Flexible Fails and Permanent Primary Care Prevented

The United States has a health policy construct that actually prevents recovery of primary care. Primary care revenue support is insufficient to keep up with the increasing cost of delivering primary care. New types of costs burden primary care practices further. Meanwhile the rewards for non-primary care choices have increased. The rewards are greater for primary care graduates that depart primary care. The rewards are greater for employers who receive more revenue when graduates convert from primary care.

Accelerating cycles of primary care deficits are the result of US policy.

1. The cycle starts with primary care deficits.
2. Innovative academicians create new sources of primary care. The designs are generic to workforce needs and are not specific to primary care or most needed primary care.
3. Despite more sources and increased graduates in each source, there is less primary care result per primary care graduate. Studies contribute to the confusion as they only measure first career choices which fail to capture steady departures from primary care in the years after graduation. Only about 30% of US primary care training results in primary care delivery.
4. Innovators propose to fix primary care with more types of primary care and further expansions of annual graduates. Others say that primary care can be fixed with reorganzation (continuity home) or innovative payment designs. No such proposal can work without changes in the US policy construct that increase primary care retention in professionals and other personnel - this requires more primary care spending, especially in 30,000 zip codes with lowest spending by design.
5. US policy does not change and this results in less retention of primary care graduates within primary care careers with flexible primary care graduates departing primary care during training, at graduation, and each year after graduation.
6. The result is ever more non-primary care with continued deficits of primary care.   

The 1980 primary care class year including six primary care sources with 14,000 graduates at 18 Standard Primary Care Years per graduate for 250,000 Standard Primary Care Years for the 1980 class year. The 2012 graduates of six sources will be 28,000 in number but the yield will be only 7 SPCYrs per graduate for a result of 195,000 SPCYrs. Standard Primary Care Year 2012

Since 1980 the United States has had substantial growth of population and primary care demand but the response has not been Specific, Measurable, Achievable, Realistic, or Timely with regard to primary care or the health access needs of most Americans. Tragically the needs are greatest in locations where the elderly, poor, near poor, rural, and underserved populations are found - in 30,000 zip codes that have lower than average to lowest primary care concentrations.

Permanent primary care family medicine is a real solution for primary care and for 200 million Americans in 30,000 zip codes, but permanent primary care choice is actually prevented by policy. Only medical students can choose permanent primary care as nurse practitioner and physician assistant primary care is flexible by design. Only medical students can choose family medicine residency training. Nurse practitioner and physician assistant family practice employed components make the same substantial contributions where needed, but only when remaining in family practice. NP and PA graduates found in family practice employment have decreased to 25% of total graduates. Even when entering family practice with its substantial primary care, rural, and underserved outcomes; the retention is not permanent. Family medicine retains primary care and rural and underserved components because of permanent family practice result.

If the United States only had permanent primary care as the source of primary care, it would know exactly how many graduates were needed each year to supply sufficient primary care. Meeting Primary Care Needs in the Latter Half of the 21st Century 

Even with a permanent source, insufficient primary care support will result in a permanent source converted to flexible. Workforce cannot remain where it is not supported. Family medicine has had greater primary care retention in the past. It is possible that this final permanent primary care source could be defeated to flexible and non-primary care. This is quite easy to accomplish as all that is required is for the current design to continue to keep revenue paid below the rapidly increasing cost of delivering primary care.

United States Policy Prevents Permanent Choice as Graduates Prefer Flexible Primary Care Training Sources To Keep Their Options Open or Outright Choose Non-Primary Care

It is not possible to recovery primary care with flexible sources. The US primary care training design is 90% flexible and only 10% permanent. Also the flexible training outcomes have steadily decreased in primary care result per graduate. Ever more graduates are required and even with expansions, the primary care deficit is not erased. A permanent primary care source has different outcomes by design.

The current US design facilitates Three Dimensions of Non-Primary Care Growth with Zero Growth in Primary Care

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Shared Savings Equals Cost Cutting By Design

Medicare needs to cut costs. It has chosen methods to cut costs that will damage the basic health care services needed by most Medicare patients. And instead of calling this cost cutting, it uses terms such as "shared savings." Even worse, the “shared savings” will result in even less health spending in United States locations that already have lowest health spending. Innovative designs are not the problem. The problem is that Medicare designers need to understand the basic health needs of most Medicare patients left behind by design.

Medicare and Medicaid face significant challenges.

Spending will continue to rise with more patients covered such as the doubling of the elderly from 2010 to 2030. The United States has continued to add more drugs, treatments, drug coverage, reasons for hospitalization, and technologies that are most costly. Politicians shout Death Squad rhetoric for any attempt to limit services. Meanwhile those needing basic services such as primary care are left behind. Medicare, Medicaid, and other patients are also left behind in 30,000 zip codes with lower or lowest health workforce.

Not surprisingly the Centers for Medicare & Medicaid Services (CMS) wants to cut costs just as in the 1990s and just as in the 1980s. In fact, the real designs since the 1980s have all been cost cutting in focus.

CMS Design Distortions

Surprisingly few realize that the CMS design is not focused on health or health care delivery for improved health. More and more studies are indicating the failure of a design that allows more and more spent on fewer Americans with little or less result. The real Medicare design favors those nearest death rather than better health and better health care. This is the design that works best for those receiving the most spending. They also influence designs and designers the most.

Designs Fail for Most Americans Forgotten By Designers

About 30,000 zip codes with 200 million Americans are dependent upon Medicare and Medicaid for substantial amounts of health spending. Another top down cost cutting (shared savings) design will result in even less spent in 30,000 zip codes. This will result in fewer primary care personnel and professionals in 30,000 zip codes. Medicare makes this worse by failing to increase primary care revenue as each year bring double digit increases in the cost of delivering primary care. Accelerating Cycles of Primary Care Decline are accelerated.

The CMS changes will make it even harder for Medicare patients (and those not on Medicare) to access primary care in 30,000 zip codes. Already practices are making changes such as limiting Medicare patient access. In states that have experienced Medicaid cuts substantial problems result for many practices dependent on Medicare and Medicaid for half of revenue. Practices that can avoid lowest revenue Medicare and Medicaid patients as well as those on little or no insurance will do so. Closures of practices, fewer personnel to deliver the care, and less volume per primary care professional will result in increasing access problems for most Americans.

What Medicare Was Before 1980 and After Redesign

Medicare has only acted to improve primary care only from 1965 to 1980 when it led the nation to a doubling of the primary care graduate design. This was the only time the primary care workforce production design was increased. Since 1980 only non-primary care has doubled and it has done so each 15 years. The Medicare design fails to reign in non-primary care with massive overspending. The Medicare design fails to pay for basic services even 2010 to 2030 when the elderly are doubling and they need local zip code care or adjacent zip code care as the elderly become more limited in mobility and transportability and need 2 to 3 times more primary care.

Cost cutting designs may be difficult to avoid, but they will not help most of the elderly or most people in the United States – by design.

How Can Primary Care Infrastructure Be Restored with Even Less Spending?

The goals of "promoting accountability for the care of Medicare Fee-For-Service (FFS) beneficiaries; requiring coordinated care for all services provided under Medicare FFS; and encouraging investment in infrastructure and redesigned care processes” are impossible goals with a cost cutting design.

The United States has not demonstrated the ability to prioritize horizontal health access needs under designs that reward vertical tertiary and quaternary services. Also the horizontal health access providers have remained true to health access service on the front lines. Those dominating US health care are the most organized subspecialty and academic interests. Accountable Care does not offer opportunities to separate out primary care in ways that allow it to survive, much less become the foundation of a viable health care system.

The Motivations for Infrastructure Investments Are Poor.

Cost cutting designs such as shared savings will make it even more difficult for necessary infrastructure reinvestments in primary care delivery. Too little spending on primary care has already resulted in over a decade of larger multi-specialty and academic practices less likely to bail out underfunded primary care.

A better choice is to fund primary care separately and directly. A separate primary care design is also an important check and balance upon appropriate care. Primary care too connected to subspecialty and hospital care can be subjected to compromise. A population based or cost based design would be best for primary care. Cost cutting is appropriate for hospital and non-primary care services that have resulted in runaway US health care costs for decades.

Benefits for the Bigger and Badder

Another concern is that only those most organized and sophisticated with top number-crunching ability would benefit. They can select the partners that they want and the populations that they want. They can even bundle services in ways that cherry pick services. Accountable Care is already a bundling of services and the failure to recognize this is also another concern with regard to the designers.

New reforms plus failure in accountability are problematic.

The Obama administration has allowed states the flexibility to have plans with a wide range of services. Also states that have not met deadlines or basic needs have not been disciplined. When the federal government sets up a program to allow financial incentives for those that make investments such as electronic records and then fails to force states to meet federal deadlines, the result is distrust of providers in federal and state designs. States have had such bad plans that lawsuits are required – and more flexibility is being given?

Even optimal states such as Oregon that are far ahead in developing state plans, those in charge cannot tell how much spending will be invested and there is a vague mention of three different types of plans. As a physician delivering care, I can tell you that a major problem is variation in health care plans. Even if people can access care, there is great uncertainty with regard to getting basic medications, referrals, or hospitalization.

At some point people who promise more for less should be held accountable. Innovations and reorganizations are spectacularly unsuccessful, especially in areas such as basic health access where the United States has failed to invest in many dimensions.

Integration Dysfunction

For decades the US has never figured out how to integrate various private, public, and grant providers. It has actually created more designs that make coordination even more difficult. Coordinated care could result from the new reforms. Unfortunately the cost cutting portion is the deal killer.

Instead of starting "population based" for a more integrated and equitable design, a shared savings payment model is required first. There are other increasing costs not considered in a cost cutting design or any design. These include rapid increases in routine costs, increases in the cost of finding and keeping trained personnel in areas such as primary care, and new costs such as electronics and software.

Without an integrated and simplified design such as single payer with universal access and standardized record keeping, the real benefits of integration and coordination are minimal. The same fragmentations result in too much cost required just to get paid such as screening patients, multiple fee scales in multiple locations for multiple services with multiple types of billing and multiple types of record keeping, etc.

Grassroots Up Versus Top Down

Accountable Care follows the same failed designs of past decades and for the same basic reason – the designers. Cost saving has been documented in models that have focused on basic personal, cultural, social, and family needs. Southcentral Foundation is such a model. Southcentral also had quality improvements and greater retention of health personnel, essential for better quality and better patient satisfaction and better health care in Alaska on complex patients.

Time and talent and treasure are three different approaches. The US design has resulted in a focus on treasure and highly specialized talent. What is also required is time spent with people and talent in people skills areas.

What If Our Nation Had a Different Design for Entry to Medical School?

Medical students before and during school are not known for substantial time availability, but what they have can be spent working with patients part time in their homes to save substantial costs. it is interesting to see energy invested in a grassroots human being effort rather a focus on research. Medical students at the School of Osteopathic Medicine Arizona have one of the most intense first years of training, yet several have found the time to devote to a home care prevention of readmission. This is a partnership between the students, the hospital, and dieticians. The results in the first two years have been outstanding. Also this was accomplished with little treasure or specialized talent. The model reinforces being there in a caring way helping patients to maximize their health - rather than more and more health care services required.

Imaging 50,000 applicants pursuing medical school based on grassroots service efforts rather than devoting hundreds of hours for research (or 250,000 applying for health professional school positions). Imagine tens of thousands working with patients, families, and neighborhoods on better health outcomes in more than just readmission.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure

Number One Two Three in Health Access

Solutions for health access primary care workforce

• Enter primary care practices at highest proportions after training
• Stay in primary care practice at highest proportions in the years after graduation
• Have the longest health professional career lengths
• Remain active in practice during a career at the highest percentages
• Deliver the highest volume of primary care when active in primary care delivery.
• Are most likely to be found in 30,000 zip codes with 200 million Americans and only 25% of total workforce (Practice Locations Outside of Concentrations) and
• Are least likely to be found in 1000 zip codes with only 11% of the population and 50% of the workforce (Super Center Concentrations).

Only family medicine residency graduates meet all of these criteria for graduates past, present, and future. Only family medicine residents have not been increased beyond the 3000 annual graduates first reached in 1980. The US primary care design has also not changed for primary care numbers since 1980 while the non-primary care design has doubled each 15 years since 1965.

Only a broadest generalist primary care source can best meet the needs of over 65% of elderly, poor, near poor, rural, underserved, lower income, middle income, disadvantaged, children in need of health care workforce, and shortage area populations.

Number 1 is United States Origin Family Medicine from a US Medical School	25 Standard Primary Care Years	Estimated Range of 23 – 30 Standard Primary Care Years depending upon age at workforce entry, gender, retention in primary care
Number 2 is United States Origin Family Medicine from a non-US Medical School	22 - 25 Standard Primary Care Years	A slight delay in entry to practice is likely to result in the potential for lesser workforce, but there may be no difference
Number 3 is non-US Origin Family Medicine from a non-US Medical School	20 – 22 Standard Primary Care Years (but broad range)	Medical education in other nations commonly results in younger age but those working toward US training and practice face delays that result in older age entry to US workforce

Standard Primary Care Years Estimates for 2012 

First career and practice location choices are simply insufficient to assess primary care sources. The Standard Primary Care Year is an important estimate of future primary care delivery assigned to the class year of graduation. 

Pediatric and Medicine Pediatrics	10 – 14 SPCYrs	Less than half and likely less than 40% will remain in primary care.
Physician Assistant Beginning Family Practice	12 SPCYrs	Steady departures over the years after graduation limit outcomes.
Nurse Practitioners Trained as Family Nurse Practitioners	6 – 8 SPCYrs	Half will be active as direct care clinicians in family practice employ. Fewest years and lowest volume result in substantially fewer SPCYrs.
Internal Medicine	3 – 5 SPCYrs	Few enter primary care and departures continue after graduation.
Physician Assistant not Starting in Family Practice	1 - 3 SPCYrs	Family practice is the predominant PA primary care vehicle
Nurse Practitioners not FNP trained	1 – 2 SPCYrs	Family nurse practitioners are the predominant NP primary care vehicle

Nurse practitioner and physician assistant contributions to rural or underserved locations in need of workforce are multiple times greater when employed in family practice as compared to NP and PA not family practice employed. NP and PA graduates not employed in family practice remain below average in needed practice locations. About 25% of NP and PA workforce are found active as family practice clinicians although declines could result in fewer.

Comments by any number of “workforce experts” about family medicine from any US origin or non-citizen source should be supportive about expansion, about selection specific to family practice, and about training specific to family practice. This entire blog was posted because non-citizen family medicine has received comments and even testimony to Congress that has not been flattering. What matters is health access delivery where needed. Even if only 7% of non-citizens average family medicine choice, this choice is an important one for 200 million Americans left behind and about to have even more difficulty.

Generic expansions of health professional training not specific to permanent family practice (MD, DO, NP, and PA) should be understood as solutions for non-primary care and practice locations that already have top concentrations. Flexible designs fail for primary care and for 200 million Americans. Flexible designs are represented by NP, PA, and IM training that can result in any number of non-primary care careers. For nurse practitioner or physician assistant training to be SMART Basic Health Access Solutions, they would have to find a way to permanent family practice by a permanent design change. Generic and flexible is failed health access.

Specific family practice is the SMART solution for health access for 200 million Americans left behind and falling further behind by design.

Physician Distribution By Concentration Zip Code Practice Locations Inside and Outside of Concentrations

More about the Standard Primary Care Year

Three Dimensions of Non-Primary Care Expansion and Zero Growth in Primary Care Design

Thanks to all 12,000 

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure a

Rural Rearrangements of the Deck Chairs

Comprehensive Rural Programs Are Not Enough to Overcome US Maldistribution By Design

There is no evidence that Rural Programs in Medical Schools actually increase rural workforce when considering the outcomes of the parent schools. Even with expansions of annual graduates in the parent schools, there has been no improvement. There is nothing wrong with rural programming. It is possible that health access outcomes could decline without rural programming or it might be possible to demonstrate problems resulting from inadequate preparation for the demands of rural practice. The fact is that rural programming has not been able to overcome overall changes in the US health design. Rural programming has not been able to keep up with population changes that increase demand such as increases in elderly, poor, and lower income patients. Lack of health spending for rural populations is the likely reason why rural programming or generic expansions are unable to improve rural access to care. In some ways rural programming can be seen as preventing solutions for health access that require increased spending in primary care, in rural locations, and in locations underserved for workforce.

New Rounds of Publications Emerge

Comprehensive Rural Programs have been promoted as health access solutions in new publications. Unfortunately the efforts of Duluth, the Rural Physician Associates Program, the Rockford program, and the Physician Shortages Area Program have not improved the rural, primary care, or family medicine outcomes when considering the parent schools of these programs - the University of Minnesota, the University of Illinois, or Jefferson.

Defeat of Rural Programming Due to Individual School Family Medicine Collapse or Decline

Declines in family medicine for Mercer from 32% to 3% will take Mercer from a top ranking proportion of graduates found in rural, found in underserved, and found in rural underserved areas to less than the national average.

The WWAMI program has long been promoted as a solution for states in need of workforce, even as states such as Alaska spend 1 million more dollars a year on primary care recruitment, retention, and locums costs alone. WWAMI has the same problem as all rural models - it leaks. The graduates have not been required to stay instate or in needed careers. The graduates are not admitted with a commitment instate or to family medicine or to rural practice or to underserved practice. The major WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) state needs remain the same - family physicians. With inadequate family physicians, locations in need of workforce are forced to pay more and more to get the same or less workforce.

Marginal and underserved rural proportions have certainly not improved for the University of Washington in the AMA Masterfile. There was an 11% proportion prior to WAMI and down to the 8 - 9% level for 1994 - 2000 graduates. The 20 - 30% family medicine level is now down to one-third this level. The rural contribution of the University of Washington have not improved at best and there are indications of steady declines. 

The main reason for success and failure appears to be the same reason. During 1965 to 1980 the United States poured billions into health care and much of this went to marginal and underserved locations with high proportions of Medicare and Medicaid patients. The 1980s cost cutting designs with increasing costs of delivering care and less revenue resulted in declines. Then the 1990s again injected funding specific to rural locations and primary care where needed for a few years before returning to cost cutting and major declines across all graduating classes of MD, DO, NP, and PA.

The University of Washington and the University of North Carolina have also been used as examples of medical schools that can accomplish dual roles of research and health access. Together all of the parent schools with rural programming actually barely keep above the US average regarding needed rural outcomes.

• Medical schools that do much better for rural outcomes are medical schools in rural locations.
• Osteopathic public medical schools have also been outstanding sources of rural physicians, instate physicians, and family medicine.
• Medical schools in the South also contribute more rural physicians, but this has to do with higher levels of rural population
• Medical schools in the Midwest also contribute more rural physicians for the same reasons - a state with a higher proportion of rural workforce.

What is most evident is little change at all - before or after rural programming.

Thirty Years of Health Access Workforce Prevention

The creation of osteopathic public medical schools was only 1970 to 1980 and further osteopathic public schools have been prevented for 30 years. At the heart of the successes of all the medical schools associated with rural workforce is family medicine, also prevented from expansion for 30 years by the US design. This remaining permanent primary care choice is difficult when primary care is marginalized, when the practice locations most common to family physicians receive the least health spending, and when many of the locations preferred by medical students are locations that have lowest percentages of workforce in family medicine. Family physicians can be tracked as steadily moving away

The University of Nebraska is another example of declines in instate, primary care, and rural workforce due to changes in family medicine and admission. The University of Nebraska has established a number of different rural programs involving 8^th grade to retention in rural practice. Unfortunately a decline to 2 - 3% family medicine choice for the great majority entering from major metro origins defeats the overall rural programming (last 4 matches at UNMC). The proportion entering from out of state and instate metro areas continues to increase (40% to 50% to 60%) and this proportion has 4 to 5 times lower choice of family medicine than in recent decades. It is difficult to fill graduate programs that do address Nebraska’s health access needs without family medicine choice. As more UNMC graduates depart the state for training and for practice, UNMC will no longer be able to keep up its contribution of half of Nebraska workforce - particularly as seniors double from 2010 to 2030.

Chen in Academic Medicine suggested that rural training tracks triple rural location in the graduates of a family medicine residency. Actually this is not specific to rural programming. simple choice of family medicine is enough to triple rural location, even when controlling for physician origins, type of medical school, and state practice location type.

Rural programs and tracks are small. Rural efforts are dependent upon sources of students that are declining (lower and middle income origin, lower and middle population density origin, children not of professional parents, rural interested, family medicine interested, first generation to college). Graduate medical education rural efforts can only exist when programs fill their residency positions (more difficult, not the best fit types chosen). Also the higher proportions of health access workforce in existing rural programs is easily overcome by the much lower and declining health access outcomes of much larger non-rural or traditional components.

The existence of such rural programming within a state or school appears to rearrange who chooses such programming without actually increasing desired outcomes. The outcomes are worse when considering entire careers of contribution due to lack of instate retention, declining primary care retention in the years after graduation from primary care training programs, and declining retention in rural locations.

Only complete school designs have made top contributions to rural workforce including rural located medical schools and osteopathic public schools. Only the family medicine proportion can be consistently demonstrated to have top health access contributions. Except in a few states (states that tend to have top workforce concentrations that drive FM out), family medicine is also associated with top instate retention. This is noted in University of Kansas graduates choosing family medicine that have 16 times greater instate rural location compared to U of KS grads not choosing family medicine. Family medicine has been the result of admission of students with factors contributing to instate most needed health access and family medicine contributes to instate most needed health access.

Graham Center Policy One-Pager    Comprehensive Medical School Rural Programs Produce Rural Family Physicians    While the title is true, the parent institutions do not have overall rural workforce gains. Also the parent institutions have barely above average rural contributions.

Which Medical Schools Produce Rural Physicians - a 15 year update

This is Blog Number 50 for Basic Health Access Blog begun in 2011.

Rural Medical Education Specific Blogs and Links

Rural Workforce 2000 to 2010 Uncle Sam says "I want you" to serve in rural locations. Uncle Sam's design says "I don't want you" to serve in rural locations. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans.

Atlas of Basic Health Access at the World of Rural Medical Education

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many (non-health access interested parties) determining training curricula, and very few focused on basic health access

Pounding Poverty Providers with Pay for Performance Designs that send even less dollars to those who care for most Americans are the reason for health access problems. Pay for Performance designs make matters worse resulting for gains in revenue for those that care for patients who naturally have better outcomes and no gain for those who care for the more complex patients. 

Speak Your Piece: Measuring Rural Health Care  Rural health care providers are paid less to provide treatment to a population that is more likely to be poor than those in the cities. Now medical researchers are saying rural hospitals don't provide the same quality of care as those city institutions that have more money and richer patients. Well......Which is it, JAMA? Where is your consistency in articles regarding quality of care? If you choose some authors that consider social determinants and other important limitations but ignore these factors in other publications, this causes confusion. 

Rural Primary Care: Stark Realities All primary care sources have declined in primary care per graduate and in rural primary care delivery per graduate. The rural Standard Primary Care Year contributions over the class years illustrate the declines in rural primary care delivery.

Non-Specific Rural Pipelines or Specific Long Term Obligations  Voluntary choice allows potential rural physicians to steadily leak away with each year of training and practice. Only very specific shaping is most likely to result in early, middle, and late career rural contributions. 

Preparing for Health Care Cuts This is not good news for rural workforce. No administration in the past 30 years has really understood the problems that result in insufficient rural workforce and matters may be even worse in 2012 and beyond.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Piddle Twiddle and Resolve Not One Damn Thing Do They Solve

In the play 1776 there are any number of wonderful allusions to Congress then and now. Former President Nixon thought so too. He requested and received an edited version regarding Cool Cool Considerate Men as he felt they too closely resembled conservatives of the time. Cool Considerate (calm, calculating, conservative?) Men are still very evident, but do they still lead well or wisely or with sufficient understanding of the daily lives of most Americans?

Congress today is a divisive Congress just as presented in 1776. Is Congress today working together affirmatively for the nation. The most basic areas important to most Americans appear to be low priority. The current physician fee crisis is a great example of Piddle Twiddle and Resolve without a solution.

It has taken years for the Medicare Physician Payment Advisory Commission, stacked with landed gentry benefiting from the designs they set, to recognize its past errors and to recommend some protection of primary care fees as compared to non-primary care. Major protests were required to get just this small change. Reasonable increases in revenue that might keep up with the costs of delivering primary care are not even on the drawing board. Primary care workforce has followed the primary care spending design as noted in Accelerating Cycles of Decline.

Primary care workforce designs have doubled primary care numbers only from 1965 to 1985. Each 15 years since 1965 the non-primary care workforce has doubled and this will continue until 2025. The US is attempting to function from 2010 to 2025 on a design that was set in place in 1980.  Despite twice as many graduates and 3 times as many primary care sources, the primary care numbers of clinicians and the primary care delivery capacity continues to decline. Policy Failure Plagues Primary Care and Permanent Primary Care Choice through Five Policy Periods
indicate designs that work or fail.

Ever more resources are spent on non-primary care while primary care faces across the board cuts on top of inadequate reimbursement. The entire mess results in distrust of government and health insurance companies by those who provide care as well as the patients who receive care.

Even physicians realize that primary care reimbursement is too little (Leigh). More practices stream to types of payment (rural health clinic and FQHC) that have the ability to cover rising costs of care rather than fee for service under SGR that has been mired in the basement. Fixes in the 1960s to that restored some basic health care infrastructure failed as costs rose faster than revenue and as redesigns sent the spending to fewer locations with greater workforce concentrations. Fixes in the 1990s failed in just a few years. But Congress has little memory for failure and has little awareness as well.

Piddle Twiddle and Resolve

Delays are common responses when more spending is involved. There is no time for most Americans in need of care and the elderly are the major example. For 50 years the US has known about the need for more care beginning in 2010 and there has been no preparation for the workforce to deliver the care. In fact the workforce most needed is declining the most.

It is already too late for the elderly of today as they double from 2010 to 2030. During this period internal medicine will collapse from 90,000 to 40,000 in primary care as this is all that 1400 entering primary care a year can provide. Family medicine can no longer increase as it has been held hostage for 30 years at 3000 annual graduates - zero growth. Sadly government reports indicate increases when increases are not possible.  Journals also fail to present the truth or the consequences of failed policy. NP and PA workforce proportions have declined steadily in the needed primary care and in the locations where 65% of the elderly are found. This is mainly about fewer remaining in family practice - the predominant midlevel primary care, rural, and underserved response as well as service to those outside of concentrations.  Geriatric workforce is also concentrated 75 - 80% where only 30% of the elderly are found.

Health care most important for the elderly is held hostage by designs that defeat primary care as well as workforce in the zip codes outside of concentrations where 68% of the elderly are found. The elderly need two to three times more primary care and this workforce must match up to zip codes where the elderly are found - particularly as they lose mobility and transportability as they age. The damage of the last few months and the next months is specific to those remaining who care for the elderly. This is compounded by the past 15 years of decline. ew years of damage.

Piddle Twiddle and Resolve

The record is solid for health policy impact and primary care. Primary care numbers doubled from 1965 – 1980 with the initial health access plan before cost increases and cost cutting designs took over. The 1990s reforms boosted primary care and family medicine to peak levels with increased primary care revenue and decreased or stagnant non-primary care. The 2010 reforms that might have helped primary care have been compromised by cuts in Medicaid and those who care for patients most in need of care, in addition to innovation focus, and reorganization focus. As commented in 1776 - “Sweet Jesus” 

Momma Look Sharp To See If You Can Find the Remaining Front Line Workforce

The basic health services needed by nearly all Americans nearly all of the years of their lives are being compromised by insufficient primary care spending (widely recognized) and insufficient workforce retained in primary care due to insufficient primary care spending. To Follow the Workforce Follow the Spending. Matters are worse with substantially more paid to non-primary care, allowing experienced primary care personnel and professionals to be hired away from primary care employment.

Is Anybody There, Does Anybody Care?

As noted by 180 days of neglect after 30 years of neglect

Piddle Twiddle and Resolve 

There is of course only one response as indicated in the play

“Sit down Bob, Sit Down Bob, For God’s Sake Bob, Sit Down”

The reply is of course  "Never, Never"

May 2012 Be a Time When Congress and leaders across our nation, Despite Divisions, Will Resolve to Work Affirmatively for Most of Our Nation

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

Leigh JP, Tancredi D, Jerant A, Kravitz RL. Physician wages across specialties: informing the physician reimbursement debate. Arch Intern Med. Oct 25 2010;170(19):1728-1734.

1776 is a musical with music and lyrics by Sherman Edwards and a book by Peter Stone. The story is based on the events surrounding the signing of the Declaration of Independence. It focuses on, and partly fictionalizes, the efforts of John Adams to persuade his colleagues to vote for American independence and to sign the document.

Link to the "Cool Considerate Men" sequence from the restored version of the film. "This sequence was cut out of the original release upon complaint by President Richard Nixon, for the song allegedly drew many parallels between the opponents of American Independence in 1776 to the modern conservative right." – forever to the right…  Dialogue Hancock – “Fortunately there are not enough men of property in American to dictate policy.” Response -  "Most men with nothing would rather protect the possibility of becoming rich than face the reality of being poor." A comment about the Republican Party is worth a read. YouTube

Graphic   Primary Care Graduate Increases, Decreasing Primary Care Delivery

Pounding Poverty Providers with Pay for Performance

United States designs for health spending consistently result in less for those who already have the lowest health spending. This is accomplished by designs that send less to those that attempt the responsibility of their care. Design changes and even reforms that are supposed to send more spending to those who care for most Americans left behind can also fail.

Because more Americans are joining those at or below poverty, particularly children, the nation should spend far more time understanding the inequities of the current and future designs.

Proposals for bonus funds were supposed to send more funding to those who care for underserved patients, family medicine and rural associations had to exert additional time and energy and research to insure that the programs actually send funding to those who deliver the needed care. Studies from North Carolina indicated that previous bonus program funding were commonly accessed by those that were not supposed to receive the funding.

Hong in JAMA demonstrated that Pay for Performance punished practitioners caring for the underserved. See comment in AFP Community Blog.

Pediatrics just published an article about the value of a continuity medical home – an article that actually demonstrated that continuity was really about advantage and discontinuity was about disadvantage. The real driver of better quality was social determinants, not the medical home concept in this study that did not really even study outcomes of actual certified medical homes.

Now Kaiser indicates much the same for Hospitals that care for those left behind. Readmission rates are much higher for lower income Americans. This is of course a function of any number of social determinant and similar demographic characteristics that add up to difficulties that lead to hospitalization and difficulties that are far more likely after hospitalization.

It is hardly possible to keep up with all the ways that funding is diverted to care of those with easier care and naturally better outcomes.

Not much comment is needed other than indicating that until designers understand most Americans and their basic needs, the designs will continue to favor few. Design changes also may insure even greater divisions.

Potential Impact of Pay-for-Performance on the Financial Health of Critical Access Hospitals (Policy Brief)    Author(s): Robert Town, Ira Moscovice  Sponsoring organization: Flex Monitoring Team
Pay-for-performance (P4P) incentives likely reduce the financial status of CAHs already in financial stress. However, P4P incentives are likely to have only a modest impact on the financial stability of CAHs.  Date: 02 / 2010

Providing Underserved Patients with Medical Homes: Assessing the Readiness of Safety-Net Health Centers  Author(s): Katie Coleman, Kathryn Phillips
Sponsoring organization: Commonwealth Fund
Surveys safety-net health centers (public hospitals and clinics, federally qualified health centers, rural health centers, and free clinics for the medically underserved) to determine their potential to become patient-centered medical homes (PCMHs). Date: 05 / 2010    A summary would be that those caring for Americans left behind have an uphill battle to qualify as medical homes. They have a major battle just trying to keep up with increasing demand.

Basically even to become eligible for increased pay, there is substantially more investment required to get where needed. Also the outcomes will be less not due to lack of effort, but due to care of underserved patients. Government designers and reformers do not understand the people most in need of care or the type of care they need or the funding required to meet their needs.

A true approach to build quality requires far more understanding and awareness and substantial time and effort to process a real design. Cost cutting focus results in rapid implementation and designers are most familiar with what works for a few rather than what would work for most.

Arizona has delayed six months beyond the required July 1 2011 federal deadline to set up their electronic verification site so that Medicaid providers can recoup their tens of thousands invested in patient management software and hardware and consultants in the past 2 years. There are only 10 days left in the year. It appears likely in at least one state that investments required to gain incentives will not even be paid as indicated. Other states short on funds and Medicaid funds may also play the delay game. This is a catastrophic event signaling to those who care for patients in need that they need to stop caring for Medicaid patients or leave the state. This is another way to Pound Poverty Providers.

One thing is certain. Taking the "safety-net" for granted is guaranteed to result in greater divisions between Americans in income, health, employment, productivity, and other measures.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies