The 25th Anniversary of the COGME Third Report and No Change By Design

Hardly a month goes by without some new proposal for more study regarding physician workforce. New studies funded and implemented and reported will not do anything but cost much more and do even less. There are reports from the 1990s that outline concisely what is needed. There has been little progress as the nation has not acted on the recommendations. 

New reports only allow those with their own agenda to add their own spin. At one point in time the experts were more in tune with workforce needs in the nation. The COGME Reports such as the Third Report have been on target - and they have been ignored.

There is really not much need to comment as the report speaks to past, present, and continued failure.

Generalist failure worse and in more places and will continue to worsen past 2020. Internal medicine will be less than 30,000 as a workforce by 2025 - 2030 or one-fourth of its previous contribution. The last PA graduate doubling resulted in no additional primary care result. This is why we should not even mention the so-called primary care solutions.

Access to care problems 

...continue although the experts of the time did manage to underrepresent the populations with problems as the rural or inner city populations are just the tip of the iceberg with regard to access woes.

Too few underrepresented minority physicians

... are also the tip of the iceberg as it would be hard to design a physician workforce that was more different than most Americans in background, careers, specialties, and locations. The process of medical education tends to defeat needed specialties, service orientation, empathy, and the ability to communicate with patients. 

The results of the last election indicate 

  • Just how little various leaders in America understand the needs of most Americans and 
  • Just how little the experts understand about most Americans and 
  • Just how little the media understands, and obviously makes matters worse. 

Shortages have worsened across needed specialties. 

From 2005 to 2013 there was a 2 to 4% average annual decrease across general surgery, general ob-gyn, general orthopedics and other general surgical specialties - specialties of critical need across 2621 counties lowest in physician workforce where 40% of Americans need basic services.

Primary care, mental health, and geriatric failures in numbers and in distribution exist. Just producing more medical students has clearly failed. Matters are worse for locations with rapidly increasing complexity and least paid services.

Runaway costs due to specialization and subspecialization 

...have been bad enough. Unfortunately additional waves of increasing cost of health care have followed. The initial specialization was followed by subspecialization and has been surpassed by administrative cost increases. Attempts to manage care or high risk or high cost patients have added as much cost as has been saved, with expansions of administrative costs in other areas. Medical error focus since 1999 has added more hundreds of billions a year closely associated with the massive increased costs of EHR/digitalization. The result is of course across the board cuts and continued underfunding of primary care, mental health, and basic services.

Each of these changes have diminished the basic health access that can be delivered - by design. 

Never in the history of the United States has so much support been diverted somewhere else and away from the team members delivering the care. The burnout, recruitment, retention, productivity, turnover, and other costs continue to tear at the fabric of care delivery.

Regional Needs Cannot Be Met

Medical education and graduate medical education as well as nurse practitioner and physician assistant education cannot address regional needs. All physicians and clinicians are far too valuable for generating revenue for the largest systems, academic systems, and others competing for care domination in the top concentration settings.

Those with top concentrations find ways to control more and more workforce. Resident work hours limitations presented 25,000 opportunities taken by NP and PA graduates. Thousands of hospitalists were hired to replace resident losses and long standing faculty shortages. Over 50,000 primary care trained physicians now occupy hospitalist positions. No one even gave a thought to the substantial impact upon primary care and care where needed.

It is not possible to address regional or local needs when more positions are created and supported where workforce is already concentrated.

The 1992 to 1996 changes did attempt to address these areas and did so for a few years. Internal medicine class years did increase back to primary care for a time and so did physician assistants. 

With the end of the decade, the small change gains were replaced such that the US has had a steady decline in access, care where needed, primary care, geriatric care, mental health care, and basic surgical care that will continue to at least 2020 and likely beyond. 

There were a few in academic medicine that realized the need for a change, and for regional focus in planning and coordination of workforce. These leaders were also ignored.

A good read from 1992 is Academic Medicine's Season of Accountability and Social Responsibility by Butler. The headlines that Butler quoted from 1991 still apply today. 
  • Newsweek: The Revolution in Medicine
  • Fortune: Taking on Public Enemy No.1
  • The New York Times: Ringing: The Health Care Alarm
  • The Wall Street Journal: Medicine Appears Costly, Researchers Say
  • Business & Health: Physician, Cut Thy Costs
  • Nation’s Business: Curbing Costs of Health
  • The New York Times: Demands to Fix US Health Care Reach a Crescendo
  • US News and World Report: Doctor’s Dilemma: Treat or Let Die?
  • Business Week: Driving Down the Costs of an Aging America
  • Newsweek: The Antibodies that Weren’t: Federal Investigators Find Fakery in Biology LabTime: Scandal in the Laboratories
  • Newsweek: The Big Business of Medicine
  • The New York Times: Medical Technology Race Adds Billions to the Nation’s Bills
  • The Washington Post: Medical Care: How Much Health Care Can We Afford?
  • The New York Times: Why Emergency Rooms are on the Critical List
  • Newsweek: Can You Afford to Get Sick?

Butler recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research. Next, he focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. He describes models of existing, successful programs. The author concludes by proposing to create a "National System of Regional Medical Care." 

What Are the Consequences of an Entire Generation of Workforce Concentrated Away from Most Americans By Payment Designs?

By 2020 the nation will have lost an entire generation of workforce (30 class years) to designs that send the most (or all) lines of revenue to the most concentrated settings in 1100 zip codes in 1% of the land area while 2621 counties lowest in physician concentrations (and many other concentrations) fall further behind by design. 
  • The top concentration Super Center zip codes have just 10% (shrinking) of the population and 45% of physicians and well over 50% of health spending. New lines of revenue supporting these zip codes are still being created. 
  • Over 30000 zip codes fight for just 30% of workforce despite 66% of the population.
  • Another comparison is 2621 lowest physician concentration counties with 40% of the workforce, 21% of active physicians, and less than 18% of health spending. Only the 36% of family physicians matching up to this 40% of Americans has any real distribution where needed. About 75% of the rural population and 32% of the urban population is found in these zip codes.

Even worse, 
  • the new designs ACA to MACRA send even less dollars where care is needed
  • the new designs ACA to MACRA steal even more dollars away from those who deliver most needed care
  • the counties in greatest need are growing fastest in numbers of people
  • the counties in greatest need are growing fastest in numbers of elderly
  • the counties in greatest need are growing fastest in complexity
  • the counties in greatest need are growing fastest in demand
  • the counties in greatest need depend upon generalists and general specialties that are shrinking by payment design
There can be no response to address primary care recovery or basic health access improvements because payment is missing and what little is sent to counties of need is also forced to be sent out of these counties by design pushed by government agencies in charge of access, by foundations with a mission for access, by primary care associations dedicated to access, and by health policists claiming to focus on access. 

Perhaps someone will begin to understand that payment design defeats the best of intentions, missions, innovations, and rearrangements. 

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.

Primary Care Must Rise from the Ashes of the Last 20 Years of Policy

Recovering General Surgery Is Impossible

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work 

Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind. More STDs with more resistance to treatment and more risky behaviors and public health funding slashed and little or no access to care - What Could Go Wrong?

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.

Copyright 2016


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