Quality in Health Care

Quality in Health Care is Really About the Quality of Lower and Middle Income Children

Robert C. Bowman, M.D.

Quality in Rural Physicians at Rural Docs in Practice

Correlations with Health Care Quality By State Rankings

While debates rage regarding the impact of primary care on quality of health, the debates seem directed inappropriately. The more important relationships are typically stronger correlations. Also studies now link production of primary care to lower and middle income children. States that do better with lower and middle income children produce more primary care in the form of family medicine, the specialty that is the broadest generalist with the best distribution to all populations, including those in need.

In fact the correlations between internal medicine and pediatric primary care and quality of care are missing. A major reason appears to be that internal medicine and pediatric physicians are more likely to be found in saturations of physicians and health resources as well as concentrations of people and income. Populations divided between rich and poor are a guarantee of too much cost for too little quality. The rich use too much health care and have complications. The poor cannot access health or access health care inappropriately. Middle class populations in the United States are more likely to have a balance in access with appropriate barriers but also better ability to make correct health care decisions regarding access to care, resources, and maintaining health.

The pathway to the health care quality correlations also is important. The author examined state data regarding education outcomes, health outcomes, income, income distributions, poverty, and more. The expectation was that some states would do well in education, others in health, others in income areas, etc. The findings were not scattered. There was a consistent pattern.

Health outcomes, education outcomes, and economic outcomes are related to one another and all are related to what happens to children in the earliest years of life, particularly the lower and middle income children that do not have the parents that can compensate for local deficiencies. 

These correlations are shared here regarding state data on health, education, income, and distributions of these demographic data.

The health care quality measure is a state ranking using two different measures, a hybrid of United Health and Project Hope rankings.

The correlations are sorted by the highest correlations

0.88        Kids Count 2007 ranking (child well being measures)

0.8          Child Well Being Rank (multiple measures)

0.824     Employment Ratio 2005

-0.735    Child Poverty % 2005 

-0.709   Poverty % 2005

0.695     Married Both Work 2005 (middle class measure)

0.686     HS Graduates % 2000 (better start)

 0.667   Gini House Income 1999 (divisions of income rich poor)

0.538     Voting Rates (also auto insurance, welfare, prison rates)

0.516     Bachelors Degree % 2004

-0.515    Underserved physician %       (note: Pay for Performance is a ridiculous concept as physicians skilled and experienced enough to care for the underserved are penalized for doing so as they associate with populations that naturally have lower health care quality.

0.43        Generalists Area Resource File (much lower correlation)

0.41        FM per 100,000 people in the state

0.112     IM and Pediatric PC per 100,000 not a significant correlation. There is not a problem with IM or PD quality. The problem is that IM and PD are associated with concentrations and divisions into too much and too little, and have guilt by association in states with lower quality that have divisions. Washington DC is an example with top concentrations of rich and poor, the greatest divisions, the worse health outcomes and the best, but overall poor health outcomes, education outcomes, and economic outcomes that are propped up by the nation in multiple dimensions.

Correlations with generalists, family medicine, and other forms of primary care are lower level correlations, explaining very little regarding health care quality (less than 20% of the variance). On the other hand the correlations related to distributions impacting children are very strong correlations.

The indicators of breadth of distribution (voting rates, income distributions, middle class measures) are all consistent. Also when there is a broad middle ground, there are more medical students admitted with higher probability of choice of family medicine, the specialty that is most likely to arise from lower and middle income origins and least likely to arise from most exclusive physician origins.

When states divide into rich and poor, the rich fail to choose family medicine, primary care, rural, and underserved careers, there is little middle class, and the poor with already the lowest probability of admission, do even worse. Typically there is insufficent investment in the poor in states with lower economics as well as states that divide into rich and poor.

By the way, when researchers use bachelor's degrees or other controls for education, they are using indicators of distributions. Researchers should avoid introducing such complications to their equations.

Lower and middle income children raised in better family structure with better nurturing and child development, better early education before age 8 when the velocity of learning slows (See Birth to Admission and Education References)

Cost, quality, and access have the same solutions.

Access is about policy, admission of physicians who share origins with the 65% left behind, and family medicine choice that doubles underserved and triples rural practice locations.

Quality is about children doing well, who also are also more likely to become family physicians (and nurses, teachers, public servants) and better citizens

Cost is also about shared origins, better access, and better quality.

Contrary to primary care assertions, the solution is not primary care. The solution involves lower and middle income children that become the patient, the nurse, the health care team, and the administrator. These are more important factors than physicians or primary care physicians for most quality impact.

Equations Describe the Quality Relationship and May Also Help Explain Regional Variation and Variation in Quality by Social Class

These equations may be the most important to consider in the design of quality equations in the areas of appropriate controls and inclusion of important variables.

Health care quality = patient factors + health team factors + system factors + physician factors

When health care quality is compared to physician factors alone, the physician factors get too much credit or blame. These flawed studies include the Institute of Medicine studies.

Higher status patients may indicate physician problems. The equation is

Health care quality = patient factors + health team factors + system factors + physician factors

But because the higher status patient is more likely to be health fluent, is more likely to make better decisions (cancels out patient factor) is more likely to have a top health care team and system (cancels out health team and system factors)

Health care quality = patient factors + health team factors + system factors + physician factors

Then the equation reduces to

Health care quality = physician factors

For lower status patients there is a different story as lower status is associated with severe deficits in health care literacy, barriers of income and education and coverage, health care teams of lower quality and resources, and system factors of lower quality and resources.

Health care quality = patient factors + health team factors + system factors + physician factors

The magnitude of patient factors is emphasized for a reason. The physician is the least of the worries but of course the physician is often blamed for the poor outcomes that are really a function of patient and design.

Regional differences involve different patient, health team, system/environment, and physician factors

Among the potential benefits of better investment in children are


Increases in the Service-Oriented Pool of Professionals - Nurses, public servants, teachers, and family physicians are more likely to arise from lower and middle income peoples and the nation needs enough to supply all of these and more, not have competition for the few remaining or be forced to select those with lesser quality potential.


Better Quality, Efficiency, and Effectiveness - Better nursing, public servant, teaching, and primary care physician quality as more are able to become serving professionals and they make better serving professionals and they are a better match up of serving professional to those that they serve.


Better Quality from the Student/Citizen/Consumer/Patient Side of the Quality Equation - Better students, patients, and health care interactions from improvements in children who make better decisions in education and life that lead to better employment and better health care coverage with all phases of the patient side of the equation improving health care quality


Education References








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