What Prevents Americans from Having Personal Primary Care

It is a great idea to have a personal physician. It is interesting that the National Academies has brought this up. But these learned scientists still have a lot to learn - especially about their academic and administrative colleagues that most influence health care design.

The United States has never had a financial design that would support a primary care physician for every person. It has never come close. It has only had progress toward this goal from 1965 to 1978. Since the 1980s each passing year or fad or bandwagon has moved the US away from this personal primary care physician goal.

This is best seen in 2621 counties lowest in health care workforce that have always had half enough generalists as well as general specialists. Moving from 46 primary care physicians to the required 90 per 100,000 as HRSA has long recommended - as never really been on the agenda of those who shape, design, and maintain the past, present, and future maldistributions of all health care professionals.

Prevention of Primary Care By Design

In Preventing Rural Health By Design published in Rural and Remote Health in 2014, Michael Halasy and I illustrated the ways that designers prevent rural health care in the US.

• "With 2.7 trillion dollars in annual health spending, America has no excuse for designs that have failed for decades with regard to rural health workforce development. Rural workforce failure can best be understood as the inevitable result of failure by design. Designs for revenue are insufficient to support the rural clinician workforce that would resolve deficits. The designs of health professional training are not specific to rural health needs."

The trail to the understanding of insufficient finances goes back to my rural primary care practice paid less for primary care services, less for Oklahoma, less for Area 99 Oklahoma, and 15% less by Reagan cost cutting thrust on new and vulnerable physicians like I was in 1983. Financial designs have been creative - but this creativity is driven by cost cutting with a new bandwagon focus of improving quality added later.

But primary care suffers steadily as seen in my Standard Primary Care Year studies in 2008. The SPCYr estimates of primary care are based on the class year of graduation. The estimates are made at the beginning of the health care professional career using primary care retention, activity, volume, and years in a career specific to each type of primary care. These studies can be compared over periods of time to see what is happening and the answer is sobering. The studies demonstrate continued declines in the primary care delivered over the careers of all sources - MD DO NP and PA. This remains mostly because fewer and fewer graduates enter primary care or remain in primary care.

Sadly this is quite logical, but academic and micromanagement dogma is difficult to reverse.

I updated the Standard Primary Care Year studies in the following table with comparisons of then and now as former sources of primary care dry up and blow away with the financial design. As primary care retention declines, it takes more graduates to provider the same amount of primary care - defeating training more as a solution. Family medicine remains the best source, but has declined from 25 to less than 14 Standard Primary Care Years delivered over a career. Nurse practitioners remain one of the worst sources as they have lowest levels of retention, activity in practice, volume, and years for a career.

My Standard Primary Care Estimates based on 2008 and predictive of the primary contributions of graduates at their time of graduation were wrong - because the primary care retention levels have fallen faster than estimated. Expansions of annual graduates completely fail to improve basic health access and will continue to fail as long as the financial design defeats basics and favors the most exclusive who are best financed and can enjoy more and better team members as well as better salaries and benefits.

But the Deceptions and Lies and Assumptions Continue

The SPCYr studies as well as studies that consider entire career contributions illustrate why some of the sources such as international graduates that have often been promoted as solutions, turn out to be the worse sources. This is because so few stay in the United States and remain in primary care and are found where most Americans most need care.

• Sadly the literature has studies that only include those who stay in the US and remain active (about 60%).
• Also the studies consider only the first few years in their careers which at the time were largely shaped by obligations which required primary care and distribution - which they have not maintained beyond this period.

The Graham Center also exposed this, but little is done. The experts still promote this low yield source, other low yield sources, and lobby for more graduates.

Some even lobby for more sources such as assistant physicians or clinical pharmacists despite the obvious failure of the new sources of the past 60 years - family medicine, nurse practitioners, physician assistants, and medicine pediatrics. Geriatrics fails miserably because the financial design hits hardest where there is inadequate payment for basic services attempted on the most complex patients.

The fact of the matter is that the health care and political designers act in multiple ways to prevent most Americans from having decent health access, much less a personal physician. The alternative agendas win, and most Americans lose.

Those who most influence health policy prevent the true and necessary financial reforms at the state, federal, and insurance payer levels. Three areas are quite obvious:

• A) No one is increasing dollars for health care, so
• B) There must be a redistribution of existing dollars. but most important
• C) Those that dominate reimbursement have stated that they they will oppose any shift of funding from procedural, subspecialty, technical to increase funding for primary care and basic services.

AAMC made such a statement recently. Many health care associations and their representatives have acted on this. This is a major mechanism that deflects reform attempts from substantial and necessary to marginal in impact and abusive to health care teams doing basic most needed services.

Look closely at this type of statement. They start with their support for more primary care dollars, but they add a catch. They would not support this at the cost of health care near and dear to them. Internal medicine trained physicians may be more sympathetic to their few remaining primary care colleagues. They also support more funding for primary care, but once again the research done demonstrates that they are against this funding if it cuts into their own revenues.

• More for fewer at higher cost leaving less for most Americans even in basic services - is the American Health Care Design. There is also little change in outcomes as costs blast ever higher and compromise the American nation - far beyond health care.

The academics and biggest systems and hospitals and practices doing best feel that their needs are so important in their minds that they are not willing to sacrifice a few billions so that most Americans could have decent levels of local workforce available to them for the first time ever. The primary care in 2621 counties lowest in health care workforce had just 38 billion in 2008 with regard to primary care spending. They needed 80 - 90 billion to be able to resolve deficits for this 40% of the population. The designers have made their situations worse by reducing what they can spend to less than 30 billion (more details below).

Payers Don't Pay

State and insurance company plans have also resisted this much needed change in health care financing also. They tend to follow the federal designs - which clearly pay less for the basics and even less where most Americans most lack care.

True reform redistributes dollars to boost up deficits of generalists and general specialists which remain at half enough for half of the population.

Health Equity in Health Care Design is Denied By Design

True health equity with regard to health care financing designs - demands true reform. Movements toward health equity are within the grasp of health care designers. But this must involve movements of dollars from most concentrated to least concentrated. They can do best in health equity by a redistribution of dollars to the providers paid less and punished most by their designs. Their various plans pay 15 - 30% less for the same practice and hospital services - punishing those most in need of dollars just because they are serving populations that have the worst finances and worst health insurance plans.

You can speculate that Medicare for All would address this or any move away from employer based health care where the worst employers have the worst paychecks, benefits, and health insurance plans. But currently this will not work until the groundwork for true reform is laid. The reason that it will not work is quite obvious. Past changes have been based on the previous designs. It is incredibly difficult to get new and increased dollars. Underpaid in 1960 is still underpaid in 1980 and 2000 and 2020 and 2040, etc. Once again the problem stems from a poor understanding with regard to the abusive impacts of past, present, and proposed health care design changes.

What the Designers Do Not Consider

Smaller and medium size practices have more Usual Disruptions as Mold describes such as changes of key personnel, billing, EMR, ownership, and location - and this was not an exhaustive list of the various situations and conditions more common in counties lowest in health care workforce as employers, employment, social supports, and other areas change. Designers focused upon adequate reimbursement for adequate workforce and access would understand and implement changes in finances to facilitate the goal of basic health access for all. Instead their constant changes interact with the Usual Disruptions to make the situations worse.

Smaller and medium size practices are harder hit by changes and rapid changes are rapidly hurting them more. Generally it costs more by tens of thousands of physicians for the various disruptions such as HITECH, MACRA, primary care medical home, and value based designs. This is also why these micromanagement "advances" have had low penetration. I based my estimates of higher costs of delivery on only a 30% penetration of these policy changes and came up with a billion dollars a year in added costs - a major force in worsening access and health equity.

Practices where most needed have populations and employers that can support them less. In Why Most Americans Should Not Celebrate Obamacare I illustrated many ways the ACA caused harm for these counties and their practices. Few designers seem to understand that health insurance expansion is not the solution when the problem is the worst health insurance plans concentrated in these counties - shaping deficits of payments and deficits of workforce. These 2621 counties had 40% of the population and about 40 - 41% of the unemployed and uninsured in 2010. They did not lack for health insurance more than other Americans - they just have the worst plans. This is shaped by the worst employers who pay local people less and pay less for benefits and contract with the worst health insurance plans for their employees.

Once again, if you do not consider these populations, their employers, their health plans, their situations, and their practices - you should not be designing health care for them.

Medicare and Medicaid plans could boost payments to support more revenue, but often pay less than the cost of delivering care to the patients being "covered." So the health plans contract care to less and less rather than supplementing local workforce and basic health access.

But What About Primary Care Progress - Sorry, No Progress By Design

My studies and Graham Center studies confirm flat lined primary care workforce and flat lined spending on primary care. Note how the non-primary care MD DO NP and PA continue to increase in a pattern similar to US health spending - and the expansions of these more costly areas require more such workforce. But primary care remains flat. And you can also consider other areas that used to generate revenue for primary care physicians such as hospital, emergency room, procedural, and other services - have been designed away.

Pay Attention. If You Double Annual Graduates and the Result is No Increase in Primary Care Result, Expansions of Annual Graduates Does Not Work to Boost Primary Care

PA and DO annual graduates have been increased by about 5% a year since the 1960s and they double about every 14 years, but the last doublings have resulted in no increase in primary care as the proportion found in primary care for those graduates has declined by half. DO primary care has predominantly been about family medicine but the family practice result has declined from 60 - 65% in the 1960s graduates to 35% by the 1990s graduates to 18% for the 2010s graduates - and the recent consolidation of GME gives DO graduates many choices outside of family medicine compared to the past - with further declines.

US MD expansions are associated with a decline in primary care yield for the class year. This is the result of fewer entering and staying in primary care. US MD expansions are therefore contraindicated as a solution for primary care and for 2621 counties lowest in health care workforce. Internal medicine was once about 160,000 primary care physicians but lining up IM residency graduates by class year in the Masterfile indicates declines to about 1000 found in primary care and active. This translates to eventual decline to just 30,000, not counting 50,000 IM grads lost to hospitalist careers more recently.

NP are subject to the same declines with primary care down to 25% in one of the few quality studies in this area done by the Oregon Center for Nursing. It is true that primary care numbers are up, but non-primary care numbers are increasing by far the most as NP and PA add more new specialties and more to each new specialty - leaving primary care and distribution farther behind.

The Designers Must Understand That

• All sources of primary care are declining in the important area of retention in primary care.
• Massive expansions of MD DO NP and PA annual graduates have not budged primary care levels.
• Primary care team members have been given more to do of higher complexity while their support is eroded away - the very definition of burnout, especially for those who value care and caring.
• They are creating the least experienced primary care workforce in the history of the US.

Lack of experience is the result of massive expansion, worsening retention in primary care, lowest activity levels, lower volume, and fewer years in a career as is best seen in NP. When you graduate over 40,000 and only 10,000 leave and the massive expansions continue as the financial design drives away those with primary care experience - you guarantee a less and less experienced workforce.

Normally about 3% to 4% of the workforce of physicians or nurse practitioners would be replaced each year by annual graduates in steady state or low growth of demand situations. So many with so little experience represents a problem that science should address - but has not.

This is another failure by design. Little is known about the microenvironments of primary care practices or the impact of inexperience. Clearly the workforce indications are bad and getting worse - and yet there is no study at all. This is a failure of the scientific community.

Almost as bad are the collections of quality and cost research studies that have major bias across the entire design from funding to publication. Few if any can explain that differences show are not explained by population differences. There has been no academic rigor applied. Studies are even published when those who sponsor studies retain censorship - a guarantee that no negative study will be published. CMS actually did this and got away with it regarding value based care. https://www.dhirubhai.net/pulse/value-based-payment-problems-deadly-basic-health-access-robert-bowman/

The National Academies and Others Who Desire More Primary Care Should See that the Solutions Are Beyond Biological Sciences. The solutions are in the area of political sciences.

Researchers or physicians can cause harm when they proceed with assumptions, even based on good intentions. At the current time, micromanagement dominates the belief system with regard to improving primary care.There is absolutely no talk of powering up primary care with a more powerful financial design. Even AAFP and other primary care advocates fail to see how value based designs power down and punish primary care - by distracting the designers from the financial design solution and by promoting higher costs of delivery forced on primary care practices - with little evidence of changing more than process as the evidence based review indicated in Annals of Internal Medicine.

The real problem is the inability to consider that good intentions and long held assumptions - are causing harm. At best the designers do not understand most Americans and what remains of their health care. At worst they do not value them.

Stop Crying Wolf About the Crisis Physician Shortages

Academic releases to the press emphasize this constantly. But there is no crisis. There is no immediacy to this. There is no danger so there is not danger and opportunity as the Chinese interpretation of crisis states. There is an opportunity to realize the problem, but the opportunity in the crisis rhetoric is exploited by those who have their own agendas - preventing basic health access for most Americans.

There is a need for action, but there has long been no action specific to the solution. The diagnosis has been made, but the treatment given is not the correct treatment. It is an ethical and moral violation to proceed with treatments that fail when their are solutions or even cures. There is a financial design cure, but this will never be adopted if shortage solutions are deflected away from financial design solutions.

There has always been such a shortage - particularly in generalists and general specialists where most needed.

• A crisis focus with massive promotion is simply the means to the end of more annual graduates, schools, programs, and more funding for training. You can guess who benefits from Crying Wolf and generation crisis immediacy. But this

Even worse the various research, academic, and other entities have promoted policy changes that violate research and scientific guidelines . They have adopted policy changes that impact tens of millions of Americans, particularly the Americans most behind in a nation of adverse designs. The design changes have proceeded

• without a focus on beneficent intent,
• without protection of vulnerable populations,
• without informed consent,
• without the proper discipline of health policies and plans that are abusive, and
• without proper scientific study.

Many forget that there were known violations of PPS/DRGs such as dumping patients out of hospitals and short staffing nurses. There were guidelines developed to address this - that were ignored. I have pointed out numerous flaws in ACA/Obamacare that are easy to see once you grasp the perspective of the 2621 counties lowest in health care workforce where the worst plans are concentrated - the ones that pay less than the cost of delivering care to insured patients - like the ACA and Medicaid expanded plans.

The Real Intent of the Designers Remains Clear Since the 1980s - the Era of Cost Cutting Dominates

The primary focus has been to cut costs - even with known consequences not only to patients and caregivers and families but also to the delivery team members. I critiqued the CMS Innovation Center early on for having cost savings at the heart of almost every project. it is not surprising it is 5 for 52 in successes.

Cost Cutting Focus Plays Out Worst for American Populations Who Need More Investments - Who Suffer from Underutilization from Poor Access from Lowest Levels of Basic Health Workforce

The science of primary care distribution also needs to be understood by our scientists. To do this primary care physician for every person level of primary care access takes about 90 primary care physicians per 100,000 according to HRSA. The financial design currently allows just 46 per 100,000 for the 2621 counties lowest in health care workforce with 40% of the population. This still requires that some travel 1 or 2 counties for primary care which I used in my determination of the 2621 counties lowest in health care workforce (smoothed for adjacency across the US).

There are reasons to have even more than 90 primary care physicians per 100,000 supported in these 2621 counties to overcome insurance barriers to care, turnover levels, patient transportation problems, and peak load problems such as October to April illness spikes. This illustrates the problems of marginal designs shaping marginal workforce while designers throw more meaningless tasks at what remains.

The primary care where most needed has too little funding, too few delivery team members, and too much to address made worse by rapid changes in policy designs that increase the challenges.

The primary care in these counties faces 45% of patient complexity (older, diseases, conditions, behaviors, lower outcomes) concentrated in this 40% of the population but the financial design supports just 25% of the primary care workforce via 20% of primary care spending.

• 45% of mental health for 40% with 23.5% of mental health providers (ARF) supported by less than 18% of mental health spending
• Women's health...
• Basic surgical...
• Geriatrics at 45% of need for 40% of the pop with just 15% of geriatricians - the list goes on

You can excuse the more specialized workforce from distribution because they often require facilities or other ancillaries, but we must never excuse the US health care designers from not supporting sufficient generalists and general specialists - that must distribute to facilitate access and care for populations with low or no access.

Why Tolerate Designers and Designs That Shrink What Remains?

The money that primary needs to expand is actually contracting. Stagnant revenue, increasing usual costs of delivery, and increasing costs of micromanagement will do that. Based on the above, these 60,000 physicians in primary care in 2621 counties lowest in health care workforce had 38 billion to invest in primary care delivery in 2008. After HITECH to value based, they have less than 30 billion that goes and stays in their hands to invest in primary care delivery.

Even worse, these 2621 counties have been growing in population numbers, demand, and complexity at the fastest rates for decades. Middle and lowest concentration physician counties are growing fast while higher concentration counties are slow to grow or are stagnant. The evidence points to increasing health care failure by design. Also the rate of growth indicates 50% of the US population in these 2621 counties by 2060 - up from 40% in 2010. There is no indication of any improvement as hospitals are being closed and compromised along with practices.

Where Has the National Academies Been

Previous contacts focused on the usual training solutions. Many solutions have been proposed. Training solutions advance and financial solutions get buried.

The National Academies have just produced more paper like COGME and others dating back 28 years.

GAO has indicated the inability of Graduate Medical Education to meet the primary care workforce or distribution of workforce. Of course the academics want more billions for GME - great for them as a source of cheap labor. But designers ignore important studies and reports and recommendations, while continuing to do what works for their kind.

There is much the research science community could do such as redirect primary care research away from quality improvement to more relevant topics such as too much workforce or least experienced workforce - by design. https://www.dhirubhai.net/pulse/please-advise-most-relevant-primary-care-research-robert-bowman/

Academics must also be reigned in or at least should be forced into areas of study to see why their recommendations are not helping. https://www.dhirubhai.net/pulse/academics-must-stop-overproducing-graduates-claiming-solution-bowman/?

It is time that researchers critically examined the health policy decisions of the United States. Those who make decisions impacting tens of millions should be held accountable just as we hold physicians or human subject researchers accountable for their practices or research. https://www.dhirubhai.net/pulse/so-much-ahrq-hrsa-primary-care-researchers-could-do-reverse-bowman/

A close review of the workforce changes over the last 70 years reveals that the only time that the United States has made any positive gains in hospitals and practices in these 2621 counties was 1965 to 1978.

But this one time gain with substantially more billions going to health care in these counties plus annual increases to cover for the increased costs of delivering care - came to an end for one big reason - BIG HEALTH COST OVERRUNS.

The bigger systems and practices abused the initial Medicare and Medicaid designs resulting in health care cost accelerations - and forcing cost cutting efforts which have played out poorly for most Americans and what remains of their health care. Those with ready access to politicians and trillions of dollars and academic designers - shape designs their way and avoid the cost cutting intentions quite nicely.

• No one should indicate that cost cutting is a solution for these counties paid lowest in 4 dimensions where the local population suffers from underutilization, not overutilization as is assumed. How can you cut costs when the practices and hospitals and services highest cost - are protected from cuts? The massive increase in administrative, management, drug, and hospital costs conspire against basic services where most needed.
• No one should should indicate that performance based or value based designs would be good for the remaining providers that face the most complex patient that inherently have lesser outcomes with half enough workforce and half enough team members and half enough social supports.

How Long for Basic Health Access for Most Americans – the Ones Who Remain Most Behind Why do we tolerate health access focused associations and foundations when they fail to put their mission areas as the top priority – or when they support micromanagement focused policies that make basic health access worse. https://www.dhirubhai.net/pulse/how-long-basic-health-access-most-americans-behind-robert-bowman/?

Micromanagement is suspect for Value and May Worsen Outcomes – By Design https://www.dhirubhai.net/pulse/micromanagement-suspect-value-may-worsen-outcomes-robert-bowman/

Designers Fail To Grasp the Microenvironment of Primary Care - the One that they continue to make worse. Suggested reading is Shifting Implementation Science Theory to Empower Primary Care Practices by William L. Miller, Ellen B. Rubinstein, Jenna Howard and Benjamin F. Crabtree in The Annals of Family Medicine May 2019, 17 (3) 250-256; DOI: https://doi.org/10.1370/afm.2353 at https://www.annfammed.org/content/17/3/250.full.pdf+html