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.

What Do Medical Home Studies Indicate?

• Associations and researchers are willing to use data sources that are not from “official medical homes” to indicate medical home value.
• Concepts are considered more important than the primary care people who deliver the care. Of course those who cut primary care funding fail to understand they are cutting the experienced people needed to deliver primary care. Primary care is about people – repeat often, especially when examining studies about primary care. 
• Methods that select patients with better social determinants will have better outcomes. Methods tha select patients with higher levels of continuity will have better social determinants and better outcomes as well as better access to care. Substantially more is also invested in health care for those who have greater access and higher social determinant levels. One would also have to ask how many criteria were needed by researchers to demonstrate a difference. 
• In the study, those of advantage were more likely to have continuity home experiences. In almost every instance of lower probability of preventive visits (age less than 1, single mom, lower income, lack of health insurance, less educated parents), those that preserved continuity had greater proportional improvement (close to 2 to 1). In other words those that somehow bucked social determinants had better care. The continuity home definition did little for those with social determinant advantages and did the most for those that managed to have a continuity home despite odds against. 
• In the study the differences are significant, but the differences are so small as not to be relevant.
• Children with a medical home were more likely to receive higher health ratings (excellent or very good) as compared to those without that were lower rated (good, fair or poor). Many would consider the noted outcomes as a matter of differences in health status.
• As with other pediatric studies, the experts consider near universal access to pediatric care. They have of course overlooked the problem of maldistribution and limited access for over half of children due to workforce limitations in 30,000 zip codes with low or lower health workforce concentrations.
• Then the study considers a 30% decreased ER utilization discussed in association with a continuity home.

At this point I just have to stop looking. This is a poor study by any number of measures. These are good people that are well intentioned. Some if not most have delivered care where needed. Sadly there is a loss of perspective.

There are significant investments of time and effort by associations and this is a likely reason why such studies are published. What is obvious from this and other studies is that changes in social determinants are required as a top priority with reorganizations of care way down the list.

The current pediatric study does not prove the value of the Medical Home as headlines indicate in Medscape – proof is almost impossible to prove in medical studies. What the Medscape headlines do indicate is poor understanding of medical studies by the medical media (or at least dramatization that is deceptive).

The investment in medical home terminology is so high that family medicine leaders have protested when studies fail to show the expected benefit. After devoting substantial funding to this area, perhaps objectivity is lost. Does Family Medicine Need New Leaders?

I am certainly for the concepts of team care, continuity of care, integration of information, and other aspects that are considered medical home concepts. These are obvious to those who have experienced the great pleasure of delivering challenging care with a supportive team. Who would be against such a design?

The problem remains that continuity home interventions are not going to solve primary care woes or the associated social determinant maldistributions.

Diverting a Nation from Real Solutions

The continuity home has been touted as a solution for the primary care woes of the nation. In fact, the Continuity Home will not improve the major health access problems of the nation. When providers present “cures” that do not work and distract patients from treatments that do work, this is considered a serious offense.

Offensive Literature and Offensive to Dedicated Primary Care Practices

It is hard not to find much of the literature developing around the medical home concept to be “offensive.”

I will continue to assert first that social determinants are far more important and that any primary care practice that has dedicated health professionals that function together as a team to provide health care, that stay together as a team, that keep the same patients, that keep the same location for care, and that have sufficient funding to accomplish the above – will have the optimal care with or without medical home designation.

If the cost of a medical home designation impedes care, medical home designation will not improve the care and may damage care.

If the medical home designation comes with more funding, the care may improve but this is likely the result of the additional funding rather than a medical home focus (beware government promises of more funding as this may not materialize).

If sites receive continuity home grants, then they will have better care because the additional funding is likely to give them an advantage in recruiting and retaining the best primary care personnel. Continuity care is clearly more likely with those that are easiest to care for, as demonstrated in the study.

Of course a real design for the care of all Americans provides sufficient primary care spending across the nation, not just for those who have grants or cost-based reimbursement.

Quality Arises from People and Relationships from the Ground Up, Not from Concepts Thrust on People from Above

Quality is the result of reflective process by dedicated team members with objective consideration of all relevant aspects of care – especially very basic awarenesses and understandings of the patients served. This process does not require certain terms such as continuity home, stroke center, chest pain centers, etc. Continuity home focus can improve care and can raise awareness of methods that can improve care, but a continuity home itself will not be the reason for change.

But if you desire a nice name or certification there are numerous places to contact, meetings to attend, and others willing to take money away from delivery of primary care. Your choice of the following or dozens of others.

On-Site Certification. The Mark of Quality that Sets Your Medical Home Above the Rest. The Joint Commission: Primary Care Medical Home 2011 StandardsAccess and Continuity in the Medical Home SettingBlueprints for Building a Medical Home

The Problem Facing Primary Care

The problem facing primary care remains the same. The problem is that revenue derived from primary care services is insufficient to keep up with rapidly rising costs. When the cost of delivering care is insufficient, the result is cuts in personnel, less experienced personnel, fewer personnel, and decrease in the ability to deliver more care and better care.

When the costs of delivering care are increased due to various innovations and reorganizations without increasing the revenue, it is possible to also result in less primary care delivery.

If a national focus on higher quality (by less volume, more costly technology, fewer personnel) results in less primary care delivered per primary care provider, the nation will have much greater problems with cost, quality, and access because the missing link is primary care personnel of all types.

The Problem of Social Determinants Ignored

If primary care experts ignore social determinants, then they do not understand the most important variables regarding cost, quality, and access. If Pay for Performance pays more for “quality,” relatively less will be paid to practices that have lower and middle income patients. This is because practices that are more likely to care for those in need of care will have lower quality ratings because of the patients that they care for. Higher quality ratings and greater pay will go to those who have better quality because of who they are.

The authors of this Pediatrics article have built another very good case for social determinants yet they have claimed that the reason is the continuity home. This is a quite serious problem for Pediatrics, for primary care, and for most Americans in need of real solutions for health access.

Better Ratings with Better Pay, or Care Delivered Where Needed?

To get lower quality ratings and less pay, continue to care for underserved, poor, near poor, rural, disadvantaged, and lower income patients.

To get better quality ratings and better pay, be sure you care for less complex people. The nation will overall have lower health care quality, higher costs, and declining access to care – but you and your practice will do better.

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

Basic Health Access Blogspot 2011

My desire for you for 2012 is for you to progress toward becoming a true leader, for you to benefit from the leadership of a true leader, and for you to select true leaders to lead our nation.  

A leader will find it difficult to articulate a coherent vision unless it expresses his core values, his basic identity…. one must first embark on the formidable journey of self-discovery in order to create a vision with authentic soul.

Mihaly Csikszentmihalyi

May the new year of 2012 be a continued journey of self-discovery for you and for our nation. I have been blessed with opportunities at East Tennessee, Nebraska, and A T Still to continue the self-discovery begun in rural family practice in Nowata OK.

Fifty Blogs in Order of Viewing Popularity

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

The Clinician Specific Medical Education Blog was also begun as a complement to SMART Basic Health Access with the most recent posting Longitudinal Clinical Experience Rating Scale and others such as Are We Short Changing Those Who Desire to Become Clinicians? , What They Don't Teach Medical Students: Doctoring , and Real Excellence in Medical Education

These join http://www.basichealthaccess.org/ and http://www.ruralmedicaleducation.org/ and http://www.physicianworkforcestudies.org/

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  - "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.

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 1980 - 2010 – Too much is the rule for US health care costs with three dimensions of rapid growth of non-primary care – the care that cannot be regulated except through limitations of workforce.

Meeting Primary Care Needs in the Last Half of the 21st Century - Really! – A SMART plan actually indicates how the US can meet primary care needs. All that is required is a focus upon specific primary care result rather than primary care that is 70% not primary care in result.

One Million Hearts Saved or 160 Million Lives Improved - 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.

To Follow the Money, Follow the Workforce – With half of workforce guided to 1% of the land area by over half of annual health spending and with substantial funding expended by 1% of the land area to get ever more dollars from any number of treasuries, there will be no interruption of every more expended for fewer Americans in fewer locations with less overall result.

Why Do Primary Care Myths and Misinformations Persist? – The evidence indicates ever less primary care from primary care trained graduates. Why are these poor sources getting worse promoted as solutions?

RPAP Is SMART and Has Been for Forty Years – The longest running rural, primary care, and health access intervention remains the best for any number of areas – especially communities in need of health access.

Countdown to the 2012 Primary Care Armageddon - There are about 132  112   99  62  18    7 days until January 1, 2012 when Medicare will be forced to cut fees to physicians by nearly 30%. These cuts have already been enacted by Congress. To prevent this action, the current Congress would need to take action – a major problem with this Congress. Over 114 days have been wasted and Congress is nearing recess.

What is Killing US is Not Four Diseases Focus - 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 US is greed, stress, ignoring the needs of children, and ignoring the development of human infrastructure. 

Pounding Poverty Providers with Pay for Performance United States designs for health spending consistently result in less for those who already have the lowest health spending. This is accomplished by designs that send less to those that attempt the responsibility of their care. Design changes and even reforms that are supposed to send more spending to those who care for most Americans left behind can also fail.

Accelerating Cycles of Primary Care Decline – When factors intersect progressively, the primary care result is much greater decline. With less revenue on the way and more distortions of primary care trained graduates away from primary care, more cycles of decline are coming.

Disease Focused Disorder Mentality or Sentimentality – After 100 years of socialization of health care leaders regarding disease focus, will we understand the consequences of too much focus on disease and ever less understanding of people and the context of care?

Why are 2008 Government Projections of Primary Care Workforce in Error? Four years later and after ignoring 10 years of evidence, this HRSA site continues to deceive. Internal medicine is heading to 40,000 by 2030, not 155,000 in primary care by 2020. Family medicine is fixed in place by 3000 annual graduates for over 30 years and cannot increase - by design. Projecting more with steadily less is a serious distortion by those supposed to leader health access for our nation. 

What Do Medical Home Studies Indicate? Those positive about the medical home are promotions that indicate the value of the continuity medical home when the real determinants of better health care are social determinants. The fact is that health care access, cost, and quality are fixed in place by designs. To understand what works, it is important to understand the designs and the designers.

The Black Hole of US Subspecialization spells Workforce Concentration, continued higher costs for health care, and Lack of Access for Most Americans

Fifty Years of Failed Primary Care Workforce Innovation – Innovation lunacy has taken on new heights, even in areas with fifty years of failed primary care workforce innovation.  

Finance-me-cratic Constants in the Bureaucratic Universe - America has come to a standstill in many important areas - health, education, leadership, and more. Recessions have always found ways to blame any number of individuals or types of people. In fact, recessions have a common cause involving the relationship between finance-me-crats, aristocrats, and bureaucrats.

What can a zip code 10032 study indicate about nurse practitioner versus physicians with data a dozen years old, providers that predominantly did not understand the language and culture of the patients, a location representative of very few zip codes in America, and the lowest aim of indicating no difference. As we understand more and more about social determinants, it should be surprising that any differences will be found in populations with the most social determinant limitations, such as those in this study.

This Will Be Brief As Will Primary Care - 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. The year 2012 is likely to be most challenging. There appears to be little hope for addressing the most important problem – insufficient revenue to keep up with double digit increases in the cost of delivering primary care.

Comparing Family Practice Sources - The nation’s MD, DO, NP, and PA graduates that remain in family practice are by far the most important solution for health access. Only family practice can be demonstrated to distribute according to the population and not according to concentrations of workforce or health spending. It is also important to understand that not all sources remain in family practice in the years after graduation. NP and PA sources continue 40 years of steady movement away from family practice - the result of flexible design.

Rural Rearrangements of the Deck Chairs - Merry Christmas December 24, 2011 Comprehensive Rural Programs Are Not Enough to Overcome US Maldistribution By Design There is no evidence that Rural Programs in Medical Schools actually increase rural workforce when considering the outcomes of the parent schools. Even with expansions of annual graduates in the parent schools, there has been no improvement. There is nothing wrong with rural programming. It is possible that health access outcomes could decline without rural programming or it might be possible to demonstrate problems resulting from inadequate preparation for the demands of rural practice. The fact is that rural programming has not been able to overcome overall changes in the US health design.

Failing Primary Care Explained By Policy Failure – Koch’s postulates are satisfied – US Health Policy can rebuild or destroy primary care as illustrated a number of policy periods across 1960 – 2010.

Generic Expansions Are Not SMART – Generic expansions of annual graduates absolutely fail for the purpose of health access. Too few enter and too few remain, even when the training program is a primary care program.

Rural Primary Care: Stark Realities – With the exception of family practice sources that remain in family practice (family medicine), the reality is that rural primary care delivery per primary care graduate has been rapidly declining for some time.

SMART Primary Care : Family Practice Contributions – Only family practice (MD, DO, NP, PA) works for the purpose of health access for 200 million Americans and over 65% of the elderly as well as all populations in need of health access. Only family practice that stays in family practice for a career (family medicine) is efficient and effective.

FInd New Family Medicine Leaders? – The best of the best are often those that ask the best questions rather than regurgitating the expected responses. When family medicine leaders question good works in family medicine journals, it is time to raise a question about family medicine leaders and where family medicine dollars have been invested, other than in more family physicians (exactly what the nation needs for the next 30 years and more).

The Squeeze Play that Fails - Medicare is supposed to be a design that facilitates health care for the elderly. But the overall US design for health care insures that most of the elderly fail in access to basic health services. 

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.

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

Myth for the Cure: Essential for Disease Focus - Do no harm is difficult when the focus is eliminating disease. Nearly all of the disease-focused treatments cause harm and some cause substantial harm to people, to groups, or to entire nations. Harm can be direct to patients or indirect within health care. At ever more spent on health care, disease focus can wreck and entire nation and impact the world.

How the Disease Focused Abuse Health Access - At number 6 on the listing was the Clinton Health Access Initiative. I thought perhaps this might be a good source to contact. But the site explained that it is really about access to drugs and treatments.

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 on just a few, or one.

Cost of Training per Unit of Primary Care Delivery – At about $30,000 - $40,000 per Standard Primary Care Year of primary care delivery over a career, family medicine stands on top. Pediatric and physician assistant graduates have twice this cost. Nurse practitioners are moving to three times greater and internal medicine has a 5 times greater cost of training per unit of primary care delivery. Sources that do not remain in family practice and that do not result in family practice have the highest cost of training per unit of primary care delivered where the nation needs primary care most - in zip codes with 200 million Americans (65%).

Who Really Benefits? Claims of benefit to health access have been pointed out as promotions and promises, impractical, deceptive, or insignificant. Over and over the design deficits do not allow health access recovery. To understand primary care failure, one must understand who benefits from designs that fail for primary care result.

Can We Have Our Billions Back Please?   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.

Exploring the Health Consequencs of Disease Focus - 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 at

Piddle Twiddle and Resolve Not One Damn Thing Do They Solve  - In the play 1776 there are any number of wonderful allusions to Congress then and now. Former President Nixon thought so too. He requested and received an edited version regarding Cool Cool Considerate Men as he felt they too closely resembled conservatives of the time. Cool Considerate (calm, calculating, conservative?) Men are still very evident, but do they still lead well or wisely or with sufficient understanding of the daily lives of most Americans?

Addressing the Primary Care Crisis – The right questions must be asked and the answers must be specific to the needs of most Americans or the US will have another 30 years of primary care failure by design.

Part I: Limitations of Awareness – Those shaping the designs have low awareness of the basic needs of most Americans. National plans and planners that fail in awareness regarding most Americans fail America. 

Lets Take a Stand for Most Americans Instead of Against – This is a response for most Americans, unlike the popular emails that are really not for most Americans. Outgoing director of Medicare and Medicaid Donald Berwick indicated much the same.

Standard Primary Care Year Estimates – Only primary care training that results in graduates that enter and stay in primary care and have the longest careers and have the most activity as direct care clinicians and have the top volume delivery and remain where needed at highest levels can help with primary care recovery. Lowest retention, shortest career, lowest volume, and fewest active requires far too many graduates to even maintain primary care levels, much less address primary care for 200 million left behind.

Rural Pipelines Versus Long Term Obligations – Rural pipelines in the US are a failure and have been for the last 30 years because of US health policy. At each of 7 or more segments in the pipeline from before admission to retirement, US health policy drives workforce away from rural locations, primary care needed in rural areas, and underserved areas common to rural settings. While academic associated entities would like greater state and federal and foundation spending at each level of the pipeline, there are solutions that are SMART and have been for 40 years.

Uncovering Cover Ups Involving the Front Lines – A British report in WWII indicated the horrific failures of the early years regarding bombing runs. The US needs an objective approach to deal with the failed front lines of primary care.

To Be SMART or Not to Have Health Access – Specific, Measurable, Achievable, Realistic, and Timely is what is required to recover health access. Generic, primary care training not primary care in result, assumption, promotion, delay, and other priorities higher than primary care (even in primary care training) are not going to recover health access.

Rural Workforce 2000 to 2010 - Uncle Sam says "I want you" to serve in rural locations. Uncle Sam's design says "I don't want you" to serve in rural locations where lowest health spending goes to lower population density, lower income density, lower employment density, lower workforce density locations that are most dependent upon lowest paid primary care and lowest paid general careers. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans. Millions hungry for health care cannot be fed by small change programs.

Critique of Commonwealth Fund Report on Ensuring Equity - A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access or the great possibilities of innovation and reorganization or technology, to have primary care or health access someone must be there to deliver the care.

Revisiting Physician Distribution by Concentration – Methods that categorize workforce by concentrations of physicians are a much better measure of too much or too little. Too much is 1% of the land area with 50% of physicians and just 10% of the US population. Too little is 30,000 zip codes with 200 million Americans (65%) left behind with lower or lowest workforce concentrations and primary care concentrations. If you understand concentrations of workforce, you can understand concentrations of health spending and how few benefit despite the claims by health professional associations that health spending is good for the nation.

Rearranging the Deck Chairs: Death Displacement– A focus on deaths prevented or lives saved is only possible with distorted thinking. We all will die. Our overall quality of life is about how our lives are impacted by our efforts and by our national desig

Choices for Higher Priority Areas That Could Make a Difference – Nations must make their best choices to put nations in a better position. The United States makes decisions that impact future generations in ways that have placed the United States in a position that has deteriorated steadily. We have also failed to learn that misguided attempts to rescue can actually make matters worse even more rapidly.

It has not been a good year for primary care or health access after 15 years of rapid decline and after 30 years of decline with only a few 1990s years of interruption.

Blogs indicate that primary care can be recovered and should be recovered, but it will take 30 consistent years of improvement for actual recovery. We have to have at least one to begin.

Accelerating Cycles of Primary Care Decline

Disruptive innovation was created as an attractive term, but innovation that is disruptive fits primary care best at the present time in the United States. Innovation is actually distracting and distorting primary care away from solutions. The last three innovative primary care training forms (NP, PA, MPD) are 60 – 75% not primary care in contributions over a career. This is a contrast with 60 – 75% primary care at their beginnings decades ago. Such rapid declines are not the result of a single cause and effect. Multiple factors accelerate the cycles of primary care decline.

Some of these changes actually accelerate primary care decline on their own. Others work to decrease primary care workforce capacity and cascade to result in another downward cycle.

This is an outline page indicating the first few factors involved in primary care decline by design.

The United States Design includes

• Ever Higher Costs of Primary Care Delivery - force cuts in personnel, less support, less volume, repeat cycle of decline - a 12% annual cost increase for 6 years doubles the cost of delivering primary care. Coupled with a freeze in primary care fees or a minimal increase, the cost of delivering primary care will continue to kill off primary care delivery and workforce.
• More Primary Care Cost Types - More types of personnel or equipment often not specific to primary care delivery, less budget remaining for primary care specific personnel, cuts, declines in primary care fees and delivery, repeat cycle of decline
• Flexible Primary Care Training + US Policy + Voluntary Choice - This is a policy driven equation for the United States that by its very nature has resulted in ever less primary care per graduate arising from primary care graduates. Tracking class years over time the US primary care per graduate level has declined to one-third the 1980 graduate level or from 18 SPCYrs down to 7 for recent graduates.    Graphic Listed
• Dysfunctional Primary Care Training – drives residents and medical students away from primary care (Keirns, Academic Medicine) - situations played out right in front of medical students are not a good idea for primary care career selection or retention
• Hamstrung Primary Care Workforce – Top priorities of insurance and government have been cost cutting for 30 years with worsening in the past 15 and worsening in most recent years. The primary care nurse is a primary example of a primary care professional that cannot participate as actively in direct patient care delivery due to the design. The design forces nurses to contact insurance companies just to get needed prescriptions, referrals, hospitalizations, goods, and services. Also they must collect information needed for care from our fragmented system. New jobs and duties such as risk management also are about cost cutting, not care delivery. What helps fail primary care is primary care professionals that are forced to do other activities other than delivering primary care - by the US designs that have been cost cutting in nature for 30 years. SMART designs are specific to enhance primary care delivery - not defeat it before it can arise.
• Training of Primary Care Is Not Primary Care Specific – Training has never been SMART or primary care specific for RN, MD, DO, NP, and PA. For 100 years the focus has moved ever more hospital and academic and subspecialty. The models that are different and are primary care specific are few and small in number, in numbers of graduates, and in national impact. The training in any training program will be shaped by the outcomes of the graduates. With fewer entering primary care and even fewer remaining in primary care, the training changes to fit graduate needs. If this is not so, the program dies for lack of graduates as graduates are interested in preparing for the jobs that exist and that allow them to do well. When programs send a minority in primary care and those attracted desire non-primary care careers, the program composition will change to fit non-primary care. Only a permanent primary care source can withstand this. Of course this is why family medicine has been a lower priority choice - due to its permanent primary care outcomes.

This is just a beginning of cycles of decline. Anyone trying to tell you that the US has more primary care or that primary care is doing well

- is selling something.

Cost of Training per Unit of Primary Care Delivery

Policy Protected Primary Care is Permanent - Family Medicine

Why Do Primary Care Myths and Misinformations Persist?

Fifty Years of Failed Primary Care Workforce Innovation

To Follow the Money, Follow the Workforce 

Failing Primary Care Explained By Policy Failure 

Three Dimensions of Non-Primary Care Increase vs Zero Growth in Primary Care 

The Black Hole of US Subspecialization

Subspecialization and Academization and Hospitalization and Centralization:

Spells Workforce Concentration and Lack of Access for Most Americans

Various health corporations and health professional associations want government and everyone else to stay away from regulating health care. The reason is clear. The design is near perfect for academic, subspecialty, and hospital interests. The corporations and associations and their stockholders and members stand to gain from more and more health spending diverted to non-primary care areas. Health insurance companies benefit from ever greater spending. More non-primary care workforce results in even more non-primary care spending and more non-primary care workforce. Total health spending captures more and more of the Gross Domestic Product. More invest in health care and share in the profits, resulting in subtractions from health care delivery.

Divisions of the United States into rich and poor are facilitated by the health design that sends so much to so few for so little benefit. Inefficient government at all levels from loss of government personnel (due to health care cost increases), inefficient business (current and past health care costs cripple), and cuts of teachers by school districts as well as poor support for basic education and basic health access are just a few consequences attributable to the US designers.

Subspecialization, Academization, Hospitalization, and Centralization are a means to an end - bad for US and good for a few. This of course is what more and more are realizing as the real United States design that impacts not only health but finances, government bailouts, and more.

The Conversion of NP and PA By Subspecialization and Academization

Nurse practitioner and physician assistant associations are also dominated by academic and subspecialty interests. More dollars per hour results in more found in non-primary care and also more ability to pay for dues, attend meetings, and participate in leadership positions. The health access workforce is busy delivering health access, has fewer other than office direct clinician care, and does not have the employer, benefit, and salary support to allow association participation. This is the same as has been found in physician associations for decades. How many more interviews devoted to the importance of primary care will be given by subspecialty nurse practitioners, even in states like Alaska that need pure strains of permanent family practice NP and PA workforce?

Nurse practitioner associations have strong connections to health insurance foundations such as United Health Care. They have testified together (for Congress) and have even implicated the best health access sources to be impaired. Those promoting the primary care source with lowest primary care delivery over a career have chosen to spread misinformation about the best source. Nurse practitioner associations, health insurance corporations, and non-for profit foundations are not the only ones who are pointing fingers at the international medical graduate component of family medicine. The NP and United testimony was a prime example of half truth and innuendo. The truth is that international graduate non-citizens choosing family medicine are number 3 or third highest as a primary care source and one of only 3 permanent sources.

• The family physician from US origins delivers 25 Standard Primary Care Years as compared to about 4 for a nurse practitioner graduate.
• The Caribbean graduate of US origin also delivers about 25 SPCYrs as a family physician.
• The non-citizen international graduate delivers about 20 – 22 Standard Primary Care Years during a career.

It takes 6 NP grads to equal the primary care delivery of a US MD or DO school family physician or one from a Caribbean school. It takes 5 NP graduates to reach the primary care delivery of a non-citizen family physician.

It is not quite deception as few understand the limitations of fewest years, least activity, low primary care retention, and lower volume.

Doctoral Degrees Dictate Decline

In the controversy about the NP doctoral movement, the really important information about workforce capacity has been lost. While various people argue quality or academic points, the facts about health care delivery during a career are lost. After 2015 it will take 10% more NP graduates to accomplish the same workforce as doctoral requirements will kill off two more years of a career (8 – 10% loss). The change will result in fewer in primary care, fewer active as direct care clinicians, and fewer serving where needed.

Readers can judge for themselves why a source that is in last place in primary care delivery should compare themselves with the number 1, number 2, and number 3 best sources of US primary care when they are number 8 and only the smaller family practice component does the real primary care and health access work of NP.

Academization, Subspecialization, Hospitalization, and Centralization Marginalize Health Access

Global directions are clear over the last century, the last 40 years, and especially the last 15. Various foundations continue to promote NP and PA workforce – in some ways contrary to their health access missions. Foundations also continue to promote innovation and reorganization when the major need for the next 20 years will remain enough entering primary care and remaining in primary care – something that flexible primary care sources cannot supply. When you present solutions that cannot work because of failure to address primary care workforce, you are clearly delaying health access recovery.

Policy Impact Forces Replicating the Subspecialty Dominant Design

Physician subspecialization dominated medicine for decades with more new specialties and more in each new specialty. Nurse practitioners and physician assistants have followed suit in the past 20 years. With the demise of managed care in the 1990s, the subspecialty avalanche accelerated. NP and PA graduates keep finding their way to a wider range of specialties and more are entering these new specialties.

NP and PA academization also continues to longer and more formal and more expensive training. This is exactly the design followed by physicians over the last 50 years as well.

The NP and PA subspecialty workforce is ideal for keeping subspecialty offices and office equipment going longer with more services and with more lab and other revenue generations.

All the above is evidence that the real designers of US health care involve academic institutions, health professional associations, health insurance corporations, those who sell medical equipment and technology, Wall Street and other investors, and representatives of these groups serving in foundations and government.

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

Why Do Primary Care Myths and Misinformations Persist?

As noted previously, all primary care RN, MD, DO, NP, and PA are greatly needed. But the probability of actually being in primary care over a career of contribution is small for new graduates in RN (10%), MD (20%), DO (30%), NP (25%), and PA (25%). Steady departures from primary care are seen for all except the small part of MD and DO that is family physicians. Family physicians are the only remaining primary care result that is relatively permanent but are only 7 – 8% of US MD and Non-Citizen IMG choose FM along with about 16 – 18% of DO and 25% of Caribbean US Origin.

The NP and PA primary care effort has stagnated because fewer have remained in primary care. The case can be made that unless more health spending is injected into primary care, the NP, PA, IM, and PD contributions will actually shrink. Family medicine is stagnated by 30 years of no increase in annual graduates from the 1980 level of 3000 per year.

One would think that common sense observations would reveal the myth of NP or PA or any flexible workforce increasing in primary care delivery  - given fixed low primary care spending with double digit increases in the cost of delivering primary care.

But common sense appears to be the one quality lacking in the US health care design. Only a permanent primary care source by training (FM) or by obligation or by restriction can result in primary care graduates actually delivering the primary care indicated by graduation from a primary care program. NP and PA graduates are not permanent primary care by training or by obligation and they are no longer restricted to primary care or underserved locations.  

Generic expansions fail for MD, DO, NP, and PA with such low and falling proportions of primary care in the years after graduation. Questions should be raised.

Why Does the United States Persist in Myths such as

• Midlevel Primary Care as solutions for primary care with fewer and fewer remaining in primary care over time. 
• Generic expansions as solutions for primary care - expansions that cannot work because of US policy for 30 years (same for NP, PA, MD, and DO).
• Innovation and reorganization as solutions for primary care - innovations that also cannot work because of policy for 30 years.
• Generic expansions of internal medicine as solutions for primary care where it takes 8 graduates to result in 1 FTE of primary care.
• Any expansion of pediatrics - Pediatric expansions for 15 years have demonstrated the futility of expansion for primary care and cannot increase primary care delivery. It would take two major changes. Graduates would have to decide to change their location preferences away from saturated locations and the US would need to inject more spending into primary care for children above the rapidly increasing cost of delivering primary care (not cuts or freezes in reimbursement).

Given US policies bad since the 1980s and worsening, only specific designs (SMART) work such as family physician specific or long term obligations or restrictive legislation forcing permanent primary care. These are the only Specific, Measurable, Achievable, Realistic, and Timely interventions given the fact that US policies drive all but permanent sources away from primary care, especially in the last 15 class years.

Why Do Myths Persist?

An obvious reason is that major players have much to gain. Perhaps it has to do with substantial gains for those that benefit by the US policy design. After capturing what will be 80% of physicians, the designers benefit with over 70% of NP and PA graduates as non-primary care workforce. NP and PA leaders benefit by being able to claim primary care.

Those benefitting can be tracked by substantial movements to teaching hospitals, academic institutions, hospitals, surgical workforce, emergency rooms, and the largest subspecialty practices. Flexible workforce such as NP and PA are valuable in a variety of specialty, hospital, and academic roles individually or together at the same time.

Those in the US that do not understand the difference between flexible or temporary primary care and permanent career choices or first career choices compared to an entire career contribution help contribute to the problem as seen in government and foundation reports, media postings, major journals, and statements of various deans and workforce experts.

Perhaps the midlevel emphasis is also a reaction to physician domination. Association with male domination may bother females and there is the feminist movement to consider. Government personnel, those in non-physician health professions, and a variety of lobbyists (when not working for medicine) may have an axe to grind. Physician leaders, associations, and lobbyists do have a way of getting other health professionals and their associations stirred up. Others believe that their own type of health care is superior. A number of alliances exist with for-profit corporations and others who may help the cause of advanced nursing. Some have consequences.

Poor Understanding of the Mechanisms of Midlevel Departure from Basic Health Access

A common problem is that few understand how much benefit there is for NP and PA that depart primary care and basic health access settings. The benefits accrue to the individuals converting, to the employers that facilitate conversion, and to the hospital and teaching hospital and subspecialty physicians in the largest group practices. Movement away from primary care and from the more underserved locations is assured with lowest health spending in multiple dimensions. Movement is assured toward the highest concentrations of workforce joining others that already receive the most lines of revenue and the highest reimbursement in each line.

NP and PA Benefit - Basically all health personnel receive higher to highest salaries when departing primary care. Nurses, physician assistants and nurse practitioners in particular are documented as paid the least in school health, primary care, and community health arenas. The most experienced follow the designs to hospital and subspecialty settings. This is where health spending is the highest and where all lines of revenue are found with the highest reimbursement in each line. This is set in place by the academic, hospital, and subspecialty designers. Primary care appears increasingly to be a job for those new, those part time, and those transitioning. The best opportunities are subspecialty and hospital where NP and PA graduates can enjoy significant flexibility, autonomy, variety, and financial reward. This contrasts with primary care where working harder matters little as there is less funding available even if those in charge of primary care clinics wanted to reward their major contributors. Pay increases usually do not cover the rising cost of health insurance and other deductions from paychecks.

Employer Benefit - Major health care employers shape designs for health workforce and health spending. Health care employers receive greater revenue from subspecialty PA and NP services and lesser revenue from primary care efforts. Flexible workforce can fit a number of situations from the most office based to intensive care settings and from multiple physicians and other team members to few.

Subspecialist Benefit - Subspecialty physician practices receive more revenue by adding NP and PA subspecialists. The subspecialty physicians in the practice do not lose revenue when adding NP or PA professionals. When a subspecialty physician is added to the group, the other established subspecialists decline in revenue generation. In other words NP and PA provide services that complement and do not compete. Guess which type of addition is likely to be preferred? (Cardiology example from The Lewin Group). The study indicated that the largest groups benefited the most – those that are most likely to be in the top concentrations of workforce. This sends NP and PA not only away from primary care but also to the top concentration locations.

Subspecialty physicians can generate more revenue with NP and PA additions for other reasons. The NP or PA at the clinic can see patients while the subspecialists are making more money doing more procedures and more expensive procedures. Hospital NPs and PAs can do much of the rounding, also preserving physician time for high revenue generation areas.

NP and PA expansions can “throw out a net” to gather ever more referrals and ever more procedures sent to colleague subspecialty physicians. Each contribution generates more revenue more than one way. Such a net can also suppress competing practices and corner the market – an increasingly successful tactic in health care used by health care insurers, large systems, academic institutions, and practically all except those attempting to deliver basic health access services. Those backlogged with more patients to see than subspecialists can get things updated with a PA or NP professional – and quicker to be seen can result in difficulties for others who remain backlogged. This is an important consideration when there is so much demand for subspecialty workforce (even though some of this is too much done for too little result and also more is due to the decline of primary care and the decline of managed care).

While it appears that there are benefits, the NP and PA changes over the years include less and less primary care and fewer remaining where needed. Only the family practice employed NP or PA can be demonstrated to consistently serve the 65% of the population in 30,000 zip codes in need of primary care and the family practice employed proportion has declined the most over the past 30 years.

The next post is about The Black Hole of United States Subspecialization that also has impacted MD, DO, NP, and PA workforce and that effectively prevents recovery of primary care and recovery of the US economy.

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

Disclaimer: Dedicated primary care MD, DO, NP, PA, and RN professionals are quite remarkable. All that separates them from non-primary care careers is their dedication, their commitment, and their desire to serve. Every other influence via policy and training sends them away from primary care. Those departing primary care for non-primary care are also not to blame as this is what the designs favor. Those who are dedicated and those who are herded away from primary care and toward existing top concentrations of workforce deserve better designs, better representation, and an accurate depiction of the United States health workforce situation. When only a few shape the designs and decisions, most health professionals and most Americans are left out by design.