In fact, it is not possible for primary care innovations, training interventions, and rearrangements to work to restore primary care or basic health access at the current time or in the foreseeable future.
The solution has always been about payment. There will be no future of primary care or future of family medicine or future of care where needed or future of rural health or future of health access without real payment reform.
There is a formula for success in all of these important areas.
- Payment needs to be substantially increased
- Above any increased cost of delivery and
- Must also be adjusted for the higher complexity that also add to costs plus
- No, repeat no, additional hoops need to be jumped through to receive this payment.
How long will we tolerate so called solutions for mental health, general surgery, etc. that are not really solutions?
Graduate Medical Education Expansion deserves particular mention as it cannot work to restore any target specialty set by ACGME. Payment defeats each and every desired workforce and practice location. In particular, family medicine choice is prohibited across preparation, admission, training, and retention. Only 6.5% of residents are trained in the 2621 counties lowest in physician concentrations. Payment actually overcomes the deficit of GME design since 21% of physicians are found in these counties - but this remains small compared to the needs of this 40% of the population left behind.
Primary Care Success Requires Investment in the People That Are Primary Care Delivery
It has become so common to see attempted interventions involving consultants, software, rearrangements of practices, academic expansions, pipelines, high risk patient focus, innovations, or payment incentives - but the fact of the matter is that primary care is broken. None of these are wrong, but they all distract from the true primary care solution.
An investment must be made in what primary care is all about -
the team members to deliver the care.
Why is it so hard to see that the team members are most of the cost because they are most of the action? Why did we ever tolerate a design where primary care practices are forced to pay for personnel who do the work of insurance companies and government - leaving little left to deliver primary care? Why is it hard to see that dollars stolen for rearrangements, innovations, software, hardware, constant chaotic changes, measurement focus - all steal from primary care itself, from the team members to deliver the care?
More team members supported to do more and in more places is the solution for primary care, basic health access, and care where needed. Anything that impairs people interacting with people to help change their behaviors, situations, environments, conditions, and other determinants - is impairing the proper focus upon changing health outcomes.
The managed care/Dartmouth innovation gurus have assumed that physician behaviors can be reigned in to result in cost savings - with manipulations to greater quality. This application is most destructive to primary care, rural health, and care where needed where lower payments, increasing demand, and higher complexity have forced them long ago to be most effective.
In fact, it is the lack of payment support that kills off primary care - as seen when there is investment in primary care in Michigan and in Home Care demonstrations - that do have good claims for cost, quality, satisfaction, and access benefits. Squeezing hurts and more squeezing hurts more.
After decades of "primary care solutions"
the problem of insufficient
primary care delivery capacity remains.
Stop the InsanityOver and over again is not working. The decades of failed primary care promotions stand testimony to the failure of the so-called "solutions." We must stop the insanity of continued failed interventions. No demonstration or grant or special program or school can address the ceiling for primary care shaped by 150 billion, with further decimation by increasing cost of regulation.
In health care involving patients there are ethical considerations. If your alternative treatment is not really a solution, then it should not be adopted or even attempted. Treatments require an evidence basis and alternative treatments that delay effective treatments are unethical at best.
Payment Designs Punish Primary Care
Many in primary care can testify to the substantial pleasure of delivering primary care in well-supported situations. At the current time many testify to the burnout and other negatives accelerating across the last decade of designs. This is entirely about increasing what must be done and the complexity while decreasing the financial and other support.
The solutions for burnout, primary care, mental health, basic services, and basic health access are one and the same. Entirely different designs are needed.
Misguided Interventions Made Worse with "Innovation
New sources of primary care, graduate medical education expansions, expansions of new primary care sources, innovative training models, and pipelines to primary care have failed.
Even worse we have measurement focus and primary care medical homes costing 5 - 8 billion more added each year. These are costly billions spent without an evidence basis for care improvement. Not surprisingly the most challenged small practices and practices where care is needed have not adopted the new innovations. Margins have been too low to tolerate the additional costs.
One can even consider that interventions forcing larger practices or closures of small practices are doing harm. There is an evidence basis for small practices as doing better in areas such as preventing admissions. But small practices are being collapsed and swallowed by health care design.
The designers out of touch with the needs of most Americans and those who care for them have designed away health access. They have added billions more in cost of delivery that result in negative margins or unpredictable futures. Their designs have overstressed primary care team members, decreased productivity, have distracted team members from care focus, and have acted to diminish overall primary care delivery capacity with the impact greatest upon the locations in most need and increasing the most in demand and complexity.
Payment needs to be substantially increased above any increased cost of delivery and must also be adjusted for higher complexity. This is the primary care solution.
A Journey of Discovery
Decades ago I began to track medical school primary care mission statements, and graduates, and county distributions of graduates, and primary care graduate outcomes. I kept maps of the counties in need of workforce and workforce changes over time. I was fortunate to have a job that supported teaching, researching, and delivering health access and also attending the various primary care, rural, and underserved meetings across the nation.
Over time I lost my enthusiasm for the job as it became apparent that the workforce was not changing, no matter what was being done. Across Nebraska counties mapped by name of physician, the names would change, but not the capacity for delivering care. After 30 years of being paid to improve access, my conscience would no longer let me keep taking money for outcomes that could never be changed.
My passion for health access has continued. But we need real solutions, not more failures.
Although many continue honest effort to resolve primary care woes, careful reflection regarding the evidence leads to the conclusion that there cannot be a solution because of the current financial design - a design that dictates all of these outcomes, the results of training, and even greater disparities.
No one contests the effectiveness of special training regarding the graduates of these programs. The problem is that 150 billion for primary care in annual spending remains a limitation - a ceiling. 150 billion for primary care limits US primary care. Only 5 billion or 10 billion in your state limits state primary care. More graduates from a special source merely displace those from other sources. There is no funding increase to grow capacity. The funding does not increase and therefore the workforce cannot increase. The funding is particularly limited in the states and counties lowest in workforce, that are also lowest in payment support.
Witness the long and growing list of failed interventions
- The US has created 4 new sources of primary care since 1960.
- The US doubled US MD grads from 1960 to 1980 and has added 30% more in the past decade.
- The US quadrupled DO grads 1960 to 1980 without primary care result as each doubling was accompanied by half as much primary care result from graduates.
- Special primary care medical schools established in the 1960 - 1980 era
- The 12 times expansion of NP graduates since 1980 from 1400 to 17,600
- The 8 times expansion of PA graduates since 1980 from 1400 to 9000 with documentation of no primary care result from the last doubling of PA graduates.
- The 10+ times expansion of Caribbean graduates at over 60% primary care trained illustrates more futility.
- Family medicine was created and increased to 3000 annual graduates by 1980 but the doubling of the FM workforce to 80,000 has only displaced other sources not permanent to primary care. This is great for FM outcomes, but overall primary care remains the same.
Training in primary care is a smokescreen long used by medical and nursing leaders to be able to claim primary care result. This is good for funding academic settings. But payment shapes fewer entering primary care and fewer that remain. This is not about salaries so much as it is about the support or lack thereof.
International graduates continue to supply 25% of US physicians but 45% choose IM - the most unreliable of all primary care sources even with primary care training. Few choose family medicine, the most reliable source. This is not surprising given their origins and early training, their experiences in the few years in the US, and the institution chosen.
The Natural Experiment of Family Medicine Expansion
Family medicine was one of the new sources of primary care. From 1969 to 1980 family medicine increased to 3000 annual graduates - a steady state level maintained even in 2016. The expansion of family medicine was most specific to primary care recovery as FM grads have remained 95% in family medicine positions - until recently. During the 1970 to 1980 class years, FM was tracked to distribute 30% of graduates to rural areas. In the 1980s, payment expansions ended as the nation entered the current era - the Era of Cost Cutting.
Stagnant payments set limits upon primary care. The increase of family medicine from 40,000 to 80,000 as a workforce from 1980 to 2005 was accompanied by a decline in the proportions of all other sources found in primary care. The family practice component of physician assistants dropped from 54% to less than 25% from 1984 to 2010. Internal medicine collapsed as a primary care sources. Pediatrics declined from 70% to 45% result for primary care. Despite substantial primary care training for nurse practitioners, only about 30% are active and in primary care. NP results in about 60% active over a career and those active are half in primary care - for 30% active in primary care result.
There simply is not enough financial support for primary care positions and there is substantially more support for non-primary care positions. Each year there are more specialties and subspecialties added and more MD DO NP and PA add to these new specialties. This leaves primary care and family practice behind by design.
Massive Expansions Have Failed for Primary Care Result
The 12 times expansions of NP graduates since 1980 from 1400 to 17,600 and the 8 times expansions of PA graduates since 1980 have done little more than replace collapsing internal medicine primary care result. PA leaders have been the most honest and track new graduate career choices. Their choices indicate that even a doubling of annual graduates is not capable of increasing primary care delivery capacity. Workforce centers have tracked PA deteriorations in the years after graduation.
Special Training Has Great Outcomes - for Special Training Graduates Only
Most deceptive are the results of special training programs in all disciplines, pipeline designs, pipeline designs with gaps filled, bonus programs, loan repayments, and retention and recruitment bonuses.
These all seem to be effective when considering the outcome of the program or track, but the graduates are still subject to the same distortions in payment in the years of practice and special track graduates merely replace and displaces others rather than increasing primary care delivery capacity. More dollars are required to be injected at all levels for success - when what is required to seal the leaks in the pipeline at all levels is higher primary care payment.
What is most consistent about primary care proposals is their benefit for those making the proposals and receiving payments. It is a sad fact that the CMS branch of HHS creates the shortages via payments tens of billions too low for primary care and the HRSA branch attempts to clean up the mess with tens of millions.
Adding a few billion to CHC payments does very little compared to 150 billion in annual primary care spending and is small change compared to 6 -10 billion a year in added costs of delivery.
The Astonishing Lack of Evidence Basis for Primary Care "Solutions"
The recovery of primary care is also the result of substantial impairment in our evidence basis regarding primary care, access, and services where needed. Even with a sustained increase in primary care payments, it would take at least a half a generation of workforce or 15 class years to recover the workforce - 2030 at the earliest. Demographic changes alone have already overwhelmed basic health access and there is worse to come.
Demand is increasing most where populations are increasing fastest and where complexity is greatest across the elderly, disabled, poor, and those with lesser health status, habits, and outcomes.
We have 2621 lowest physician concentration counties with 40% of the population that depend upon generalists for 50% of workforce and general specialties for 30% with primary care stagnant and general specialties in decline. At each level lower payment shapes less workforce across the states with lesser concentrations of workforce, the counties, the zip codes, and the practices. We have even paid less for services provided by NP, PA, young physicians, rural practices, small hospitals, and rural hospitals across years or decades. Across places with concentrations of more complex patients and patients with lowest paying plans, we have lesser concentrations of workforce and more challenge and we pay less.
Then in a further act of discrimination, Pay for Performance Designs have been implemented - a design with over 12 studies most consistent in indicating lesser payment where the care is most complex and where care is most needed.
The deficits are shaped by lower payments for primary care, mental health, cognitive, office, basic services, and care where needed and much higher payments for procedural, technical, specialized, newest services, provided in places with higher concentrations of physicians, income, people, education, and outcomes.
Where workforce is most needed the most needed specialties are failing by payment design. Where primary care is most needed, graduates fail to enter or remain in primary care even if "training" in primary care across MD DO NP and PA.
Family practice result has taken the most grief from payment design. Each class year MD DO NP and PA graduates fall to new lower proportion records each year due to expansions and fewer found in family practice. Each new specialty and subspecialty created adds more MD DO NP and PA graduates and leaves fewer remaining in family practice - by payment design.
As goes family practice, so goes access. Only family practice MD DO NP and PA are found in the population based distribution (36% of FM in 2621 counties with 40% of the US) where population is growing fastest in numbers, complexity and demand.
You cannot succeed in access by failing to support generalists and general specialists that are 75% of the workforce where most Americans most need care.
The only way that any of the above will be more successful is by increasing US payments to support primary care, decreasing the cost of primary care delivery, and likely both. The biggest providers get the best breaks and the smallest end up getting paid less and face the challenges of chaotic change and rapidly increasing costs.
Instead our nation cuts primary care payments or keeps them stagnant while the designers increase the cost of delivery (administration, regulation, EHR, digital, recruitment, retention, turnover).
There can be no recovery of primary care, mental health, general surgery, general orthopedics, or other general surgical services until there are increases in payments.
Compared to Other Nations
"In comparison to adults in the other 10 countries, adults in the U.S. are sicker and more economically disadvantaged. The resulting challenge to the U.S. health system is compounded by higher health care costs, greater income disparities, and relatively low levels of spending on social services."
In the counties where 40% of Americans are clearly most left behind, the US does not even rank among developed nations and appears to be 50th to 60th at best.
Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform
Biomedical Focus is Ruining US
More Quality Measures for Homebound Seniors - Not Hardly - why not improve access for the 45% most left behind rather than making care more complicated and measure focused
What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care.
Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.
Primary Care Must Rise from the Ashes of the Last 20 Years of Policy
Recovering General Surgery Is ImpossibleSix Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.
Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work
Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind. More STDs with more resistance to treatment and more risky behaviors and public health funding slashed and little or no access to care - What Could Go Wrong?
Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior - the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care
Does Anyone Understand that High Cost High Need Patients Drive Consumption?
Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance
Most Visited Early Blogs
Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care
Finance-me-cratic Constants in the Bureaucratic Universe
Meeting Primary Care Needs in the Last Half of the 21st Century
Exploring the Health Consequences of Disease Focus
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.Martin Luther King, Jr.
Robert C. Bowman, M.D. Robert.Bowman@DignityHealth.orgThe blogs represent the opinion of the blogger alone.
Copyright 2016
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
