Rural Rearrangements of the Deck Chairs

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

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

New Rounds of Publications Emerge

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

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

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

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

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

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

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

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

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

Thirty Years of Health Access Workforce Prevention

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

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

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

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

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

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

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

Which Medical Schools Produce Rural Physicians - a 15 year update

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

Rural Medical Education Specific Blogs and Links

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

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

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

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

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

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

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

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

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

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!. 

Comparing Family Practice Sources

The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations of workforce or health spending. It is important to understand that not all sources remain in family practice in the years after graduation.

Family Practice Retention Using Different Measures

Advance for PA and NP surveys have more detailed information that goes beyond just training program. AANP data indicates training or main specialty, but is limited in actual work components. Workforce cannot be defined without important components that define the actual work - such as positions and employment – especially for the most flexible primary care training sources (NP, PA, IM) where over 65% of graduates are found outside of primary care delivery.

Family medicine remains over 90% in family practice employment throughout a career. The distortions of US health policy have driven away all sources from primary care except those most permanent - family physicians. Few other options are a good thing for health access for most Americans. In studies of 1997 – 2003 family medicine residency graduates only 2% had entered additional training by 2005. About 1 percentage point was found in either geriatrics or sports medicine and 1% entered obstetric, surgical, psychiatric, or other training including primary care training. There was no deterioration across the six graduating classes (about 2% across each class) – another indication that family practice is an enduring choice for family physicians. Family medicine residents have consistently been the marker to compare retention in career choice.

Retention within family practice insures a consistent rural level of 22% or more for all graduating classes found in rural locations (3 times other physicians), over 14% found in high poverty underserved locations (2 times other physicians), and over 50% (2 times other physicians) found in 30,000 zip codes outside of concentrations of physicians with 65% of Americans.  Family physicians are found at 30 per 100,000 across the wide range of populations and locations in need.

Nurse practitioner training can claim 50% of graduates trained family practice, but only 25% of NP workforce remains in family practice employment. Also since NP workforce is the most recently graduated workforce due to recent rapid expansions, further departures to even lower FP proportions should be expected with additional years after graduation. Unlike family physicians that are relatively fixed in family practice, nurse practitioners have many other opportunities and locations and specialty choices at greater rates of pay. These also generate more revenue for employers than primary care. These strong forces work year after year to divert nurse practitioners away from primary care, rural, and underserved locations – even when they train in family practice.

Physician assistants have followed the physician design shaped by the health policy construct. This has resulted in declines from over 40% to less than 20% entering family practice in the past 25 years. The newest PA graduates should follow the pattern of the last few decades by continuing to depart primary care and family practice in the years after graduation. This was noted across the primary care friendly 1990s by Larson and Hart.

Physician assistants dedicated to family practice have what may be the top rural proportion at 30%. Other PA types that are all below the 15% in rural practice PA average. Family practice PAs are 30 times more likely to be found in a federally qualified rural health clinic, 6 times more likely to be found in Community Health Centers, and 2 – 4 times more likely to be found where needed when compared to other PA types (AAPA). Departure from family practice moves physician assistants away from all locations and populations in need of health access.

The secret of health access is retention in family practice. When comparing SMART solutions, those dedicated specifically to family practice activities and duties day in and day out are most important. Most retention, most active in practice, most volume, and most years helps make the most for SMART Basic Health Access

Rural Workforce 2000 to 2010

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

The last major contribution that has remained specific to rural locations is family medicine. Family medicine during the decade from creation until the 3000 annual graduate level in 1980 has been the only consistent contribution for rural workforce increase. Other sources old and new have steadily departed primary care, family practice, and more general types of careers. These are all departures away from rural locations and toward top concentrations of existing workforce - according to Uncle Sam's design for health spending and health workforce. .

From 2010 to 2020 the nation can expect declines in primary care retention and lower proportions in rural locations. No projections of rural workforce from 2010 to 2020 should consider increases in rural primary care short of rural sites paying substantially more each year for locums, recruitment, and retention. More dollars required just to get primary care and hold it is another indication of the wrong direction - away from efficient, effective, and sufficient primary care. Generic expansions simply fail to work. More specific focus is needed

Family Medicine – The Good News Was More for 2000 to 2010, The Bad News is No More By Design

Family medicine has increased its rural primary care delivery from 2000 to 2010 primarily because it added more graduates than departed when progressing from the 1980 to the 2010 graduating classes. This is at an end as the design of 3000 annual graduates for 33 class years has filled out to its maximum workforce at 100,000 strong (33 yrs x 3000 grads). Now that 3000 are entering and leaving each year, equilibrium has been reached. This has been the good news.

The bad news is that there will be no more family medicine workforce increases since annual family medicine residency graduates continue to remain at or below 3000. Family physicians have reached the maximum design level of 30 per 100,000 for the broad range of populations in need. This design level will be decreasing as the US population grows without any increase in family medicine. 

Family medicine, like all primary care sources, will continue to be widely sought out by all who are desperate for primary care for the next 30 years. Family medicine will remain multiple times more likely to be seen by elderly, poor, near poor, disadvantaged, urban, CHC, and other populations left behind. ...(Ferrer, others)

Overall US primary care design failure together with the neglect of family practice workforce will make it more difficult for rural sites to compete. Expansions of family medicine would have addressed all of these needs most specifically, but there have not been expansions in this one SMART source.

Paying more to get less for those that already have the least is clearly the US design
that will most impact rural communities for 2010 to 2030 just as in 1980 to 2010.

Nurse Practitioners: Maximum Expansion With Minimal Increase

There is little reason to expect a signficiant increase in direct care clinician nurse practitioners in rural areas. The AANP data had 22.5% of 102,829 direct care clinicians found in rural locations in 2000. This declined to 17.5% rural for the 2010 sampling based on 135,000 direct care practitioners in their database. Simple math indicates about 23,147 direct care rural NPs for 2000 and 24,030 for 2010.

The "good news" is that NP numbers in rural areas have reached family medicine numbers. This is entirely due to massive expansions that have doubled NP annual graduates each 6 to 12 years since 1980. Going from half as many annual graduates as family medicine to 3 times as many to result in the same rural workforce is not good news. The bad news is that FM and NP are not likely to change much. For 2000 to 2010:

A 35% increase in direct clinician workforce with a 4% increase
in direct clinician rural workforce

is not a good indicator.

Nurse practitioner rural contributions are stagnant for the same reason as primary care stagnation and underserved stagnation - too little national spending for rural, primary care, and underserved components. Rural spending deficits are a direct impact. Rural workforce is also 40 - 100% primary care and about 40% of underserved workforce is found in rural locations. Family practice, rural practice, underserved practice, and primary care are most closely associated with one another and with failures in the US designs.

The absolute lack of health spending is complicated by relative spending much greater elsewhere as the US design results in so much spent on non-primary care services and so much more spent inside of concentrations. The result is less and less primary care and more and more workforce found in existing top concentrations of workforce.  

The NP workforce moves elsewhere by design to concentrate in top concentrations as in PA, MD, and DO workforce. Flexible sources of primary care (NP, PA, IM, PD, MPD) are versatile workforce that continue to move to more different specialties and locations with each passing class year and each year after graduation – movements away from basic health access. Flexible designs are most vulnerable to the distortions of the US design. 

Departures of nurse practitioners away from family practice during training, at graduation, and each year after graduation are a reflection of this flexibility. This is a simultaneous loss of all forms of basic health access in one career change alone. About half of total nurse practitioners train in family nurse practitioner programs but only 25% are found employed in family practice. Rural primary care per graduate declines are essentially about departures from family practice.

Why Ignore Basic RN Workforce?

Basic registered nurses are a major commonly ignored rural workforce and are also a major ignored primary care workforce. The current 270,000 primary care registered nurses are a greater number than the current 220,000 primary care physicians. Low pay is common to all primary care careers. Only school nurses are paid less than primary care nurses.

Physician Assistants - More Elsewhere But the Same for Rural Primary Care

The physician assistant doubling of annual graduates in the past 10 – 12 years has already indicated little change in primary care, rural, or underserved contributions despite the doubling – all the result of fewer entering and remaining in family practice. The 200% increase in non-primary care numbers during this doubling indicates the US design influence. Movements away from family practice and locations in need of family practice are shaped by the designs.

The family practice PA is 30 times more likely to be found in a federally qualified rural health clinic and is 6 – 7 times more likely to be found in a Community Health Center. The PA remaining in family practice positions has 30% rural location rates nationwide. Family practice declines from 36.5% of PA workforce in 2000 to 25% by 2010 have resulted in a decline from 23% to 15% of all PAs in rural locations. Only 20% of newly minted physician assistants are entering family practice. There are also indications of departures steady over time even if policies improve (as indicated with steady departures of those tracked from 1990 – 2000 by Larsen and Hart).

Internal Medicine and Pediatric Contributions

Internal medicine has experienced a massive decline in primary care retention for major losses of rural primary care that will continue starting 2000 until at least 2030. How low this goes depends upon how few remain in primary care below 20%. Distribution to rural areas is not likely to improve and will also be more costly. Internal medicine and pediatric specialties are greater in number and in subspecialization - an indication of even fewer for rural workforce. Pediatric primary care graduates continue to prefer academic and higher income locations where workforce is already concentrated (Cull).

Surgery Contributions

With movements of newer residency graduates away from general surgery, general orthopedics, and general obstetrics-gynecology, these movements also represent lower probability of rural location.

SMART Formulas

Only family physicians remain where needed. Only family physicians have not been expanded in annual graduates for 30 years – by aberrant US designs that concentrate workforce in top concentrations leaving most Americans behind – especially rural Americans.

Upcoming Blog Subjects

Consequences of Expansion and of Low Primary Care Retention: Workforce Least Experienced in Primary Care

Patients visiting family physicians will generally be visiting primary care clinicians that are likely to have the most primary care experience. Other sources that have expanded rapidly (NP, PA), other sources that depart primary care steadily in the years after graduation (NP, PA, IM), and other sources with lower volume (NP, PA) are likely to have less to much primary care experience.

Quality Is Much More About Patient Factors and Much Less About the Provider

Less experience in a workforce does not mean differences in patient care outcomes. Research studies with proper designs are likely to 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 less about the provider. Underserved patient outcomes were demonstrated to be lesser and the reason had to do with the characteristics associated with being underserved. Rural patient outcomes are going to be lower because the patients are from rural locations. Studies that attempt to paint rural hospitals, underserved clinics, or physicians serving the underserved as lower quality represent flawed research designs.

Studies attempting to compare types of providers are often comparing apples to oranges – common even in major government reports and major journals. Research often influenced by physician leadership has distorted research to give too much credit to providers of care - and too much of the blame as well.

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. Failure in perspective is also a primary measure of arrogance and poor awareness of the needs of most Americans left behind.

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

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