Part I Million Hearts Limitations of Awareness

One Million Hearts Saved or 160 Million Lives Improved

Part I: Limitations of Awareness

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

Meeting Primary Care Needs in the Last Half of the 21st Century - Really!. 

Clinician Specific Medical Education

SMART – Specific, Measurable, Achievable, Realistic, Timely

One Million Hearts Saved or 160 Million Lives Improved

Where Should Our Leaders and Our Designs Take Us as a Nation?

Million Hearts is another attempt to turn risk factors into saved lives - specifically reductions in heart attacks and strokes. The targets are once again human behavior changes (patient and provider) regarding aspirin, blood pressure, salt, cholesterol, and transfats. The campaign involves a number of federal agencies and health leaders, but the campaign will not address the top issues facing most Americans in their life, death, or health.

Health and Human Services in the United States represents biggest government that dwarfs all other world governments other than the United States government and total government in all but a few other nations. Health and Human Services and other government leaders play a key role in guiding health care in our nation as well as economics, jobs, and health spending. Not surprisingly those shaping our health care designs invest billions of dollars to influence our government, particularly with health care a much more stable investment compared to most for the last decades.

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

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

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

Our Nation must stop, repeat stop, its magical thinking with far too much emphasis on innovation and reorganization and manipulations of numbers. We have far too little emphasis upon people - especially people with basic health needs and people that can address basic health needs - for entire careers with best experience and coordination and dedication. We fail to understand people and the people that serve people. When we understand most Americans and the teacher, nurse, public servant, public health, and primary care workforces that serve most Americans, we fail to understand America and what is best for Americans.

Introduction

For 100 years our national priorities have been focused upon health innovations and interventions that cost more, yield less, and benefit less.

The Million Hearts Campaign appears to be an attempt to save lives but it is still a continuation of the past 100 years and a process that no longer works for better lives or health for most Americans. Our leaders have been taught by the same people that have led the United States to the brink of financial ruin as we spend far too much on health care – impairing all budgets that involve people at all levels. This in itself makes government at all levels from school districts to the national level inefficient an ineffective as we have to cut teacher, public servant, nurse and other front line jobs just to satisfy the health care cost demands. Poor awareness has also impaired our judgment in defense expenditures, bailouts, and financial system rewards.

Those doing well in America are doing better than ever by any number of measures (top 1%, top 10%, CEOs, healthiest, wealthiest, most and best health care coverage, the most highly educated, children of professionals, highest property value living places, most social and political organization).

We have forgotten how to address the basics – basic birth to age 8 in children, basic health access, public health, clean water, sanitation, use of government dollars efficiently and effectively to make a nation more efficient and effective. We have forgotten how to maintain a nation and the people that maintain and progress a nation - those on the front line serving occupations. 

In the realm of major health campaigns, we have been focused on curing diseases such as breast cancer and heart disease. Meanwhile failures in health are more evident as well as failed health designs that make matters worse for the nation. More move toward health care in search of profits as health care (especially non-primary care) is one of few routes available to profit in a sinking United States economy – an economy sinking faster mainly due to too much health care for too few at costs far too high. These campaigns have begun to abuse statistics by making claims that are just not possible – reduce smoking and obesity and save 1 trillion dollars, spend much more now to get cures from research in the future after 50 years of little gain in cures, or save one Million Hearts.

Playing the same old tunes is not going to address the needs of 160 million Americans at the current time. Shell games indicating innovation as a solution or reorganization disrespect those who are dedicated to making a difference as well as those who need a difference made in their lives. Focusing ever more attention on one area that has had 50 years of work is not likely to result in much more improvement.

The limitations of the interventions are easily seen and are the same limitations facing 160 million Americans – whose health care is more about limitations and barriers than specific biomedical markers indicating some small increased probability of future death. These predictions also use equations that are far from complete, with much or most of the reason for future death unexplained. But this does not stop the biomedically trained, the biomedically profiting, the biomedically employed, or those representing biomedical interests. Until we understand much more about the human condition and human relationships with regard to health conditions, we will not address the barriers to better life and health.

Governments across the globe have been shaken up increasingly in recent years due to government that has grown distant from the people. The United States should pay attention more than which side should win. When government has leaders that are less representative of the people and less mindful of the people, there are any number of consequences to most of the people.

Our leaders in government are less and less representative of most Americans. Our professionals that shape America's decisions are less and less representative of America. Health care is a prime example. Our health care design has been shaped by few and fails in impact for most Americans. Our health care spending and the economic impact of health care favors a few Americans in a few locations with most Americans left out by design. In such a setting it is difficult to even craft a design that can help most Americans as those that can influence designs have such a poor grasp of how to impact the daily life and health needs of most Americans. Until dominant perspectives understand that excesses for some lead to consequences for most, there will not be improvement.

So we have Million Hearts that once again attempts to turn aspirin, blood pressure, salt, cholesterol, and transfats into better lives.

We are not quite to “let them eat cake” or “fiddling while Rome burns” but we are not going to receive much gain for the effort, especially for those in the 160 million left behind. The Million Hearts campaign will directly or indirectly reinforce the past decades of more done for less at higher cost with little benefit. The Million Hearts campaign will take interventions that work best on those doing well - interventions that work less well on those who are least well – in health and job and income categories.

The Million Hearts campaign will not introduce or reinforce tough decisions that should have been made each year for 30 or more years. We must spend less on the few and more on the many. We must reduce non-primary care spending and increase basic health services spending specific to places and populations that need the basics. We must redirect spending from those nearest death or those dying to interventions that would result in improved national outcomes for future generations.

Most of all the political and health care leaders of the United States must reinforce a single basic truth – we will all die. How we choose to live or die as well as our collective decisions that shape life and death, impact quality of life for far more people than we grasp at the current time.

It takes national campaigns to focus attention elsewhere, rather than the basic needs of most Americans left behind in so many ways important to a nation – in basic nurturing and child development, in early education, in basic health care, and in other basics. Only a focus on improving the daily lives of most Americans will improve America and such a focus may actually gain far more than a Million Hearts saved because spending a little more on the many in ways that make small improvements can have major improvements in outcomes. Allowing a continuation of ever more spend for fewer for less result is intolerable in health care.

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

Major Journals Fail Primary Care Once Again

Major journals have slipped in another article that apparently was designed for controversy and for widespread distribution to media outlets. The title of this Health Affairs article is not original or easily misunderstood - "Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services as Compared to Other Countries." Health Affairs published the bait. Media outlets such as the NY Times were hooked.

Controversy will once again divert the nation from addressing real problems such as deficits in primary care. The American Medical Association has chimed in for a defense. Once again too much focus on physicians with the most highly specialized services will defeat basic health access.

What is common to major journals, media outlets, and the past 30 years of political administrations is a poor understanding of primary care. Errors of perspective and analysis are far too common. It is not a surprise that one of the Health Affairs authors is a member of the Obama health care team (written prior to joining the team). The current administration has made little progress and various reports and appointments may move basic health access the wrong directions. (The Health Resources Services Administration still has primary care projections for 2020 that are impossible to reach).

The nation's leadership still has little clue what goes on day after day for most Americans in areas such as basic access to health where they are left behind by US designs of health spending and health workforce. Special programs are not the real solutions. The solutions require understanding the reason for most Americans to be left behind. Steady work over 100 years has shaped the current design favoring those in top concentrations with steady and progressive declines in basic health access and primary care over this time. 

The Health Affairs article indicates that primary care physicians in the United States are paid more than in other nations. Those reading the article will first of all be confused as the article is not an easy read or one easily accessed. Entire books have failed to capture primary care differences as well as national design differences. It is not surprising that the media repostings of this article have emphasized the controversy without much indication of substance.

The authors wanted to compare other nations and physician fee differences and apparently chose the most dramatic examples to further their plan. Health Affairs allowed them to cherry pick their analysis from a huge volume of possible data that could have been chosen. Their discussions of orthopedics and primary care are actually minimal compared to their plan to do nation to nation comparisons. But primary care will be even more confusing to those reading the article. And interpretations by those in Congress could result in serious consequences for most Americans.

The title stands alone and needs little supporting evidence - Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries – the journal could have saved the 9 pages by just posting the title alone - we get this already. But primary care gets caught in the crossfire and the controversy.

One can also figure out that the US might just need to pay more for primary care because it pays way too much for non-primary care. With voluntary choice dominating health professional education, once students are admitted into training the designs drive lesser supported primary care to become non-primary care. Design flaws require more pay to keep primary care retained in primary care. This is especially indicated in flexible primary care workforce designs (nurse practitioner and physician assistant sources). Those most flexible that can go to primary care or not require higher pay to remain within primary care.  This point could have been made in a few paragraphs, but the article goes on to compare all manner of data across various nations – those who are very different than the atypical US situation.

The article and the inevitable media reports imply that primary care is either well paid or paid too much. This is confusing and distracting. Authors, health care designers, current political administrations, future administrations, and national designers need to understand much more about the current situations facing primary care and basic health access for most Americans.

There are many indications of insufficient primary care spending in absolute dollars or primary care spending relative to non-primary care spending:

• The United States has inadequate and declining primary care workforce, particularly in 30,000 zip codes with 65% of the US population – locations left behind with lower to lowest concentrations of total health workforce, primary care workforce, and health spending. The US design favors top concentrations of health workforce with top concentrations of health spending. This shapes top concentrations in all facets, including primary care. Over 60% of primary care is stacked in 3400 zip codes clustered together in zip codes with 75 or more physicians where 72% of US physicians are found with only 35% of the US population. Over 70% of internal medicine and pediatric workforce is also found in these top concentration zip codes. Only family medicine with 50 - 55% of workforce outside of concentrations has anything resembling needed distribution and persistent primary care by design
• Even greater concentrations of workforce are found in over 1000 zip codes that have absolute top concentrations of primary care with 150 – 250 primary care physicians per 100,000 in only 1% of the land area with 11% of the population. These are clearly the sites with the most lines of revenue and the highest reimbursement in each line - and top concentrations of workforce and support personnel.
• Deficits of primary care facing most Americans are an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support. This is complicted by insufficient health spending in 30,000 zip codes with 65% of the population as compared to zip codes with top concentrations of workforce and spending.
• Primary care not supported by grants or by capitated methods of payment or by private insurance has been in trouble for quite some time with increases in the cost of delivering primary care and insufficient reimbursement from Medicaid or Medicare or those with low or no health insurance coverage. The article does point out that primary care successes where populations are wealthy and are well covered with private insurance.
• Every one of 6 primary care sources (NP, PA, IM, PD, MPD, FM) has been impacted by fewer graduates remaining in primary care during training, at graduation, and each year after graduation. More are found in hospital and subspecialty and non-primary care areas. Primary care graduates deliver less and less primary care during their careers with each passing class year. This is also an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support.
• Primary care graduates matched to their class years indicate gains in primary care only 1965 to 1980 with a slight short gain in the 1990s. At all other times, primary  care delivery capacity has been in decline. Primary care numbers only doubled from 1965 to 1980. Non-primary care numbers have doubled from 1965 - 1980, from 1980 to 1995, and from 1995 to 2010 and will double again from 2010 to 2025. Primary care graduates are now two-thirds non-primary care in workforce result, but perspectives have so far not allowed this discovery. Primary care can be counted on to be stagnant for decades to come. Non-primary care cannot even be counted with three dimensions of expansion simultaneously progressing.
• Only family medicine remains with 80% or greater retained in primary care over a career. All other sources have 15 – 45% of graduates found in primary care. Substantially less primary care delivery is the result. The steady year after year decline indicates more declines to come although internal medicine, physician assistant, and nurse practitioner decline rates have to slow as so few remain in primary care and proportions approach zero.
• Family medicine itself is an indication of inadequate primary care support. Family medicine is the only career recognizable as a permanent primary care source at the current time. Students choosing family medicine must integrate past influences, training experiences, and future perceptions as they make this decision. Family medicine remains at 3000 annual graduates and has not increased in annual graduates for over 30 years. This is zero growth or no expansion at all. One would not expect a permanent primary care source to expand without better support for primary care in absolute dollars or relative dollars for primary care compared to non-primary care. The specific solution for rural, underserved, primary care, elderly, poor, CHC, and near poor populations is the one road not taken - an indication of little or no US emphasis upon basic health access - by design.

Solutions: more basic health access spending specific to locations and populations and more spending upon primary care where needed

Solutions specific to health access would require diversion of a few percentage points of hospital and academic and subspecialty spending from 3400 zip codes. This small percentage would result in 10 – 20% greater spending upon 30,000 zip codes with 65% of the population. Such is the concentration of health spending as compared to the small proportions spend in rural or underserved settings.

Solutions specific to primary care would require a few percentage points taken from non-primary care to provide a 10 – 20 percentage points to primary care. Critical Access Hospitals have taken rural hospitals off the critical list because CAH funding captures a few percentage points from all other hospitals to resuscitate rural hospitals. This change was required because cost cutting designs for health spending after 1980 resulted in massive rural hospital closures. The design changes defeated rural health gains 1965 to 1980. Once again those in charge at the top failed to consider basic services needed by most Americans. Rural primary care is clearly facing the greatest possible crisis at the current time with declines in primary care workforce and continued declines in sources of rural workforce. 

Given those in top concentrations in charge of the health care design, the result will be the same as in the past 30 years

• Stagnant spending in primary care with stagnant to declining primary care workforce
• Stagnant health spending in 30,000 zip codes with 65% of the US population
• Increased health spending in a variety of non-primary care and hospital settings (and crippling increases in the national GDP spent upon health care)
• Increased health spending in 3400 zip codes that already have top concentrations of workforce which will shape even greater concentrations of workforce. 

Articles that imply primary care doing well will not help address the major health access problems facing most Americans. A similar problem is announcements of grants for a few million here and a few million there while hundreds of billions poor into just a few zip codes under the dominant design for health spending.

The practice settings with the most lines of revenue and the highest reimbursement in each line are able to take workforce from any other settings.

In the past decade alone teaching hospitals have already claimed tens of thousands of primary care nurse practitioners and physician assistants to replace resident workforce lost (work hours restrictions).

Hospitalist workforce has claimed over 20,000 internists and 30,000 total physicians in addition to more non-physician clinicians.

The US designs are crafted by teaching hospitals and hospitals and associations. The designs allow those in top concentrations to prosper with even more consequences for those left behind. Also design changes tend to shift greater responsibility elsewhere as in hospitalist workforce with hospitals discharging patients and responsibilities onto lesser paid primary care settings and already overburdened primary care nurses - increased work and responsibility for little or no increased revenue. This is another example of errors of perspective where one action has a number of consequences.

Again and again lower paid primary care workforce has been tapped to address non-primary care areas over and over – emergency, geriatric, sports medicine, hospital, teaching hospital, urgent, and hospitalist with more to come. Primary care nurses, nurse practitioners, physician assistants, and physicians are paid less and this results in higher levels of turnover (loss of continuity) as well as departures from primary care to non-primary care careers.

Designers fail in specific primary care training, fail with departures of primary care graduates from primary care, fail to consider important areas such as experience in primary care that result in continuity, and fail to design policies that retain primary care or assist in the delivery of primary care. Innovative solutions are still associated with NP and PA workforce that were created for primary care and basic health access, but articles fail to point out that NP and PA workforce have been diverted over two-thirds to non-primary care workforce. Articles and experts fail to illustrate these failures. By working steadily for what works for a few, most are left behind steadily and progressively - by design and by those who are supposed to critically appraise designs.

Pay for Performance is another innovative design that works for those in top concentrations. It is not a surprise that this reward originated in top concentration circles. Physicians caring for patients in top concentrations receive top quality ratings by caring for those that have top socioeconomic status. For once JAMA got this one right. The Hong study in JAMA indicated physicians rated low quality just for caring for the underserved. Unfortunately it is rare for journals to consider the more global perspective just as it is rare for authors or workforce experts to capture this perspective. State designers interested primarily in cuts and cost savings have little or no understanding of the increased future costs or health care consequences that they are shaping year after year. Only recently with the Medicaid Randomization study (Baicker) have we had any clue regarding just how much having health care coverage matters. Health Affairs has been exposed to the right perspective, but how many booster doses are needed? 

Primary care personnel are more difficult to retain due to designs that pay more for hospital, subspecialty, and non-primary care areas. The US designs insure shortages of personnel, less experienced personnel, and higher costs just to obtain personnel for locations with the least workforce that often have the most complex populations. The past, present, and future reimbursement designs have shaped these outcomes by resulting in steadily less paid for low primary care billing codes relative to non-primary care code. Pay for Performance has demonstrated no major benefit as well as harm to underserved settings that have lower quality specifically because they care for patients left behind by US designs for education, economics, jobs, and health care.

Health Affairs has dedicated entire journal issue contents to primary care innovation and reinvention without including a hint of how the US would actually have the primary care workforce to address primary care delivery, much less innovation in primary care. This tends to distract from solutions rather than contribute to solutions.

Designers have all contributed to substantial dysfunction in primary care from fragmentation in care and from more competition from sources with much better revenue (urgent, emergent, non-primary care) and from policies that convert primary care trained graduates to non-primary care workforce.

Primary Care Practice Internal Design Failures

Primary care has continued to require more and more personnel (more overhead) at a time when primary care is more difficult to deliver. And the next 20 years of aging and other changes will make this even worse.

Within primary care sites, the practice dynamics represent serious problems. More and more personnel are required that are not actually involved in primary care delivery. Two new modes of care delivery have been created because the costs of overhead are too high (collaborative care, boutique care). Both modes are a fit for certain providers and patients, but result in even less primary care delivery arising from the primary care workforce that is already too few.

Primary care has multiple more barriers to efficient care. Billing for primary care is way too complex with way too many sources with way too many requirements. Receptionists must screen for fraud and collect ever more information. Primary care nurses direct clinics, insure compliance, train staff, keep on top of new weekly care care requirements, take calls, make important care decisions regarding triage, gather ever more fragmented health information, and spend countless hours dickering with insurance companies so that patients can get appropriate care. Government and insurance company efforts force every more innovative technology and equipment and personnel uses that are increasingly expensive with little help for what matters

• primary care volume sufficient to overcome health access deficits and
• primary care quality.

More cost for less care delivered to fewer is not a good plan when half of the nation is being left behind by design.

Specific and SMART Solutions for US Health Care Woes

• Universal health insurance coverage specific to primary care (not all care)
• Single payer specific to primary care (also separates primary care spending from the chaos and marginalizations of current US payers).
• Primary care specific training for primary care workforce that remains specifically in primary care for a career. MD, DO, NP, PA, and RN students in this plan would be admitted with requirements to serve the careers and locations needed. Instead of grossly inadequate selection and training specific to primary care, the US would be specific. Current training is one size fits none made worse by voluntary choice plus aberrant policies. These result in concentrations of workforce and inadequate primary care. Also junior or senior students dedicated by obligation to primary care should spend a year as a health care team member in a primary care setting helping to provide care for people in one of the 30,000 zip codes in need of primary care
• Primary care should be steadily sent more revenue with non-primary care sent less, until US workforce is back in balance and US health spending decreases rather than increases. This results in less loss of primary care workforce as well as primary care workforce with greater experience and greater continuity. Does Primary Care Experience Matter? This also forces higher volume from non-primary care that will also help address shortages of non-primary care.

Or we can all wait another year or two or a decade to see what happens as non-primary care expands in three dimensions and primary care remains flat by design.

SMART designs for health access and primary care will be opposed by existing designers using major journals, government reports, and the media to make their points - to keep the typical policies intact and to keep top concentrations of spending flowing to locations with top workforce concentrations - with few or no responsibilities - and with the usual guarantees of high profits. Finance-me-cratic Constants

Additional Major Journal Failures

What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.


In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.


Why Are HRSA Projections of Primary Care So Wrong?

Does Primary Care Experience Matter?

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

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

Consistency in Primary Care Experience

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

Rapid Expansion Leads to Less Experience

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

Years of Experience 

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

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

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

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

Lower Volume and Less Primary Care Experience

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

Less Primary Care Specific Focus in a Source of Workforce

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

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

Payment Designs that Impair Continuity

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

Does Less Experience Translate to Lower Quality?

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

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


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

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

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