Go Path: Vulnerable Populations

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Soon No Specialties Left to Limit Family Medicine Scope

Johnson matk at 23:57 0

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Recent meetings of family physicians brought up the age old question of expanded scope. Some raised concerns about threats to this scope. As is the usual, what is most important is the context. Where half of Americans are found, there is not a reason to be concerned about scope.

Only in highest concentration settings are family physicians limited - since all specialties other than family medicine concentrate in higher concentration settings.

The competition is less and less of a problem regarding broad scope for family physicians in lowest physician concentration counties. Few of the other specialties remain and many are in decline.

This places more burdens upon the remaining family practice workforce. This comes at a bad time as the practices require more time for documentation and there is less time for expanded scope such as hospital and procedural activities.

As discussed previously in recent blogs, the payment designs continue to be the major limitations for all of the above workforce types. Generalist and general specialty services are 90% of the services in these lowest concentration counties. The overall payment design pays less for the basics and the basic services are paid less in these counties. This is a poor design where care is more complex and resources are more limited.

Notably the attacks on scope have proceeded from insurance and payer designs.

Liability premium costs put the brakes on many procedures - and a key route to better revenue generation in practices sent the least revenue by payment designs. This forced full scope obstetrics beyond many family physicians, unless they predominantly did such work to support the liability premiums. Hospitals are closing and obstetrical services are closing in these 2621 lowest concentration counties also a consequence of payer designs failing for the basic hospital services of these smaller facilities.
Government and insurance payers have also dumped assistant surgery - once a key expansion of scope and another revenue generator.

Countdown Workforce in Lowest Concentrations

FP positions filled by MD DO NP and PA distribute best at 36% to match up to this 40%. FM is 24% of local workforce where needed and reaches 38% when counties do not have a hospital or in the states such as Nebraska and Kansas.
General internal medicine was 13% of local workforce where needed but is collapsing to 30,000 or below. The 4 times greater multiplier for top concentration settings will substantially reduce this contribution to 5% or below.
Contrary to many studies indicating the need for geriatricians, they fail for distribution where the elderly and most complex elderly are found. Only 13% of geriatricians are found in this 40% of the population where 45% of the elderly are found. Geriatrics fails for financial design reasons - basic services paid too low and complexity too high. Inkind contributions from academic centers, nursing homes, rehab centers, and large hospitals insure that geriatrics remains concentrated along with the physician origins most closely associated with higher concentration settings.
Pediatric workforce is only 6% and stable but pediatric physicians are stacked toward concentrations along with every other specialty other than family medicine. Gender changes, origin changes, and payment changes will further limit distribution.
Mental health fails for lowest concentration counties where this 40% of the population easily has 45% of mental health problems. Only 23% of mental health providers overall and 17% of psychiatrists are found in these counties.
Shrinkage of public health has long complicated care in lowest concentration counties and has also expanded scope.
General surgeons were 27% with general orthopedics at 24% and general obstetrics gynecology at 22%. These and other general surgical specialties have been shrinking at 2 - 4 percentage points a year from 2005 to 2013 in the AMA Masterfile. There has been no sign of stopping. This should not be a surprise since these are the lowest paid services. These are also some of the oldest physicians - an indication that training of these basic surgical types is incapable of addressing care where most Americans are found and are increasing most in elderly, demand, and complexity.

All physician types who could act to reduce family practice scope are concentrating and contracting. This should result in lower physician concentrations overall and higher proportions of family medicine in the lowest concentration county physician workforce.

In addition to challenges of scope, the challenges from patients are also significant - and are substantially increased in these places with lowest resources and workforce.

US Population	40%
SNAP/Food Stamp Spending	42%
Poor Americans	43%
Elderly Americans	43%
Obese Americans	43%
Social Security Spending	43%
Smoking Americans	45%
Preventable Deaths	46%
US Veterans	46 - 48%
Poor Children	47%
Social Security Disability $	47%
Diabetic Americans	50%

40.7% Uninsured 2014 (so much for health insurance expansion as not that much different than the 40.2% of the population in lowest concentration counties)

40.2% Population in 2010
38.6% Population in 1990
36.6% Population in 1970

The lowest concentration counties are fastest growing in numbers (30% faster than US average), in elderly, in demand, and in complexity - only the finances remain stagnant, miring these counties at 115 physicians per 100,000 and likely less.

Combinations such as Dual Eligible patients, homebound elderly, poor children, those with more mental health days, and those with poor to fair health status are more likely to be seen in these settings. The permutations that add to complexity are endless but the support has been limited by past, present, and future designs.

Housing and other lower cost of living factors shape patients with lowest paying plans into lowest physician concentration counties. Those stuck cannot leave and those driven out of higher concentration counties (financial reasons, lack of affordable housing) accumulate. The health payment plan failures shape the workforce failures.

Family physicians increase in proportion as local determinants of health decrease. The payments also decrease for the same office codes. The new Pay for Performance designs place additional limitations with higher costs and more penalties because of the populations in lowest concentration counties. The discrimination has been documented, but the bandwagon of Pay for Performance Rolls On.

The major battle remains the financial design that rewards non-basic services and penalizes those who most serve where needed, their patients, the communities in need of services, and basic health access in the United States.

But the new health care law, if enacted, will make matters worse. The impact will be substantial upon Red Counties already hurt by cuts in the supports noted above, with more to come.

The Few Least Healthy Counties or 2621 Lowest Physician Concentration Counties

From March 25, 2017 - Cries of victory may ring out today after the apparent defeat of the misguided Republican Replacement Plan, but the sand people will be back and in greater deception. The designs over past decades will continue to be shaped by those with their own agendas - agendas that are a poor fit with the needs of most Americans or true improvements in health outcomes.

Frying Pan to Fire for Red Counties - Health care designs helped rebuild health access 1965 to 1978 via JohnsonCare. Many of the current Red Counties were blue back then but have since switched. Health care designs 1980 under ReaganCare slashed and burned health care in Red Counties as seen in hundreds of closures of small and rural practices and hospitals. Designs 1990 - 2010 and since 2010 have also failed for Red Counties.

Austerity Focus CMS Payment Design cognitive vs procedural errors of perspective Family Medicine health access health care design flaws Vulnerable Populations

The Primary Care Finances Fight Is THE Fight For Vulnerable Populations

Johnson matk at 01:11 0

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

Family physicians are the most likely to encounter vulnerable populations. Addressing the needs of these populations requires more team members with better support. The team members are the ones most compromised in the past three decades of payments too low and cost of delivery too high made worse by rapid chaotic change.

Family medicine leaders have set up a series of meetings. The track record of these large gatherings is not stellar. The first of these meetings addressed access. The second of these meetings focused upon vulnerable populations. There is a third planned to address primary care workforce. The result will be more panels, reports, centers, and initiatives. But this will not address access, vulnerable populations, or primary care workforce.

When a single area is important to all of the core missions of family medicine associations, this should be the dominant if not the only focus.

Reports, Panels, Centers, and Grants are what CMS does when it cannot take care of health care delivery. Family medicine associations support more of the same.

"Continuing a long history of tackling disparities in patient care head on, Julie Wood, M.D., M.P.H., AAFP senior vice president of health of the public and science and interprofessional activities, announced the launch of the AAFP Center for Diversity and Health Equity, an initiative that will focus on addressing the social aspects of health care.
"The AAFP has developed its Center for Diversity and Health Equity to take a leadership role in addressing social determinants of health, nurturing diversity and promoting health equity through collaboration, policy development, advocacy and education," Wood told AAFP News."

Expanding access is a requirement for addressing vulnerable populations.

Vulnerable populations were once considered a small population. Austerity focus and the 21st century addition of 2 trillion more dollars to health care (past 3 trillion now) have conspired to compromise domestic discretionary spending and many if not most of the supports for vulnerable populations.

Austerity focus at the state and federal level and worsening health care costs both act to compromise health care, education, economic, and other outcomes.

Within health care, the changes also compromise the financial designs for primary care and basic services - the generalists and general specialties that are 90% of local services where care is most needed and where vulnerable populations are most likely to be found. The basic services, especially those delivered where most needed, are the ones that are provided by those least organized. Those most organized will continue to protect their interests. This will send an increasing burden to those who remain to deliver basic services - more patients, more added to vulnerable populations, more elderly, more with mental health needs, more with chronic illnesses, more complexity, less support, fewer team members, and more regulations. Vulnerable populations have no place to go other than to multiply. Family physicians are most prevalent where health access is in greatest need and this is where vulnerable populations are concentrated. Family medicine must fix the financial design for any real hope of addressing access, vulnerable populations, and primary care workforce.

The dominant US designs assure the rapid expansion of vulnerable populations to become the majority of Americans due to

Widening disparities in children in multiple outcomes shaping increased numbers of vulnerable populations.
Cascades of future impacts due to US children being last or next to last across child well being factors among developed nations.
Disparities in education and other spending at the state level with impacts upon health, education, and economic outcomes
Disparities in health spending 9 to 1 in favor of 79 top physician concentration counties as compared to lowest physician concentration counties
Lowest payments for primary care and basic services services that are 90% of the services where needed
Highest population growth (twice the average for decades), highest growth of the elderly, increasing complexity, and greatest increase in demand in 2621 lowest physician concentration counties - making populations more vulnerable (Red counties and a few dozen rural counties with a majority that are minorities and some of the worst disparities)
Forced migrations of vulnerable populations (fixed income, disabled, elderly, lower to middle income, Veterans) to lowest physician concentration counties where housing costs are lower and where climate is better for health conditions (43 to 48% of these populations are found in this 40% of the nation's population, The ranks swell to include 45 to 48% of diabetics, those with preventable deaths, smokers, and obese Americans.
The tripling of the elderly in the US by 2040
Rapid increases in minority populations
Closures of rural and small hospitals shaping populations in counties without a hospital and with subsequent declines in local workforce as one of the fastest growing populations in the nation due to more counties added and higher populations in the counties added
Cuts in payments to providers serving vulnerable populations from ReaganCare to ObamaCare.
Pay for performance (value based, readmission penalties, MACRA)) penalizing providers who serve vulnerable populations as outcomes are more likely to be lower because of the local, resource, patient, community, and other factors present

AAFP should save the dollars for the final forum on primary care workforce.

COGME III did enough 25 years ago.

The promises of CMS and primary care associations and various expert gatherings will not address vulnerable populations, health access, or primary care workforce. This requires more specific efforts. Every dollar that AAFP can generate should be focused upon what will actually address beleaguered primary care team members, vulnerable populations, and health access. There must be no rest from this labor until the payment designs are improved for primary care, for mental health, and for basic services. This critical change must occur where vulnerable populations are more likely to be found - where access and primary care workforce are most compromised.

It is time for True Primary Care Advocates to wake up to historical fact. The only time of progress in these heavily conferenced areas was

During the one period of time from 1965 to 1978
When more dollars were being injected into primary care and
When more dollars were being injected to support more team members where health access was most needed via
Expansions of Medicare and Medicaid spending,
Spending closely associated with vulnerable populations.
It also helped that this was a period of relatively less increase in cost of delivery
with increases in payment rates helping to cover the costs of inflation.

The Era of Cost Cutting Since 1980 With Rapidly Increasing Costs of Delivery

Since 1980 the payments have been stagnant and have at times have been cut. In addition, the cost of delivery has gone up due to regulation, turnover costs, higher than inflation costs of supplies and other practice essentials.

The largest practices and systems demand and get higher payments for the same services and even annual escalation clauses. The smallest practices and providers get take it or leave it least paying contracts from payers.

The largest practices and systems demand and get discounts from suppliers - leaving the rest to make up the difference.

The one sure thing since 1980 has been disparities worsened by numerous designs that shape health, education, economics, and children.

Clinging to Past Glory Is Misguided as Only Payment Has Mattered

Appearances have been deceiving. Numerous family medicine interventions looked good at the beginning but have not worked since. Family medicine and primary care associations and leaders still cling to the past. This time of great success when everything worked is the period of 1965 to 1978

The 1965 to 1978 policies are why so many "interventions" appeared to work

FM departments and student interest groups in every school,
Student resident conferences,
Primary care schools, and pipelines to primary care and rural practice.
FM reached 30% rural practice location rates by 1980 only to shrink below 20%. Only the hospital based (emergency, hospitalist) remains 26% rural because of better financial designs for hospital based FM grads.
All primary care sources have fallen away from primary care - as dictated by the financial design.
These all required steadily increasing injections of dollars to support the positions - the positions that once expanded primary care and care where needed. The financial designs fail for the positions and the team members to address health access, vulnerable populations, and primary care delivery capacity.

No training interventions can actually work because of failed payments. Decades of data support the same findings across the vast stretches of America where most Americans fail most in access - then and now. Tracking confirms little change other than names changing, or initials changing behind the name. Rather than patting people on the back for the success of their program or pipeline, it is important to examine what is actually happening nationwide, or across counties left behind, or regarding the practices that address vulnerable populations.

We still have 2621 lowest physician concentration counties that are persisting due to the same lowest paying, least supportive payment plans - compromised to lowest paying levels by those who take advantage in higher concentration settings and those who set payment policies based on their immersion in higher concentration settings.

A better financial design is the major requirement
for access and vulnerable populations and primary care workforce.
Why do family medicine leaders avoid what is critical
to all of the major family medicine missions?