by those who resurrected family medicine? Not even family physicians are superior.

Also since family physicians are most likely to be found caring for those left behind, do family medicine leaders understand that Pay for Performance designs are most likely to adversely impact family physicians? Why would family medicine leaders promote designs that fail to work for family physicians? Why would family medicine leaders promote designs that fail to indicate improvement in quality as noted in Great Britain on entire populations of general practitioners incented to improve blood pressure control?

Family physicians and generalists can be correlated with higher quality outcomes, but this is not necessarily because of family practice or because of generalist practice. Internal medicine and pediatric primary care can be linked to lower quality, but this is clearly not due to pediatric or internal medicine physicians who just happen to be more concentrated in locations where Americans divide more into richer and poorer with higher costs and lower quality by design.

States that make investments in the right places do have more family physicians and more generalists because of these investments and because of better distributions of education, health, and other spending. Similarly the medical students from a broad range of income and parent education levels are most likely to be found in family medicine. Those who will become family physicians, family physicians, primary care workforce, populations left behind, and entire populations benefit by better distributions. This is a primary illustration that correlations are not causative.

The context of current family medicine and current family medicine leadership is important. Past efforts for family medicine departments in all medical schools and family medicine programs in each state were largely successful, but did little to improve health care or the status of family medicine. Family medicine relegated to just 3000 annual graduates per year for 30 years has not helped.

Current family medicine leaders wasted precious millions in studying the Future of Family Medicine - a focus that came up with innovation instead of more dollars for primary care and more family physicians. FFM was largely a marketing approach influenced by a marketing firm. Not suprisingly family medicine came up with a marketing approach that emphasized a new family medicine re-design. Frustrated leaders can sometimes make poor decisions. Perhaps influenced by the short term cure approach common to academics, family physician leaders attempted to break out. Note that no one demonstrated problems with the old family medicine design except too few family physicians and too little primary care spending - by design.

The Primary Care Medical Home was a great fit for this marketing approach. Soon Family Medicine leaders found a way to dedicate an entire floor of the Emerald Green palace (AAFP Headquarters) to the PCMH. After investing so much on "the Future of Family Medicine," it is not surprising that there are complaints. Of course these have more to do with leaders making the wrong decisions. The future of family medicine is as it always has been - more family physicians continuing to serve those most in need of care and supported by a nation that recognizes the need for designs that fit the most Americans not the fewest.

Family medicine is number 1 by far with no competitors regarding the delivery of basic health access over an entire career. Lack of staying power insures that all other primary care and non-primary care competitors fall far short of family medicine. United States health policy insures that any new competitors will end up 60% - 70% not primary care, as with the last few creations.

Family physicians have 53% chosen to serve the nation where it most needs workforce - in 30,000 zip codes with 65% of the population left behind including higher proportions of elderly, poor, near poor, rural, lower income, middle income, less health covered, less health literate, less educated, and those with the least health spending by design (Ferrer, Rosenblatt, Bowman, Mold, others).

Granted that it is difficult to live and breath family medicine in academic centers where only 4% of faculty are family medicine by design (Barzansky, JAMA). Granted that much of the political capital is expended each year attempting to keep Title VII intact for family medicine leaders - a focus that continues to result in distraction away from improvements in primary care reimbursement for nearly all family physicians as well as more family physicians.

So why have family medicine leaders not been successful in promoting what really works for two-thirds of Americans?

Why has family medicine leadership not specifically worked to increase the number of family physicians?
Why is primary care reimbursement marginalized year after year for 30 of the last 35 years and soon to be 20 in a row?
Why did family medicine leaders fail to hold Health Affairs accountable for entire issues dedicated to primary care and to maldistribution when there was no discussion at all of the workforce that would actually be needed to deliver the care?
Why have family medicine leaders failed to expand family medicine when family medicine residency gradates clearly deliver the most primary care per graduate and the most health care where health care delivery is most need?
Why do family medicine leaders persist in the support of an additional year of training that will result in a 4% cut in primary care delivery per graduate?
Why have family medicine leaders allowed the termination of accelerated family medicine training - training that saved 12% of training costs, insured more family physicians, resulted in 30% - 50% greater family physicians where needed, and enhanced the front line clinician training of numerous accelerated graduates who have become family medicine faculty?
Why have family medicine leaders failed to promote the Minnesota Rural Physician Associates Program nationwide - optimal family medicine training with rural family physicians that actually helps deliver more care where needed in addition to training more specifically for the front line family medicine, primary care, general surgeons, and women/'s health physicians needed? This is of course exactly the workforce most needed and most ignored.
Why have family medicine leaders failed to establish family medicine medical schools that deliver 100% family medicine residency graduates specifically trained for the front lines and located 60% or more where 65% of Americans need health care? Even one such school will lead to substantial shakeups in health professional training.
Why do physician assistants and nurse practitioners continue to attract attention when each passing class year and each year after graduation results in steady and substantial decline in the proportion in primary care, underserved areas, rural areas, and places in most need of health care?
Why have family medicine leaders not called upon nurse practitioner and physician assistant training designs to be permanent - resulting in 80 - 90% remaining in family practice for entire careers as with family physician training? Only 20% of PAs entering family practice and less than 25% of NP employed in family practice is intolerable compared to 95% of family physicians remaining in family practice.
Why do family medicine leaders support generic expansions - approaches that fail to result in more primary care because fewer of all other sources other than family medicine remain in primary care? Does family medicine understand that family medicine increasing from 40,000 to 100,000 actually resulted in fewer of other sources remaining in primary care because health spending on primary care did not support the necessary primary care and drove other flexible sources away from primary care to non-primary care careers?

Effective problem solving indicates that when the pathway to family medicine is blocked, other pathways will be created. More departments and programs are not solutions. Family medicine specific medical schools are a solution - for family medicine, for family medicine leaders, for those in need of primary care, and for Americans left behind by policy design.

It is not too late for existing family medicine leaders.Come back to family medicine and the essence of family medicine - health care for 65% of Americans left behind by design.

Family medicine has always been on the cutting edge of what is right. The last 30 years of changes have done nothing but make family medicine even more essential. Why can't family medicine leaders understand this? Why can't family medicine leaders experience the joy of being the right choice at this time and place in US health care and US health workforce?

The family medicine leaders who re-established family medicine working for 2 decades and the 100,000 family physicians deserve much better.

Spend less time arguing with journals, less time with government, and less time with academics.

Spend more time with 65% of the nation left behind - before, during, and after training just like family physicians.

If the pathway to becoming a family medicine leader results in leaders that do not understand what is most important - change the pathway to family medicine leadership.

If the pathway to becoming the physicians most needed by the nation is blocked - change the pathway to family medicine.

If 30 years of government program focus has continued to fail to address the health care needs of most Americans - change the focus to more family physicians and more primary care spending.

If the leaders of the last permanent primary care health access source fail to focus in this area, who remain to lead basic health access at all?

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!.

SMART Basic Health Access in November

Who Really Benefits from ?

Addressing the Primary Care Crisis

The Squeeze Play That Fails

How the Disease Focused Abuse Health Access

Deifying Disease By Design

Can We Have Our Billions Back Please?

Exploring the Health Consequences of Disease Focus...

What Is Killing US Is Not Four Deadly Diseases

This Will Be Brief As Will Primary Care

Who Really Benefits?

2011-11-25T10:57:00.000-07:00

In past Basic Health Access blogs, claims of benefit to health access have been pointed out as promotions and promises, impractical, deceptive, or insignificant. Over and over the design deficits do not allow health access recovery. Most of these assertions and assumptions and promotions fail as they simply ignore massive and increasing shortages of the best and most experienced and most committed basic health access professionals – by far the most pressing need for basic health access for the next 20 years and likely longer.

The US simply does not have a design for training and for supporting the workforce needed for over half of Americans.

Past blogs have indicated that claims of benefit for rural areas or underserved areas are not entirely true as the real benefits go to academic institutions, software companies, or others who help themselves by the design. Foundations appear to be innovative and cutting edge by recommending new types of primary care despite the fact that these types are 3 to 1 not primary care in result.

Some foundations fueled by the billions going to health insurance corporations (such as United Health Care) appear to be promoting types of workforce that undercut physician workforce – a sure way to create more easily controlled health professionals - centralizing control in the hands of fewer and those most distant from care delivery. Sadly designs have already been implemented that will result in massive excesses of non-primary care led by 70 - 80% of nurse practitioners and physician assistants found in non-primary care areas. Massive expansions without real focus are a sure way to increase health care costs and more profits for health insurance companies, academic institutions, and large systems - those that benefit most from non-primary care excesses and ever higher costs with more subspecialized care.

Innovation and reorganization appears attractive during periods of desperation, but fixing desperation is about fixing designs that result in failure - not more innovation and especially not more innovation that proceeds from those that shape failed designs. All else tends to fail because of the policy design. Pipelines worked when policy worked but then failed when policies failed. Innovation and reorganization could work with a better design, but cannot work without a better policy design. No design can work without the workforce to serve where needed as this shapes health spending, health access, and distributions of health spending. Ever greater focus on innovation and reorganization is not the correct approach.

The one type of primary care that predates all new types has the best primary care retention and the best distribution in the most important category – delivery of primary care where needed as measured over an entire career of workforce contribution. The broadest generalist primary care workforce is always the solution for health access as long as it remains broadest generalist over an entire career. Family medicine existed before the innovations, got better because of the formalization of family medicine training, has remained most valuable for the past 40 years of family medicine's existence, and still contributes the most to primary care, to rural health, to care in underserved locations, and to local health care for 30,000 zip codes with 65% of the population and increased proportions of all in most need of care. Family medicine is also the one type of health access that has not been expanded in 30 years because so few under current policy will make a permanent choice of primary care most likely to be found where the US design sends the least spending.

Any evidence based focus on health access would see this as designers of US health care actually avoiding health access interventions such as family medicine that have worked for far more than the past few decades.

Readers are invited to review the following link and decide for themselves if Alabama, Kentucky, Arkansas, the Mississippi Delta, or other rural areas will really benefit, or whether the funds will go for someone else’s purposes (beyond the political desires of whatever administration is current). Year after year, administration after administration, Congress after Congress, we see the same news releases – but we continue to fail in basic health services despite spending far too much money upon health.

Agriculture Secretary Vilsack Announces Funding to Improve Access to Health Care in Rural Areas Nov 21, 2011 -- Agriculture Secretary Tom Vilsack last week announced funding to establish telemedicine and other health care projects to address unmet health care needs in the Delta region.

I have learned to examine these various claims of benefit to see who benefits. This is another in a long and glorious tradition of political claims that fail in specific benefit to those most in need.

Will Arkansas, Illinois and 48 other states keep pouring millions into pre-health programs that fail to result in return in investment given only 1 out of 3 that actually make it to admission and less than 1 out of 5 that may serve in some needed career or location? Perhaps states will finally figure out that they should obligate MD, DO, NP, PA, and RN students at admission to train for needed health access locations – as a condition of admission. Then funding at each of 7 different levels is of little consequences since at least 90% will serve the first 25% of their careers where health professionals are needed – instate in locations in need. This is a far cry better than medical schools that attempt partial pipelines where only 1 in 8 graduates are found where needed, and mostly because they chose family medicine. A major advantage known for training is trainees that prepare for their careers all of the years of training. When trainees exhibit this (rural family medicine, pediatrics) or are obligated for these careers, they will better prepare themselves for such careers because their pathway was known from the start. See Addressing the Primary Care Crisis.

Does $700,000 for interlinked rural intensive care units work, or perhaps would $700,000 mobilize resources to attack maternal obesity in Mississippi - a condition that kills at least 4 youngest mothers a year across the state? Will these rural hospitals even survive the next 5 years of cuts? Will any intervention help when our nation divides further into richer and poorer – the reason for increased stressors especially in those most left behind and the reason for increased food consumption and other adverse behaviors resulting in poor maternal outcomes long before pregnancy?

I have to admit that linking rural sites is a good idea as in Project Echo in New Mexico, but will this project have a Dr. Sanjeev Arora and the U of NM and public health driving collaborative two way access. Project Echo in New Mexico focuses on delivering care to people in need of care – not stroke. The benefits are also better trained primary care professionals on the front lines. Another benefit is far fewer specialists needed with more primary care supported where needed rather than the current design that steadily collapses all health workforce toward 1% of the land area.

Is it helpful to pay 3 million dollars to have an urgent care center in Mound Bayou? Is this expenditure a measure of the failure of one of the first Community Health Centers in the nation to actually work? Why not primary care or CHC offices open until 8 or 9 PM? Was there no ER willing to branch out and if not, perhaps the reason was the lack of health care coverage or sufficient available local health spending? If the area was unable to sustain urgent care for 80 miles, does it need urgent care? Will 3 million dollars as a one time expenditure prop up an urgent care that is not viable under the existing design? Will the urgent care have the workforce needed or will it steal local primary care workforce and compromise local primary care? Can urgent care paid multiple times more for the same services help a region short on cash, short on workforce, and short by US design?

Then there is this political announcement:

“Since taking office, President Obama's Administration has taken historic steps to improve the lives of rural Americans, put people back to work and build thriving economies in rural communities.”

Should we be impressed after 30 years of such press releases?

Do the examples of a few rural locations mean anything in a sea of shortages caused by designs for elsewhere? Can centralized designs shaped by those most centralized really help locations that require decentralized training, workforce, and spending? There will never be enough in any special program to help rural areas, underserved areas, and most Americans in need of basic health services. Total failure is the result of poor designs that have totally failed. Double or triple or quadruple the special program spending would not help. The across the board cuts directly or indirectly or relative over decades will make matters worse for areas that need more spending, not less. The designers can use delay tactics and can confuse only if we let them. Real designs for health and for health care are needed.

For 30 years administration after administration has failed to distribute health spending and health workforce that would truly improve the lives of rural Americans as well as stimulate jobs and “thriving economies” in rural America. Each 15 years the designs can be traced as sending ever more spending to facilities not found in rural locations in need, sending ever more spending to non-primary care least seen in rural locations, and sending ever more spending to settings with the most health spending already.

Designs for 30 years that are cost cutting in nature, rather than designs for health or health care, are not good for most Americans. The designs leave 70% of rural Americans behind due to marginalization of family practice and primary care and health access. Only rural locations that have managed to replicate the largest urban system designs thrive because they find their way to all lines of revenue and the top reimbursement in each line - and have lowest percentages of primary care and family medicine by design.

Designs that favor those who already have the most workforce and the most lines of revenue and the highest level of reimbursement in each line fail most Americans left behind who have the fewest lines of reimbursement and the lowest levels of reimbursement (rural hospitals, primary care) as well as the least workforce and least economics from health care – by design.

But the media releases, major journal articles, academic planning, accountant-led cost cutting measures, and government reports will all continue. Perhaps one reason is that we all grasp at straws held out. As long as we believe that we can keep our own special programs intact and fund them at ever higher levels we will keep grasping at straws - and will delay real improvements. Financially, politically, and practically it is not possible to hold on to special programming, but we persist.

What we must do to actually resolve so many deficits for most Americans is to work together on a real design based on health and health care down to the local level.

Instead we have spending concentrated in disease focus, concentrated in too few locations, and concentrated on too few for too little result. Also we have the resultant cost cutting design in consequence and too little spent on most Americans in nearly all zip codes.

The Squeeze Play That Fails

How the Disease Focused Abuse Health Access

Deifying Disease By Design

Can We Have Our Billions Back Please?

Exploring the Health Consequences of Disease Focus

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D. Basic Health Access Web Basic Health Access Blog

SMART Basic Health Access World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!.