Pounding Poverty Providers with Pay for Performance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.

In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.

What Do Medical Home Studies Indicate?

• Associations and researchers are willing to use data sources that are not from “official medical homes” to indicate medical home value.
• Concepts are considered more important than the primary care people who deliver the care. Of course those who cut primary care funding fail to understand they are cutting the experienced people needed to deliver primary care. Primary care is about people – repeat often, especially when examining studies about primary care. 
• Methods that select patients with better social determinants will have better outcomes. Methods tha select patients with higher levels of continuity will have better social determinants and better outcomes as well as better access to care. Substantially more is also invested in health care for those who have greater access and higher social determinant levels. One would also have to ask how many criteria were needed by researchers to demonstrate a difference. 
• In the study, those of advantage were more likely to have continuity home experiences. In almost every instance of lower probability of preventive visits (age less than 1, single mom, lower income, lack of health insurance, less educated parents), those that preserved continuity had greater proportional improvement (close to 2 to 1). In other words those that somehow bucked social determinants had better care. The continuity home definition did little for those with social determinant advantages and did the most for those that managed to have a continuity home despite odds against. 
• In the study the differences are significant, but the differences are so small as not to be relevant.
• Children with a medical home were more likely to receive higher health ratings (excellent or very good) as compared to those without that were lower rated (good, fair or poor). Many would consider the noted outcomes as a matter of differences in health status.
• As with other pediatric studies, the experts consider near universal access to pediatric care. They have of course overlooked the problem of maldistribution and limited access for over half of children due to workforce limitations in 30,000 zip codes with low or lower health workforce concentrations.
• Then the study considers a 30% decreased ER utilization discussed in association with a continuity home.

At this point I just have to stop looking. This is a poor study by any number of measures. These are good people that are well intentioned. Some if not most have delivered care where needed. Sadly there is a loss of perspective.

There are significant investments of time and effort by associations and this is a likely reason why such studies are published. What is obvious from this and other studies is that changes in social determinants are required as a top priority with reorganizations of care way down the list.

The current pediatric study does not prove the value of the Medical Home as headlines indicate in Medscape – proof is almost impossible to prove in medical studies. What the Medscape headlines do indicate is poor understanding of medical studies by the medical media (or at least dramatization that is deceptive).

The investment in medical home terminology is so high that family medicine leaders have protested when studies fail to show the expected benefit. After devoting substantial funding to this area, perhaps objectivity is lost. Does Family Medicine Need New Leaders?

I am certainly for the concepts of team care, continuity of care, integration of information, and other aspects that are considered medical home concepts. These are obvious to those who have experienced the great pleasure of delivering challenging care with a supportive team. Who would be against such a design?

The problem remains that continuity home interventions are not going to solve primary care woes or the associated social determinant maldistributions.

Diverting a Nation from Real Solutions

The continuity home has been touted as a solution for the primary care woes of the nation. In fact, the Continuity Home will not improve the major health access problems of the nation. When providers present “cures” that do not work and distract patients from treatments that do work, this is considered a serious offense.

Offensive Literature and Offensive to Dedicated Primary Care Practices

It is hard not to find much of the literature developing around the medical home concept to be “offensive.”

I will continue to assert first that social determinants are far more important and that any primary care practice that has dedicated health professionals that function together as a team to provide health care, that stay together as a team, that keep the same patients, that keep the same location for care, and that have sufficient funding to accomplish the above – will have the optimal care with or without medical home designation.

If the cost of a medical home designation impedes care, medical home designation will not improve the care and may damage care.

If the medical home designation comes with more funding, the care may improve but this is likely the result of the additional funding rather than a medical home focus (beware government promises of more funding as this may not materialize).

If sites receive continuity home grants, then they will have better care because the additional funding is likely to give them an advantage in recruiting and retaining the best primary care personnel. Continuity care is clearly more likely with those that are easiest to care for, as demonstrated in the study.

Of course a real design for the care of all Americans provides sufficient primary care spending across the nation, not just for those who have grants or cost-based reimbursement.

Quality Arises from People and Relationships from the Ground Up, Not from Concepts Thrust on People from Above

Quality is the result of reflective process by dedicated team members with objective consideration of all relevant aspects of care – especially very basic awarenesses and understandings of the patients served. This process does not require certain terms such as continuity home, stroke center, chest pain centers, etc. Continuity home focus can improve care and can raise awareness of methods that can improve care, but a continuity home itself will not be the reason for change.

But if you desire a nice name or certification there are numerous places to contact, meetings to attend, and others willing to take money away from delivery of primary care. Your choice of the following or dozens of others.

On-Site Certification. The Mark of Quality that Sets Your Medical Home Above the Rest. The Joint Commission: Primary Care Medical Home 2011 StandardsAccess and Continuity in the Medical Home SettingBlueprints for Building a Medical Home

The Problem Facing Primary Care

The problem facing primary care remains the same. The problem is that revenue derived from primary care services is insufficient to keep up with rapidly rising costs. When the cost of delivering care is insufficient, the result is cuts in personnel, less experienced personnel, fewer personnel, and decrease in the ability to deliver more care and better care.

When the costs of delivering care are increased due to various innovations and reorganizations without increasing the revenue, it is possible to also result in less primary care delivery.

If a national focus on higher quality (by less volume, more costly technology, fewer personnel) results in less primary care delivered per primary care provider, the nation will have much greater problems with cost, quality, and access because the missing link is primary care personnel of all types.

The Problem of Social Determinants Ignored

If primary care experts ignore social determinants, then they do not understand the most important variables regarding cost, quality, and access. If Pay for Performance pays more for “quality,” relatively less will be paid to practices that have lower and middle income patients. This is because practices that are more likely to care for those in need of care will have lower quality ratings because of the patients that they care for. Higher quality ratings and greater pay will go to those who have better quality because of who they are.

The authors of this Pediatrics article have built another very good case for social determinants yet they have claimed that the reason is the continuity home. This is a quite serious problem for Pediatrics, for primary care, and for most Americans in need of real solutions for health access.

Better Ratings with Better Pay, or Care Delivered Where Needed?

To get lower quality ratings and less pay, continue to care for underserved, poor, near poor, rural, disadvantaged, and lower income patients.

To get better quality ratings and better pay, be sure you care for less complex people. The nation will overall have lower health care quality, higher costs, and declining access to care – but you and your practice will do better.

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

Major Journals Fail Primary Care Once Again

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

Controversy will once again divert the nation from addressing real problems such as deficits in primary care. The American Medical Association has chimed in for a defense. Once again too much focus on physicians with the most highly specialized services will defeat basic health access.

What is common to major journals, media outlets, and the past 30 years of political administrations is a poor understanding of primary care. Errors of perspective and analysis are far too common. It is not a surprise that one of the Health Affairs authors is a member of the Obama health care team (written prior to joining the team). The current administration has made little progress and various reports and appointments may move basic health access the wrong directions. (The Health Resources Services Administration still has primary care projections for 2020 that are impossible to reach).

The nation's leadership still has little clue what goes on day after day for most Americans in areas such as basic access to health where they are left behind by US designs of health spending and health workforce. Special programs are not the real solutions. The solutions require understanding the reason for most Americans to be left behind. Steady work over 100 years has shaped the current design favoring those in top concentrations with steady and progressive declines in basic health access and primary care over this time. 

The Health Affairs article indicates that primary care physicians in the United States are paid more than in other nations. Those reading the article will first of all be confused as the article is not an easy read or one easily accessed. Entire books have failed to capture primary care differences as well as national design differences. It is not surprising that the media repostings of this article have emphasized the controversy without much indication of substance.

The authors wanted to compare other nations and physician fee differences and apparently chose the most dramatic examples to further their plan. Health Affairs allowed them to cherry pick their analysis from a huge volume of possible data that could have been chosen. Their discussions of orthopedics and primary care are actually minimal compared to their plan to do nation to nation comparisons. But primary care will be even more confusing to those reading the article. And interpretations by those in Congress could result in serious consequences for most Americans.

The title stands alone and needs little supporting evidence - Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries – the journal could have saved the 9 pages by just posting the title alone - we get this already. But primary care gets caught in the crossfire and the controversy.

One can also figure out that the US might just need to pay more for primary care because it pays way too much for non-primary care. With voluntary choice dominating health professional education, once students are admitted into training the designs drive lesser supported primary care to become non-primary care. Design flaws require more pay to keep primary care retained in primary care. This is especially indicated in flexible primary care workforce designs (nurse practitioner and physician assistant sources). Those most flexible that can go to primary care or not require higher pay to remain within primary care.  This point could have been made in a few paragraphs, but the article goes on to compare all manner of data across various nations – those who are very different than the atypical US situation.

The article and the inevitable media reports imply that primary care is either well paid or paid too much. This is confusing and distracting. Authors, health care designers, current political administrations, future administrations, and national designers need to understand much more about the current situations facing primary care and basic health access for most Americans.

There are many indications of insufficient primary care spending in absolute dollars or primary care spending relative to non-primary care spending:

• The United States has inadequate and declining primary care workforce, particularly in 30,000 zip codes with 65% of the US population – locations left behind with lower to lowest concentrations of total health workforce, primary care workforce, and health spending. The US design favors top concentrations of health workforce with top concentrations of health spending. This shapes top concentrations in all facets, including primary care. Over 60% of primary care is stacked in 3400 zip codes clustered together in zip codes with 75 or more physicians where 72% of US physicians are found with only 35% of the US population. Over 70% of internal medicine and pediatric workforce is also found in these top concentration zip codes. Only family medicine with 50 - 55% of workforce outside of concentrations has anything resembling needed distribution and persistent primary care by design
• Even greater concentrations of workforce are found in over 1000 zip codes that have absolute top concentrations of primary care with 150 – 250 primary care physicians per 100,000 in only 1% of the land area with 11% of the population. These are clearly the sites with the most lines of revenue and the highest reimbursement in each line - and top concentrations of workforce and support personnel.
• Deficits of primary care facing most Americans are an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support. This is complicted by insufficient health spending in 30,000 zip codes with 65% of the population as compared to zip codes with top concentrations of workforce and spending.
• Primary care not supported by grants or by capitated methods of payment or by private insurance has been in trouble for quite some time with increases in the cost of delivering primary care and insufficient reimbursement from Medicaid or Medicare or those with low or no health insurance coverage. The article does point out that primary care successes where populations are wealthy and are well covered with private insurance.
• Every one of 6 primary care sources (NP, PA, IM, PD, MPD, FM) has been impacted by fewer graduates remaining in primary care during training, at graduation, and each year after graduation. More are found in hospital and subspecialty and non-primary care areas. Primary care graduates deliver less and less primary care during their careers with each passing class year. This is also an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support.
• Primary care graduates matched to their class years indicate gains in primary care only 1965 to 1980 with a slight short gain in the 1990s. At all other times, primary  care delivery capacity has been in decline. Primary care numbers only doubled from 1965 to 1980. Non-primary care numbers have doubled from 1965 - 1980, from 1980 to 1995, and from 1995 to 2010 and will double again from 2010 to 2025. Primary care graduates are now two-thirds non-primary care in workforce result, but perspectives have so far not allowed this discovery. Primary care can be counted on to be stagnant for decades to come. Non-primary care cannot even be counted with three dimensions of expansion simultaneously progressing.
• Only family medicine remains with 80% or greater retained in primary care over a career. All other sources have 15 – 45% of graduates found in primary care. Substantially less primary care delivery is the result. The steady year after year decline indicates more declines to come although internal medicine, physician assistant, and nurse practitioner decline rates have to slow as so few remain in primary care and proportions approach zero.
• Family medicine itself is an indication of inadequate primary care support. Family medicine is the only career recognizable as a permanent primary care source at the current time. Students choosing family medicine must integrate past influences, training experiences, and future perceptions as they make this decision. Family medicine remains at 3000 annual graduates and has not increased in annual graduates for over 30 years. This is zero growth or no expansion at all. One would not expect a permanent primary care source to expand without better support for primary care in absolute dollars or relative dollars for primary care compared to non-primary care. The specific solution for rural, underserved, primary care, elderly, poor, CHC, and near poor populations is the one road not taken - an indication of little or no US emphasis upon basic health access - by design.

Solutions: more basic health access spending specific to locations and populations and more spending upon primary care where needed

Solutions specific to health access would require diversion of a few percentage points of hospital and academic and subspecialty spending from 3400 zip codes. This small percentage would result in 10 – 20% greater spending upon 30,000 zip codes with 65% of the population. Such is the concentration of health spending as compared to the small proportions spend in rural or underserved settings.

Solutions specific to primary care would require a few percentage points taken from non-primary care to provide a 10 – 20 percentage points to primary care. Critical Access Hospitals have taken rural hospitals off the critical list because CAH funding captures a few percentage points from all other hospitals to resuscitate rural hospitals. This change was required because cost cutting designs for health spending after 1980 resulted in massive rural hospital closures. The design changes defeated rural health gains 1965 to 1980. Once again those in charge at the top failed to consider basic services needed by most Americans. Rural primary care is clearly facing the greatest possible crisis at the current time with declines in primary care workforce and continued declines in sources of rural workforce. 

Given those in top concentrations in charge of the health care design, the result will be the same as in the past 30 years

• Stagnant spending in primary care with stagnant to declining primary care workforce
• Stagnant health spending in 30,000 zip codes with 65% of the US population
• Increased health spending in a variety of non-primary care and hospital settings (and crippling increases in the national GDP spent upon health care)
• Increased health spending in 3400 zip codes that already have top concentrations of workforce which will shape even greater concentrations of workforce. 

Articles that imply primary care doing well will not help address the major health access problems facing most Americans. A similar problem is announcements of grants for a few million here and a few million there while hundreds of billions poor into just a few zip codes under the dominant design for health spending.

The practice settings with the most lines of revenue and the highest reimbursement in each line are able to take workforce from any other settings.

In the past decade alone teaching hospitals have already claimed tens of thousands of primary care nurse practitioners and physician assistants to replace resident workforce lost (work hours restrictions).

Hospitalist workforce has claimed over 20,000 internists and 30,000 total physicians in addition to more non-physician clinicians.

The US designs are crafted by teaching hospitals and hospitals and associations. The designs allow those in top concentrations to prosper with even more consequences for those left behind. Also design changes tend to shift greater responsibility elsewhere as in hospitalist workforce with hospitals discharging patients and responsibilities onto lesser paid primary care settings and already overburdened primary care nurses - increased work and responsibility for little or no increased revenue. This is another example of errors of perspective where one action has a number of consequences.

Again and again lower paid primary care workforce has been tapped to address non-primary care areas over and over – emergency, geriatric, sports medicine, hospital, teaching hospital, urgent, and hospitalist with more to come. Primary care nurses, nurse practitioners, physician assistants, and physicians are paid less and this results in higher levels of turnover (loss of continuity) as well as departures from primary care to non-primary care careers.

Designers fail in specific primary care training, fail with departures of primary care graduates from primary care, fail to consider important areas such as experience in primary care that result in continuity, and fail to design policies that retain primary care or assist in the delivery of primary care. Innovative solutions are still associated with NP and PA workforce that were created for primary care and basic health access, but articles fail to point out that NP and PA workforce have been diverted over two-thirds to non-primary care workforce. Articles and experts fail to illustrate these failures. By working steadily for what works for a few, most are left behind steadily and progressively - by design and by those who are supposed to critically appraise designs.

Pay for Performance is another innovative design that works for those in top concentrations. It is not a surprise that this reward originated in top concentration circles. Physicians caring for patients in top concentrations receive top quality ratings by caring for those that have top socioeconomic status. For once JAMA got this one right. The Hong study in JAMA indicated physicians rated low quality just for caring for the underserved. Unfortunately it is rare for journals to consider the more global perspective just as it is rare for authors or workforce experts to capture this perspective. State designers interested primarily in cuts and cost savings have little or no understanding of the increased future costs or health care consequences that they are shaping year after year. Only recently with the Medicaid Randomization study (Baicker) have we had any clue regarding just how much having health care coverage matters. Health Affairs has been exposed to the right perspective, but how many booster doses are needed? 

Primary care personnel are more difficult to retain due to designs that pay more for hospital, subspecialty, and non-primary care areas. The US designs insure shortages of personnel, less experienced personnel, and higher costs just to obtain personnel for locations with the least workforce that often have the most complex populations. The past, present, and future reimbursement designs have shaped these outcomes by resulting in steadily less paid for low primary care billing codes relative to non-primary care code. Pay for Performance has demonstrated no major benefit as well as harm to underserved settings that have lower quality specifically because they care for patients left behind by US designs for education, economics, jobs, and health care.

Health Affairs has dedicated entire journal issue contents to primary care innovation and reinvention without including a hint of how the US would actually have the primary care workforce to address primary care delivery, much less innovation in primary care. This tends to distract from solutions rather than contribute to solutions.

Designers have all contributed to substantial dysfunction in primary care from fragmentation in care and from more competition from sources with much better revenue (urgent, emergent, non-primary care) and from policies that convert primary care trained graduates to non-primary care workforce.

Primary Care Practice Internal Design Failures

Primary care has continued to require more and more personnel (more overhead) at a time when primary care is more difficult to deliver. And the next 20 years of aging and other changes will make this even worse.

Within primary care sites, the practice dynamics represent serious problems. More and more personnel are required that are not actually involved in primary care delivery. Two new modes of care delivery have been created because the costs of overhead are too high (collaborative care, boutique care). Both modes are a fit for certain providers and patients, but result in even less primary care delivery arising from the primary care workforce that is already too few.

Primary care has multiple more barriers to efficient care. Billing for primary care is way too complex with way too many sources with way too many requirements. Receptionists must screen for fraud and collect ever more information. Primary care nurses direct clinics, insure compliance, train staff, keep on top of new weekly care care requirements, take calls, make important care decisions regarding triage, gather ever more fragmented health information, and spend countless hours dickering with insurance companies so that patients can get appropriate care. Government and insurance company efforts force every more innovative technology and equipment and personnel uses that are increasingly expensive with little help for what matters

• primary care volume sufficient to overcome health access deficits and
• primary care quality.

More cost for less care delivered to fewer is not a good plan when half of the nation is being left behind by design.

Specific and SMART Solutions for US Health Care Woes

• Universal health insurance coverage specific to primary care (not all care)
• Single payer specific to primary care (also separates primary care spending from the chaos and marginalizations of current US payers).
• Primary care specific training for primary care workforce that remains specifically in primary care for a career. MD, DO, NP, PA, and RN students in this plan would be admitted with requirements to serve the careers and locations needed. Instead of grossly inadequate selection and training specific to primary care, the US would be specific. Current training is one size fits none made worse by voluntary choice plus aberrant policies. These result in concentrations of workforce and inadequate primary care. Also junior or senior students dedicated by obligation to primary care should spend a year as a health care team member in a primary care setting helping to provide care for people in one of the 30,000 zip codes in need of primary care
• Primary care should be steadily sent more revenue with non-primary care sent less, until US workforce is back in balance and US health spending decreases rather than increases. This results in less loss of primary care workforce as well as primary care workforce with greater experience and greater continuity. Does Primary Care Experience Matter? This also forces higher volume from non-primary care that will also help address shortages of non-primary care.

Or we can all wait another year or two or a decade to see what happens as non-primary care expands in three dimensions and primary care remains flat by design.

SMART designs for health access and primary care will be opposed by existing designers using major journals, government reports, and the media to make their points - to keep the typical policies intact and to keep top concentrations of spending flowing to locations with top workforce concentrations - with few or no responsibilities - and with the usual guarantees of high profits. Finance-me-cratic Constants

Additional Major Journal Failures

What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.


In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.


Why Are HRSA Projections of Primary Care So Wrong?

What can a study from Zip Code 10032 teach America about Primary Care?

This JAMA study from Zip Code 10032 appears to compare nurse practitioner care with physician care. The study aimed low, intending to demonstrate no difference between physicians and nurse practitioners. As we understand more and more about social determinants, it should be surprising that any differences will be found in populations with the most social determinant limitations, such as those in this study.

This study can only teach America about a small portion of primary care for primary care delivered 1995 – 1999 in and around zip code 10032 about people that live in or around zip code 10032 some of the time. This study presented in a national journal is one of the least relevant with regard to United States primary care and United States health care.

The study uses old data, the sites of practice were different and the nurse practitioners actually changed locations during the study. Zip code 10032 is one of the most densely populated in the US with transportation and access unlike most of the US. The patient population was 80% Hispanic, neither type of provider spoke the language well, and there was little consideration of language or culture. Given the substantial social determinant considerations, it is unlikely that any variations between providers can be demonstrated as in numerous studies illustrating social determinants as major limitations of outcomes.

What will emerge from this study is controversy. This was an obvious reason for the publication. What will escape notice is whether the study was representative or even useful given the limitations of the design and the passage of 12 years since the study ended.

A major problem in health professional literature is lack of relevance. Studies can demonstrate significant differences in areas such as pharmaceutical drug treatment without being relevant. The significant differences are so small in impact such that hundreds or thousands must be treated to result in a single improvement. This often involves more costs and often does not improve overall outcomes such as better health or longer life.

Another failure in relevance is that studies commonly involve populations that are not representative of the American people. For example certain populations can be studied over and over again while others have few studies. Drug studies once again tend to involve a very narrow range of patients. Health care studies also involve a narrow range. The classic studies illustrate care of the 1 person in 1000 found in academic centers where most studies are done.

People who can access health care can be studied while those who cannot access health care and those with limited health access are less likely to be studied, particularly when using databases involving services. No services means no studies. Those studied are more commonly higher income, more urban, and more likely to have health care coverage. Those studied are often those with access or too much access. This presents a problem since America understands less to much less about populations left behind or over half of the nation.

The studies that are funded follow the health spending patterns. About 85% of the research funding goes to 3400 zip codes clustered together in 4% of the land area where the nation has top concentrations of researchers, teachers, academic institutions, information systems, health professional associations, and subspecialists. Foundation funding follows the same pattern of all lines of revenue and the top level in each line directed to zip codes inside of current concentrations of people, income, health professionals, and health spending. Physician Distribution by Concentration

What is substantially left out of awareness, understanding, and health spending is over half of the American population and basic health access areas most important to half of Americans left behind such as primary care, rural health, and care for underserved populations.

JAMA has already demonstrated that it is capable of publishing articles that comprehend the impact of social determinants of health and variations in the quality of care to underserved populations (Hong, September 2010). JAMA has also demonstrated failure in this ability as noted in a recent article about Critical Access Hospitals. This has been addressed at Which is it JAMA?

Once again JAMA presents a study in a way that appears to indicate national representation. Although the subject of the study is a comparison of primary care nurse practitioners to primary care physicians, it is important to understand what the study represents and does not represent. It represents a finding of not much difference with regard to two different types of primary care providers in a certain setting. This study also involves a location and population that is one of the most atypical in the nation.

Before you jump to conclusions about bias on my part toward nurse practitioners, I urge you to review any number of writings that have consistently avoided a quality argument. Quality arguments make little sense in a land missing in primary care where social, environmental, and political decisions have so much influence beyond a provider. Even nurses have more influence as they often encounter patients before, during, and after care and typically encounter those that are in need of better quality of care. 

As an expert in basic health access, an area largely missing for most Americans, my bias is in favor of those missing from health access. My perspective is also an objective look at what studies can and cannot demonstrate – an area I commonly find not addressed in most primary care studies involving workforce. This also comes with the full knowledge that what I note is not likely to be as relevant in ten years if we actually begin to examine health care - from more correct perspectives.

This study is also lacking in this area. JAMA once again fails to indication important study limitations in areas such as relevance for the nation, the impact of social determinants of health, and understanding the context of care provision involving the study. Zip code 10032 and surrounding zip codes are the likely sites for care as well as the locations of residence for those accessing care during the study. The population density of the area is most atypical as there are 70,000 to 100,000 people per square mile. This is up to 1000 times the population density of the nation and 100 times the 1000 people per square mile where most people reside in the United States. The study area is just inside of a bullseye of top concentrations of health workforce and health spending surrounded by populations short of health access by our national design. Zip codes east and north of this map are designated as shortage zip codes (HPSA) completing the doughnut of top concentration surrounded by shortage.

Even populations inside of concentrations lack health access as implied by the study of course very little about their health access was reported by the study.

Zip code 10032 has

• A well developed public transportation system – important for health access and missing for most people. 
•  A top income level (but also a top cost of living and significant numbers in poverty)
•  A top concentration of primary care including primary care sources not listed such as training sites for MD, NP, and PA graduates. 
•  A top concentration of health professionals 
•  A national lowest level of primary care and family practice by percentage of the workforce (those most consistent in primary care and in breadth of primary care scope are often driven away by narrow scope and marginalization). Internal medicine and pediatric proportions are also highest in such areas - concentrations of people, income, and academics.
• Top concentrations of subspecialists - Such areas have highest utilization rates, and paradoxically most difficult times finding specialists – specialists find a way of increasing utilization that has defeated any and all attempts at reform. One possibility is that the patients were least impacted by primary care as their care was provided by ready availability of other venues from care in other nations to self care to local support to other primary care to subspecialty to neighbors and friends. This is much less of an issue in rural locations or in settings with a complete population studied. 
• New York has 1.39 times more physicians per person and this location is one of the highest concentrations in New York. About 85% of physicians are found in zip codes with over 75 physicians in New York. Only a few states with top health spending have such concentrations of physicians. In 2005 the one zip code of 10032 had over 900 physicians and likely has over 1000 now.
• New York state has about 20 to 1 richest to poorest or top income quintile to bottom income quintile and the practice environment around 10032 may be more divided similar to Washington DC at 30 to 1.
• Primary care may be most challenging for providers as relatively lower salaries also are compounded by highest cost of living.
• Highest cost of delivering primary care (or any care) also can be a limitation on the care provided during encounters.

Some of the study limitations include

• Over 80% of the patient recruitment involved Spanish language. There was not mention of Spanish language with regard to the patient encounters. There was a limited mention of Spanish language in the providers. The language factor was not included in the study outcome. Gender and other similar background areas have been noted to be important in measures of patient satisfaction. Patients matching up best in background to their patients tend to rate satisfaction higher and this may impact quality as well. This is a huge problem for primary care when so much of the interaction measured in an encounter is person to person.
• Only 1316 patients is a small fraction of those who could have participated. It is a tiny fraction of the local population and of the primary care and of the overall care provided. 
• There is not mention of what proportion of the care of the patient was delivered under study parameters. No conclusions can be made about overall care outcomes as the study was too short, too small, and too limited.
• Health care delivered in the late 1990s during a peak emphasis on primary care under managed care influence – arguably one of the most cost effective periods in primary care in the nation’s history. Since this time less efficiency is likely (tests, referrals). The significant investment of Columbia Presbyterian was noted since 1993 in the article.
• Nurse practitioners emphasis has changed as have the proportions remaining in primary care. Studies often imply a larger primary care role but fail to mention the limitations. Only 70% of total NP graduates are found active as direct care clinicians and only 35% are listed in primary care (HRSA Nursing Reports 2004 and 2008). Remaining in primary care is difficult for nurse practitioners as with physician assistants and physicians. Smaller portions of NP graduates train in primary care and this is even smaller compared to advanced nursing totals. Fewest years in a career also limit primary care contributions for NP compared to physician or physician assistant.

The article did not demonstrate much in the way of differences. This should not be a surprise for a number of reasons listed above and a few more. First, health care outcomes are far more likely to be driven by factors related to patients rather than type of provider. Patients or their mothers or their spouses have substantial say over encounters. For those not in the country for substantial period, there are even more outside determinants and influences. 

Does the study support quality of care as same or similar for nurse practitioners versus physicians?

Yes and no. The study statistics support same or similar care. Given the limitations of all workforce studies and failures of realistic attempts to control for important variables, it is safe to say that current workforce studies fail to have the ability to demonstrate differences in one or more key areas:

•  Too short, not comprehensive enough, not enough isolation of the study subjects from other sources of care, lack of randomization, failure regarding controls, and failure with regard to the inclusion of many controls as indicated by Hong in JAMA and the Oregon Medicaid randomized study.

Readers can decide whether JAMA, editors, reviewers, authors, sponsors, or key stakeholders such as nurse practitioners or health care associations or health insurance foundations have an agenda. As far as this editor, author, and reviewer can state after 28 years of delivering and teaching and researching health access, I see evidence of lack of critical review by reviewers, failure of editors in editing in areas such as demanding critical review and more limitations in the published article, and widespread campaigns involving multiple articles submitted in areas such as generic expansions of physicians or nurse practitioners, the value of primary care without much justification, generic sources of primary care as solutions for primary care that are 60% - 85% not primary care, and basic health care needs of most Americans largely ignored.

And matters are getting worse not better – in directions of health spending and in the health information sources that are supposed to guide our national leaders.

Journals, editors, health professional associations, and academic institutions focus on innovative models of primary care workforce and primary care delivery but fail to focus on more primary care spending more specific to primary care services - the only real way to increase primary care delivery capacity in the nation and to improve health access and to improve the quality of primary care - mainly by moving more patients into basic health access.

Our current design with too few remaining in primary care workforce insures least experienced in primary care and also more patients moving to little or no health access and

That is a problem for cost, quality, and health access for an entire nation.

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

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