Deifying Disease By Design

In a recent video released to the world, top experts have revealed their agenda for making progress with regard to disease focus. Local and state have not been enough. National is not enough. They want the entire world to focus upon eradication of thousands of diseases which they conveniently categorize into just a few - or actually one disease.

In the video there is a first a comment about the problem of the term “non-communicable disease” (a negative term), and then there is adoption of the term “NCD.” This is a continuation of a process to make thousands of heart, lung, and other diseases into Four Diseases Focus and then into just one - NCD.

Those in charge are very effective with regard to focusing attention upon disease (not better health, not better health care, not health care for entire populations). They have been first to call for a UN summit on the problem of non-communicable diseases.

Forget the fact that the nations left behind mostly need clean water, sanitation, better housing, decreases in massive pollution, and other basics.

Forget the fact that the major problem for nations such as the United States is a disease focused design that results in 20% of all dollars sent to health care – crippling the economy and resulting in ever more stress and more disease and poorer health as a result.

Forget the fact that most Americans have limitations with regard to basic health access in one or more dimensions - because so much is spent upon disease focus.

Forget the fact that disease focused health spending crowds so many dollars into so few diseases with care delivered in very few locations.

Those in charge that are disease focused are not happy with just the domination of medical journals or government reports. They are not yet pleased with their ability to get ever more disease focused testing and ever more disease focused training and ever more disease focused treatments.

Forget that they have the ability to convince legislators to do what they want even when the evidence is poorly supportive - because those that sell tests and equipment and research harvest vast sums of money by disease focus.

Forget that they accepted billions of dollars of government, drug company, and foundation dollars spent on disease focus - dollars that shaped their admission, their training, their advancement and promotion, and their thinking.

They are not happy controlling government health leaders and panels. They plan to get above the health ministers to heads of government and finance ministers.

Remember that they do not understand that their single-minded focus on disease eradication is breaking the bank of government at all levels (school districts to federal) and businesses of all types already (that pay more and more each year for health care insurance). Forget that school districts have to cut teachers and education focus to balance health care spending or that governments cut public servants to pay for ever increasing health insurance costs and insurance companies just pass disease focus back to us with higher costs of insurance.

The disease-focused see the need to spend ever more on costly tests and treatments that look good on paper but are actually even more costly and less effective in actual result.

How many more times will we need to see failures when moving from paper to populations before we decide to apply the recommendations to 1 to 2 million people before applying them to 300 million?

Application to entire populations is a process, not a concept. Concepts are easy, process is hard. Is it a surprise that the US failed to understand Deming and fails to understand quality with a focus on concept rather than process? Application of health concepts to process has yet to be captured on paper or even in reports or entire books.

An example of disease focus is seen in diabetes - or rather the several diseases that are combined under the term diabetes.

• First, the definition is changed and results in substantially more found with "diabetes".
• Second, economic conditions result in more stress and more difficulty addressing the root causes of diabetes. Eating too much and drinking too much and poor diet are just a few of the behaviors people turn to when stressed. Those most stressed also find it harder to get health care and the best health care.
• Third, diabetes is declared as epidemic, because of the direct and indirect influences of disease focus.

The disease focused are not bad people. They are actually quite nice. They are among the brightest on the planet. They are also passionate about what they do and how they hope to help others. It takes more than best and brightest or the most passionate. It takes practical and relevant to lead health care effectively for entire nations.

Process is far more important than concept. The health of entire populations is all about process and little about concept.

Like nearly all of us, those passionate about diseases are frustrated with politicians. They are also certain that their approaches will work, just like any number of interventions that failed to work well beyond the basics of food, sanitation, water, housing, and immunizations. After all they were doing disease focused research before medical school and during medical school long before they even had any clinical training. Disease focused research shaped their path to medical school. The influence continued in the first two years before there was much in the way of clinician training at all. If you do not understand this, just pick up any of the 30,000 applications for medical school each year and compare how much space there is to pointing out just how much research focus their is in applications.

The disease focused will also be more frustrated as progress is gained in evidence-based medicine – indicating that their plans for disease focused domination can be exposed as wrong. In fact the very word non-communicable disease is a separation from communicable diseases that still kill millions a year and the youngest and some of the most important for nations - like parents.

The disease focused will also be frustrated by those that point out that health and health care delivery outcomes are more about people and the conditions of populations – not disease-focused care.

How will the disease focused react when more and more evidence points out that disease focused care is what is breaking the bank and causing stress, obesity, mental health problems, lack of focus upon children and those newest to life (where interventions are most effective), and more focus on those at the end of life where little real gain in life is possible at increasing cost?

New blog and posting at

Clinician Specific Medical Education -  What They Don't Teach Medical Students: Doctoring

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

Can We Have Our Billions Back Please?

Barrett's Esophagus: Another Disease Focused Failure

Why would an advocate for basic health access keep hammering on disease focus? The answer is simple. For decades we have more different researchers and subspecialists creating more reasons to spend dollars anywhere but on basic health care services, especially services needed by over half of Americans.

Disease Focus is Way Out of Hand

As long as those that control health care find hundreds of reasons to send more billions to each new reason, the United States will never get around to caring for 160 million or more Americans already left behind in even the basic services.

Insurance companies do not care about higher costs. They just collect more dollars - more to cover the increased costs and even more to cover the possibility that the costs will be higher. According to the American Medical Association report, over 70% of health care markets, do not have enough competition to keep them from doing this. They have wiped out the competition. More dollars turn into more dollars and then we need to train even more subspecialists costing more dollars while our economy falters from the fast rising health care costs. More subspecialists with higher incomes divert us from primary care workforce not only in physicians but in nurse practitioners and physician assistants.

Attempting to Kill Off a Killer

For years we have feared Barrett's esophagus. After all Barretts is only one small step away from esophageal cancer. We get acid sloshing up into the esophagus, the esophageal tissue changes, and then there is esophageal cancer. Tens of thousands have had referrals to GI docs to have endoscopy. Even more have been self referred back for future endoscopies and more biopsies. We have some patients getting endoscopy each 6 months because they are considered high risk. One problem with all of this is that esophageal cancer still continues to kill. Testing must actually work to decrease death from cancer.

No studies have demonstrated any impact of this substantial investment in more and more upper endoscopy. The lack of evidence has not prevented widespread application. Physicians trained to stamp out disease found a disease to stamp out and attempted to stamp it out.

It is hard not to get emotional. Esophageal cancer is one of the nasty cancers that eat away from the inside. By the time the cancer shows up, it has often spread. It is easy to see why patient and physician would want to prevent a cancer or identify one early.  I feared Barretts and esophageal cancer in my father for years.

Each episode of heartburn in my father seemed in my mind to head him toward this area. I was frustrated with him for not going. I was frustrated with his physicians, some of my earliest physician mentors, for not scoping him. I got my own upper scope for the same reasons. It turns out that they were right and I was wrong. As it turns out, these recommendations were based on bad data.

High Cost and Low Yield

This particular attempt to eliminate cancern has been very costly for not much gain. The reason is that the risk of progression of Barretts to esophageal cancer is much lower than previously indicated. Higher risk estimates for annual change mean that screening tests need to be more often. Lower risk translates to less often for the test, or not at all.

The previous estimates were about 1 out of 200 progressing to esophageal cancer each year. As it turns out, a number of studies now indicate less than 1 in 800 will progress. This means you can wait more years between test, or not test at all.

Billions Later We Have the Answer

Now we find out that the best policy should have been no widespread screening. Limited screening should have proceeded as part of a research protocol. Experts remind us that no study has yet demonstrated that screening has actually resulted in lower death rates.(David A. Johnson, M.D.)

More scopes from above and below have also cost billions of dollars in the cost of procedures, in the additional GI specialists required, and in terms of primary care workforce. More IM graduates to GI means less internists for primary care. Also about 3% - 4% of nurse practitioners have moved to GI despite primary care training. We all pay more to health insurance for scopes and more scopes.

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


Exploring the Health Consequences of Disease Focus


Myth for the Cure

Social Conditions as a Cause of Disease

One Million Hearts or 160 Million People


Failure of Disease Management to Save - a caution for PCMH as well

Exploring the Health Consequences of Disease Focus

Cost Cutting Consequences

The past 30 years have been cost cutting designs in the US. Past leaders have shaped health care focused ever more on disease, subspecialty, and academic interests. A previous Congress reacted with an attempt to cut costs, but this has resulted in the disaster set for Jan 1, 2012. Regardless of political party, the political and health leadership has failed the basic health needs of most Americans and neither party has any plans to spare essential basic services from the cuts to come.

Themes for the Week

1. Identifying and exposing disease focus - the enemy of basic health access, reasonable costs, and affordable health care for people

2. Returning nations to basic health access restoration

It is a difficult task to identify all the ways that the United States uses to avoid better and more efficient health care, but awareness building is a first step to change.

Those focused on disease appear to be more and more sensitive to the charges and consequences of disease focus, so they more and more attempt to link their disease focused activities to the appearance of better health and prevention. Make no mistake, this is still disease focus by those trained by disease focus, research funded by disease focus, and priority funded in practice by disease focus. it is very hard to untrain a physician or researcher or policist from disease focus as this has been the focus of the past 100 years.

Better health or a design to deliver health care is very different from approaches that attempt to stamp out death. Just as a reminder, no matter how much death delayers attempt to sell death delay, death cannot be stamped out. It can only be delayed. We will all physically die. We should all hope not to take our nation with us when we go.

Death is what happens at the end of life and disease focus is also what happens at the end. What happens at the end of life is highest cost health care for very little gain, also because this is end of life. What hurts most is that disease, death delay, and end of life focus - ALL HURT THE YOUNGEST WHO ARE MOST DISTANT FROM DEATH. They have to endure multiple generations dying an sucking up all available resources before they can receive the benefits of being near death. What we do assures that the youngest will have an earlier death. This is what our death numbers statisticians are also beginning to say.

The themes of death delay can be seen in recent works. In just the last few days some CDC researchers paved the way for 19 billion more dollars for Hepatitis C screening on the entire age  - those most likely to have Hep C. CT scans are proposed for "prevention" of lung cancer death but of course there are incredible costs associated with such testing, including the interventions required. In each of these areas involving diseases such as various lung cancers or forms of hepatitis there are problems.

There are those who test positive and are positive and may improve with treatment, if they are positive with the right form of lung cancer in the right place or the right substrain of Hepatitis C, etc.

There are those who test negative but are positive and may sue

There are those who test positive and are negative who face substantial costs and disability for no reason at all other than the testing.

There are those that test positive and do worse because of the testing and procedures and treatments.

There are consequences of all of the above, especially lost real wages, lost jobs, and lower Social Security in the future because of lost income. Of course these are costs not fully considered in the analysis. Also not considered is the fact that we spend so much for so few at the end of life that we have very little remaining for most Americans - such as $44,000 spent per year for the top 1% in health costs and less than $800 a year for 50% of Americans (this is a range of 6 times more than the national average to 10 times less than the national average of about $8000 per person).

Recent works in the area:

Redesigning Away from Disease Focus to Redesign for Health Care

The New Four Diseases Focus Is Still Disease Focus Not Health Focus

One Million Hearts Saved or Health Access for 160 million Myth for the Cure - More awareness of disease cannot help most Americans who need entirely different designs that even allow health care participation.

Accountable Health Access from Government  SMART designs can address health access needs but government must specifically focus upon health access result.

Take Home Example from US Health Care

Health care cost increases kill off our businesses and force them to terminate employees to balance their budgets. Much the same is true in governemtn where teachers and public servants are cut so that the ever increasing cost of health insurance can be met. Even health care entities must cut nurses and other personnel as their own fast rising health care costs impair their ability to deliver health care.

This posting represents to advice to those in other nations or in future generations that fail to learn from the United States example developed over the past century of disease focus.

As health care spending approaches 20% of Gross Domestic Product in the US (over twice as much per person as nearest competitors), those who pay for health care under the US design are being compromised - all governments at all levels from school district to federal and all businesses

Disease focus is the reason for health care cost overruns - more and more spent for fewer people for fewer years of their lives with spending in just a few locations.

Those with disease focus have found more new ways to fund this focus, including claims of cure. These are little more than death delay at every higher cost for the last years and months of life. Major journals and foundations and government reports all support this focus.

Non-Primary Care Workforce Equals Cost Overruns

The vehicle of this destructive plan is non-primary care workforce. The United States has only increased primary care workforce training numbers by design from 1965 - 1980. All US physician workforce doubled during this period - both primary care and non-primary care. This was also the first and last time primary care has been significantly increased in the past century.

Health care costs from 1965 - 1980 should be considered reinvestment in health care infrastructure - infrastructure that was collapsing under the privatized and profit driven US design. Cost increases continued in the 1980s but the non-primary care workforce increased even more as each specialty receive higher reimbursement compared to primary care and there were ever more services to bill. Primary care was already in trouble with limited billing codes, even more limited increases, double digit costs of delivering primary care magnified by double digit inflation. 

Not surprisingly the cost overruns continued in non-primary care and in overall health care costs. The original Medicare and Medicaid designs had been changed over 15 years. This is when the designs changed to cost cutting rather than health in focus. This cost cutting focus has continued because the costs have never been reigned in. In the 1990s there was a business and goverment coalition that brought the nation to its senses for a few years - long enough to restore the economy and take the nation on the longest recent run of economic progress. But the powers that be soon resumed control. Non-primary care will never be reduced under the current designs for training and support that emphasize non-primary care.

Doubling Troubling Workforce

The US training design has doubled non-primary care MD, DO, NP, and PA numbers entering the non-primary care workforce each 15 years since 1965. The first 15 years from 1965 - 1980 was the only time of primary care doubling. The 1980 design is still what we have with internal medicine decreased and replaced by the small portion of physician assistants and nurse practitioners remaining in primary care.

Non-primary care doubling in numbers each 15 years has been the case from 1980 to 1995 and from 1995 to 2010, and from 2010 to 2025. That is correct, the expansions of MD, DO, NP, and PA have already set in motion the next doubling and the foundation of another doubling 2025 - 2040. This is because it takes 25 - 35 years to fully express expansions already set in motion. For example the 3000 annual FM grads reached in 1980 have reached their maximum of 100,000 as a workforce and cannot go beyond this maximum as FM is still 3000 annual grads. IM down to 1400 entering primary care a year from 2000 to 2015 is already set to be less than 45,000 by 2030. Medicare fee cuts may help the US reach this level by 2025. The US will still graduate 250,000 or 25% of total physicians from internal medicine residency programs, but 80% will be non-primary care. A similar 80% of NP and PA and MD will be non-primary care - all shaped by the US designs.

Non-primary care will continue to increase  Three Dimensions of Non-Primary Care Increase Are Obvious and this will mask the lack of increase in primary care by designs since 1980 in training and funding support. After all, deans and nursing workforce leaders still claim substantial proportions of their graduates in primary care, when the reality is fewer entering and fewer graduating and departures each year after graduation - even for those who enter primary care. This is the legacy of a flexible non-specific primary care design rather than permanent.

Because primary care has essentially not changed for 30 years in the United States, the rapid increase in the cost of health care has almost entirely been about non-primary care expansions. In many ways, the only way to limit health care cost increases is to limit non-primary care workforce. Sadly this is the health care that has doubled by US design each 15 years since 1965.

Primary care workforce and primary care costs have been limited by generic designs that only result 30% in primary care result. The low priority placed on primary care is what sends twice as many to non-primary care as compared to primary care delivery. This is not necessarily about salary or benefits. Primary care is frustrating with the least experienced personnel (by insufficient funding and getting less) and with the least support and with by far the least understanding. Training is also not specific to primary care for RN, MD, DO, NP, or PA.

Primary Care Remains Limited and Non-Primary Care Remains Limitless

Primary care costs remain low due to too little workforce. Primary care also has effective cuts for two reasons - the first is annual double digit increases in the cost of delivering primary care (without any increase in reimbursement and with new types of costs) and the second is across the board cuts that are forced upon primary care due to non-primary care excesses.

Unlike primary care with numerous inherent cost limitations, non-primary care is almost limitless by design. Non-primary care has demonstrated an amazing utility to escape any and all cost cutting measures. Those promoting disease focus have multiplied in recent years making it even more difficult to reign in costs. Proponents can trot out death squads, can fund patient advocacy groups, can set up various cancer or specific disease poster children, or target legislators who have had family impacted by specific diseases.

Non-primary care is allied with corporate, academic, institution, and health professional association interests - those who control the designs for spending and for workforce. Academic institutions once shunned patent seeking faculty and now embrace them, promote them, and develop private corporations to profit by them.

Perhaps understanding the development of this mess over the past 100 years may help those who have earlier versions in place that may be more subtle. Of course United States student populations fail most in history and those not understanding history are indeed doomed to repeat it - by design.

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

What Is Killing US Is Not Four Deadly Diseases

This Will Be Brief As Will Primary Care

Lets Take a Stand for Most Americans Instead of Against

Myth for the Cure: Essential for Disease Focus

Critique of Commonwealth Fund Report on Ensuring Equity

Failing Primary Care Explained By Policy Failure

What Is Killing US Is Not Four Deadly Diseases

The Myth for the Cure and others in the Disease Focused Crowd Are Now Selling Four Diseases to the United States and to the World Health Organization.

What is killing the United States is not hundreds of heart diseases or thousands of cancers or lung diseases all lumped together. These are great strategies to market well or to fund raise more efficiently or to siphon off ever more health spending as as simplistic 4 diseases. This also makes it seem that we only have 4 disease to cure. We have made slow progress on a few diseases - period. Our major advances have been in clean water and food and immunizations and basic health habits - areas that we have been forgetting as primary in importance. Microbes still teach us these areas and the futility of technology, but we fail to listen.

Disease is just the end stage. We all will die. We can choose how we die. More importantly, if we allow our designs for health and health care to be controlled by those focused on disease and delaying death, we will actually impair the lives of more and more people and those youngest.

After 100 years of marketing disease, we are beginning to understand that disease focus can actually kill more people. We have known for decades what really kills the United States in economy, people, income, jobs, and productivity.

Greed

No explanation is needed here, we know it, we tolerate it, and it kills us as a people and a nation. We fail particularly when Greed wins over Need.

Too Much Stress

When stressed too much we eat too much, smoke too much, drink too much, and do all the behaviors that cost our nation year after year and generation to generation – and our design insures more left behind and fewer at the top. We also pack people into the unhealthiest places that divide most into rich and poor in income as well as in health. We design this and greed exploits this. Divided states and populations have the most costly and worst health outcomes – enough said.

Ignoring the Needs of Children

This is my number one disease choice. As a nation we spend far too little time and effort and resources on the first months and years of life. This results in children who are defeated in education, jobs, health decisions, and citizenship from the start. Spending upon disease in the last months and years of life can be seen as compromising the youngest from their start. Votes by Congress such as Part D Medicare clearly will take trillions out of current and future budgets to care for those oldest who can contribute least to the future of our nation. This was voted to Medicare recipients that already had health care coverage and already had coverage for drugs. It was a specific package to get votes from the elderly and an affront to the next three generations to come that cannot vote yet and will be ever less able to meet the needs of the nation. Other state and federal and insurance designs also steal the future from our children.

Failing to Support our Human Infrastructure

Those on the front lines are our Human Infrastructure – teachers, nurses, police and other public servants, primary care, public health, military, and more. They are far more likely to arise from the 65% left behind. They also represent America to our children by their jobs and their interactions.

Disease focus is set to move US past 20% of the annual Gross Domestic Product, but this is apparently not enough. Our health professionals are selected and trained and paid specifically to address disease with their teaching, research, and work effort. Not surprisingly Greed, Stress, child failures, and lack of human infrastructure support facilitate disease focus and disease spending to ever greater heights.

So next time that you hear about Four Diseases, recognize the marketing of disease and the compromise of health. When you hear Race for the Cure, remember Myth for the Cure and $400,000 or greater salaries for those leading the charge. When you see salaries of $400,000 and up for subspecialty physicians or 20% of the top 1% as physicians, you will understand the focus on disease rather than health. When you understand primary care penalized and non-primary care rewarded you will understand why only 25% of nurse practitioner graduates and 25% of physician assistants and 25% of medical school graduates remain in primary care for careers and decades of shortages of primary care for over half of US.

What are the antidotes to Greed, Stress, Arrogance, and Ignorance?  Sacrifice, Service, Togetherness, and Belonging

All are about Connectedness.

Myth for the Cure

Social Conditions as a Cause of Disease

One Million Hearts or 160 Million People

Failure of Disease Management to Save - a caution for PCMH as well

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

Hard to keep up with the disease focused coming from so many directions in so many diseases.

Thought I was updated, but one more about billions that will be wasted on Lung Cancer Screening not to mention the harm done directly and indirectly with more disease creation.http://www.medscape.com/viewarticle/752955  if you have Medscape or immediate promotion by http://www.news-medical.net/news/20111029/LCA-hails-NCCN-for-lung-cancer-screening-guidelines.aspx   Watch how rapidly this is spread.

Worth reflection for this day and time in history:

Commonwealth Wants SGR Repeal, RCB wants health leaders to discover that health focus is not about disease and designs for health care should not have disease focus.

The Daily Yonder shared my concerns today regarding 11/2/11 as worst day for primary care in the past 4000 days. Like Soylent Green, Primary Care is People – People delivering the care to people – when the design supports people to deliver the care that they need when they need it and where they need it.

After 100 years of disease focus, the nation is finally becoming aware of the consequences of disease focus - failed health designs. These designs result in ever more spent for ever fewer people for even fewer years of their lives with care delivered in ever fewer locations. This is also ever more health spending for fewer locations.

The excesses have resulted in steady compromises of basic health services for nearly all Americans needed nearly all of the years of their lives in nearly all locations.

Primary care was supposed to be the centerpiece of President Obama's health care reform bill — the way the country was to reduce the amount it spends on medicine. So why is his administration allowing cuts of primary care that will kill off more primary care?

This Will Be Brief As Will Primary Care Blog just previous

Or past blogs months ago warning about the changes to come

It is my hope that Commonwealth, Major Journals, government leaders, and other health care leaders begin to understand that innovation and reorganization is exactly the wrong approach at the current time. Research is also not needed. What is needed is people that commit to delivering primary care for entire careers with the nation committed to supporting them. By the way this is what nurses, teachers, soldiers, and public servants need and we have made progress only in much better support of our soldiers (compared to recent decades)

The United States cannot recover primary care by technology, innovation, or reorganization. The best it can do for innovation is what it has ignored for 40 years - put tens of thousands of RN, MD, DO, NP, and PA out in the health access field year after year – before training, during training, and after training, and for entire careers.  

RPAP Is SMART and Has Been for Forty Years

With regard to the current flash in the pan popularity of many folks running for positions or power or leadership - As noted in the American President, Michael J. Fox's character noted

“People want leadership, Mr. President, and in the absence of genuine leadership, they'll listen to anyone who steps up to the microphone. They want leadership. They're so thirsty for it they'll crawl through the desert toward a mirage, and when they discover there's no water, they'll drink the sand.”

Do not drink the sand. Practice thoughtful reflection and avoid the mirage. Desperation never works well for democracy and also manages to defeat capitalism by allowing greed to reign over long term investments that are better for the nation and the companies. Desperation works well for those that sit in wait of desperate opportunities and are first in line although last in need.

We are all as grains of sand in the grant scheme of things, but connected together we can be more.

This Will Be Brief As Will Primary Care

THE TOTAL DISREGARD OF BASIC HEALTH ACCESS AND THE CRITICAL IMPORTANCE OF PEOPLE SERVING PEOPLE

Anyone with any understanding at all regarding primary care understands that primary care is about people. Primary care is people delivering primary care services to people. Primary care involves the most basic health services, those needed by nearly all Americans nearly all the years of their lives in nearly all locations.

Primary care fees go 50 - 60% to support the services of primary care personnel attempting to deliver more primary care with less money and support. When you cut primary care, you kill off primary care personnel, primary care services, primary care delivery capacity, and one of the few remaining sources of economic impact from health care for 30,000 zip codes with 65% of the population.

New Blog Posting at

Pounding Poverty Providers with Pay for Performance

December 21, 2011 - Also after 4 months, Congress has failed to act on basic funding for Medicare fees, tax reforms, and the basic needs of 3 million unemployed Americans.

HARD TO DO MORE DAMAGE TO AMERICANS IN NEED OF HEALTH CARE

Why would any general take out the front line soldiers? Without a front line, the rest would soon be overwhelmed and overrun. This is already the case, and a major reason why health care is already too expensive, inefficient, and ineffective.

If you tried to impair health or health care for most Americans or if you tried to eliminate health care spending as a vehicle for economic recovery for most Americans, it would be hard to think of a way to do more damage. Primary care is 40 - 100% of the workforce in 30,000 zip codes with 65% of the population. Kill off primary care and you kill off jobs, services, and economic impact - and especially where most needed. As far as Medicare goes, those over 65 consume 2 to 3 times more primary care. Primary care demand increases the most as Americans age. Why would anyone who understood primary care or the needs of age 65 and up allow primary care to be chopped in pieces. Areas already shortest in primary care are most dependent on primary care and are also most dependent upon Medicare and Medicaid - and both are failing to support primary care.

THERE IS NO PROFIT IN PRIMARY CARE ONLY PEOPLE AND SERVICES

Primary care fees do not go to the pocketbooks of primary care physicians. Primary care fees do not go to stockholders or investors. Frankly there are no profits or to attract investors. Academic centers that did invest in primary care in the 1990s lost small fortunes even when primary care costs were much lower. Large systems and academic centers long ago decided to stop propping up failing primary care years ago. Primary care doing well had to concentrate on the wealthy or find another reimbursement design that actually keeps up with the increasing cost of delivering primary care (capitated).

UNHEALTHY AND INHUMANE DEFICITS OF SERVICES - UIDS - FORMERLY HHS

Health and Human Services today announced plans for a 27% cut in people to deliver primary care. This translates to a 40% cut - 27% starting Jan 1 2012 plus the usual 13% increase required to continue to deliver primary care in 2012 as compared to 2011. Somehow HHS thinks that primary care is profitable that it can take 40% less and do just as well. This is of course unfathomable. Health and Human Services or HHS needs to become UIDS - Unhealthy and Inhumane Deficits of Services.

After pointing out government reports with gross exagerrations of primary care numbers, after pointing out declining primary care despite a doubling of primary care graduates, after pointing out false claims of production of primary care that is 70% not primary care, after pointing out RPAP and other training solutions that work not only for training but for delivering more primary care where needed, after pointing out abuses of grant designs, after pointing out To Follow the Money Follow the Workforce,

a minimum requirement for some hope is a clean sweep of the health leaders of this administration.

TOTAL LACK OF AWARENESS OF PRIMARY CARE

From the start, the Obama Admininstration has claimed the benefits of primary care. These are now seen as empty arguments. To claim the benefits of primary care such as savings of other health care costs, you actually have to understand primary care. Primary to understanding primary care is to understand failure of primary care as failure due to too little support. Lesser support should be understood as destroying primary care and the ability of primary care to save health care costs. It is also failure to address the frustrations of more and more Americans losing basic services in a wide variety of areas.

Primary care was to be a cornerstone of Obamacare just as in RomneyCare or Managed Care. Cracks in the Obama argument appeared with failures in Romneycare as there was simply insufficient primary care resulting in far more costs than planned. Now the Obama Administration is acting in ways that will insure even less primary care.

In a short time Obama will have only a few choices

• admit another major error and terminate his health advisors and change primary care to a 10% minimum increase in reimbursement, or
• keep the current plans and give the election to anyone else, or
• allow another Democrat to run for president  - one not connected with current health care plans or health care leaders

This failure in primary care, regardless of what finally happens on Jan 1 2012, represents a betrayal of 240,000 primary care physicians, 50,000 primary care nurse practitioners, 270,000 primary care nurses, 30,000 primary care physician assistants, and about 1 million other dedicated primary care personnel. It is a betrayal of those who have hung on to deliver primary care despite year after year of steady design failure. It is a betrayal of those who helped design Obamacare. It is a failure of those who worked to support Obama.

Already it is too late to do much to prepare for this disaster, one that could be substantially worse with anything less than the best possible influenza year in recent history. It is too late for responsible health care providers and systems to notify their patients or their employees. It is too late to anticipate the major changes to attempt to adjust care needs due to primary care losses.

Most of all it represents a total failure to understand the basic health needs of the American people.

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

Historical Perspective

From 1965 to 1980 the initial Medicare and Medicaid designs invested heavily in restoring health care infrastructure. After decades of caring only for people that can pay the most, health care was in ruins for most Americans. Primary care was disappearing in the 1950s and 1960s.

The Medicare and Medicaid initial design doubled primary care and also doubled non-primary care numbers of MD, DO, NP, and PA. This was the first and only doubling of primary care.

Primary care numbers arising from the design have remained the same without change each 15 year period since 1980 and already confirmed for 2025. This will mean essentially 50 years without a change in primary care while non-primary care doubles in MD, DO, NP, and PA numbers each 15 years. Family medicine is still at 3000 annual graduates just as in 30 years ago. PD is stagnant and has been for 15 years. Internal medicine has been decreasing by 2000 - 2500 per year due to only is 1400 entering. Internal medicine should decline much faster, by 3000 to 3500 each year. It will reach the 40,000 level much sooner than 2030 with this change and with far better options other than primary care.

It took 15 years for the designers to redesign Medicare and Medicare their way. With this redesign, government was forced into cost cutting. For the past 30 years, Medicare and Medicaid have not been designs for health or health care. For 30 years they can best be described as designs for the support of those focused on disease and delaying death a few years or months.

It took only 5 years for the designers to blow away the managed care design. It took only months to subvert the 2010s reforms that really never were. Without primary care workforce, no design works. With even more insufficient primary care reimbursement, there are even greater primary care deficits to come.

Primary care has been failing for one simple reason. The annual costs for delivering primary care have exceeded the funds required to deliver primary care. The cost increases are double digit like all other health care. Unlike other health care, primary care has not been able to create new services, corner specific health markets, drive off competitors, or address even basic financial needs.