Why a Native American Medical School Cannot Deliver on Promises Made
Promises are being made that a Native American medical school will resolve rural reservation deficits of primary care. It cannot. Promises are being made that this new school will return Native American physicians to their origin locations. It will be greatly limited in the ability to do so. The financial designs for health care for Native Americans, rural Americans, Medicaid, primary care, and general specialty services are the reason for basic health access deficits and deserts of health care workforce. These are outside of the ability of tribal reservations or medical schools or nurse practitioners or physician assistants to address.
Rural health deficits remain despite decades of efforts.
Rural health experts and rural health associations remain convinced that training can fix deficits of workforce. They point to programs and schools that do very well, but the deficits remain. Those doing the training promote their training well, but the deficits remain. The financial design does not change. The services available locally are lowest paid basic services and they are paid at rates 15 - 30% lower for rural practice and rural hospital services. Increases in the cost of delivery from usual sources have been difficult to overcome and the mandated innovation and regulation costs have made finances worse. Rural and also small hospitals have been closed by the hundreds and continue to close at 1 to 2 each month - by design. Practices are compromised and closing by design.
- The solutions are almost entirely financial - but are difficult to make for those with less power.
Osteopathic graduates appear to be a solution
High levels of family practice result have contributed to primary care, rural, and underserved contributions for osteopathic graduates. But the osteopathic family practice outcomes have changed over time. Osteopathic annual graduate numbers have doubled about every 14 years and each time the family practice result most important for distribution has been cut in half - for no gain in primary care or care where needed. The same is true for physician assistants. Even faster growth in NP graduates has not resolved deficits. US MD graduates have increased 35% since 2003 and the primary care result is shrinking despite the increase in graduates. Even fewer enter and remain in primary care. More choose fellowships and highly specialized training, even when starting in primary care after primary care training.
No school or program across MD DO NP or PA should ever make a claim of being able to solve shortages of workforce unless they can singlehandedly change the financial design specific to primary care in these practices and locations.
- The deficits discussed by OSU and tribal leaders are about the financial design. They are specific to primary care for Native Americans and for rural Americans. The financial design failure involves Medicaid, Medicare, and other worst public and private health insurance plans. Where these plans are concentrated, they create and maintain deserts of primary care, mental health, women's health, general specialists, and Basic Health Access. (and since these areas have lowest levels of workforce, it looks like higher levels of workforce are a solution - wrong again)
There are major consequences when health professional training schools or programs make false claims and believe in these claims
It could be said that they are exploiting rural populations or Native populations or populations behind in basic health access for their own gain.
More politically correct statements would indicate that many programs, schools, and leaders believe that training more or special training can fix deficits. This is what they have been taught by past leaders and deans and association efforts. This thinking represents assumptions passed on for decades.
- Even simple math involving basic economics and dollar distributions reveals the truth - and movements away from workforce solutions over time.
Massive Expansions of Four Sources of Health Professionals Have Not Resolved Deficits
Massive expansions of MD DO NP and PA graduates for decades at 6 to 12 times the annual population growth level have not fixed deficits and deserts. Many claims have been made of successes - despite obvious failures for tribes, rural populations, and most Americas with half enough generalists and general specialist.
The dollars needed to pay for the workforce and team members to resolve deficits - are not there.
The ultimate consequences will involve substantial numbers of MD DO NP and PA graduates
- As far too many are produced and
- As the health care dollars going to health professionals remain stagnant with pay and benefits being marginalized already and
- As the four main types of health professionals with too many work to undermine each type
- As health care systems and other employers are fewer and larger and more powerful with health professionals moved to a lower role and rating scale.
Readers are encouraged to understand the consequences that all but those nearing retirement will face with too many graduates, stagnant health care dollars going to health professionals, continued cost cutting, and a low priority placed on health professionals by the fewer and larger health employers. The various types are already being undermined by each other with more to come. Independence and autonomy are often promised, but are also going away.
American Health and Education Designs Reflect American Values, or Lack Thereof
Deserts exist because our nation does not value certain people or nutrition or primary care or pharmacies enough to resolve the deficits. Rural locations, Native Americans, and primary care are all not valued. Primary care, basic services, smaller practices, office services, and cognitive services are not valued so the primary care and mental health and women's health deserts continue and worsen.
There are many more deficits and deserts that exist by design. There are still deficits of running water, sanitation, bandwidth, electrical power, and basic government services for those not valued.
School funding is often based on property taxes with states making up some of the gaps to help with education funding for low property value school districts. States often fail to address these gaps. Other states are bowing out of education funding.
Not only do health care designs cause insufficient primary care, designers are worsening deficits by the forced addition of metrics, measurements, and micromanagements.
- Point to ponder - How can it get worse for Native American primary care? They are lowest paid in primary care in states with lowest payments and with plans that pay the least and with plan requirements to pay more for costly measurements that also disables their primary care delivery team members with additional burdens - that also decrease revenue due to lower productivity.
- About 130 million Americans reside in 2621 counties with 40% of the population. These counties lowest in health care workforce concentrations had about 60,000 primary care physicians in 2008 and these practices received about 20% of primary care spending to support 25% of the primary care workforce to attempt to serve 40%. They received and could invest 38 billion in their primary care delivery.
- Since 2008 the expansions of HITECH to ACA to MACRA to PCMH to Value Based designs have done little to increase revenue but have required about 1 billion more a year leaving less than 30 billion to invest in primary care delivery.
Only 30% of the practices could implement these changes because of poor finances and other reasons. Tragically these physicians are blamed for not being progressive - when the changes are forcing physicians to try to get by with fewer and lesser team members while working a second job to prop up their failing practice. The corporations, consultants and experts that design their finances - steadily make their situations worse and force them away from the practices, patients, and communities that they love.
- Going backwards in finances is the wrong way for solutions - and the worst financial declines are seen in practices involving cognitive, office, basic, most prevalent,and most needed services. All but the largest practices and systems have been hit hard by constant policy changes worsening the costs of regulation and innovation.
OSU, tribes, rural associations, and primary care associations have not addressed the financial design. Medical schools and powerful physician and hospital associations fight against shifting health care dollars from procedural, technical, hospital, and subspecialized services to pay for the basics.
Primary care associations call out those who lobby against a redirection of health care funding toward primary care, but they also cause damage to primary care delivery. Some primary care associations and foundations that say that they support primary care and health access but support costly and burdensome metrics, measurements, and micromanagements.
Medical education leaders that say that they want to resolve deficits or promote health equity should first support better distributions of health care dollars rather than opposing distribution. Primary care associations and foundation efforts should focus on better finances and support, not designs that disable finances and primary care team members.
America Does Not Value Rural People or Most Americans Most Behind
About 12% of the US population is found in rural settings with half enough generalists and general specialists by design along with 32% of the urban population. This is seen in 2621 counties lowest in health care workforce for a total of 40% of the US population not valued - and growing to 50% by the 2050s. A majority treated like a minority is true for most Americans and for primary care.
The story of Native Americans long indicates abuse.
They are still not valued as only about $2000 per person is sent to Indian Health Services (previously 8 billion for 4 million people). This is one fifth the level of health care spending compared to average. Also many tribes have found that they can do better by managing their own health care.
Native Americans on Medicaid in rural areas are devalued in these three dimensions.
- Medicaid is one of the worst plans for patients and for providers.
- Rural located practices are often paid less and many do not get an outpatient facility fee as with hospital outpatient care.
- Medicaid only pays 70 - 90% of the cost of delivering primary care to Medicaid patients.
- Many providers fail to take Medicaid, another deficit by design.
These designs have not changed. In fact the practice finances have been made worse by the added innovative and regulatory costs of delivery.
IHS fails to pay enough and Medicaid forces practices to rob from other sources of revenue to support the care of Medicaid patients. Since the practices with high levels of Medicaid patients also tend to have higher levels of Medicare and other worst plans - the situation is even worse. Lower income levels and lesser employers in an area contribute to lesser plans and high deductible plans - the worst possible for local people and providers.
- This is what prevents adequate workforce.
Native American leaders or schools would have to change the financial design - to change primary care deserts into oasis-es. They would need state legislation, federal legislation, and health insurance cooperation to transform any desert into an oasis.
Am I Inconsistent in Community Based Medical Education?
Why would I oppose this new medical school expansion that appears to be decentralized and focused upon a population behind in workforce?
This author has long supported rural medical education, pipelines, and community based medical education efforts. But there are only pieces present in any existing, current, planned, or future medical school
This design does have Native American focus in origins and some aspects of training curricula and location. It does not line up all factors for long term retention in primary care where most needed.
This school will be subject to osteopathic certification standards. Native students likely to be excellent family physicians - may not graduate. Numerous examples exist for osteopathic and allopathic students that never became physicians. Many will be stuck with extra years of training and massive debt with inability to pay this debt off.
Training in a Native location is not the same as training in your own Native location. Their residency training after medical school may also not be Native American focused. After graduation, many are likely to choose specialties other than family medicine - the only specialty that has population based distribution. Osteopathic graduates were once 60% family practice but in each of three past doublings of DO graduates, the primary care proportion has been cut in half for no gain in primary care via expansion - none, zero, zip, nada. Their training will not be specific to their origins, to their future location, to family medicine, or to the situations of their practices.
There are designs that could address all of the above and much more. It turns out that reservations are the ideal training sites for these ultimate community based medical education designs (MD DO NP or PA)
Why a Native Reservation Would Be the Ideal Training Site for Resolving Their Primary Care Desert Situations
If you focus on reservation origins, preparation, selection, training, and obligation after training - all of the tumblers click into place. After a decade spent at a site before training and after another decade of college and training at a site and after a decade of obligation, essentially you will have all possible connections made for entire careers of service where needed. This is also the workforce most specifically prepared, trained, and retrained. It is also a far more experienced workforce than the current US primary care workforce where those who enter are few and those who stay in primary care are even fewer.
Reservations have the autonomy to set up their own types of health professionals and can easily argue that they require this because of a century of past failures.
Also if you create a new kind of health professional or physician
- You can train specifically for reservation populations, situations, and conditions
- You can best enforce local service for long term retention in a career. There will be few other options.
Native reservations would be ideal for the creation of a special medical school or health professional training. They could design the training that would arise from Native populations and train locally. Native reservations could set up their own certification and licensure for their graduates. This has been done successfully by nurse practitioners with their own certification and with online training. This design would allow them to be flexible in training and also very specific for Native practice locations. The Native Americans that did not want to practice in reservations would understand this from the start. They should only enter training if they planned to stay. One other change should be made. The preparation for this family medical school should be local involving health and education projects. The teens and young adults demonstrating their ability to work well with others, to work in teams, and to be change agents - would be selected for admission.
Preparation and Selection May Matter Most
Practices cannot change outcomes - but people working in the community and investing their time and energy with others can make a difference.
The reservation model has entirely different selections - which requires entirely different preparation. This preparation component may be the most important of all. The focus would not be the usual focus in traditional medical schools - on science prowess, prestigious college, great recommendation letters, performance during interview day, and standardized test scores.
Traditional medical education is faulted for not having graduates with shared origins, optimal in team interactions, and stellar in people communication skills. Admissions focus can be on service, but the focus given this area is small compared to science and academic performance. A better reservation physician would have stellar interpersonal skills with passable academics. The process best for Native and various rural or lower concentration populations would be specific to their needs.
Teens and young adults preparing for local tribal schools and practices and social work positions would work locally to facilitate population based projects and changes. And as local Tribal Teachers and Physician and Social Workers, they would benefit from a small army working in homes, with groups, or out in the community on projects.
Child development, health literacy, education, behaviors, parenting, and social determinant factors must be addressed. COVID has clearly exposed much about America - especially the lack of generations of preparation to best address this epidemic and those to come.
Fight Design Discrimination to Restore Basic Health Access - and Our Nation There are 3 very important reasons to fund basic services to a greater degree where they are most needed. We should fight for this even if the dollars must be taken from highly specialized care to be budget neutral. We have to fight for the basics and for those most in need, even if those doing well by the current designs fight back and oppose us.
Why?
1. BECAUSE THOSE PRACTICING WHERE MOST AMERICANS MOST NEED CARE NEED THE SUPPORT – and our nation fails them, and they deserve not to face discrimination by design
2. BECAUSE MOST AMERICANS MOST BEHIND MOST NEED THE SUPPORT– and our nation fails them, and they deserve not to face discrimination by design
3. BECAUSE OUR NATION CANNOT IMPROVE HEALTH, EDUCATION, ECONOMIC, AND SOCIETAL OUTCOMES – because the designers are making choices and shaping designs that make disparities and outcomes worse.
https://www.dhirubhai.net/pulse/basic-health-access-can-only-recovered-local-efforts-robert-bowman/?
If you understand social determinants, they you should fight value based designs that worsen social determinants and likely outcomes. Follow the dollars to see who wins and who loses. https://www.dhirubhai.net/pulse/social-determinant-focus-argues-against-value-based-designs-bowman/
Pipelines to primary care or underserved practices continue to fail to work to resolve deficits of health care workforce because the financial design has not resulted in increased dollars for the increase in that workforce. Specific training can improve the suitability of training, but is incapable of addressing the deficits. Those focused on addressing shortages need our nation to value most Americans and those few who remain to serve them despite half enough dollars and team members. https://www.dhirubhai.net/pulse/rural-primary-care-underserved-pipelines-still-work-resolve-bowman/
Why Do These Constant Promotions of Successes Bother Me So Much?
https://www.dhirubhai.net/pulse/ignoring-most-americans-behind-across-housing-health-education/?