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. 

Reforming the Reforms of the Reformers

Numerous documents indicate the reasons for increasing US health care costs. Most are written by the designers of health care. This puts them in the unique position of not understanding health care cost, quality, and access from the perspective of most of the American people as they care so little for them - by design. 

The Seven Drivers are listed from Kaiser Health News (KHN) which use the Bipartisan Committee as a source. The numbered statements are from them. The rest is from RCB.

1. We pay our doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient

The KHN says fee for service is bad. It certainly is the way that non-primary care manages to find ways to generate more revenue and bypass any cost saving reforms. Fee for service has been the way to build services and workforce – with the consequence of high costs.

Fee for service is a way to reward volume and development of services and workforce, along with better fees for the services - this is why non-primary care has grown rapidly along with the health care servies in 1% of the land area with 50% of workforce and the greatest numbers of services and the most expensive services. The designers in these zip codes have designed health care their way.  Finance Me Crats     To Follow the Money, Follow the Workforce   Health spending patterns shape health workforce and vice versa.

Health care systems get bigger with less competition and the most exclusive services are unregulated with runaway costs. Meanwhile those employed in health care, including doctors, are forced to do what employers and stockholders want – more profits.

Primary care is in need of growth, more volume (not less), and has a limited number of services. Primary care should have the incentive to grow of fee for service or at least not the cutbacks for 30 years as issued by health insurance, Medicare, and Medicaid.

Revised fees, flat rates, and bundlings are innovative ways that can help reduce costs for specialty services, but are not a good choice for primary care that ends up with the short end of the stick. Innovations turn cooperative health provider efforts into competitive and primary care loses in the mix.

KHN says electronic records help. The evidence is mixed and the cost of increased information access drives health care costs up and also occupies more time, reducing primary care volume. This sends more millions to less or no access. HIT has also resulted in closures of primary care offices and services to people most in need of health access. The true intent of cost reduction has been seen rather than supposed improvements. Health info also is used to increase revenue generation with no improvement in care or access or it can be used to commit fraud or what is mostly fraud but legal. These generate increased revenue and higher health care costs.

Perspective of health access primary care - each change ends up cutting primary care out even more along with most Americans left behind by design. No change passes the test of no harm in cost, quality, or access to those already most vulnerable - most of US.

2. We're growing older, sicker and fatter.

While this is true, mostly the nation is dividing into a few with the keys to national and personal treasuries, and most Americans left behind. The nation is dividing toward a very few who rule who are ever less aware of America and Americans and most Americans who fall behind with poorer health, less health care coverage, less access to care, lesser jobs, and little economic impact benefit from the health care design. Most are being marginalized by politicians, health care designers, and economic leaders who are out of touch with most Americans. Politicians realize they can gain more with glitz, innuendo, and personal attacks. All the way to the top there is realization that intellectual discussions of the issues are not the way to get elected. Health care discussions, especially in primary care, are more about promotion rather than solutions.

3. We want new drugs, technologies, services and procedures.

We do want advances, but what are promoted as advances rarely are advances as studies are showing. We get tests that result in more tests and more expensive tests and no better health information. We get tests that lead to procedures that harm or kill. We get promotions directly to us for “advances.” We suffer from the side effects of advances and this results in more health care services and costs. We also have corporations that get laws passed so that they can have greater markets – such as digital mammography that is not an improvement but has much greater cost, or CT scans marketed for any number of conditions, or non-communicable diseases – a new way of marketing disease drug technology focus. We have software, marketing, drug, device, and other corporations expanding their claws on health care dollars and their hold on your wallets and our government treasuries.

And yes, as KHN points out the new are much more costly than the old with little or no help. A Nobel prize winning physician recently pointed this out in cancer care. He also continues to focus his research on interventions that work, rather than marketing those that fail to work. He had to go to another country to get the cooperation needed to do this work. The US market is too lucrative to attempt to develop real improvements as there are so many that generate so much for so little gain - the real US health design.

4. We get tax breaks on buying health insurance -- and the cost to patients of seeking care is often low.

Very few have such health insurance. Most have health insurance that has so many hoops and holes that we are all disgusted – and get less needed care as a result. Many have high deductible health insurance (the only thing that they can afford) which prevents basic health access – care that could prevent higher costs.

But why does this article ignore health insurance as a factor driving up the cost of health care as they just pass on the costs, increase rates, force government and business to cut employees to balance budgets. Could it be that both parties in the Bipartisan want to avoid making powerful insurance companies angry?

Also this article ignores Basic Health Access with maldistribution of health providers and barriers that prevent care. This is a huge problem impacting most Americans, but not those that write articles about health care.

5. We don't have enough information to make decisions on which medical care is best for us.

Well the real problem should be evident now more than ever before. We have way too much information thrown at us and those that finance the information can process their way to money, fame, power, government treasuries, and more. They move far faster than we can investigate and prosecute. Meanwhile we have little real education and human development - requirements for processing information. The loudest voices and those that sound the best win, even when a bad choice for most.

More health information would be nice, but comes at great cost – driving costs up more. Also the information is slanted like this article – away from specific solutions such as less non-primary care workforce (fewer MD, DO, NP, and PA specialists) and more primary care that remains 90% in primary care and distributes best to serve most Americans (family medicine).

As an example of information and promotion rather than solution - Note that nurse practitioners and physician assistants are promoted as primary care solutions, but only the 25% that end up employed in family practice are much help to primary care or to half of Americans in locations with lower to lowest workforce.

Two thirds of NP and PA help promote non-primary care workforce and more profits for health care and higher costs. This is because the US health care design pays more for non-primary care services and NP and PA can help increase revenues with more services, tests, technologies, and procedures with lower employee costs and higher profits. This is no reflection poorly on NP and PA, who benefit from the non-primary care employment. As long as designs reward the designers, the MD, DO, NP, and PA workforce will grow their way and result in much higher health care costs. A major reason for NP and PA not found in primary care is tens of thousands hired by teaching hospitals to fill gaps in workforce left by their own rules and regulations. This moves NP and PA where needed to where health care costs the most. Three Dimensions of Non-Primary Care Expansion Driving Higher Costs - Increase in annual graduates, increased proportions entering non-primary care training, 70% of primary care graduates as non-primary care workforce.

6. Our hospitals and other providers are increasingly gaining market share and are better able to demand higher prices.

Market share is a good example, but see who is buying up the market share. Insurance companies are doing even better as they use their information to buy up the most profitable to shape their control for decades to come. Insurance companies shape confusions such as government control as noted as the Politifact Lie of the Year. Confusion leads to inaction and continued profits - because of the current designers benefitting from the designs. Academic centers also do well under our design, but want even more dollars sent to their zip codes that already receive by far the most health care dollars per person under our design.

7. We have supply and demand problems, and legal issues that complicate efforts to slow spending.

This article was far too vague and confusing and failed to implicate the designers of our current designs – the real reason for spiraling health care costs in the way they influence government and US.

Americans need designs for basic health access, workforce that serves them where they are located, and health spending that make sense for most Americans not just a few.

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