Primary Care Cannot Fix Health Outcomes

The review of primary care as a factor in improving outcomes looks impressive. We hear it all of the time. I urge you to see through this. More primary care or different primary care cannot fix our broken health care or our broken populations. Our nation has to do that.

Discussions with Family Medicine Leaders Who Think More or Different Primary Care Can Fix Our Nation

Agreement depends upon the timing, tone, and content. If I talked with family medicine leaders about the NP studies claiming that they do better with the Medicare population and how they use data from Washington State which makes their studies look better, they would likely support my assertions that this was because they included Washington State which tends to have better outcomes – especially when 40 – 50% of the population studied was Washington State.

If I pointed out that the NP vs MD studies were quite flawed with old data, convenience data, biased design, biased publication, and deficits controlling for differences in the populations being compared – not to mention a change in the NP site of care – many physician primary care advocates would agree.

If I pointed out that those who have doubled their workforce (PA, DO) by doubling annual graduates have not increased primary care yield significantly from those graduates, some might see and understand. Others might not agree. Nurse practitioners would point to major increases in numbers of NP in primary care - while failing to see that this has improved primary care delivery capacity or basic health access where needed.

Bad Science Is Still Bad Science Rather You Are For or Against What Is Said

Studies can lie. Rural hospital outcomes look to be worse than urban. The same is true with higher vs lower volume hospitals. Those who have some awareness of the major differences involved in the populations involved can see through these. Sadly the editors and reviewers cannot.

But When You Advocate for Primary Care, Do You Help or Hurt?

Do you see how primary care is being promoted and in ways that prevents us from looking at the population differences that shape outcomes?

Do you see that entirely new primary care associations have been created that get millions to promote primary care – but they have not changed primary care? Do you see how they push the bandwagons – patient centered, higher functioning, social determinants, primary care medical home?

Do you see how Americans try everything to get the best solution - and end up not solving the problem at all?

At this time of COVID, do you see how this has become and opportunity to get your area funded?

A recent journalist question was well intended. "If you had 50 million to invest in rural health, what would you do?" I can see how they have such questions shaped in their minds, but they are never told about the primary care financial design with billions less a year for primary care, for primary care in states of need, for primary care in counties of need, and stolen for bandwagons.

If the dominant information exchanges in our nation are shaped by bandwagons

It is hard to point out that more primary care graduates fail to resolve primary care deficits. It is complicated to point out how more burdensome regulations and innovations have make primary care practice worse - and can potentially shape worse outcomes. Declines in health spending where populations most need the jobs, economics, and social determinants - will defeat outcomes. The impact will be the same if

  • Paid less
  • Penalized more
  • Force to pay more billions a year for metrics, measurements, micromanagement
  • The result is lower productivity in team members and higher burnout and turnover

How will we ever address deficits of workforce, especially when the bandwagons never focus on the financial design and usually make it worse?

If the dominant information exchange involves training as a solution to deficits – training more graduates or training graduates in special ways – how will we ever increase the numbers of team members to deliver primary care where needed, or their abilities?

Our financial design continually shapes fewer and lesser for primary care for most Americans. Is that so hard to see?

If we do not change the information – we cannot change the values or what we need to value.

How do we change spending toward the populations most behind – to actually improve outcomes – if we ask for spending in primary care or innovation or regulation or micromanagement or elsewhere?

And For Family Physicians

Should those in practice tolerate the continual push of academic family medicine for more funding and their claims that they are a solution for deficits of primary care?

  1. Despite the continued decline in primary care retention
  2. Despite decreasing family physicians active in family practice with each passing class year
  3. Despite more difficulties hiring and keeping graduates in family practices
  4. Despite higher costs of turnover and higher frequencies of turnover

Does the Dean's Lie Apply to Family Medicine?

The deans lie has long been exposed by family medicine. Deans were lying by saying that they schools are producing primary care. They were caught counting matches of their medical students to internal medicine and pediatrics and other specialties lowest yield for primary care result. Internal medicine is only good for 10% yield of primary care, yet they count this for primary care result?

Why don’t we fess up in family medicine and note that the most recent FM graduates are only good for 50% in primary care, and likely less in the future?

Perhaps this will be easier to see when the COVID impacts are known and volume declines close and compromise more primary care practices.

How much does it take to be a lie?

How much does this distract from the financial design solution required for primary care building?

The Problems with Promotions of Primary Care

It is very common for the families of family medicine to promote primary care. Clearly family practice positions filled by MD DO NP and PA are most important for basic health access since these are the only ones that distribute in a population based distribution – not concentrating in concentrations of workforce.

But as we have discussed endlessly, this requires an entirely opposite financial design. Going in to family medicine or family practice is not important. What is important is staying in these positions. We need a design from a nation that values basic health access or at least does not

  • pay less for primary care,
  • pay less in the states in need,
  • pay less in the counties in need,
  • with even lower payments due to penalizing these practices more.

We must transfer the understanding that this financial design failure is the reason for failure of Basic Health Access impacting most Americans. Our nation

·        Does not value these populations

·        Does not value basic services

·        Tolerates abuse of these populations and those who serve them

In our zeal to promote primary care, we go too far.

We are also scientists – and should understand scientific studies and their flaws. This is particularly true

·        When we are desperate and want to prove that our kind needs support

·        When we believe in what we do in primary care

·        When we have been sold that higher levels of primary care shape better outcomes –

Higher levels of primary care are associated with better outcomes, but the populations where higher levels of primary care are present are entirely different in social determinants, situations, environments, insurance plans, health spending, and in numerous other ways that our nation shapes disparities.

Our Nation, States, Insurance Companies, Politicians, Policists, and Health Care Designers Shape Disparities – this is important to understand

Numerous Primary Care Home Studies Are Flawed. They often minimize the costs incurred. They are too short term to be of value. They have researchers focusing on proving value. They have promotions by those advocating for primary care. These studies often compare two different populations that not surprisingly have two different outcomes.

Note also that such studies are not pure. Government interventions have been some of the worse. Who can define ACO or other acronyms that constantly change definitions, policy, and more?

The Oregon Study Has Major Flaws

·        In addition to being too soon and not controlling for population and not controlling for changes in the population over time.

·        The Oregon study should be regarded as propaganda for primary care medical home.

·        At the usual costs per physician for implementing primary care medical home, Oregon spent hundreds of millions on process. Consultants, CEOs, advisors, coordinators, and corporations that do not deliver care were the ones that benefited.

Ask yourself or those from Oregon

·        Who got this money? Was this invested locally, or shipped away from practices and populations in most need of the dollars?

·        Did Oregon primary care sites boost salaries, benefits, employment of physicians or others delivering care?

·        Did they have improvements in recruitment, retention, turnover costs, productivity, and morale?

·        Did they end deficits of primary care?

·        How can they improve health access when they spend more on non-delivery areas?

Oregon’s primary care medical home efforts do not measure up. I did calculations and reviews of this in 2016. Viral spread of the promotional summary with the promoters names prominent at the top, makes it difficult to counter their arguments.

Oregon has long figured out how to get good press and does this well. Family medicine and primary care wanted such an announcement, and got it.

Some of the Oregon works are impressive, such as

·        Randomized studies of Medicaid (the only one)

·        Community-Based Priority Determination - Earlier in time their process of prioritizing state spending on health care with a community voice was a masterpiece. A physician trying to bring some emphasis on community-based decision making can do much as a health care leader

So Reflect About This, Does Primary Care Improve Costs and Quality?

·        I do believe that there are studies that indicate that investing in primary care can marginally reduce costs

·        I think that more investment in primary care can possibly improve outcomes, maybe, depending upon how it is invested

This is why I think it ludicrous to force value based designs

·        That may pay more to primary care with better outcomes (that serve better populations)

·        That are more costly and burdensome and disabling to practices

·        That will pay less to practices that care for populations that inherently have lesser outcomes

Trying to Force the Value Based Bandwagon as the Means to Better Primary Care Funding – Has Not Worked

Trying to Force the Value Based Bandwagon as the Means to Better Primary Care Funding – Will Not Work

Trying to Force the Value Based Bandwagon as the Means to Better Primary Care Funding – Will make outcomes worse – just follow the billions of dollars more each year diverted

Studies of improved access to care are consistent in claims of access, cost, and quality improved. Sadly these studies involve the home bound elderly, hospice patients, and others most left behind in the US. These represent extremes. If you have a randomized trial of any kind or any high value scientific research method – please share it. They do not exist. Oregon’s randomization of Medicaid came closest.

BCBS Michigan also did an upfront investment in primary care with some improvements. Sadly this likely increase in Basic Health Access was put into the background by the massive overpromotions of Primary Care Medical Home. Notice how the bandwagon promotions claim credit, while the likely reasons are left behind.

Be careful what you believe as it can distort your thinking – the information spread - and distract from real solutions.

Yes, if we invest more in primary care where needed, we might eventually see an improvement in outcomes. This would be the long term effect of billions more a year spent where jobs, income, and social determinants are lower in our nation.

Conversely, health policy designs that pay less for these practices and hospitals, that divert many more billions from these populations to pay for meaningless health insurance, and that divert more billions away from generalist and general specialty practices to pay for metrics and measurements and micromanagements – will worsen outcomes eventually along with worsening access and more. The outcomes declining will be across health, education, economics, and more – as seen in our nation for decades as shaped by similar designs.

What we value wins, and most of us lose.

About Primary Care, Managed Care, and other entities Being Marketed

 It is important to see the close relationship between marketing and promotion and the focus on innovation, rearrangement, regulation, and micromanagement. In my opinion, the smaller and more needed and more abused practices do not need any of this – and die by design. This is another way that most Americans and their providers suffer.

Primary care medical home arose from marketing – as promoted by primary care associations. It was to be a help for marketing primary care. While this fits where primary care competes, it is not much of a solution for most Americans that have half enough primary care (and general specialists). They have providers that do not have to market. Their problem is being paid too little while being forced to pay too much for innovation and regulation. These PCMH documents formed the bases for the latest CMS debacle.

Let’s Apply What We Have Learned About Populations Shaping Outcomes – Not Emphasizing Primary Care or Promotions

As far as the comprehensive study that was done (More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations – clearly this is a comparison of 2 different populations that are going to have differences across social determinants, relationships, situations, and more.

People are coming around to social determinants, environments, relationships, and other individual and social factors as shaping outcomes from birth or before.

Researchers that want to prove a point can do so

–       as I did long ago with rural curricula and choice of rural family medicine as a career. I can learn, and teach about this

–       There are too many flaws in these types of studies to count.

–       Rural vs urban hospitals still got published despite comparing apples to oranges flaws and the obvious difference in the populations.

–       The same is true with studies that trashed low volume hospitals – who have different populations, lesser payments, different workforce, different services, and other differences.

–       Hospitalists that were female, IMG, and younger looked better – and in each case the populations being compared were different.


Stop the madness and the distraction. Journals, editors, reviewers, and others must do better – yet we see worse.

Note how what is a bandwagon or popular wins out – because dramatic gathers attention. This gives a clue as to the bias inherent in the process

Do you really think that foundations or governments that fund researchers want an objective finding – or do they want confirmation of what they already believe?

I did a study of the hospitals with Readmissions Penalties highest in year 2 – highest then was a 1 to 2 percent withhold. This highest level of penalty was found in

·        3% of urban hospitals

·        5% average

·        9% of rural hospitals

·        14% of the few remaining hospitals in 2621 counties lowest in health care workforce where the workforce is lowest, the social resources are lowest, the social determinants are least, and the hospital finances are worst – and were made even worse. These studies and ratings are even worse because of return to the mean, small numbers impacts, and other flaws of the rating method

Or if you prefer, you could do the same study with primary care levels or numerous social determinant levels or local support resource levels or compared to education or economic factors or outcomes.

They will have the same association.

County level data shows much the same – and education, health, economic, and other data demonstrates the same associations. But then you would have had to collect county data for decades and process it and compare it - as I have done for decades. This was a lot harder before county health rankings existed.

Sometimes you even present this data at rural conferences about Quality - and no one listens.

How Did We Get This Far?

If you go to association and government meetings and Datapolooza events, guess what? You will believe in metrics, measurements, micromanagement, and meaningless use. You will believe that this works even in places with little or no workforce and few local resources.

The discredited Dartmouth researchers focused our attention – and the nation – on more micromanagement. It infects much of what we do after decades. The policies have set us back for decades. The managed care to Dartmouth to Orsag to ACA linkage is very clear. Policies have been created and implemented with little awareness of the consequences. We should not celebrate 10 years of ACA. Perhaps if there were less politization, we would see through it.

Has this helped us or the people that we serve – or our nation?

Designers Lie When they Promote Primary Care Recovery Lies

Acute Abuse Is Still Abuse, As Is Chronic Abuse of Those Behind By Design https://www.dhirubhai.net/pulse/acute-abuse-those-behind-vs-chronic-valued-robert-bowman/

Translates to a worsening of health access where access is least, with similar design problems dating back to the 1980s (although 15% lower pay for new physicians in 1983 was dealt with after about 2 years of abuse). Historically the Designers have been abusing these practices and people since the 1980s.

What CMS proposes is a small increase that is more than blown away by the above - late, small, and adding to burdens

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care July 30, 2011

The 25th Anniversary of the COGME Third Report and No Change By Design Reforms Proposed 1991 still missing as of 2016

Designers Ignore 40% of Americans in 2621 Counties Stuck with Lowest Levels of Health Care Workforce There is no excuse for not supporting the generalists and general specialists in these counties who have become the oldest and most abused workforce by design.

Does Medical Education Fight Disparities or Cause Them - Medical schools and their leaders have grabbed headlines for their tiny examples - but they continue to support the payment designs that worsen disparities - the designs that profit them most

Seasons of Distortion Rather Than Accountability and Social Responsibility - Academic Leaders Once Called for Important Reforms in Major Addresses - No One Paid Attention - The Headlines Highlighting the Abuses of Health Care Remain the Same

The Glut of Workforce Exposed But Ignored from January 2019 - Payments are bad enough for most needed services during this time of declining finances and declining demand, but enter the massive glut of NP PA DO and MD graduates who continue to increase 6 to 12 times faster than population growth.

Think Twice About a Medical Career

Primary Care Get Caught by Physician Pay Crossfire https://www.dhirubhai.net/pulse/primary-care-gets-caught-physician-pay-crossfire-reprint-bowman/

Primary Care Collapse Is More than Rural https://www.dhirubhai.net/pulse/primary-care-collapse-impacts-more-than-rural-robert-bowman/


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Robert Bowman

Basic Health Access

4 年

More about flawed health outcomes studies using the primary care example. https://www.dhirubhai.net/pulse/why-outcomes-studies-flawed-primary-care-example-robert-bowman/?

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James Franks

Owner, James Franks Family Medicine

4 年

Agree. Poor and less educated populations, and the physicians serving them, are hurt by the present health care design. It is driving health care providers out of these areas.

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