Rural Rearrangements of the Deck Chairs

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. Rural programming has not been able to keep up with population changes that increase demand such as increases in elderly, poor, and lower income patients. Lack of health spending for rural populations is the likely reason why rural programming or generic expansions are unable to improve rural access to care. In some ways rural programming can be seen as preventing solutions for health access that require increased spending in primary care, in rural locations, and in locations underserved for workforce.

New Rounds of Publications Emerge

Comprehensive Rural Programs have been promoted as health access solutions in new publications. Unfortunately the efforts of Duluth, the Rural Physician Associates Program, the Rockford program, and the Physician Shortages Area Program have not improved the rural, primary care, or family medicine outcomes when considering the parent schools of these programs - the University of Minnesota, the University of Illinois, or Jefferson.

Defeat of Rural Programming Due to Individual School Family Medicine Collapse or Decline

Declines in family medicine for Mercer from 32% to 3% will take Mercer from a top ranking proportion of graduates found in rural, found in underserved, and found in rural underserved areas to less than the national average.

The WWAMI program has long been promoted as a solution for states in need of workforce, even as states such as Alaska spend 1 million more dollars a year on primary care recruitment, retention, and locums costs alone. WWAMI has the same problem as all rural models - it leaks. The graduates have not been required to stay instate or in needed careers. The graduates are not admitted with a commitment instate or to family medicine or to rural practice or to underserved practice. The major WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) state needs remain the same - family physicians. With inadequate family physicians, locations in need of workforce are forced to pay more and more to get the same or less workforce.

Marginal and underserved rural proportions have certainly not improved for the University of Washington in the AMA Masterfile. There was an 11% proportion prior to WAMI and down to the 8 - 9% level for 1994 - 2000 graduates. The 20 - 30% family medicine level is now down to one-third this level. The rural contribution of the University of Washington have not improved at best and there are indications of steady declines. 

The main reason for success and failure appears to be the same reason. During 1965 to 1980 the United States poured billions into health care and much of this went to marginal and underserved locations with high proportions of Medicare and Medicaid patients. The 1980s cost cutting designs with increasing costs of delivering care and less revenue resulted in declines. Then the 1990s again injected funding specific to rural locations and primary care where needed for a few years before returning to cost cutting and major declines across all graduating classes of MD, DO, NP, and PA.

The University of Washington and the University of North Carolina have also been used as examples of medical schools that can accomplish dual roles of research and health access. Together all of the parent schools with rural programming actually barely keep above the US average regarding needed rural outcomes.

• Medical schools that do much better for rural outcomes are medical schools in rural locations.
• Osteopathic public medical schools have also been outstanding sources of rural physicians, instate physicians, and family medicine.
• Medical schools in the South also contribute more rural physicians, but this has to do with higher levels of rural population
• Medical schools in the Midwest also contribute more rural physicians for the same reasons - a state with a higher proportion of rural workforce.

What is most evident is little change at all - before or after rural programming.

Thirty Years of Health Access Workforce Prevention

The creation of osteopathic public medical schools was only 1970 to 1980 and further osteopathic public schools have been prevented for 30 years. At the heart of the successes of all the medical schools associated with rural workforce is family medicine, also prevented from expansion for 30 years by the US design. This remaining permanent primary care choice is difficult when primary care is marginalized, when the practice locations most common to family physicians receive the least health spending, and when many of the locations preferred by medical students are locations that have lowest percentages of workforce in family medicine. Family physicians can be tracked as steadily moving away

The University of Nebraska is another example of declines in instate, primary care, and rural workforce due to changes in family medicine and admission. The University of Nebraska has established a number of different rural programs involving 8^th grade to retention in rural practice. Unfortunately a decline to 2 - 3% family medicine choice for the great majority entering from major metro origins defeats the overall rural programming (last 4 matches at UNMC). The proportion entering from out of state and instate metro areas continues to increase (40% to 50% to 60%) and this proportion has 4 to 5 times lower choice of family medicine than in recent decades. It is difficult to fill graduate programs that do address Nebraska’s health access needs without family medicine choice. As more UNMC graduates depart the state for training and for practice, UNMC will no longer be able to keep up its contribution of half of Nebraska workforce - particularly as seniors double from 2010 to 2030.

Chen in Academic Medicine suggested that rural training tracks triple rural location in the graduates of a family medicine residency. Actually this is not specific to rural programming. simple choice of family medicine is enough to triple rural location, even when controlling for physician origins, type of medical school, and state practice location type.

Rural programs and tracks are small. Rural efforts are dependent upon sources of students that are declining (lower and middle income origin, lower and middle population density origin, children not of professional parents, rural interested, family medicine interested, first generation to college). Graduate medical education rural efforts can only exist when programs fill their residency positions (more difficult, not the best fit types chosen). Also the higher proportions of health access workforce in existing rural programs is easily overcome by the much lower and declining health access outcomes of much larger non-rural or traditional components.

The existence of such rural programming within a state or school appears to rearrange who chooses such programming without actually increasing desired outcomes. The outcomes are worse when considering entire careers of contribution due to lack of instate retention, declining primary care retention in the years after graduation from primary care training programs, and declining retention in rural locations.

Only complete school designs have made top contributions to rural workforce including rural located medical schools and osteopathic public schools. Only the family medicine proportion can be consistently demonstrated to have top health access contributions. Except in a few states (states that tend to have top workforce concentrations that drive FM out), family medicine is also associated with top instate retention. This is noted in University of Kansas graduates choosing family medicine that have 16 times greater instate rural location compared to U of KS grads not choosing family medicine. Family medicine has been the result of admission of students with factors contributing to instate most needed health access and family medicine contributes to instate most needed health access.

Graham Center Policy One-Pager    Comprehensive Medical School Rural Programs Produce Rural Family Physicians    While the title is true, the parent institutions do not have overall rural workforce gains. Also the parent institutions have barely above average rural contributions.

Which Medical Schools Produce Rural Physicians - a 15 year update

This is Blog Number 50 for Basic Health Access Blog begun in 2011.

Rural Medical Education Specific Blogs and Links

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. Dozens of special programs can no longer hide the fact of an aberrant basic design that fails rural Americans.

Atlas of Basic Health Access at the World of Rural Medical Education

Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many (non-health access interested parties) determining training curricula, and very few focused on basic health access

Pounding Poverty Providers with Pay for Performance Designs that send even less dollars to those who care for most Americans are the reason for health access problems. Pay for Performance designs make matters worse resulting for gains in revenue for those that care for patients who naturally have better outcomes and no gain for those who care for the more complex patients. 

Speak Your Piece: Measuring Rural Health Care  Rural health care providers are paid less to provide treatment to a population that is more likely to be poor than those in the cities. Now medical researchers are saying rural hospitals don't provide the same quality of care as those city institutions that have more money and richer patients. Well......Which is it, JAMA? Where is your consistency in articles regarding quality of care? If you choose some authors that consider social determinants and other important limitations but ignore these factors in other publications, this causes confusion. 

Rural Primary Care: Stark Realities All primary care sources have declined in primary care per graduate and in rural primary care delivery per graduate. The rural Standard Primary Care Year contributions over the class years illustrate the declines in rural primary care delivery.

Non-Specific Rural Pipelines or Specific Long Term Obligations  Voluntary choice allows potential rural physicians to steadily leak away with each year of training and practice. Only very specific shaping is most likely to result in early, middle, and late career rural contributions. 

Preparing for Health Care Cuts This is not good news for rural workforce. No administration in the past 30 years has really understood the problems that result in insufficient rural workforce and matters may be even worse in 2012 and beyond.

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

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?

Congress today is a divisive Congress just as presented in 1776. Is Congress today working together affirmatively for the nation. The most basic areas important to most Americans appear to be low priority. The current physician fee crisis is a great example of Piddle Twiddle and Resolve without a solution.

It has taken years for the Medicare Physician Payment Advisory Commission, stacked with landed gentry benefiting from the designs they set, to recognize its past errors and to recommend some protection of primary care fees as compared to non-primary care. Major protests were required to get just this small change. Reasonable increases in revenue that might keep up with the costs of delivering primary care are not even on the drawing board. Primary care workforce has followed the primary care spending design as noted in Accelerating Cycles of Decline.

Primary care workforce designs have doubled primary care numbers only from 1965 to 1985. Each 15 years since 1965 the non-primary care workforce has doubled and this will continue until 2025. The US is attempting to function from 2010 to 2025 on a design that was set in place in 1980.  Despite twice as many graduates and 3 times as many primary care sources, the primary care numbers of clinicians and the primary care delivery capacity continues to decline. Policy Failure Plagues Primary Care and Permanent Primary Care Choice through Five Policy Periods
indicate designs that work or fail.

Ever more resources are spent on non-primary care while primary care faces across the board cuts on top of inadequate reimbursement. The entire mess results in distrust of government and health insurance companies by those who provide care as well as the patients who receive care.

Even physicians realize that primary care reimbursement is too little (Leigh). More practices stream to types of payment (rural health clinic and FQHC) that have the ability to cover rising costs of care rather than fee for service under SGR that has been mired in the basement. Fixes in the 1960s to that restored some basic health care infrastructure failed as costs rose faster than revenue and as redesigns sent the spending to fewer locations with greater workforce concentrations. Fixes in the 1990s failed in just a few years. But Congress has little memory for failure and has little awareness as well.

Piddle Twiddle and Resolve

Delays are common responses when more spending is involved. There is no time for most Americans in need of care and the elderly are the major example. For 50 years the US has known about the need for more care beginning in 2010 and there has been no preparation for the workforce to deliver the care. In fact the workforce most needed is declining the most.

It is already too late for the elderly of today as they double from 2010 to 2030. During this period internal medicine will collapse from 90,000 to 40,000 in primary care as this is all that 1400 entering primary care a year can provide. Family medicine can no longer increase as it has been held hostage for 30 years at 3000 annual graduates - zero growth. Sadly government reports indicate increases when increases are not possible.  Journals also fail to present the truth or the consequences of failed policy. NP and PA workforce proportions have declined steadily in the needed primary care and in the locations where 65% of the elderly are found. This is mainly about fewer remaining in family practice - the predominant midlevel primary care, rural, and underserved response as well as service to those outside of concentrations.  Geriatric workforce is also concentrated 75 - 80% where only 30% of the elderly are found.

Health care most important for the elderly is held hostage by designs that defeat primary care as well as workforce in the zip codes outside of concentrations where 68% of the elderly are found. The elderly need two to three times more primary care and this workforce must match up to zip codes where the elderly are found - particularly as they lose mobility and transportability as they age. The damage of the last few months and the next months is specific to those remaining who care for the elderly. This is compounded by the past 15 years of decline. ew years of damage.

Piddle Twiddle and Resolve

The record is solid for health policy impact and primary care. Primary care numbers doubled from 1965 – 1980 with the initial health access plan before cost increases and cost cutting designs took over. The 1990s reforms boosted primary care and family medicine to peak levels with increased primary care revenue and decreased or stagnant non-primary care. The 2010 reforms that might have helped primary care have been compromised by cuts in Medicaid and those who care for patients most in need of care, in addition to innovation focus, and reorganization focus. As commented in 1776 - “Sweet Jesus” 

Momma Look Sharp To See If You Can Find the Remaining Front Line Workforce

The basic health services needed by nearly all Americans nearly all of the years of their lives are being compromised by insufficient primary care spending (widely recognized) and insufficient workforce retained in primary care due to insufficient primary care spending. To Follow the Workforce Follow the Spending. Matters are worse with substantially more paid to non-primary care, allowing experienced primary care personnel and professionals to be hired away from primary care employment.

Is Anybody There, Does Anybody Care?

As noted by 180 days of neglect after 30 years of neglect

Piddle Twiddle and Resolve 

There is of course only one response as indicated in the play

“Sit down Bob, Sit Down Bob, For God’s Sake Bob, Sit Down”

The reply is of course  "Never, Never"

May 2012 Be a Time When Congress and leaders across our nation, Despite Divisions, Will Resolve to Work Affirmatively for Most of Our Nation

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

Leigh JP, Tancredi D, Jerant A, Kravitz RL. Physician wages across specialties: informing the physician reimbursement debate. Arch Intern Med. Oct 25 2010;170(19):1728-1734.

1776 is a musical with music and lyrics by Sherman Edwards and a book by Peter Stone. The story is based on the events surrounding the signing of the Declaration of Independence. It focuses on, and partly fictionalizes, the efforts of John Adams to persuade his colleagues to vote for American independence and to sign the document.

Link to the "Cool Considerate Men" sequence from the restored version of the film. "This sequence was cut out of the original release upon complaint by President Richard Nixon, for the song allegedly drew many parallels between the opponents of American Independence in 1776 to the modern conservative right." – forever to the right…  Dialogue Hancock – “Fortunately there are not enough men of property in American to dictate policy.” Response -  "Most men with nothing would rather protect the possibility of becoming rich than face the reality of being poor." A comment about the Republican Party is worth a read. YouTube

Graphic   Primary Care Graduate Increases, Decreasing Primary Care Delivery

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.

Because more Americans are joining those at or below poverty, particularly children, the nation should spend far more time understanding the inequities of the current and future designs.

Proposals for bonus funds were supposed to send more funding to those who care for underserved patients, family medicine and rural associations had to exert additional time and energy and research to insure that the programs actually send funding to those who deliver the needed care. Studies from North Carolina indicated that previous bonus program funding were commonly accessed by those that were not supposed to receive the funding.

Hong in JAMA demonstrated that Pay for Performance punished practitioners caring for the underserved. See comment in AFP Community Blog.

Pediatrics just published an article about the value of a continuity medical home – an article that actually demonstrated that continuity was really about advantage and discontinuity was about disadvantage. The real driver of better quality was social determinants, not the medical home concept in this study that did not really even study outcomes of actual certified medical homes.

Now Kaiser indicates much the same for Hospitals that care for those left behind. Readmission rates are much higher for lower income Americans. This is of course a function of any number of social determinant and similar demographic characteristics that add up to difficulties that lead to hospitalization and difficulties that are far more likely after hospitalization.

It is hardly possible to keep up with all the ways that funding is diverted to care of those with easier care and naturally better outcomes.

Not much comment is needed other than indicating that until designers understand most Americans and their basic needs, the designs will continue to favor few. Design changes also may insure even greater divisions.

Potential Impact of Pay-for-Performance on the Financial Health of Critical Access Hospitals (Policy Brief)    Author(s): Robert Town, Ira Moscovice  Sponsoring organization: Flex Monitoring Team
Pay-for-performance (P4P) incentives likely reduce the financial status of CAHs already in financial stress. However, P4P incentives are likely to have only a modest impact on the financial stability of CAHs.  Date: 02 / 2010

Providing Underserved Patients with Medical Homes: Assessing the Readiness of Safety-Net Health Centers  Author(s): Katie Coleman, Kathryn Phillips
Sponsoring organization: Commonwealth Fund
Surveys safety-net health centers (public hospitals and clinics, federally qualified health centers, rural health centers, and free clinics for the medically underserved) to determine their potential to become patient-centered medical homes (PCMHs). Date: 05 / 2010    A summary would be that those caring for Americans left behind have an uphill battle to qualify as medical homes. They have a major battle just trying to keep up with increasing demand.

Basically even to become eligible for increased pay, there is substantially more investment required to get where needed. Also the outcomes will be less not due to lack of effort, but due to care of underserved patients. Government designers and reformers do not understand the people most in need of care or the type of care they need or the funding required to meet their needs.

A true approach to build quality requires far more understanding and awareness and substantial time and effort to process a real design. Cost cutting focus results in rapid implementation and designers are most familiar with what works for a few rather than what would work for most.

Arizona has delayed six months beyond the required July 1 2011 federal deadline to set up their electronic verification site so that Medicaid providers can recoup their tens of thousands invested in patient management software and hardware and consultants in the past 2 years. There are only 10 days left in the year. It appears likely in at least one state that investments required to gain incentives will not even be paid as indicated. Other states short on funds and Medicaid funds may also play the delay game. This is a catastrophic event signaling to those who care for patients in need that they need to stop caring for Medicaid patients or leave the state. This is another way to Pound Poverty Providers.

One thing is certain. Taking the "safety-net" for granted is guaranteed to result in greater divisions between Americans in income, health, employment, productivity, and other measures.

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

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.