Go Path: Disruptive Change

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Family Medicine Must Move Beyond the 1960s Design to Address the 2040s

Johnson matk at 00:54 0

health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..

The designs for training and for payment that worked so well to improve health access during the 1960s and 1970s gave the illusion that training alone could make up the workforce gaps. Such is not the case. The financial design fueled the 1960s and 1970s improvements. The failure of this design since the 1980s prevents further gains - continuing to leave most Americans behind. The family medicine leadership still clings to the 1960s design, but must embrace a 2040s design to continue to lead in family medicine, in primary care, and in health access.

It is quite revealing that family medicine associations and leaders have embraced the innovation/regulation/certification bandwagon. There is a willingness to embrace the academic, association, institution, and association designs. But do these designs match up to family medicine now - or in the future?

Past family medicine graduates that were active were 90% committed to office family medicine for decades. More recent tracking indicates 70% and the rate of decline suggests even less for newer graduates.

As family medicine graduates fall to 65% or 55% in office family medicine, will family medicine leaders consider the flaws of their 1960s model?

Voices of concern have become a chorus. There is also little indication of a rise of public support - the kind that brought family medicine into existence.

The initial family medicine design

...was based on a desire for acceptance into the academic community.

The decision for 3 years of residency instead of 2 was guided by this desire.
FM came close to a four year design recently - a really bad design for numbers of FM graduates, for graduates in debt, and for delays in income generation.
FM claimed successes from FM student interest groups, departments, and other interventions during the brief periods of increased FM choice, but fails to understand that these do little as demonstrated in many more class years and primarily due to the financial design.
Family Medicine journal still eats up pages each year promoting departments in every medical school.
Similarly family medicine leaders have gone along with the academics in areas such as innovative payment models and Primary Care Medical Home.
Maintenance of certification is no longer evidence based for outcomes improvements, but FM leaders still cling to this model and to the substantial overcharges for such certification. The initial claims of being "more academic through recertification" persist now as back then.

FM Is a Mismatch for the Academic Design

Family medicine is community based, population based, accessible, distributed, and service devoted. The academic design is isolated, concentrated, inaccessible, focused on few people, and is devoted to itself. Even the best intentioned medical schools of the 1960s and 1970s have been remolded into the academic design. Mercer is an outstanding example of one of the best for Southeastern counties in most need of physicians led by over 30% FM choice but declined below 5% and lost distribution - during the reign of a family physician dean. The academic design is more prosperous and hard to resist. The preparation, the admissions, and the training all reward the most exclusive at the expense of the most normal.

The academic design is what has concentrated 45% of physicians into 1% of the land area in 1100 zip codes with 10% of the population. Meanwhile 40% of Americans in 2621 lowest physician concentration counties have 22% of physicians and less than 13% of health spending.

The academic designs and designers fight against true payment reform. True payment reform is about increases in basic, cognitive, office, primary care, and mental health services with decreases in the more to most specialized services. Academic designs create more lines of revenue and result in the highest payments in top concentration settings. Even lower payments go where care is most needed and penalties are most likely because of the least healthy patients.

Family medicine cannot prosper in places that fight the very reforms needed for family medicine and what family medicine does best.

The designs pay less where family medicine is more important and where Medicare populations are concentrated and where physician concentrations are lowest. This is seen in the table below categorized by the proportions of family physicians in a county from least to most.

Family Medicine Was a Miracle Event

The Flexner Design nearly wiped out generalists. More dollars for fewer in fewest locations made matters worse. There was little hope for basic care for most Americans until...

Family medicine was restored by family practice general practice physicians that fought hard state to state - using the popular support of Americans for a restoration of a personal family physician.

The restoration of formal family medicine in training and in practice has been the one major positive change in health access since the 1970s. It was not accomplished by the new type of training alone. The major lesson of the 1960s and 1970s was not innovative training. The message was a redistribution of dollars. The dollar distributions required permanent generalists. The permanent generalists required the dollars.

Family Medicine, Medicare, and Medicaid

July 30, 1965 or 52 years ago, Medicare and Medicaid were signed into law. The dollars represented a redistribution in the initial design. Changes in the design from more to less supportive for primary care, family medicine, and care where needed are important to understand.

Family medicine timing was a great match for the increasing revenue via new sources (Medicare and Medicaid). Training that could distribute matched dollar distributions. As more family physicians graduated, there were more dollars to support them and in the rural locations and lowest physician concentration counties where Medicare and Medicaid are concentrated.

The training models of the 1970s were worshipped - including the WAMI (now WWAMI) design and others. These models have largely failed with the decline of the financial design and the decline of family medicine choice in graduates

Numerous examples of "success" can be seen including the dramatic 12 to 20 times multipliers of distribution where needed with choice of family medicine in the graduates of the U of Kansas and U of Nebraska. But the overall capacity in lowest concentration counties in these states did not change. FM wiped out other primary care in a rearrangement of the deck chairs. The problem remains insufficient health care dollars - by designs steadily changed 1980 to the present.

Family Medicine Reached the Limits of the Initial Design by 1980

Since 1980 the financial design has changed from support for team members to cost cutting.

Training outcomes follow the financial design and family medicine has eroded from 90% of active family physicians in office based practice to less than 70% with newer graduates at lower levels.
This was also illustrated by 30% of the 1970s FM graduates found in rural locations - a level that has declined to less than 20% steadily over time. Now hospital based FM docs have 26% rural location rates - powered by hospital spending which is much better than office services design.
By 1980 the family medicine graduates reached 3000 graduates. Since this time there has been little progress in what matters most in family medicine, in the primary care financial model, and in health access for most Americans. The linkage between these areas is undeniable.
All sources of primary care are failing, falling to steadily lower levels entering primary care and steadily lower remaining in primary care.
All sources of care for lowest concentration counties are failing despite more dollars to prop up incentives.
Billions more have been added to costs of delivery in lowest physician concentration counties - sent further behind by design.
Greater proportions of the population and family physicians are falling behind by design.

The 1960s financial design has failed and with this failure the training design has not been able to make up the gaps.

This leaves choices:

Do nothing and allow family medicine to become something else not associated with primary care, health access, or care where needed (seems to be the current choice).
Expend all available association, department, residency program, and family medicine physician resources on improving 6% spending for primary care to 12% (not happening)
or
Develop a 2040s model that delivers on health access regardless of the payment design.

Value-based designs appear to be the favorite of family medicine leaders. There is no evidence that this will power up the financial design. There is evidence of discrimination against those who provider care for the most complex and least healthy - and family physicians fit into this category.

How Can Family Medicine Embrace Social Determinants and Not Understand Discrimination in Payment Design?

Full understanding of social, personal, community, and local resource determinants of health indicates the futility of clinical interventions for improving health outcomes

Particularly in primary care with so many other influences before, during, and after encounters
Particularly where 40% of family physicians are found in places with lowest concentrations of workforce, resources, and determinants of health.

These two major areas for the 2040s family medicine design can be addressed by

Locally focused preparation, selection, training, and obligation
Health access specific training
Health outcomes improvement focus
Change agent focus across preparation, selection, training, obligation, and practice

Moving from Academic Mismatch to Family Medicine Match

"One size fits all" preparation, selection, and training has not been a good fit for most family physicians serving where most Americans need care.

Family medicine and primary care subservient to payers, large systems, and large practices will continue to result in compromises for family physicians and for their patients.

Lesser payments for primary care, mental health, cognitive, office, and basic services fails most where most need care.

Family physicians should embrace a model that will continue to focus on health access and lowest concentration settings.

When Visualizing the 2040s Model, the Wrong Way Designs Are Exposed

Triple Aim has been a Triple Threat to primary care where needed. Outcomes are fixed by population situations and conditions. Cost of delivery increases have impaired the financial engine that drives access and motivates team members. Patients cannot be satisfied without substantial investment in primary care - not anything that the Triple Aim/micromanagement/innovation crowd is willing to do.

It has been hard to see the family medicine leadership embrace Triple Aim and ignore the consequences on family medicine physicians, teams, and health access. This has helped to understand that the 1960s model is still dominant. FM leaders still want to belong more than they want family physicians to make a difference.

The 2040s model is specific to reducing costs, improving outcomes, and matching up family physicians to the populations that they serve. There is no need for rural origin or minority origin – which may not include the origins specific to care where needed and certainly not the careers needed to match up to populations similar to origin. The 2040s model does not care if trainees begin at age 14 or age 40. The design is specific to a lasting commitment to integrate with the community and practice and health outcomes.

The 2040s Design Is Specific to Facilitating Team Member Work in Health Access

The key to health access, the keystone of family medicine, is facilitating the work of team members. There should be little separation between those preparing, those selected, those training, those under obligation, and those practicing. Each facilitates and mentors the others for an efficient and effective model reaching far beyond offices and deep into communities.

More 2040s and Moving Beyond the 1960s Model

Establishing the model visualized in the 1950s and 1960s has been a laudable goal. But the academic partners in this model have other agendas. The payer partners continue to fail by sending only 6% of spending for primary care for 55% of services. The payer partners have become opponents via cost cutting, neglect, denials, delays, and meaningless increases in the costs of delivery to match meaningless distractions for team members.

The players and payers are not going to accomplish true reform. They are not going to change the payment design that results in ever higher concentrations of health care workforce in fewer locations leaving increasing proportions of Americans further behind by design.

The 2040s model works best with better payment, but it can also accomplish what it must without a payment change. Ideally the major increases in primary care revenue would occur by significant reductions in procedural, technical, highly specialized, and hospital based care. This is best for returning balance in workforce in terms of spreading out workforce and restoring primary care, mental health, and basic surgical services.

In bed with academics also has been a reason for family medicine to be attached to regulation, innovation, and certification - all to the detriment of family physicians and especially those in FM delivering on the promise of health access where most Americans need care.

The focus on the original model (academic, department, centralized) has resulted in FM trying to be more in ways that FM should not be. It is the best at health access and it should focus on being more in health access and changing most Americans left behind to better health outcomes.

The past focus has prevented visualizing the model that has to exist in 2040 when 45% of Americans and 50% of the most complex populations will reside in 2700 lowest physician concentration counties. Will they be ignored from just 1980 to 2020 or 1980 to 2040 with still another 20 class years of graduates needed to begin to make a difference.

This could easily be 2800 counties

As more counties lose their last hospital. The loss of a hospital is a major contributor to loss of specialties other than family medicine, setting the county behind in dollars, workforce, access, and health outcomes. You cannot cut jobs and dollars without worsening local outcomes.
As urban and rural populations grow in these counties.
As natural or man-made disasters occur in higher concentration counties.
As housing collapses in higher concentration counties. The housing debacle sends more Americans and the most vulnerable to lowest physician concentration counties - the have lowest workforce and lowest local resources. It also sends more to become homeless or depend on other family, but the available and affordable housing as well as a lower cost climate forces a move to lowest physician concentration counties.

Why No More Funding Despite Growth in People, Complexity, and Demand?

How will local health access clinics deal with these areas unless they become the focus of preparation, selection, training, change agent development, and change agent family physicians?

How will the nation deal with disparities under a health care payment design that worsens disparities?

Discovering the Discrepancies

This blog began after photos appeared regarding the early FM leaders that were present at the creation of the annual family medicine student/resident meeting. Those of us around in the late 1970s were able to meet some of these men and women. We learned to respect what they did. But they were human. And they were focused on the issues of the time.

My experiences in rural practice and in organized medicine, taught me to question. Were these efforts helping or hurting? It was clear that the AMA and state associations were certainly not helping health access, primary care, or care where needed. The staff and the leadership had agendas different from what I considered the best interests of family medicine, rural practice, and primary care.

This critique was sharpened in academic efforts including immersions in physician databases, the workforce literature, and county demographics.

Promoting and then Demoting the Pipeline

For 30 years I helped to develop, maintain, and expand the pipelines to family medicine and health access careers. It was obvious that family medicine was limited. FM needed to continue to reach down to medical school year 1 and 2 and down to the summer before medical school and then down into college. Rural and minority programs have long worked their way deeper and earlier. But even these efforts are limited.

These pipeline models are fun to create and maintain, and appear to make a difference. However they are limited by their academic connection many times stronger than the community connection. The lessons of community projects, Community Oriented Primary Care, and Community Friendly Training all point to earlier and more comprehensive efforts at the community level.

An entirely different process of preparation, selection and training is required to blast beyond 3000 annual FM graduates and beyond practitioner to change agent. This is beyond the multiple claims of health access success as the design is specific to health access where half of Americans most need care.

The residency programs remain an awesome contribution – but the movement away from academic connections should have continued. The FM residency needs a better preparation and training before residency – as well as an obligation and health access contribution after residency.

This is a commitment model – a model lacking in the current design.

The process of preparation should begin when students reach the age when they desire to improve their social interactions – in middle school. The health access change agents are not the same as the best and brightest in scores. Those who demonstrate the ability to relate, work in teams, and accomplish change are the preferred selections. Rich in personal, group, and community interactions is assessed via personal, group and community interactions.

Health outcomes changes require changes in people and communities. Family medicine has the only distribution capable of facilitating change where needed. FM has always needed the teens and twenties working within their communities on the way to becoming change agents in FM, other health careers, and teaching. Meetings at the state and regional level should reinforce local activities such as needs assessments, assessments of readiness for change, and interventions driven by the community, revisions, and continued progress. Students need mentors and change agent activities.

Communities can afford to invest in a graduate who will spend medical school, residency, and 7 years of practice facilitating health access and health outcomes. Current designs that send dollars and graduates into higher concentration counties are poor value for most Americans.

How else should we measure value in health access medical education?
Is there any other better training for health access other than a community-based continuity model that begins and ends immersed in the community?
What will work in disasters or with worsening of situations in major metro areas or with a further deterioration in academic support for health access?

About 200 million people will be looking for basic care in their communities in 2040. These are places with half enough care. They are already most dependent upon family practice. They receive the least payments and try to deliver the most services to the most complex patients with the least local resources.

There is no movement toward meeting their needs. Family medicine leaders are the only ones positioned to make a difference for this half of the nation. They cannot help by clinging to a 1960s design.

AAFP Academization Core Access Principles Determinants of Health Disruptive Change errors of perspective health care design flaws health workforce STFM

Focus on Change Agents to Change the Culture to Healthier

Johnson matk at 10:13 0

health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..

In family medicine we most need change agents and least need those who remain stagnant and unable to change the course of health access, of primary care, and of health outcomes for most Americans. We fail in training and in family medicine workforce because we fail in selection and preparation in ways that training cannot address.

The STFM blog highlighted the quality improvement potential of family medicine residents. There is so much more potential for those that begin efforts much earlier and work throughout their lives as change agents.

The Social Beginning Is the Beginning of Change Agents

Potential medical students and others preparing for health and education careers should spend age 14 to 30 years working in their communities improving health, education, and local resources in their communities. These important interactive life experiences should be the most important determinants for selection as nurses, public health officers, or family physicians. Selections should be based on the demonstrated ability to reshape lives toward better health, education, situations, environments, and relationships.

Studies demonstrate difficulty if not impossibility with regard to training medical students in service orientation and empathy. These areas have been linked to primary care careers, but many still lack these important characteristics most important for changing people. It is likely that change agent characteristics are shaped long before medical training.

Why do we still cling to medical training as able to shape these change agent areas?
Why do we still believe that medical training can resolve deficits of workforce even with known deficits of the payments to support the workforce to address the deficits?
We have far too many beliefs and assumptions that prevent needed changes.

As soon as humans become social and most interactive, their interactive abilities should be developed by opportunities to facilitate people change - starting age 14 for some and later in others.

The Culture of Health Required to Change Outcomes Requires Change Agents

The Culture of Health that we most need to improve health outcomes, requires entirely different culture shaping the needed change agents.

Why do experts discover this at the end of their careers, after watching another 300 million dollars in grants fail to improve much more than process?

We have enough data to know much about disparities, but still lack the local focus to address them.

Just a few local projects include child development, facilitation of education, enhancements of parent involvement from the earliest years of life, development of community resources, projects mentoring youth, and Community Oriented Primary Care interventions working with local health care and local leaders on specific areas as guided by community needs, preferences, and readiness. Unless you experience the awesome power of community mentorship and community outreach, you will never understand the true assets and resources of even the most underserved and disadvantaged communities.

Our nation cannot be fixed from above.
It can only improve from the ground up.
Anyone who says they can fix America from above
is selling something Americans have bought too much of already.

Culture, Context, Continuity, and Commitment

Only preparation, selection, training, and payment design specific to health access within the context of local community, culture, and practice can address the basic needs of most Americans most behind as well as facilitating the higher primary care, community health, public health, child development, education, and similar functions.

When students are prepared and selected the ways that are best for most Americans, their thoughts and actions and reflections can reshape an entire nation. Lack of making a difference for decades indicates our continued failure by design.

We completely lack the focus on continuity at the highest levels and the focus on commitment at the highest levels for impact at the local level.

Family Medicine Needs a New Beginning

Learning the Most from Those Most Different and Those Making a Difference

I have learned the most from those with different backgrounds and those who have experienced different training, often self-engineered (rural, accelerated FM residents, older students or FM grads, previous nursing or public health, activist students and residents, qualitative researchers, faculty that practiced where needed before becoming faculty). At STFM, these were generally seen in the 5 or 10 minute presentations - not the big ticket areas. Much learning occurs when you meet with these individuals and learn from them, between sessions or during sessions. As with curricula, it is the extracurricular that can be most enlightening.

Sadly our nation learns the least from most Americans most behind - and fails them most by designs shaped by those who know them least. They are damaged by lack of awareness to some degree, but mostly by those who focus on "their version" of quality efforts not realizing that what they do is most damaging where outcomes are already worst. The fact that we tolerate Pay for Performance designs is most revealing.

The P4P designs lack evidence basis for health outcomes and have evidence basis for discrimination against providers who care for those most complex with lesser health and most in need of care. Those with different backgrounds, preparation, selection, training, and careers would never tolerate this. Leading a nation to change requires us to change who we are in ways that can help our graduates change others and an entire nation.

Shame on us for accepting the rescue plans of any political party and the sellout of American health care by corporate greed and the many misguided CMS designs. Shame on us for not addressing the substantial error in the literature - particularly regarding medical error and quality improvement. Why do we tolerate the literature shaped by bandwagon assumptions and beliefs? Where is the critique and logical reasoning that should have protected us and most Americans?

Less Focus on Parties and More Focus on People

Political parties obviously have little focus on most Americans. Parties are most important to parties who have parted with people.

Party atmospheres are also promoted by Family Medicine Party associations. I must admit enjoying family medicine parties, otherwise known as STFM Regional and Annual Meetings and Annual Meetings of the Students and Residents. But parties often distract from needed change.

One change that should have been done long ago is breaking up a very expensive Student Resident Faculty party in August in Kansas City. Students going to the meeting are already committed with few going that have yet to decide. There is great potential for intervention before medical school and at state or regional levels.

Changes should include:

Making it regional or state
Making it a celebration of Doctors Ought to Care or COPC projects involving age 14 up student projects.
Making it a health career orientation for secondary education students.

There is great power in Rural High School Career Fairs or matching up students to community mentors and projects.

Even a focus of the Kansas City party on medical students just admitted to medical school would be better than those already committed to FM. Some of the best FM interventions were timed before medical school - timing prior to formal curricula that often retards the most important learning.

The focus of early and often interventions would be attracting change agents to family medicine. The benefits at the community level would be enormous, and communities would learn to appreciate local students and their activities. They may also be more willing to support them as students, medical students, or local family physicians.

Isn't it quite clear over 100 years that our nation

has moved away from the health care needs of most Americans,
has moved away from the health workforce needed by most Americans,
has moved away from the support of that workforce
has moved away from the preparation and selection needed for that workforce
has moved away from the specific training needed for that workforce
has moved away from community level resources, projects, promotions, and performance.

Why not spread the focus on the Culture of Health and focus on the change agents to bring about such a culture?

Best Beginnings for Health Access Careers Are Quite Different. Medical Students Remain a Poor Choice for the Health Care Needs of Most Americans - too exclusive in origin, background, medical school, training, and distribution.

Are Departments of Family Medicine Necessary?

Rural Medical Education Rearrangements of the Deck Chairs

Why More Federal Dollars for Graduate Medical Education Still Not Able to Produce the Workforce Needed for Most Americans Now and Especially Not in the Future?

Bandwagon Disruptive Change health care design flaws Lean Primary Care Wrong Way Physician Behavior Change

Is Lean Primary Care the Next Bandwagon?

Johnson matk at 13:03 0

health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..

Bandwagon movements have been very common in primary care. They have been very distracting. The failure of Primary Care Medical Home for many reasons now leads to the need to have another bandwagon. Lean Primary Care may lead the charge to become the next bandwagon.

The rosy reviews have been seen in the usual media sources. These indicate a 5% increase in productivity, guaranteed to attract attention. Whether this was Lean or the movement of physicians into the action is impossible to address - except in the media and in the article.

Which would you read

Scaling Lean in Primary Care Impacts on System Performance or
Moving Physicians from Back to Front Offices Improves Performance

Lean Primary Care Meets Many of the Criteria of Primary Care Medical Home

The usual suspects are present such as inflated claims for results despite short term data collection. The problems also persist:

Lean is too vague - a similar problem with Primary Care Medical Home. There is no way to assess whether these are selective clinics with better patients and cash flow or not. Changes do tend to work for quality and costs in such patients and clinics. Terms such as not for profit mean little. The same is true for safety net.
Confounders that could explain the results without "Lean" are seen. For example, the physicians were moved from their private offices to work places shared with the medical assistants. The paper could have been titled and written differently because of the location rearrangement instead of "lean." Lean obviously draws more attention but may not explain the findings.
The study location was vague. A not for profit can be profitable or not as well as in better or worse locations. The entire context of the study is difficult to assess. Primary Care Medical Home and other innovations are more likely to do well with patients already spending too much and with inherently the best outcomes. Generally these practices have the best insurance plans that also pay better - as is also seen in the largest practices. Larger means better contracts and annual escalation clauses. Smaller often means take it or leave it contracts and concentrations of patients with lowest paying plans.
The primary care physician definition was vague. Those providing even as low as 5% FTE were included. The selection should have been over 50% FTE as primary care physicians. Fragmentation can be pushed, continuity may not be as easily pushed.
The study combined different primary care types but did not offer a breakdown - IM can be more costly and least efficient, as have certain types of not for profits. Rural family medicine can also have high complexity and more chronic disease. An obvious concern would be whether patients had as many care needs met.

Other problems common to primary care remain:

No show and same day were not mentioned. Dealing with these areas alone can change results.
Nurse practitioners were not mentioned.
Physician assistants were not mentioned.
The word nurse was mentioned, but it is not certain that RNs were involved as many have been eliminated from primary care over the decades due to cost factors.
Community was not mentioned
Changes in patient panels were not mentioned.
Clinical quality was essentially not measured and should not have been mentioned. A few measures are not reflective of overall quality and should not be represented as same. There are no patient controls for quality.
Physician satisfaction was also difficult to assess due to short length of the study as noted. It is not clear how readiness for the change was assessed, a possible indication that it may not work other than in early adopters

Flow was pushed - which could be good in some poor productivity settings (Veterans Administration, others) but may not be good in others running on or over the edge.

There will be more studies, and given the current example there should be more questions than answers generated.

Disruptive Change errors of perspective Higher Cost of Delivery innovation dysfunction Primary Care Medical Home

Punishing Primary Care with Medical Homes

Johnson matk at 17:53 0

health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..

Context matters in health care. This is because outcomes are about the patient, community resources, social determinants, environments, situations, behaviors, housing, and other personal and community factors. Outcomes are predominantly not about clinical interventions. This is a very difficult to understand but most important concept. Clinical interventions are small change regarding health outcomes.

The context for this blog response is a recent Commonwealth Review of PCMH. There were changes in a few outcomes, but overall there was little change. "PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care visits, emergency department visits, inpatient visits, and four quality measures." The article claims that context matters, and may explain the lack of outcomes for primary care medical home.

High Cost for Little Change Via PCMH - the Opposite of Value

Primary care medical home costs run about $80,000 to $100,000 per primary care physician (Annals FM). This is about 20% of the typical revenue generation of a primary care physician. Spending 20% to return a few % or no percent in change is not sustainable in primary care. Primary care is already in decline with stagnant revenue and increasing costs for areas beyond primary care medical home costs, and many can ill-afford any additional costs much less major costs.

Fire, Aim, Ready Innovations

An incredible amount of time, effort, grant funding, and promotion has gone into primary care medical home. There is little explanation for PCMH other than

Innovation Worship after decades of stagnation in primary care
The need for marketing primary care in locations where enough primary care is present to result in competition.

The massive outlays have always been questionable with primary care finances so marginal.

Studies have demonstrated serious issues with PCMH from the start such as lack of a uniform definition and variations in application. Recent studies and reviews have indicated variations in the outcomes measured, problems with comparison groups, and one huge issue.

Innovation and Accountable Care Has Much To Be Accountable For

The lack of value due to high cost of PCMH without significant outcomes improvements
The lack of PCMH where most Americans most need care
The poor assumptions made by those who push innovation without understanding most Americans in need of care and those who serve them.
Primary care associations that support innovative policies that make practice difficult for most of their members.
Rapidly rising cost of delivery
Accelerating morale, productivity, and turnover problems
Innovations that lack an evidence basis for significant outcomes improvements such as PCMH and Pay for Performance
Regulations such as MACRA that exceed the design specifications of Congress and the consultant for the regulation (RAND)

Serious Consequences from Innovation Dysfunction

Primary care medical home and other innovative changes have clearly contributed to the increasing levels of burnout and morale problems.

Turnover is already over $300,000 per lost primary care physician and turnover is another problem when team members are so stressed by the primary care financial design. Training for PCMH is most difficult when team members trained in primary care are lost.

Poor Primary Care Medical Home Distribution May Have a Reason

PCMH has had poor penetration into lower physician concentration counties. PCMH has often involved those most organized who can lobby for grants and special funding.

The practices that have had lower payments and higher costs of delivery have not been in a position to consider a much higher overhead model such as PCMH. Small practices and practices where physicians are nearing retirement face many challenges involving PCMH, EHR, and measurement focus.

The cost to change billing and payments has been substantial. Obamacare did temporarily increase Medicaid payments to the level of Medicare, but then this expired after two years. Dr. David Sundwall estimated that the cost of these changes negated the extra revenue. Once again the designers underestimated the consequences of their design.

Despite the problems, there are articles that tend to label physicians not very progressive for not embracing new innovations. More understanding is needed by those who do not understand primary care facing the most challenges with the least support - for decades.

The innovators are asking for costly innovations from people who know their practices, their situations, and the sad financial design that most impairs what their team members can do already.

Financial Compromise Via Decades of Payment Designs

Large practices and systems have been receiving increasing revenue via higher payments from two methods - greater negotiating power and annual contracted escalation clauses. Smaller practices, primary care practices, and practices in locations with few insurers have been falling behind decade after decade.

The risks are much greater for smaller practices with patients that have greater challenges and lesser outcomes.

More Complex Patients in Primary Care, Especially Lower Concentration Settings

For decades physicians have been paid based on the assumption that subspecialized care was more complex. Studies have now demonstrated the complexity of primary care. Fellowship training may take more years but this is no reason to send so many more dollars for services that take little time. Complex care needs support, not punishment.

The most complex patients are found in lowest physician concentration counties where there are higher concentrations of disabled, diabetics, elderly, poor to fair health status, and deficits in health literacy and local resources to go with lesser concentrations of health care workforce.

These local, population, and community factors set outcomes at lowest levels such as 48% of preventable deaths for this 40% of the population. Pay for Performance is clearly discriminatory, resulting in even lower payment for those least paid already.

The deficits are the result of decades of lowest payments for primary care plus even lower payments where care is needed plus lower still because small practices have no negotiating power with regard to payers.

Higher Primary Care Functions Are the Goal of All Primary Care Practices

Primary Care Home Advocates act as if primary care practices desire to function poorly This assumption is wrong. This assumption is a major problem for a number of reasons.

Studies indicate better outcomes from small practices of 9 or less physicians (Casalino, Health Affairs).
Small practices know their patients and their community.
Small town practice facilitates working with the community in ways that can impact outcomes not available to those in larger, more concentrated settings
Numerous family medicine doctors of the year and rural health awardees demonstrate outreach, coordination, services integration, Community Oriented Primary Care, and other endeavors.
Payment changes are needed to support primary care higher functions.
Primary care offices need to be doing higher functions, not doing the administrative work that should be done by insurance payers

This rural family physician in the 1980s was working with the health department, a weight control group, local social workers on teenage pregnancy prevention, and was a part of the local ministerial alliance as well as other community group efforts. He proposed one of the first assisted living operations - despite being paid the least by state, by Area 99 codes for the state, and by being a new physician via ReaganCaree. Reasonable support would have facilitated a longer stay and more interactions. From this perspective, the claims and promotions make primary care look bad as if it is lacking in more than just finances.

Higher primary care functions such as integration, coordination, and outreach require more team member support. In primary care, the largest budget item is personnel and the team members that deliver the care are essential. When supplies, computer, EHR, health info maintenance, and other costs increase by necessity or regulation, the team members that deliver care are compromised. This is clearly seen with declines in productivity and morale with increasing burnout.

Rapid Change Often Favors Those Already Doing Well

Primary care medical home is not established, has substantial variation, is costly at a time when primary care margins are too thin already, places greater challenges upon team members, and requires substantial changes.

One theme to remember in this time of innovation worship is that the only insurance companies, systems, practices, and hospitals that are able to decreased costs and improve outcomes are those

that were paid well (or overpaid)
that had the least complex patients with inherently the best outcomes, and
that generally have had the ability to figure out that they can do well financially with an innovation.

The innovation bandwagon works against those that are not well paid, that have the most complex patients, and that have the highest costs of delivery

Actual Compromise of Health Outcomes - Follow the Money

Designs that ship scarce health care dollars outside of lowest concentration settings compromise team members and also outcomes. Health, education, economic, and other outcomes are dependent upon dollars that stay in a community.

Dollars shipped in to communities and dollars retained in communities for human interactions and for support of humans are dollars that improve outcomes.
Dollars shipped out of communities in most need of dollars
help shape disparities.

Dollars shipped out for certifications and regulations, dollars shipped out to practice consultants, dollars shipped to mail order pharmacies by innovative designs that compromise local pharmacies, dollars redirected by school consolidations, dollars not sent by states to lowest property value school districts, dollars concentrated in highest concentration settings by paying more for highly specialized care with least payment flowing to primary care and lowest concentration settings, payment designs that have compromised small practices and hospitals, and various innovations all steal dollars from places in most need of dollars for a widening of disparities and a worsening of outcomes.

It is important to examine the context of health care dollar distributions with over $30,000 per person expended in 79 top physician concentration counties and less than 3500 dollars sent to 2621 lowest physician concentration counties - a 9 times disparity.

Improvements in health, education, economic, and other outcomes
require disparities in a wide range of areas to be addressed
specific to patient, student, worker, and community.

Increased Costs Have Consequences - Especially in Health Care

Two Forces Shaping Declines in Outcomes indicates that spending billions more for innovations adds to health care costs and fuels across the board cuts, austerity focus, and compromise of domestic discretionary spending - contributing to worse outcomes.

Most Needed Health Access Requires a Better Design, Not Poor Assumptions

There are many poor assumptions regarding primary care. My son at age 3 had a saying, "Sometimes it just be's." Basic health care services need not be fancy, but they should exist. The fact that many if not most Americans lack for basic health access is indication for different payment designs to support this foundational care.

People want basic services and primary care provides these services.
Primary care exists for basic services.

Why Castigate Higher Volume?

Even former insurance CEOs indicate that office services do not break the bank. With 55% of services for just 6% of annual health spending, primary care is a great bargain. Higher volume is actually indicated as it is the only solution for resolving access to care barriers.

Volume of care is both a friend and an enemy

Higher volume for primary care where needed is a friend
Higher volume where patients can access care and can overutilize care is an enemy
Four times greater volume of specialty services in a number of metro areas is an enemy shaping concentrations of workforce, greater competition, and increased numbers of such services to support concentrations of workforce
Higher volume of highest paid services that are multiple times more likely in populations without access barriers may well be responsible for cost overruns.

In places where most of the US population resides in counties with lowest concentrations of physicians, volume is not the enemy. About 90% of the local services are basic generalist and general specialty services - primary care, mental health, basic surgical services. The lack of volume in these areas is a huge problem.

When you see primary care leaders pontificating about volume as a problem in primary care and basic services - you are seeing them repeat academic and policy designer concepts. They are not passing on information important for

Restoring Basic Access to Care.

Jumping on bandwagons, innovation worship, and assumptions from designers immersed in highest concentration settings are killing access, local health workforce, health outcomes, and human beings where Americans remain behind in lowest concentration settings.