Critique of Commonwealth Fund Report on Ensuring Equity

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

The COMMONWEALTH COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM    October 2011

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

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

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

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

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

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

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

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

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

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

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

Generic Fails for Health Equity, Specific Is Required

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

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

It is not enough to think good thoughts.

Actions are required that bring thoughts into reality.

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

SMART Basic Health Access

Ensuring Equity

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

Overview

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

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

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

SMART Basic Health Access     World of Rural Medical Education

Basic Health Access Blogspot 2011 - Summaries and Links for 2011

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

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

Clinician Specific Medical Education

SMART – Specific, Measurable, Achievable, Realistic, Timely

Failing Primary Care Explained By Policy Failure

Graphics illustrate the changes across all types of primary care with permanent primary care career choices prevented by policy and flexible primary care sources driven away from primary care by choices of those not intending primary care, by situations during training, at graduation with poor entry to primary care, and each year after graduation as US policy shapes workforce steadily toward non-primary care and practices with top concentrations of existing workforce.

AMA and Masterfile data except as noted.

Each primary care source has declined in primary care entry and primary care retention except for the very limited policy periods when some improvements in primary care spending were noted.

The United States has increasingly favored the academic, subspecialty interests that are most likely to be found in top concentrations of existing workforce. This leaves behind primary care and populations most dependent upon primary care for their local health care, economics, jobs, and leadership - across 30,000 zip codes with 65% of the population, far more than just the designated underserved populations, and more than 65% of poor, near poor, rural, Community Health Center, elderly, and disadvantaged populations.

These are all populations more likely to be served by family pratice MD, DO, NP, and PA - but only when retained in family practice - something that current policy fails to do for NP and PA graduates with so many new and rewarding options outside of health access - by design.

Over and over United States leaders in health and policy have been reminded of failing primary care and the reasons involving policy failure, training failure, and workforce failure. The failure of primary care is a consequence of a few people and a few associations and a few in government that have managed to set up designs that favor themselves rather than most in America. It has become easy for those with vast quantities of health spending by design, to resist any changes in the design. Witness 15 years to subvert the initial Medicare and Medicaid design and only 5 years to marginalize managed care changes and only a matter of months to defeat real health reforms 2010 to present that mattered for most Americans. 

The United States does not have a design that addresses health care for a majority of the American people. Despite various promises at the federal level, the local and state levels are likely to negate any gains. The reason is quite simple.

The US health care design works best for a few people
for a few years (or months) in their life
with care delivered in a few locations at high cost

 and with limited outcome compared to the cost. 

Primary care is one of the best examples of health design failures. Government regulations impair primary care as shaped by panels dominated by academic, subspecialty, and association interests. Insurance company policies magnify the problems and both require increasing personnel and costs in primary care offices to address regulations. These additional costs and personnel are not associated with actual delivery of primary care services. Primary care failure is a failure for all Americans. Few understand that

Primary care is care needed by nearly all people nearly all years of their lives in nearly all locations delivered by those with the least support and the most complex tasks.

Substitutes for primary care deficits are costly and have consequences in areas such as morbidity and mortality - when too much or too little is done too late. Specialists Putting Mark On Strained Primary Care   With fewer PCPs, patients seek services from anyone, and that could raise utilization and costs   By Frank Diamond

The American College of Physicians has tracked the primary care demise noting that  "The United States has yet to implement comprehensive strategies to recognize, support, and enhance primary care to the degree necessary to reverse a worsening primary care shortage."  in HOW IS A SHORTAGE OF PRIMARY CARE PHYSICIANS AFFECTING THE QUALITY AND COST OF MEDICAL CARE?

The World Health Organization "gets it" so why does the United States not "get it."

Primary care costs are limited by lack of MD, DO, NP, PA, and RN workforce -limitations that will persist for at least the next 20 years - limitations that keep primary care workforce too small and less efficient and less effective. Primary care costs kept low are not a good idea. Contrast this with non-primary care costs that have consistently escaped any regulation, primarily because those doing well under US designs have fought any and all attempts to rein in costs. They have been successful non-primary care workforce has doubled each 15 years and now has Three Dimensions of Expansion that will continue to increase non-primary care. To Follow the Money, Follow the Workforce is a good way to understand the impacts of US policy preferences and consequences. 

As primary care counts down to January 1, 2012 across the board cuts in Medicare fees including primary care, there is little understanding of the priority of primary care, what is actually primary care support, and who delivers primary care in the United States. Various advocacy groups advocating for their piece of primary care, claimed or actual, have managed to impair a consistent focus on the needs of most Americans.

Major journals, government reports, and associations contribute to the confusion by indicating primary care solutions that are not solutions, by indicating primary care numbers that are numbers of graduates and not numbers actually delivering primary care, and by indicating workforce solutions such as flexible primary care sources that are least likely to enter and remain in primary care. Permanent primary care solutions such as physician family practice have existed before, during, and after various reform attempts, but have actually been avoided as choices. When comparing sources of family practice, retention in family practice is what matters for career long health access contributions. Family medicine stays in family practice and US policy drives flexible NP and PA sources away from family practice and away from solutions for primary care and rural and underserved workforces.

Government that decides not to function is not helping to address basic health access. Goverment reduced to "no decision" will result in across the board cuts in Medicare and Medicaid at federal and state levels. No decision as the result of no undersanding will contribute even more to primary care failure.

Only two times in the last 50 years has the United States made policy changes that resulted in increases in decisions for primary care - both entry and retention. Only from 1965 - 1980 and during the 1990s has primary care workforce gained a boost. During 1965 - 1980 massive injections of cash basically doubled all workforce, including primary care. Five years after Five Periods of Health Policy and Physician Career Choice, this work is even more relevant today.

In the final analysis the 1965 - 1980 primary care workforce growth, basically the only significant growth in primary care workforce in a century, was predominantly about the first and only expansion of family medicine - moving from few hundred to 3000 annual graduates. The lack of improvement is also about policy designs that fail to favor health access, most Americans, and the family physicians most closely associated with both. Resistance is futile as flexible sources cannot resist US policy that drives them away.

Family physicians stay in family practice and in primary care because of the family medicine design that makes departure from family practice difficult (few options). But policy and training designs make it difficult to choose the permanent primary care source of family medicine - a career choices prevented, as is care for most Americans.  

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

Standard Primary Care Year Estimates 2012 Class Year

The Standard Primary Care Year is a common sense measuring tool. Graduates must meet all of 4 criteria to deliver primary care - train in primary care, remain in primary care, serve long careers, and deliver signficant volume.

It is not enough just to graduate primary care - especially with US policies that drive primary care graduates away from primary care before training, during training, and each year after graduation.

The Standard Primary Care Year estimate = Average Career Years X % remaining in PC for a career X % active for a career X % volume.

Rural primary care is estimated by the rural percentage times the SPCYr. Top primary care delivery goes to those with the longest careers, most primary care retention, most activity, and most volume. Family medicine with only 10% of annual primary care graduates will contribute 36% of the primary care delivery result for 2012 and higher proportions of rural or underserved result for the nation.

 

2012 Class Year Estimates for Primary Care Delivery Using the Standard Primary Care Year

	NP not FNP	FNP Trained	PA not FP Start	PA with FP Start	FM Trained	IM Trained	PD Trained	MPD Trained
% Primary Care	15%	54%	10%	50%	91%	15%	39%	43%
Years in Career	24	24	33	33	33	32	33	32
% Remaining Active	70%	70%	75%	75%	84%	82%	82%	82%
Volume Relative to FM	70%	75%	75%	80%	100%	86%	95%	95%
SPC Years Per Graduate	1.76	6.30	1.86	9.90	25.23	3.38	10.03	10.72
Rural SPC Years/Grad	0.176	1.764	0.186	2.970	5.550	0.338	0.802	1.715
Underserved SPCYrs/Grad	0.212	0.945	0.223	1.782	3.784	0.305	0.902	1.286
Outside SPCYrs/Grad	0.670	3.465	0.613	5.445	13.369	0.948	2.807	4.288
Proportions of Primary Care
Rural % for Career	10%	28%	10%	30%	22%	10%	8%	16%
Underserved % for a Career	12%	15%	12%	18%	15%	9%	9%	12%
Outside of Concentrations %	38%	55%	33%	55%	53%	28%	28%	40%
Primary Care Grads at 28,340	4,000	4,000	5,500	1,300	2,800	7,300	3,000	440
Proportion of Grads	14.1%	14.1%	19.4%	4.6%	9.9%	25.8%	10.6%	1.6%
Total SPCYrs for 2012 at 185,470	7,056	25,200	10,209	12,870	70,631	24,710	30,077	4,716
Proportion of SPCYrs (Class Yr)	3.8%	13.59%	5.5%	6.94%	38.08%	13.32%	16.22%	2.54%
		All NP		All PA	All FM	All IM	All PD	All MPD
2012 Average of 6.89 SPCYrs per Grad		4.03		3.39	25.23	3.38	10.03	10.72

Lowest primary care delivery goes to those with the shortest careers, lowest primary care retention, lowest activity, and lowest volume. United States primary care delivery has decreased from 18.6 SPCYrs per graduate in 1980 to less than 7. Annual primary care graduates have increased from 14,000 to 28,000 since 1980. Decreases from 260,000 to 195,000 indicate a 25% decline in primary care delivery capacity for the class of 2012 compared to the class of 1980.

Steady declines in primary care retention for NP, PA, IM, PD, and MPD have resulted in less primary care delivery per graduate. The doubling of NP and PA annual graduates each 6 to 12 years since 1980 has made this less apparent. SMART analysis specific to primary care delivery is required to understand career contributions - not training type or the first years in a career.

Basic health access workforce calculations are not complex to understand. A nation that desires primary care workforce, rural workforce, workforce for underserved areas, and workforce for 65% of the population (outside of current concentrations) places a priority upon permanent broad generalists in designs for training and designs for practice support. As graduates depart primary care and family practice, they depart most needed careers and locations. 

With zero growth in annual graduates for family medicine over the past 30 years, the nation has avoided the choice of the most specific solution. Similarly steady departures from family practice for NP and PA across the class years and across the years after graduation have limited the health access result.

The dedicated family practice component is critically important and yet remains virtually unrecognized for this stellar health access contribution.

Perhaps the upcoming Primary Care Week will decide to recognize this retention where most needed, the only positive area in a dismal year for primary care with more dismal times to come as revenue declines and costs of delivering primary care mount.

Departures from primary care have negated primary care delivery result for 5 out of 6 primary care sources. The US designs have shaped annual graduate expansions emphasizing those most generic and least specific to family practice and primary care. The result has been minimal primary care, rural, and underserved result - least health access by design.

The result of the US primary care design

has been maximal result for non-primary care

and for zip codes that already have top concentrations of workforce.

Basic Health Access Contributions in Primary Care for the Class of 2012

Rural (RUCA) Location	NP not FNP	FNP Trained	PA not FP Start	PA with FP Start	FM Trained	IM Trained	PD Trained	MPD Trained
Rural SPC Years/Grad	0.176	1.905	0.278	3.564	5.550	0.338	0.802	1.715
Location % for Career	10%	28%	10%	30%	22%	10%	8%	16%
35,661	706	7620	1531	4633	15539	2471	2406	755
Proportion By Source	2.0%	21.4%	4.3%	13.0%	43.6%	6.9%	6.7%	2.1%
Underserved (Shortage High Poverty Zip Code)
Underserved SPCYrs/Grad	0.212	1.021	0.334	2.138	3.784	0.305	0.902	1.286
Location % for Career	12%	15%	12%	18%	15%	9%	9%	12%
25,638	847	4082	1838	2780	10595	2224	2707	566
Proportion By Source	3.3%	15.9%	7.2%	10.8%	41.3%	8.7%	10.6%	2.2%
Outside of Concentrations (30,000 Zip Codes, 65% of the US Pop, 200 million)
Outside SPCYrs/Grad	0.617	3.742	0.975	6.534	13.369	0.948	2.807	4.288
Location % for Career	35%	55%	35%	55%	53%	28%	28%	40%
85,954	2470	14969	5360	8494	37434	6919	8422	1887
Outside PC Proportion	2.9%	17.4%	6.2%	9.9%	43.6%	8.0%	9.8%	2.2%

SMART focus upon primary care results in improved basic health access result. When small proportions of the annual graduates deliver multiple times the needed health access result, designs should favor what works best rather than what ends up as non-primary care or in top concentrations of existing workforce. Designs that fail for basic health access fail most Americans.

The United States needs more primary care, rural primary care, underserved primary care, and primary care outside of existing workforce concentrations. SMART requires a focus upon what works - not generic expansions or technology or innovation - but people to deliver primary care where needed.

More details on The Standard Primary Care Year for 2012 including comparative results for types of medical schools and programs

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