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.

Primary care fees go 50 - 60% to support the services of primary care personnel attempting to deliver more primary care with less money and support. When you cut primary care, you kill off primary care personnel, primary care services, primary care delivery capacity, and one of the few remaining sources of economic impact from health care for 30,000 zip codes with 65% of the population.

New Blog Posting at

Pounding Poverty Providers with Pay for Performance

December 21, 2011 - Also after 4 months, Congress has failed to act on basic funding for Medicare fees, tax reforms, and the basic needs of 3 million unemployed Americans.


Why would any general take out the front line soldiers? Without a front line, the rest would soon be overwhelmed and overrun. This is already the case, and a major reason why health care is already too expensive, inefficient, and ineffective.

If you tried to impair health or health care for most Americans or if you tried to eliminate health care spending as a vehicle for economic recovery for most Americans, it would be hard to think of a way to do more damage. Primary care is 40 - 100% of the workforce in 30,000 zip codes with 65% of the population. Kill off primary care and you kill off jobs, services, and economic impact - and especially where most needed. As far as Medicare goes, those over 65 consume 2 to 3 times more primary care. Primary care demand increases the most as Americans age. Why would anyone who understood primary care or the needs of age 65 and up allow primary care to be chopped in pieces. Areas already shortest in primary care are most dependent on primary care and are also most dependent upon Medicare and Medicaid - and both are failing to support primary care.


Primary care fees do not go to the pocketbooks of primary care physicians. Primary care fees do not go to stockholders or investors. Frankly there are no profits or to attract investors. Academic centers that did invest in primary care in the 1990s lost small fortunes even when primary care costs were much lower. Large systems and academic centers long ago decided to stop propping up failing primary care years ago. Primary care doing well had to concentrate on the wealthy or find another reimbursement design that actually keeps up with the increasing cost of delivering primary care (capitated).


Health and Human Services today announced plans for a 27% cut in people to deliver primary care. This translates to a 40% cut - 27% starting Jan 1 2012 plus the usual 13% increase required to continue to deliver primary care in 2012 as compared to 2011. Somehow HHS thinks that primary care is profitable that it can take 40% less and do just as well. This is of course unfathomable. Health and Human Services or HHS needs to become UIDS - Unhealthy and Inhumane Deficits of Services.

a minimum requirement for some hope is a clean sweep of the health leaders of this administration.


From the start, the Obama Admininstration has claimed the benefits of primary care. These are now seen as empty arguments. To claim the benefits of primary care such as savings of other health care costs, you actually have to understand primary care. Primary to understanding primary care is to understand failure of primary care as failure due to too little support. Lesser support should be understood as destroying primary care and the ability of primary care to save health care costs. It is also failure to address the frustrations of more and more Americans losing basic services in a wide variety of areas.

Primary care was to be a cornerstone of Obamacare just as in RomneyCare or Managed Care. Cracks in the Obama argument appeared with failures in Romneycare as there was simply insufficient primary care resulting in far more costs than planned. Now the Obama Administration is acting in ways that will insure even less primary care.

In a short time Obama will have only a few choices
  • admit another major error and terminate his health advisors and change primary care to a 10% minimum increase in reimbursement, or
  • keep the current plans and give the election to anyone else, or
  • allow another Democrat to run for president  - one not connected with current health care plans or health care leaders
This failure in primary care, regardless of what finally happens on Jan 1 2012, represents a betrayal of 240,000 primary care physicians, 50,000 primary care nurse practitioners, 270,000 primary care nurses, 30,000 primary care physician assistants, and about 1 million other dedicated primary care personnel. It is a betrayal of those who have hung on to deliver primary care despite year after year of steady design failure. It is a betrayal of those who helped design Obamacare. It is a failure of those who worked to support Obama.

Already it is too late to do much to prepare for this disaster, one that could be substantially worse with anything less than the best possible influenza year in recent history. It is too late for responsible health care providers and systems to notify their patients or their employees. It is too late to anticipate the major changes to attempt to adjust care needs due to primary care losses.

Most of all it represents a total failure to understand the basic health needs of the American people.

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 and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely

Historical Perspective

From 1965 to 1980 the initial Medicare and Medicaid designs invested heavily in restoring health care infrastructure. After decades of caring only for people that can pay the most, health care was in ruins for most Americans. Primary care was disappearing in the 1950s and 1960s.

The Medicare and Medicaid initial design doubled primary care and also doubled non-primary care numbers of MD, DO, NP, and PA. This was the first and only doubling of primary care.

Primary care numbers arising from the design have remained the same without change each 15 year period since 1980 and already confirmed for 2025. This will mean essentially 50 years without a change in primary care while non-primary care doubles in MD, DO, NP, and PA numbers each 15 years. Family medicine is still at 3000 annual graduates just as in 30 years ago. PD is stagnant and has been for 15 years. Internal medicine has been decreasing by 2000 - 2500 per year due to only is 1400 entering. Internal medicine should decline much faster, by 3000 to 3500 each year. It will reach the 40,000 level much sooner than 2030 with this change and with far better options other than primary care.

It took 15 years for the designers to redesign Medicare and Medicare their way. With this redesign, government was forced into cost cutting. For the past 30 years, Medicare and Medicaid have not been designs for health or health care. For 30 years they can best be described as designs for the support of those focused on disease and delaying death a few years or months.

It took only 5 years for the designers to blow away the managed care design. It took only months to subvert the 2010s reforms that really never were. Without primary care workforce, no design works. With even more insufficient primary care reimbursement, there are even greater primary care deficits to come.

Primary care has been failing for one simple reason. The annual costs for delivering primary care have exceeded the funds required to deliver primary care. The cost increases are double digit like all other health care. Unlike other health care, primary care has not been able to create new services, corner specific health markets, drive off competitors, or address even basic financial needs.


Popular posts from this blog

The Essential True Reform Restores Primary Care and Much More

The Glut of Health Workforce Exposed But Ignored

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