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. 

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

Rural Rearrangements of the Deck Chairs

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

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

New Rounds of Publications Emerge

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

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

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

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

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

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

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

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

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

Thirty Years of Health Access Workforce Prevention

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

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

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

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

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

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

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

Which Medical Schools Produce Rural Physicians - a 15 year update

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

Rural Medical Education Specific Blogs and Links

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

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

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

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

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

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

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

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

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

Accelerating Cycles of Primary Care Decline

Disruptive innovation was created as an attractive term, but innovation that is disruptive fits primary care best at the present time in the United States. Innovation is actually distracting and distorting primary care away from solutions. The last three innovative primary care training forms (NP, PA, MPD) are 60 – 75% not primary care in contributions over a career. This is a contrast with 60 – 75% primary care at their beginnings decades ago. Such rapid declines are not the result of a single cause and effect. Multiple factors accelerate the cycles of primary care decline.

Some of these changes actually accelerate primary care decline on their own. Others work to decrease primary care workforce capacity and cascade to result in another downward cycle.

This is an outline page indicating the first few factors involved in primary care decline by design.

The United States Design includes

• Ever Higher Costs of Primary Care Delivery - force cuts in personnel, less support, less volume, repeat cycle of decline - a 12% annual cost increase for 6 years doubles the cost of delivering primary care. Coupled with a freeze in primary care fees or a minimal increase, the cost of delivering primary care will continue to kill off primary care delivery and workforce.
• More Primary Care Cost Types - More types of personnel or equipment often not specific to primary care delivery, less budget remaining for primary care specific personnel, cuts, declines in primary care fees and delivery, repeat cycle of decline
• Flexible Primary Care Training + US Policy + Voluntary Choice - This is a policy driven equation for the United States that by its very nature has resulted in ever less primary care per graduate arising from primary care graduates. Tracking class years over time the US primary care per graduate level has declined to one-third the 1980 graduate level or from 18 SPCYrs down to 7 for recent graduates.    Graphic Listed
• Dysfunctional Primary Care Training – drives residents and medical students away from primary care (Keirns, Academic Medicine) - situations played out right in front of medical students are not a good idea for primary care career selection or retention
• Hamstrung Primary Care Workforce – Top priorities of insurance and government have been cost cutting for 30 years with worsening in the past 15 and worsening in most recent years. The primary care nurse is a primary example of a primary care professional that cannot participate as actively in direct patient care delivery due to the design. The design forces nurses to contact insurance companies just to get needed prescriptions, referrals, hospitalizations, goods, and services. Also they must collect information needed for care from our fragmented system. New jobs and duties such as risk management also are about cost cutting, not care delivery. What helps fail primary care is primary care professionals that are forced to do other activities other than delivering primary care - by the US designs that have been cost cutting in nature for 30 years. SMART designs are specific to enhance primary care delivery - not defeat it before it can arise.
• Training of Primary Care Is Not Primary Care Specific – Training has never been SMART or primary care specific for RN, MD, DO, NP, and PA. For 100 years the focus has moved ever more hospital and academic and subspecialty. The models that are different and are primary care specific are few and small in number, in numbers of graduates, and in national impact. The training in any training program will be shaped by the outcomes of the graduates. With fewer entering primary care and even fewer remaining in primary care, the training changes to fit graduate needs. If this is not so, the program dies for lack of graduates as graduates are interested in preparing for the jobs that exist and that allow them to do well. When programs send a minority in primary care and those attracted desire non-primary care careers, the program composition will change to fit non-primary care. Only a permanent primary care source can withstand this. Of course this is why family medicine has been a lower priority choice - due to its permanent primary care outcomes.

This is just a beginning of cycles of decline. Anyone trying to tell you that the US has more primary care or that primary care is doing well

- is selling something.

Cost of Training per Unit of Primary Care Delivery

Policy Protected Primary Care is Permanent - Family Medicine

Why Do Primary Care Myths and Misinformations Persist?

Fifty Years of Failed Primary Care Workforce Innovation

To Follow the Money, Follow the Workforce 

Failing Primary Care Explained By Policy Failure 

Three Dimensions of Non-Primary Care Increase vs Zero Growth in Primary Care 

Cost of Training per Unit of Primary Care Delivery

The cost of primary care training can be compared to primary care delivery over a career. Additional calculations can integrate the proportions of graduates found in certain locations to generate the contributions in rural primary care, underserved primary care, and primary care delivery outside of concentrations (in 30,000 zip codes with 65% of the US population left behind). The cost of training per unit of primary care is much less for family medicine. Other sources that yield less primary care per graduate are inefficient primary care sources.

Real Measures of Efficient and Effective Primary Care

The United States does not require more primary care in 3400 zip codes where primary care is saturated. The United States must have primary care that has demonstrated the ability to locate outside of concentrations. This must be kept in mind. Internal medicine, adult NP, pediatricians, and pediatric NP sources all result in lesser primary care delivery and lower proportions compared to the best primary care sources.

The categories for NP and PA divided into family practice or not family practice as the family practice component contributes the lion’s share of the midlevel primary care, rural, and underserved contributions. The physician figures involve those attending United States or Caribbean medical schools. Graduate medical education does deliver some primary care and does contribute to revenue generation and these items were not included.

Cost of Training Relative to Primary Care Delivery over a Career

	Cost of Training	Cost per SPCYr	Cost per Rural SPCYr	Cost per Under-served SPCYr	Cost per Outside SPCYr
NP not FNP	$380,000	$215,420	$2,154,195	$1,795,163	$615,484
FNP Trained	$380,000	$55,850	$199,463	$372,330	$101,545
PA not FP Start	$440,000	$158,025	$1,580,247	$1,316,872	$451,499
PA w/FP Start	$440,000	$37,037	$123,457	$205,761	$67,340
FM Trained	$950,000	$37,661	$171,185	$251,072	$71,058
IM Trained	$950,000	$280,653	$2,806,532	$3,118,369	$1,002,333
PD Trained	$950,000	$94,756	$1,184,452	$1,052,847	$338,415
MPD Trained	$1,050,000	$97,957	$612,228	$816,304	$244,891

When the focus is primary care delivery from primary care training, substantially more graduates are required when sources remain in primary care at low levels.

Recent cost of training figures are listed at the table at the end of the blog and include cost of living and cost of all higher education and training (post high school). These are also figures that are appearing optimistic due to ever higher cost of higher education and even more problems that will drive primary care to lower retention and less primary care delivered over a career. Family medicine would also decline but not to the same degree as the more flexible sources.

Only family medicine is efficient for the purpose of primary care delivery. If a few family medicine leaders succeed in adding a year to FM training, this would decrease career length by 4% and would add about $120,000 to training cost resulting in a $5000 increase to $43,000 per SPCYr. More importantly millions of additional Americans would be left behind with a smaller FM workforce. 

Pediatric expansions are unable to increase the primary care result. More graduates over the past 10 years have merely replaced those departing. There simply are not the openings for PD primary care where PD primary care is willing to locate. Internal medicine appears to be much the same with more moving away from primary care. For all practical purposes, any expansions for the purpose of primary care physician production must be specific to family medicine. Only permanent primary care obligations could improve flexible IM, PD, MPD, NP, and PA results. 

The nurse practitioner training cost will increase substantially in 2015 with two years more required training (up $120,000) and an 8 – 10% decrease in the years in a career. This results in a 33% increase cost per primary care year for family nurse practitioners – an increase from $55,850 to about $73,486 per Standard Primary Care Year. The major NP primary care and health access delivery rests on the shoulders of family nurse practitioners as so few outside of family practice contribute to primary care and primary care where needed. 

Family nurse practitioners are 50% of NP graduates, but only 50% of FNP graduates remain in family practice employment. 

There is a better decision for nursing leaders who desire to be truthful and maintain their assertion of primary care delivery from nurse practitioners. The appropriate move is to permanent primary care family practice rather than permanent doctorates. Without that move, nurse practitioner claims of primary care contributions must be qualified to only a small portion of NP graduates.

Currently nursing workforce leaders and various foundations that promote NP training as solutions for primary care are greatly exaggerating the benefits and are minimizing the cost.

Only the few NP and PA graduates that get certified and enter the workforce and enter family practice employment and remain in such employment contribute at significant levels, but even these melt away over time. Such is the power of non-primary care compared to primary care in the US design.

The Basic Calculations of the Standard Primary Care Year

	% Primary Care	Years in Career	% Remain Active	% Volume	SPC Years Per Grad
NP not FNP	15%	24	70%	70%	1.76
FNP Trained	54%	24	70%	75%	6.8
PA not FP Start	15%	33	75%	75%	2.78
PA with FP Start	60%	33	75%	80%	11.88
FM Trained	91%	33	84%	100%	25.23
IM Trained	15%	32	82%	86%	3.38
PD Trained	39%	33	82%	95%	10.03
MPD Trained	43%	32	82%	95%	10.72

FM with greatest retention, years, activity, and volume delivers the most primary care in a career. Nurse practitioners not training in family practice or physician assistants not starting in family practice (80% of entering PA) contribute least along with internal medicine. The reason is so few remaining in primary care. 

Distribution By Location Type

	Rural %	Under-served %	Outside %
NP not FNP	10%	12%	35%
FNP Trained	28%	15%	55%
PA not FP Start	10%	12%	35%
PA with FP Start	30%	18%	55%
FM Trained	22%	15%	53%
IM Trained	10%	9%	28%
PD Trained	8%	9%	28%
MPD Trained	16%	12%	40%

Optimistic early practice estimates were given for all except FM. The actual proportions of other sources decline due to departures from family practice and from primary care over their careers. Only continued retention in family practice keeps optimal distribution. Only family medicine is retained in family practice for career long retention, documented in the FM figures from the AMA Masterfile and the Robert Graham Center. 

Cost of Training Considerations

	College	Health Prof	Graduate	Cost of Living
NP not FNP	$30,000	$100,000	$70,000	$180,000
FNP Trained	$30,000	$100,000	$70,000	$180,000
PA not FP Start	$120,000	$125,000		$195,000
PA with FP Start	$120,000	$125,000		$195,000
FM Trained	$120,000	$200,000	$300,000	$330,000
IM Trained	$120,000	$200,000	$300,000	$330,000
PD Trained	$120,000	$200,000	$300,000	$330,000
MPD Trained	$120,000	$200,000	$400,000	$330,000

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!. 

Generic Expansions Are Not Smart 

SMART Primary Care : Family Practice Contributions...

Still the Health Access Solution for Most American... 

Revisiting Physician Distribution by Concentration... 

Rural Primary Care: Stark Realities 

To Follow the Money, Follow the Workforce 

Why are 2008 Government Projections of Primary Care Workforce in Error?

Standard Primary Care Year Estimates

Failing Primary Care Explained By Policy Failure