The Health Access Medical School: A New Model Worthy of Investment and Replication

And the Only Route to Basic Health Access Recovery

Robert C. Bowman, M.D.   rcbowman@atsu.edu

There is no good news for 65% of the American people in need of basic health access in the United States. The students that are most likely to deliver most needed health access are admitted to medical school at lowest probability and the probability of admission continues to decline for them. The most exclusive origin students crowd out the more normal in admission to medical school and also enter the US from international medical schools. Exclusive origins and training are the rule in other countries. US medical education is also shaped ever more exclusive in training, even less exclusive schools.

The end result is that the US fails to produce most needed health access physicians – rural physicians, underserved physicians, and family physicians with 2 to 4 times greater levels of primary care, rural, or underserved careers.

The Basic Health Access Workforce Requirements Are:

Studies Consistently Demonstrate the Best (and Only) Remaining Health Access Workforce Solution for Those Left Behind By the Current Design including:

In each case only the broad generalist family practice mode has demonstrated higher probability of most needed basic health access. More graduates with average or below choice of health access careers will not resolve massive health access deficits.

Only family practice MD, DO, NP, and PA forms are 2 – 4 times more likely to be found serving the populations in most need of basic health access that are far more than a majority of the American people. And only family physicians stay in the broad generalist family practice mode. Family physicians are documented at a consistent 30 – 40 per 100,000 with equity in distribution noted in service to the poor, to the near poor, to those less educated, to border populations, to poor states, to predominantly minority rural counties, and to all ages in need of basic health access.1-6

The only model that can address each of these areas is a model that graduates 100% into a broad generalist primary care specialty that stays in this broad generalist mode for a lifetime of health care delivery. At the current time, only one primary care training source comes close. Family physicians have the longest careers (35 years or longer), the highest volume of primary care for any source (sets the gold standard at 100%), the highest percentage remaining active (85%), the highest percentage remaining in primary care (85 – 90%), and the top percentages distributing to rural and to underserved populations. Other proposed solutions for primary care such as internal medicine (10% primary care retention), nurse practitioners (only 33%) and physician assistants (only 25%) are not solutions for primary care; they are solutions for specialty workforce. In addition to moving away from primary care, nurse practitioners and physician assistants have moved steadily away from the family practice mode that is the only component that delivers greater than average rural and underserved workforce for most needed health access.

Because family physicians stay in the family practice broad generalist mode, the basic health access workforce that is produced will stay where basic health access is most needed. During training, at graduation, and each year after graduation for decades the physician assistants and nurse practitioners have been leaving family practice. This is distorted by studies that list the specialty of training and fail to list the actual practice delivery. The United States will need all hands on deck to serve basic health access for the next 35 years if not the next 50 years of graduates. Until a basic level of primary care production is met and not hampered by steady losses and declining retention, it takes 35 class years of graduates to reach sufficient levels.

One problem for basic health access is that even those most resistant to current health policy, family physicians, are having a difficult time remaining in primary care. Although declines are not severe as in other sources of primary care, some interventions are need to protect and preserve existing primary care so that the nation can actually rebuild primary care. To do so, the nation must address limitations in production and also primary care retention.

Limitations of Previous Health Access Models

The major problem with a total health access model is that prospective medical students say they are interested in basic health access, but fail to choose these careers. The medical students know full well that what they say does not matter, as long as they get in. Even when special admissions involve rural origin or minority origin physicians or when training involves additional focus on rural or on underserved health access, graduates are free to follow other career paths. Since the United States rewards specialty careers with the most salary, support, health care team members, and resources, it is not a surprise that those even of best intentions are deflected from basic health access.

The United States has long known that schools admitting broadly and focused on broad training delivered most needed health access at higher levels. Schools that have been successful for decades or over one hundred years include osteopathic schools, Historically Black schools, schools with graduates speaking fluent Spanish, 1970s primary care focused schools, and osteopathic public schools. But limitations remain.

The best rural health access schools have been Duluth and West Virginia School of Osteopathic Medicine. Even so, Duluth could only manage 50% family medicine even during the best policy periods in the 1970s and 1990s. With current policy and despite the same admission and training focus, Duluth could only manage 36% family medicine in 2009 graduates. West Virginia School of Osteopathic Medicine leads the nation with over 40% of graduates in rural areas and 22% found in rural underserved locations, but changes in admission and training necessitated by an increase from 66 to 200 graduates will change outcomes.

Even with maximal admission and training, basic health access can suffer. The decline in family medicine choice in both schools will decrease the rural primary care contributions. What such school needs is a way to boost family medicine from one-third to three-thirds or 100%. While this does not seem indicated since graduates of Duluth and WVSOM will still deliver 50 – 100 times more rural primary care than graduates of the top 20 medical schools ranked by MCAT scores, this basically triples the basic health access production of the best current sources.  

It is difficult to understand the limited contributions of the top 20, 30, or 40 medical schools in prestige rankings. The combined impact of admission of the most exclusive in origin with the most exclusive scores and the most exclusive training and career choices results in a concentration of over 80% of graduates in 4% of the land area in top saturations of physicians and non-physicians. Using the framework of experiential place, these most exclusive graduates were born, raised, educated, and trained in top concentrations. It is not a surprise that they fail to distribute where most needed. While US medical education moves steadily toward more exclusive and most concentrated, the direction needed for basic health access workforce is steadily away from most exclusive to more normal.

Tragically one of the impediments to this movement toward basic health access workforce capacity is insufficient basic health access capacity. The massive cost increases of the 1970s and the 1990s were at least partially due to insufficient basic health access. A rapid shift of more Americans given financial access to health care would overwhelm existing primary care and result in cost overruns as patients with pent up demand over the past decades sought care. Now if the primary care funding was sufficient, this would allow some rebuilding of primary care and rebuilding of health care in lower and middle income America. Of course reimbursement for primary care is often loss leader funding, insufficient for even basic care much less rebuilding.

Also the prerequisite for any rebuilding is adequate primary care workforce. Supplies of primary care must be restored at the beginning. This must be before significant health reforms such as extending reasonable health care coverage from a minority of Americans to a majority. Together with sufficient basic health access nurses and sufficient support for facilities, basic health access can be restored.

The Beginning of Health Access Recovery in the Dimension of Practitioner Workforce

The solution is to bypass current US policy that drives physicians away from basic health access careers. This would be a contract to actually deliver health access. Those truly interested in basic health access would sign this contract and would be on a path to basic health access. This contract would obligate the admitted medical student to 15 years of primary care served within the state that sponsored them in exchange for their costs of medical education. They would be able to practice in any one of the zip codes in the state that did not have top concentrations of physicians. The applicant would also not be burdened with the prospect of being sent to an unsuitable location. They would not be required to spend time caring for prison populations. The intent of the basic health access plan with federal, state, and local support is a lifetime of primary care delivered by a physician who has maximal interactions with populations in need of care before admission, during training, and decades after graduation. For those skeptical of long term contracts, Japan has such a school and contract with 95% of graduates complying with rural practice requirements.7 By the way, those violating this contract must plunk down about a quarter of a million dollars cash, more than enough to fund a replacement who is willing to enter and remain in a basic health access career.

What Does This Health Access Model Address?

·         Most needed basic health access that is currently being destroyed by the health policies of the nation with remaining primary care converted to hospital, hospitalist, specialty, emergent, and expensive non-continuity care modes.

·         Local primary care is the focus, saving substantial patient transportation and out of pocket costs.

·         Instate primary care – grossly insufficient in most if not all states

·         Reductions of primary care losses outside of the state – crippling the states  that are in most desperate need and that have the most vulnerable populations

·         Retention of instate health care workforce for over half of the states of the United States that donate their education, higher education, and medical education investments to states with top concentrations of physicians, economics, and health care funding. The plan helps health care to unite the United States rather than dividing states and populations into rich and poor via the economics attributable to health care.

·         Forces all states to invest in basic health access workforce rather than stealing from other states and nations – accountability rather than profiteering

·         Massive annual increases in recruitment costs, retention costs, signing bonuses, broker fees, locums temporary workforce, and medical education costs that result in insufficient workforce that is not continuity in terms of not remaining in primary care, not remaining in a location, and not involved with the local population or health care needs

·         The model also supplies most needed health access workforce during the 6 or 7 years of medical school and residency training. The trainees help to support local health access delivery as they are integrated into the health care team for years rather than the current situation where they “visit” health access settings for a few weeks resulting in even greater burdens related to orientation and scarce practitioner time rather than helping to contribute to health care in a longitudinal training format. Basically the trainees work in the locations where they are most likely to practice, train under same or similar future colleagues, work with the health care team members that they are the same or similar to those they are likely to work with, and as graduates they also help shape their colleagues and replacements by participating in training.

This is a Model That Maximizes Most Productive Primary Care and Health Access, Delivery of Health Access Where Most Needed, Continuity at the Highest Levels, and Maximum Satisfaction of Patient, Trainee, Practitioner, and Facility.

The current lack of design insures minimal satisfaction of patient, practitioner, trainee, facility, state, and nation in basic health access parameters as well as other components of health care delivery.

What Does This Model Not Address?

While the model establishes a separate path to basic health access and requires separate funding for this training, it does not enjoy the benefit of separate accreditation (that favors specialization and concentration in training environments), sufficient funding for basic health access facilities, sufficient funding for basic health access nurses, and sufficient funding for support of basic health access practitioners. The current US design insures compromise, such as more funding for temporary workforce that limits the care of patients and the benefits and salaries of current nurses and physicians. Sufficient funding for training and support for all of the basic health access components must be supplied.

Also once the nation actually does graduate about 12,000 annual graduates that remain 90% in primary care and deliver 90% of the volume of a family physician and remain 90% active, it will take 35 years of graduates before the nation approaches sufficient primary care delivery. Even with projections of 45,000 primary care graduates from internal medicine, pediatric, family practice, nurse practitioner, and physician assistant training programs in the year 2045, this will still be only half of the primary care needed for the United States population.

Basic Logistics of the Model

References

1.            Bowman RC. They really do go. Rural Remote Health. Jul-Sep 2008;8(3):1035.

2.            Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).

3.            Bowman RC. Ten biggest myths regarding primary care at http://medicinesocialjustice.blogspot.com/2009/01/ten-biggest-myths-regarding-primary.html. 2009.

4.            Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.

5.            Mold JW, Fryer GE, Phillips RL, Jr., Dovey SM, Green LA. Family physicians are the main source of primary health care for the Medicare population. Am Fam Physician. Dec 1 2002;66(11):2032.

6.            Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.

7.            Matsumoto M, Inoue K, Kajii E. Long-term effect of the home prefecture recruiting scheme of Jichi Medical University, Japan. Rural Remote Health. Jul-Sep 2008;8(3):930.

8.            Bowman RC. The Basic Logistic Regression Tables: Taxonomy, Themes, Theories of Experiential Place and Basic Health Access.  http://www.ruralmedicaleducation.org/basichealthaccess/taxonomies_themes_theories.htm.

9.            Bowman RC. Basic Health Access: Rural Workforce.  http://www.ruralmedicaleducation.org/basichealthaccess/Most_Needed_Health_Access_Rural.htm.

10.          Bowman RC. Steps to Basic Health Access.  http://www.ruralmedicaleducation.org/basichealthaccess/Steps_To_Health_Access.htm.

11.          Bowman RC. Basic Health Access Concepts That Must Be Understood.  http://www.ruralmedicaleducation.org/basichealthaccess/Basic_Access_Concepts_to_Review.htm.

12.          Bowman RC. Principles of Basic Health Access.  www.ruralmedicaleducation.org/basichealthaccess/principles_summary_points.htm.

13.          Bowman RC. Past, Present, and Future Primary Care in the United States: Health Access Recovery That Fails Versus True Recovery.  http://www.ruralmedicaleducation.org/basichealthaccess/Health_Access_True_Recovery.htm.

www.basichealthaccess.org

www.physicianworkforcestudies.org

www.ruralmedicaleducation.org