Articles by "insufficient cognitive payment"
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Periodically there are calls for Academic Medicine to be accountable for health care in areas such as health care workforce. This accountability includes the larger dimension of people with substantial limitations in their health care such as rural populations or underserved urban populations. The access situations are worsening across primary care, mental health, and general specialties - those who provide 90% of care for half of the population most in need of care. The lack of any significant improvement for decades indicates barriers not easily addressed. In fact it may well be that the top priorities for academic and largest systems are such that true reforms are prevented - reforms that would address the primary care, mental health, and basic services payments that are essential for distributions of services and broadening of health access.

A social mission or accountability would require academic and other health care leaders to stand up for higher payments for basic services, decreases in costs, and increases in support for providers caring for increasingly complex patients. Instead there are no such cries and there are new designs that make the financial design worse - and make it more difficult for the team members to deliver the care to the half of the population most left behind. 

Health care is about people and health access practices are over half dedicated to personnel. The support of the personnel who deliver care is most important. Designers and their designs have had adverse impacts. 

Making a difference is about tens of billions a year redirected where dollars can matter most. Without financial design reforms, training designs are incapable of generating the graduates that can be supported where they are most needed. Academic leaders can continue to avoid responsibility or even blame for worse designs while they can continue to cry out for more support to train more graduates - even if those graduates cannot actually go where needed or serve most Americans most behind by design.

Most Americans are getting the minimum with less to come. 

More special social mission events and articles have not ended with calls for accountability or demands for true reform in payment - so they have failed.

More primary care associations have been created and funded with more special projects and greater support of innovation, regulation, and certification - making matters worse.

Not even family medicine with 70% of graduates in office based primary care has grasped the design flaws that make matters worse - sending academic entities farther away from social mission and accountability for the basic access of greater proportions of Americans.

More special schools, programs, pipelines, and promotions will not result in necessary health access improvements arising from MD DO NP or PA graduates. In fact the numerous announcements each month represent a distraction from real primary care solutions.

Academic Centers Lack the Perspective of the Need for Major Change

Perhaps this "social mission" or "social responsibility" appears to be quite difficult for academic entities and those that they influence. Curricular emphasis is easy and temporary. True health reform is hard work. Reforms have usually arisen outside of academic centers as seen in Medicare and Medicaid - although the case can be made that the academic, foundation, government, association, and corporate designers managed to redirect Medicare and Medicaid after only 15 years of operation. Managed care took less than 5 years. ACA was dead on arrival for true reform such as balancing cognitive vs procedural. 



Access to care is a horizontal, decentralized broadening of mission quite different from the vertical, highly specialized care organizations specific to academic institutions. Previous essays have discussed the process of academization or distancing, making it difficult to consider situations and conditions. 

It Can Take Decades to Realize the Limitations of Academic Efforts

As a medical student I had great respect for academic medicine and medical centers. My time as a rural physician trained me in dimensions untouched by academic training - community, health access, care where needed, social dimensions. Even as I learned more, I still clung to academic medicine as a solution and hoped to bridge the academic and rural communities in my quest for solutions for health access. It is quite clear that this cannot happen now or for decades to come. 

The financial design prevents generalists, general specialties, rural practice, primary care, mental health, small practice and care where needed. The academic designers continue to sit on panels and influence government in ways that prevent true reform. True Reform    

The thirty years teaching, researching, and delivering health access as an academic physician were great years and involved great people and great meetings - but the research and the academic interventions even coordinated across preparation, selection, and training have resulted in no progress in basic health access. Nebraska still has the same levels of inadequate workforce across the same 70 counties that still have physicians despite substantial efforts at all levels and a genius family medicine residency program design (shaped by Jim Stageman and Mike Sitorius working with state and institution players). The Nebraska county map over the fifteen years of observation had different names and initials with more family physicians, but fewer internists and little change in delivery capacity. 

My editorial work as North American editor of Rural and Remote Health confirmed little progress. The research in the US as in other nations indicates the successes of various programs or models. But despite the successes, the lowest physician concentration counties remained lowest with inadequate workforce - and many fell to even lower concentrations as funding declined, hospitals closed, or economics changed. 


A medical school or training program can be stellar in "social mission" 
with great documentation of superior results 
but half of the people in the state remain to have improvements in access.

More commonly the studies are as flawed as those that promote international graduates as solutions - studies that fail to consider 30 - 40% who leave the US and that fail to consider departures from primary care and from areas of need in the years after graduation. 

With More Study the Truth is Obvious

It finally registered that most Americans are losing in health care design as in the designs for education, economics, banking, housing, and other areas. Why expect different when economics, education, health, and their designs are so closely related to one another? If you truly understand the social, personal, local determinants that shape 60 - 70% of outcomes, then you can begin to see the numerous flawed perspectives and solutions.

Lowest physician concentration counties confirm these adverse changes and the difficulties of addressing care where needed without True Reform. Students and residents interested in family medicine desire Equity. Family physicians Paid Less for Doing More Where Needed are frustrated and they are moving away from primary care as have all other primary care sources for the last few decades. The recent implementations of pseudo-reforms in payment have made matters worse and the designs have moved all the way to Discrimination in Payment.

Pay for performance has been widely promoted by family medicine leaders for some time and the associations continue to support these designs, even as they discriminate against family physicians in particular and other providers choosing to care for the most complex populations that inherently have the worst outcomes.

Once again lowest physician concentration counties represent lowest levels of workforce and access and highest concentrations of most complex patients with the most chronic diseases and other situations, environments, and conditions that make care even more complex.

Academics should sound off when practices and policies are not evidence based - yet they have not done so. Family medicine associations should be looking for issues to support such as opposing discrimination in payment, especially when the evidence basis for innovative designs is lacking. 

Do Unto Others...

The academic message for science, evidence basis, and public good have been compromised over the decades. Now when I see the social mission preached from academic leaders, even those respected for social mission articles, it is hard to listen. Those speaking fail to see the lack of progress despite the rhetoric for decades. Great concepts presented are as limited as the results for the last 40 years.

Real gains and real changes take real dollars, tens of billions more for primary care where needed. Only about 40 billion goes for primary care in lowest concentration counties with half enough primary care. Yet this is tolerated and made worse as more billions are subtracted in each of the new categories - HITECH, ACA, MIPS, MACRA, and Primary Care Medical Home. Worsening collections and turnover costs are bad, but the financial design actually prevents lowest concentration counties from being able to support more team members to deliver the care. 

More are falling behind in more ways with much worse to come. Health care design continues to leave greater proportions of Americans behind. The 40% in lowest workforce concentration counties will be 50% by 2040 as hospitals close in these counties and as housing affordability collapses in higher concentration counties force more of the most medically and financially vulnerable to move to lowest concentration counties.

Why would we expect different when most Americans are falling behind 
in economics, education, and other key societal areas? 

The social mission in medicine begins and ends with basic health access. For many Americans, health care fails because access fails.

Next is a review of the Academic Medicine Scorecard compared to the call for accountability made in 1990 by Dr. Butler, Chairman of the AAMC at the time.
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The transformation of primary care requires payers and players. The payers have said no so the players are too few and are often overwhelmed where the players are most needed. Primary care needs fuel and a more efficient financial design, especially in the small and rural practices and those where care is most needed. The controversies continue to hold primary care hostage, especially primary care where needed where half of Americans will reside by 2040.

The primary care financial design begins with only $500,000 to $600,000 in revenue per primary care physician as the fuel to propel the activities of primary care physicians, clinicians, and teams for a year. Unfortunately the fuel supplied is lower where primary care is most needed and is higher where contracts gain annual escalation clauses for those largest, most organized, and in locations of least workforce need. 

Recent blogs have illustrated just how much fuel is stolen and how inefficient primary care delivery has become. True Reform    Equity    Paid Less for Doing More Where Needed
Business Models for Primary Care Small vs Large       Discrimination in Payment

Associations, foundations, institutions, journals, and others cry out for solutions to workforce deficits, maldistribution, and costly inefficiencies.
  • But often their solutions such as expansions of graduates add to runaway health care costs and overutilization as primary care is fixed in place and expansions add more workforce and more costs for non-primary care areas.
  • The financial design does not allow distributions of dollars to the places where generalists and general specialties provide 90% of services. Only a true reform in cognitive vs procedural would redistribute dollars. This true reform has the added effect of supporting primary care, mental health, and basic services to go with better dollar distribution.
  • Changes in the financial designs are opposed by the payers and the non-primary care players that do well by the current design.
  • Only 6% of health spending for 55% of services in the area of primary care
So Let Us Begin the Dialing Down the Dollars Countdown - the Destruction of Health Access

About $500,000 to $600,000 in revenue is the main fuel source. About 50 - 60% of the primary care budget is personnel costs. Increases in the non-personnel areas act to decrease personnel. Increases in personnel to do non-clinical care reduces the clinical personnel area. Overall declines in revenue, increasing costs of delivery, and impacts upon productivity all hurt primary care viability and adversely impact primary care delivery capacity.

Family medicine member surveys indicate worsening of revenue with less revenue from hospital/procedural and non-office payments to go with fewer patients seen a week in the office. 

Declining Revenue and Less Payment and Lower Collections

Small practices, rural practices, practices in lowest physician concentration counties receive 10 - 20% less for the same office codes. This puts them down $50,000 to $100,000 in revenue compared to largest and most organized such as those propped up by hospital outpatient payment and those with 5% annual escalation clauses via negotiated insurance contracts (if these include primary care). 
As the percentage of family medicine in a county goes up, the concentration of physicians goes down and the payment goes down for Medicare (2011) for 99214 code from $74 down to $64 as seen in the last blog graphic. Where family physicians are over 30% of the local workforce, Medicare concentrations are highest (1.3 multiplier). Payments for private insurance also tend to be worst in these settings. 

The AAFP member surveys indicate that FM is rapidly increasing in Medicare and Medicaid proportions - not surprising because the people of lowest physician concentration counties have been fading in age and in finances. This impacts 36% of FM docs in these counties with 40% of the US pop.

Where most Americans most need care, primary care revenue adjusted for payments results in only about $500,000 per primary care physician. Equity in payment would boost this to $600,000.

$500,000 and Counting Down

Collections failure where care is most needed is a $30,000 to $50,000 greater loss per primary care doctor ($15,0000 to $25,0000 per NP or PA) as less is collected. 

This leaves...

$450,000 and Counting Down

Maintenance of Certification is $1000 to 2000 a year but has been increasing rapidly and without justification. The losses triple when considering lost revenue.

$432,500 and Counting Down

The listing of costly expenses lacking in evidence basis is long, prestigious, and heavily promoted. Digitalization and regulation has long been adding $15,000 to $40,000 per doc per year. Some years have been more costly than others:

  • $400,000 and Counting Down - MGMA indicated $32,500 for HITECH over a 1 to 2 year period
  • $370,000 and Counting Down - Additional digitalization, HIT, security costs, updates, maintenance
  • $290,000 and Counting Down - MACRA added $40,000 for a bigger increase than usual - Health Affairs
Obviously these costs are more than can be sustained, so practices have had to sell out, close, or merge. Outside supplementation is required. Smaller practices with physicians near retirement offer few options. The populations involved are not attractive to large systems or others who might take over.

The countdown will continue to illustrate the serious issues with the design.

Turnover costs are small for the large and over $100,000 a year per doc for most needed. NP and PA turn over twice as fast compared to PC docs but this may not apply in high turnover settings. Lesser payment for NP and PA services has long contributed to departures from primary care and care where needed. 

Only 22% of physicians are in lowest concentration counties with 40% of the US along with 23% of mental health providers and 26% of active NP and PA.

The $300,000 cost of turnover for each primary care doctor with losses about each 3 years includes recruitment, retention, marketing, locums, orientation, low volume early on, adjustment costs for new physicians, benefits lost or insurance payouts.

For the purposes of countdown, half of this turnover cost of $100,000 per year results in $50,000 a year loss to the practice. This leaves

$240,000 and Counting Down

Note that communities are no longer able to prop up small practices. Hospitals have often closed or are closing - resulting in less ability to prop up primary care. Hospital losses decrease local physician concentrations - leaving mostly family practice.

$160,000 and Counting Down

PCMH is $40,000 per PC physician for the largest and 2 - 2.5 times this for smaller practices which tend to be critical for access where needed. The cost for a small practice in a needed location would be $80,000.

The countdown has obviously resulted in inability to support primary care - a reason for too few and overwhelmed.

Costs Are Increasing in the Usual Practice Budget Areas 

Costs are obviously increasing faster than inflation and in multiple dimensions. For decades supplies and equipment have increased faster for medical practices. Supplies are higher cost for the small in some part due to discounts given for those largest, most organized. Insurance goes the same way.

Payment Equity - the True Payment Reform

ACA did not take on the most important reforms such as balancing payments between basic services and those considered procedural, technical, or subspecialized. 

The academic/association/foundation/institution/corporation designers have not pushed this reform - critical for basic access to care and the ability of any training intervention to work for access improvements.

Why Promote Inequity When Equity in Payment Is Required?
Why Promote Higher Cost of Care for No Gain in Outcomes - Lower Value By Design?

Associations most connected with primary care and care where needed such as American Academy of Family Physicians (AAFP) have promoted regulation, innovation, and certification rather than opposing these measures that destabilize primary care and primary care where needed - where family physicians (and NP and PA in family practice positions) are most likely to be found. Even when family medicine residency graduates have fallen from 90% office based to less than 65% office based with worse to come, there is not a protest. Internal medicine has collapsed for primary care with hospitalist careers mopping up those who do not go on to do one or more fellowships. Even with NP and PA falling to lower proportions in family practice positions (their dominant primary care contribution), there is little protest. Even when expansions fail to result in actual primary care increases as measured over the careers of the greater numbers of graduates, there is no protest.

Accountable Care Design for Most Americans...

... requires accountability for the above for any hope of improvement for most Americans behind by design.

As the financial model fails, so does the ability of training to address deficits of workforce. This worsens turnover costs, lowers distribution, and increases the costs of incentives.

Bailouts for the Few But Not Most

Banks, large corporation, and Wall Street firms have had bailouts but there is little help for agriculture failures, manufacturing failures, and cutbacks that have contributed to economic stagnation or decline. 


There has been no bailout for 30 - 40% of Americans - no extension of unemployment. Most Americans do not rate investments. Few Americans receive the most investments. SNAP, disability, Social Security, and similar cuts represent cuts in what supports most Americans, leaving more benefit for fewer by design


Fuel is failing where fuel is most needed
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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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    Once again the designers are promising a solution for shortages of physicians that cannot work. The expansion of graduate medical education will not send more physicians to counties short of physicians. Expansions of MD DO NP and PA have all resulted in steadily higher concentrations in fewer counties that already have higher concentrations. The evidence is already in the databases. Until the financial design is fixed with more dollars for basic services, there will be no solution for care where needed.




    MD DO NP and PA are finding more ways not to go into primary care and this pathway is all about dollar distributions, or lack thereof.

    Under the current financial design there is no way that any GME, MD, DO, NP, or PA expansion can actually address shortages. GME is 94% in the wrong counties with only 6% found in counties lowest in physicians, health spending, economics, and health outcomes. Residents are 154 per 100,000 in 79 top physician concentration counties. The 2621 lowest physician concentration only have 115 active physicians per 100,000 and this may be shrinking further. Residents are concentrated at a ratio of 24 to 1 or 154 per 100,000 in top concentration counties to 6.4 in lowest physician concentration counties.

    Residents tend to locate in the same state and same county or nearby county after graduation - another factor in poor distribution. The US has 6 - 7 top concentration states and 30 left behind. The same is seen in counties with 79 top physician concentration counties and 2621 lowest physician concentration counties - essentially the Red Counties and about 50 rural counties with majority African American, Hispanic, or Native American populations.

    Workforce goes where the dollars go and the dollars dictate higher and lower concentrations of physicians. Family practice positions filled by MD DO NP and PA are the only population based distribution with about 36% found in lowest concentration counties with 40% of the population. All other specialties concentrate as physician concentrations increase as seen below. The Ratio is a measure of concentration. It takes multiple times more graduates to result in a lowest concentration physician. The higher the ratio, the more it takes.

    More correctly, the limitations in dollars going to these counties limit the workforce as seen in the 2010 data on NP and PA and the 2013 AMA Masterfile.

    Active Physicians Per 100,000 in 2013 Counties By Physician Concentrations
    Top Concentration to Lowest Ratio Top to Lowest Top Higher Middle Lowest
    % of US Population 10% 20% 30% 40%
    Counties in Category 79 152 286 2621
    Primary Care Best to Worst Distribution Ratio of Top to Lowest 32 million people 64 million people 96 million people 128 million people
    Family Medicine 1.18 30.77 33.08 29.19 26.03
    NP/PA Fam Practice Position 1.18 Estimated
    FM then Geriatrics 2.57 0.36 0.31 0.23 0.14
    General Ob-Gyn 3.42 20.48 15.21 10.99 5.99
    Medicine Pediatrics 3.44 2.58 1.75 1.01 0.75
    General Pediatrics 4.13 32.55 22.16 15.79 7.88
    All Active Physicians 4.14 468.12 304.77 222.06 113.05
    Internal Medicine 4.31 64.79 42.72 30.85 15.03
    Internal Med Geriatrics 7.46 2.81 1.63 0.98 0.38
    Physician Assist NPI 2010 2.71 43.73 28.94 25.05 16.13
    Advanced RN NPI 2010 3.21 104.06 66.55 45.98 32.41
    Other Specialties
    General Surgery 2.75 11.69 7.82 6.12 4.25
    Gen Orthopedics 2.86 9.08 7.19 5.57 3.17
    Physician Assist Not FP 3.70 Estimated
    General Urology 4.08 5.41 3.63 2.67 1.33
    Otorhinolaryngology 4.20 5.42 3.42 2.57 1.29
    Intervent Cardiology 4.45 1.39 0.99 0.70 0.31
    Ortho Sports Med 4.58 1.10 0.71 0.55 0.24
    Advanced RN not FP 4.60 Estimated
    Ophthalmology 4.93 11.20 6.98 5.03 2.27
    Anesthesiology 4.94 24.03 16.54 12.57 4.87
    General Radiology 5.26 16.64 10.65 7.29 3.16
    Gastroenterology 5.40 8.71 5.31 3.88 1.61
    Gen Cardiology 5.53 14.12 8.65 6.02 2.55
    Radiation Oncology  5.58 3.01 1.80 1.29 0.54
    General Pathology 5.69 7.07 4.04 2.93 1.24
    Physical Medicine 5.89 5.44 3.74 2.61 0.92
    Nephrology 5.90 5.97 3.58 2.57 1.01
    Other specialties have worse distribution




    Nurse practitioners and physician assistants are also not the solutions as claimed. If anything, they are more flexible with substantial movement following the payment dollars to more support, less complexity, and higher salaries. More specialties are added with more added to each new specialty - leaving primary care and family practice positions behind. Turnover is higher in NP and PA, previously twice as high as for physician primary care. Moving from lower support to higher support is a move away from morale issues, burnout, higher turnover, and more to do with less to do it - such is the power of the financial design. More to do in areas such as primary care includes the rapid changes of innovation, regulation, and certification. It is hard to design as many obstacles to care as team members in primary care where needed have faced - with more to come.

    Note how geriatrics is not a solution. Too few enter and too few distribute. This is also the result of a crippled financial design with payment too little and complexity too high. In kind donations are needed to support geriatrics usually by academic institutions, largest systems, or nursing homes. The result is a 7.46 ratio for extremely poor distribution.

    The elderly and their cardiac, lung, cancer, and diabetic conditions are concentrated with 45% found in lowest concentration counties. High ratios are seen in these specialties. Endocrinologists are 10 to 1 against lowest concentration counties where 50% of diabetics are found and only 12% of endocrinologists. Smokers, obese Americans, and those with mental illness are concentrated in lowest concentration settings along with preventable deaths.


    The Newer Graduates Have Worse Distribution

    The oldest physicians are seen in lowest concentration settings. This is an indicator of lack of replacement by newer physicians. It is also a predictor of worse to come. Hospitalists and emergency physicians have registered increases in lowest concentration counties - but have greater growth in higher concentration settings. Even worse, these tend to be family physicians who were often previously in primary care. Indeed, the family medicine contribution has decrease from 90% office family practice to less than 70%. The levels are even lower in newer graduates. Soon, entire graduating classes at FM residency programs will be avoiding office family medicine as has been the case for internal medicine and pediatrics for some time.

    No Expansion of MD DO NP and PA Can Work for Distribution

    No expansion of primary care or surgical residency positions can result in more serving in primary care or general surgical specialties as too many move on to additional fellowships or other careers. Internal medicine is over 85% not primary care. Pediatrics is one-third primary care. New FM graduates may be 60% primary care and could break the 50% level without payment change. PA is down to less than 20% and NP will soon be there too. There simply is not enough payment to provide the care and the team members and the support for such complexity. General surgery, general ob-gyn, general orthopedics and other general surgical careers are not chosen by graduates who have must better support, less complexity, more team members, and locations similar to their exclusive origins by taking one or more fellowships.

    Even targeted MD DO NP and PA interventions for rural or underserved or Teaching Community Health Centers cannot work. These graduates may fill needed positions at higher levels. Good for them and for their program. But this only displaces other graduates from such positions. Such is the dominating power of the financial design. Only so many dollars go to these positions in places of need. Lowest concentration counties do not need a rearrangement of the deck chairs and more games playing by academics - they need real solutions.

    Too few dollars equals too few positions. 

    But designers are not looking to add dollars in any place or service. It has been cost cutting as the dominant policy since the 1980s. Even worse, the basic services and the practices least organized and most distant and smallest have been ignored. 

    It's the Economy Stupid - The Economics Fail to Measure Up

    It is the financial design that is broken with too few dollars designed to go to the places shortest in MD DO NP PA and RN. It takes more dollars going to 2621 lowest concentration counties to actually begin to redistribute workforce, services, and dollars. These are counties with services that are 90% lowest paid generalist and general specialty services. Only increases in office, cognitive, mental health, basic, primary care services can redistribute funding. 

    Real Solutions


    • A 15 - 20% boost to the same payments as higher concentration settings. These are practices paid 20% less for the same service delivered.  Primary care should be separately and equitably paid - not more marginalized where care is already most marginalized.
    • After equity, a 20% boost in payments for basic services represents a 40% boost for care where most needed - this would need to be maintained from 2018 to 2040 with adjustments due to any additional cost of delivery increases (regulation, innovation, certification) to hope to provide care for 45% of the population in these counties in 2040. We are already 10 years behind in a process that takes 20 years.
    • Primary care is only about 6% of spending for 55% of services - a small boost in dollars represents a large gain in terms of primary care team function. Michigan did not get a boost from Primary Care Medical Home. Blue Cross invested in primary care with more dollars to get the boost. It takes more dollars for more and better team functions including higher primary care functions.
    • Reduction in cost of delivery - HITECH to ACA to MACRA has added more than $100,000 cost of delivery per physician. This is at least a 16% cut in revenue for another 20% lost considering productivity and other consequences. 
    • Turnover is up to $300,000 per lost primary care physician and may be higher in these lowest concentration counties with more consequences and higher turnover. This is at least $100,000 a year that has to be paid by the practice, a local facility if it exists, or the community. None of these has the dollars to spare where dollars are least concentrated.
    Acceleration of Growth of Population in Lowest Physician Concentrations

    Hospitals are important for the support of physicians. Without a hospital the emergency room and hospitalist positions go away - the only growth seen in recent years. The general surgical specialties also tend to go away. This leaves primary care behind and tends to erode the internal medicine leaving family medicine behind. The financial design has most eroded family practice MD DO NP and PA - most important for counties without a hospital.

    In the next decade, more counties will be added to the lowest concentration counties. At closures of 15 hospitals per year in these counties, the number could easily reach 2800. They are already paid less. About 40% of rural hospitals have negative margin. Readmissions penalties hit them harder - 2 to 3 times harder. But there is worse to come.

    CMS just announced that it will be taking away the disproportionate share funding beginning as early as October. They have already announced cuts in support for high cost medications. The combination of ACA and the current administration plus potential cuts by Congress will worsen matters. 

    Health access practice is about the population. What happens to the population shapes access and also health outcomes. Losses of SNAP, housing, utility support, and disability funding will hit lowest concentration counties hardest. This will add to the costs and complexities of delivering care where needed.
    • Lily Tomlin — 'Lady, I do not make up things. That is lies. Lies are not true. But the truth could be made up if yo know how. And that's the truth.'
    The Deans Lie, the GME Lie, the Innovation Lie, the Regulation Lie, and the Certification Lie - all need to come to the light of day as we turn to exposing the truth. No matter how many times the medical and nursing deans and leaders and associations claim to be a solution, the truth is seen in failures over decades and over major expansions.

    Payments Are Broken and Are Being Made Worse


    A return to evidence basis is indicated, as in the end of pay for performance schemes that are known by major reviews of the evidence basis not to result in improvements in health outcomes. From P4P to Readmissions Penalties to Value Based, these have been costly and discriminatory - especially for the providers that take on the challenge of serving where most needed where patients inherently have lesser outcomes before and after care, regardless of care.

    And even worse, the payment designs all lead to fewer dollars going to these counties - resulting in worse outcomes. Health information technology promotions are rampant these days, but these are cash transfers from lowest to highest concentrations - the formula for greater disparities and worse outcomes in lowest concentrations.

    The GME Recommendations Are Self-serving 

    GME expansions cannot solve the physician shortage. It cannot get physicians to places where physician positions are not supported by the financial design.

    GME expansion promotions also have a distorted literature base - as seen in international medical graduates promoted as a solution. This was exposed in the recent rural location and retention study from the Graham Center. Not surprisingly there was no headline or promotion of this fact. My studies using the cross section Masterfile have long indicated poor contributions from IMGs. The international graduates overall have some of the worst distribution - right there with Harvard, Yale, and other most exclusive US MD school graduates. Only a few states benefit. Only graduates from a few nations contribute above average. About 20 - 30% leave the nation after training. This is but one major flaw in these studies. Only studies of the first few years demonstrate distribution - which is actually limited as well. 

    Cherry picking results is promotion, not the truth.

    The Logic Is Undeniable

    If GME leaders truly think that expansions are the solution, then we must graduate 3 to 7 times more to solve shortages. Obviously graduating many more is destructive to those who find themselves deep in debt and at the mercy of employers during a time of a glut of MD DO NP and PA. This time may not be too far away.

    No MD DO NP or PA Expansions can fix shortages that are actually about the financial design. Too few dollars to too few places supporting too few positions is the real problem. Reversing the financial design is the only true solution.
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