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

Addressing the Primary Care Crisis

John Geyman, MD was asked various questions about the Primary Care Crisis. I recommend his book Breaking Point - How the Primary Care Crisis Endangers the Lives of Americans.

But I also have some variations of my own from the answers that he has given to the folks at Health Workforce News.

What is the primary care crisis, and how did it come about?

The last time that the United States supported primary care was 1965 to 1980. Before that and after that, the US has failed. Only from 1965 to 1980 did the US double primary care by designs that doubled the number of MD, DO, NP, and PA graduates that served in primary care. It is important to remember that in the United States design based on flexible primary care training, primary care graduates ofen fail to go into primary care. Only from 1965 to 1980 did graduates remain consistently in primary care in all the 6 primary care sources. Only from 1965 to 1980 did US health policy and training result in top primary care retention. Since 1980 five sources have claimed to be primary care but only family medicine delivers on the promise of primary care consistently.

From 1965 to 1980 the US doubled primary care and also doubled non-primary care  by design. Only from 1965 to 1980 did any intervention for primary care work. Since this time and increasingly to the present, the United States policy has driven primary care graduates away from primary care.

Each 15 years since 1980 the US had doubled non-primary care but primary care has remained static in a policy design that favors non-primary care and forgets primary care. A design that sends so much more each year to non-primary care sets up far too much for patchwork programming to overcome. It is not possible for any special programming or intervention to succeed in delivering on primary care promises short of a permanent choice - of which only family medicine is representative. Voluntary choice plus US health policy fails for the purpose of primary care, rural, and underserved workforce. The existence of special programs actually distracts the US away from understanding the failure of policy plus voluntary choice. Health and political leaders fail to act in the best interest of the entire nation, 70% of rural populations, and 60% of urban populations as well as elderly, poor, near poor, disadvantaged, lower income, middle income, less insured, uninsured, less employed, less educated and less health literate populations. All except those most advantaged in multiple dimensions lose out.

The reason for primary care failure, basic health access failure, and most health care failures for most Americans is flawed designs.

How is this crisis affecting the health care that Americans receive?

The primary care crisis is only a symptom of total failure in the American health care design. Only those who have been healthy or those that are most urban, highest income, and top occupation are untouched by the poor American design for health care. What is most apparent to academic, political, media, government, and foundation leaders is not what is happening to most Americans and solutions such as innovation and reorganization are not going to fix massive shortages of primary care RN, MD, DO, NP, and PA - the result of defective designs for policy and training.

Words no longer can describe the daily experience of those who should be accessing care but cannot, those who avoid care due to barriers, those who do not understand the need for care when they should, those who do not understand the care provided, those who get too much care and are injured, those who get testing that results in their poor health,

and all Americans who are experiencing recession in no small part because of a design that cripples nearly all businesses and all levels of government with far too much health care cost for far too little health care result.

The designs are so bad that school districts must cut teachers and marginalize education due to health care costs, health systems marginalize nurses, state and local government must cut public servants to balance budgets, states must minimize public health and primary care with too few, and government looks to accountants for cost cutting designs rather than working closely to develop a real plan for best health for nearly all Americans and a health care workforce to match this plan - one that will not defeat our nation by costing too much and delivering too little for too few. 

For primary care to recover, the entire health system must be redesigned not for primary care, but for better health and better health care for nearly all Americans. Primary care and basic health access cannot survive a black hole that sucks all health spending into 1% of the land area with 50% of workforce and 60% of health spending.

What changes would you make in medical education to encourage students to go into primary care?

The time for encouragement, passive methods, and voluntary choice is over. It is time for the workforce design to work for 65% of Americans left behind in 30,000 zip codes. After nearly two decades working on pipeline designs that have failed to work because of policy failure, my resolve follows the evidence of success – not more promises that fail. It is not possible to improve the delivery of care where needed until there is workforce where needed. To change patterns of health spending, the US must begin to shift where workforce is located and what careers are chosen. MD, DO, NP, and PA students not willing to choose the needed careers and locations will need to find other occupations.

Many if not most MD, DO, NP, and PA schools and programs must offer the following options. The following example is the physician trianing example. Private schools must also be convinced to contribute to the physician workforce needed for all Americans, not just health care delivered to a few Americans a few years of their lives delivered in a few locations.

Limited Choice Options

1. Choose to go elsewhere for training where you can find voluntary choice options.
2. Choose to serve in basic health access with a signed obligation.
3. There are no other options as the focus is upon most Americans, not just a few.

Medicine is not a pathway to serve you or to serve your desire to stamp out some disease. Medicine is a pathway to serve those in need of better health. Designs to train physicians and to deliver health care must contribute to an efficient and effective nation, not burden a nation.

Basic Health Access Admission and First 25% of Your Career Served Where Needed

To become a physician you must serve in practice in a zip code in need of workforce for at least 8 years after training. The obligation design will commit enough graduates for a sufficient amount of time needed to reduce the deficits. This is entirely different than send me more money and we hope we can convince enough to serve where needed.

Those accepting the commitment must be prepared to use all of their training to prepare for such a career. A career as a health professional is substantially individual in implementation. Each day of training for years must prepare for an 8 year or longer commitment to serve where the obligation indicates. Failure to do this will result in loss of the ability to practice medicine. Those entering should not even consider an option to buy out this obligation.

If you sign on to become a physician under this plan, you will honor this commitment. If you are not sure about this, go elsewhere. If you fail to honor this contract at any time, you will pay the entire cost of training a replacement. This is not a penalty. This is entirely about health access for people in need of health access. You will provide health access or you will pay for another in your place or you will not practice medicine. The intent of this program is an entire lifetime served as much as possible on the front lines delivering basic health services to those most in need of services.

Choose as a condition of admission to become a family physician remaining instate for 15 years at your choice of practice in all zip codes except the most saturated with primary care (increasing the instate primary care workforce maximally due to top retention in primary care and highest probability of remaining in primary care and highest probability of remaining instate in primary care, especially after 23 years or more of instate life experiences including all training and practice experiences).

Choose as a condition of admission to become a family physician serving where needed for at least 8 years in a zip code that has insufficient primary care (all but 4% of the land area with top saturations, serving where 53% of family physicians are found already).

Choose as a condition of admission to become part of the surgical workforce in this state where needed in a rural area for at least 8 years serving in general surgery, general ob-gyn, or another general career. (area short of surgical workforce but able to sustain such workforce, definitely not in 3400 zip codes with top concentrations where 75 - 80% of such workforce is found, but not in the smallest locations where such workforce cannot be sustained).

Choose as a condition of admission to become a mental health professional remaining instate in a needed location for at least 8 – 10 years. (any child psychiatrist, psychiatrist in small urban or rural area, just not a psychiatrist in a location in 4% of the land area with top workforce saturations).

Your training will involve as much time as possible spent in a health access location (preferred method will be entirely health access in location in a continuity team) working with health access physicians as clinician-faculty. You will not be spending your time living in places with top concentrations of physicians and training in such places. Your training will be active not passive. Your training will be clinician specific, not basic science and research in focus. Even the purpose of your training is to facilitate more and better health care services where needed. You will become an active part of the local health care team.

You will recruit the next generation of health access professionals and you will train the next generation – inherent in the design. You will facilitate health access before admission, during training, and after training by design.

Your best preparation to gain admission is to demonstrate that you are interested in becoming a servant clinician. You must demonstrate at least adequate academics but your people skills and patient care skills must be consistently superior. Those who have already served on the front lines as part of a basic health access team will have preference in admission.You must be aware of the health needs of those you will serve or you must become aware of these needs before graduation. You should choose carefully as your commitment involves the next 14 – 18 years of your life. This will also include consideration of those closest to you in life. Those connected to you will need to be willing to make the same commitment.

You should not worry about being taken advantage of during your obligation. Sites that even appear to take you for granted will lose your services and the services of any obligated physicians for a period of years in duration with a period of probation to follow afterward.

Communities, practices, hospitals, and others who employ obligated physicians will do all possible to take good care of the servant clinicians on the front line – something America has failed to do for teachers, nurses, primary care, public health, and basic health access professionals for quite some time.

The above example is a state design specific to physicians. Designs can also be set up for any health professional for primary care associations, for all Community Health Centers, for predominantly African American or Hispanic or Native American or low income counties that are rural counties, or a similar population. The more specific populations will need the most specific commitments and results as this is a design that begins before training and extends until retirement - anchored by commitment alone.

How can we get more primary care physicians to practice in rural America?

The above program design takes care of primary care physicians in more than rural America. The design is specific for rural and urban populations left behind in primary care as well as basic health services in women’s health and surgical care and mental health. This is not about just primary care or just about rural America. This is about the basic health services needed by 65% of Americans.

Japan has a design for front line health access workforce in rural areas. The design has worked for 40 years and is being expanded. Such a design that results in specific workforce needs being met indicates what the United States should do to be specific.

What are the barriers to implementing these changes?

The barriers are quite simple. Most Americans suffer in silence under failed designs. To address their basic health needs, the United States must have designs that are Specific, Measurable, Achievable, Realistic, and Timely.

The barriers are lack of awareness and lack of understanding of what works and has worked for 40 years. The barriers are designs that result in specific gain for a few with consequences for those left behind.

The long term commitment extending from before training and encompassing all training and extending after training is the only design that is SMART. All other designs result in the funding, emphasis, faculty, training, or other components benefiting someone else. Rather than increasing the funding before training, at each year of training, for recruitment, for retention, and for locums and their brokers, the United States must have an efficient and effective design – a SMART design.

Thanksgiving is over. We should indeed be thankful for what we have in health care - but so should most Americans not just a few.

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 Expansion

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

Rural Pipelines Versus Long Term Obligations

Generic expansions nationwide can be expected to result in no change from the 9% of physicians found in rural areas. To few remain instate, choose needed locations, and remain instate in needed locations.

Voluntary pipelines are still limited by lack of specific focus. Voluntary pipelines are based on the theory that improvements in admission and training and family medicine choice will multiply the result for higher percentages instate in the desired primary care or rural or underserved outcome. Multipliers do work, but represent small relative changes.

Rural pipelines applied nationally can deliver about 20% instate rural practice location. This is better than 3% instate most needed rural for generic expansion, but is still not optimal. Lack of specific instate practice retention and lack of career choice for specialties suitable for rural location limit desired outcomes. Voluntary choice allows career choices outside of family medicine (FM), the only specialty choice that multiplies rural location significantly (triple). Even when choosing IM, surgery, ortho, and ob-gyn the US MD graduates have been subspecializing rather than remaining in the general careers.  Instate rural proportions of graduates are single digit for the average and for most state medical schools in the US.

Family medicine tracks linking medical school to residency training can deliver 30 – 40 percentage points of instate rural at least for the first half of a career (the limits of data on such tracks). After 7 years instate with additional time likely prior to admission, the impact on practice location instate is strong. Drift out of state is likely to reduce this proportion over the second half. The rural contribution indication overall in areas such as accelerated tracks has been 40% rural. The family medicine model also addresses small and isolated rural locations. For example the FP to nonFP ratio for U of KS grads indicates a 16 times multiplier for small and isolated rural). Those choosing KS and family practice have characteristics that facilitate optimal health access placements.

Family medicine tracks do not address the other half of rural workforce needs such as general surgeons, ob-gyn physicians, orthopedists, anesthetists, urologists, and general types of cardiology, GI, etc.

Long Term Obligations

The contributions of voluntary models pale compared to long term obligation models. Long term obligation models as illustrated by Jichi in Japan (Matsumoto) can deliver 70% instate and at least 50% instate rural workforce over a career. Over half of this contribution is up front by the 8 year design of the obligation. Such a design also addresses the specialties needed beyond just family medicine.

The challenges are not small for a long term obligation. Iron-clad contracts, informed consent, and interstate or federal compacts are required. States such as Montana are making specific contracts to assure return to Montana after training - by design. Also protections are needed for those under obligation - of course much of primary care workforce needs protection from marginal treatment under the current primary care design.

Medical schools such as Jichi have a cohort effect with all graduates heading to the same types of practices. Japan has implemented commitment tracks in public schools in all 47 prefectures. There will be similar obligations but the cohort effect is likely to be less. Of course Jichi graduates have been leading many of these efforts.

Commitment tracks themselves are a useful admissions tool. Rather than candidates for medical school claiming all types of service, rural, small town, or family practice interests - they would be known as willing to sign the obligation contract or not. This might help the admission committee choose other candidates more likely to remain instate and in careers most needed by the state.

Summary Estimates

The estimates using rural workforce years after graduation indicate 20% of a career instate and rural or about 7 rural instate years per graduate for 28 per year in a pipeline design with voluntary choice

This compares to compared to 50% instate rural or 17 years spend instate rural in a career using the long term obligation.

With 8 long term committed rural graduates for 8 years and decreasing down to 3 after age 54, a state can count on at least 38 rural physicians at any given time 30, 50, or 70 years later - by design. If the output seemed to be falling short, the obligation length could be increased - again resulting in no increase in cost with a specific increase in rural outcomes. Ten year obligations would likely increase yield to about 44 rural physicians.

Voluntary methods are regressive under US policy designs. Failures of voluntary designs require more generic expansions resulting in substantially more costs for no better primary care result (or less result). Pipelines require increasing maintenance costs across each of 5 or so segments not counting support of rural training sites if included. Funding must be injected to improve the yield across each segment - yields that have been declining already. Long term obligations are selected by those that have every incentive to shape their training for their first 8 years of practice - rural instate practice.

For most of my career I have promoted pipelines. Objective analysis indicates that pipelines only worked prior to 1980 when just about anything worked - by designs that increased spending in primary care, rural, and underserved areas.  Recovery of rural workforce, underserved workforce, and primary care workforce will require specific efforts. Assumptions have not worked for 30 years with more to come.