Facilities For Basic Health Access
Bypassing the Inadequate US Health Access Facility Design or Movement to Real Infrastructure
Compromise in the most basic top priority areas for nations is never good policy. Basic nutrition and nurturing, family structure, child development, early education, basic access to health, basic public health, basic public security, and basic housing represent the foundation of a nation that leads to stability and optimal function even in times of great challenges.
The US has demonstrated complete failures in the policies that are supposed to result in basic health access primary care facilities. The US does not need patchwork Band-Aids. It needs real facility infrastructure.
Once the US had a broad range of types of facilities. Each addressed different needs. Also various forms could survive together. The current design has deteriorated far away from the needs of most of the population as well as those who would work in these facilities and deliver most needed health access.
Basic health access facilities could once be created and maintained by independent primary care physicians. Solo rural family physicians could begin and maintain practices at one time. Private primary care practices could survive even near academic centers as the support levels were less imbalanced. The US design began with maximum distribution as even the smallest practices could survive with a nurse and a family physician, but policies make this nearly impossible.
States, cities, and counties have also established basic health access, but states centralized and privatized and moved away from health access clinics. Counties and cities have moves away from uncontrolled health care costs as much as possible. Foundations were also able to help at the local and state level. Once started, the basic health access facilties started by Foundations (Sears and Roebuck, others) were able to be maintained, for a time.
Rural and small hospitals could also once support primary care, but this has become more difficult. For a time rural hospitals could shift hospital resources to support basic health access, but federal regulations and insufficient federal support led to declines in health access as well as closures of rural hospitals. Hospitals that attempted to maintain local primary care practitioners could run afoul of antitrust regulations. Large urban systems that had rural hospital chains dropped dozens of rural hospitals almost overnight as the hospitals could no longer be sustained.
Rural hospitals were given a new life with Critical Access funding, but this funding is hospital in nature. Critical Access hospitals also help to destroy primary care by converting family practice physician assistants and physicians into ER and hospitalist practitioners and by converting primary care physicians to hospitalists. Practitioners seeing larger volumes of patients in continuity settings were shifted to positions without continuity and without the efficient and effective care delivery. The capitated arrangements allow ER and hospitalist costs to be shifted to Critical Access facilities, but the cost to the nation is more primary care lost. Also desperate rural hospitals also turn to locums physicians and nurses and end up paying more and more for workforce to get less and less care delivery that fits local needs. Locums is also a mechanism that destroys existing continuity primary care workforce. Inherent in the process is dollars that could be spent on health care that are shifted to brokers, profiteers, enterpreneurs, and stockholders. The United States tolerates those who profit off of those desperate for basic health care. What is the next step? Elementary education only for those who can pay for school as in the most desperate nations? Once the US has a solid health access foundation, it can afford to let some pay much more for convenience care. Until nearly all of the US population has the reasonable access to basic care that is so much more efficient and effective, it must address exploitation in the name of health.
Multispecialty large group practices once supported primary care, but with primary care relegated to loss leader status by policy, specialists are less willing to supplement the primary care effort. Care can be coordinated between primary, secondary, and tertiary care venues, but not unless each segment can stand on its own. Primary care works as a foundation, but not as a loss leader for others not really focused on true basic health access primary care.
Medical schools could once afford to support primary care clinics, but closures and downsizing have been seen from Texas to Nebraska to Maine. Metro primary care levels were cut in half in less than a decade in Nebraska as state and federal policies conspired. The University of New England announced the closure of primary care services for 20,000 patients. While tragic, the situation is predictable. Federal governments have had policies that mandate much, but provide little support for the mandates. For all primary care clinics, more and more must be done just to provide basic care with increasing costs and with increasing regulations. For medical schools this is more difficult as other services have much greater return on investment. It is difficult to maintain efficient and effective primary care when hospital and specialty care have so much greater funding and support and reward.
The US populations that increase from 15% to 20% to 25% to 30% in poverty have less and less local primary care available. This decline in health access with decreasing income, increasing poverty, decreasing health care coverated, and related demographics is interrupted only by a few bypass mechansms that allow primary care access to remain. Family medicine training programs, other primary care training programs, and Community Health Centers all have demonstrated the ability to survive in practice locations with the highest poverty levels, the lowest income levels, and the poorest health insurance coverage.
Bypass funding shifted from grant sources have been able to support basic health access where most needed; however, federal and state support for primary care training has been more and more limited. The current design for graduate medical education allows family practice residency positions to be converted to specialty positions that capture much higher rates of GME funding. Family medicine programs have been downsized or closed with primary care reimbursement remaining a major problem. Not only does the nation lose the capacity to graduate permanent primary care, it also loses services to the primary care patients of such programs and clinics. Family medicine training sites are also three times more likely to be located in zip codes in need of physicians as compared to other training programs located in top concentrations of physicians including saturations of primary care.
About 18% of family medicine departments are in debt and low primary care reimbursement does not allow progress toward debt relief or support of the many health access activities of family medicine departments. Family medicine departments in many ways were set up for medical education, contrary to other departments, and family physicians are twice as likely to be listed in the Masterfile as medicla teaching faculty compared to other specialties. The generalists in each specialty are critically important in maintaining the teaching and health access focus in medical schools, but are the ones most likely to receive cutbacks in these challenging times. Primary care lost out long ago within internal medicine departments as research, subspecialties, and graduate medical education took over. Medical schools tolerate dysfunctional primary care training in internal medicine and pediatric clinics that conspire to drive students and residents away from primary care.1 At the heart of the dysfunction is the US policy design.
Bypassing Health Access Facility Policy: the Story of Community Health Centers
The bypass scenario with the most current attention is Community Health Centers. From the first few hundred patients in Boston and Mound Bayou to the current millions of patients, Community Health Centers have continued to supply basic health access infrastructure. At a recent meeting of the National Association of Community Health Centers, the theme of having to bypass US health policy to deliver most needed health access was a clear message.
Community health centers continue to care for the nation�s neglected peoples and are required to do even more with recession. Community Health Centers have worked for populations without insurance, for Medicaid patients, and for patients in locations near CHCs, but to be considered more of a health access solution for more patients, changes will be needed.
Perhaps the greatest challenge for CHCs that still have limited funding relative to the populations left out of health care coverage is proper balance. There is not a balance between those charged with the mission, facility support, health care team members, and primary care workforce.
CHCs are clearly facilities that deliver health access, but their support of health care team members has been poor. New entry receptionists, billing personnel, techs, and nurses are common. With more experience, health care team members move on. It was tragic at the recent Chicago meeting to find a number of CHCs that have terminated registered nurses. With new graduate RNs facing difficulties finding entry training for hospitals and with CHCs cutting back on the RNs that are critical for continuity health access, the overall effect is chilling for nursing supply. In Arizona colleges those who could opt toward nursing are considering other options.
The studies have documented more than sufficiently the importance of primary care for efficient and effective care, but few realize how much basic health access clinics must overcome to provide this high quality care. The policy design that rewards every other health venture other than primary care insures that CHCs struggle with personnel issues in multiple dimensions. Hospital and specialty care is funded at the highest level. This allows them to cherry-pick the best employees and lure them with greater pay and better environments. CHCs, like so many other primary care sources, are left with some very dedicated health care team members, newly trained personnel, and those that may not be the most efficient or effective. This is entirely a function of health policy that allows those with higher priority in the health care design to get what they want regardless of the cost to others.
CHCs also have not done well with physician relationships. The medical directors at clinics, state meetings, and national meetings consistently bring up the topic of resolving differences between the CMO and the CEO. Chief medical officers and CHC leaders still have difficulties. Physicians still are underrepresented in CHC leadership. The worst situations involved physicians with obligations. CHCs have not always treated such physicians fairly. Physicians also tend to be relatively independent personalities. Sometimes they are just not cooperative. At other times they are appropriately concerned about the health care quality delivered. A proper balance between facilities, leadership, health care team members, and physicians is needed. The national design has also mismatched urban origin physicians to rural locations or international origin physicians to settings less conducive to efficient and effective care. The care design set up by obligations can also impede the development of a stable primary care workforce foundation.
CHCs also have not done well with nearby competing physicians or clinics. With various inequities in funding support for various types of clinics, it can be difficult for all to survive, even when all are needed for sufficient local access to health.
Few understand that CHCs, despite federal support, also rely heavily upon primary care reimbursement. With limited primary care reimbursement and limited Medicaid coverage and even more patients, the challenges continue. CHC budgets include the same increasing employee health costs as everyone else. CHCs that are unable to attract enough permanent personnel require temporary workforce. The CHCs are also having to pay more and more for temporary health personnel and physicians. Locums costs are going up substantially in states such as Alaska. The most desperate facilities are left behind as they pay more and more for less workforce. With decades of major primary care shortages remaining, matters are only going to get worse.
With the rising personnel costs and the increasing strains of delivering the most needed care, it is even possible for CHCs to treat existing nurses and physicians in ways that drive them off, worsening the problem.
CHCs and Federally Qualified Health Centers are like all federal and state programs. While most are appropriately placed in location, others have been developed (or even added) in locations with the top concentrations of physicians in the United States. The Bush Administration prided itself on up to 40 new sites added a year that did not have physicians. In a study of 40 zip codes added in one year, only 7 of the 40 in rural areas appeared to meet the criteria of lack of proximity to primary care physicians.
The CHC design has still failed to find a balance between mission and personnel to deliver the mission and facility needs. Community Health Centers are not the only answer for primary care facilities, but they are an important and effective answer.
A real answer is a permanent primary care in all three dimensions: facilities, health care team members, and primary care practitioners. It is the personnel area that will be by far the most challenging for CHCs for the next decades. To understand solutions for CHCs it is important to understand who is selected to practice in CHCs and who CHCs choose the most. Those most likely to be found delivering care in CHCs are basic nurses and family physicians, the very personnel in shortest supply in US design. Family medicine choice doubles urban CHC location and triples rural CHC location. Unless the US bypasses current policy to result in permanent health access nurses and permanent health access family physicians, the needs of CHCs will not be met and the nation will also not have a true health access foundation.
Bypassing Policy: Rural Health Clinics
The US could not be trusted with sufficient support of rural clinics. Policy had to be bypassed to create rural health clinics. This policy bypassed the pittance paid for primary care to provide real funding to support basic access to health. Then regulations had to be created to keep predatory hospitals and individuals from using the rural health clinic model for their own gain. Nurse practitioners and physician assistants were once an important part of this rural health clinic plan. Physician assistants in family practice are 30 times more likely than other physician assistant types to be found in rural health clinics. But nurse practitioners and physician assistants have moved away from family practice choice following US health policy. This threatens basic health access and the vehicles that attempt to provide basic health access primary care. Family medicine choice triples rural location rates for physicians above the influence of origins and training. Rural health clinics need basic nurses and family physicians, the very personnel in shortest supply in US design. Unless the US bypasses current policy to result in permanent health access nurses and permanent health access family physicians, the needs of rural health clinics will not be met and the nation will also not have a true health access foundation.
Bypassing Policy:
The US could not be trusted with sufficient support of the basic health access rural hospitals that were the infrastructure of rural health systems. After rebuilding rural health systems from 1965 - 1978, the United States began to tear rural health systems apart with funding neglect, lower rated funding for rural and smaller hospitals, neglect of basic workforce needs, and increased funding for those in greater concentrations of people, income, physicians, and health resources.
Policy had to be bypassed to create Critical Access Hospitals. A tiny percentage of funding from all hospitals was distributed to hospitals with the least funding. Without this transfer, millions of Americans would have lost basic access to care. Once again failures in nursing production and family medicine production threaten this vehicle of basic health access.
Is anyone listening? Capitated or cost-based models are funding models that rebuild. The United States rebuilt a neglected health care system with early Medicare capitation but runaway costs due to abuses by those less in need of recovery forced a change. The US now has the need to rebuild all facets of neglected health access primary care. The situation is so bad that only the capitated or cost-based settings survive. Bypass mechanisms are what remain intact. Perhaps the goal should be real infrastructure funding rather than a poorly coordinated patchwork. The rebuilding cost for decades of neglect should be cost based or at least it should involve realistic funding that will allow the maintenance and support of sufficient primary care facilities, health care team members, and primary care workforce.
It is a travesty to consider fee for performance attempts to "save costs" or incent changes with underfunded facilities, too few and lower quality health care team members, grossly insufficient primary care workforce, and patients with severe barriers to basic health access in many dimensions. Only those out of touch with the reality of health care facing primary care and those left out of the health care system would result in such neglect.
Even if too much was spent on primary care and primary care patients, it would be spent in the populations and locations most in need of recovery in the United States, much the same with any population based distribution such as schools, public health, child development, and each of the areas needed for a true recovery of the United States.
Missing Persons in health access - What Was, What Is, and What Could Be in Visible Graphics
Facts Important in Basic Health Access Medical School Type and Career Choice and Most Needed Health Access
What can we discern about future primary care from the 2009 Match and 2009 graduates of NP and PA programs? The answer is steadily declining primary care delivery. Match lists were used to generate future primary care contributions. Allopathic private and top ranking MCAT schools graduate the fewest that remain in primary care and past graduates consistently have the lowest primary care, family practice, rural, and underserved outcomes.
