Is an Academic Social Mission Possible Given Policy Designs?

Periodically there are calls for Academic Medicine to be accountable for health care in areas such as health care workforce. This accountability includes the larger dimension of people with substantial limitations in their health care such as rural populations or underserved urban populations. The access situations are worsening across primary care, mental health, and general specialties - those who provide 90% of care for half of the population most in need of care. The lack of any significant improvement for decades indicates barriers not easily addressed. In fact it may well be that the top priorities for academic and largest systems are such that true reforms are prevented - reforms that would address the primary care, mental health, and basic services payments that are essential for distributions of services and broadening of health access.

A social mission or accountability would require academic and other health care leaders to stand up for higher payments for basic services, decreases in costs, and increases in support for providers caring for increasingly complex patients. Instead there are no such cries and there are new designs that make the financial design worse - and make it more difficult for the team members to deliver the care to the half of the population most left behind. 

Health care is about people and health access practices are over half dedicated to personnel. The support of the personnel who deliver care is most important. Designers and their designs have had adverse impacts. 

Making a difference is about tens of billions a year redirected where dollars can matter most. Without financial design reforms, training designs are incapable of generating the graduates that can be supported where they are most needed. Academic leaders can continue to avoid responsibility or even blame for worse designs while they can continue to cry out for more support to train more graduates - even if those graduates cannot actually go where needed or serve most Americans most behind by design.

Most Americans are getting the minimum with less to come. 

More special social mission events and articles have not ended with calls for accountability or demands for true reform in payment - so they have failed.

More primary care associations have been created and funded with more special projects and greater support of innovation, regulation, and certification - making matters worse.

Not even family medicine with 70% of graduates in office based primary care has grasped the design flaws that make matters worse - sending academic entities farther away from social mission and accountability for the basic access of greater proportions of Americans.

More special schools, programs, pipelines, and promotions will not result in necessary health access improvements arising from MD DO NP or PA graduates. In fact the numerous announcements each month represent a distraction from real primary care solutions.

Academic Centers Lack the Perspective of the Need for Major Change

Perhaps this "social mission" or "social responsibility" appears to be quite difficult for academic entities and those that they influence. Curricular emphasis is easy and temporary. True health reform is hard work. Reforms have usually arisen outside of academic centers as seen in Medicare and Medicaid - although the case can be made that the academic, foundation, government, association, and corporate designers managed to redirect Medicare and Medicaid after only 15 years of operation. Managed care took less than 5 years. ACA was dead on arrival for true reform such as balancing cognitive vs procedural. 

Access to care is a horizontal, decentralized broadening of mission quite different from the vertical, highly specialized care organizations specific to academic institutions. Previous essays have discussed the process of academization or distancing, making it difficult to consider situations and conditions. 

It Can Take Decades to Realize the Limitations of Academic Efforts

As a medical student I had great respect for academic medicine and medical centers. My time as a rural physician trained me in dimensions untouched by academic training - community, health access, care where needed, social dimensions. Even as I learned more, I still clung to academic medicine as a solution and hoped to bridge the academic and rural communities in my quest for solutions for health access. It is quite clear that this cannot happen now or for decades to come. 

The financial design prevents generalists, general specialties, rural practice, primary care, mental health, small practice and care where needed. The academic designers continue to sit on panels and influence government in ways that prevent true reform. True Reform    

The thirty years teaching, researching, and delivering health access as an academic physician were great years and involved great people and great meetings - but the research and the academic interventions even coordinated across preparation, selection, and training have resulted in no progress in basic health access. Nebraska still has the same levels of inadequate workforce across the same 70 counties that still have physicians despite substantial efforts at all levels and a genius family medicine residency program design (shaped by Jim Stageman and Mike Sitorius working with state and institution players). The Nebraska county map over the fifteen years of observation had different names and initials with more family physicians, but fewer internists and little change in delivery capacity. 

My editorial work as North American editor of Rural and Remote Health confirmed little progress. The research in the US as in other nations indicates the successes of various programs or models. But despite the successes, the lowest physician concentration counties remained lowest with inadequate workforce - and many fell to even lower concentrations as funding declined, hospitals closed, or economics changed. 

A medical school or training program can be stellar in "social mission" 
with great documentation of superior results 
but half of the people in the state remain to have improvements in access.

More commonly the studies are as flawed as those that promote international graduates as solutions - studies that fail to consider 30 - 40% who leave the US and that fail to consider departures from primary care and from areas of need in the years after graduation. 

With More Study the Truth is Obvious

It finally registered that most Americans are losing in health care design as in the designs for education, economics, banking, housing, and other areas. Why expect different when economics, education, health, and their designs are so closely related to one another? If you truly understand the social, personal, local determinants that shape 60 - 70% of outcomes, then you can begin to see the numerous flawed perspectives and solutions.

Lowest physician concentration counties confirm these adverse changes and the difficulties of addressing care where needed without True Reform. Students and residents interested in family medicine desire Equity. Family physicians Paid Less for Doing More Where Needed are frustrated and they are moving away from primary care as have all other primary care sources for the last few decades. The recent implementations of pseudo-reforms in payment have made matters worse and the designs have moved all the way to Discrimination in Payment.

Pay for performance has been widely promoted by family medicine leaders for some time and the associations continue to support these designs, even as they discriminate against family physicians in particular and other providers choosing to care for the most complex populations that inherently have the worst outcomes.

Once again lowest physician concentration counties represent lowest levels of workforce and access and highest concentrations of most complex patients with the most chronic diseases and other situations, environments, and conditions that make care even more complex.

Academics should sound off when practices and policies are not evidence based - yet they have not done so. Family medicine associations should be looking for issues to support such as opposing discrimination in payment, especially when the evidence basis for innovative designs is lacking. 

Do Unto Others...

The academic message for science, evidence basis, and public good have been compromised over the decades. Now when I see the social mission preached from academic leaders, even those respected for social mission articles, it is hard to listen. Those speaking fail to see the lack of progress despite the rhetoric for decades. Great concepts presented are as limited as the results for the last 40 years.

Real gains and real changes take real dollars, tens of billions more for primary care where needed. Only about 40 billion goes for primary care in lowest concentration counties with half enough primary care. Yet this is tolerated and made worse as more billions are subtracted in each of the new categories - HITECH, ACA, MIPS, MACRA, and Primary Care Medical Home. Worsening collections and turnover costs are bad, but the financial design actually prevents lowest concentration counties from being able to support more team members to deliver the care. 

More are falling behind in more ways with much worse to come. Health care design continues to leave greater proportions of Americans behind. The 40% in lowest workforce concentration counties will be 50% by 2040 as hospitals close in these counties and as housing affordability collapses in higher concentration counties force more of the most medically and financially vulnerable to move to lowest concentration counties.

Why would we expect different when most Americans are falling behind 
in economics, education, and other key societal areas? 

The social mission in medicine begins and ends with basic health access. For many Americans, health care fails because access fails.

Next is a review of the Academic Medicine Scorecard compared to the call for accountability made in 1990 by Dr. Butler, Chairman of the AAMC at the time.


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