Basic Health Access Blogspot 2011

My desire for you for 2012 is for you to progress toward becoming a true leader, for you to benefit from the leadership of a true leader, and for you to select true leaders to lead our nation.  

A leader will find it difficult to articulate a coherent vision unless it expresses his core values, his basic identity…. one must first embark on the formidable journey of self-discovery in order to create a vision with authentic soul.

Mihaly Csikszentmihalyi

May the new year of 2012 be a continued journey of self-discovery for you and for our nation. I have been blessed with opportunities at East Tennessee, Nebraska, and A T Still to continue the self-discovery begun in rural family practice in Nowata OK.

Fifty Blogs in Order of Viewing Popularity

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

The Clinician Specific Medical Education Blog was also begun as a complement to SMART Basic Health Access with the most recent posting Longitudinal Clinical Experience Rating Scale and others such as Are We Short Changing Those Who Desire to Become Clinicians? , What They Don't Teach Medical Students: Doctoring , and Real Excellence in Medical Education

These join http://www.basichealthaccess.org/ and http://www.ruralmedicaleducation.org/ and http://www.physicianworkforcestudies.org/

Major Journals Fail Primary Care Once Again - Major journals have slipped in another article that apparently was designed for controversy and for widespread distribution to media outlets. The title of this Health Affairs article is not original  - "Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services as Compared to Other Countries." Health Affairs published the bait. Media outlets such as the NY Times were hooked.

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 1980 - 2010 – Too much is the rule for US health care costs with three dimensions of rapid growth of non-primary care – the care that cannot be regulated except through limitations of workforce.

Meeting Primary Care Needs in the Last Half of the 21st Century - Really! – A SMART plan actually indicates how the US can meet primary care needs. All that is required is a focus upon specific primary care result rather than primary care that is 70% not primary care in result.

One Million Hearts Saved or 160 Million Lives Improved - The Million Hearts Campaign has been shaped by those leading health care – government, associations, business, and insurance. Million Hearts is not a poor choice in itself. It is what Million Hearts represents that is the problem. Million Hearts represents numerous choices past, present, and future that have not worked for most Americans. These continued choices distract and divert attention from what works. A focus upon diseases and risk factors is quite different when compared to specific focus upon the basic needs of most Americans.

To Follow the Money, Follow the Workforce – With half of workforce guided to 1% of the land area by over half of annual health spending and with substantial funding expended by 1% of the land area to get ever more dollars from any number of treasuries, there will be no interruption of every more expended for fewer Americans in fewer locations with less overall result.

Why Do Primary Care Myths and Misinformations Persist? – The evidence indicates ever less primary care from primary care trained graduates. Why are these poor sources getting worse promoted as solutions?

RPAP Is SMART and Has Been for Forty Years – The longest running rural, primary care, and health access intervention remains the best for any number of areas – especially communities in need of health access.

Countdown to the 2012 Primary Care Armageddon - There are about 132  112   99  62  18    7 days until January 1, 2012 when Medicare will be forced to cut fees to physicians by nearly 30%. These cuts have already been enacted by Congress. To prevent this action, the current Congress would need to take action – a major problem with this Congress. Over 114 days have been wasted and Congress is nearing recess.

What is Killing US is Not Four Diseases Focus - The Myth for the Cure and others in the Disease Focused Crowd Are Now Selling Four Diseases to the United States and to the World Health Organization. What is Killing US is greed, stress, ignoring the needs of children, and ignoring the development of human infrastructure. 

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.

Accelerating Cycles of Primary Care Decline – When factors intersect progressively, the primary care result is much greater decline. With less revenue on the way and more distortions of primary care trained graduates away from primary care, more cycles of decline are coming.

Disease Focused Disorder Mentality or Sentimentality – After 100 years of socialization of health care leaders regarding disease focus, will we understand the consequences of too much focus on disease and ever less understanding of people and the context of care?

Why are 2008 Government Projections of Primary Care Workforce in Error? Four years later and after ignoring 10 years of evidence, this HRSA site continues to deceive. Internal medicine is heading to 40,000 by 2030, not 155,000 in primary care by 2020. Family medicine is fixed in place by 3000 annual graduates for over 30 years and cannot increase - by design. Projecting more with steadily less is a serious distortion by those supposed to leader health access for our nation. 

What Do Medical Home Studies Indicate? Those positive about the medical home are promotions that indicate the value of the continuity medical home when the real determinants of better health care are social determinants. The fact is that health care access, cost, and quality are fixed in place by designs. To understand what works, it is important to understand the designs and the designers.

The Black Hole of US Subspecialization spells Workforce Concentration, continued higher costs for health care, and Lack of Access for Most Americans

Fifty Years of Failed Primary Care Workforce Innovation – Innovation lunacy has taken on new heights, even in areas with fifty years of failed primary care workforce innovation.  

Finance-me-cratic Constants in the Bureaucratic Universe - America has come to a standstill in many important areas - health, education, leadership, and more. Recessions have always found ways to blame any number of individuals or types of people. In fact, recessions have a common cause involving the relationship between finance-me-crats, aristocrats, and bureaucrats.

What can a zip code 10032 study indicate about nurse practitioner versus physicians with data a dozen years old, providers that predominantly did not understand the language and culture of the patients, a location representative of very few zip codes in America, and the lowest aim of indicating no difference. As we understand more and more about social determinants, it should be surprising that any differences will be found in populations with the most social determinant limitations, such as those in this study.

This Will Be Brief As Will Primary Care - Anyone with any understanding at all regarding primary care understands that primary care is about people. Primary care is people delivering primary care services to people. Primary care involves the most basic health services, those needed by nearly all Americans nearly all the years of their lives in nearly all locations. The year 2012 is likely to be most challenging. There appears to be little hope for addressing the most important problem – insufficient revenue to keep up with double digit increases in the cost of delivering primary care.

Comparing Family Practice Sources - The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations of workforce or health spending. It is also important to understand that not all sources remain in family practice in the years after graduation. NP and PA sources continue 40 years of steady movement away from family practice - the result of flexible design.

Rural Rearrangements of the Deck Chairs - Merry Christmas December 24, 2011 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.

Failing Primary Care Explained By Policy Failure – Koch’s postulates are satisfied – US Health Policy can rebuild or destroy primary care as illustrated a number of policy periods across 1960 – 2010.

Generic Expansions Are Not SMART – Generic expansions of annual graduates absolutely fail for the purpose of health access. Too few enter and too few remain, even when the training program is a primary care program.

Rural Primary Care: Stark Realities – With the exception of family practice sources that remain in family practice (family medicine), the reality is that rural primary care delivery per primary care graduate has been rapidly declining for some time.

SMART Primary Care : Family Practice Contributions – Only family practice (MD, DO, NP, PA) works for the purpose of health access for 200 million Americans and over 65% of the elderly as well as all populations in need of health access. Only family practice that stays in family practice for a career (family medicine) is efficient and effective.

FInd New Family Medicine Leaders? – The best of the best are often those that ask the best questions rather than regurgitating the expected responses. When family medicine leaders question good works in family medicine journals, it is time to raise a question about family medicine leaders and where family medicine dollars have been invested, other than in more family physicians (exactly what the nation needs for the next 30 years and more).

The Squeeze Play that Fails - Medicare is supposed to be a design that facilitates health care for the elderly. But the overall US design for health care insures that most of the elderly fail in access to basic health services. 

Does Primary Care Experience Matter? Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature. One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices.

Still the Health Access Solution for Most Americans - Health access workforce solutions have always been and will always be the broadest scope generalists. Other workforce even with slightly greater specialization or limitation in age range or limitation in scope will remain limited in distribution. Other sources fail to remain in primary care and fail to distribute outside of locations where workforce is already saturated at top concentrations

Myth for the Cure: Essential for Disease Focus - Do no harm is difficult when the focus is eliminating disease. Nearly all of the disease-focused treatments cause harm and some cause substantial harm to people, to groups, or to entire nations. Harm can be direct to patients or indirect within health care. At ever more spent on health care, disease focus can wreck and entire nation and impact the world.

How the Disease Focused Abuse Health Access - At number 6 on the listing was the Clinton Health Access Initiative. I thought perhaps this might be a good source to contact. But the site explained that it is really about access to drugs and treatments.

Deifying Disease By Design - In a recent video released to the world, top experts have revealed their agenda for making progress with regard to disease focus. Local and state have not been enough. National is not enough. They want the entire world to focus on just a few, or one.

Cost of Training per Unit of Primary Care Delivery – At about $30,000 - $40,000 per Standard Primary Care Year of primary care delivery over a career, family medicine stands on top. Pediatric and physician assistant graduates have twice this cost. Nurse practitioners are moving to three times greater and internal medicine has a 5 times greater cost of training per unit of primary care delivery. Sources that do not remain in family practice and that do not result in family practice have the highest cost of training per unit of primary care delivered where the nation needs primary care most - in zip codes with 200 million Americans (65%).

Who Really Benefits? Claims of benefit to health access have been pointed out as promotions and promises, impractical, deceptive, or insignificant. Over and over the design deficits do not allow health access recovery. To understand primary care failure, one must understand who benefits from designs that fail for primary care result.

Can We Have Our Billions Back Please?   Why would an advocate for basic health access keep hammering on disease focus? The answer is simple. For decades we have more different researchers and subspecialists creating more reasons to spend dollars anywhere but on basic health care services, especially services needed by over half of Americans.

Exploring the Health Consequencs of Disease Focus - The past 30 years have been cost cutting designs in the US. Past leaders have shaped health care focused ever more on disease, subspecialty, and academic interests. A previous Congress reacted with an at

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?

Addressing the Primary Care Crisis – The right questions must be asked and the answers must be specific to the needs of most Americans or the US will have another 30 years of primary care failure by design.

Part I: Limitations of Awareness – Those shaping the designs have low awareness of the basic needs of most Americans. National plans and planners that fail in awareness regarding most Americans fail America. 

Lets Take a Stand for Most Americans Instead of Against – This is a response for most Americans, unlike the popular emails that are really not for most Americans. Outgoing director of Medicare and Medicaid Donald Berwick indicated much the same.

Standard Primary Care Year Estimates – Only primary care training that results in graduates that enter and stay in primary care and have the longest careers and have the most activity as direct care clinicians and have the top volume delivery and remain where needed at highest levels can help with primary care recovery. Lowest retention, shortest career, lowest volume, and fewest active requires far too many graduates to even maintain primary care levels, much less address primary care for 200 million left behind.

Rural Pipelines Versus Long Term Obligations – Rural pipelines in the US are a failure and have been for the last 30 years because of US health policy. At each of 7 or more segments in the pipeline from before admission to retirement, US health policy drives workforce away from rural locations, primary care needed in rural areas, and underserved areas common to rural settings. While academic associated entities would like greater state and federal and foundation spending at each level of the pipeline, there are solutions that are SMART and have been for 40 years.

Uncovering Cover Ups Involving the Front Lines – A British report in WWII indicated the horrific failures of the early years regarding bombing runs. The US needs an objective approach to deal with the failed front lines of primary care.

To Be SMART or Not to Have Health Access – Specific, Measurable, Achievable, Realistic, and Timely is what is required to recover health access. Generic, primary care training not primary care in result, assumption, promotion, delay, and other priorities higher than primary care (even in primary care training) are not going to recover health access.

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 where lowest health spending goes to lower population density, lower income density, lower employment density, lower workforce density locations that are most dependent upon lowest paid primary care and lowest paid general careers. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans. Millions hungry for health care cannot be fed by small change programs.

Critique of Commonwealth Fund Report on Ensuring Equity - A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access or the great possibilities of innovation and reorganization or technology, to have primary care or health access someone must be there to deliver the care.

Revisiting Physician Distribution by Concentration – Methods that categorize workforce by concentrations of physicians are a much better measure of too much or too little. Too much is 1% of the land area with 50% of physicians and just 10% of the US population. Too little is 30,000 zip codes with 200 million Americans (65%) left behind with lower or lowest workforce concentrations and primary care concentrations. If you understand concentrations of workforce, you can understand concentrations of health spending and how few benefit despite the claims by health professional associations that health spending is good for the nation.

Rearranging the Deck Chairs: Death Displacement– A focus on deaths prevented or lives saved is only possible with distorted thinking. We all will die. Our overall quality of life is about how our lives are impacted by our efforts and by our national desig

Choices for Higher Priority Areas That Could Make a Difference – Nations must make their best choices to put nations in a better position. The United States makes decisions that impact future generations in ways that have placed the United States in a position that has deteriorated steadily. We have also failed to learn that misguided attempts to rescue can actually make matters worse even more rapidly.

It has not been a good year for primary care or health access after 15 years of rapid decline and after 30 years of decline with only a few 1990s years of interruption.

Blogs indicate that primary care can be recovered and should be recovered, but it will take 30 consistent years of improvement for actual recovery. We have to have at least one to begin.