Who Really Benefits?

In past Basic Health Access blogs, claims of benefit to health access have been pointed out as promotions and promises, impractical, deceptive, or insignificant. Over and over the design deficits do not allow health access recovery. Most of these assertions and assumptions and promotions fail as they simply ignore massive and increasing shortages of the best and most experienced and most committed basic health access professionals – by far the most pressing need for basic health access for the next 20 years and likely longer.

The US simply does not have a design for training and for supporting the workforce needed for over half of Americans.

Past blogs have indicated that claims of benefit for rural areas or underserved areas are not entirely true as the real benefits go to academic institutions, software companies, or others who help themselves by the design. Foundations appear to be innovative and cutting edge by recommending new types of primary care despite the fact that these types are 3 to 1 not primary care in result.

Some foundations fueled by the billions going to health insurance corporations (such as United Health Care) appear to be promoting types of workforce that undercut physician workforce – a sure way to create more easily controlled health professionals - centralizing control in the hands of fewer and those most distant from care delivery. Sadly designs have already been implemented that will result in massive excesses of non-primary care led by 70 - 80% of nurse practitioners and physician assistants found in non-primary care areas. Massive expansions without real focus are a sure way to increase health care costs and more profits for health insurance companies, academic institutions, and large systems - those that benefit most from non-primary care excesses and ever higher costs with more subspecialized care.

Innovation and reorganization appears attractive during periods of desperation, but fixing desperation is about fixing designs that result in failure - not more innovation and especially not more innovation that proceeds from those that shape failed designs. All else tends to fail because of the policy design. Pipelines worked when policy worked but then failed when policies failed. Innovation and reorganization could work with a better design, but cannot work without a better policy design. No design can work without the workforce to serve where needed as this shapes health spending, health access, and distributions of health spending. Ever greater focus on innovation and reorganization is not the correct approach.

The one type of primary care that predates all new types has the best primary care retention and the best distribution in the most important category – delivery of primary care where needed as measured over an entire career of workforce contribution. The broadest generalist primary care workforce is always the solution for health access as long as it remains broadest generalist over an entire career. Family medicine existed before the innovations, got better because of the formalization of family medicine training, has remained most valuable for the past 40 years of family medicine's existence, and still contributes the most to primary care, to rural health, to care in underserved locations, and to local health care for 30,000 zip codes with 65% of the population and increased proportions of all in most need of care. Family medicine is also the one type of health access that has not been expanded in 30 years because so few under current policy will make a permanent choice of primary care most likely to be found where the US design sends the least spending.

Any evidence based focus on health access would see this as designers of US health care actually avoiding health access interventions such as family medicine that have worked for far more than the past few decades.

Readers are invited to review the following link and decide for themselves if Alabama, Kentucky, Arkansas, the Mississippi Delta, or other rural areas will really benefit, or whether the funds will go for someone else’s purposes (beyond the political desires of whatever administration is current). Year after year, administration after administration, Congress after Congress, we see the same news releases – but we continue to fail in basic health services despite spending far too much money upon health.

Agriculture Secretary Vilsack Announces Funding to Improve Access to Health Care in Rural Areas  Nov 21, 2011 -- Agriculture Secretary Tom Vilsack last week announced funding to establish telemedicine and other health care projects to address unmet health care needs in the Delta region.

I have learned to examine these various claims of benefit to see who benefits. This is another in a long and glorious tradition of political claims that fail in specific benefit to those most in need.

Will Arkansas, Illinois and 48 other states keep pouring millions into pre-health programs that fail to result in return in investment given only 1 out of 3 that actually make it to admission and less than 1 out of 5 that may serve in some needed career or location? Perhaps states will finally figure out that they should obligate MD, DO, NP, PA, and RN students at admission to train for needed health access locations – as a condition of admission. Then funding at each of 7 different levels is of little consequences since at least 90% will serve the first 25% of their careers where health professionals are needed – instate in locations in need. This is a far cry better than medical schools that attempt partial pipelines where only 1 in 8 graduates are found where needed, and mostly because they chose family medicine. A major advantage known for training is trainees that prepare for their careers all of the years of training. When trainees exhibit this (rural family medicine, pediatrics) or are obligated for these careers, they will better prepare themselves for such careers because their pathway was known from the start. See Addressing the Primary Care Crisis.

Does $700,000 for interlinked rural intensive care units work, or perhaps would $700,000 mobilize resources to attack maternal obesity in Mississippi - a condition that kills at least 4 youngest mothers a year across the state? Will these rural hospitals even survive the next 5 years of cuts? Will any intervention help when our nation divides further into richer and poorer – the reason for increased stressors especially in those most left behind and the reason for increased food consumption and other adverse behaviors resulting in poor maternal outcomes long before pregnancy?

I have to admit that linking rural sites is a good idea as in Project Echo in New Mexico, but will this project have a Dr. Sanjeev Arora and the U of NM and public health driving collaborative two way access. Project Echo in New Mexico focuses on delivering care to people in need of care – not stroke. The benefits are also better trained primary care professionals on the front lines. Another benefit is far fewer specialists needed with more primary care supported where needed rather than the current design that steadily collapses all health workforce toward 1% of the land area.

Is it helpful to pay 3 million dollars to have an urgent care center in Mound Bayou? Is this expenditure a measure of the failure of one of the first Community Health Centers in the nation to actually work? Why not primary care or CHC offices open until 8 or 9 PM? Was there no ER willing to branch out and if not, perhaps the reason was the lack of health care coverage or sufficient available local health spending? If the area was unable to sustain urgent care for 80 miles, does it need urgent care? Will 3 million dollars as a one time expenditure prop up an urgent care that is not viable under the existing design? Will the urgent care have the workforce needed or will it steal local primary care workforce and compromise local primary care? Can urgent care paid multiple times more for the same services help a region short on cash, short on workforce, and short by US design?

Then there is this political announcement:

“Since taking office, President Obama's Administration has taken historic steps to improve the lives of rural Americans, put people back to work and build thriving economies in rural communities.”

Should we be impressed after 30 years of such press releases?

Do the examples of a few rural locations mean anything in a sea of shortages caused by designs for elsewhere? Can centralized designs shaped by those most centralized really help locations that require decentralized training, workforce, and spending? There will never be enough in any special program to help rural areas, underserved areas, and most Americans in need of basic health services. Total failure is the result of poor designs that have totally failed. Double or triple or quadruple the special program spending would not help. The across the board cuts directly or indirectly or relative over decades will make matters worse for areas that need more spending, not less. The designers can use delay tactics and can confuse only if we let them. Real designs for health and for health care are needed.

For 30 years administration after administration has failed to distribute health spending and health workforce that would truly improve the lives of rural Americans as well as stimulate jobs and “thriving economies” in rural America. Each 15 years the designs can be traced as sending ever more spending to facilities not found in rural locations in need, sending ever more spending to non-primary care least seen in rural locations, and sending ever more spending to settings with the most health spending already.

Designs for 30 years that are cost cutting in nature, rather than designs for health or health care, are not good for most Americans. The designs leave 70% of rural Americans behind due to marginalization of family practice and primary care and health access. Only rural locations that have managed to replicate the largest urban system designs thrive because they find their way to all lines of revenue and the top reimbursement in each line - and have lowest percentages of primary care and family medicine by design.

Designs that favor those who already have the most workforce and the most lines of revenue and the highest level of reimbursement in each line fail most Americans left behind who have the fewest lines of reimbursement and the lowest levels of reimbursement (rural hospitals, primary care) as well as the least workforce and least economics from health care – by design.

But the media releases, major journal articles, academic planning, accountant-led cost cutting measures, and government reports will all continue. Perhaps one reason is that we all grasp at straws held out.  As long as we believe that we can keep our own special programs intact and fund them at ever higher levels we will keep grasping at straws - and will delay real improvements. Financially, politically, and practically it is not possible to hold on to special programming, but we persist. 

What we must do to actually resolve so many deficits for most Americans is to work together on a real design based on health and health care down to the local level.

Instead we have spending concentrated in disease focus, concentrated in too few locations, and concentrated on too few for too little result. Also we have the resultant cost cutting design in consequence and too little spent on most Americans in nearly all zip codes.

The Squeeze Play That Fails

How the Disease Focused Abuse Health Access

Deifying Disease By Design

Can We Have Our Billions Back Please?

Exploring the Health Consequences of Disease Focus

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!. 

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.

To Be SMART or Not to Have Health Access

Many new proposals attempt to be seen as solutions for basic health access. Even more fail to be solutions. Few will remain objective in the next 20 years of desperation in primary care workforce. Those eager to meet their own agendas will continue to wave the primary care banner even with less than one-third of graduates delivering primary care workforce. Readers should understand  that what is being promoted as a primary care solution is typically generic, not specific.

This blog will focus on solutions that have worked and that will work. This blog will help eliminate solutions that will not work or cannot work.

What works in primary care is SMART focus upon primary care - Specific, Measurable, Achievable, Realistic, and Timely. What does not work is less spending upon primary care, less spending in locations in need of primary care, flexible sources of primary care that fail to remain in primary care, and claims of primary care that are not measurable or achievable or common sense.

Designs that work:

• spend more upon primary care, 
• spend more in locations in need of primary care, 
• spend most specifically on primary care service delivery, and 
• spend training funds on types of workforce that are most likely to serve in health access for 100% of their career delivering the most primary care per graduate. 

These are designs that work for an entire nation when applied to an entire nation. When these designs are not compromised by spending elsewhere not primary care, nations can count on primary care staff, nurses, and professionals that remain in primary care, that continue to gain primary care experience, and that deliver the best primary care for the least spending.

SMART works when the focus is specific for primary care. SMART principles also work for rural health with specific rural focus.