Family Medicine - Silver Lining or Black Cloud
I just wish that the rich culture that I experienced growing up in a family medicine clinic in the 1960s and 1970s still existed. It does not. Perhaps this is my own self interview. It is a lament for what it was, what it has become, and where it could all go - if we do not pay attention to US populations most behind and value them and what remains of their health care.
Family medicine began with great promise. The initial leaders were grassroots family physicians practicing and sacrificing even more time to develop family medicine and family medicine training at the nation, state, and financial levels. This was evident to me even as a student in an elite medical school. I do not doubt the shock of Baylor leaders when 8 of us went into family medicine.
I remember so many good conferences and activities and mentors
I continue to think about Waco - how the FM program was the result of meetings with community leaders and how it was a vehicle for health access. It was a total package with cooperation by both hospitals, county health, city health, the medical society and auxiliary, and more. There were so many teaching me at all levels, especially patient and church contacts who struggled with diseases, injustices, and more.
I remember the community projects of the students, and their mentors, and the award we got - followed by termination by NHSC as they turned to worthless loan repayments and away from influencing students with state projects and AMSA HPDP that always had twice as many students interested compared to slots available.
I remember the David City physicians and other rural physicians in SERPA that became RCCN - are represents one of the best efforts to preserve and protect and expand local care for most Americans most behind.
My 30 year focus on basic health access has returned me to lessons learned in solo rural practice.
Why do we punish generalists, general specialists, care where most needed, and those most specific to such care?
Stagnant revenue, more complexity in patients and in care, higher costs of delivery via inflation, more types of meaningless micromanagement costs, and higher costs in each type - defeat us, particularly where we are most important and are paid less as seen in Medicare 2011 data.
And the rural situation actually applies to most Americans - especially the populations growing fastest in numbers, demand, and complexity as their local health care is designed away.
Rural colleagues take on second jobs to support their failing practices but eventually are driven away from the practice, patients, community, and way of life that they love. Hospital and practice closures also kill local health care leadership.
Training Interventions Cannot Fix Deficits of Basic Health Access
I have learned that training interventions such as more types of graduates (NP PA FM), massive expansions of graduates across NP PA DO and MD, special training programs, and pipelines to primary care or rural practice cannot overcome the financial design.
Anyone with a basic spreadsheet loading in the 4 to 6% annual expansions for decades - can see that this will be too many and the bubble will burst - especially with 4 sources growing too fast - but warning signs are ignored. Nursing has no excuse as they have had too many and too few in the past - and clearly understand doing best with slight deficits and avoiding too many.
The failure of massive expansions to touch chronic basic health access deficits is obvious.
Teaching CHCs will also fail. This is because Medicaid is the worst health plan, particularly in 30 states. As NACHC has long pointed out, Medicaid pays less than the cost of delivering Medicaid patient care. We patch this with another federal designation - but of course this fail to fix the poor quality plans that cause the problem. Yes, teaching CHCS like other special programs will train more specifically for that type of practice, but more graduates locating in CHCs will only displace others.
Failures of Training Are entirely about the limitations of dollars in fixed amounts
The Disconnect Between the Academic Literature and the Reality of Chronic Deficits
Outstanding success involving training interventions can be seen in research publications. Programs, schools, pipelines, and types of training can demonstrate higher proportions and higher odds ratios of graduates in target locations. This has a great appearance until you see no improvements in primary care delivery capacity in the target areas over decades of time.
When you begin to question research, you can then make new and better discoveries specific to most Americans most behind
Eastern rural health focus while at ETSU taught me about Appalachia - and the counties that improved as rural moved suburban and jobs changed around Atlanta, Knoxville, and at biggest interstate exchanges. But the counties without best employers stayed behind - and marginal health, education, government job, and social support contributions do not help. Since these four are major contributors - the marginalization of each one specifically harms most Americans most behind. And of course our trade policies tend to work out poorly for those who used to have employment in manufacturing and other areas.
You can then see that economic improvements, better jobs, better employers, and much and better private plans are required for the real important changes in local health care. This was a lesson learned from Gerald Doeksen and Rural Health Matters with influences on me from the 1980s to the present. Once again the current US health care design contributes to local problems because local health care and economics are so dependent upon local employers and public plans.
You can see that the problems in health insurance are not about the uninsured. The problems are mostly about poor quality insurance. The 40% of Americans in 2621 counties lowest in health care workforce had about 40% of the uninsured before 2010. They did not lack for insurance more than other Americans, they have always had the worst quality plans.
Expanding the worst plans cannot help and may cause harm, especially when the plans are a poor fit for local health care where most needed, create barriers to care, and help shape half enough generalists and general specialists. This was the lesson taught by rural managed care projects who developed SERPA RCCN and this expanded from rural Nebraska to multiple states. They found out that they needed to work with local employers and employee benefit managers - and did.
We hear far too much about what cannot possibly work, and far too little about what has worked to preserve local care, independent practice, care where needed, and care as free from outside compromises as possible. Does it help when leaders promote higher functioning primary care which plays out poorly in places with half enough of each workforce to integrate and coordinate and even less social support with higher complexity?
Academic assumptions and thinking hid these lessons, but when I began to question and had time away from Academics, there was more clarity.
Looking back I see that I could make it in rural practice in the 1980s when I had better sources of revenue - procedures, obstetrics, assistant surgery, and billing for ER and hospital services. This was also before the revenue stagnation took hold.
I find it helpful to remind people that the original Medicare and Medicaid designs were new sources of dollars and built up health care where needed substantially. More dollars for populations lower in income and older in age translated to more health care dollars in counties most behind. And the 1965 to 1980 designs had increases for the costs of inflation. This changed in the 1980s when Type 1 Micromanagement Cost Cutting took over - The Era of Cost Cutting that still dominates health policy designs.
Stagnant revenue, best paid services designed away, costs of inflation not covered, and new costs such as micromanagement defeat Basic Health Access.
Losses in these procedural, technical, hospital areas result in dependence upon lowest paid office services.
But the major problem facing Basic Health Access is Big Health. Our academic and other health care leaders join hands and agree that primary care needs more dollars. But they circle up the wagons to prevent a rearrangement of funding away from them to support basic health access lacking for most Americans. They are very powerful in shaping health care design their way.
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More reports and studies will not add to what we have known for over 30 years.
I hope that family medicine leaders come to the awareness that despite more graduates, FM grads deliver half as much primary care since fewer stay in FM due to the financial limitations and better options. There is no excuse for designs that drive NP PA DO and MD away from primary care faster than can be estimated.
There is no excuse for health care leaders that promote sources of primary care with just 2 to 5 Standard Primary Care Years of primary care delivery per graduate - lowest contributions of all. Why is primary care delivery capacity so hidden when it is so important to our nation and to people lacking in basic health access?
Class Year Comparisons
You can see the class year to class year changes in the AMA Masterfile categorized by office primary care. There are declines in primary care retention not only for FM, but for all NP PA DO and MD primary care sources.
We also need critical review in key areas of family medicine focus
It is increasingly clear that the financial design improved family medicine choice as seen in the initial rise from zero to 3000 by 1980. This is not about FM departments or faculty or curricula or student interest groups.
FM has always been about normal, not exclusive. Normal origins, normal medical schools, and reasonable health policy.
Exclusive origins, scores, medical schools, and training combine with worst health policy for worst FM choice and even more consequences for most Americans.
You can scare medical students into FM as seen in the managed care scare in the mid 1990s. You can force them into FM as seen in osteopathic students until the recent combined match gave them the full range of choices. NP and PA were once forced into rural and underserved and primary care - but no longer. Free market effects drive all away from primary care and where needed.
Family Medicine Leaders Hope for Better, But Choices Have Not Worked Out
We had great hopes for the Primary Care Medical Home and for performance based care - but we found that these were costly and were limited in changing outcomes. They are even more costly for the practices not the largest - especially the ones with the worst financial designs.
Why push value based designs, except in the hope of better revenue that has not materialized in decades of so called reforms? Even now if states forced health care plans to pay more for primary care, top of the list is value based payments. Will this really help if the revenue increases are marginal and the costs of delivering care continue to be increased?
We must call it what it is - Type 2 Micromanagement Quality Improvement. Type 1 Micromanagement Cost Cutting was bad enough, since it has hurt those smaller, more distant, less organized, most vulnerable, and less politically focused the most. Declining revenue closes and compromises more practices and hospitals.
But Type 2 Quality Improvement adds to the problems as seen inside of practices. Obsessive Measurement Disorder may well impact health care most, with more to come.
Did we realize that pay for performance and value based would also complicate care complexity, distract team members, decrease productivity, encourage turnover, and help shape fewer and lesser delivery team members due to the higher costs of measurements, metrics, micromanagement, digitalization, innovation, regulation, and rearrangement?
Incremental Primary Care Improvements Will Not Significantly Impact Cost or Quality
Starfield and others reached a level of worship. You could see this at conferences, at AAMC Workforce Meetings, and other gatherings. She did recognize other factors as shaping outcomes, but the attention to her work was about primary care levels compared across nations. Did this help or hurt? Great works such as these should be recognized, but we need to have solutions. They often do not offer solutions but can contribute to understanding what would work.
We also need to avoid false claims. Is it going to help when more dollars go for primary care and outcomes do not change - as in the CMS Innovation project?
Are we beginning to understand that incremental improvements in primary care levels cannot significantly improve costs or quality - set predominantly by patient and population factors? Massive changes in access for populations most behind with movements from low or no access to superior access can indeed improve cost and quality through access - but smaller incremental changes are quite different.
Focus on Most Americans Most Behind to See More Clearly
Family medicine and rural health taught me to look at what is best for Basic Health Access where most needed. Crabtree and others taught me to look inside of practices. Mold teaches about the failures of problem based care and the usual disruptions that hit all but the biggest practices.
My mentors and studies have led me to question what many consider success. I have developed categorizations that can help understand primary care delivery, deficits of health care dollars, and limitations of health outcomes.
We must understand that health care is being designed away across the American populations that are growing fastest. Most of us understand that health care favors the few as in the biggest corporations, institutions, practices, and hospitals. But do we understand how the designs for revenue and micromanagement harm most Americans - and especially those of us serving where most needed?
Physician Distribution By Concentration Categories
Distributions of physician related economics by concentrations can be seen. It is hard for academics to claim world-class patient care when most of the nation suffers from deficits in basic care.?
This does not prevent AMA and AAMC from touting the economic impact of physicians at 2.2 million dollars per year that the physician is active.? Figures include 700,000 active physicians for 2013 from the AMA Masterfile, 2.2 million for the economic impact per physician from the AMA, adjusted using 3 million for top concentration physicians to 1.7 million for lowest concentration due to differences in payments and specialty types,?3.2 trillion used for total spending, adjusted for additional spending lines in top concentrations (21% to 29% of health spending). The resident concentration of 154 per 100,000 people is greater than the total active physician workforce in lowest concentration counties at 114.6 per 100,000. Combining active physicians, residents, and faculty results in even greater disparities as the comparison is over 650 to less than 130 from highest to lowest. The lowest concentration counties are essentially the red counties in the 2016 election plus the predominantly minority blue rural counties (Black Belt, southwest border counties, Native American)
The academic publications or reports avoid discussing the exclusive origins or the divisions created from so many jobs, services, and dollars in few places and the few jobs, services, and dollars where most Americans are found.
Granted health care for most Americans most behind is not going to have the most specialized physicians, services, and facilities - but there is no excuse for massive deficits of generalists and general specialists. There is no excuse for paying less and less as workforce levels decline. There is no excuse for leaders who are self serving and fail to be mindful, selfless, and compassionate and act in ways that insure that their delivery team members fail in these three areas.