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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

 


 

 

 


 

 

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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.
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    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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      It has become common to promote innovations as solutions without sufficient testing and without really considering the possibility that the intervention might not work as planned. After decades of failure to resolve cost, quality, and access woes across medical error focus, managed care, managed cost, EHR/HIT, PCMH, alternatives to physicians, insurance expansion, and numerous forms of Pay for Performance - the cost, quality, and access problems remain. Telehealth deserves to be critically examined as a solution for rural or underserved populations.



      First of all, telehealth will be priced in a way that supports expensive medical personnel, managers, CEOs, and investors. There is no intent for service for those low or no pay or with worst insurance. This will require payment.

      Medicare and Medicaid patients will play a major role as they are concentrated in places with lowest concentrations of physicians. Indeed this is a major reason for shortages. These are the places receiving lower payment for the same services in a number of dimensions. Arguably these are the highest value settings. These are settings that have not been given the chance for higher payment across the past four decades. How Can CMS Improve Value In the Most Valuable?

      Why not invest in the most valuable rather than a new innovation that will cost more and is not really focused upon access, cost savings, or quality?

      Costs

      The costs of health care must increase because of telehealth. Someone has to pay for the equipment, personnel, connections, security, and more. 

      As with convenience clinics, there will be utilization increases.  This occurs due to the telehealth visit and also as a result of the telehealth visit.

      Much of what telehealth can do is pass on the patient to another health care provider. There will be claims of saved lives, but frankly there is no way to actually tell what would have happened. But there will be patients referred for additional care and costs and consequences.


      From TeleOutreach or Teleprofiteering - The Ecology of Medical Care considers 1000 people and about 800 a month have some health concern or symptom, 327 think about seeking care, and 217 visit an office (half in primary care). Those who think about profit all waking hours know that they can exploit about 30 more visits from each of three categories - those who have symptoms, those who think about a visit, and those who visit an office. 
      The potential is to have as many visits from telehealth as seen in primary care. At $50 - 100 dollars a televisit for hundreds of millions in additional visits a year one can see the attraction to those who devote their lives to profit.


      More patients will go from those with minimal symptoms, more will go from those thinking about going for care, and more will go from those who seek care. 

      The potential for profit is high with expanded coverage of telehealth services to Medicare and Medicaid and other populations less health literate and less able to navigate the complexities of the care system.

      Outcomes
      Outcomes will not be improved. Outcomes are not about clinical intervention. Outcomes are about the patient, local, and community factors. Telehealth does not impact these areas and indeed may erode them.
        
      Colds and Bronchitis - Americans already access too many antibiotics, often for the possibility of saving 1 day of symptoms in a 10 - 11 day session of illness.

      Urinary Symptoms - 70% of the women getting antibiotics will not need them and those who have sexually transmitted diseases or cancers or hormonal reasons for their urinary symptoms will not have a culture or urine test or follow up to state otherwise. 

      High Fever - High fever is a complex medical condition that continues to test clinicians that have full access to the patient and family as well as basic tests.

      Access

      Access barriers will remain. Those in most need of access will not even be able to access telehealth. Accessing prescriptions when needed will also be a problem - a much worse problem since mail order pharmacies and lowest payments for small or independent pharmacies have been depleting pharmacy access. The mail order impact upon local pharmacies is a relevant example to consider regarding the impact of telehealth upon local primary care.

      Health literacy and internet literacy fail where access fails because workforce receives too little payment for the costs of delivery too high and accelerating.

      Access barriers will likely worsen. Primary care depends upon a mix of underpaid complex services and overpaid simple services. Telehealth will steal the simple dollars that do not require time and team members, leaving the greater challenges for local primary care.

      Missing the Complexity of the Interaction

      Telehealth is single problem focused and misses the mark addressing patients with multiple areas to consider and multiple areas to address. 

      Telehealth is less likely to focus on preventive care, chronic care, or caregivers. 

      Telehealth is not going to have a thing about making sure that all with asthma have access to asthma meds regardless of their presenting symptoms. Whatever is learned by the encounter of use for the family or community is not shared for improvement of the family or community.

      Who Is For Teleprofit
      • Innovation Bandwagon Promoters
      • Those who desire to profit from Telehealth
      • Primary care providers diverted to telehealth from undersupported primary care with more added to do each year
      • CEOs, recruiters, and managers organizing the telehealth
      • Researchers who want telehealth to look good and fund studies
      • Those who don't care what happens to local workforce
      • Drug companies (doing well by convenience care predicts doing well by telehealth)
      • Dermatologists
       Who Should Not Be for Teleprofit
      • Local primary care practices
      • Local leaders hoping to improve local economic impact
      • Those who understand that dollars diverted from local care can damage local workforce and local outcomes
      • Those seeking value in health care (outcomes / costs)
      • Primary care associations seeking to keep their members active in primary care positions rather than being diverted to numerous other ventures
      A Question to Ask Local Community Advocates and Leaders Representing Rural Health, Primary Care, and Local Access

      The question is,
      • Do you want local family practice bringing dollars in to your community into a practice or local health system where team members also work locally and spend dollars locally in ways that can help reverse the disparities that actually make outcomes worse
      • Or do you want to ship your scarce local dollars to someone sitting at home in a high concentration setting adding more to health care costs and sucking dollars out of communities that most need dollars - employed by CEOs making much greater sums.
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      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.
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