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 

Deifying Disease By Design

In a recent video released to the world, top experts have revealed their agenda for making progress with regard to disease focus. Local and state have not been enough. National is not enough. They want the entire world to focus upon eradication of thousands of diseases which they conveniently categorize into just a few - or actually one disease.

In the video there is a first a comment about the problem of the term “non-communicable disease” (a negative term), and then there is adoption of the term “NCD.” This is a continuation of a process to make thousands of heart, lung, and other diseases into Four Diseases Focus and then into just one - NCD.

Those in charge are very effective with regard to focusing attention upon disease (not better health, not better health care, not health care for entire populations). They have been first to call for a UN summit on the problem of non-communicable diseases.

Forget the fact that the nations left behind mostly need clean water, sanitation, better housing, decreases in massive pollution, and other basics.

Forget the fact that the major problem for nations such as the United States is a disease focused design that results in 20% of all dollars sent to health care – crippling the economy and resulting in ever more stress and more disease and poorer health as a result.

Forget the fact that most Americans have limitations with regard to basic health access in one or more dimensions - because so much is spent upon disease focus.

Forget the fact that disease focused health spending crowds so many dollars into so few diseases with care delivered in very few locations.

Those in charge that are disease focused are not happy with just the domination of medical journals or government reports. They are not yet pleased with their ability to get ever more disease focused testing and ever more disease focused training and ever more disease focused treatments.

Forget that they have the ability to convince legislators to do what they want even when the evidence is poorly supportive - because those that sell tests and equipment and research harvest vast sums of money by disease focus.

Forget that they accepted billions of dollars of government, drug company, and foundation dollars spent on disease focus - dollars that shaped their admission, their training, their advancement and promotion, and their thinking.

They are not happy controlling government health leaders and panels. They plan to get above the health ministers to heads of government and finance ministers.

Remember that they do not understand that their single-minded focus on disease eradication is breaking the bank of government at all levels (school districts to federal) and businesses of all types already (that pay more and more each year for health care insurance). Forget that school districts have to cut teachers and education focus to balance health care spending or that governments cut public servants to pay for ever increasing health insurance costs and insurance companies just pass disease focus back to us with higher costs of insurance.

The disease-focused see the need to spend ever more on costly tests and treatments that look good on paper but are actually even more costly and less effective in actual result.

How many more times will we need to see failures when moving from paper to populations before we decide to apply the recommendations to 1 to 2 million people before applying them to 300 million?

Application to entire populations is a process, not a concept. Concepts are easy, process is hard. Is it a surprise that the US failed to understand Deming and fails to understand quality with a focus on concept rather than process? Application of health concepts to process has yet to be captured on paper or even in reports or entire books.

An example of disease focus is seen in diabetes - or rather the several diseases that are combined under the term diabetes.

• First, the definition is changed and results in substantially more found with "diabetes".
• Second, economic conditions result in more stress and more difficulty addressing the root causes of diabetes. Eating too much and drinking too much and poor diet are just a few of the behaviors people turn to when stressed. Those most stressed also find it harder to get health care and the best health care.
• Third, diabetes is declared as epidemic, because of the direct and indirect influences of disease focus.

The disease focused are not bad people. They are actually quite nice. They are among the brightest on the planet. They are also passionate about what they do and how they hope to help others. It takes more than best and brightest or the most passionate. It takes practical and relevant to lead health care effectively for entire nations.

Process is far more important than concept. The health of entire populations is all about process and little about concept.

Like nearly all of us, those passionate about diseases are frustrated with politicians. They are also certain that their approaches will work, just like any number of interventions that failed to work well beyond the basics of food, sanitation, water, housing, and immunizations. After all they were doing disease focused research before medical school and during medical school long before they even had any clinical training. Disease focused research shaped their path to medical school. The influence continued in the first two years before there was much in the way of clinician training at all. If you do not understand this, just pick up any of the 30,000 applications for medical school each year and compare how much space there is to pointing out just how much research focus their is in applications.

The disease focused will also be more frustrated as progress is gained in evidence-based medicine – indicating that their plans for disease focused domination can be exposed as wrong. In fact the very word non-communicable disease is a separation from communicable diseases that still kill millions a year and the youngest and some of the most important for nations - like parents.

The disease focused will also be frustrated by those that point out that health and health care delivery outcomes are more about people and the conditions of populations – not disease-focused care.

How will the disease focused react when more and more evidence points out that disease focused care is what is breaking the bank and causing stress, obesity, mental health problems, lack of focus upon children and those newest to life (where interventions are most effective), and more focus on those at the end of life where little real gain in life is possible at increasing cost?

New blog and posting at

Clinician Specific Medical Education -  What They Don't Teach Medical Students: Doctoring

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!. 

Clinician Specific Medical Education

Finance-me-cratic Constants in the Bureaucratic Universe

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

(Note Finance-o-crats was changed to Finance-Me-Crats - a better term with those that have self-interest above nation and political party.)

"Let me end my talk by abusing slightly my status as an official representative of the Federal Reserve. I would like to say to Milton and Anna: Regarding the Great Depression. You're right, we did it. We're very sorry. But thanks to you, we won't do it again." November 8, 2002 by Ben Bernanke (the current Chairman of the Federal Reserve), as he agreed with Friedman in blaming the Federal Reserve for its role in the Great Depression. Bernanke should remember that

"Hell hath no fury like a bureaucrat scorned." -- Milton Friedman

The bureaucratic mentality is the only constant in the universe.  Leonard McCoy, M.D. (Bones of Star Trek) - There are a number of timeless quotes from docs fighting with bureaucrats to keep health care alive where people need health care. The first female Native American physician came to be because she witnessed bureacratic health care and vowed to bring health care to people in most need of better health.

Smaller portions of Americans left behind have grown to become most Americans left behind and sadly few realize that the very designs of health care leave them behind. In American financial, education, and health wealth follows designs. Health care follows the finance-me-crat pattern of more for fewer with high profit and little responsibility.

Take equal parts aristocrat, bureaucrat, and finance-me-crat - mix for 100 years and you have the American health care design  - one size fits none. - RCB

To recover as a nation and to prevent further economic distress across the globe, America must bail out from the financial crises aided and abetted by finance-me-crats (investment cost and risk greater than reward with those responsible escaping responsibility)

and the real estate bubble burst aided and abetted by finance-me-crats (investment cost and risk greater than reward with laws protecting finance-o-crats in case of bubble burst)

and the student debt loan bubble about to burst aided and abetted by finance-me-crats (investment cost and risk greater than reward with laws protecting finance-me-crats in case of bubble burst).

Scandals rock college sports aided and abetted by finance-me-crats while responsible university leaders looked the other way (and those responsible seem to mock the destruction heaped on so many lives and reputations).

Health care spending ends up less and less in the hands of those who deliver health care with more and more spending ending up in the hands of finance-me-crats and those making profits shaped by finance-me-crats. We spend ever more for ever less result for all Americans except finance-me-crats and finance-me-crat wannabes.

Health insurance reforms needed for decades to reign in health insurance laws appear to be on the way out along with other reforms. The health insurance design was set up by finance-me-crats in each state to guarantee maximum profit with little risk or responsibility while individuals and their families suffer the consequences and sometimes can get justice at even consequence to a decent life.

Also finance-me-crats benefited from increased profits by blaming the new reforms that had not taken effect - a nice strategy to deceive the American people about the new reforms. In other words, reforms have failed and will fail to address the basic finance-me-crat modus operandi - maximal profit regardless of consequences with little investment or risk by redesigning American business and government.

Finance-me-crats have also found ways to spin media perceptions so that areas such as health care appear to be under government control when the real control is in the hands of finance-me-crats and those that they can hire, collaborate with, or influence.

Congress is constantly distracted and distorted in composition and in behavior by finance-o-crats who shape special laws governing insurance, real estate, college loans, health insurance, and taxation including decades of special tax protections for the ultrawealthy at federal and state levels.

Special interest groups led by finance-o-crats and protected by Supreme Court decisions funnel billions of dollars into divisive interests. Millions can flow from outside of states to shape elections inside of states allowing maximal control for minimal cost and little responsibility. A few billion injected in the right direction can divide the nation and divide states and divide political parties. Such behind the scene designs succeed in preventing identification of finance-o-crats as a major problem - along with frustrating the American people about becoming involved in governing.

And when the nation was at its knees desperate for some cash to help recover much of the nation from the abuses of finance-me-crats, the finance-me-crats, always first at the feeding trough, were quickest to react and were the first to waste the recovery dollars for themselves and for their allies. This spending resulted in limited recovery for maximal cost and the spending also illustrated finance-me-crat disdain for the great responsibility of using government funding wisely or for recovery.

Perhaps America should focus more on the role of finance-me-crats who have done what the founders of American government tried to avoid for 200 years - voting the US treasury into the pockets of those with too much government influence.

This one is certainly less like the usual basic health access posting, but if we continue to send more and more concentrations of spending to those already with concentrations, we will not have basic health access or much of anything involving basic services. Daily Yonder Article on Primary Care Cuts Planned Jan 1, 2012

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!. 

Clinician Specific Medical Education

SMART – Specific, Measurable, Achievable, Realistic, Timely

To Follow the Money, Follow the Workforce   Health spending patterns shape health workforce and vice versa.

Why Do Government Reports Project Increasing Primary Care When Fewer Enter and Remain in Primary Care?

Health Workforce Designs for Health Access Have Tried Everything Except What Has Worked for Health Access.

A Major Reason for Runaway Health Care Costs: Three Dimensions of Non-Primary Care Expansion while Primary Care is Shutout 3 to 0.

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

Promotors of generic expansion have commonly mentioned primary care workforce increase. At best primary care workforce remains a side effect of expansion. Training and spending and accreditation in primary care remain subservient to non-primary care interests and influences. Even primary care associations are compromised by members and leaders influenced primarily by non-primary care influences. The US should not expect an increase in primary care because this is what has been designed. Non-primary care is quite another result.

Primary care projections are actually quite easy to make. The best estimates are guided by recent decades. Recent decades of stagnation in primary care indicate no growth. Primary care spending is stagnant, permanent primary car such as family medicine is stagnant, and flexible primary care sources have been departing primary care. The US will remain at zero growth even with expansions as fewer remain in primary care during training, at graduation, and after graduation. Predictions of primary care as no growth should be easy due to stagnation in primary care spending and increases in the cost of delivering primary care - major determinants that insure declines in primary care delivery capacity. This is a design that sends primary care steadily away from primary care.

Addressing Disbelief and Assumption

For those still not convinced, the opposite approach may help. Why not calculate non-primary care workforce increase? Predictions of non-primary care workforce are most difficult with three dimensions of increase in 4 sources of health professional workforce.

• Generic expansions of nurse practitioner, physician assistant, osteopathic (DO), and allopathic (MD) annual graduates
• Increasing proportions of NP, PA, DO, and MD entering non-primary care (from 60% past 70%)
• Primary care graduates steadily converting to non-primary care over their careers

People and politicians and even academics like to think in short term solutions and cures. Short term solutions are not possible in workforce. Workforce designs result in an annual graduate number and it takes  30 - 35 years or the average career length to change the overall workforce design (25 years for NP with shortest careers).

For example it took over 30 years of graduates from 1980 to 2010 in family medicine to translate 3000 annual graduates into 100,000 for the current workforce. Steady increases from 30,000 to 100,000 were seen over this time. The Health Resources and Services Administration projected family practice to increase to 144,000. This is not possible as the family medicine annual graduates remain fixed at 3000. Even with a doubling of family medicine to 6000 in 2011, family medicine would fall short. Internal medicine primary care projections are similarly in error. Projection methods are exposed as problematic for primary care, particularly when primary care does not remain in primary care. Poor understanding of the basics goes all the way to the top experts.

Other sources not bound by primary care limitations have increased in annual graduates although the result is far more non-primary care than primary care. Sources such as NP and PA have doubled in annual graduates each 6 - 12 years since 1980 and have moved from 50% to over 65% not in primary care. Steady departures from NP and PA primary care continue with teaching hospital, emergency care, and subspecialty diversions leading the way. The last PA doubling (100% increase from 3000 to 6000 annual graduates) resulted in over a 200% increase in numbers entering non-primary care and just a 30% increase in primary care entry (AAPA). This small increase of about 3% a year will be negated due to departures in the years after graduation as Larson and Hart noted even during the 1990s - a much better primary care time period.

Osteopathic increases in annual graduates could have resulted in more primary care under a different national policy design, but the expansions have been countered with declining family practice choice from 65% (prior to 1970) to 35% in the 1990s to 17% for no gain in annual family practice - the predominant DO primary care vehicle. Family medicine entry remains fixed at about 500 - 600 per year. Only the fact that family medicine is the most permanent primary care source results in any stability of osteopathic primary care output - but there is no gain either.

And US population growth continues and the elderly that use 2 to 3 times more primary care are doubling by 2030 and we might have increased primary care demand from expansions of health care coverage (might).

MD declines in primary care involve all sources. There is a decrease in family medicine from 14% to 7% of US MD graduates, half as many internal medicine graduates (20 - 25%) enter primary care as compared to 1990s levels (over 50%), and pediatric graduates have decreased from 70% to 40% remaining in primary care. A 30% US MD expansion will not cover the losses for an overall decrease in primary care delivery per graduate from by far the major source.

What If We Stopped at Current Annual Graduate Levels and at Current Proportions Entering Primary Care?

Even if the US stopped all expansions and held at the current levels without further departures from primary care, this would be 6,500 annual physician assistant graduates times 33 years per graduate times 75% non-primary care for 161,000 in non-primary care and 56,000 in primary care (predominantly employed in family practice). About as many physician assistants will be inactive as will be found in primary care.

The nurse practitioner maximum would be 200,000 given about 8000 annual graduates. These have most recently been 70% found in the direct clinician component with 35% found in primary care (HRSA Nursing 2008). This results over 25 class years in 90,000 for a non-primary care workforce and 60,000 in nursing (especially nurse staff) positions, and 50,000 in primary care (predominantly family nurse practitioners remaining in family practice employment). Primary care comes in third in priority for nurse practitioner workforce.

The physician contribution will remain 100,000 for primary care from FM, about 42,000 from primary care IM and 48,000 for pediatrics. The non-primary care result is 192,000 for IM graduates and 58,000 for PD graduates. Family medicine and medicine pediatrics both contribute about 10,000 each to result in 270,000 for non-primary care with a total of 196,000 for physician primary care.

The total would result in 280,000 in primary care and 525,000 for non-primary care and 60,000 for nursing - and this is just the result from primary care graduates.

The total non-primary care is already set for 1.4 million as a workforce and will be higher with annual graduate expansions and stable or declining primary care proportions.

What resulted in increased primary care delivery in the 1990s with substantial NP and PA primary care efforts working together with MD and DO is quite different. The boost in workforce effort from working together will be found predominantly in non-primary care.

The 1990s design was 29% for primary care for the 2020s result. The 2010 design is set for 16% primary care result or less. The non-primary care workforce result is important to examine.

In 10 or 20 years, we will once again revisit the continual major blunder in US health care workforce reports - the lack of a SMART design steady for 30 - 50 years in the future instead of oscillating wildly.

The consequences of non-primary care excesses are substantial. Those that have promoted generic expansions and non-primary care excesses will have once again visited more problems upon our children and grandchildren as fantasy does not translate into reality.

The financial and economic repercussions of health care design are still poorly recognized. The US has clearly found a way to limit primary care workforce and primary care spending. Low priority assures little growth in this spending relative to increasing non-primary care demands.

Non-primary care workforce is quite another matter. Non-primary care workforce has always found a way to escape cost limitations (increased volume, more testing). Non-primary care expansions have been a major reason for continued health care cost increases and will be a major reason why 2020 will bring 20% of the GDP spent upon health care. This leaves less and less for all other areas other than health care. Even worse is increasing costs for people intensive endeavors such state government budgets, local and school district budgets, federal costs, and American employers. Greater deficits and lesser productivity are programmed in place by failure of health care design.

Only Specific, Measurable, Achievable, Realistic, and Timely designs work - with permanent primary care the specific focus along with sufficient primary care spending to deliver primary care to an entire nation rather than just half.

A best guess is that about 10 - 15 years from now (sooner if health care costs are reigned in more) there will be too much non-primary care workforce. Of course those claiming economic benefits from expansion will still be claiming these benefits as health care consumes an ever larger proportion.

By the time we figure out the consequences of too much, it will be too late to stop the momentum as there will be another 15 to 30 years of increase even if annual graduate levels no longer increase. Once again it is easy to forget that an annual graduate level takes 30 years for full realization. Increases in non-primary care (or any workforce) that are too rapid inevitably overshoot the mark 15 - 20 years later. There are other consequences to consider. If nurse practitioner annual graduates double as in each 6 to 12 years since 1980 the consequences will be dire for basic registered nursing workforce depleted of more and more experienced RNs.

Another decade of expansion of non-primary care workforce will result in many other national financial and economic concerns. The US rapidly forgot the lessons of economic decline as the result of rapidly rising health care costs. Few now remember $1200 of the cost of a car required for health care. The cost is now higher. Not surprisingly manufacturing has been substantially removed from the United States due to past, present, and future health care costs.

The lessons of the 1990s remain valid - costs reigned in for even a short time set the nation on course for one of the longest recent runs in economic progress in recent US history - even with a brief design change.

Spending more on health care is not going to contribute to economics in any area other than economic ruin. Designs that result in too much non-primary care must also be reigned in if there is to be hope for economic recovery.