Critique of Commonwealth Fund Report on Ensuring Equity

A Critigue of Ensuring Equity    A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations

The COMMONWEALTH COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM    October 2011

A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access, to have primary care or health access someone must be there to deliver the care.

 This foundation sponsored report attempts to focus attention upon bringing equity to health care. This is a most important area, but the report fails to mention primary care workforce other than the following:

• Additional efforts may be required to develop the workforce pipeline, such as an expansion of medical education debt relief for primary care providers, specialists, dentists, and others practicing in health centers, safety-net hospitals, and medically underserved areas. P12 also repeated on p39 
• Additionally, efforts may be needed to increase the number of physicians and allied health professionals available to deliver such care. P14 also repeated on p41 
• Expanding the work­force and engaging the private sector’s providers to serve vulnerable populations is critically important as people gain health insurance under the Affordable Care Act. P24

Schools and students may need debt relief, BUT PEOPLE NEED HEALTH ACCESS. And this requires workforce. And this requires that the workforce be in position. With only 25% of workforce found in 30,000 zip codes with 200 million Americans (65%), serious design flaws exist.

Like Health Affairs issues devoted to Disparities (October 2011)  and to Primary Care (May 2010) as well as other government and foundation reports, the reports fail to indicate how the nation can get to health equity. To actually innovate, reorganize, reform, or change health access, first and foremost there must be

• Primary Care Workforce and a specific type of workforce: Family Practice Workforce

In this report as in almost all other similar works, there is little attention paid to the family practice RN, MD, DO, NP, and PA requirement for a move toward equity. Family practice of all types can be found with 50% or greater proportions practicing in 30,000 zip codes with 65% of the United States population. Family practice is the local zip code or adjacent zip code solution because of its stellar distribution. In many ways family practice is repelled by practice locations with top concentrations of workforce resulting in much greater distribution.

Primary care not family practice barely reaches national average distributions at half the distribution of family practice.  Internal medicine and pediatric primary care is found 70% in 3400 zip codes clustered together in less than 4% of the land area with only one third of the United States population. This compares to 72 - 75% of total US workforce found in such top concentrations. The elderly, poor, near poor, rural, lower income, middle income, disadvantaged, underserved, and Community Health Center populations are all greater than 65% found outside of concentrations. Non-family practice is out of position to facilitate health equity.

Primary care broadest generalist that stays broadest generalist for an entire career is required and only family medicine meets these two criteria. Family practice employed PA and NP work just as well, but only when staying in family practice. The family practice physician assistant is 30 times more likely to be found in rural health clinics and is 6 – 7 times more likely than other PAs to be found in Community Health Centers. No other type of PA reaches beyond the 15% of physician assistants found in rural areas and family practice PAs are found in rural locations at 30%. Family nurse practitioners are not only the dominant primary care source, they are the dominant rural and underserved component also. Unfortunately only 25% of generic NP or PA graduates contribute as family practice.

Family practice physicians are twice as likely to be found in all underserved locations, are 2 to 3 times more likely to be caring for the elderly and others left behind, and are 3 to 4 times more likely to be found in rural locations compared to other types of physicians.  In the graduates of each US medical school family practice multiplies health access. Across all birth origin types, family practice multiplies health access. This consistency is found for the past 40 class years of family medicine. Because NP and PA proportions of family practice continue to decline, the health equity contributions have decline - by at least half in the last 30 years. More and more graduates are required to achieve the same result for NP and PA. 

If the nation really priorities health equity with primary care retention and primary care distribution as top priorities, it would have expanded family medicine. Instead family medicine remains at the same 3000 annual graduates first reached about 30 years ago.

Generic Fails for Health Equity, Specific Is Required

Other sources of primary care are first of all not able to remain within primary care and second of all they are not capable of the distribution required to deliver on promises of health equity. The United States cannot resolve equity by graduating more that deliver more non-primary care than primary care and by graduating more that barely reach the national average regarding distribution where needed.

More generic primary care will not address health equity. Nurse practitioner and physician assistants sources are dilute sources for health equity. More generic nurse practitioners result in only about 1 in 4 that serves in family practice direct practitioner care with only half of these serving where most needed. More generic physician assistants results in less than 25% family practice with again only half of these found where needed. More generic osteopathic graduates result in less than 17% family practice. Despite the recent doubling of osteopathic graduates the decrease from 35% to 17% family practice has negated health access gains. More generic allopathic (US MD) graduates result in 7% family practice. A decline from 14% to 7% defeats health access and expansions will not make up the gap. Only 10% of registered nurses are in primary care and even fewer are found in family practice settings and those found where needed are cut in half again.

It is not enough to think good thoughts.

Actions are required that bring thoughts into reality.

Robert C. Bowman, M.D. http://www.basichealthaccess.org/
http://www.basichealthaccess.blogspot.com/

SMART Basic Health Access

Ensuring Equity

http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Oct/Ensuring-Equity.aspx

Overview

Equity is a core goal of a high performance health system. However, there is a growing health care divide in the United States, where vulnerable populations—those lacking health insurance, low-income families, and racial and ethnic minorities—are at higher risk for poor health and poor health outcomes than the rest of society. The Affordable Care Act will expand insurance coverage and bolster the parts of the health system that serve vulnerable Americans, yet much work remains. This report from The Commonwealth Fund Commission on a High Performance Health System examines the problems facing vulnerable populations and offers a framework for moving forward. It features three overarching strategies to close the health care divide: 1) ensure that health coverage provides adequate access and financial protection; 2) strengthen the care delivery systems serving vulnerable populations; and 3) coordinate care delivery with other community resources, including public health services.

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

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

Still the Health Access Solution for Most Americans: Family Practice

Health access workforce solutions have always been and will always be the broadest scope generalists. Other workforce even with slightly greater specialization or limitation in age range or limitation in scope will remain limited in distribution. Other sources fail to remain in primary care and fail to distribute outside of locations where workforce is already saturated at top concentrations

Inside of Concentrations - About 3400 zip codes clustered together in 4% of the land area enjoy top health spending per capita, all lines of revenue, and the top reimbursement in each line. This is where 72% of workforce and 70% of all primary care except family practice is concentrated. These zip codes with top concentrations of physician workforce are dominated by hospital, academic, and subspecialty interests – the same interests that dominate health professional associations and health education associations and the panels that influence government designs for revenue and for workforce. Consistent steady force applied over 100 years can accomplish amazing design changes - and the consequences of the resultant design.

A design that favors basic health access is the opposite from a design favoring concentrations of workforce in concentrations of workforce. Basic health access design is a design that results in the most broad scope generalists and a design that preserves general types of specialists. This is a design that is most likely to result in practice location in 30,000 zip codes with the 65% of Americans that found outside of concentrations. This is also a design that favors economic recovery for most Americans.

One problem with emergent recovery designs is that those most consistently at the feeding trough are already in place. Those outside are left behind when new funding emerges. Not surprisingly Americans have been frustrated with the feeding trough and with those feeding - but especially by being left behind.

Designs that favor those inside of concentrations favor those that already have the top economic impact per person from health care. According the the AMA, office based physicians contribute about 2 million per physician. In zip codes with 200 or more physicians with 11% of the population this translates to $10,000 to $15,000 per person in local economic impact. Practice locations outside of concentrations receive $800 to $2000 in office based physician economic impact. The differential is much worse when considering non-office based contributions as the hospital, academic, and research economic impacts are even greater at 80% to 90% inside of concentrations due to higher proportions of such workforce inside of concentrations.

When you follow the workforce, you follow the health spending. This is the traditional design that concentrates health spending with health workforce concentrations instead of distributing health spending according to the population distribution.  

Designs that result in recovery in primary care involving family practice and redistributions of primary care spending where primary care is most needed are designs that favor economic recovery for the people in these locations that are more likely to be lower income, middle income, poor, near poor, rural, underserved, disadvantaged, and complex in health care needs.

The existing design is not capable of addressing economic impact for most Americans. Economic impact from medical education is incredibly concentrated with 50% of 500 billion dollars a year concentrated in a few dozen zip codes in six states – states that already have top physician concentrations (AAMC data). Generic expansions of graduate medical education also fail to distribute health spending or health workforce. Ultimate concentrations of workforce follow top GME spending.

While health care and medical education and physicians are important to economic impact, the current designs fail to benefit most Americans. Those influencing the design are also unlikely to allow the designs to change as they control hundreds of billions of dollars each year in health care spending. Only a small portion need be diverted to influence Congress, government information, the media, insurance companies, health systems, and others important to the design. Those outside of concentrations have no effective lobby for two major reasons. First they are outside and second they are outside delivering the care needed by most Americans nearly all of their lives.

Family practice MD, DO, NP, and PA graduates are found distributed most consistently according to the population, but only when they remain in family practice employment. Family practice retention over a career is the critical component for basic health access. Family practice retention is 95% for family medicine residency graduates but only 20 – 30% of total NP or PA graduates are found in family practice employment. Physicians becoming family physicians can be tracked steadily departing top concentration locations across birth to medical school, medical school to residency, residency to practice, and to subsequent practices. The choices that lead to family practice lead to improved distribution.

A design that favors departures of primary care graduates from primary care and departures of non-physician clinicians from family practice is the same design that concentrates workforce and health spending inside of concentrations.

Permanent broadest scope generalists are the requirement for health access as such permanency forces distribution where needed. Flexibility in workforce allows a switch rather than a fight and stay or a move to a place better suited for primary care. The ability to switch away from family practice is not a good characteristic for the basic health needs of most Americans.

Family medicine residency graduates have long set the mark for retention within career. Non-physician clinicians that choose and remain in family practice have the same or better distribution as compared to family physicians although they have lesser productivity over a career (volume, years in career, activity in practice).  Rural primary care also illustrates the differences as well as non-physician clinician declines in health access contributions per graduate.

Non-physician clinicians have been proposed as primary care solutions, but generic expansions have not been good primary care solutions for NP, PA, MD, or DO. The generic solution is not specific to primary care or to family practice.       Permanent … broad scope… generalist.

The reason for rapid expansion of NP and PA workforce is great versatility. This versatility is also the reason for departures from primary care and from family practice. Non-physician clinicians are by far the most flexible workforce with a wide range of specialty and location choices. New specialties and subspecialties are being created and numbers continue to increase in each specialty. This all comes at the cost of lower retention in family practice over the years after graduation. The United States now has to graduate two to three times as many NPs and PAs to get the same primary care, rural primary care, or underserved primary care. This indicates a design steadily moving away from health access where needed and toward top concentrations. 

Departures from family practice and from primary care insure location departures from rural or underserved or outside practice locations – a consequence of greater concentration inside. Fewer broadest scope generalists insures more concentration. More will distribute health access as long as health spending is directed to support those who do distribute. Ever lower concentrations in locations outside of concentrations, shrinking health spending outside of concentrations, increasing population growth outside of concentrations, and increasing demand from patient populations outside (elderly, lower and middle income) will also result in greater shortages. The United States unfortunately has indications of nearly all of the above for even less basic health access result in the future. Primary care itself has no indication of any increase in the face of rapidly increasing demand.

Permanent retention in broadest scope general practice is required for distribution to 60% of the urban population and 70% of the rural population – those in most need of primary care workforce in locations with primary care is 40% to 100% of the local workforce – and the economic impact of health care upon the community.

When local primary care is controlled by those outside of the community, this can lead to even less local economic impact. With primary care revenue insufficient for the cost of delivering primary care, it is likely that local primary care for the purpose of local health care will be less likely. Those supporting primary care from outside may have agendas not specific to local primary care or local health care.

Consistent changes in physicians, physician assistants, and nurse practitioners to subspecialized and hospital based careers force ever higher concentrations and lesser distribution. Graduates are less likely to be found in family practice, generalist careers, or general types of specialties that have demonstrated better distribution. A recent example of a design change was the conversion of tens of thousands of primary care nurse practitioners and physician assistants to become teaching hospital workforce to replace the gap resulting from resident work hours restrictions. Movements from generalists to teaching hospitals represents the maximal possible change toward concentration in a relatively short period of time. This is made even worse by studies that indicate that health care quality has not improved in teaching hospitals with the resident work hours restrictions.

Consequence without benefit is not a good design change. Movements of tens of thousands of internists from primary care to hospitalist careers also result in changes in practice location. Substantial responsibilities have been shifted from hospitals with greater resources to primary care with less to least resources. Primary care nurses are being pummeled with greater fragmentation, more responsibility, and no improvement in support. Hospitals have saved substantial costs and generate more revenue – with consequences for those outside. Primary care needs respect, much higher priority, and suffiicient funding to deliver primary care rather than constant marginalization.

All workforce except for that associated with family practice employment can be tracked moving toward concentrations and away from primary care steadily over time. Family medicine is the only permanent family practice source and is therefore the source most resistant to concentration. Already this has resulted in family medicine multiple times more likely to be found serving the elderly, poor, near poor, rural, disadvantaged, Community Health Center, and shortage area populations left behind (Ferrer, Mold, Rosenblatt, Bowman).

Lower and middle income and fixed income populations are most dependent upon family medicine with practice location a key determinant. The elderly that are most likely to be on fixed incomes are a prime example of a population that must move away from the highest concentrations of cost of living to more reasonable locations. In the process older and oldest Americans must depart concentrations of primary care, stroke centers, and heart attack centers to locations with less access to a wide range of services (Perotta). Over the next 20 years the elderly and all others left behind will be left even further behind.

The one source that could have addressed their needs, family medicine, has not been expanded in annual graduates for 30 years. After a generation with zero growth of annual graduates, family medicine has reached its design level of 100,000 for 3000 per year. Unfortunately the elderly and all others most dependent upon family medicine have now entered a 20 year period from 2010 to 2030 with most rapid growth in primary care demand.

Most Americans do not need 30 more years of more of the above designs that fail most Americans in one or more dimensions. What they need is more spending outside of concentrations, less spending inside of concentrations, more spending upon primary care, less spending in non-primary care, and more spending on the health care needed by nearly all Americans nearly all of the years of their lives in nearly all locations.

Whether you call broadest scope generalists MD, DO, NP, or PA does not matter. What you must make sure of is that whatever is produced, stays permanently as broadest scope generalists in primary care. This is the only design that works for most Americans and Americans most in need of health care. When people propose solutions, ask them the "P" words - permanent, primary care, and population-based distribution. Better yet, have them sign a binding contract to deliver more than promises by SMART designs. 

Revisiting Physician Distribution by Concentration Coding

Geographic coding often involves concentrations of people relative to land area such as rural or urban or most urban. Why do studies of physician workforce use coding based on ratios of people to land area? Why not use ratios of health workforce or physician concentrations as compared to people?

Top concentrations, marginal concentrations, and underserved concentrations are more relevant to those seeking care, and are most relevant for basic health access where local or adjacent zip code care is a priority.

Geographic coding such as rural versus urban actually has problems when compared to physician concentration coding. Isolated rural and small rural locations (Cooperstown NY, Marshfield WI) can have top concentrations of physicians. Rural Concentrations of physicians are about 3% of United States physicians and about one-third of rural physician workforce.

Also using workforce concentrations, types of workforce can be compared. One important area stands out. The MD, DO, NP, and PA family practice employed component is the only component that distributes according to the population and therefore according to primary care demand. All other primary care, specialty, hospital based, and subspecialty choices are more likely to be found in zip codes with increasing concentrations of physicians. Claims of better or best distribution are only about family practice and only when graduates stay in family practice.

What matters with regard to physician workforce is the ratio of physicians to the population. Patterns of workforce concentration can also be compared to various populations. Top concentrations create their own consequences, as in doughnuts of zip codes with shortages of workforce that surround clusters of top concentration zip codes. This is a design that results in the most barriers to health access. Primary care is also concentrated inside of concentrations, with the exception of family practice.

Physician Distribution by Concentration Coding emerged from immersion research involving secondary physician databases. With physicians in 2005 compiled by zip code, patterns of concentration were more easily understood.

Top concentrations tend to be subspecialty, academic, and hospital in focus with a vertical orientation of the design.

Most Americans are found in zip codes that are horizontal or health access in focus, dominated by primary care and generalists and general types of specialties.

This presents a problem because the workforce most needed by most Americans is the workforce least produced and least retained by American designs.

What emerges is the fact that those influencing health professional training and multiple Congresses and Presidents over many decades are found in top concentrations with benefits bent steadily this direction with little real competition. The health care delivery most promoted as outstanding to the world arises from these zip codes. The fact is that the United States has a Super Center design with a super sized consumption of health care spending and health care workforce and health care consequences – including lesser health and wealth for substantial portions of the United States population. More details and category characteristics can be found at Physician Distribution by Concentration.

Concentration Coding Categories

	Physicians per 100,000 Population (280 is avg)	% of Office Based Economic Impact /  % of US Physicians	% of Total US Pop / % of FM Docs	Physician to Pop and FM to Pop Ratio
Super Center 200 or more physicians, < 1% land area	1100	51.1% 46%	11 - 12% 20% of FM	4 to 1 1.8 to 1
Major Center 75 to 199 docs,  3% land area	400	28.3% 22%	22% 27% of FM	1 to 1 1 to 1.2
Marginal Urban higher income and lowest poverty	150	13.5% 20%	35% 25% of FM	1 to 2 1 to 1.25
Urban Underserved lower income and higher poverty	80	2.3% 4.5%	13% 7% of FM	1 to 3 1 to 1.5
Marginal Rural average income and average poverty	130	2.7% 4%	8 - 9% 10% of FM	1 to 2 1 to 1
Rural Underserved lower income and higher poverty	105	2.2% 3.5%	8 - 9% 9% of FM	1 to 3 1 to 1

Highest poverty urban or rural sites have about 60 physicians per 100,000. AMA Economic Impact of Office Based Physicians used with AMA Masterfile 2005

Graphics of the PDC Coding

Inside of concentrations = Super Center and Major Center zip codes with one-third of the population and highest concentrations of physicians, health workforce, economics, income, facilities, health spending, and economic impact from health care. Zip codes inside of concentrations are also clustered together in small portions of states, counties, and cities for least accessible health care. Inside of concentrations are even higher concentrations of health spending and economic impact per capita.

Outside of concentrations = Marginal or Underserved zip codes with two-thirds of the population and same or greater proportions of elderly, poor, near poor, rural, underserved, disadvantaged, and complex populations as well as lower health resources and health spending.

Two geographic patterns are common with lesser concentrations. These include large areas of low concentrations and doughnut patterns. Doughnut rings of lower to lowest workforce concentration surround zip codes with highest concentrations of workforce. Doughnuts can be urban or rural. New York City urban zip codes surrounding Manhattan indicate highest central and lowest peripheral concentrations. In the Midwest highest metro concentrations are surrounded by nearby rural zip codes, at least until urban sprawl overtakes low concentrations.

The most subspecialized workforce is found at 60 – 65% inside of Super Center zip codes in 1% of the land area with 11% of the population. About 80 – 92% are found inside either Super Center or Major Center concentrations along with 85% or more of residents in training, faculty, and research physicians. Training dollars and research dollars follow these concentrations of workforce as do concentrations of health spending for the most specialized procedures.

Designs developed over the past 100 years have consistently favored those most inside of concentrations. Zip codes inside of concentrations can access all lines of health service revenue and reap the highest levels of revenue in each line. Zip codes inside can recruit staff, nursing, clerical, and practitioner workforce away from primary care and from lesser concentrations due to greater health spending – by design.

Primary care is assured the least experienced personnel and workforce by designs that send the most experienced inside of concentrations leaving those most inexperienced and those most dedicated behind on the front lines. New designs by states and insurance companies may result in even less primary care spending sending even more workforce away from basic health access to top concentrations – or the US could continue the old design of too little revenue for the increasing cost of delivering primary care for steady, albeit slower declines.