Basic Health Access

Please reconsider your plans to devote major resources to expand family medicine graduates. We must work together for FM, but we must be effective. Effective efforts must be specificity to address the problem. The problem in primary care cannot be solved by training. More reports, conferences, staff resources, and association resources would waste time, effort, and energy. It is meaningless to attempt to expand any primary care, generalist, or general specialty workforce without the dollars specific to support more delivery team members. Only a major improvement of the financial design can support more team members in more locations - especially where most Americans have the least by design. The lack of effectiveness of more graduates is obvious and has been for decades. New sources of primary care and massive expansions of four sources have not resolved deficits of primary care or workforce where needed. The glut of workforce created will make matters worse. The finan...

We should send a clear message to the "experts" and the media and associations and health professional training institutions: Please stop the insanity of doing the same thing over and over again expecting a different result.  New innovative types of workforce have failed to resolve workforce deficits despite massive expansions More new types and more expansions have failed. More new types and more expansions are proposed. It is the financial foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed. It Is Not the Initials or the Expansion, It is the Financial Design It is not about who is a better health professional or the type of training. Expansions are not the solution for any domination or perceived domination of health care. Texas has another new medical school planned but a family physician dean will not be able to keep the promise of more doctors where nee...

Once again the designers are promising a solution for shortages of physicians that cannot work. The expansion of graduate medical education will not send more physicians to counties short of physicians. Expansions of MD DO NP and PA have all resulted in steadily higher concentrations in fewer counties that already have higher concentrations. The evidence is already in the databases. Until the financial design is fixed with more dollars for basic services, there will be no solution for care where needed. MD DO NP and PA are finding more ways not to go into primary care and this pathway is all about dollar distributions, or lack thereof. Under the current financial design there is no way that any GME, MD, DO, NP, or PA expansion can actually address shortages. GME is 94% in the wrong counties with only 6% found in counties lowest in physicians, health spending, economics, and health outcomes. Residents are 154 per 100,000 in 79 top physician concentration counties. The 2621...

Expansions of clinicians are out of control. There appear to be no obstacles to accelerating numbers of clinicians. This is the result of more sources of clinicians plus expansions in US MD, US DO, Caribbean, non-citizen international, nurse practitioner, and physician assistant training. Graphics indicate the most rapid increases in nurse practitioner workforce, rapidly leaving US population growth behind. The total number of physician assistants who could practice is much higher as only 60% are clinically active. The US Population will increase only 29% from 2010 to 2040 but the active clinician workforce is set to increase by 100%. There might be some decline in the growth of annual graduates for any source, but the last doubling of NP graduates from 8000 to 16000 in less than a decade indicates that high numbers are not a limitation. The ten times expansion since 1980 does not appear to be facing limitations. Nursing school graduates have also increased substantially,...

Dramatic headlines now highlight profiteering in hospice services.This should not be a surprise to those who track workforce. Hospice has consumed steadily more nurses in recent HRSA nursing reports. When the nation sends more spending to a service, more workforce follows because workforce is required to be able to deliver the services. Nurses have moved steadily toward higher pay and toward the most lines of revenue with the highest revenue in each line just like physicians, physician assistants, and nurse practitioners. All also move toward higher pay for less hours as well. About 85% of nurses are forced though hospital entry positions after nursing school - by designs that send the most spending to hospitals. Witness the current nursing problems as hospitals have already ratcheted back. With 30% more spending compared to the costs of delivering care, health services expand rapidly - as in just about any other health care business. More profits draw more investors and resul...

Promotors of generic expansion have commonly mentioned primary care workforce increase. At best primary care workforce remains a side effect of expansion. Training and spending and accreditation in primary care remain subservient to non-primary care interests and influences. Even primary care associations are compromised by members and leaders influenced primarily by non-primary care influences. The US should not expect an increase in primary care because this is what has been designed. Non-primary care is quite another result. Primary care projections are actually quite easy to make. The best estimates are guided by recent decades. Recent decades of stagnation in primary care indicate no growth. Primary care spending is stagnant, permanent primary car such as family medicine is stagnant, and flexible primary care sources have been departing primary care. The US will remain at zero growth even with expansions as fewer remain in primary care during training, at g...

Achievable primary care is one of the weakest areas in the workforce literature. Enough annual graduate expansion of any primary care source will increase primary care, but steady declines in the proportion remaining in primary care in the years after graduation make this a less efficient and less effective process for the purpose of addressing primary care workforce. With primary care graduates departing primary care it is not possible to recover primary care.  Despite projections of primary care increases by government and by major associations, the US is actually losing ground in basic health access primary care. Increases in cost of training, more graduates required for less primary care result, and increases in the costs of locums, recruitment, and retention insure failure in primary care delivery with the current voluntary and flexible design that facilitates departures from primary care. Studies and reports that project primary care workforce place too mu...