True Solutions for Health Care for Most Americans Most Behind

Our nation continues to avoid health care solutions specific to most Americans most behind. There is continued failure with worsening regarding the finance of their health care, or lack thereof. Training designs are the opposite of what they need. Health care interventions are absolutely the wrong choice to transform this population most behind not only in health care but in education, health literacy, economics, and other areas.

A Macro View can easily see that the solutions proposed by those doing best in health care - are a poor fit for those behind most in many areas beyond just health care.

This Posting Will Discuss True Solutions that Must Be From the Inside. Outsiders need not apply as they are out of position and are unaware.

1. Direct contracting is the best solution for the financial design specific to these Americans most behind. They need to have control - not big government, big insurance, and those promoting misguided solutions. Outsiders propose and promote designs that often are the opposite of what is needed inside of these communities, practices, and hospitals.
2. Training specific to their needs is required, not the opposite designs we have now.?According to what most Americans need - we prepare wrong, select wrong, train using the wrong curricula, train for the wrong specialties, train in the wrong locations, and fail to obligate service where most needed. The training focus also results in failure to support such service where needed. Hint - Demonstrations of service orientation, team work, empathy, and change agent quality should guide preparation, selection, and training first and foremost. Exclusive scores and colleges and academics select for those least like most Americans who have demonstrated lowest levels of generalist and general specialty services and careers spent with these populations.
3. Outcomes changes require transformation of the local population. These cannot be transformed by health care alone. These cannot be transformed by outsider designs and designers that have a track record of decades of punishing them with meaningless, costly, burdensome, and ineffective solutions such as DRG to managed care to HITECH to value based solutions that have failed to improve outcomes and have acted to worsen access. These designs also have not lowered cost. The succession of worst designs has benefited mostly those already doing well and their higher concentration populations. Any simple economic analysis of the cash flow changes?indicates this. If you understand health equity, disparity production and maintenance, social determinants, and non-clinical drivers of health outcomes - you have a chance of understanding this.

Not a Crisis, a Chronic Catastrophe and Discrimination By Design?

A great example of promotion for self-gain is the created crisis of workforce. Look at this destructive accelerating cycle that has resulted in massive overproduction of graduates. There are deficits. More graduates are produced. The financial design prevents distribution or increases in generalist and general specialty workforce. The deficits continue. There are calls for new types of graduates and increases in the number of graduates. The deficits remain and worsen. There are new calls for training solutions that do not work and have not worked for decades.

There is not a crisis with regard to workforce shortages.

Crises are short term, not involving generations of time. Crises are created by those who want to promote their own solutions (AAMC, AMA, their state to state campaigns) that often do not work. They create crises periodically when they think the time is right to expand graduate medical education or increase other funding for training. The newest wrinkly is moving to the state level with more media and social media postings.

We know that their designs do not work for primary care or where needed from COGME, GAO Reports, and other studies. GME is evidence based not to work for primary care or where most needed. GME is concentrated where it is already most concentrated in about 6 states, a few dozen counties, and a few hundred zip codes.

And the massive expansions of MD, DO, NP, and PA graduates for decades of class years clearly have not improved concentrations of workforce where this is least concentrated. You would expect some improvement after an expansion at 6 to 10 times the growth rate compared to annual population growth - but the deficits remain and are specific to the counties and specialties valued least and stuck with concentrations of the worst Medicaid, Medicare, and private insurance plans for providers and this population.

The expansions have been specific to more non-primary care workforce as primary care remains flat in dollars and in workforce and has been for decades.

These basic health access problems have always existed for over 60 years.

Take note that FM, NP, and PA were all new types of workforce created to address these deficit areas. FM expanded rapidly from zero to 3000 annual graduates with maximal distribution from 1970 to 1980 as shaped by optimal financial designs. The new Medicaid and Medicare plans resulted in billions more for these counties most behind - ideal for family medicine that maximized primary care and distribution. FM has stagnated in the bankrupt financial designs of the 1980s to the present. The primary care retention and rural and underserved contributions have declined. Those in office FM still distribute the best, but remaining in office FM is most difficult because of the financial design.

The nurse practitioner and physician assistant contributions were better when these types were new, but their expansions have been negated for health access as they have more independence, more autonomy, and more career choices to follow. They add new subspecialties with more added to each subspecialty - and this comes with greater concentration and less distribution. They have chosen the better financial design and have left primary care and where needed, just like physicians. In other words, the more that they are treated like physicians, the worst their contributions where promises were made.

Only the family practice positions filled by FM, NP, and PA worked for population based distribution with 36% found in the 40% of the population in 2621 counties most behind - but they work only as long as they remain in family practice positions. When they have had opportunities to leave and follow a better financial design to better salaries, benefits, and team support - they have done so.

NP and PA have become more accepted and are more independent. This translates to situations where they are less forced to serve where needed as compared to the early primary care and rural and underserved requirements. This has resulted in losses as good sources for basic health access where most needed.

In the graphic below see how all sources of primary care deliver less primary care over their careers compared to the 1970s graduates. The product of years in a career, activity, primary care retention, and volume is what determines the Standard Primary Care Year - a measure of future primary care delivery over a career. Fewer years in a career (NP), lower activity (NP), lower primary care retention (PA, NP, IM), and lower volume (NP, PA) contribute to lower levels of primary care delivery. This also contributes but to lesser primary care experience. https://www.dhirubhai.net/pulse/real-crisis-facing-health-professionals-too-many-far-fast-bowman/?

Declines in primary care delivery also are associated with declines in basic health access where most needed because 90% of local services are basic generalist and general specialty services. More graduates to produce less result can be seen.

The 2621 counties lowest in health care workforce with 40% of the population in 2010 are growing fastest and will be 50% by 2060 or a majority of the US population. The health care design is concentrating more workforce in concentrations.

The population in concentrations is growing slowest in contrast to these 2621 counties growing fastest in population numbers, demand, and complexity.

The financing and training are wrong and so are the attempts to improve outcomes from within health care. Health care is only one of the areas behind in outcomes as the population characteristics, demographics, and social determinants shape behind in health, education, economics, and more outcomes.

How Can You Fix the Financing, the Training, and the Outcomes?

You certainly cannot fix the financing or the training with designs shaped by those doing well. You also cannot fix the numerous outcomes problems via health care practices and hospitals - which are mostly missing from these locations, have limited contact with people, and the encounters are mostly too little, too late, focused elsewhere, and already cost too much.

True Solutions for Most Americans Most Behind

The 2621 counties most behind have 75% of the rural population and 32% of the urban population that are truly behind in health care financing and training and outcomes. These include the Red Counties as well as minority rural counties with Native, African American, and Border Hispanic populations. There are solutions for all of these various counties

1. Direct contracting for their populations that have half enough generalists and general specialists and the worst of the Medicaid, Medicare, high deductible, and private insurance plans

2. Training specific to these counties with origins, preparation, training, and obligation specific to these counties

3. A small army of future teachers, nurses, public servants, physicians and other human infrastructure who serve the community beginning at age 14 to young adult doing change agent work in homes, groups, and specific to child development, parenting, health literacy, public health, prevention, early education, and community activities.?

Immediately You May State Your Opposition to an Obligation

There is a near universal opposition to obligations. Many ask why should there be forced services where you do not want to go. But once again, they fail to see what is being shaped by a design specific to these Americans. It is not about the trainee. The focus is on service where most need care. Also there is nothing quite like complex primary care that is well supported - which this design does. And if you have roots and all experiences in a community, why depart?

If you have origins, training, and obligation in such a location and have a small army of dedicated young people who look to you for guidance and leadership - why would you ever want to leave? Generation to generation you would be improving the local population and outcomes and community and practice.

The current design clearly results in worsening in the community and outcomes and situations, and environments - driving off those who could care most and make a difference.

There is also a fourth need. Our nation needs many more who understand these 3 above areas and focus promotions on these areas

The major problem facing most Americans is that the leaders and designers and promoters and those who set up conferences and learning activities and administrative training and health policy - do not understand them.

You would think that AAFP, foundations, and others who have a focus on health access would understand but they do not. AAFP has 36% of active family physicians serving these counties with 40% of the population. Often these family physicians are the remaining health care in these counties.

The proportion of FM in a county goes up as reimbursement goes down and other workforce goes down. An association that was truly focused on advocacy for most Americans most behind, for most of its members with contact with these counties, and for health access - should be very specifically focusing attention on true solutions. These family physicians most important for what remains of basic health access need help - not more harm.

AAFP has been ineffective in changing the financial design or the training or the outcomes, or areas that could lead to these changes. AAFP and others in primary care still support medical homes and value based care - perhaps hoping that these would change the financial design. They ignore the high costs of such changes, the low margins of these practices, or the changes shaping fewer and lesser team members in ways that disable what remains of local health care where most needed.

AAFP and Many Others fail to see that 1983 to the present and beyond has resulted in policies that continue to make the financial design worse.

Micromanagement focus specifically worsens the financial design - stealing more of the fewer dollars going to primary care where most needed and worsening productivity, burnout, turnover, and worse. The Commonwealth Foundation still pushes micromanagement and expansions of the worst health insurance for these populations and what remains of their health care. The worst health insurance plans concentrated in these counties have always been the problem that results in deficits of workforce. Solutions from outside by those who do not understand these populations, generally make the problems worse, not better.

How can these counties improve with "advocacy" associations and foundations and government efforts that remain focused on areas that are marginal or that worsen the situation for these counties (value based, worst health insurance expansions, worsening cash flow from insurance or micromanagement dollars stolen from these counties and returning little)?

Those feeding closest to the trough want more and are making it more difficult to see true solutions. And too many of us promote their solutions that do not work.

There?is a lack of progress in these three areas important for them to have some control over their fate and future improvements in outcomes and more. This results in chronic worsening by design.

These counties should never be abused and yet they have always been abused by health, education, training, economic, health insurance, health access, and other designs. If you do not understand this, perhaps some personal study is needed in these areas.

These counties have always had health professionals least like them and the health care financial designs result in much higher costs for turnover ($100,000 per FTE of primary care per year) along with lower productivity and lack of local leadership contribution. The training is also the opposite of what they need and is most likely to shape graduates to follow the financial design into most urban highest income places with concentrations of most everything - like their origins.

Why Would These Solutions Work

These community base solutions do work. They help outsiders to understand the people and those who serve them. They work to begin the process of transforming the population. They help unleash the resources from within the population.

McKnight and Asset Based Community Development Kark, Salber, and others demonstrated the value of COPC and other community based interventions. They came in to South Africa from the outside and were trying to fix the high mortality rate from traffic accidents. They found an entirely different environment and began by trying to understand and to work with the population on their most basic needs - rather than forcing solutions that were important to them, but not relevant locally.

These lessons for those willing to learn help to teach that the solutions for populations most behind are about them and derive from them. Those attempting to solve their problems from above predominantly selling something that benefits them.?

I contest the statement that DPC is for them - because DPC has not yet understood them or been designed for them. In the early DPC postings, turns out DPC was multiple times more likely to serve those with over $100,000 income. Of course these are people doing better to best that figure out such good deals while those Americans most behind are dealing with many other problems.?

But direct contracting for entire regions - has merit.

I would also point out the example of SERPA/Blue River Valley moving to RCCN in southeast Nebraska built by dedicated rural family docs working to retain community control of as much health care as possible working with local hospitals and employers and more - despite state lack of cooperation and big health nearby fighting them. Their efforts to work with local employers to help their benefits managers improve products for them and for their employees - are notable. Their office manager roundtables and group purchasing should be examples for all.

I continue to find it hard to understand why this model is not explored and widely discussed in AAFP meetings, media, and more.?

If you want solutions for most Americans most behind - you actually have to work with them and understand them and work for them specifically. See through promotions to see real solutions - by design.?

Bob Bowman

Basic Health Access