The Depersonalization of Personal Primary Care in America

Personal care has been broken to pieces steadily and progressively by the US health care design. The heart of health care is relationship - between delivery team members and patients, caregivers, community, state, and nation. Where care is most needed it is most lacking by design - and the designs are making this worse.

Delivery team members are shaped fewer and lesser by the financial design and what remains of their energy is drained by meaningless tasks. This complicates their full time and attention to patients, caregivers, and families.

They become so focused on finances and keeping afloat that they cannot focus attention on the community, environments, state, and nation. They are also being forced to leave practices where needed and their leadership and other community contributions are terminated - as has tragically been the case for me in the 1980s and so many up to recent colleagues.

A hideous combination of complexities makes it difficult to fight at the state and national levels where there is little awareness of the problems created or the role of state, federal, and other payers.

Enter the Heroes That Can Build Awareness and the Need to Change

Mold is one of my heroes because he has the awareness needed to capture the decline. Two articles stand out recently - Usual Disruptions and Failure of the Problem Oriented Medical Paradigm - both in Annals of FM with summaries below. His work resonates with my own experiences from rural practice to rural medical education to a focus on 2621 counties most behind in health care workforce.

In my mind he salvaged the 117 million wasted by AHRQ on quality improvement with an article demonstrating key areas not addressed in the primary care financial design. Since these specifically complicate the small and medium practices most important for basic health access for Americans most behind, this is quite important. See below for Usual Disruptions.

Those who preach innovation from above have no idea how they are further complicating the personal and professional lives of delivery team members. Any article that could build awareness with regard to the many and increasing problems faced by small and medium size practices where most needed is a help.

In the Problem Oriented Failure he captures the movement from people focus to thing focus:

• "Our problem-oriented approach to health care, though historically reasonable and undeniably impactful, is no longer well matched to the needs of an increasing number of patients and clinicians. This situation is due, in equal parts, to advances in medical science and technologies, the evolution of the health care system, and the changing health challenges faced by individuals and societies. The signs and symptoms of the failure of problem-oriented care include clinician demoralization and burnout; patient dissatisfaction and non-adherence; overdiagnosis and labeling; polypharmacy and iatrogenesis; unnecessary and unwanted end-of-life interventions; immoral and intolerable disparities in both health and health care; and inexorably rising health care costs."
• "A new paradigm is needed, one that humanizes care while guiding the application of medical science to meet the unique needs and challenges of individual people. Shifting the focus of care from clinician-identified abnormalities to person-relevant goals would elevate the role of patients; individualize care planning; encourage prioritization, prevention, and end-of-life planning; and facilitate teamwork. Paradigm shifts are difficult, but the time has come for a reconceptualization of health and health care that can guide an overdue transformation of the health care system."
• "Geriatric rehabilitation exposed me to a new way of thinking about health and health care, one focused on goals instead of problems. It led me to wonder whether such a shift in focus might offer a way forward. What if we viewed health not as the absence of health problems, but as the ability to derive as much enjoyment, satisfaction, enrichment, meaning, and fulfillment as possible from life’s journey? What if instead of asking, “What’s the matter with you?” we first ask, “What matters to you?” "
• "Despite the potential advantages of goal-oriented care, there will be major implementation challenges beginning with the words we use. For example, problems would be reframed as risk factors, obstacles, challenges, and opportunities, and what we now call goals (eg, systolic blood pressures of less than 140 mm Hg and hemoglobin A1c?levels of less than 7%) would be considered strategies. Record systems would have to be reorganized around the 4 major goals, research methods expanded to account for individualization, clinical practice guidelines reconfigured to reflect the impact of interventions on meaningful outcomes, and quality standards reimagined. Payment methods would need to reward processes of care and cognitive services beyond diagnosis and treatment, the appropriate duration of encounters determined by the participants, not payors or administrators."
• "The problem-oriented medical paradigm has had a long and productive life. It now deserves a good death."

?https://www.annfammed.org/content/20/2/145

Mold in the New England Journal IN 1986 - Way Ahead But We Are Still Behind

"In biology, the term "cascade" refers to a process that, once started, proceeds stepwise to its full, seemingly inevitable, conclusion. Common examples are the clotting cascade and the complement cascade. Processes that occur in molecular systems often have correlates in larger systems. It is our contention that cascade effects are frequently operative in the clinical care of patients, and that recognition of this fact gives us a better understanding of the clinical decision-making process." https://www.nejm.org/doi/full/10.1056/NEJM198602203140809

I see much the same in our health policy approaches that have caused so much harm to most Americans most behind in basic health access.

If You Cannot See the Signs Then You Should Not Do the Designs

Cascade effects are killing primary care with declines in primary care retention, worsening finances shaping worse situations, better opportunities outside of primary care cycling ever down for worse and worse.

There is absolutely no logic to paying less and causing higher costs of delivery and disrupting care and caring most where basic care is already half enough.

Triple Aim Has Been a Focus But

Triple Aim costs and distractions have specifically targeted the relationships, the team support, and the smaller practice solvency already most challenged

Equitable Payments - Not Hardly

Medicare 2011 data was supposed to expose physician abusers capturing the most dollars - but this data was downloaded and categorized by counties and by physician concentrations. This analysis exposed 15% lower payment where workforce was missing across most of the US population due to worst health plans.

• Medicare compromises what remains of their health care with DRG/PPS designs, cost cutting, lower payments, and higher costs of delivery
• Medicaid with worst plans in about 30 states is bad enough, but these states also tolerate the worst private health insurance also.
• High deductible can be abusive and fails for financial protection.
• The VA plan does not work well for half of veterans due to their location, situation, transportation, and more.
• Native and African American and Hispanic rural populations remain far behind along with 75% of the rural population in 2621 counties lowest in health care.
• 32% of the urban population lives in 2621 counties lowest in health care workforce by design - 90 million

How hard is it to see that most Americans are most behind as they and their providers are not valued or supported well?

See how the payments decline with declines in workforce concentrations. See how family practice with best distribution is most abused with lower payments where it is most important at higher proportions of the workforce - or the entire local workforce. See how complexity increases with declining payments as the elderly, poor, disabled, and those with the worst employers are concentrated where payments, access, and workforce are less by design.

Why Value or Performance Based Designs in These Counties Most Behind

Worst diseases, conditions, environments, behaviors and outcomes are inherent to these counties and worst financial designs are not helping.

Consider also that these practices where most needed and where most abused by the financial design and innovation progress face $300,000 in turnover costs and losses by my estimate (up from studies indicating $225,000 by Buchbinder) with a loss of a primary care physician - about every three years now by studies. this is an unsustainable 15 - 20% of revenue generated. This translates to a budgetary outlay of $100,000 per fte of primary care per year. This shrinks what can be applied to other personnel or what can be done to facilitate access or process.

The office of rural health in Alaska indicated about 11 million annually in recruitment, retention, locums costs about a decade ago. This was increasing by a million a year or about 10% more each year. For the nation's practices most behind this is about 500 million a year deducted from what can be done by these practices.

Obsessive Measurement Madness in Health Care and Beyond

You will not see a better description of the micromanagement madness than at this site via Sullivan and Muller. https://thehealthcareblog.com/blog/2019/02/13/obsessive-measurement-disorder-etiology-of-an-epidemic/ If you are promoting managed care, micromanagement, cost cutting, quality improvement, or value based designs, this is a must read. You must consider the many assumptions and flaws and harms and potential harms that this does to those who deliver the care, particularly where care is most difficult to access. The impacts of this disorder are seen in education, economics, and more.

Why is it so hard to see that a focus away from people is a questionable focus in any health care or education design that requires maximal person to person focus?

The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma

James W. Mold, Margaret Walsh, Ann F. Chou and Juell B. Homco

Mold has also figured out reasons why quality improvement projects are not implemented, especially in small and medium size practices, due to changes in key personnel, billing, EHR, location, ownership. This is one of few studies in this area and it was not exhaustive as there are many more internal factors as well as community factors. These can be costly and can contribute to inability to adapt to any number of changes.

The Annals of Family Medicine April 2018, 16 (Suppl 1) S52-S57; DOI:?https://doi.org/10.1370/afm.2201

These and other areas disrupt the practices and the personal and professional lives of the delivery team members and can shape fewer and lesser delivery team personnel. This is of course the opposite direction from higher functioning and patient centered primary care that demands more and better delivery team members - forget the costly homes, community consultants, scribes, technologies, integrations and coordinations that requires more personnel as well as the existence of local mental and women's health (largely not there)

To Review

The 25% of the primary care workforce where 40% of Americans have half enough generalists only had 38 billion a year to spend on delivering care or 20% of primary care spending in 2008.

• From this subtract the higher and increasing turnover costs.
• From this subtract the higher costs per physician plus new types of costs for each new digitalization or regulation or innovation or reorganization from HITECH to ACA to MACRA to homes to value based since 2008.
• From this subtract inflationary costs not compensated due to flat line funding for generalists and general specialists which may be worst where the weakest and worst quality plans are prevalent in the 30 worst states for such plans
• Decrease this result for lost productivity (read revenue decline), burnout (and worse), and declining local economics where they are already lowest.

Do you see how the high and increasing delivery costs of micromanagement, inflation, and turnover are not considered in the financial design?

We also know more about barriers set up by insurance plans that can exclude local physicians where needed. There are also barriers erected by insurance of such low quality that local providers cannot or will not accept such patients. Such is the lot of those who are supposedly "covered" by insurance plans.

• Do you see how the problem in health insurance is more about the quality of the health insurance and the payments, rather than uninsurance?
• Can you see how 40.2% of the population did not lack for health insurance more than others as these 2621 counties had 40.6% of the uninsured?
• Why expand the worst quality plans when the major problem is the quality of the insurance plans?
• Do you really expect improvements in access with the worst payments - the ones that can pay less than the cost of delivery?

Punishment of the Prevalent and Most Needed, Protection of the Bigs

Cognitive, office, basic, most prevalent, and most needed services are punished in the US design in so many ways.

Larger health care practices and hospitals and Big Health Care entities are rewarded in many ways. Unlike smaller and most needed health care, they can change their mixes of services, locations, and more. Those smaller and most needed are a captive to their populations and their plans and situations and lower health outcomes inherently.

Those smartest who use the best health care information can focus on the best plans, best outcomes populations, best finances, and best locations which they can cherry pick for best profits. Not surprisingly the first generation ACO worked out very well for those who already had the analytic capacity to be sure that they did well. ACO has not worked out so well in many cases. And cherry picking works for ACO to get Shared Savings. All you have to do is dump the physicians with higher cost or lower quality patient populations.

The biggest also had to have health information systems and often developed their own or partnered to do so. But those small or medium size often did not have these and have had to pay higher and ongoing costs.

Procedural, technical, subspecialized are rewarded most. This rewards most concentrated workforce and punishes those smaller and most needed.

Flat lined primary care???

The Health Resources and Services Administration projects a 17?percent increase in primary care physician demand yet only 11?percent net growth between 2013 and 2025.2

2 Health Resources and Services Administration.?National and regional projections of supply and demand for primary care practitioners: 2013–2025?[Internet]. Rockville (MD): HRSA;?2016?Nov [cited 2021 Nov 18]. Available from:?https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/primary-care-national-projections-2013-2025.pdf ?Google Scholar

First of all, there is not likely to be an increase in net growth as primary care dollars to spend on primary care workforce are flat to declining as seen above.

Graham Center studies and my studies see little change in finances or in workforce. Essentially the massive expansions of US MD, DO, NP and PA have been about non-primary care increases, higher health care costs, and greater concentrations of health care workforce.

Most Importantly - Big health has the most powerful lobby.

It has the best information to anticipate a change in policy, modify it, or prevent a change that would not be best for their profits. They actively work before, during, and after implementation to do even better. They prevent a shift from those doing best to build up basic care where most Americans are behind. What would help is chump change to them such as a boost from 40 billion to 80 billion for primary care for 40% of the US population - but they prevent any such changes.

Note that they say that they are for primary care and they are for Health Equity - but not in My Big Health Back Yard.

Remember that 1% of the land area in 1100 zip codes with just 10% of the US population enjoys 45% of the physician workforce bolstered by similar concentrations of health professional training has well over 50% of health care spending. The 99% are left behind.

Physician Concentrations Are Helpful in Understanding Distributions of Dollars and Who Wins and Who Loses By Design

Only family practice stands out as equitable and only the MD DO NP and PA who tolerate the worst financial designs and stay in family practice positions - distribute equitably.

Who is going to fight for basic health access?

Foundations such as The Commonwealth Foundation is fighting for insurance expansions that do not do much and promotes micromanagement changes that can cause worsening. The Families of Family Medicine hitched the Future of Family Medicine on the primary care medical home which might be nice for marketing of practices with competition and better payments - but fails where primary care payments are lower and there is little competition due to so few. The Families of Family Medicine continue to work with CMS in the hope of better payments but this has been a pipe dream for decades. Supporting new payment designs is counterproductive until the designers understand and value primary care and person to person care and care where most Americans have the least access.

• More resources, not medical homes, for primary care The “medical home” concept has become counterproductive. It is muddling the debate about how to improve medical care without raising costs, and it is punishing primary care clinics. A recent paper by Ricardo Mosquera et al. illustrates both problems. At the beginning of the paper, the authors assert there is no solid evidence for the claim that “patient-centered medical homes” (PCMHs) cut costs. That assertion is correct.

The Standard Primary Care Year Calculations Indicate No Possibility of Resolving Primary Care Deficits

Primary care retention continues to decline across all of the major sources. Even family medicine, once resistant, is in decline as new opportunities such as urgent, emergent, and hospitalist careers await. Declines in ER physician positions taken will leave even more territory for disgruntled FM and primary care doctors.

My lowest range estimates of primary care made in 2011 were too rosy as primary care retention declines have continued faster than anticipated. The Standard Primary Care Year represents the future primary care delivery over a career based on activity, volume, retention, and years in a career. Theoretical maximum is 35 x 100% x 100% x 100* for 35 SPCYrs with FM best in all 4 originally for about 25 but down to half of that as FM grads have moved to urgent, emergent, hospitalist, and other careers with better financial designs. FM distribution declines from 30% to 16% rural also follow the financial design failure.

Obviously internal medicine, NP and PA sources are low yield with only about 2 to 4 SPCYrs per graduate. It takes about 5 to 7 such graduates to produce the same primary care as a single FM grad - but it now takes 2.2 current FM grads to produce the same primary care as a single 1975 FM grad.

All sources are melted away from primary care and where most needed by the financial design.

Impossible Dream - Training Cannot Resolve Primary Care Deficits

Using the Standard Primary Care Year you can calculate the number of graduates that it would take to resolve primary care deficits set for 80 - 90 primary care physicians per 100,000 and about 350,000 standard primary care years per class year.

An ideal source with 35 standard primary care years per graduate would require 10,000 annual graduates, but no such source exists. The best sources is family medicine, but it continues to decline in primary care retention. The result is this graphic that demonstrates an ever increasing number of graduates - and the impossibility of training designs to resolve primary care deficits.

More Types of Graduates and Massive Expansions Have Also Failed

More of Interest

Seema Verma Hyperventilates About Tiny Differences Between ACOs Exposed to One-and Two-Sided Risk - Kip Sullivan

There is no meaningful difference between the performance of Medicare ACOs that accept only upside risk (the chance to make money) and ACOs that accept both up- and downside risk (the risk of losing money). But CMS’s administrator, Seema Verma, thinks otherwise. According to her, one-sided ACOs are raising Medicare’s costs while two-sided ACOs are saving “significant” amounts of money. She is so sure of this that she is altering the rules of the Medicare Shared Savings Program (MSSP).

Of course there is this graphic from the CMS Innovation Center that Indicates 5 for 52 in successes. This counters here argument about savings and about any innovation.

Could it be that you so belief in innovation and technology and believe in the assumptions of micromanagement and managed care groupthink that you will fail to see anything negative?