Wednesday, January 16, 2013
Friday, October 26, 2012
Numerous documents indicate the reasons for increasing US health care costs. Most are written by the designers of health care. This puts them in the unique position of not understanding health care cost, quality, and access from the perspective of most of the American people as they care so little for them - by design.
Robert C. Bowman, M.D.
SMART Basic Health Access
Saturday, December 31, 2011
Prevention of Primary Care Recovery By Design
- The cycle starts with primary care deficits.
- Innovative academicians create new sources of primary care. The designs are generic to workforce needs and are not specific to primary care or most needed primary care.
- Despite more sources and increased graduates in each source, there is less primary care result per primary care graduate. Studies contribute to the confusion as they only measure first career choices which fail to capture steady departures from primary care in the years after graduation. Only about 30% of US primary care training results in primary care delivery.
- Innovators propose to fix primary care with more types of primary care and further expansions of annual graduates. Others say that primary care can be fixed with reorganzation (continuity home) or innovative payment designs. No such proposal can work without changes in the US policy construct that increase primary care retention in professionals and other personnel - this requires more primary care spending, especially in 30,000 zip codes with lowest spending by design.
- US policy does not change and this results in less retention of primary care graduates within primary care careers with flexible primary care graduates departing primary care during training, at graduation, and each year after graduation.
- The result is ever more non-primary care with continued deficits of primary care.
Friday, December 30, 2011
Even optimal states such as Oregon that are far ahead in developing state plans, those in charge cannot tell how much spending will be invested and there is a vague mention of three different types of plans. As a physician delivering care, I can tell you that a major problem is variation in health care plans. Even if people can access care, there is great uncertainty with regard to getting basic medications, referrals, or hospitalization.
At some point people who promise more for less should be held accountable. Innovations and reorganizations are spectacularly unsuccessful, especially in areas such as basic health access where the United States has failed to invest in many dimensions.
What If Our Nation Had a Different Design for Entry to Medical School?
Medical students before and during school are not known for substantial time availability, but what they have can be spent working with patients part time in their homes to save substantial costs. it is interesting to see energy invested in a grassroots human being effort rather a focus on research. Medical students at the School of Osteopathic Medicine Arizona have one of the most intense first years of training, yet several have found the time to devote to a home care prevention of readmission. This is a partnership between the students, the hospital, and dieticians. The results in the first two years have been outstanding. Also this was accomplished with little treasure or specialized talent. The model reinforces being there in a caring way helping patients to maximize their health - rather than more and more health care services required.
Imaging 50,000 applicants pursuing medical school based on grassroots service efforts rather than devoting hundreds of hours for research (or 250,000 applying for health professional school positions). Imagine tens of thousands working with patients, families, and neighborhoods on better health outcomes in more than just readmission.
Tuesday, December 27, 2011
- Enter primary care practices at highest proportions after training
- Stay in primary care practice at highest proportions in the years after graduation
- Have the longest health professional career lengths
- Remain active in practice during a career at the highest percentages
- Deliver the highest volume of primary care when active in primary care delivery.
- Are most likely to be found in 30,000 zip codes with 200 million Americans and only 25% of total workforce (Practice Locations Outside of Concentrations) and
- Are least likely to be found in 1000 zip codes with only 11% of the population and 50% of the workforce (Super Center Concentrations).
Number 1 is United States Origin Family Medicine from a US Medical School
25 Standard Primary Care Years
Estimated Range of 23 – 30 Standard Primary Care Years depending upon age at workforce entry, gender, retention in primary care
Number 2 is United States Origin Family Medicine from a non-US Medical School
22 - 25 Standard Primary Care Years
A slight delay in entry to practice is likely to result in the potential for lesser workforce, but there may be no difference
Number 3 is non-US Origin Family Medicine from a non-US Medical School
20 – 22 Standard Primary Care Years (but broad range)
Medical education in other nations commonly results in younger age but those working toward US training and practice face delays that result in older age entry to US workforce
First career and practice location choices are simply insufficient to assess primary care sources. The Standard Primary Care Year is an important estimate of future primary care delivery assigned to the class year of graduation.
Pediatric and Medicine Pediatrics
10 – 14 SPCYrs
Less than half and likely less than 40% will remain in primary care.
Physician Assistant Beginning Family Practice
Steady departures over the years after graduation limit outcomes.
Nurse Practitioners Trained as Family Nurse Practitioners
6 – 8 SPCYrs
Half will be active as direct care clinicians in family practice employ. Fewest years and lowest volume result in substantially fewer SPCYrs.
3 – 5 SPCYrs
Few enter primary care and departures continue after graduation.
Physician Assistant not Starting in Family Practice
1 - 3 SPCYrs
Family practice is the predominant PA primary care vehicle
Nurse Practitioners not FNP trained
1 – 2 SPCYrs
Family nurse practitioners are the predominant NP primary care vehicle
Nurse practitioner and physician assistant contributions to rural or underserved locations in need of workforce are multiple times greater when employed in family practice as compared to NP and PA not family practice employed. NP and PA graduates not employed in family practice remain below average in needed practice locations. About 25% of NP and PA workforce are found active as family practice clinicians although declines could result in fewer.
Saturday, December 24, 2011
The WWAMI program has long been promoted as a solution for states in need of workforce, even as states such as Alaska spend 1 million more dollars a year on primary care recruitment, retention, and locums costs alone. WWAMI has the same problem as all rural models - it leaks. The graduates have not been required to stay instate or in needed careers. The graduates are not admitted with a commitment instate or to family medicine or to rural practice or to underserved practice. The major WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) state needs remain the same - family physicians. With inadequate family physicians, locations in need of workforce are forced to pay more and more to get the same or less workforce.
Marginal and underserved rural proportions have certainly not improved for the University of Washington in the AMA Masterfile. There was an 11% proportion prior to WAMI and down to the 8 - 9% level for 1994 - 2000 graduates. The 20 - 30% family medicine level is now down to one-third this level. The rural contribution of the University of Washington have not improved at best and there are indications of steady declines.
The main reason for success and failure appears to be the same reason. During 1965 to 1980 the United States poured billions into health care and much of this went to marginal and underserved locations with high proportions of Medicare and Medicaid patients. The 1980s cost cutting designs with increasing costs of delivering care and less revenue resulted in declines. Then the 1990s again injected funding specific to rural locations and primary care where needed for a few years before returning to cost cutting and major declines across all graduating classes of MD, DO, NP, and PA.
- Medical schools that do much better for rural outcomes are medical schools in rural locations.
- Osteopathic public medical schools have also been outstanding sources of rural physicians, instate physicians, and family medicine.
- Medical schools in the South also contribute more rural physicians, but this has to do with higher levels of rural population
- Medical schools in the Midwest also contribute more rural physicians for the same reasons - a state with a higher proportion of rural workforce.
Only complete school designs have made top contributions to rural workforce including rural located medical schools and osteopathic public schools. Only the family medicine proportion can be consistently demonstrated to have top health access contributions. Except in a few states (states that tend to have top workforce concentrations that drive FM out), family medicine is also associated with top instate retention. This is noted in University of Kansas graduates choosing family medicine that have 16 times greater instate rural location compared to U of KS grads not choosing family medicine. Family medicine has been the result of admission of students with factors contributing to instate most needed health access and family medicine contributes to instate most needed health access.
Graham Center Policy One-Pager Comprehensive Medical School Rural Programs Produce Rural Family Physicians While the title is true, the parent institutions do not have overall rural workforce gains. Also the parent institutions have barely above average rural contributions.
Which Medical Schools Produce Rural Physicians - a 15 year update
This is Blog Number 50 for Basic Health Access Blog begun in 2011.
Barriers To Primary Care Innovation Regarding Training: Too Many Stages in the Path Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many (non-health access interested parties) determining training curricula, and very few focused on basic health accessPounding Poverty Providers with Pay for Performance Designs that send even less dollars to those who care for most Americans are the reason for health access problems. Pay for Performance designs make matters worse resulting for gains in revenue for those that care for patients who naturally have better outcomes and no gain for those who care for the more complex patients.
Speak Your Piece: Measuring Rural Health Care Rural health care providers are paid less to provide treatment to a population that is more likely to be poor than those in the cities. Now medical researchers are saying rural hospitals don't provide the same quality of care as those city institutions that have more money and richer patients. Well......Which is it, JAMA? Where is your consistency in articles regarding quality of care? If you choose some authors that consider social determinants and other important limitations but ignore these factors in other publications, this causes confusion.
Non-Specific Rural Pipelines or Specific Long Term Obligations Voluntary choice allows potential rural physicians to steadily leak away with each year of training and practice. Only very specific shaping is most likely to result in early, middle, and late career rural contributions.