Say No to Assistant Physicians or Any New Innovative Type of Health Professional

The NY Times posted an article about doctors who could not get a residency. It is tragic that they are unable to continue their training to be able to practice medicine. But it is wrong to publish that assistant physicians or any new innovative type of health professional is a solution.

This is the usual lie sold to them from the pages of the academic playbook - those who profit from more and more graduates paying more in tuition dollars.

SHORTAGES OCCUR WHERE THE HEALTH CARE DESIGN

SELLS OUT THE PRACTICES AND HOSPITALS WHERE 40 - 50% OF AMERICANS REMAIN BEHIND BY HEALTH AND OTHER DESIGNS

• With 15 - 30% lower payments in Medicare and Medicaid
• With lowest payments from the private plans in addition to people who can pay less due to lower income, lack of employment, or worst employment

End of Story, or should be.

True Innovation Should Help the Company and the Consumer - the Practice and the Patient, especially Where Most Americans Most Lack Care

True Health Reform and Health Equity Must Redistribute Dollars to Redistribute Workforce and the Academic and Largest and Corporations Doing Well - Oppose True Reform Because it would take a small portion of their profits.

Look at the Evidence Regarding More New Types

In the past 60 years we have created new sources such as physician assistants, nurse practitioners, family physicians. We have also massively expanded these sources with the help of government and big business foundations including health insurance foundations. They constantly promote themselves as the solution for health access and primary care.

But we have not been improving health access for 40% of the US population most behind since the 1980s. Each new source is limited by the financial designs specific to primary care and specific to places with deficits.

• FM was created and from 1970 to 1980 blasted up to 3000 annual graduates. But there has been little growth since - not surprising as only 1965 - 1980 did the US invest in these counties and their health care most behind. FM was specific to the concentrations of elderly and poor in these counties and the original Medicare and Medicaid designs pumped many more billions into these practices and counties and populations. Turns out that this is more important than the source. Since 1980, cost cutting has ruled. Academics never have valued them and almost extinguished them by the 1960s. The financial design changes supported the explosion to 86,000 active FM docs. With a much better financial design and fewer opportunities to leave FM (hospitalist, urgent, emergent, other careers), FM rocked as the health access source with population based distribution supported by 80% in office FM and 30 year careers. But notice that the deficits remained - confirming the financial design as the real cause. Even worse FM docs still get the least support because of the populations that they serve - who have little and are treated like dirt by designers. Their designs are particularly abusive to these populations and their workforce. The NP and PA who remain in family practice positions also have population based distribution but are subject to the financial design. More and more leave for other specialties and subspecialties with a much better financial design.
• NP went from zero to 10000 annual graduates by the 1990s with relatively slower growth, but then the emphasis was placed on expansion - and they found sources of funding - government, insurance company foundations, and the graduates themselves. At the current time NP grads are blowing past 40,000 added each year. But NP are leaving primary care and where needed at staggering rates. You see, NP also follows the health care design and the dictates of employers. NP and PA are the choice to replace as many of the most costly highly specialized physicians as possible. This is a best financial practices selection by employers, big systems, and academics - for more profits for the largest who can do even better - by innovative new types of workforce.
• PA and DO continue to increase at 5% more each year - 8 times the population growth level. Both are documented as flat lined for primary care result despite the massive expansions. Recent doublings of annual graduates have done little for primary care while the primary care result has increased more than 200% at entry into careers and likely even higher as PA move away from primary care in the years since graduation. DO primary care residency choice took a dive when the residency match was unified - and many DO grads no longer were forced into what they could get - an FM residency. This also allows them to choose more internal medicine - a major route out of primary care to more specialized IM careers.
• US MD once had the wise workforce leadership. They saw the need to stop diploma mill disasters 100 years ago (Flexner Reforms) and acting to establish stringent criteria for licensure. There were too many physicians that were poorly trained. But since 2003 the US MD leaders have not been wise. Perhaps they are responding to the More Graduate Warfare of other sources. US MD graduates since 2003 are up 35% and continue to expand at 3 to 4% a year - at 6 times faster than population growth.

It is interesting to see nursing leadership ignore the diploma mill NP problem, ignore shortages of faculty and patient material, ignore rigorous certifications and licensure seen in RN, and ignore massive overproduction of NP graduates - especially since the consequences of too many RNs are well known over the past 50 years. But of course they may not be wise. RN is also being expanded at 6% a year at 10 times the annual population growth.

The above points to the real problem - the financial design. RN clearly has to produce too many since so many fall away from RN - because of how they are treated. Generalists and general specialists where most needed have the worst financial design and have to pay much more for replacement workforce, other turnover costs, equipment, supplies, and each and every new change by state, federal or insurance company regulation - such is the US health care design.

Note that the massive expansions have created the least experienced health care workforce in the history of the United States. This is particularly true for primary care because so many depart and take their primary care experience out of the primary care pool of workforce. The faster you expand, the higher the number of graduates and the greater proportion of graduates in the workforce with no experience at all having just entered.

Note that 3 to 4% of workforce should be lost each year for a steady state workforce in a nation with little population growth. Note that the US does need more health workforce due to the aging of the nation, but this rate of aging will be slowed. Expansions should be limited to 1 to 1.5% a year - not 4 to 6% more a year.

Note that new sources with massive expansions have not resolved deficits of primary care or care in 2621 counties lowest in health care workforce

This 130 million population in 2010 continues to increase at the fastest rates - but their health care is prevented and eroded by financial design.

They have half enough of the basics across primary care, mental health, women's health, and basic surgical. They are paid 15% less by Medicare plans (in Medicare 2011 data) and generally have concentrations of Medicaid plans paying less than cost of delivery. They have concentrations of high deductible insurance because of the lower incomes of their populations. They have the worst private plans often due to worst employers with their worst benefit packages including worst health insurance plans.

Even worse, the do-gooder foundations and others that influence health policy are still pushing expansions even though the absolute worst health plans are being expanded - the ones that most harm local health care where most needed.

Why Not Examine the Past History of New and Old Workforce Sources Before Another New Source or More Massive Overexpansions

We still have proposals for geriatric, pharmacist, assistant physician, other nurse specialists, and more to be licensed and operate much like physicians with varying degrees of supervision or not - but why would anyone think that any would work

Why Would You Torture Any of these Assistant Physicians or Enslave Them Longer as the Conditions for All Health Care Workforce Deteriorate?

• The national health care spending is not increasing for health professionals
• More in the workforce will split the same or less dollars
• Fewer and larger health care employers assure worse treatment and continued declines in salary, benefits, or both.

Look at the 45 40 25 20 Rule with 45% of demand for 40% of the population but 25% of the primary care workforce supported by just 20% of primary care spending

Look at mental health care. Numerous new types but still deficits. Like primary care in 2621 counties there is 45% of mental health need for this 40% of the US pop with just 23.5% of mental health providers. They are supported by only 15 - 20% of mental health workforce spending and even lower proportions of overall mental health spending. Only 15% of psychiatrists are found in these places with some of the worst situations, conditions, support resources, and financial designs. Psychiatrists, geriatricians, and cancer care providers are all stacked in higher concentration settings. Overutilization of psychiatrists is 2 to 4 times across various counties highest in concentrations of health care workforce.

Can You See How the Financial Design Concentrates MD DO NP and PA and likely any new source?

• But they could be forced to distribute - This is a lie spoken by all of the above sources and their deans or program directors - to get funding and get started. They have failed.
• What about pipelines and special training - Been there and done that for decades and promoted pipelines to my great chagrin now. Even if a program or school looks good with multiple times more graduates found in target settings or careers, the financial design is still a limitation. They are merely a deck chair on the Titanic as the primary care ship goes down by financial design.
• What about value based care? - This is an abomination. Many support this hoping to improve the financial design even though numerous innovative designs since the 1980s have failed to improve the financial design. Value based care is more costly to deliver and plays out poorly where there are already lowest finances, fewest team members, and greater costs of delivery made much worse by metric, measurement, and micromanagement focus. Read many articles carefully and you will see that what they claim to be higher value or value based care (ChenMed) is actually bringing basic health access to disabled, complex, elderly, or hospice populations that previously lacked access. Also Medicare Advantage and other revenue sources are better sources. ChenMed has not responded to my critique and continues to minimize their access improving techniques. And why not? Value based care IS THE BOMB, the micromanagement bombshell, the driver of the train going down baby down.

Primary care in 2621 counties ...

must deal with 45% of US complex populations in this 40% of the population with just 25% of the primary care workforce supported by 20% of primary care spending - with stagnant revenue and worsening costs by about a billion or two more each year from usual and innovative/regulatory charges. They had about 38 billion to invest in primary care delivery in 2008 and now have less than 30 billion - for fewer and lesser delivery team members.

So highest complexity, half enough generalists and general specialists, half enough social supports

- and the designers demand integration, coordination, other higher functions, and patient centered care?

THE FACT OF THE MATTER IS THAT THEY HAVE CONTINUED TO DESTROY WHAT REMAINS OF CARE AND CARING IN SOME VERY SPECIFIC PLACES AND POPULATION WHERE THEIR DESIGN FAILS THESE AMERICANS AND THOSE WHO REMAIN TO SERVE THEM.

About that the volume to value mantra.

You see this constantly in the media and often by those who influence or design health care. They have no clue how much damage they are causing.

The assumption of volume as a means of higher profits does not work for primary care or where most needed. These practices often boost volume as the means to the end of financial survival. It is a primary mechanism to preserve what little is left of BASIC HEALTH ACCESS.

Volume is access. Destruction of care and caring are mostly about the financial design along with fewer and lesser team members.

Experts Ask Why Do Many Physicians and Practices Fail to Progress in Micromanagement, especially where care is most needed?

• Many practices realize the futility of changing outcomes shaped by decades of previous adverse life experiences in populations with lowest education and health literacy levels who often do not have access to broadband or much in the way of patient education materials.
• They have seen the shifting sand of the definitions of outcomes as some measures are found to be lacking or too burdensome. Practices can also shape their own outcomes by selecting various measures. What the heck? This is not rigorous or meaningful - and established practices know this.
• Many primary care practices in these 2621 counties are financially defeated or see this as their future. Why spend much more for metrics and measurements when your practice is near the end?
• Many are near retirement in these counties across generalists and general specialists as the average age of these fewer remaining physicians is higher - another indication of lack of replacement as well as those newer and younger not staying. Once again the financial design is the key.
• In my estimates of the additional costs of delivery added by HITECH to MACRA to PCMH to Value based, I only estimated 30% penetration to get about 1 billion in additional costs of delivery added each year from 2008 to 2018 - with more to come. This is about 2% of revenue generation subtracted as revenue is held flat or declines. Each year these practices have to put up with more to do and less remaining to do anything.

Stop Saying that Training or New Types of Graduates Can Fix Deficits. They have not done so and cannot do so - by design.