Part I Million Hearts Limitations of Awareness

One Million Hearts Saved or 160 Million Lives Improved

Part I: Limitations of Awareness

It is not a bad idea to battle against preventable illnesses and deaths. Million Hearts is a campaign designed by top federal and health care experts with the goals of changing people behavior and physician behavior. These behaviors are focused on an increase in the use of aspirin and a decrease in smoking, a decrease in blood pressure, a decrease in cholesterol, a decrease in salt intake, and a decrease in transfat.

When a nation goes to battle, it must know its enemies, the limits of its methods, the strengths of the enemy, the false assumptions that you will make, and the weakness of your own leadership – glaringly apparent in the first months or years of any war.

"It is said that if you know your enemies and know yourself, you will not be imperiled in a hundred battles; if you do not know your enemies but do know yourself, you will win one and lose one; if you do not know your enemies nor yourself, you will be imperiled in every single battle."   Sun Tzu   Art of War (Good timing as this was on Star Trek Next Generation as I was writing this).

We will be imperiled in every battle in Million Hearts as well as in the battle for a Million better child outcomes and a Million of any number of federal, state, or private efforts - because we fail in understanding our strengths, weaknesses, and assumptions.

We demonstrate little understanding of what is preventable or not, the limits of risk factor modification (including the limits in the populations in need of modification), what it requires to accomplish greater prevention and greater proportions with prevention, what can result in fewer deaths (or what can result in more deaths), and

We fail when we focus inappropriately on preventable illnesses and deaths when there are other higher priority areas - balancing budgets, stimulating jobs, reducing health care costs, better children, and health access. We fail when we can accomplish one Million Hearts and much more by improving children and better health access.

And we forget that we cannot win against the enemy of death and many if not most of its causes. Death is inevitable. We all will die. All efforts will fail as death will conquer. – You get the point, but do the experts?

If you do not think something as simple as aspirin can damage or kill, try this illustration. The same computations that indicate lives saved also indicate the substantial group not improved, the one that has a hemorrhagic stroke, those that have bad outcomes anyway, and those that have bad outcomes because of aspirin. There is also the problem of going to the store and finding aspirin at a reasonable cost - one certain to increase because of the retail opportunities afforded by Million Hearts. So even in best case settings, Million Hearts efforts can be expensive and costly – especially in populations that do not actually benefit or that are at higher risk from harm.

Most importantly right now, the nation has a great need to focus on very pressing priorities. Health care leaders must focus on health care in rural, underserved, and primary care settings – health care more endangered with each passing day.

We have a ton of tough high priority problems right now. Yet we have leaders that are spending their political and media and social organization capital in areas that are not going to help the nation right here right now where it needs help, particularly with primary care facing serious problems and health care costs moving to 20% of GDP and beyond.

This bothers me greatly as a primary care physician. Million Hearts interventions all demand more primary care workforce (RN, MD, DO, NP, PA, team members) and a more experienced primary care workforce and a better trained primary care workforce and primary care workforce that is distributed to 30,000 zip codes or adjacent zip codes where 65% of Americans need primary care. Failures in basics such as education, health coverage, and primary care make it difficult for any interventions to succeed. Again I would have to point out that changes in the design that free up primary care nurses from onerous tasks with little benefit (insurance and government requirements especially) and place them back into direct patient care encounters and directing health care encounters - would be one of the best ways to address Million Hearts and health access improvements for 160 million left behind.

SMART designs work to achieve more for less cost with better result. 

Also sending RN, MD, DO, NP, and PA students for long term continuity experiences with primary care health teams would greatly expand primary care services and access and training and outcomes - by design.

Why the Focus on One Million Hearts and Not a Focus on 160 Million (Introduction)

The Million Hearts Campaign has been shaped by those leading health care – government, associations, business, and insurance. Million Hearts is not a poor choice in itself. It is what Million Hearts represents that is the problem. Million Hearts represents numerous choices past, present, and future that have not worked for most Americans. These continued choices distract and divert attention from what works. A focus upon diseases and risk factors is quite different when compared to specific focus upon the basic needs of most Americans.

• One Million Hearts Saved or 160 Million Lives Improved   Million Hearts is another attempt to turn risk factors into saved lives - specifically reductions in heart attacks and strokes. The targets are once again human behavior changes (patient and provider) regarding aspirin, blood pressure, salt, cholesterol, and transfats. The campaign involves a number of federal agencies and health leaders, but the campaign will not address the top issues facing most Americans in their life, death, or health.
•  Part I Million Hearts Limitations of Awareness  We demonstrate little understanding of what is preventable or not, the limits of risk factor modification (including the limits in the populations in need of modification), what it requires to accomplish greater prevention and greater proportions with prevention, what can result in fewer deaths (or what can result in more deaths).
•  One Million Part III Higher Priorities A Million Hearts Campaign that hopes to change human behavior should realize that the easiest and best way to change human behavior is changing humans during birth to age 8. To have people decide to improve their health, they must be invested in a better future. Children reduced to growing up in survival mode may never be able to focus on a better future.
•  Rearranging the Deck Chairs: Death Displacement Saving lives sounds quite heroic, but the reality is that we are at best only displacing or delaying death for a few years. We will all die. We will all die. We will all die…… We spend the most health care dollars at the end of life in ways that are wasted. We spend the most on just a few and the least on the most. We spend so much at the end of life for few that the quality of life is impaired for many.

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

Does Primary Care Experience Matter?

Few studies critique primary care workforce sources - especially the popular sources promoted as primary care solutions. The public receives information via the media that is even more distorted and promotional in nature.

One area to consider is experience in primary care delivery. Readers are cautioned that experience in primary care may not translate to quality for any number of reasons, but experience may be important to certain populations, workforce designers, and those in need of the most complex primary care delivery. Those most experienced in primary care contribute substantially to primary care continuity teams. It is difficult to see how continuity is aided by primary care sources with the least experience in primary care and with the least retention within specific primary care practices. 

Consistency in Primary Care Experience

Patients visiting family physicians are likely to visit sources with the most primary care experience. Family medicine is a mature stable workforce with about 3% of the family medicine workforce arising from each class year for the past 33 years. Least increase in annual graduates and maximal retention within primary care is a combination that results in most primary care experience. 

Rapid Expansion Leads to Less Experience

Primary care sources that have expanded rapidly (NP, PA) contribute to a workforce that is less experienced in primary care. A doubling of annual graduates each 6 – 12 years since 1980 results in substantially more non-physician clinicians who are new to primary care and to all other specialties as well. 

Years of Experience 

Years of Experience	Nurse Practitioner 2003 AANP	Nurse Practitioner 2007 AANP	Family Physician 2007 and Beyond
0 - 5 years	61%	45%	18%
6 - 10 years	23%	29%	15%
11 - 15 years	6%	15%	15%
16 - 20 years	3%	4%	15%
21 - 25 years	4%	3%	15%
26+ years	2%	4%	22%

The nurse practitioner data represents generic years of direct care clinician experience. The family physician proportions are 90% specific to primary care experience. Slowing of expansion has led to slightly more experience in recent NP workforce, but experience remains far less than the steady state year to year contribution of FM. Also nurse practitioners will rarely reach 26 or more years as entry into primary care averaging age 40 will result in 25 years of experience by age 65. Departures in the years after graduation will result in only the most dedicated with substantial years of primary care experience.

Departure from Primary Care in the Years After Graduation Leads to Less Experience

Certain primary care sources depart primary care steadily in the years after graduation (NP, PA, IM). Those who begin in primary care often depart primary care. Even physician assistants in primary care departed primary care from 1990 to 2000 under improving primary care policy conditions (Larson and Hart). Primary care retention woes lead to delivery by those least experienced as those more experienced depart primary care.

Lower Volume and Less Primary Care Experience

Primary care sources with lower volume (NP, PA) are likely to have less primary care experience. Fewer encounters, encounters less complex, and encounters with lesser responsibility can all contribute to lesser primary care experience.

Less Primary Care Specific Focus in a Source of Workforce

Sources of training that contribute a minority of graduates into primary care workforce can have training that is also distorted away from primary care. Graduate outcomes are powerful influences upon training. Internal medicine is over 75% not primary care in result. The consequences include dysfunctional primary care training that may drive medical students and residents away from primary care choices (Keirns, Academic Medicine).
Nurse practitioner and physician assistant graduates are found over 65% outside of primary care delivery as direct care clinicians. This could fall to 75% outside of primary care if expansions slow down and non-physician clinician workforce gets a chance to age. Steady departures over time have a number of consequences that few are willing to discuss.

It is tough for training programs or health professional associations to remain focused upon a minority of graduates, alumni, or members.

Payment Designs that Impair Continuity

AAPA studies indicate physician assistants departing for another primary care practice for a 4% increase in pay and departing primary care for a 10% pay increase. Payment designs that favor certain practices and non-primary care career choices distort flexible primary care workforce sources the most. Low pay for primary care tends to drive all primary care sources toward lower continuity and away from the practices with already least primary care workforce.

Does Less Experience Translate to Lower Quality?

Less experience in a workforce does not necessarily mean differences in quality. Research studies will continue to show no difference in the quality of care for different types of providers. The reason is that patient outcomes are more about the patient and patient environment and are less about the provider. Practices that include experienced primary care team members can benefit from the experience in ways helpful to those delivering care who are less experienced.

It is sad that we forget over and over that health care access, health care cost, health care status, and health care quality are mostly about the patient. 


Any design that hopes to result in more experience to deal with the increasing complexity of primary care and any design that hopes to result in more continuity…

Must result in greater support of the primary care personnel such that they can remain in primary care and in their current sites – by design.

Steady and consistent is not exciting, but it is Specific, Measurable, Achievable, Realistic, and Timely.

Rural Primary Care: Stark Realities

All primary care sources have declined in primary care per graduate and in rural primary care delivery per graduate. The rural Standard Primary Care Year contributions over the class years illustrate the declines in rural primary care delivery. The Standard Primary Care Year is multiplied by the proportion of the primary care component found in rural areas.

Declines in Rural Primary Care Delivery per Primary Care Graduate

Family Medicine has declined also, but other sources have had greater decreases due to substantial departures from primary care.

Estimated Rural Primary Care Year per Graduate Changes By Class Year 

	PA	NP	FM	IM	PD	MPD	Average
1965	3.07	1.77	7.08	2.27	2.72	4.84	3.14
1980	3.18	1.77	6.92	1.86	2.36	3.90	3.22
1995	2.55	1.63	5.86	1.38	1.70	2.88	2.52
2010	1.21	1.03	5.12	0.39	0.90	1.63	1.31
2025	0.94	0.82	4.49	0.28	0.68	1.22	1.03
2040	0.86	0.75	4.28	0.25	0.51	1.05	0.92

Even though the nation has continued to generically increase annual primary care graduates, this costly intervention is not capable of addressing rural primary care needs. The reason is steadily lower rural primary care delivered per graduate.

SMART requires specific emphasis upon primary care and rural primary care for dependable health access contributions. Not SMART is costly generic expansions of annual graduates that depart primary care and rural locations steadily over time.

Family medicine contributes by far the most health access per graduate, but has also declined in primary care and in rural primary care. Family medicine has long set the standard for least departure from the career of training. Family medicine still represents a standard. All primary care sources have moved to shorter careers and less activity. Declines in other sources represent compounded losses due to departures from primary care. 

The family physicians of the 1970 - 1980 era also had 30% rural rates as for this one time in history the United States increased spending upon rural areas and underserved areas and primary care - the three health spending areas most impacting rural primary care. Family medicine as the broadest generalist primary care source of the time was ideal for the new opportunities created by the new design. This was also the last major design change, the last expansion of family medicine, and the last expansion of primary care delivery capacity.  

Stagnant spending in rural, underserved, and primary care areas are the real reasons for declines in rural primary care with workforce only a reflection of designs that send health spending elsewhere.

Nurse practitioner and physician assistant primary care contributions would have remained stable - if NP and PA workforce remained family practice for entire careers. But departures from family practice during training, at graduation, and each year after graduation have simultaneously defeated primary care, rural, and underserved NP and PA contributions. Teaching hospitals alone have converted tens of thousands from primary care to hospital and subspecialty workforce.

Departures from health access are about the great versatility of NP and PA workforce. They have gained widespread acceptance in non-primary care and far beyond rural locations. Departures from basic health access result in significant gains in salary for the graduate and result in significant gains in revenue generation for the employer. Such is the design that reward non-primary care and services delivered in top concentrations of workforce.  

New physician assistant entry into family practice has been cut in half to 20% in the past 15 years (AAPA) and only 25% of total nurse practitioners contribute in family practice employment (Advance for NP and PA surveys). Physician assistants in family practice have 30% rural location rates (2 to 4 times other PA types), 30 times the rural health clinic rates compared to other PAs, and 6 times the Community Health Center location rates (AAPA). 

Family medicine residency graduates continue to remain steady in primary care delivery per graduate as well as the proportion found in rural locations - SMART factors that result in SMART contributions. Rural primary care remains most consistent in family medicine.

NP and PA primary care and rural primary care contributions nationwide for the United States  still continue to increase slowly. This is due to a massive expansion of non-physician clinicians 1980 to 2010 with a doubling of annual graduates each 6 to 12 years. Even without further expansion, the NP and PA workforce will continue to grow for 25 more years as the design level of annual graduates fills out to become more workforce.

Sadly this workforce will not have the same primary care emphasis. Decreasing retention in family practice over this time period has resulted in 3 times more PA graduates required for the same PA rural primary care delivery and twice the NP graduates required for the same rural primary care delivery compared to 1980. Longer training and lower yield of primary care and rural primary care translate to much greater costs of training for the same or lower yield of health access workforce.

Sources other than family medicine require 4 to 10 graduates to contribute the same rural primary care over a career as a single family medicine residency graduate.

Rural health care delivery by non-primary care sources may also be more difficult as non-primary care physicians and non-physician clinicians are moving to more subspecialized types least likely to distribute to rural locations in need of workforce. Rural practice location rates have been higher in the general surgeons, general obstetric-gynecologists, general orthopedists, and general IM specialists - careers less preferred by emerging graduates.

Major journal articles, health professional association reports, and government actions have indicated serious errors with regard to awareness of primary care and rural health care. Inappropriate comparisons, overestimates of future primary care, failure to emphasis specific solutions such as family practice, and continued payment design flaws plague rural health access. Recent government errors include bonus payment designs for physicians in shortage areas that did initially failed to work for broad scope generalists common to rural locations and bonus payments that required the use of a form not used by rural health clinics. Government spending upon primary care training is least specific for rural primary care as only 30% of funded graduates will actually be found in primary care and even lower proportions will be in the family practice component most essential for rural primary care. Epidemic poor awareness is the culmination of 30 years of progressive failure.

Most of all, leaders exhibit poor understanding regarding design failures for primary care for those most dependent upon primary care. Primary care is 40 - 100% of local workforce for rural areas in need of primary care and family practice is 40 - 100% of that local primary care. As other specialties decline in concentration with decreasing concentrations of people, income, and health care coverage, family practice MD, DO, NP, and PA remain.

Generic and innovative does not work. Specific and achievable does work.

Spending upon rural primary care must be addressed for any increase in rural primary care workforce or rural primary care delivery. Changes 1970 to 2010 indicate the reasons. As family medicine filled out from 40,000 to 100,000 over a 40 year period, this permanent primary care source actually displaced more flexible sources from primary care and from rural primary care. Increases in NP and PA family practice also contributed to displace IM, PD, MPD, and non-family practice PA and NP. Generic expansions fail for primary care or for rural primary care, especially during a time of stagnant support for rural primary care delivery and increasing costs of delivering primary care.

Recovery of primary care requires SMART - Specific, Measurable, Achievable, Realistic, Timely  

States are already spending millions more each year for locums, recruitment, and retention costs without increasing primary care delivery. This is not SMART.

Pounding Poverty Providers with Pay for Performance from 12/2011 indicating more ways to send funding elsewhere.

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