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The recent Beyond Flexner postings and social mission articles have revived interest in Academic Medicine's Season of Accountability and Social Responsibility by William T. Butler, M.D. Dr. Butler gave this address to AAMC in 1990 and expected a response - one that never came.

The following are predominantly Dr. Butler's words with an update regarding the lack of progress regarding his calls to action.

Public Concerns About the Overall Health Care System

Dr. Butler declared that academic medicine had entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. His recommendations are followed by comments regarding academic medicine addressing these concerns or not.

Public concerns have continued. There has been no progress in this area. The political arena has been a distraction, but the concerns continue. The same types of headlines listed not only are seen in the media headlines, but also across social media and numerous Business, Health Info Tech, and other journals and magazines.Medicine has lost respect and physicians have lost substantial ability to shape health care design.
Academic designs have made matters worse for those who deliver basic health access. The partnership between managed care and accountability researchers resulted in micromanagement. This movement has added countless billions in additional health care costs based on assumptions and lack of evidence basis for health outcomes improvement.
Worst of all is that the design changes have made it more difficult for the team members that deliver the care. Some physicians cry out, often those older who experienced much better environments, but not associations or academic designers.

Butler then reviews earlier seasons of academic medicine and the responses. He recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research.

Efficiency and confidence are lagging still. Academic centers push for more lines of revenue and fight to keep the highest reimbursement in each line - designs that they largely shaped and maintain.
1100 zip codes in 1% of the land area have top concentrations of physicians at 45% of physicians in places with 10% of the population. Over half of health spending is transferred to these settings making it difficult for half of the nation to receive even the basic care.
The graduate medical education design results in only 6.5% of residency positions found in 2621 lowest physician concentration counties with 40% of the US population.
The expansion of GME is a primary example of the problems of academic medicine - lack of efficiency, training failure, and continued promotion of funding that widens disparities in dollars, workforce, and access.
Residents in their fellowship years are paid only $60,000 and have small levels of benefits but often generate as much as subspecialty physicians paid $400,000 or more with some of the most lucrative benefit packages. More residents at these fellowship

Next, Butler focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. Butler flat out states that generalists are the cornerstone of the medical profession.

Generalists have substantially failed due to academic medicine and academic influences that prevent true health care reform - more support for cognitive, basic, office services.
Generalists and general specialties are shrinking as a function of US academic medicine, primarily because generalists, general specialties, and health access are prevented by the designs that academic medicine continues to shape.

Butler describes models of existing, successful programs.

The WAMI model looked good because it existed when the financial design for primary care was better 1965 to 1980. Since that time the model and other training models are limited by the financial design and the inherent suppression of generalists - particularly family medicine.
The models that Butler promoted in the article were limited to only a small influence regarding solutions for underserved rural or urban practices.
The financial model prevents any MD DO NP or PA training solution.
The Deans Lies and the GME lies continue across MD DO and NP. No promises of improvements in primary care, health access, and care where needed should be made until academic medicine promotes true payment reform - more fuel for the generalists and general specialties.

The author concludes by proposing to create a "National System of Regional Medical Care." He urges the AAMC to continue its leadership by designating a task force to examine how such a regional system could be established within this decade.

States used to do statewide and regional planning, but this is largely left up to the largest systems and practices that control the health care dollars.
The regional plan failed to progress.
Regional primary care officers in positions above hospitals could actually help to hold hospitals and hospitalists accountable for not coordinating care with primary care offices.

Most of the school and program successes we still revere are really about the one period of time with substantially improved finances - a time when the US steadily sent more dollars to lowest physician concentration counties. This was due to early Medicare and Medicaid 1965 to 1980. An improvement in the financial design shaped improvements in workforce and in access. The rush for schools, programs, special incentives, and pipelines to claim credit obscures the obvious reason for improvement.

Dollars injected into the care of those poor and elderly were specific to lowest physician concentration counties then as now, if we chose to do so. The original designs are not the same and the dollars are unlikely to go where needed as determined by designs from the 1980s to the present.

There are those who can point to "their program" or curricula as successful, but a rearrangement of the deck chairs type of success is failing 200 million people as will more easily be seen in 2040. As is often said it is amazing what can be accomplished if no one cares about who gets the credit but it is also true that those who claim credit falsely distract from the investments of time, talent, and treasure that do make the difference.

We are already a decade too late in workforce improvements specific to these counties to be in place by the 2040s. True reforms specific to most Americans by 2050 seem even more distant.

Care for most Americans left behind requires an entirely different financial design. This is the only way that the traditional health professional education design will to work for MD DO NP and PA.

Anyone who promotes anything other than major financial reform as a solution is giving false hope. Health care interventions that do not improve patient outcomes and can worsen them are condemned, for good reason. The same should be true for those who promote any solution for health access that does not substantially improve the financial design.

CMS Payment Design cognitive vs procedural Discrimination By Design errors of perspective MACRA Pay for Performance Subspecialization

Attempts to Address Overutilization Leave Most Americans Behind

Johnson matk at 00:54 0

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Four decades of attempts to address overuse have not only failed to rein in overuse, the efforts have contributed to under-utilization and more Americans left behind by design.

Overuse has long been 2 to 4 times higher in highest physician concentration counties. Overuse supports too much workforce for few and results in too little for many. Overuse steals the workforce needed elsewhere and makes it appear that there are deficits of workforce with the need for more graduates - when the problem remains overutilization.

Payment Design Plus Profit Motive Plus Political Power

Overutilization is largely the result of the payment design and profit motive and political power. The payment design results in too much paid for highly specialized services and too little for the basic services (primary care, mental health, basic specialties).

Profits are best supported by the march to ever more types of procedures and technologies that are paid the most because they are newest and most subspecialized. The profits by those most organize pave the way for political power - power that prevents true reforms such as more for cognitive, office, and basic services as well as services where most needed for those smallest and least organized.

Too much for too little result, too much profit over the basics, and too much power vs too little - these are what drive the US health care design the wrong way.

Payment Design Diverts Workforce

Nurse practitioners and physician assistants have followed the higher payments to new specialties with more added in each specialty. The dollar distributions shaped by payment policy would not allow more primary care physicians, clinicians, or team members.

The effects of payment upon the physician workforce are obvious - and this pattern is being repeated in the rapid changes seen in NP and PA workforce. For decades NP and PA were promoted as solutions for primary care, care where needed, and efficient care.

It is obvious that there is no solution for care where needed as the deficits remain despite massive expansions.
Primary care similarly remains stagnant by design.
The NP and PA "efficiency" advantages claimed in primary care did not work out in lowest paid primary care paid even lower.

NP and PA advantages have best been seen in non-primary care. As the specialty and subspecialty barriers all fell away, the NP and PA advantages shaped new career options. The NP and PA graduates helped highly specialized practices

to capture more market share,
to handle the basics with NP and PA graduates
to shift highest paying procedures and services to subspecialty physicians for maximal revenue generations,
to allow care delivery in multiple sites (office, different hospital sites), and increase utilization of existing testing equipment and personnel.

This has allowed largest systems and practices to cut expensive subspecialty physician costs to the minimum while maximizing services, testing, and billing.

Expansions Facilitate Increases in Workforce, Services, and Overutilization

Massive expansions of PA from 1500 to 9000 annual graduates a year and NP 1500 to 20,000 a year since 1980 have substantially contributed to increasing utilization, higher costs, and overuse.

Recent doublings of NP, PA, and DO graduates have not contributed to more primary care as expansions are negated by fewer remaining in primary care. MD primary care results are shrinking despite expansion - as fewer remain in primary care. There is no other choice. The numbers of positions are limited by the revenue - minus the other costs of delivery and more limited by delivery costs that have been increasing.

Blocked from primary care by the annual revenue limitation of 160 - 180 billion for primary care or 6% of spending (minus expenses), NP and PA and DO and Caribbean and MD expansions have fueled the massive increases in non-primary care workforce.

The workforce design compliments the increased utilization of highest cost services and penalizes basic services. Expansions of graduates cannot improve access as the basic services are all prevented from expansion by payment design.

Suppressing the Basics Accentuates the Highly Specialized

Even worse, the deficits of primary care and access facilitate greater utilizations of higher cost services - emergency care, specialty care, subspecialty care, urgent care, and convenience care.

More graduates translates to more workforce and more highly specialized workforce - leaving the basics far behind.

Ever Higher Health Care Costs Are Unopposed

Runaway health care costs have followed

From rapid ever purer expansions of non-primary care workforce
Plus rapid expansions of administrative costs
Plus digitalization costs
Plus micromanagement costs

The increases in administrative and non-delivery costs have been significant. These include more personnel in administration and management, managed care efforts, managed cost interventions, and managements of high risk patients which have added about the same costs as would have been saved by management efforts (The CBO was right).

The consequences of spreadsheet cost cutting have been significant. Physicians have often told the cost cutters of the consequences, but they are long past listening. The cuts look good on paper but translate poorly to the real world where complex interactions between individuals, groups, and society are difficult to capture. The CBO was right, the White House and Steven Brill Were Wrong by Kip Sullivan.

Additional and substantial tens of billions a year have been added by HITECH to ACA to MACRA to value based. The Pay for Performance additions are some of the worst, adding higher cost of delivery for no significant change in outcomes (Annals of IM review) while discriminating against those who provide care to more complex patients with inherently lesser outcomes as noted in increasing numbers of studies past 15 already. Pay for Performance has delayed needed reform - especially cognitive vs procedural.

The obvious result of so much more for little or no gain in outcomes has been failure in value. The US has obviously been moving the opposite direction from value. This is another reason why attempts at value basis are misguided at best.

Consequences of Cost Cutting (Caused by Overutilization and Costs Too High)

Overutilization has been bad, but innovation and regulation and certification efforts have made the situation worse. Cost cutting has been a very non-specific tool with a four decade history. The collateral damage has been greatest

in primary care with 55% of services delivered
in basic services care where needed where margins are thinnest
in small practices where cost of delivery increases are most

Those largest, most organized, and most powerful are in the best position

to prevent adverse legislation
to reshape regulation is desired ways
to influence implementation

Those doing best are the largest and most organized in places where workforce is most concentrated.

Good business decisions require that essential areas not be cut and may even need to be given increases because they are essential - but this has not happened. Even worse the basics have continued to fall relative to those highest paid and overutilizing - dragging more team members, clinicians, and physicians this direction.

Those smallest, least organized, and most basic have steadily been left behind as overutilization, overregulation, overadministration, and overcertification have continued while costs have worsened, outcomes have worsened, value has worsened, and access has worsened - with the worst impacts on increasing proportions of Americans - your choice of 30 to 50% and increasing.

Closures and compromises of small practices and small hospitals continue where care is most needed, where populations are growing fastest, where fewest health care dollars go already, and where more dollars are required to be shipped to higher concentration settings - by each new permutation of the health care design.

Only those immersed in higher concentrations could fail to see the situations, conditions, environments, and compromises.

Research Immersed in Concentrations Results in Policies Rewarding Concentrations

The research base has long been immersed in the places and practices and systems that are largest and that most overutilize. The latest designers from managed care to Dartmouth to the present have continued to base their assumptions on this top 20% most concentrated. The research has long ignored those who fail to access services. The data is also distorted when the populations involved have difficulty accessing care in places where insufficient workforce and other access barriers exist - where underutilization is a major problem.

The research differences promoted widely have largely been the result of comparisons of different populations - not the various clinical interventions that have gained press.

cognitive vs procedural Core Access Principles Determinants of Health Discrimination By Design Equity in Payment Higher Cost of Delivery True Reform in Payment

True Reform is Needed to Get from Last to First for US Health Care

Johnson matk at 10:18 0

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Health care in the United States is notable for being the worst when comparing health care among wealthy nations. A Commonwealth article was published in NEJM highlighting four areas that need to improve. Interestingly an improvement in primary care finances would address all four areas, but this discussion was avoided. Fitz Mullan had another article promoting the social mission just published in JAMA. Once again addressing bankrupt primary care finances would contribute to the social mission. Lofty ideals are easy to discuss, but the hard work is missing when it comes to addressing access barriers, disparities, and most Americans falling farther behind. You cannot get from last to first by failing to address areas that must be reformed - areas that actually shape insufficient access, insufficient primary care, insufficient team member support, and disparities.

Goals, Aims, and Missions must be replaced with specific actions.

True Reform Is the Beginning

The foundation, institution, association, government-associated authors can begin to address four areas and the social mission by a true reform focus - equity in payments for basic services compared to most specialized and compared across the nation.

The authors fail to indicate the one most important area for improving primary care, mental health, and basic access services -

more payment for cognitive, office, basic services.

This must be the top priority even if less goes for procedural, technical, subspecialized. This is the only way to balance generalist MD DO NP and PA vs non-generalists.

Primary care is the best distributed of all workforce and therefore is the best route to distributing health care dollars.

About 70% of local services where needed in 2621 counties lowest in physician concentrations are primary care services.
Lowest paid basic services are 90% of local services.
Only 6% of spending goes for primary care which involves 55% of services and also covers 50% of mental health services.
Where hospitals are missing, are threatened, or have closed - primary care is even more important.
Distributions of dollars also help to distribute improved outcomes as outcomes improvements require dollar improvements in areas such as education, economic development, housing, local resources, and other areas. Designs that concentrate create disparities. Designs that distribute can help address disparities.

Procedural, technical, subspecialized services are rewarded the most and are most concentrated where physicians are most concentrated. These are also the places where the institutions, largest systems, corporations, foundations, and associations are most powerful and are most willing to oppose this top priority reform. Primary care and basic services are a small proportion of local services and workforce where there is immersion in highest concentrations. The academic/research/workforce consultant/payment policy gurus are not going to support true reform.

Will academic, foundation, association leaders identified with social mission, access barriers, primary care, and disparity reduction stand up - perhaps at the risk of their jobs and reputations?

Authors that move in the most powerful circles have to stand up and promote this true reform even if other academic, association, foundation, institution colleagues oppose this reform.

Other nations have better balance involving higher levels of generalists. Higher concentration counties in the US rank well among other nations. Half of the US population ranks far below all developed nations in generalist to population ratios.

Despite the wondrous and expansive rhetoric regarding training interventions as a solution for generalist deficits, it has long been clear that generalist MD DO NP and PA workforce has been prevented by payment design. Few enter and even fewer remain - by financial design. The primary care design also results in a less experienced primary care workforce that may not perform as expected. Higher functions such as integration, coordination, outreach, and community partnerships are more likely with better designs that result in better retention and improved continuity.

No MD DO NP PA school or program or special training design can address gaps in primary care, mental health, and basic surgical services until this true primary care payment reform is addressed.

Once again this is about the limitations in primary care with revenue too low overall and specifically in places where half of the US population most needs care.

The US Health Care Design Is Specific to High Cost and Low Yield Outcomes

The runaway health care costs have been fueled by overutilization of highest cost services. These are services typically provided in higher to highest physician concentration counties. These services offer the least improvements in outcomes for the highest costs.

Expansions of subspecialty, administrative, and micromanagement costs continue to drive lowest yield for highest cost. These changes over the decades have acted to increase disparities.

Disparities are widened by overspending where services are concentrated and by underutilization involving most Americans.

Expansions of MD DO NP and PA workforce have been successful in one area - increasing non-primary care workforce. The expansions of the NP and PA programs have been ideal for a more efficient financial design - for non-primary care practices. Replacing as many most costly subspecialist physicians as possible is essential to lowering costs of delivery - of non-primary care services. This also boosts profit margins for higher to highest concentration providers.

True Reform Needs a Solid Financial Design

A universal coverage for primary care with 20% higher payments would be a start. Universal coverage for primary care is more palatable and more affordable. It is already a best value at 55% of services for 6% of spending.
Universal coverage for primary care with a 20% boost would be a 25 or 30% improvement for places with lower collections and greater challenges in billing, delays, and denials of payment. There would also be benefits in terms of less turnover and productivity losses.
A universal payment scale paying the same for office codes across the nation would bring equity to primary care payments for another 20% boost for those paid lowest - where services are most impaired by the current design.

The recommendations above would likely provide 45% more revenue for primary care where primary care is lacking - especially in lowest concentration counties. This redistribution of dollars would be a best match to the counties and practices most in need of workforce. Efforts specific to It also avoids the very costly and compromising issues of the current overproductions of MD DO NP and PA graduates.

Best Timing for True Reform

The time to do this was 2010 to allow at least 30 years to be able to address the populations most left behind that are increasing from 40% to 50% of the population by 2040. Sadly the US has not been moving from 40 to 60 billion to expand access as the insurance expanded pays too little and requires too much innovation, regulation, and certification cost. Economic improvements have also avoided these counties resulting in further deficits where turnover costs are highest and are increasing most.

Basic health access deficits bad and worsening are about patients with lowest paying insurance plans concentrated where deficits of workforce are greatest, where costs of delivery are increasing fastest, and where complexity is increasing most in multiple dimensions.

A reasonable understanding of the social and other non-clinical determinants of health that dominate in shaping health, education, and other outcomes...

...leads to the conclusion that billions taken away from lowest concentration counties by each of HITECH, digitalization, MACRA, and Primary Care Medical Home results not only in a decline in access but also a decline in health outcomes - as the non-clinical determinants are worsened. Education has a similar discriminatory design and a similar loss of billions from these counties by measurement focus. Measurement focus is ridiculous when these are counties that need to retain dollars to retain workforce and improve outcomes.

The designers underestimate the disparities caused by the health payment policies including worse outcomes due to dollars 3 times greater spent in 79 top physician concentration counties with over $30,000 spent per capita and 3 times less or less than $3000 per capita spent in lowest physician concentration counties that should have 50% of Americans by 2040.

Further Decline By Design Impacting More Americans

Demographic and other changes insure worse to come. This is because of housing collapse, closures of small hospitals, and meaningless costly micromanagement and other non-delivery costs accelerated. Housing collapse drive more financially and medically vulnerable populations to lowest concentration counties, closures of small hospitals add 10 - 12 counties a year to the ranks of lowest concentration counties, and micromanagement steals billions more each year from areas such as primary care that only get a minimal 35 - 40 billion for primary care.

This is officially half enough in raw numbers of dollars required and only one-third enough given the higher concentrations of poor, elderly, fixed income, disabled, veteran, poor child, diabetic, obese, smoking, and mentally ill populations in these counties.

You can add the latest research indicating concentrations of populations with lower health care literacy, nonadherence, high risk, and high cost.

Runaway health care costs are fueled by overutilization in higher concentration counties, highest payments for the highly specialized services that do the least for health outcomes, decades of increasing administrative costs, decades of increased profits distributed to a few Americans. Runaway health care, military, and prison costs together with austerity focus compromise the personal, state, federal, employer, and local investments needed to change outcomes. Better investments in people, local resources, environments, and situations is required for better outcomes. This was noted but was not emphasized.

Much of the recent confusion, distraction, and inefficiency added is about the insertion of micromanagement into health care design - a bandwagon assumption that cannot improve outcomes as noted in evidence based reviews.

If you stand for access then you must stand up for true payment reform. If we cannot get foundations with a mission for access to support access improvements specific to the needs of most Americans, we will not make progress in access, costs, or outcomes.

AAFP CMS Payment Design cognitive vs procedural Discrimination By Design health care design flaws innovation dysfunction insufficient cognitive payment

Students and Residents in Family Medicine Want Equity

Johnson matk at 00:52 0

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Students and residents should focus AAFP upon equity. Equity in payment would be a good start. Dollars are maldistributed in health care and this contributes to inequities in workforce, access and outcomes as disparities drive social and other determinants of health the wrong way.

AAFP wants to present the best case scenarios to students and residents, but there are major issues that must be addressed. Equity is indeed and important theme worthy of discussion

Equitable payments for primary care, mental health, and basic services should be most important for student or residents that truly hope to deliver these basics - especially in places with half of Americans where inequity and disparities dominate. There should be no deception that most Americans are doing well. American health, education, and economic outcomes indicate that few do very well and most are left behind. Future family physicians deserve to know the big picture as family physicians are most likely to care for those left behind in multiple dimensions.

Inequities Cognitive Vs Procedural

Basics including cognitive and office services should be paid more and procedural, technical, subspecialized should be paid less to obtain equity in workforce and equity in distribution of workforce

Inequities Higher Vs Lower Concentration Counties

The designers have created for themselves multiple lines of revenue and the highest reimbursement goes to those in highest concentrations of workforce. Inequity is over 50% of health care spending going to 1% of the land area in 1100 zip codes with just 10% of the population but 45% of physicians. So much for so few in few locations makes equity impossible. Since outcomes are minimal at high cost, value is low across US health care.

Attempts to address inequities in payment are vigorously resisted by the academic, association, institution, foundation, corporation designers.

Equity Translates To...

Equity would translate to equitable access, equitable distribution of workforce, and equitable payments. Equity in payment is required so that training interventions can result in equitable distributions of workforce.

Even if students or residents want to provide primary care or care where needed - the designs make this most difficult. Too few positions are supported.

Equity in Access

Access is impaired by 2 to 3 times less local workforce for 40% of Americans in 2621 lowest physician concentration counties - counties that receive less than 13% of health spending and only have 22% of primary care workforce. The only equitably distributed workforce is family medicine with 36% of family physicians to match up best to this 40% of the nation. All other specialties concentrate in counties with higher to highest concentrations of physicians - leaving most Americans behind along with higher concentrations of elderly, Veterans, disabled, and others most complex and least served.

The 2621 lowest physician concentrations have lowest concentrations of MD DO NP and PA workforce because the counties have concentrations of people with the worst paying plans. They also have concentrations of people with lesser social determinants in places with least economic impact.

These 2621 counties only get about 40 billion in primary care revenue each year. Payments are 15% lower for the same services. This translates to 6.6 billion less in payment. Equitable payment would go a long way to support primary care teams and higher functions - denied by design. Collections issues result in 5 - 10% less for 2 to 4 billion less.

HITECH to MACRA has diverted 8 to 10 billion that can no longer be used to support care delivery. In fact it never gets a chance to circulate locally as it comes in and goes out before it can help address jobs, economics, or social determinants. The design concentrates health care dollars in higher concentrations and results in less equity for lower concentration counties.

Payment inequities make matters worse. Payments are lower for primary care and are 20% lower for the same services in these lowest physician concentration counties. HITECH to MACRA has resulted in over $100,000 per primary care physician in uncompensated cost of delivery increases. Payments lower, costs of delivery higher, and complexity of patients greater is the opposite of equity.

Widening Inequities By Design - Does Family Medicine Care?

These 2621 lowest physician concentration counties are growing faster in population and in numbers of counties:

Inequities in payments for basic services continue to result in small and rural hospital closures which decrease local workforce
Specialties other than family medicine exit counties without hospitals to add more counties to the 2621 lowest concentration counties.
Small practices are more common in lowest concentration counties and small practices are also being compromised by payments too low, costs of delivery too high, and complexity increasing
Affordable housing is vanishing in higher concentration counties and most in these counties are paying too much already. The housing crisis picks off the most vulnerable in physical, mental health, and financial need. Many have no choice other than to move to lowest workforce concentration counties lowest in resources but often with better cost of housing, better cost of living, and better climate.

Inequities Made Worse By Design After Design

A few Americans benefit from financial designs that put more wealth into the hands of fewer leaving most Americans behind.

About 74% of top college positions go to children of top income quartile parents with only 3% arising from the bottom quartile and less than 13% from the bottom half in income.

Health care dollar distributions shape similar inequities. By 2040 half of the US population will reside in 2800 - 2900 lowest physician concentration counties because of hospital inequities, inequities in education funding, and inequities in housing that drive the most vulnerable in physical, mental, and financial capabilities to reside in lowest concentration counties with least resources, worst social determinants, and greatest patient complexities.

The top 79 physician concentration counties with 10% of the population receive over $30,000 per person in health spending while the 2621 lowest physician concentration counties receive $3000 per person in spending - ten times less. Highly specialized services added, more new and expensive drugs, precision medicine, increased administrative costs, more practice consultants, more software, and more health info tech all divert dollars from lowest to higher concentration counties.

Six states have top concentrations of physicians and residency training. Thirty states have lower to lowest concentrations of physicians and residency training. The 2621 lowest physician concentration counties with 40% of Americans only have 6% of residency training. Because these counties have too little spending, there is no chance that any training intervention can actually reduce inequities in distribution of workforce. The nurse practitioner and physician assistant maldistributions plus expansions actually worsen health spending disparities.

The leadership of AAFP often shapes the information going to students and residents, but students and residents should do their own exploration and analysis. They should pay close attention:

to their future
to more equitable future for them and for their patients,
to a more equitable future for half of Americans left behind by design.

Should students focus on small proportions of the population or should they consider half of the US population a worthy cause to address?

Perhaps students and residents can help the Families of Family Medicine to understand that they need to reconsider innovation, regulation, and certification that make care more complex, add to costs of delivery, decrease productivity, and add to inequities in payments, workforce, and access - by design.

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

Business Models Large Vs Small Primary Care Practices

The GME Lie Distracts from Payment Reform

Veterans Not the Only Ones Driven Out of Housing and Out of Town

Focus on Change Agents to Change the Culture to Healthier

Why Are 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?

Insanity and Discrimination in Payment Design Help to Maintain Shortages of Workforce and Access Barriers

ACA CMS Payment Design cognitive vs procedural Complex Elderly Discrimination By Design innovation dysfunction Primary Care Solutions Small Health Care

Business Models Large Vs Small Primary Care Practices

Johnson matk at 19:22 0

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

Triple Aim, innovation, regulation, certification, cost cutting, and other changes have widened the gap between small primary care practices and large practices for the past 37 years. The treatment of small practices and those that they serve will some day be recognized as discrimination by design.

Revenue and Collections

The financial design for primary care has been an issue since the 1980s. Stagnant payments, increasing costs of delivery, and increasing complexity represent the Triple Threat to primary care. This threat is most prevalent in the smaller practices.

15% higher payment are common in large vs small practices for the same office codes (Medicare Data 2011). This translates to about $65,000 less payment per primary care doctor. This is shaped by a number of different factors such as being small or rural, not being associated with a hospital, being in the wrong state, and being less organized.
Large systems and practices often have 5% annual escalation clauses. Small practices have take it or leave it contracts that are burdensome to the practices and their patients.
Larger means the ability to strategize, to shift resources for best profit, to choose and adapt location, patient population, and health plan contracts for maximal revenue, maximal outcomes, least cost of delivery, and most local resources. This has not been so for smaller and less organized practices where revenue has been stagnant and practices are fixed in place, population, and location.
About 10% is lost to collections in large primary practices vs 15 - 20% for small. A 5 percentage point differential translates to $50,000 per doc per year.
Delays and denials can be more challenging for small practices and for the insurance plans more likely in small practices

Higher Costs of Delivery Via Innovation, Regulation, Certification

Rapid changes are more difficult for small practices with fewer and less specialized personnel. In the last decade a number of regulation, innovation, and certification changes have been thrust upon primary care. In general, the adverse impacts are more likely for small practices. Sometimes these changes have been implemented even when knowing these adverse impacts.

$32,500 for HITECH per doc (MGMA)
$30,000 at least for additional digitalization, HIT and similar costs
$40,000 for MACRA per doc (Health Affairs)
$43,000 for Primary Care Medical Home (PCMH) for large practices - $60,000 to $105,000 in other estimates (Annals FM) - likely higher cost for smaller practices

The costs of the above may be greater for small practices although some small practices are spared (by MACRA) or are choosing not to spend the dollars. CMS has already published the expected problems for smaller practices via MACRA.

Productivity losses occur due to the above but these have been poorly studied. Additional time for documentation has been studied and extra hours a day per physician for documentation, messages, and internal reviews add up. Burnout, higher turnover, and morale problems have increased due to all of these above.

The bottom line has been shave so much that personnel have not been added to address these areas. More burden is placed on fewer taking more time and effort for little in the way of apparent gain.

Value based and other forms of Pay for Performance have already been reviewed for adverse impacts. Smaller practices tend to have patients that are inherently less healthy which will result in lesser payment.

Another assumption of the micromanagers is that larger providers are better. Actually larger practices have different and better finances, advantages in team members, and patients with inherently better plans and outcomes.

There is an assumption that larger practices and systems will absorb smaller practices for their own good. Why would an insurance plans, systems, or practices absorb practices where patients are more complex and have lesser outcomes and fewer resources. Many that do have better finances in mind, not the care of the patients in the small practices. Small practices are focused locally and actually had better outcomes in studies by Casalino. These better outcomes for practices smaller than 10 physicians and especially for 1 and 2 person practices were a surprise to researchers - who were looking for worse.

Why blast small practices away, and local focus, and community orientation for dubious benefits, if any? Much of what is published has dubious value despite the focus on "value based."

Even worse is the discrimination inherent in innovative "accountable" payment designs. Underserved practices such as seen in Community Health Centers have had direct studies demonstrating the discrimination inherent in Pay for Performance (Hong, JAMA). Pay for Performance Fails to Deliver

Higher Costs of Personnel Turnover

Buchbinder indicated $225,000 cost for primary care physician turnover years ago. A reasonable update of the costs of recruitment, retention, locums, lost productivity, orientation costs, and adapting to the practice and patients and team members would be $300,000 for the turnover cost of a lost primary care physician. This translates to $100,000 per primary care doctor per year with turnover about each 3 years.

Smaller practices face over $100,000 per primary care turnover per year with less than 3 year averages and higher costs of recruitment, retention, advertising, orientation, lost revenue, lost productivity, and other adaptation costs
Larger practices may face little in the way of turnover costs as recruitment and retention incentives, advertising, and gaps can be filled by minor adjustments of existing personnel and physicians.

Small practices that run short on workforce end up losing patients to other practices because they cannot schedule new patients or return established patients to care. This represents a future problem with revenue and more difficulties balancing personnel to revenue. A poor financial design worsens this common scenario. If revenues decrease it can be hard to replace a physician assistant, nurse practitioner, or a physician. Large practices can make up gaps by shifts among remaining workforce.

A sudden decline of 2 physicians, physician assistants, or nurse practitioners in a small practice requires substantial management to restore revenue and stabilize existing and future workforce.

Recent studies in Annals of FM regarding rural practice indicate that higher turnover is seen around metro areas and in places lowest in concentrations of physicians. These are where small practices are more prevalent. Larger practices are often sought by new graduates or by those departing small practices.

Twice the turnover and half the revenue generation limit nurse practitioner and physician assistant contributions. Scope of practice and complexity of patient care can be challenging for new graduates. Expansions of NP to 20,000 annual graduats and PA to 9000 acts with the poor financial design to set up a revolving door situation resulting in limitations in new area such as primary care experience.
Many of the short and long term effects of the current financial design have not been considered or studied.
The value of a long term primary care physician retained for 10 - 15 or more years is recognized, but again studies have failed to consider the positive contributions while the negative assumptions continue to be published and promoted.

Higher Costs in Non-Personnel Areas of Primary Care

Supplies, equipment, and insurance costs are discounted for large practices and practices in large systems. Some largest can even negotiate to result in no waste as the suppliers are responsible for the supplies. Only the supplies used are charged to the practice. Size dictates negotiating power for higher payments and lower costs as document in studies of insurance, systems, and practices. The costs for non-personnel areas run about $40,000 to $50,000 per primary care physician. Savings from size were estimated at $10,000 per primary care physician. Very efficient large practices can save substantially in discounts and less waste. Smallest practices end up paying for these discounts as suppliers recoup their losses.

Physical Plant Costs

Cost of office space, utilities, maintenance, and property taxes are higher for large practices. Best locations with best patients and best insurance plans are costly. However this increased cost is offset by better payments, depreciation, investment, and contributions. Small practices often receive support from hospital or community although support is limited by federal laws and poor finances inherent in small hospitals and small or lower income communities.

Additional Limitations for Small Practices

Small practices are often located where patients are more complex and have more chronic diseases and fewer resources. Medicare, Medicaid, disabled, poor, fixed income, and vulnerable populations are often more concentrated in small practice settings. Poor payment, poor support, and poor design make greater complexity of practice, patient, and community even more difficult.

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Get Beyond Salaries To Understand Failed Design

Johnson matk at 00:09 0

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Data is often collected, processed, and promoted for dramatic impact. Dialing for dollars is very lucrative when it comes to health care. The controversies dominate our attention as health care eats its way through our budgets, our employer budgets, our state budgets, and the federal budget. Physician salary data is a popular attraction. This data is often used to claim that physicians seek careers associated with higher salaries. The payment design shapes much more than physician salaries and in turn shapes those in our nation that win and those that lose - by national design.

Data from Medscape

The payment design has long favored procedural-technical services over office-based/cognitive/basic services. The highest paid physicians perform procedures that are paid at highest rates. Other highest paid physicians are those that perform higher volumes of higher paid procedures. These highest rates have been determined by academic, hospital, and physician association representatives that have dominated payment panels. The favor is returned as highest payments work well for academic institutions, largest systems, and associations.

Not surprisingly, the highest paid and highest volume services are the easiest to overutilize. Knee surgeries, cosmetic procedures, cardiac stents, prostate surgeries, tonsillectomies, and skin procedures are big business. Dr. Otis Brawley first came to my attention in his talks about too much done. He learned from hospital CEOs how various screening tests were reliable for harvesting a set amount of dollars in areas such as prostate surgery.

In a cruel irony, the tide has turned against unnecessary procedures and higher volume. This has also been applied to those lowest on the scale. As noted by various experts, higher volume of lowest paid office services has not broken the bank. But higher volume is castigated. Sadly, those paid least and limited to office services have had little choice other than to try to increase the volume. As costs of delivery have been forced higher, there are no good choices. In office based practice, the decisions can lead to fewer team members and lesser paid team members - a short term fix with cascades of consequences.

Brave New World for the Procedurally Focused

At the top of the scale can be seen those who have been able to separate from hospitals and systems, thus providing some competition for higher salaries. Surgical centers involving orthopedic and other procedures have done well for orthopedists and others establishing such centers. Orthopedic surgeons fresh out of fellowships get paid the same as the orthopedists nearing retirement.

The fact of the matter is that the national design for payment shapes winners and losers. Winners are indicated previously. Those most procedural, technical, subspecialized, and centralized are most organized for best payment and profit. Those less organized, not the biggest, not centralized, not academic, office-based, cognitive, and basic have had lesser payments. The consequences of lesser payment are many:

Lower salaries for those lower on the scale is just one consequence. Salaries are higher for those generating more under the payment design.
Team members working for those generating lesser payment are fewer and have more different tasks. They often follow the pay gradient to better support. The most specialized physicians can hire and support the most specialized team members who do much of the work. Public health and Community Health Centers are lowest on the scale. Academic and private primary care can pay better. More specialized practices and hospitals raise the ante. The most specialized can pay best. Stable team members, continuity, more team members, and more experienced team members follow the dollar gradient.
Nurse practitioners and physician assistants have followed this pay gradient following the physician example and adding more different specialties and subspecialties with more added to each new career type. This results in fewer and fewer remaining in primary care, especially in family practice.
Care where needed is compromised by design. About 90% of the services where needed (rural, underserved, 2621 lowest concentration counties) are generalist and general specialty services. Primary care, mental health, and general specialty services are stagnant to declining where 40% of Americans are found. The workforce is aging - another indicator of lack of replacement and other consequences.
Paying the least for these basic services means sending the least dollars to these lower concentration settings where 40 - 50% of Americans are found. The designs for payment actually create the shortages that are seen. Team members in these areas face the most complex populations and have the least support - by design.
With fewer dollars shipped to settings that already have lowest health, education, and economic outcomes - outcomes worsen as disparities widen.
The academic centers that train MD DO NP and PA graduates benefit by having shortages such that they can generate more interest for funding more graduates - who still cannot go where needed because of payment design.

There really is no reason for the designers to change the design. It serves them very well. Those who do the studies and the reports shape the design. They also give the press releases and engage the media.

Most Americans lose in the design in a number of ways. They are the least likely to become physicians at 3 to 1 against. Even those that become physicians are least likely to become the physicians that shape the design. The designs are shaped by those far away, most exclusive, and most different than most Americans.

Medscape and other information brokers do very well at capturing and selling our attention. Often the way the information is presented paints a certain impression. Not surprisingly the picture that is painted hides more than is shown.

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

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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?