Exploring the Health Consequences of Disease Focus

Cost Cutting Consequences
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 attempt to cut costs, but this has resulted in the disaster set for Jan 1, 2012. Regardless of political party, the political and health leadership has failed the basic health needs of most Americans and neither party has any plans to spare essential basic services from the cuts to come.

Themes for the Week

1. Identifying and exposing disease focus - the enemy of basic health access, reasonable costs, and affordable health care for people

2. Returning nations to basic health access restoration

It is a difficult task to identify all the ways that the United States uses to avoid better and more efficient health care, but awareness building is a first step to change.
Those focused on disease appear to be more and more sensitive to the charges and consequences of disease focus, so they more and more attempt to link their disease focused activities to the appearance of better health and prevention. Make no mistake, this is still disease focus by those trained by disease focus, research funded by disease focus, and priority funded in practice by disease focus. it is very hard to untrain a physician or researcher or policist from disease focus as this has been the focus of the past 100 years.

Better health or a design to deliver health care is very different from approaches that attempt to stamp out death. Just as a reminder, no matter how much death delayers attempt to sell death delay, death cannot be stamped out. It can only be delayed. We will all physically die. We should all hope not to take our nation with us when we go.
Death is what happens at the end of life and disease focus is also what happens at the end. What happens at the end of life is highest cost health care for very little gain, also because this is end of life. What hurts most is that disease, death delay, and end of life focus - ALL HURT THE YOUNGEST WHO ARE MOST DISTANT FROM DEATH. They have to endure multiple generations dying an sucking up all available resources before they can receive the benefits of being near death. What we do assures that the youngest will have an earlier death. This is what our death numbers statisticians are also beginning to say.
The themes of death delay can be seen in recent works. In just the last few days some CDC researchers paved the way for 19 billion more dollars for Hepatitis C screening on the entire age  - those most likely to have Hep C. CT scans are proposed for "prevention" of lung cancer death but of course there are incredible costs associated with such testing, including the interventions required. In each of these areas involving diseases such as various lung cancers or forms of hepatitis there are problems.
There are those who test positive and are positive and may improve with treatment, if they are positive with the right form of lung cancer in the right place or the right substrain of Hepatitis C, etc.
There are those who test negative but are positive and may sue
There are those who test positive and are negative who face substantial costs and disability for no reason at all other than the testing.
There are those that test positive and do worse because of the testing and procedures and treatments.
There are consequences of all of the above, especially lost real wages, lost jobs, and lower Social Security in the future because of lost income. Of course these are costs not fully considered in the analysis. Also not considered is the fact that we spend so much for so few at the end of life that we have very little remaining for most Americans - such as $44,000 spent per year for the top 1% in health costs and less than $800 a year for 50% of Americans (this is a range of 6 times more than the national average to 10 times less than the national average of about $8000 per person).
Recent works in the area:

One Million Hearts Saved or Health Access for 160 million Myth for the Cure - More awareness of disease cannot help most Americans who need entirely different designs that even allow health care participation.
Accountable Health Access from Government  SMART designs can address health access needs but government must specifically focus upon health access result.

Take Home Example from US Health Care

Health care cost increases kill off our businesses and force them to terminate employees to balance their budgets. Much the same is true in governemtn where teachers and public servants are cut so that the ever increasing cost of health insurance can be met. Even health care entities must cut nurses and other personnel as their own fast rising health care costs impair their ability to deliver health care.
This posting represents to advice to those in other nations or in future generations that fail to learn from the United States example developed over the past century of disease focus.
As health care spending approaches 20% of Gross Domestic Product in the US (over twice as much per person as nearest competitors), those who pay for health care under the US design are being compromised - all governments at all levels from school district to federal and all businesses

Disease focus is the reason for health care cost overruns - more and more spent for fewer people for fewer years of their lives with spending in just a few locations.

Those with disease focus have found more new ways to fund this focus, including claims of cure. These are little more than death delay at every higher cost for the last years and months of life. Major journals and foundations and government reports all support this focus.

Non-Primary Care Workforce Equals Cost Overruns
The vehicle of this destructive plan is non-primary care workforce. The United States has only increased primary care workforce training numbers by design from 1965 - 1980. All US physician workforce doubled during this period - both primary care and non-primary care. This was also the first and last time primary care has been significantly increased in the past century.
Health care costs from 1965 - 1980 should be considered reinvestment in health care infrastructure - infrastructure that was collapsing under the privatized and profit driven US design. Cost increases continued in the 1980s but the non-primary care workforce increased even more as each specialty receive higher reimbursement compared to primary care and there were ever more services to bill. Primary care was already in trouble with limited billing codes, even more limited increases, double digit costs of delivering primary care magnified by double digit inflation. 
Not surprisingly the cost overruns continued in non-primary care and in overall health care costs. The original Medicare and Medicaid designs had been changed over 15 years. This is when the designs changed to cost cutting rather than health in focus. This cost cutting focus has continued because the costs have never been reigned in. In the 1990s there was a business and goverment coalition that brought the nation to its senses for a few years - long enough to restore the economy and take the nation on the longest recent run of economic progress. But the powers that be soon resumed control. Non-primary care will never be reduced under the current designs for training and support that emphasize non-primary care.
Doubling Troubling Workforce
The US training design has doubled non-primary care MD, DO, NP, and PA numbers entering the non-primary care workforce each 15 years since 1965. The first 15 years from 1965 - 1980 was the only time of primary care doubling. The 1980 design is still what we have with internal medicine decreased and replaced by the small portion of physician assistants and nurse practitioners remaining in primary care.
Non-primary care doubling in numbers each 15 years has been the case from 1980 to 1995 and from 1995 to 2010, and from 2010 to 2025. That is correct, the expansions of MD, DO, NP, and PA have already set in motion the next doubling and the foundation of another doubling 2025 - 2040. This is because it takes 25 - 35 years to fully express expansions already set in motion. For example the 3000 annual FM grads reached in 1980 have reached their maximum of 100,000 as a workforce and cannot go beyond this maximum as FM is still 3000 annual grads. IM down to 1400 entering primary care a year from 2000 to 2015 is already set to be less than 45,000 by 2030. Medicare fee cuts may help the US reach this level by 2025. The US will still graduate 250,000 or 25% of total physicians from internal medicine residency programs, but 80% will be non-primary care. A similar 80% of NP and PA and MD will be non-primary care - all shaped by the US designs.
Non-primary care will continue to increase  Three Dimensions of Non-Primary Care Increase Are Obvious and this will mask the lack of increase in primary care by designs since 1980 in training and funding support. After all, deans and nursing workforce leaders still claim substantial proportions of their graduates in primary care, when the reality is fewer entering and fewer graduating and departures each year after graduation - even for those who enter primary care. This is the legacy of a flexible non-specific primary care design rather than permanent.

Because primary care has essentially not changed for 30 years in the United States, the rapid increase in the cost of health care has almost entirely been about non-primary care expansions. In many ways, the only way to limit health care cost increases is to limit non-primary care workforce. Sadly this is the health care that has doubled by US design each 15 years since 1965.

Primary care workforce and primary care costs have been limited by generic designs that only result 30% in primary care result. The low priority placed on primary care is what sends twice as many to non-primary care as compared to primary care delivery. This is not necessarily about salary or benefits. Primary care is frustrating with the least experienced personnel (by insufficient funding and getting less) and with the least support and with by far the least understanding. Training is also not specific to primary care for RN, MD, DO, NP, or PA.
Primary Care Remains Limited and Non-Primary Care Remains Limitless
Primary care costs remain low due to too little workforce. Primary care also has effective cuts for two reasons - the first is annual double digit increases in the cost of delivering primary care (without any increase in reimbursement and with new types of costs) and the second is across the board cuts that are forced upon primary care due to non-primary care excesses.

Unlike primary care with numerous inherent cost limitations, non-primary care is almost limitless by design. Non-primary care has demonstrated an amazing utility to escape any and all cost cutting measures. Those promoting disease focus have multiplied in recent years making it even more difficult to reign in costs. Proponents can trot out death squads, can fund patient advocacy groups, can set up various cancer or specific disease poster children, or target legislators who have had family impacted by specific diseases.
Non-primary care is allied with corporate, academic, institution, and health professional association interests - those who control the designs for spending and for workforce. Academic institutions once shunned patent seeking faculty and now embrace them, promote them, and develop private corporations to profit by them.

Perhaps understanding the development of this mess over the past 100 years may help those who have earlier versions in place that may be more subtle. Of course United States student populations fail most in history and those not understanding history are indeed doomed to repeat it - by 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

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
SMART – Specific, Measurable, Achievable, Realistic, Timely


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