The Only Future for Primary Care 2020 and Beyond

Our nation does not support those who serve where most needed across health, education, public service, and social support. Our nation is as strong as its human infrastructure. A nation that does not value people or serving human infrastructure is falling apart - and it shows. Primary care is the front line for health care and is most abused by design where it matters most. Only a much better financial design can save it. As it turns out this is also a major way to having health care that contributes to health equity and better outcomes instead of the current designs that make them worse.

Teachers make less that other college graduates and most constantly abuse their personal budgets and family times to address the needs of their job and students. Public servants are tasked with keeping our people safe, no easy task with politicians, promotions, and social media tearing us apart. Teachers and public servants serving where most needed have by far the most difficult jobs where families are falling apart and where students are growing up in survival mode - with few long term goals and little to lose.

In health care primary care represents the front line and is half of health care services. This most prevalent service is even more dominating for the parts of the nation most behind in health care design. Where most Americans most need care the primary care proportion increases to the 60 - 65% range together with basic general specialty services this becomes 90% of the health care services available locally.

A better financial design is the means to the end of better access where needed, improved social determinants, and improved outcomes. But our health care designs continue to worsen basic health access for most Americans as well as their social determinants and outcomes. These designs shape fewer and lesser team members to deliver the care - the exact opposite of the changes needed.

Future of Family Medicine Goals 2021 to 2060 Specific to Most Americans Most Behind and Those Who Serve Them, Especially Family Physicians

There is one main goal to consider for 2021 and beyond

1.      A 10% annual increase in revenue for the foreseeable future without any additional regulatory, innovative, or disruptive cost of delivery increases

 Period

That's it.

This is not a complicated report as we often see with rural health solutions. This is not about a complicated program involving more training or special interventions with tons of bureaucracy and more technology, consultants, and corporations involved (as is common to health care design).

 For the Duration Needed, Until Fixed

This increasing revenue distribution would be continued, until there is resolution of the deficits and access barriers that have been chronic – and are worsening. This would go entirely for the payment of the services provided - without the attachment of some abusive value based design. The dollars changing health care access and social determinants in the communities and practices receiving the dollars will eventually improve the outcomes. The current designs of health care that steal more billions a year for meaningless health insurance, meaningless measurements, and meaningless reorganization will continue to accelerate shortages and poor outcomes.

The Scope of the Abuse Is Not Small, more than just rural or underserved.

Rural primary care practices in need serve only 10% of the US population. This is small compared to the 25% of primary care workforce or 60,000 primary care physicians in 2621 counties lowest in health care workforce. These counties have long suffered with half enough primary care (46 per 100,000 in 2013 compared to 80 – 90 per federal guidelines). This 40% or 130 billion people has 75% of the rural population or 30 million with access limitations plus 90 million or 32% of the urban population to make up the 40% of the US population in 2621 counties lowest in health care workforce.

Using the AMA Masterfile and Area Resource Files you can see how the designs have always failed going back decades.

• Take home point. The designers do not understand this population or their health care. Their designs clearly hurt health care in these counties as well as hurting the people.

Value Based Hurts, Not Helps

There is a price for metrics, measurements, and micromanagement. There is also a price tag charged to primary care where most needed each year. This price tag forces 1 billion more a year to be lost from investment in local primary care jobs and in the local population.

The design fails for the US as a whole as well. The micromanagement focused value based designers are increasing the costs of their health care while their outcomes are not improving – the opposite of value based design. More likely is that the costs are going up and the outcomes are steadily being shaped lower over time – by the health care design (but also the education, economic, and other designs).

The health care designers thought that they could tinker with the health care designs and technologies to make outcomes better. They have made them worse.

• They assumed that overutilization was the problem and applied their solutions to overutilization, not understanding that most Americans suffer from inadequate access which has been made worse by their designs.
• They have hurt Americans most behind the most as well as the delivery team members that serve them.
• They have delayed the true solution - an honest to goodness better financial design for the remaining basic health services for half of the US population.

You can see how these counties, their health access, and their economics, jobs, and social determinants are made worse by health care design.

They have always had the worst designs impacting this 40% of the US population with 45% of care complexity – an overwhelming burden considering just 25% of the MD DO NP and PA primary care workforce in these counties supported by only 20% of primary care spending with steady declines in what they can actually spend on local primary care delivery capacity – by design

 Discrimination By Design

1.      The Medicare 2011 data that I translated to the county database indicated 15% lower office payments (lower where the health care workforce is lower and as the proportion of family physicians in the county increases)

2.      Medicaid patients are concentrated in these counties along with those with lower income (translates to lower collection rates also)

3.      Medicare and Dual eligible plans are concentrated in these counties

4.      High deductible plans are concentrated in these counties (different mixes in different counties, but in general the worst paying plans and the worst treatment for patients and providers in these plans)

5.      The worst employers are found in these counties and they have the worst salary, pay, and benefits including the worst health insurance (noted that these 2621 counties did not lack for employment or for health insurance more than others, they just had the worst employment and the worst health insurance – and the expansions of health insurance have been the worst plans also).

6.      The economics derived from manufacturing, mining, and agriculture are down, particularly with trade policies and continued outside the county ownership

7.      The economics from education are the worst as state designs based on property taxes hurt counties with lower property value and large areas of untaxable land, and the federal designs involve too few dollars with policies inconsistent in helping high poverty settings

8.      The economics derived from social supports are also a top 5 economic contributor and are stagnant and threatened – disability, social security, food stamps, unemployment, and more

9.      The economics derived from health care are substantially down

a.      Negative cash flow involving billions more a year from mandatory health insurance that take 90 cents on the dollar out of the county and return only 10 cents to local providers

b.     Negative cash flow involving a billion more a year extracted from primary care practices to pay for HITECH to ACA to MACRA to PCMH to value based leaving less than 30 billion and not counting more dollars lost from closed and compromised practices

c.      Negative cash flow from the abuses of the worst health insurance plans with delays, denials of coverage, and lowered payments

10.  Turnover costs are increasing and the advertising and locums required are increasing outflow of dollars. Frequency of turnover is increasing. About $100,000 per fte of primary care in a practice per year is the result of $300,000 costs/losses per lost primary care physician with a loss each 3 years

11.  Productivity has been going down via digitalization, regulation, innovation, and disruption

12.  The Usual Disruptions are worse for the practices in these counties as the practices are smaller and more vulnerable to changes in key personnel, billing, EHR, ownership, location, and other factors that have been demonstrated to impact new changes toward quality improvement (Mold, Annals FM)

It would seem that increasing the revenue would be a solution for

1.      Increased participation in Medicare, Medicaid, and worst plans

2.      Primary care delivery capacity

3.      More and better team members (not the opposite)

4.      Higher functioning primary care – integration, coordination, in person and telehealth outreach, etc

5.      Patient centered primary care

6.      Care and caring capacity

7.      Better support of primary care training in places in need of primary care (only 6% of GME positions found in these 2621 counties with 40% of the US population)

8.      Improving jobs, cash flow, economics, social determinants, and outcomes derived from social determinant improvements.

Health Care Design Favors Few and Ignores Most

Notice that all lines of revenue with the highest levels of reimbursement in each line can be found in 1% of the land area in 1100 zip codes with 10% of the population and over 45% of physicians. Some of these lines of revenue have been created by academic and largest systems – which benefit them greatly and act to concentrate health care workforce away from most Americans.

 If you value health equity, this one goal is a move to health equity involving better access, distributions of health care dollars, cash flow, jobs, economics, and social determinants.

If you value the fight against disparities – this is the fight that health care should prioritize. This should be a primary argument with the big health entities and associations fight against redirections of health care dollars from most specialized to most basic, office, cognitive, prevalent, and most needed care.

If you see a dean, AAMC, AHA, AMA, or other health care leaders or associations say that they support health equity, or that they fight disparities, or that they want better access – call them out.

Why this is even more important

These 2621 counties lowest in health care workforce have been growing fastest for decades from 32% to 40% and likely to 50% by 2060. The 10% of the population in highest concentration counties is not growing and the 20% in higher concentration counties have slow growth – about half of the US pop growth average. The 30% in middle physician concentration counties are growing at above average levels with lowest concentration counties growing at a slightly higher rate than middle (same as middle in some decades)

·        The US designs are creating shortages and access barriers as the workforce is fixed at lower levels as the populations increase –

·        And the populations in lowest concentration counties are older, poorer, sicker, have less access, and have less social support

Do you understand why performance based or value based designs are not only wrong, they discriminate, cripple, and likely kill?

Please, if you are a family medicine leader, reconsider your recommendations regarding value based care, performance based designs, and other design change that hurt us and the populations that we serve.

Bob Bowman

Basic Health Access