What Veterans Need Is Family Practice

A Veterans Reform Bill specific to the health access needs of most Veterans should read - 16 billion to go to family practice clinicians and teams - the ones who can deliver the care needed for Veterans behind by design. Unfortunately a small fraction of 16 billion will go to care for Veterans with poor access and the family practice clinicians and teams who could best resolve their access woes.

Veterans Administration focused care cannot serve Veterans 
because it is focused as described - on the Administration of Care for Veterans. 
What is wrong at the VA is wrong across American health care designs.

Geography describes the problem and the solution

Some 30 - 35% of Veterans are in rural settings. Over 70% and perhaps as many as 75% are found in counties or zip codes with deficits of clinicians. These 2800 counties or 40,000 zip codes have 68% of Americans and even higher proportions of elderlyAmericans, Medicare populations, Medicaid populations, working poor, rural,lower income, fixed income, and others behind by US design - and perhaps highest percentages of Veterans.

Geography, lower and fixed incomes, and high cost of living locations dictate where over two-third of Americans can live - outside of concentrations of high costs. Over 70% of Americans cannot afford to live in the 200 counties or 3000 zip codes with highest cost of living, highest property values, and the only ready access to care under United States designs. Veterans increasingly arise from populations left behind and increasingly are found in locations left behind where the overwhelming majority of Americans are found.

Veterans care has been and will remain highly centralized away from Veterans.

VA administration, VA training, and other VA expenditures are highly centralized, highly specialized, and unresponsive by design - a design that needs to be replaced, not pumped up with billions more in spending. Our nation needs decentralized health administration, decentralized practice locations, decentralized training, decentralized focus of care, and care that is responsive to local needs and local accountability.

Veterans need clinicians locally to be able to care for their health care needs – not some distant and diffident facility. Veterans need care for them, not just for their diseases. Veterans have established outpatient centers (CBOC) but these have not been open for enough hours and fail to offer the range of services needed by veterans.Veterans will still need to travel hours to get to centralized veterans locations, because the design still prevents use of private physicians like family physicians - physicians distributed like veterans distribute, especially those in most need of care.

Veterans need family practice – 
the only type of workforce that has demonstrated distribution 
to the locations where veterans are found in the past and at the present and for the future.

As with past bailouts, those who actually deliver the care were crowded out at the Congressional feeding trough by those with various agendas who dominate the feeding trough. 

The result is always a solution that fits agendas but not the care needs of most Veterans – the ones who were not receiving care in the first place.

The time was right to make a major change to focus on the needs of most veterans, but this opportunity was lost. To understand these problems, the awareness needs to come from those who have suffered.

Who knew about the problems facing Veterans long ago?

To understand the problem of poor access, one must experience access problems. Veterans and their families have known about this for years. They have been writing Congress and expressing their problems to no avail. Clinicians working with veterans have also been vocal about the problems – but have lost their jobs. Eventually the administrative excesses (that most define Veteran's care) resulted in exposure and 16 billion dollars.

But this will not specifically address the needs of most Veterans.

Veterans Administration focused care cannot serve Veterans 
because it is focused as described - 
on the Administration of Care for Veterans. 

Care must be focused on delivery and those who need care and those who deliver that needed care. The VA logistics are impossible because of the distribution of Veterans and their health care needs. Only a design specific for Veterans, integrated with the needs of all other populations in need of health access, can meet the needs of Veterans.

The problem of American health care is too much administrative cost 
with too little remaining for care delivery 
and even less remaining for care delivery where care is most needed. 

Why "More Graduates" Will Continue to Fail Veterans and Most in the US

More medical school, nurse practitioner, or physician assistant annual graduates and more massive expansions of their associations, leaders, and administrators will not fix the health access woes of Veterans because too few graduates (7 - 25%) serve their MD, DO, NP, and PA careers in family practice positions. A family practice position filled (not just training) is a requirement to be a best solution for most Veterans and other populations long left behind by design. A family practice position established, offered, and filled is a position that has three times the distribution where needed. Production of other types of workforce does not result in this multiplier.

To be a real health access solution, 
over 50% of MD, DO, NP, or PA must end up in family practice 
as measured over their entire careers - not just for a few years of a career.

Family medicine is a real solution with 90% remaining in family practice positions, but the requirement for medical school prior to family medicine training prevents family medicine due to only 7 - 18% FM result. A design that prevents family medicine loss is required - a permanent family practice result by design for MD, DO, NP, and PA.

Veterans need their care provided locally across most of America where most Veterans are found, not in facilities relevant for 1% of the land area. Veterans need training fully integrated with practices where family practice positions are filled by MD, DO, NP, and PA graduates. These are also the broadest generalist graduates that will be the faculty to train these solutions for the care of most Veterans and most of all of the various populations behind by design. These practices are imbedded in the communities in need of care and the practices are primarily about health access, community, and improving health in their patients and the community. These are true teams made up of a number of types of individuals and clinicians that are all focused upon health access. Our current separations and fragmentations cannot accomplish this.

Family Practice Specific Clinician Training

Veterans need family physicians arising from 3 years of preparation, 3 years medical school, and 3 years of family medicine training. This 9 year period and the years before and after training must be spent at locations where 70% of Veterans are left behind by design. Training must be specific to the populations in need of care – not more training in top concentrations where care is in excess as is health spending for such care.

Veterans need NP and PA graduates who are obligated to family practice positions for a lifetime – not the current generic graduates that end up in more new specialties with more added to each new specialties – leaving family practice and most Veterans behind by design.

Veterans also need efficient care, not 2 seen per hour. Improvements in health access are about more millions of Americans seen for more of their care rather than fewer seen and fewer of their problems addressed. This is not about insurance solutions. This is about the right workforce with the right support in the right locations – where most Veterans need care. More spending, more graduates, more insurance, and more bailouts will not fix care where needed. Specific designs are required, especially to avoid consequences from bailouts.

16 billion in bailout spending is a flashback figure

The 16 billion for the VA bailout brings back memories of 16 billion in bailout spending for health information technology.  Billions more in spending plus more billions more due to subsequent legislation has been a great contribution to the coffers of software companies and those employed for technology reasons – but this has not improved health access or primary care or care in 40 states behind by design. 

The 16 billion for Veterans similarly is not specifically focused upon the needs of most Veterans. The design adds few sites – not the hundreds more sites needed to fit the needs of most Veterans. The 16 billion will go for the usual care in the usual sites with the usual problems of care for few.

Veterans and their families need local care arising from local clinics that meet nearly all of their health care needs - especially primary care, mental health, urgent, and emergent needs. These are the needs not met by American design with Veterans designs some of the worst.

Those attempting to solve health access woes must understand the needs of Americans with health access woes – and the family practice clinicians that serve them.

Understanding the family practice distribution is important to those who truly want to help most Veterans and most Americans. FM docs are distributed equitably at 30 per 100,000 people where care is most needed, including rural areas where about 35% of veterans are found. Family physicians are more likely to be found where veteran, elderly, fixed income, low income, CHC, rural, Medicare, Medicaid, low pay, no pay, and lower clinician concentration county populations are found. Family physicians are more likely to be found where complexity and barriers to care increase and as income, health literacy, education level, health status, other clinicians, and support resources decrease. 

Every other specialty melts away to lower concentrations and lower distribution in the zip codes and counties in need of care - where most Americans are found. 

Non-family practice MDs, DOs, NPs and PAs are great 
- for facilities far away from most Veterans.

Family practice NPs and PAs, those filling family practice positions, are equitably distributed where care is needed - but their numbers are not enough because the training designs are not specific to family practice result and the spending design is horrendous for the support of family practice clinicians and teams. 

Veterans need family practice, but so do most Americans behind by design. 

Most if not all of the 16 billion bailout now as well as past 16 billion dollar bailouts - should go to support family practice clinicians and teams. Support for the ones who deliver the care where needed is support for most Americans behind by design.

If your focus is health access, primary care, mental health, women's health, urgent care, emergent care, and care where needed - your solution is permanent family practice by design.

America and Americans can do better by supporting existing and future family practice clinicians and their teams and practices rather than marginalizing them further - along with the populations that they serve.

Relevant Works

Exploring the Consequences of Disease Focus

Physician Distribution By Concentration

To Follow the Money Is to Follow the Workforce and Vice Versa

Recent Works

Perverse Health Payment Dividing US

How To Resolve Health Access for 40 States Behind By Design

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Overcoming Barriers to Health Access Including ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access?

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

Best of Basic Health Access

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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