Lets Take a Stand for Most Americans Instead of Against

This is my response to a mass email circulating the nation.

The email claims doom and gloom with ruin to come. While those who have read my work would claim that I do the same, my attempt is to raise awareness of solutions that do not work and will not work while focusing on solutions that have worked and will work.

The mass email blames more recent events and leaders rather than design changes and designers over the past 100 years and especially the past 30 years.

The email mentions democracies failing after 200 years or about the time since we have existed as a nation. It mentions the problem of democracies failing as they began to vote treasuries to few people - a real concern of all who desire equitable government.

What the emails assert provocatively and simplistically:

Let’s take a stand!!!

Borders:    Closed!

Language:    English only

Culture:    Constitution,  and the Bill of Rights!

Drug Free:  Mandatory Drug Screening before Welfare!

NO freebies to:   Non-Citizens!

Lobbyist:   Gone!

And this is my response. It is a longer response because it takes longer to explain. Just a few words cannot explain our designs and their consequences or what it will take to fix the design problems plaguing most Americans. Sputnik was not a real threat, but it did indicate to Americans that they were falling behind in areas of great importance - such as the education of their children. The solutions were all complex but decades later the successes are clear. We had to sacrifice for future generations and we did. The outline of President Kennedy made sacrifices clear as well as the priority of our economy. Avoiding profiteering was also noted, something that our health care designs promote.

I agree that we should stop people from voting the treasury to themselves – and health care is a good place to start.

All great nations have treasured their children – a method guaranteed to guarantee the treasuring and best outcomes for all in a nation. Our nation has moved to favor the few with the most. Innovative designers have found new ways to vote even more money into their pockets. Current treasuries were not enough. We have found new ways to spend money now and tax generations of children not yet born – especially in health care.

Health care is a primary example of a design that moves federal and state treasuries to those who are the best at receiving health care spending. We spend ever more on the elderly and those who are poor but we fail to get much more out of life and health

BECAUSE THE REAL DESIGNERS OF HEALTH CARE ARE THE FEW WHO GET THE MOST

It is never as simple as blaming government, or industry, or associations, or corporations, or scapegoats such as populations that are in the minority. Small changes guided steadily in one direction can mean major changes over a century of time.

Health care is a best example of those slowly and steadily voting themselves past, current, and future treasuries. With more limitations in true outcomes, innovative thinking can focus in other directions. This innovative thinking is focused upon how to get more spending dedicated to health care and more health spending for specific types of health care. This is of course spending that does little for our health care while doing a lot for the real designers of health care.

As I noted previously To follow the money, follow the workforce and who benefits from the workforce and the design. I learned from learning about the workforce and you can also become aware of the results of our designs.

Where the US has concentrations of health care workforce, the US has concentrated health spending, and the designers can also be found shaping top concentrations in health and other areas. If you can understand the concerns that give energy to the current protests, you can understand problems related to the designs.

In health care we have gone way beyond just voting our limited government treasuries. Big Thinking has moved beyond existing and limited treasuries shaped by Wall Street. (Finance-me-cratic Constants)

We have Big Business insurance companies that have figured out how to tax all government and businesses for ever higher health care insurance premiums from us and our businesses and government. We have academic institutions and hospitals that focus on the highest technologies.

We go along because we think it helps us, as noted in Myth of the Cure. We go along partially because we want "the best" and because none of us want to die. Of course few of us realize that none of us will avoid dying. We fall prey to the myth - by design. Most of all we fail to realize that one of the best gifts that we have to give - is a better future for our children, their children, and their nation - long after we are gone.

What makes matters worse in recent decades is that health care designs are protected by laws designed by state governments and insurance companies such that even abuses cannot be redressed by the courts. Any of us who differed with health insurance actions have had little recourse for correction, by designs set up by insurance companies. We rarely deal with insurance claims so we have little awareness or priority in this area. Insurance companies always deal with this, hire lobbyists to focus on areas of their interest, and place legislators to insure their interests are met. 

The Supreme Court is an example of a current case filed against the State of California for abuses. California designs are so bad that not even health care providers participate much - the lowest level of participation in the nation. The Chief Justice would prefer to avoid hearing a case because of past laws and also because such a case would open up a flood of additional cases. No court that values justice should fear more cases that involve basic access to health care. A nation that values rights for all should not deny most Americans the right for basic health care - by designs that are flawed. 

With the help of Congress and the Drug Company/Medicare/AARP and other lobbies, we have also tolerated this and the massive debt accumulation. The past and current treasuries were not enough. Part A and Part B were not enough. We found ways to tax future generations for current health designs and current health spending. We found new ways to pay even more from treasuries to Part D Medicare, care in the last year of life (and not good care either), long term care (and not good care either), drug costs, hospital costs, and subspecialty costs.

Despite being the number 1 nation by far in health care costs, we rate a failing grade of 62 compared to various US states doing well and health care in other nations. We should be at least in the top 20 but we fall way down the list and are falling further. (Commonwealth Report Why Not the Best?)

Obamacare as the problem? - hardly. Why blame the most recent without even the beginning of impact that has had the least influence on the design and was greatly limited by the efforts of the true designers within the first weeks of the reform proposals?

Why do you think that the designers so vehemently oppose any mention of any design in any other nation? Why do so many myths suddenly appear about health care in such nations within hours of the beginning of such discussions? American health care developed uniquely because it has been allowed to focus on what was best for the designers without regard to the needs of most Americans.

What you see now is the result of American Designs BY Americans but Not FOR Americans. Our designs are the result of the past 30 years of American leaders designing American health professionals and American health care.

Resistance is Futile When Resistors Are Few - By Design

Anger with government control or Obamacare cannot change the last 30 years of failed health professional training failing to care for the most or the last 30 years of reimbursement changes that favor the least over the most. Even Medicare and Medicaid are vastly changed from the initial design and away - changes engineered by the designers steadily working day after day and year after year for their best interest - by design.

The design leaves 65% of the nation's Americans, especially those many generations in America, behind in health and behind in the economic impact of health care, and behind in the health of the public. Public health and primary care are only a few examples of being left behind.

Less money goes to locations where Americans have been in America the longest. The census reports document those born in America not doing as well as those born outside - for decades.

So let us review the rest of the demands made. What about health care designs?

EMAIL Focus on Borders:    Closed!     

Health care is a primary example of erroneous borderline thinking. US Borders are not closed to the pathway to one of the highest income jobs in the world - the US physician. US designs so reward the subspecialty physicians that parents prepare their children for years so that their children can come to the United States before, during, or after medical school. They pull out all the stops to get their children to compete for graduate medical education training in the United States.

The 110,000 a year trained in the US by billions of federal dollars during residency training are 40 - 45% born in other nations. The 90% of US born citizens can only claim 66% of graduate medical education positions (NRMP data). Even getting into a US medical school is harder for those born in the United States. Foreign born US citizens have 1.4 times greater levels of admission to US medical schools. For those born in the US, if you are not born to a higher income American you have a low chance of admission a 14% to 30% probability compared to the national average. Those of most urban and higest income and professional families are 2 to 10 times more likely to become physicians. The range of 6 times less to 6 times more represents the great divide between Americans left behind and Americans that will be ahead - by design.

Also instead of investing in United States medical schools and schools in states in need of health care, more have been trained in other nations for medical school - a substantial loss of economic impact inside of the United States. This is also a design that means more physicians for locations with top concentrations and fewer for locations with most Americans.

Only highest income, most urban, children of professionals have a real chance to become US physicians whether they were born in the US or in other nations. They are also free to go to the careers and specialties that they want - but the US health care design shapes them away from the careers and locations that we need for care for most Americans.

And census after census reveals that foreign born populations actually do better than US born populations in a wide range of US societal measures, but these facts escape Americans who are so focused on illegals rather than overall immigration. Foreign born populations have much better housing, do better in income and jobs, and have better health care outcomes.   Scapegoating has always been a way for blame rather than solutions. Blaming those from other nations, rich or not, for our problems is no excuse for American failures involving American children.

One reason for foreign born success is American born failure. Americans have ignored nurturing, child development, education, and opportunity for American born children - so that those born in other nations that come here do better than those born here - by design. America has always benefited by those coming to America – a lesson lost on Americans just as the message of American children lost is also left behind.

By the way, the hospitals that get the federal funds for training are supposed to prepare workforce for the needs of all Americans focus the funding and the training on hospital needs. Even when the funding goes for “primary care” the training programs result in dysfunctional primary care that drives medical students and residents away from primary care (Keirns, Academic Medicine). Not surprisingly they fail to result in the primary care general internists and family physicians that most Americans need, especially the elderly.

Yes this does mean that the promises of Romneycare and Obamacare were empty promises when it came to saving health care costs - primarily because the promises came without the health access workforce that was ready and able to take in the additional patients to provide basic care instead of care in ERs, urgent cares, subspecialist offices, and hospitals.

The promises of the Continuity Home, Pay for Performance, and other innovations and redesigns and technology are in error. WE HAVE FORGOTTEN THAT PRIMARY CARE IS ABOUT PEOPLE FACE TO FACE WITH PEOPLE. We must have the people dedicated and experienced in primary care to deliver primary care.

In fact nearly all of the promises made about primary care are empty promises - until we have become SMART and focus specifically upon primary care training and primary care trained graduates that remain in primary care with primary care spending sufficient to support the needed primary care workforce. Meeting the Needs for Primary Care is possible by 2050, but likely not sooner because of our designs and their consequences.

The elderly are a primary example of failures of the past 30 years of administrations. For decades that we have known about "Baby Boomers." We have known that America's elderly were set to double from 2010 to 2030. Health care for the elderly is noted for 2 to 3 times more primary care demand. Despite this there has been no planning for the elderly in their basic needs. 

All Behind for One and One Behind Represents All

What few realize is that the locations with over 65% of the elderly are 30,000 zip codes with over 65% of the poor, near poor, rural, underserved, disadvantaged, and minority populations. When we chose to leave any of these behind in basic health access, we chose to leave all behind. Medicare and Medicaid focused in these areas did well for most Americans. Medicare and Medicaid designs bent to serve those in top concentrations fail to serve most Americans.

The elderly in many cases will always represent those behind. Lower cost of living areas are requirements for all left behind. The elderly move to lower cost locations because of fixed income requirements. They will always remain in these locations or move to these locations with less workforce - because they are older and on fixed incomes. Also Medicare and Medicaid will always be more important in these populations and locations, because of higher levels of Medicare and Medicaid patients. Of course these are locations and populations that are not well understood by designers focused on a design that does not work for most Americans. The elderly move away from locations with the top concentrations of primary care, stroke centers, and heart attack centers because these places are too costly for elderly Americans.

Family practice is a good example of what designers leave behind.

No other physician or non-physician group distributes to those left behind at multiple times. The designs that leave 65% of Americans behind also leave behind family practice - those most likely to serve them. Family practice MD, DO, NP, and PA all serve all of the populations left behind and are less likely to be found where the nation has top subspecialization, health spending, and hospital care.

Family practice nurse practitioners and physician assistants are found with 50% or more where needed, but have decreased from 50% family practice to 25%. The reason is a design that rewards NP and PA departure from family practice to other careers and locations for higher pay, better support, and more benefits (and less complexity of care). The flexible design of NP and PA training fits the needs of the designers, but not the needs of most Americans.

Family physicians are an example of a permanent design that is least flexible. Family physicians also remain at 50% or more where needed. They do far more primary care and primary care where needed than NP and PA graduates because 80 - 90% stay in family practice for their careers. Family physicians remain fewer because the design for health care makes it difficult to commit an entire career to primary care - plain and simple.

US Primary Care Result - Consequences of Designs

There will be no increase in family physicians (remaining at 100,000 nationwide). Even worse we will have internal medicine physicians declining from 80,000 to 40,000. We have such a great design for those in need of basic health services (tongue in cheek). If you are alive in 2030 and we use 2011 to 2030 to focus on a design that works for most Americans and most over age 65, then by 2030 we could have a design that works better and by 2050 we could have a real health access design.

In other words, the older and oldest would have to invest in a real future for American health care without having much benefit from the design during their time. This is called sacrifice – the kind that builds a nation. Lack of sacrifice fails a nation - by design. As we grow more aware of the magnitude of the failure, we will blame each of any number of administrations and leaders - but blame will not result in solutions.

Less sacrifice and more focus on me and my kind and those oldest and nearest the end of their time - this is a guarantee of failure for those left behind.

You can choose to build or choose to crumble nations – Health care is just one design to change for the most and away from the least.

Substantial US physicians fail this test as they are not English native. US physicians also are less likely to speak the language of their patients - English or not English. Studies demonstrate more problems due to lack of awareness, deficits in interactions, and poor communication skills. Awareness of your patient and community and language and culture is important. Each of these areas is compromised by our designs, resulting in compromise for many. The elderly are also another group that require additional time, additional explanations, and additional understanding. Our health care design focuses health care away from time, explanation, and understanding.

In English native physicians and in those not native to English (Annals of Internal Medicine discipline rates) we tolerate higher levels of adverse medical events. In medical schools we do not screen for poor communication skills well and 25% are likely to have adverse events resulting from lowest communication skills (Tamblyn, JAMA). In physicians entering from other nations, the English skills are tested - but communication skills are still not tested well. 

Beyond English and communication skills is the need for a physician to have some level of awareness of the health needs of most Americans. American political leaders, leaders in health care, and leaders in health professional education all flunk in this awareness - otherwise we would have health professionals and health designs that worked for most Americans.

Those accepted at higher and higher levels to US schools are lower in awareness and higher in parent income level and higher in test scores but lower in empathy levels and are less likely to choose the careers and locations needed for basic care. Those who are more likely to choose the careers and locations needed come from the same 65% left behind. They are also more likely to be aware of the needs of most Americans as they are from most Americans. They are typically disadvantaged, poor, near poor, lower income, and middle income – all of those least likely to become health professionals and health leaders.

America has such a great design as those with the least awareness lead the health care of a nation!

This is of course a major American problem for all American designs – not just health care.

Also those not born in the US are least likely to be found in family medicine (7%) and even when choosing internal medicine (over 45% of non-citizen) they only end up 1 out of 6 found in primary care workforce over an entire career. But of course we still allow government primary care funding to go to training that fails most at primary care workforce. We fail to focus limited funds upon primary care that actually results in primary care and primary care 2 - 4 times more likely to be found where most needed or to care for the elderly.

And non-citizen physicians are most likely to be found in 1% of the land area in top concentrations and are least likely to be found in 30,000 zip codes left behind with 65% of the US population.

But non-citizens accepted into US graduate medical education positions allow Manhattan, Boston, DC, Chicago, Philadelphia, and similar largest city teaching hospitals to get billions of federal dollars to concentrate more physicians in higher concentrations for highest concentration people of all origins. Also only a few zip codes in these cities gain the funding and the workforce, leaving doughnuts of underserved populations around those that benefit most by the design. Purple means top concentrations (and Wall Street) and yellow is left behind and red is left behind the most - in health care, in economics from health care, etc.

If we limited non-citizens to fewer US graduate medical education positions in locations with top concentrations already, we would shift more funding from states that get the most GME funding to states with the lowest levels of workforce and the least GME spending. Since residency training location is the most important marker of practice location, we would actually send workforce where needed. But even when we have designs that work, we have designers that find ways around the design - designs that maintain concentrations within top existing concentrations. Physician Distribution By Concentration can reveal much about concentrations and health spending.

EMAIL Focus on Culture:    Constitution,  and the Bill of Rights!

The government has finally figured out some of the abuses and fraud by insurance companies, drug companies, and various get rich provider groups. But numerous ways of getting paid much to do little still exist and are passed by the Congress and have been approved by presidents 1980 to the present.

As a new physician entering the workforce in the most desirable choice of primary care, in rural practice, in an underserved area, in an underserved state– the Reagan administration gave me a present of a 20% cut in reimbursement because I was a new physician, sent me the lowest reimbursement in the nation as Area 99, killed off my rural hospital with Prospective Payment (hundreds), killed off my training program part time job, and ignored the resolution that I initiated through the Oklahoma legislature for One Zone Medicare. About 30 states and their needs have been ignored for 30 years or more.

The AMA was no better as viewed when I was the first elected representative from the Young Physicians Section. The Texas Medical Association took positions that risked important rural  health legislation. The designers have great power and influence that do not focus attention where health care is needed. Their needs trump the needs  of the nation over and over. 

Even today, many want to throw out new health care laws, but this also means allowing health insurance companies to abuse even more Americans, delay more payments, deny care due to previous conditions, abuse the mentally ill, extract more dollars out of pocket, and deliver even less care for even higher profits for few. I have been abused personal for care for my family costs of up to $50,000. My family has been denied important care at critical moments in their life.

I advocate for health access and primary care and basic services but my opposition includes health insurance lobbies promote primary care sources that are least likely to deliver primary care. Hospitals and practitioners that I work with face major cuts because they care for those who need care the most involving basic health services.

Pay for Performance and other designs reward those who care for the easiest to care for and penalize those who make the career choices that we need doctors most to make. Major Journals fail in even the basics involving workforce for primary care or for populations left behind even when dedicating entire issues to these topics. Foundations also are limited in their reports and are often distracted by innovation focus rather than basic health workforce to deliver basic health services.

Abuses designed in California and other parts of the nation such as New Jersey were taken to Washington DC. The result has been economic devastation for thousands of rural communities and others dependent upon government for a design for reimbursement that was fair for rural hospitals, small hospitals, and primary care services. Now we have the consequences as we have 55% of our health care resources and spending in only 1% of the land area with 11% of the population. Large insurance companies getting larger, large systems getting bigger, urban hospitals, subspecialists, and non-primary care interests get the most health spending with those outside of specialization and other large concentrations losing. High tech companies, software companies, lawyers of all types, accountants, and lobbyists win and we all lose – by design. They all design special legislation and special legislators to pass legislation – by design. They spend the most and even cross borders to control elections in other states – by designs including designs approved by the Supreme Court.
EMAIL Focus on Drug Free:  Mandatory Drug Screening before Welfare!

Talk to employers. Drugs are abused by large segments of the American population with most sources of these drugs inside of America. Ask small business employers how hard it is to find drug free workers now - the ones that come into your house and do repairs or maintenance or put together whatever little remains of American manufacture after Americans and their businesses have left little manufactured in the US. Drugs of all types have invaded the lives of all of us and our children and grandparents. They have changed the designs for our families and for our children - drug companies push drugs very well. Even when pushing for better health and prevention, you find drugs, drugs, and more drugs as the way. Just as drug stores make a killing on tobacco, drug companies make a killing selling more drugs to deal with drug problems.

 
Our drug companies have marketed narcotics legally and illegally to our detriment. Even the government could not avoid prosecuting such abuses. Companies like Purdue-Frederick got off easy with $600 million (Oxycontin) when billions should have been paid out across all states. The precedent was Big Tobacco that did the same - creating and marketing addicting products and lying about the effects. Designs for addiction kill bodies and minds and dreams for the addict and those around them.

Our ERs are increasing 10% in volume each year. The result is even higher increases in very expensive health care costs each year.  Prescription drug abuses are a major increasing problem - prescribed pain meds, prescribed stimulant medications for age 4 to 54, prescribed anti-depressants (Drug Abuse Warning Network). Pain killers have been fraudulently marketed by drug companies. Paid consultants that even worked in academic institutions pushed such drugs to the public. Pain pill pushing drug clinics added to addiction. Each new week brings out more practitioners prosecuted, but no progress means even more abuses remain.

Go sit outside a methadone clinic some time. Those going in are clearly not on welfare. They have jobs, drive nice cars, have jobs, and resemble all of us. When they go to some clinics that are supposed to help you get your dependency under control, some will increase your narcotic doses - a tactic that assures that you will be there a year or more longer because it will take longer to get off the drugs - if you can get off at all.

Justice would mean drug testing for any employed person so that they can get paid a paycheck at all. Try to explain to employers about a positive drug test for being on an approved program.

Also the drug testing results are easy to distort. This has become a fast growing multi-million dollar business. One can make the case that those that can pay will pass tests.  Only the truly poor and destitute and busiest will test positive. This is of course the same as those that can pay for the best lawyers will avoid entanglements while those left behind suffer the most.

Laws only work well in a nation that practices the Golden Rule more and more and Gold as a Rule less and less.

EMAIL Focus on NO freebies to:   Non-Citizens! 

As noted above, we reward non-citizens with our highest income and highest education access. And because we make it hard on kids of all origins, we make it harder for our kids and grandkids. Who in their right mind (no pun intended) would make it harder for anyone to get education, particularly the youngest children who need the best start to even participate well in capitalism and democracy? Best start for all does allow the most to compete and drives the best outcomes for the most. Worse start for the most drives the worst for the most and allows only the fewest to make the most.  

EMAIL Focus on Lobbyist:   Gone!
Lobbyists are indeed the major problem for inequitable American health care. Health care also gives examples of two of the worst moments in Congress and both events were shaped by lobbyists - Part D Medicare and the assault on a Congressman. Both have cost us trillions diverted to the designers and away from care of most Americans.

One violent event in US history has helped shape higher costs for health care. Activists seniors were led by lobbyists who used this as a pathway to become became legislators. These seniors were led to accost a Congressman (Rostenkowski) and ended any reasonable ways to fund Medicare deficits with means testing (higher monthly fees for those who can afford to pay so that all can have better care that does not bankrupt the nation. It was one of few that would have taxed seniors to pay for seniors instead of seniors taxing the nation for their ever increasing cost of care.

A cowardly Congress decided not to take a stand and turned tail and ran, not standing up for one of their members or standing up to self-serving seniors.

Politicians claiming death squads are fed information by lobbyists to prevent important changes in the health care design. This focus on the few and dramatic results in less health care for most Americans. The AARP works to assure that we fail to have any reasonable cost cutting measures. Insurance company executives in back room sessions using a small portion of their revenue hired consultants to find the best way to spin health care design changes. Consultants won the award for the Politifact lie of the year - government control. Fox news leaders instructed employees to use the words government control.

Americans believe much that is not true about health care, making it hard to design health care at all - leaving those in charge of the design even more in control.

Government control?   What a myth. Reading this you see who controls the designs and it is certainly not over 65% of Americans or what they would desire of government or of health care.

The drug company lobby faced deliberations of cost cutting in Congress in 2003. They merely wanted to prevent government from being able to negotiate costs of drugs. They got much more than preventing this cost cutting measure. Drug companies managed to get trillions of future dollars promised to them from Part D Medicare. They got laws preventing the government from negotiation of drug price. Powerful interests controlled Congress and use hundreds of billions to continue this control.Lobbyists now are defending their stand to keep 12 years of protection for some drugs before they can become generic. They oppose a reduction to 6 years as proposed. Already 50 Congressman have already signed on to send more profits for longer to drug companies. This also insures that we all pay more and more for drugs to drug companies, who add little more to our health care other than costs.

Lies have become common for health professionals and their associations. Health professional associations of nurses and physicians promise primary care but do not deliver primary care workforce despite billions in annual spending. More primary care from nurse practitioners is claimed, yet only 1 in 4 nurse practitioners remains employed in family practice. This small portion is the only valid claim to direct patient care primary care for nurse practitioners and is the only source that distributes 50% or greater to meet the needs of 65% of Americans in 30,000 zip codes.

Questions should be asked of the advance nursing movement that results in little for care most needed by most Americans. Why does nursing leadership ignore the largest primary care force of all – the 270,000 primary care registered nurses? Why does our design hamstring our primary care nurses. Primary care nurses due to insurance company designs must spend much of their time trying to convince insurance companies to approve needed medications, consultants, hospitalizations, and procedures. The secret is that the health care design is not about care, it is about cutting costs and making more for insurance companies - leaving less for most Americans by design. Insurance companies have taken over the designs from government and from most Americans.

Government control of health professional training is a myth. Only 1 in 3 graduates of primary care training programs will actually serve careers of primary care. The only permanent primary care source is family medicine and family medicine remains at 3000 annual graduates - a level first reached in 1980. The one source that is most closely associated with care of elderly, middle income, lower income, poor, near poor, disadvanged, and rural populations is the one source that has not been expanded. The one source that is 85% likely to remain in primary care compared to 40% or less for all other sources is the one source not expanded. Only when Americans demanded a source of basic care in the 1970s did family medicine get a real start and rose from a few hundred to 3000. This was perhaps the last time Americans had any say about the workforce.

But now the designs allow family medicine training positions to be converted to subspecialty positions as in the Mayo Clinic and dozens of other institutions. These institutions benefit more by producing less primary care and more subspecialized workforce - by our design. More for fewer means less for most Americans.

Health care associations actually promote themselves as being good for the economy of the United States. Reading their reports indicates that half of the economic impact of medical schools (AAMC - over 500 billion) goes to just a few dozen zip codes in six states. The Wall Street Manhattan zip codes with top concentrations from economic and financial designs also have top health spending by design.

Health care associations determine the people (most often association, academic, and subspecialty physicians) that make up the panels that advise the nation on health care spending. The AMA shapes the panels and also shapes reports that indicate the economic benefit. The problem is that those that understand office based physician distribution understand that these designs send 5 times as much health spending for office based physician care to 1000 zip codes in 1% of the land area. The designs result in substantially more spending due to even higher concentrations of hospital, teaching, and research in these 1000 zip codes - by the American design.

Health care associations want billions more taken from Medicare (your health care dollars) to train even more subspecialists that you will rarely if ever see. Each subspecialty physician, physician assistant, and nurse practitioner will result in increased health spending for the United States – by design.

Meanwhile the family practice doctors and nurse practitioners and physician assistants that do see seniors and most in need of the most health care the most, are declining to a lower and lower percentage of those produced. Primary care training designs have only doubled primary care numbers from 1965 – 1980. Since 1965 each 15 years the United States design has doubled non-primary care numbers – guaranteed already through 2025.

Only one small medical school in Minnesota (Duluth) manages to produce 50% family physicians year after year. This one school represents an investment by the state of MN in a medical school to serve the needs of most in MN rather than the least. This one school represents one of the major economic contributors to small urban and rural locations in MN and other states. But this one model has remained a model for 40 years. Medical education expands the areas that do the least and fails to expand those that do the most with the least. Billions of economic impact has resulted from a small annual investment not counting the health services, community leadership, and other aspects.

The US design shapes concentrations not distribution. Duluth is one of only a few medical schools that sends 70% of graduates to zip codes that represent 65% of the population. The top medical schools rated by national rankings send only about 20% to zip codes in need.

What works for most Americans left behind is left small and low priority. What works for few Americans is rated most highly, gets the most lines of revenue by design, and gets the highest reimbursement in each line.

Special programs are a bad idea for one reason - they hide the truth of an American health design that fails most Americans. Special programs are the political darlings of a Congress that can extract millions in contributions to do more of the same - little for most Americans. Each year Congress gets more and more, especially when some member threatens to cut a special program (Medicare, rural hospitals, primary care training, police department funds, education department)

By the way, blaming physicians is a bad idea. They may benefit, but they are less and less the designers as fewer remain as employers and as more and more are employees. Health care designs are shaped more and more by investors who desire a national design that guarantees profits. This is the Wall Street design, if you did not notice it yet.

Blaming physicians is another good tactic played out by designers that do not want their designs to be discovered. And a design that results in lower cost workforce competition and a lesser future for physicians is really not a design that physicians would have shaped. In the US for 100 years and in other nations such as Japan, physician associations have learned to prevent competition and keep the physician levels smaller to keep demand high. A massive US expansion of non-physicians and an expansion of physicians who do the least for the most is not a good design.

This American design certainly works well for those who benefit from more training, longer training, lower cost of personnel, higher profits for those associated with top concentrations, more profits for investors, and ever more spent on the highest cost areas.

Few Americans benefit for a few years of their lives, often near the end of their life with benefits for just 1% of the land area. This leaves less for most Americans for most of their lives in most locations.

Do you want real health care for real Americans and for most Americans? Take over the designs for education, health care workforce, and health care spending.

Remember when courts fought for most Americans left behind and we complained about the courts. Well even the courts have been left behind and we have more laws and more lawlessness.

Nations that invest the most time, talent, and treasures on the youngest will have the best results – in education, employment, creativity, and longevity – by designs favoring most Americans.  

Past and oldest generations taught about time, talents, and treasures - and must learn the most to return focus their time, their talents, and their treasures to those least in age - for any real hope of avoiding ever more destruction - by designs.

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

Countdown to the 2012 Primary Care Armageddon

There are about 132 days until January 1, 2012 when Medicare will be forced to cut fees to physicians by a flat rate of 29.5%. These cuts have already been enacted by Congress. To prevent this action, the current Congress would need to take action – a major problem with this Congress.

Before the end of the year you will hear much about these cuts and why these should not take place. This has been the case each year for a number of years. The fact of the matter is that many of the physician fees should be cut, but there are some fees that should not be cut. Primary care cuts are a very bad idea at the current time.

Even if Congress does miraculously decide to act in a timely fashion, with time enough to allow those delivering services to prepare (too late already), it is likely to cut fees paid for services in a simplistic way. These cuts will include primary care fees along with all others. Across the board cuts are likely as few in this nation understand important differences such as the difference between primary care and non-primary care.

Non-primary care is the area that has substantially increased the cost of health care in the United States for decades. Soon 20% of our Gross Domestic Product will be health care services. This is best indicated by a doubling of non-primary care workforce each 15 years since 1965. More than a doubling is possible in the next 15 year period. Physicians, physician assistants, and nurse practitioners are two to three times more likely to be found outside of primary care as compared to those inside of primary care.  Non-primary care has also demonstrated that it can maintain profits even with attempts at cost cutting.

Non-primary care services are the services needed by the fewest Americans for only a few years of their lives delivered in only a few locations. Primary care services are those needed by nearly all Americans nearly all of the years of their lives needed in nearly all locations. The reason for primary care problems is that the national design favors the few rather than the needs of nearly all.

Non-primary care interests have been providing ever more services for fewer. Primary care has been forced to do more with less - for decades. Primary care has reached a breaking point. This is not about profits or physicians. It is mostly about what is most important – people in need of primary care.

More Americans than ever need primary care. Seniors will double in numbers in the next 20 years and seniors need two to three times more primary care. With serious deficits of primary care and all sources of primary care moving to fewer remaining in primary care, it is the worst possible timing for any cuts in primary care fees.

Primary care is the area most closely associated with basic access to health care services. US designs have resulted in only one doubling in primary care workforce, from 1965 to 1980. Stagnant primary care delivery capacity has been the rule since this time. Primary care has been associated with health care cost savings although this may be more about increased costs due to non-primary care excesses.

Unlike non-primary care that has many options to preserve and maximize profits, primary care has few options. Primary care has no waste to cut. Primary care budgets are mostly about people who deliver primary care services. Cuts in primary care result in cuts in personnel and cuts in primary care services, or closures of clinics delivering primary care.

Primary care has not increased as those that invest in health care have far better investments to make. Primary care has rarely enjoyed investors or investment capital as primary care does not come close to 30% revenue over the costs of delivering care. Non-primary care services have increased most rapidly because it has attracted the most investors. This is logical given higher reimbursement for non-primary care services. To Understand Workforce One Must Follow the Money.

Primary care spending remains just 5% of total health spending – a pittance compared to the needs of 310 million Americans and barely enough for 140 million – by design.

For 30 years primary care graduates have been driven away from primary care - by design. Rather than a real design for primary care with real primary care spending, the United States has a patchwork of patches. The 1965 – 1970 redesign doubled primary care delivery capacity – for the only time in the nation’s history. The 1990 patch worked for a few years. The 2010 fix never came and is not likely. About every 20 years a fix has been needed for the primary care revenue design because the costs of delivering primary care have gone up faster than reimbursement.

This is the message Congress needs to hear from seniors and from most Americans. This message should be passed out to patients and posted in primary care offices:

If Congress does not act by January 1, 2012 to prevent the scheduled 29.5% cut in primary care reimbursement, this primary care office will have to reduce services or close. Many other offices will be forced to do much the same. Primary care is down to the basics - people serving people. We have no fat to cut. Long ago the designs for health care in this nation forced those delivering primary care to be very dedicated just to deliver primary care.

As your responsible provider of care, we want to inform you of this possibility so that you can make other arrangements if need be. As long as we can, we plan to keep serving you. We hope to keep serving you right here in this office. Whether we are able to do so depends mostly upon you and what you do.

We hope to help you keep having a nice day.

To Follow the Money, Follow the Workforce

Dramatic headlines now highlight profiteering in hospice services.This should not be a surprise to those who track workforce. Hospice has consumed steadily more nurses in recent HRSA nursing reports. When the nation sends more spending to a service, more workforce follows because workforce is required to be able to deliver the services.

Nurses have moved steadily toward higher pay and toward the most lines of revenue with the highest revenue in each line just like physicians, physician assistants, and nurse practitioners. All also move toward higher pay for less hours as well. About 85% of nurses are forced though hospital entry positions after nursing school - by designs that send the most spending to hospitals. Witness the current nursing problems as hospitals have already ratcheted back.

With 30% more spending compared to the costs of delivering care, health services expand rapidly - as in just about any other health care business. More profits draw more investors and result in more services - including those that might not be as needed. This is the case for health services other than primary care or public health.

Primary care physicians, nurse practitioners, physician assistants, and registered nurses get paid less - unless they convert away from primary care. Conversion is easy for these flexible sources of workforce. Conversion away from primary care is not simple for family physicians. Not surprisingly 70 - 85% of NP, PA, and IM primary care sources are found outside of primary care.

Only school nurses get paid less that primary care nurses for a variety of reasons including schools having to cut all types of personnel including teachers, teaching assistants, and nurses. Education and health systems are personnel intensive and therefore health care cost intensive and with increasing health care costs, the cuts must involve those most important to the delivery of education in the United States. School district budget officers have been telling this to us for years. Why don't we listen?

Why do we allow profiteering that results in such rapid health care cost increases? This is guaranteed to defeat our businesses, our economy, our schools, our health care delivery, and government budgets at all levels.Why did we forget the lessons of the 1980s when health care drove us to our knees and reining in health care costs for a few years allowed the economy to kick off the longest recent run of economic progress in the nation's history? We thought it crazy to pay thousands more for a car due to health care costs. Now we pay thousands more for education, for health care, for government, and more.

One way to cut back on health care costs is just to say no - that is to more workforce in certain areas. The US has doubled non-primary care workforce each 15 years by design changes resulting in ever more non-primary care workforce (See Three Dimensions of Non-Primary Care Increase) A design that rewards higher pay for non-primary care results in more growth and also more workforce moving to non-primary care, even those trained in primary care that are now 70% moving to non-primary care careers.

Generic expansions must stop and the US must have specific training in primary care that is forced to remain in primary care. This is partly for restoration of primary care and mostly about stopping the incredible cost increases for non-primary care.

Cutting back on non-primary care is a very good idea as no one has found a good way to rein in non-primary care spending. Primary care is already cut back. The cut back is due to too little primary care spending that has limited the primary care personnel and the services that can be provided. Primary care is personnel intensive and has relatively few codes that have not had major improvements in reimbursement.

Non-primary care profits can be preserved by more services, by fewer personnel, by more technology, by billing code creep, and by new services not yet facing cost controls. Also people desperate for very specific non-primary care services have thousands of advocacy groups clamoring for more when we have ever less available for health spending - if we hope to have a nation at all.

Even the highest income only give 14% for taxes and we passed 14% years ago. We are at 17.5% of our Gross Domestic Product spend on health care and will not stop until we reach at least 20% according to government sources. By that time we will have doubled non-primary care once again and incredible pressures will push health spending higher.

Primary care and basic health access and public health lose out in the competition - as in the past 50 years except for 1965 - 1980. But even then when we doubled primary care, we increased non-primary care slightly higher. And since 1980 we have had stagnant primary care because we have diverted more and more resources to non-primary care - which has doubled each 15 years as we have gone along with those haphazardly shaping the design over the past 100 years.