How Can You Have Person Centered Primary Care when Most Americans Have Half Enough?

New articles appear daily about Person-Centered or Person Driven Care. Health Affairs has a new one in Forefront that has an excellent description of what should happen, but the article as usual has little awareness with regard to how this is prevented for most Americans.

The enemy of true innovation is the financial design that impairs basic health access for 40 - 50% of Americans. It is the financial design that shapes fewer and lesser delivery team members and the inability to innovate adequately. The federal, state, and employer health plans are the payers that prevent person centered, higher functioning, or transformed primary care where outcomes, workforce, and social drivers are worst.

There is a very specific need for more and better delivery team members to address the heart of health care, the most important innovation of all: the innovation one on one between the patient/family/caregiver and the team member. But the financial design has deprived most Americans of any hope of having higher functions met.

How do you integrate, coordinate, outreach, satisfy, or support with half enough primary care, mental health, women's health, and basic surgical in places with the most complex and poorly supported populations? The US design only supplies 23 - 26% of each of these most important basics to 2621 counties lowest in health care workforce with 40% of the population. The spending for each specialty is less than 20% of the US total. It does not take much to understand that this is a design specific to fewer and lesser team members made progressively worse by stagnant revenue, increased inflationary costs of delivery not covered, and new types of micromanagement with increases in each costly type.

None of the new types of workforce such as nurse practitioners, physician assistants, and family physicians created since the 1960s have addressed these counties and massive expansions of MD DO NP and PA have also failed. These expansions far exceed demand even with complexity adjustments and are faster than growth of dollars for these health professionals at 6 to 10 times faster than population growth. This alone indicates that no training intervention can overcome the financial design.

Easily 50% of the population is prevented from higher functioning care because of Medicaid design plus lowest concentration counties plus plan specific barriers to access via narrow networks, inaccurate lists of in network providers, and practices that say that they take Medicaid or other plans - but do not.

And much worse is on the way. These 2621 counties lowest in health care workforce have been growing fastest in population numbers, demand, and complexity for decades. Almost as fast in growth are middle workforce concentration counties. The US design that favors procedural, technical, subspecialized, biggest, most concentrated, and most costly has shaped more workforce in top concentration counties and highest workforce concentration counties - where the US is stagnant to lowest in population growth.

Historically only during the new Medicare and Medicaid designs of 1965 to 1980 did we significantly increases in the dollars going through poor, elderly, disabled, low income populations to build up local practices and hospitals.

Since the 1980s flat revenue that fails to address the increasing costs of delivery is what consistently defeats basic health access and any hope of higher functioning or patient centered care for most Americans.

Practices Dedicated to Best Care for their Patients Are Forces to Be Innovative to Have Adequate Finances to Support Their Mission

Miller and Crabtree in Annals of Family Medicine outlined the need to be innovative just to have a financial design to support the practice mission, as the traditional design is insufficient for the various missions described in this person centered article. The designers will not design for primary care well until they learn about the inside-out approach. Designs from outside and above and far away - consistently fail.

ChenMed is also an example of a best Medicare Advantage negotiated financial design for higher functioning and patient centered primary care. This shapes more and better delivery team members taking complex patients with low to no access (homebound, disabled, Dual Eligible) to superior multifaceted access. BUT THIS ULTIMATE SUCCESS IS NOT ABOUT VALUE BASED DESIGN. This because outcomes can be significantly changes just two ways - transforming the population slowly generation to generation and movements from little or no access to superior access. Incremental and short term changes are not going to reverse generations of decline.

Note that only a major change in primary care access can change outcomes. Incremental changes are not enough to overcome the social driver and other powerful non-clinical determinants of health.

Health Insurance Design Shapes Deficits of Workforce and Deficits in Delivery Team Members

Where our nation has concentrations of elderly, poor, lower income, disabled, and chronically ill populations then you will find the worst Medicare, Medicaid, and private insurance plans. The worst employers compound the problem with worst paychecks, benefits, and private health insurance plans.

Note that Medicare 2011 data illustrates ever lower Medicare payments as the levels of workforce get lower.

Family practice positions filled (filled, not training) by MD DO NP and PA are 36% found where 40% of the population is most behind. Equitable distribution is penalized most by lower payments where they most important at 50 - 100% of remaining primary care.

The most important Next Step to Making Person-Driven Outcome Measures A Reality for Most Americans Most Behind is entirely about the economics.

No other discussion is needed or should be allowed until there is an actual movement to double investment across the generalist and general specialty practices specific to the 40 - 50% most deprived by design.

So My Commentary on Person Driven Outcomes

1. Follow The Economics - This is entirely the solution for person-driven outcomes and it must shape more and better delivery team members

2. Begin To Institute Measures In Settings That Require Goal Setting - NO, because of the costs and distractions. Designers MUST understand that metrics, measurements, and micromanagements have worsened the financial design, burdened the outnumbered team members, and cannot change outcomes set in stone by non-clinical drivers.

3. Educate Patients And Family Caregivers - Yes, the fulfillment of the process of primary care is important. But the task of education is far more complex where Americans have lowest levels of education, health literacy, internet access, bandwidth, social supports, and delivery team members. They face the most complex patients with the worst behaviors, conditions, diseases, and outcomes - inherent to their location. And the financial design has been closing their hospitals and practices which deprives them of the locally focused health care leadership.

In conclusion these most complex patients and populations will need a transformation of our current leaders and a transformation of the financial design away from those doing best to provide for the basics of most Americans doing the worst.

As a final comment. Those who hope for Medicaid innovation to divert funding to address housing or other drivers of outcomes once again fail to see the inadequate funding that supports fewer and lesser delivery team members where the worst Medicaid and other health plans are concentrated.