Training Cannot Overcome Deficits By Financial Design

I loved my career in rural medical education. Only rural practice was better. As a rural medical educator I felt very comfortable with the fact that there were many ways to improve the preparation for rural practice. Over time I grew uncomfortable as I recognized more and more that training was not going to overcome workforce deficits.

The sad fact is that special training works for those associated with special training. Special training does not reduce the problem of inadequate access to care. The proof is in the concentrations of primary care where needed. These concentrations of primary care have remained the same - about half enough. Yes it is true that a special training program or school can have higher proportions serving in locations of need - but their success only results in displacement of others - FM for what was IM, and NP/PA for previous IM or FM. The specially trained replace the traditionally trained. This is a rearrangement of the deck chairs rather than an increase in concentration of workforce where needed.

One rural medical education design that may help a few locations. By moving faculty and other residency resources to rural settings, that particular rural setting can have some improvement in workforce. Indeed in Nebraska there were substantial faculty and resident contributions in the RTT and 2 month continuity rural rotation sites. In contrast, the short term medical student and resident rotations often represent a burden upon rural practices.

Beyond these very limited carefully coordinated contributions at a few sites across the nation, the evidence  does not support resolution of workforce deficits via training as measured in physicians or clinicians per 100,000.

We can claim local benefits of coordinated rural training as noted. 
We can claim that our program or school has better distributional outcomes. 

But we cannot claim that our efforts limited to training have contributed to deficit reductions with overall improvement of recruitment and retention to higher concentrations of workforce. More resulting from one program can only displace more from a different program or type of training. This was seen in Nebraska as the family physicians replaced internists and as NP and PA increased – but the local workforce contributions remained the same.

Because of changes in health professional education, there are more consequences. The change to more physician assistants and nurse practitioners has resulted in greater turnover. This NP and PA turnover rate has been recorded at twice the level of physician primary care. Physician turnover has increased, however, and frequency of turnover is an increasing problem for all sources.

The Financial Design Remains Stronger than Training Influences

MD and DO have added more specialties with more added to each new specialty. Once NP and PA were widely accepted outside of underserved areas and primary care, they have been versatile workforce across a wide range of locations and specialties.

Internal medicine residency graduates have long had a wide range of specialty choices - and have taken them. Family medicine residency graduates were also limited in choices until recently, but the breakdown of primary care financing has resulted in great demand in urgent care and emergent care. Rural emergency room and rural hospitalist positions are filled by family physicians. More options with better financial backing translate to shorter stays in primary care.

Primary care physicians may be down to less than a 3 year stay with a cost now over $300,000 in losses and costs for each lost primary care physician. This is over $100,000 per year per FTE on top of $50,000 per year for digitalization, $100,000 per year for administration, over $40,000 a year for MACRA, and over $60,000 a year for Primary Care Medical Home.

If anything, the financial design changes prevent making any statements about training being able to address shortages. When primary care practices where needed have 8 billion fewer dollars a year to invest in primary care, a major consequence is reduced capacity to deliver primary care. The 38 billion for primary care in 2621 lowest primary care concentration counties is down to just 30 billion after HITECH to ACA to MACRA to PCMH. This 30 billion results in less primary care delivery capacity for all sources of graduates. The actual costs of innovation are each 50 - 100% higher for the practices where most needed. These primary care practices have lowest collection rates and their payments are 15% less - by design (Medicare 2011 data).

Claims of Being Able to Address Workforce Gaps Are Common and Distract Our Nation from the Necessary Changes Needed in the Financial Design

Deans, associations, schools, or program directors that make such statements represent a barrier to addressing the true cause of deficits – the financial design. The evidence of lack of improvement of workforce has been present for decades. Immersion in training appears to prevent objective review regarding the ability of training to address workforce deficits.

Massive Expansions Have Failed to Resolve Deficits

Massive expansions of MD DO NP and PA at 6 to 12 times the annual population growth rate of 0.7% have been unable to resolve deficits. Four sources expanding at massive rates together would have been more than enough to address needed distribution. The DO NP and PA massive expansions have continued since the 1980s, joined by US MD since 2002. Caribbean expansions have also been massive. International graduates still are 20 – 25% of all physicians. Rural, primary care, mental health, women’s health, basic surgical workforce, rural health, and lowest physician concentration county deficits remain.

Recruitment and retention failures point to financial failure. In fact, more spent on costs of turnover or lost to turnover add to the costs of delivery. Costs of delivery increased contribute to financial design failure. Costs or losses include recruitment and retention incentives, advertising, brokers, locums, lost productivity due to losses and orientation of new team members, and lost revenue.

Funding Is Fixed at Certain Levels for Primary Care,
Rural Health, and Care Where Needed

Consider that there is only a fixed amount of funding going to primary care and to family practice positions. This is limited in counties with concentrations of the patients with the worst public and private plans.

There are fewer dollars to invest in rural primary care over the last decade of innovation, regulation, certification, and digitalization. In fact there are billions fewer as seen in lowest concentration counties that have lowest concentrations of MD DO NP and PA.

Primary care functions on only about 6% of health spending or about a steady 160 - 180 billion a year for a decade. Correcting for the proportion of primary care workforce or 25% serving this 40% of the population and correcting for lesser payments by 15% (Medicare 2011) and for 10% lower collections specific to lowest concentration counties, this indicates about 38 billion that was once available.

Now subtract ten years of increasing costs of delivery. The costs per primary care physician have increased for HITECH, MACRA, and Primary Care Medical Home and each has cost 50 – 100% more to implement compared to the practices in higher concentration counties. Correcting for lower rates of participation, this still results in 8 billion dollars that once could be spent in these counties but now goes outside for software, hardware, IT, security, consultants, training, innovation, and certification. These are dollars stolen from the personnel budget – specifically from the dollars that remain to invest in those that deliver the care.

It is not possible to recruit, retain, or recover primary care with 30 billion instead of 38 billion when about 80 – 90 billion represents sufficient primary care with even more needed for higher functions such as outreach, coordination, and integration.

Increases in Physician Concentrations Can Occur, But Are Not About Training

Examine carefully where deficits have improved and you will see changes in the populations and the health plans and collections. Examples include Appalachia near expanding metro areas, along the interstate highways, and in places with changes to better employers with better health plans. Economics, plans, and other changes increase revenue and shape higher concentrations of primary care.

Some dollars can be injected by grant funding or special funding although this can be negated by losses of the small practices that do not have this better level of financial support. Small hospitals once could support local primary care but they also have faced worsening financial designs and many have closed. They are not able to bail out local primary care or other basic services.

About 25% of workforce where needed involves women's health and 4 basic surgical specialties. Each of these have been declining by 2 percentage points a year since 2005. Few pass up the chance to do one or more fellowships. The workforce where most needed in these specialties is the oldest - indicating the lack of replacement.

Declines in Family Practice Proportions and Retention

Another indication of failure to resolve deficits can be seen in family practice. Family practice positions filled by MD DO NP and PA are the only ones that demonstrate population based distribution. Unfortunately even those training in family practice and starting in family practice are now falling away in the years after graduation and the years after entry.  Each source of workforce has declined to steadily lower proportions in primary care and especially in family practice positions.

Family medicine rode the efforts of the 1950s and 1960s to gain formal training and rode the financial design improvement of early Medicare and Medicaid from 1965 to 1978. FM grads from the 1970s set record levels of 30% rural location rates and 90% of those active found in office family medicine for a career.

But then the financial recession in primary care began. The Era of Cost Cutting took hold and the powerless and those providing care for them began to lose in the 1980s and steadily since that time.

Family medicine is down to 16% rural and the newest graduates have even lower levels. Hospital based FM is 26% rural – but this is once again about a different financial design involving ER, urgent, and hospitalist positions – the directions of rapid departure of family practice and other sources of primary care.

The Red Zone Specialties are those most likely to be burned out. They are most likely to plan to leave their current practice and are most likely tp plan to reduce hours of work a week. Generalists and general specialties - 75% of the workforce where needed, are Red Zone specialties. The decline of a specialty and the decline of the status of a specialty is about the financial design - especially when contrasted with the specialties doing much higher paid services and more concentrated in places most organized for highest payments and most lines of revenue.

Powerful Win and Powerless Lose

A recent blog article in Health Affairs asks an important question. Social determinants are important in shaping outcomes, but is there something even more important shaping social determinants? If so those powerless are shaped poorly and the powerful do best. Those associated with the most powerful win and those most associated with most Americans most left behind lose.

Family medicine residency graduates can be considered casualties in the struggle for power - a struggle where the powerful win and the powerless lose. Family practice physicians and clinicians lose the most because they distribute the best in their family practice positions - the positions that most serve the powerless.

Some separate from the powerless. Others are hit hard by designs that hurt most Americans and those who serve them most.

Declines in primary care retention and departures from serving where needed indicate departure from the powerless and movement toward the powerful.

Consequences of Rapid Turnover of Primary Care and Family Practice

Internal medicine departures continue and for all practical purposes the primary care internist has been financially designed away from care where needed. They were once 13% of the physician workforce where needed, but declines in primary care and distribution negate this source. The growth to over 50,000 hospitalists was the final blow.

Family medicine residency graduates are also no longer reliable for retention in primary care. Less than half of recent graduates are expected to be found in primary care within 10 years of graduation. Steady declines from 90% to 65% a decade ago to less than 50% are the result of the financial design. Pediatrics remains only about 5 – 6% of the workforce in rural or in lower concentration counties.

Some NP and PA increases will cover the losses due to their massive expansions, but they will not stay long. This is one of many mechanisms moving primary care from most to least experienced in a span on less than a generation of workforce. NP and PA will also have to cover the declining family medicine yield as well.

The previous 30 year careers in primary care from IM, FM and PD resulted in encounters with physicians averaging 12 to 14 years of 3000 to 5000 patients a year. This was once a most experienced and dedicated primary care workforce. Few planned to leave and few considered leaving. That was then, but now the primary care, urgent care, retail care, and emergency care is a mix of different sources with fewer years of experience and fewer encounters per year. There is not the same level of long term commitment and many may be searching for changes shortly after arrival.

The primary care workforce experience problem continues to worsen. This is made worse by those who leave after 5 or 10 or 15 years, taking their primary care experience with them.

Worse to Come with Half the Nation Behind by 2040 or Sooner

This is not a sane, rational workforce design, particularly for the rural or lower concentration county practices that represent concentrations of COPD, smoking, obesity, diabetes, premature deaths, poor, poor children, elderly, oldest of the elderly, Veterans, and mentally ill
  • not to mention half enough basic workforce  
  • not to mention half enough local resources 
  • not to mention most rapid population growth decade after decade since the 1960s 
  • not to mention more counties added to the lowest concentration 2621 – likely 2800 by 2040 due to continued small practice and small hospital closures 
  • not to mention housing failure in higher concentration counties forcing millions of older, sicker, poorer, more vulnerable populations to move to lower concentration counties with housing available and more affordable 
  • not to mention the cuts in Medicare and Medicaid this year which have played out worse for those smaller, least organized, and most important for health access 
  • not to mention increases in administrative costs and practice complexities (instead of decreases this year as promised)
Powerless people are concentrated while those most concentrated do ever better. This appears to be the case across health care design as with education and economics.

The attempts to "improve" health care and education actually result in more stresses and less support for those who deliver health care or education.
    Consequences of Massive Expansions - Even More Massive Expansions of Highest Cost Lowest Value Services and Workforce

    The result of massive expansion during a time of fixed financial capacity in rural, lower concentration, primary care, and basic service settings can only be massive expansion of procedural, technical, subspecialty workforce in places that already have top concentrations.

    Osteopathic graduates have been predominantly family practice as their primary care yield. Family practice choice has been cut in half with each doubling of osteopathic graduates - leaving no gain in primary care despite doublings as DO decreased from 70% to 35% to 18% family practice.

    This is what happens to MD DO NP and PA graduates with massive expansion of workforce forced beyond the generalists and general specialties that provide 90% of rural services and services where most Americans most need care.


    The designers that shape training and shape the financial design, do very well via the massive increase in highly specialized workforce paid best for their services. This shapes more specialized workforce and more concentrated workforce. Graduate medical education dollars also shape benefits for the designers. And even with deficits of GME dollars, the teaching hospitals find it beneficial to expand residency positions to improve revenue generation at lower cost of resident salaries and benefits.

    The consequences are seen in runaway health care costs - impacting many facets of American life and premature death, including budgets adversely impacted at all levels from national to state to local to employer to personal.


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