Rural or Primary Care or Underserved Pipelines Still Will Not Work to Resolve Access Barriers Via Training Interventions

More government funding is being divided up to attempt to improve rural health care workforce. It will not work. The funding is tiny compared to the yearly destruction of basic health access practices and hospitals where most needed. The designers would actually have to understand how they shape, maintain, and worsen access barriers - before any improvement will be seen.

Credentials

I have been teaching, researching, delivering basic health access for over 30 years starting with solo rural practice in lowest paid primary care in the lowest paying state in the lowest paid Area 99 in the state while taking a 15% cut as a new physician. I apologize for taking so long to recognize the reality of the failed financial design.

Ignoring the obvious, I believed in the hope of training to resolve deficits. I was wrong.

I tried and failed. I helped to develop the term rural pipeline and have led rural med ed efforts in institutions, in associations, in states, and in international circles.

In the US, training cannot resolve deficits of workforce or primary care or half enough generalists and general specialists for half of the US population.

True change requires that we value basic services that are 65% of services and 90% of local services where most Americans most need care. True change requires

• that we value the Americans in lowest concentration counties and
• that we value basic services and
• the fewer practices and hospitals that remain in these lowest concentration counties

It is a matter of values and over decades of time, the designs have been worsened - with worse to come.

The financial barriers must be overcome.

• These practices and hospitals in the 2621 counties lowest in health care workforce are paid the least by 15% to 30% for the same services
• And sometimes even less because of concentrations of the worst public and private health insurance plans.
• They are supported less by payment and have the fewest general specialty workforce to share the load and have least local social support resources
• They are attempting to care for the US populations growing fastest in numbers, demand, and complexity that will be a majority of the US population by 2060 based on the last 50 years of fastest population growth in these counties

Worst Financial Designs Shape Permanent Deficits and Access Barriers

Their revenue is stagnant by design.

• They had 38 billion as their share of national primary care spending in 2008. The funding does not increase.
• The funding does not cover the 1 billion more a year in usual costs of delivery
• The funding does not cover the 1 billion more a year cost of delivery for HITECH, MACRA, PCMH, and value based designs or the delays and denials and security costs and costs of updates. Not surprisingly there is lowest penetration of these innovations and regulations at 30%. They can hardly tolerate 1 or 2 more billion a year for 50 to 70% compliance with innovation and regulation.
• Nor can they tolerate more penalties for not having better finances or because they care for populations inherently lower in outcomes. But the designers value performance based incentives that discriminate against them.
• The designers do not understand them. Their funding does not cover the usual disruptions for these practices that are more likely to be smaller and medium sized, the ones that Mold found to be most disrupted by changes in key personnel, billing, EHR, ownership, and location. Not considered were local economic changes, losses of local employers and jobs and health insurance coverage, significant illnesses in delivery team members and families - but you would have to understand these practices to have a clue. The designers do not have a clue.

The Designers Value Everything Not Basic Health Access

Our health care designers reward procedural, technical, subspecialized, hospital, and longer training. They do not value experience, continuity, dedication, retention, or community contributions. They do not compensate for

• usual cost of delivery increases,
• the additional costs of innovation and regulation
• new technology or equipment
• usual disruptions more common in practices most needed

The designers will pay for outpatient care with a facility fee to cover some of this gap, but most of these practices get paid marginally and do not get paid a facility fee. Hospitals are valued, but not practices where most needed.

Again and again others are valued and paid - but not them.

Until our national, state, CMS, health insurance designs pay equitably and sufficiently to have twice the team members instead of half enough - no training will ever resolve deficits and access barriers.

Rural Medical Education Has Value in Specific Preparation and Training, But Cannot Resolve Deficits

Nebraska did as well as any with pipelines. Pipeline successes as seen in UNMC graduates choosing family medicine were 12 times more likely to be found in Nebraska in one of the 70 counties chronically short of workforce. But observations over decades reveal the obvious -

• the workforce levels never changed.

This is because the financial design never changed.

Programs, schools, or other training interventions can look good - but do not resolve deficits set in stone by the financial design.

We need to value resolution of deficits - not training leaders that claim to be solutions while shortages, deficits, and access barriers remain and worsen.

New Wrinkles Make Finances Worse, Not Better

Innovation and regulation have resulted in fewer and lesser delivery team members - away from higher functioning primary care or patient centered primary care.

The designs worsen access, they worsen cash flow, they worsen social determinants, and worse.

If You Understand Social Determinant and Other Factors That Shape Outcomes

... then you can see how the financial designs involving insurance expansion, worst insurance, and micromanagement worsen outcomes. If you take away cash flow, economic impact, jobs, and social determinants - you will worsen outcomes

Why Is It So Hard to Grasp This?

To understand how the designs hurt instead of help, you would have to understand

• primary care finances where most needed,
• the impacts of the concentrations of the worst health insurance,
• the one time improvement 1965 to 1978 when more billions were sent into these practices and counties, with failures in financing since
• the funding diversions of micromanagement,
• the limitations of outcomes that are about populations and not practices, and
• the power of the micromanagement lobby

This is required to see how we got where we are and what must be done before any intervention can work.