Medicine

Health Access Failure from the Start

Health Access Results Can Be Multiplied By Earliest Investments and Specific Health Access Focus. A Continuation of the Current Design Will Fail Most Americans.

A common mistake is believing that you can impact the end points (college tracks, medical school influences, loan repayments). When you are talking about national outcomes and improvements, the end points are far too late as they are dependent upon "the matrix of relationships" as Deming often noted. Previous life experiences shape subsequent encounters and situations. Health care is one of the ultimate examples of complexity - and even the best research fails to consider the numerous pre-existing influences that shape health outcomes.

Birth to Higher Education Pipeline Failure

Prevention of higher education and medical school from the start.

The United States is dead last in child well being. This acts to prevent most American children from higher education and a path to medicine (Unicef Report Card 11)
The United States invests little in age 0 – 6 compared to nations doing well in child well being and in subsequent education and other outcomes (Unicef).
The United States fails in education finance. School districts must depend upon a local tax base and property values – a design for less for most American children.
States behind the most often thrust even more responsibility on school districts with lesser property value (Strange School Funding Formulas, Baker and Corcoran in Education Trust Funding Inequities, others). Is School Funding Fair?
Children from higher, middle, and lower property value school districts layer out such that even the lowest performing in the higher property value districts can outperform the best of the lower value districts.
The United States fails in higher education as few children other than those from highest income families can access the colleges that lead to medical education and other advanced degrees.

From a 2013 New York Times Article - Andreas Schleicher, who runs the O.E.C.D.’s international educational assessments, put it to me this way: “The bottom line is that the vast majority of O.E.C.D. countries either invest equally into every student or disproportionately more into disadvantaged students. The U.S. is one of the few countries doing the opposite.” The inequity of education finance in the United States is a feature of the system, not a bug, stemming from its great degree of decentralization and its reliance on local property taxes.

Each of these results in disadvantage for most children as measured by lower probability of higher education and medical school admission as well as higher probability for children of advantage.

Dividing the Nation By Income in Medical School Admission

Over 60% of Medical Students arise from the top 20% in Parent Income (AAMC data)
20% arise from the second 20% - equity
Less than 20% arise from the bottom 60% of American children (AAMC data)
Lower income rural county origins and Mexican American populations have 5 times lower probability of admission

The problem is not necessarily with medical school admission as the same situations are found in higher education. College has been a prerequisite for medical school for 100 years.

Dividing the Nation By Income in Higher Education

74% of the College Students for the top 146 colleges arise from the top 25% of the Nation’s Children as rated by socioeconomics (Carnevale and Rose, New Century Foundation, Left Behind for a 3 to 1 Ratio Favoring Those Are Most Advantaged
Race and ethnicity are often cited as representing major differences. One problem with race/ethnicity is that ethnicity involves differences in income, education level, geographic location, and other dimensions.
Asian origins are higher income and most urban and are associated with a 3 times greater probability of medical school admission with over 20% of medical students despite less than 6% of the population. The highest income most urban Asian Indian component is an 8 times greater probability or 7% of medical students with less than 1% of age 18 - 24 in the US population. The same highest ratios apply for highest income, most urban, children of professionals/highest educated parents.
Rural origin physicians have declined from over 25% of physicians entering the workforce to less than 7% in the past 50 years with white rural US born males down to 2%. Increases in non-white, foreign born, urban, higher income origin, and female physicians are a poor fit for rural areas as each dimension more likely to distribute is in decline - steadily replaced by those less or least likely to distribute.

Highest Income Origin, Most Urban Origin, Children of Highest Educated/Professional Parents appear to benefit from a widening gap as compared to other origins as seen in data regarding US medical students.

Even when not gaining admission to a US MD school, the expanding osteopathic and Caribbean opportunities and other international schools (US born Asians going to Asian nations for medical school) offer more routes to becoming a physician.

Normal children in America have little chance with lesser opportunity shaped by design. Those most different and unlike most Americans in a number of dimensions are more likely to become US physicians.

Physicians with Origins Immersed in Top Concentrations from Birth to Graduation

Are least likely to choose primary care
Are least likely to remain in primary care when training in primary care
Are least likely to choose family medicine
Are least likely to remain in core specialties
Are least likely to distribute where needed
Often move state to state, failing to remain in states in need of workforce - reinforced by more specialized careers that dictate states, counties, zip codes, and practices

Origin changes, training changes, and policy changes all contribute to family medicine choice cut in half and internal medicine primary care retention cut from 60% to less than 20% in the past 18 years. Family medicine and internal medicine primary care

Represent 33 - 40% of physician workforce where workforce is needed
Are the most important sources of health care for the elderly populations that are doubling from 2010 to 2040
Are the most important sources where counties are growing the fastest in population growth and in primary care demand.
Since internal medicine primary care is steadily declining, the family practice sources are even more important.

The United States will continue to produce Too Many and Still the Wrong Physicians

Solutions for Health Access Are the Opposite of the Designs for Training and Practice Support

Instate location for 30 states behind, not 6 - 10 states with top concentrations of physicians and graduate medical education
Primary care - permanent over a career, not just during training
Workforce in counties and zip codes in need of workforce such as 2600 counties with lowest concentrations of clinicians and 40% of the United States population

State public medical schools have been admitting more highest income, most urban, children of professionals that move from state to state. These students have replaced students who are more average in income, normal to rural in geographic origin, and those from a wider range of parent education and occupation.

In Nebraska the family medicine choice of those that dominate admissions is 2%. Those steadily being replaced over recent decades are those more connected to the state with a wider range of origins that have 15 - 30% family medicine choice, better primary care, and higher instate retention. Choice of family medicine at UNMC is associated with over 20 times more instate practice location in the 88 counties in need of workforce out of 93 in Nebraska. Family medicine more than triples distribution where needed, but it is more than just family medicine as the characteristics that result in family medicine also result in better distribution. This is why you cannot just influence health access or family medicine choice in medical school or late in the game.

Real solutions focus upon the instate, permanent primary care, and workforce where needed very specifically across origins, preparation, all training, and practice support.

In Kansas the family medicine choice is a 16 times multiplier of Kansas practice in 98 counties in need of workforce as compared to practice elsewhere out of state or in Kansas counties with top concentrations of clinicians.

If we are to ever deal with health disparities, the patients and the clinicians must be addressed.

Most American patients need a better start. They also need a physician that is more like them in origins and one that is trained specifically for their needs. Our "one size fits none" medical education design is least specific for care where needed and Americans most in need of care.

We must deal with designs that are causative with regard to disparities. Some like to blame individuals for their plight, but these arguments go away when we are talking about designs, designs for education, and impacts on children who are dependent upon our designs. Our nation is dependent upon child development and early education for outcomes outcomes across education, economics, jobs, ideas, and health.

Designs that impact before birth, in the first months, and in the first years of life are important to understand. Our has very little investment in education - less than 8% of school funding. The financial responsibility is at the state level - for adequate funding and to address inequitable funding due to local school districts that have little property value to tax. Some states do very little, and some states provide 60% or more of funding. States that invest more and less, would not surprise you as the same states that invest more do better in a number of outcomes.

Insufficient funding is bad, and property based taxation is even worse as lower property value schoolchildren face the worst discrimination. And when states fail in school funding distributions they are failing in jobs and economic impact for these school districts. And these areas of a state are even more dependent upon such spending in education, health, social security, and other areas for substantially more of their economics.

When Katrina hit, Houston Independent School District was able to absorb a substantial portion of the refugees into Houston schools - because it was in better financial shape, because the legislature required cash reserves, and because HISD accepted the challenge. The central metro areas have been losing out to suburbs, the legislature has slashed funding, and lawsuits have been required to attempt to address worsening situations for Texas schoolchildren statewide. How things have changed an in a short period of time. Now the deficits of funding impact the entire state, especially the school districts facing the greatest challenges. Even the higher property value school districts are feeling the effects. Within school districts there are also tough choices.

Do the districts make the tough choices to attempt to meet the needs of most children, or do they shape their spending and programs to favor the children of advantage as their powerful parents continue to demand?

I see the same theme across education, health, primary care, economics, and health spending. With declines, those doing well cling more to what they have, sending more into a downward spiral and even those of advantage with them.

In graduate medical education, our teaching institutions cling to their funds and produce ever higher specialized workforce - preventing workforce needed for most Americans.
Highly specialized physicians, the institutions, and their associations cling to higher payment for their services defeating primary care payment (half of the services) and the primary care workforce that is half of the physician workforce where care is needed.
Urban power overcomes rural need as the formulas that determine federal spending can send funds to school districts with higher concentrations of kids in poverty but lower percentages (7 - 10%) while the spending fails for rural school districts with higher poverty but lower concentrations of impoverished kids.
Lower and middle income children have received little help with higher education funding support as the colleges dangle scholarships in front of higher income parents - parents who can afford to pay higher tuition and may also support the colleges in other ways.
Stalled progress in higher education opportunity has reached the attention of the nation's top experts, but little has been done.

Parents need to understand what happens in education. In the classroom, in the school, in the district, and in the state, the key measures are about the 50% left behind, not the few doing well. Those doing well have numerous advantages and will likely do well without investments in child development, early education, or catch up programming. For most American children, these recovery investments are essential. When the designers decide that cuts on costs are the only dictate, the powerful parents will direct the remaining funds to their children.

Most Americans will lose in this process of squeezes within squeezes, leaving an entire nation further behind.

Worsening disparities will continue to make matters worse

What we understand about social determinants indicates that declines in income, education, and other determinants will shape worsening health outcomes. Cash flow into an area can aid in development and recovery. Cash flow restrictions or requirements to send cash outside of an area can result in social determinant changes such as declines in jobs, income, and other areas. Rural and single county hospital closures are an example of such declines. An acceleration of closures of practices and hospitals where needed is the small scale example. State and national changes indicate massive changes in cash flow.

Federal and state funding cuts in child development, education, nutrition, Social Security, and health care where needed will worsen cash flow, jobs, economic impact, and situations where disparities exist as these are areas even more dependent upon these investments.
Downsizing business changes, centralization of government positions (social services, extension), mergers of businesses and health care, and consolidations of schools all represent compromises of cash flow, jobs, income,
Largest urban and rural systems take over those smaller. Some even proceed despite violations of the law. Local health care needs and local cash flow are compromised while centralized location benefit.
Mail order prescriptions took billions away from local pharmacies and economics while centralizing spending in just a few US locations.
Requirements for health care providers to spend more for consultants, software, and other "advances" will send more dollars out of counties in need of spending. Practices will not be able to support local workforce as delivery personnel must decline to pay more for non-delivery budget items.

Unicef Report Card 11

NYTimes Update of Higher Education Access Deficits

Admission Ratios - Highest income, most urban, children of professionals/highest educated parents

Houston Chronicle Article Regarding Discrimination in State Education Funding

Recent Works

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

How To Resolve Health Access for 40 States Behind By Design

Preventing Rural Workforce By Design

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation

Information Technology Cannot Heal - Time to Get Out of the Way of Healing and Those Who Can Help Remove Barriers to Healing

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Overcoming Barriers to Health Access Including Portions of ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access?

How Bad Medicine is Sweeping The Country.

Best of Basic Health Access

Blogs indicate that primary care can be recovered and should be recovered.

Robert C. Bowman, M.D. [email protected]

Basic Health Access Web Basic Health Access Blog World of Rural Medical Education

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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