Is the Institutes of Medicine Waking Up?

Population Based Care is a beginning for IOM. How about Basic Health Access for Most Americans?

The Institutes of Medicine plays a key role as a designer of health care. Up and coming health care designers and those established as designers are a part of the infrastructure of IOM. Designers move around between associations, corporations, institutions, and foundations to gain credentials to reach the IOM and other positions of influence.

Is the reality of designs and designers gone awry finally taking hold at IOM? Can IOM move from academic focus to a population based focus with more academics focused upon population health?

IOM has just now established a Roundtable on Population Health

This is decades after some understanding of the impact of smoking cessation upon population health - an impact greater than cancer research regarding evaluation and treatment until about 15 years ago. Until that time, population health mattered more than all of the research and development, the new treatments, and the new evaluation methods.

Perhaps the designers are becoming aware of the flaws of their designs?

After jumping on the bandwagon to promote nursing as a substitute for physicians, perhaps the IOM can consider their influence.

IOM Made Poor Choices in Reporting Nurses as Substitutes for Physicians

The most important primary care impact of nursing is the 250,000 primary care nurses - ignored by IOM as an impact. The IOM could have chosen how nurses and physicians complimented one another. Instead they chose a small portion of just 50,000 nurse practitioners to illustrate for primary care - a most dilute source. 

If IOM had examined how the designs of health care act to prevent primary care RNs from doing more before, during, and after encounters they would have contributed greatly as the 250,000 primary care RNs are the largest primary care workforce in the nation. Nurses forced to beg insurance companies for care for their patients in primary care offices is still a primary reason for ineffective primary care, for high cost of primary care delivery without more patients seen, and for high insurance company profits. 

Message to IOM - Take on health insurance companies who have helped to design primary care into a difficult corner where primary care offices must hire employees to work for health insurance companies to save them money, reward hard working primary care nurses, and influence fewer nurses to leave primary care and RN jobs.  Shortages of RNs are already a major problem for health care settings serving most Americans left behind. Lack of focus of nursing leaders upon basic nursing may be even more problematic for the nation's largest health workforce.

Message to IOM - After nurse practitioners have declined to 25% of total graduates as active direct care clinicians involved in primary care, you might at least mention the declining ability to substitute for primary care physicians. When a workforce adds new non-primary care specialties with more in each specialty added each year, primary care suffers and the primary care source most important for 200 million Americans behind by design suffers most (employed family practice). 

Wrong Way Primary Care Designs Persist

Numerous foundations and the last 30 years of presidential administrations including the Obama Administration - have failed to support primary care recovery. 

Most Primary Care Per Graduate

Failure of specific support of training that results in the most primary care per primary care graduate (FM) - instead the support is generic or goes to support the primary care sources resulting in the least primary care result. An example is the CMS Graduate Nursing innovation that claims primary care focus, but will result in just 2 Standard Primary Care Years per graduate or about 10 - 12 times less result than family medicine and 3 times less than the best nursing choice - family nurse practitioners. If primary care is the goal, then why not establish permanent family practice? Why support dilute nursing solutions sending funding to institutions that have demonstrated less support for primary care in the past?

Most Primary Care Delivered Where Needed

Failure of specific support of the specific primary care sources most likely to distribute - family medicine and the employed family practice components of NP and PA

More Primary Care Spending

Failure to increase primary care revenue to the level of 20 - 30% greater than the cost of delivering primary care by forcing more primary care personnel into tasks that do not deliver primary care (higher cost, less productivity), by forcing higher costs of health information technology in equipment and maintenance and personnel time/effort, and by forcing misguided quality focused efforts that cannot result in great quality (because quality is fixed in place by social determinants and patient situations) but will result in less volume and higher cost compared to revenue. Pay for Performance fails for practices serving the underserved and for practices serving most Americans left behind. Quality focus also fails because these take time and effort that are not likely to improve quality and will result in more millions with lower or no health access - a real decline in health care quality as quality cannot begin without the beginning of health access. 

Note to IOM and other designers - Solving primary care recovery is required before quality can improve.

More Health Spending in Zip Codes with Multiple Times Less Health Spending

Failure to increase the health care dollars spent in 30,000 zip codes with lower to lowest health workforce - Over half of Americans are left behind by designs that fail for the workforce needed and the increased health spending per person needed to recover that workforce. Insurance coverage is nice, but fails without the primary care workforce. Until the rewards for non-primary care decrease and the support for primary care increases, the barriers to health access and health care quality will remain.

Additional failures are continued support of training that requires more and more dollars for less primary care workforce result. Training is supported that also requires more and more dollars in incentives to get less distribution 

Note to Designers: Family medicine requires less dollars for more result in each. 

Failure in Understanding Social Determinants and Patient Situations That Shape Health Outcomes

The IOM has done some good by highlighting physician errors. But the methods used result in too much blame placed on physicians and too much credit given. Proper studies must have the right variables included. When regression equations are loaded with physician variables, the studied blame or credit physicians too much. Any researcher familiar with regressions knows that adding the right variables results in decreased impact for the previous variables. The right variables can also result in the physician variable as knocked out of a significant contribution.

Studies of health care outcomes involving quality and cost must have

• Patient variables 
• Patient situation variables
• System variables
• Health care team variables
• Physician or provider variables

Also there must be understanding of the patient differences. For example the higher income patient types that receive the most care (and therefore shape the most health care data), have less limitations from patient, patient situation, system, and health care team variables as they get the best of all of these by their location and situation. This is inherent in the payment designs. For these populations the physician may have more influence as other variables may not have as much influence.

On the other hand the American populations most left behind by design - most Americans - are impacted substantially by patient variables, patient situations (access, housing, transport, cannot get off work), system variables (coverage, provider situations), health care team variables (high turnover, too few, less support) with the physician less likely to have impact. 

Many great health care "advances" fail to work for most Americans. For an example one can examine chemotherapy. Who has the family support to endure months of disabling treatment, or the finances, or the education or contacts to figure out puzzling instructions or the way to actually get best care? Who is least likely to receive the optimal doses, have the most side effects, or face the terrible choice between working or getting care? Who can get to rescue care in a timely fashion to avoid dying from side effects?

There has been IOM failure to understand that the controls used by many if not most health care studies involving populations - are not adequate. Studies supportive of this include studies by Hong in JAMA and by the Medicaid Randomization Studies in Oregon. Poor examples include the apples and oranges Critical Access Hospital study in JAMA where rural hospitals with different and lower funding, different and lower workforce, different and lower status populations had different and lower outcomes.

Perhaps the IOM has decided to get involved when teaching hospitals started seeing that their readmission rates were causing major problems for their cash flow - due to social determinants that result in lesser outcomes for the patients that they serve.

Or perhaps the IOM will figure out that a focus on residency work hours limitations will result in substantial harm and little real good. 

• No improvements in teaching hospital quality due to social determinant limitations
• Losses of 30,000 nurse practitioners and physician assistants and other personnel from primary care and other settings to fill shortages of teaching hospital workforce resulting from residency work hours limitations
• An additional year or two required for some specialties during training with 4 - 10% loss of workforce for the graduates with such longer training - resulting in a less productive workforce and more cost of training and more graduates needed for the same result

Primary care and rural health are topics that have been "addressed" recently by IOM and the nation has no better primary care or rural health result. 

Perhaps IOM has failed most because it allows distractions from the most effective treatments. Alternative or innovative treatments that distract patients from effective existing treatments have been areas of focus for IOM.

The IOM should exposed alternative solutions for primary care, health access, and rural health as less than the most effective. It should support permanent broadest generalists as a real solution for primary care and for rural health and for most Americans left behind by design. 

Permanent broadest generalists exist (in FM) and have the most primary care delivery over a career, the most primary care delivery per graduate where needed, result in more spending upon primary care, and result in more spending in practice locations in need of health spending

Other sources may be innovative or alternative, but they result in no increase in primary care workforce (flexible and depart primary care), far less primary care delivery over a career, far less primary care delivery per graduate where needed, and concentrations of workforce in the specialties and locations where top concentrations are already found.

True value in primary care is 90% retention in primary care, 90% retention in employed family practice, most primary care experience, lowest turnover, highest volume, longest career length, lowest training cost for the yield of primary care, best distribution, lowest cost of incentives for the distribution result. 

IOM could expose government health access failures such as projections of 155,000 primary care internists by 2020 rather than the decline to less than 45,000 by 2030. IOM could point out that family medicine has reached its 90,000 maximum - all that can result from 3000 graduates a year for 30 class years. It could noted that the HRSA projection of 144,000 is impossible for 2020 or for any time - without an increase in annual graduates. IOM could expose the projection methods as fatally flawed and responsible for our yo-yo imbalances of workforce for decades.

IOM should play a role in examining entire careers of primary care capable graduates. It should find that the United States can spend 21 billion dollars a year on 14,000 annual graduate permanent broadest generalists and have sufficient primary care. Instead it tolerates six sources of primary care at a cost of 21 billion dollars for half enough primary care delivery result - because the primary care sources end up only 30% primary care in result.

There are few areas where the nation can spend less and get more and solve health access woes for nearly all Americans. IOM should figure this out.

Population Based Care is a beginning. How about figuring out how health care cost and health care quality are really about the first months and years of life of a child (child well being)? How about studies to figure out how physician origins are a mismatch for the care of most Americans and are getting worse? How about Basic Health Access for Most Americans?

If IOM can gain some awareness of most Americans, it could figure out solutions for these and other most pressing problems. But it faces the problem of its own designers who are most out of touch with most Americans and their daily lives. IOM cannot be fixed from insider efforts. As with most quality issues, the solution requires the perspective of outsiders.

Solutions specific to health access, long term investments in children from the earliest ages, shaping influences of outsiders who can best inform interventions - these represent the advances that IOM and other designers must seek. 

Send your concerns to IOM, to Commonwealth, to Kellogg, to RWJ, or to your institution or association. Most Americans are counting on you for a different next 30 years for a needed change.

Cleaning Up Primary Care Reports

Highlights of the Sanders' Primary Care Report are Numbered and are followed by Critique

Senator Sanders and Fitzhugh Mullan MD are respected individuals. Their reports about health access make great contributions. There are errors in their assumptions about primary care workforce. Strong solutions can help recover primary care. Dilute primary care training solutions resulting in low proportions of graduates found in primary care workforce will not recover primary care.

For primary care recovery the United States must focus upon 

1. Most primary care delivery per primary care graduate
2. Most primary care where needed
3. More primary care spending, and 
4. More spending where health care spending is multiple times per person lower. 

National experts that truly want to recover primary care and basic health access must support these principles. Interventions must be consistent with these principles and must not result in the opposite effects.  

Interventions must avoid spending dollars upon primary care training that fails to result in primary care, that fails to result in primary care where needed, and that results in more dollars spent where multiple times greater spending is already found.  

From Senator Sanders report (in blue)

1. Between 1965 and 1992, the PCP-to-population ratio grew by only 14%, while the specialist-to-population ratio exploded by 120%.

Actually primary care increased nicely from 1965 to 1980 because 4 principles were followed – more primary care workforce that remained predominantly in primary care, more primary care specific to distribution where needed, more primary care spending, and more health care spending where low levels exist. 

All six primary care sources were 65 - 90% primary care in result. Specific primary care focused medical schools were created. Family medicine was given new life in formal residency training and expanded to its current level of 3000 annual graduates by 1980. Primary care had higher support relative to non-primary care until Medicare and Medicaid were redesigned. Redistribution was accomplished as guided by significant service corps field staff.

Since 1980 the designs have resulted in lesser primary care workforce, stagnant levels of primary care that distributes, stagnant primary care spending, lesser support of primary care compared to specialty care, and no improvements in health care spending in 30,000 zip codes with 200 million Americans – zip codes with multiple times less health care spending by design. 

A brief period 1990 to 1995 with a doubling of Medicaid expenditures in the directions of expanded health access and more spent where needed also demonstrated the same principles with the same increased primary care response (more FM, higher primary care retention).

Since 1995 the primary care recovery principles have been ignored and non-primary care has enjoyed the greatest favor with the most lines of revenue and the most reimbursement in each line. Also this has resulted in massive increases in non-primary care workforce that now includes nurse practitioners and physician assistants who contribute two-thirds of their careers to non-primary care workforce.

2. Despite the fact that more than half of patient visits are for primary care, only 7% of the nation’s medical school graduates now choose a primary care career.

It is possible for half of the nation’s patient visits to be primary care visits, but visits are a very bad measure to compare as a contrast of primary care or non-primary care. More visits with lower reimbursement contrasts with fewer visits at much higher revenue. 

Only a very few US schools have levels of 7% primary care. No current US source has such low levels.

Only 7% of the nation’s allopathic medical school graduates choose family medicine – the nation’s sole remaining primary care source at 90% retained in primary care for a career.  About 5% will remain in internal medicine primary care and another 5% in pediatric primary care for 17% lifetime primary care result for allopathic US MD graduates. 

Osteopathic graduates are about 30% primary care in result or about the same as nurse practitioner and physician assistant graduates. 

Caribbean graduates are 70% US citizens and those returning to the US for training are 26% FM and about 40% internal medicine for over 45% primary care result over a career. 

Non-citizen international graduates are 7% family medicine and 45% internal medicine for about 20% primary care result for a career. Non-citizen workforce has lowest levels of distribution - the wrong direction for primary care recovery. Internal medicine predominant sources have lowest distribution while family medicine predominant sources have highest distribution.

The worst sources of primary care are the nation’s most exclusive schools ranked by MCAT scores, research dollars, or graduate medical education positions. These medical schools have 3% family medicine choice, 3% internal medicine primary care (of 25%), and 3% pediatric primary care (of 12%) for about 10% total as a career primary care result for the most elite 20 – 30 schools only.

The figure of 7% for primary care for US medical school graduates is a serious error.

3. Fifty years ago, half of the doctors in America practiced primary care, but today fewer than one in three of them do.

It is true that only 1 in 3 physicians, 1 in 3 physician assistants, and 1 in 3 nurse practitioners are direct care clinicians active in primary care. The designs supported by corporations, governments, associations, institutions, and other designers of US health care are what result in such outcomes.

4. Over a doctor’s lifetime, specialists earn as much as $2.8 million more than PCPs. Radiologists and gastroenterologists, for example, have incomes more than twice that of family physicians.

It is true that specialists make more income and have greater benefits and support compared to family physicians. The nation’s highest paid physicians also reside in the highest cost of living settings and have less years in a career and enter practice later. 

In about 10 years due to massive increases in specialists, there will be more challenges for physician specialists. Rapid increases in MD, DO, NP, and PA annual graduates with higher proportions entering non-primary care training, and with two-thirds of primary care trained graduates entering non-primary care will present substantial challenges for physicians hoping to find non-primary care positions. There will be cuts in reimbursement and competition from lower cost NP and PA workforce. Established specialty physicians will hire fewer physician specialists as their versatile NP and PA colleagues will handle much of the routine specialist work in ways allowing them to maximize revenue generation while minimizing operating costs compared to hiring a specialty physician. Witness physician assistants in dermatology generating over $600,000 in revenue, passing on procedures to their physician colleagues, making top salaries, and costing less for their employers.

5. The average primary care physician in the United States is 47 years old, and one-fourth are nearing retirement.

Age and retirement figures are used for dramatic impact. This impact is enhanced because few understand age differences, differences in primary care sources, the effect of low primary care retention, and differences in primary care experience.  

Family physicians have about 16 years of primary care experience by age 47 and will remain 90% in primary care for their careers. 

Nurse practitioners at age 47 will have less than 6 years of a career but the actual primary care experience of the 47 year old NP will be far less due to lower primary care retention, least activity, most part time work, and lowest volume of primary care delivery. Family nurse practitioners at age 47 will have one-fifth the primary care experience of a family physician at age 47. FNP will have one-fourth of the primary care experience of a family physician by age 65 for both. If the FNP is one of few remaining permanent to family practice, they will have slightly over one-third of the primary care experiences of a family physician.

By age 47 only about 15% of internal medicine graduates will be found in primary care. Departures of those with primary care experience will reduce the average level. Primary care internal medicine will be younger as a result of losses in the years after graduation. Primary care pediatrics will also have the same issues with less experience due to losses from primary care, higher levels of part time, and possibly shorter careers.

Ideally primary care workforce would be most experienced (and potentially most effective as in some studies) with about 3% entering and 3% retiring each year for 2050 and beyond when population growth is relatively flat at about 400 million. 

Ideally the careers would last 40 years of high volume care with highest levels of activity. Designs that result in fewest years, lowest retention in primary care, lowest activity (most part time), andlow volume insure the least experienced primary care workforce, the most costlytraining for the yield of primary care, and likely the most costly health outcomes. Age 47 would be the half way point. 

Teaching hospitals took 30,000 NP and PA graduates as replacements for the resident workforce lost due from work hours restrictions. Hospitals captured 22,000 internists to hospitalist positions. These represent substantial losses of primary care workforce and primary care experience.

US policy could prolong primary care careers and retain more in primary care by increasing primary care support, by protecting primary care workforce from theft by non-primary care (hospitals, convenience care, others), by minimizing the cost of delivering primary care, by minimizing the need for new investments for older physicians, by decreasing liability costs that prevent part time work, and decreasing the reimbursement to non-primary care. 

Instead the US policies have forced more primary care cost due to more personnel required (without increasing revenue), more turnover in primary care personnel (lower productivity), more cost of health information technology, and other cost increases. The specialists benefit even more by designs that favor their revenue generation, including more uses of NP and PA as non-primary care providers.

The one thing in favor of primary care physicians working longer is that they can often obtain better health care plans via employers than via Medicare.

The overall result is earlier retirement and more primary care providers departing primary care.

6. Only 29% of U.S. primary care practices provide access to care on evenings, weekends, or holidays, as compared with 95% of doctors in the United Kingdom.

The UK has entirely different workforce and incentives. Primary care clinicians in the US do better by working after hours and on weekends in urgent and emergent settings because of higher pay. Many primary care physicians support their primary care practices by doing weekend or evening work. About 55% of family physicians provide urgent care in their practice settings or during evenings and weekends.   

About 20 – 30% higher revenue compared to the cost of delivering primary care would result in more evening and weekend hours. Years of stagnant primary care revenues with rapidly increasing costs of delivering primary care result in shrinking primary care and attempts to pack more in fewer hours.

7. In 2012, it took about 45 days for new patients to see a family doctor, up from 29 days in 2010. After Massachusetts expanded health insurance coverage in 2006, the waiting time for new patients to see a primary care provider increased 82%.

Massachusetts is a top physician concentration state. It was also heavy in internal medicine primary care workforce - workforce rapidly declining. Substantial NP and PA workforce was converted to teaching hospital workforce. 

Family physicians are found 53% in zip codes where lower to lowest concentrations of health care workforce are found. These are the zip codes where most Americans are behind in health care coverage - coverage that has improved. These are also the zip codes that have 200 million Americans or 65%. Over 68% of the Medicare and Medicaid populations are found in these locations along with all populations left behind. Low paying federal programs, low coverage, no coverage, and lesser income all contribute to lowest health workforce.

Increases in health care coverage most impact populations associated with 53% of family physicians. Matters will worsen since family medicine is also the only source not expanded for 32 class years – still just 3000 annual graduates. Population growth, the rapid growth of the elderly, and health insurance growth will stretch the limited primary care in 30,000 zip codes with lowest workforce. The source most likely to distribute where needed is the source 3 times more likely to be chosen by the elderly and all populations left behind. FM will shrink relative to the growth. Internal medicine is being cut in half from 90,000 to 45,000 from 2000 to 2030. NP and PA contributions per graduate are far less than in past decades as fewer remain in primary care.

The US has a training design that has expanded all of the primary care sources with fewer years, less activity, least primary care retention, lowest experience, and lower volume.

8. Nearly 57 million people in the United States—one in five Americans—live in areas where they do not have adequate access to primary healthcare due to a shortage of providers in their communities.

Actually 200 million Americans or 65% are found in 30,000 zip codes with lower to lowest health care workforce and 40% of primary care workforce. Only family medicine distributes equitably at 30 per 100,000 to all of these zip codes. NP and PA would be solutions if permanent in employed family practice but less than 25% are found in employed family practice – the requirement for distribution.

9. Half of emergency department patients would have gone to a primary care provider if they had been able to get an appointment at the time one was needed.

This is more data in support of major changes in primary care from flexible to permanent and from low or no profit to 20 - 30% more revenue generated compared to the costs of delivering primary care. 

Emergency rooms are not a good choice for a location as only 20% are found in 30,000 zip codes where 65% of Americans and 68% of the elderly are found. ERs are out of position for services, including the elderly in most need of rapid access to stroke and heart attack care.

10. Nurse practitioners account for 19% of the U.S. primary care workforce, and physician assistants account for 10%.

Nurse practitioner graduates have reached 200,000 but only 55,000 provide primary care and the volume of primary care provided is the equivalent of 25,000 to 30,000 primary care physicians. 

Family physicians are only 10% of primary care capable graduates (3,000 of 28,000) yet they will provide 39% of the primary services arising from same class year graduates of IM, NP, PA, PD, and MPD programs. Their proportions of primary care where needed are even higher. For example the family physician will average 24% rural location rates for 6 rural Standard Primary Care Years per graduate. This compares to 1.2 Rural Standard Primary Care Years per graduate for a family nurse practitioner graduate or a PA starting in family practice. The level is multiple times less for the generic NP or PA graduate.

The total graduate numbers are a serious distraction from the most important outcomes of primary care delivery over a career per graduate. Family medicine residency graduates at 24 or greater Standard Primary Care Years per graduate lead in primary care delivered over a career. PD and MPD with half the primary care retention have half of this contribution. IM, NP, and PA are at 4 Standard Primary Care Years per graduate or 6 times less over a career. Least activity as a US primary care clinician with lower volume and fewer years results in least primary care delivery.

The last doubling of physician assistant annual graduates resulted in a 100% increase in annual graduates, a 200% increase in non-primary care, and a 30% increase in primary care entry numbers (AAPA data). The 30% greater numbers starting in primary care will also dissolve as this flexible source departs primary care after entry. 

Internal medicine graduates, nurse practitioner, physician assistant, and pediatric graduates cannot demonstrate significant primary care delivery increases with expansions of annual graduates due to steady departures from primary care during training, at graduation, and in the years after graduation.