Primary Care Decline By Design

Health care leadership in the United States is failing.

• Too many health professionals are departing their careers, their practices, and their lives too soon. Our leaders have failed to protect and support those who serve. Too few medical and nursing students plan to enter careers of direct patient contact.
• Our leadership has failed to address the 42 year marginalization of nursing, our most numerous health professionals. Diagnosis Related Groups, Prospective Payment, and Profit focus have shaped hospitals and systems into survival mode due to the worst health plans and payments while other hospitals and systems focus on profit mode. Both modes of operation shape fewer team members, lower ratios, higher turnover, and less experienced team members.
• For four decades the most numerous services known as primary care have been steadily eroded in what is most important - most and best delivery team members
• The most numerous populations are being compromised as their remaining health care is designed away. This is seen where the elderly, poor, disabled, and weakest employers are concentrated along with the worst public and private plans. The 2621 counties lowest in health care workforce have suffered 42 years of hospital losses by the hundreds and also the losses of lines of revenue and the losses of countless practices, jobs, delivery team members, and their important leadership and organization skills - their personal effort and that of their spouse and family. What is needed most and is most missing from health care design across vast regions, is being destroyed. It is beyond criminal and beyond discrimination to take down what remains of health care where most Americans are most behind and are growing fastest in population numbers, demand for care, and complexity.
• Decades of designs favor the few who drain our treasuries and impede health care delivery, especially involving the most numerous populations, professionals, and services.
• New terms such as moral injury capture the frustrations of health professionals. What is valuable to health professionals is apparently not valued by their employers and those who design health care. Aligning government, health care employers, and payment designs with what health professionals value is extremely important. This lack of alignment is perhaps the most tragic stab in the back of all for professionals bound to duty and castigated even in their appropriate protests.

MELTED Away is a dominant theme impacting health professionals

MELTED Away is

• More for team members to do
• Ever higher in complexity despite
• Lesser in both
• Team Member numbers and in Team Member capability
• Eroding care and caring, and
• Disrupting the only innovation that matters, one on one with each patient

MELTED Away is has long been impacting the most numerous professionals, services, and American people.

MELTED away also impacts teachers and other basic human infrastructure as well as physical infrastructure. Our budgets at all levels tell the toll on efficiency and effectives in our nation from twice too much health care, military, debt, and prison spending. Budgets in health care and education reflect what we value. Budgets diverted to result in fewer and lesser team members are eroding our nation generation to generation.

Value is defined as - the importance, worth, or usefulness of something

• Value importance, worth, or usefulness in primary care is in the delivery of care and in the focus on caring
• Value in primary care must be the innovation that matters most - the innovation one on one with each patient
• Value is recognized as found in the higher primary care functions such as integration, coordination, and outreach
• Value is primary care that gains, keeps, and advances Most and Best Delivery Team Members. Most and Best is the answer to the value equation for all of the above

A continuation of fewer and lesser delivery team members would be more evidence of accelerating cycles of decline.

What happened to the RN MD dyad so powerful and lasting so long until the designers switched from support to cost cutting and the political games began with basics, vulnerable populations, and those who serve them harmed design after design? Why do so few remember or even explore?

What happened to destroy the most experienced primary care workforce in our history with office internal medicine at 150,000 strong before the dramatic 1980s collapse. The 150,000 was due to over 60% retained in primary care at 5000 per class year for 30 class years. This was supplemented with long term family practice general practice generalists? Did we learn from cuts in revenue, losses of lines of revenue, and higher costs of delivery not met especially in the 1980s when office costs of delivery were close to twice the rate of the major inflation of the time? Did we learn about expanded fellowships and rewarding procedural, technical, subspecialized, and hospital to a much greater degree than basics and care where needed? The latest planned cuts that include basics and populations most behind illustrate what is valued and who is not valued.

Why can we not see that we have the least experienced primary care workforce in our history? We have expanded health professional training and are at a massive level of100,000 MD DO NP and PA a year entering the US workforce - and yet gaps worsen. We lose more of our workforce faster and they take their years of experience out of the pool. In primary care with such a poor design, many depart and primary care retention sets new lows year after year and class year after class year in all sources. The experienced primary care team members are replaced by those with low or no experience. Lower activity and volume levels and numerous distractions limit what our primary care health professionals can do.

When did we start valuing concepts and cost cutting more and people less?

• The concept of value ratios or value based applied to primary care is a distortion of what is most of value.
• Value in primary care is served poorly with the addition of more duty distractions not involving patient care.
• Multiple newly added costs of delivery gang up with fast rising usual costs of delivery to defeat team member support within primary care budgets.
• Metrics, measurements, micromanagement, digitalization, regulation, and certifications hurt in the budget and also strain team members with added duties.

We do not need primary care steadily reduced to fewer and lesser delivery team members. To return to most and best team members, we need to reverse course. We must turn back the declines in long term continuity of delivery team members that compromise each important learning dimension. We need to return to most and best team members in the following areas

• Dedicated to the same specialty
• Remaining within the same practice,
• Remaining in the same team learning with the other team members, and
• Learning more and more about the community
• Always applied to the same continuity patients.

We need maximal relevant experience and long term continuity for the ultimate value in primary care.

We need team members that relate best to patients and to each others, not to a computer screen.

Performance based designs have always been just that - a focus on the work of a performer. Health care and caring are far more important than performing.

Value based is about metrics, measurements, and micromanagements. When did we make rules that stated that it is better to satisfy metrics than it is to satisfy patients by innovating one after another time after time?

Why open primary care up to the deceptions of gaming? Why added incentives? A lifetime in the basic health access service of others was always enough, until the games took over. The time of being puppets on strings must come to an end. Primary care never needed games before, it was a worthy challenge.

When we started down the managed care/Dartmouth/overutilization/cost cutting trail, did anyone consider the consequences of designs based on research involving few Americans and ignoring serious consequences of overutilization focus with vast regions of the nation impaired in access and suffering from underutilization and inappropriate utilization? Of course not, just like Diagnosis Related Groups and other micromanagement, the vulnerable populations are not protected even when they are up to a majority of the American population or will be soon.

In year 2 of readmission penalties, the data release was coded by geographic locations. The county means for the 2621 counties permanently behind in access demonstrate worse outcomes and drivers of outcomes with many more not listed. Not surprisingly their hospitals had the highest proportion punished at 14% given the top 1 to 2% penalty. Rural to urban was 9% to 3% or 3 to 1. The average was 5% of hospitals with the top 1 to 2% portion of revenue withheld.

Studies have indicated these consequences and yet the value based penalties and ratings continue.

The 2621 counties with 40 million rural people and 90 million urban people are growing fastest. They are purer for behind involving outcomes, drivers of outcomes, health insurance plans, access, and benefits from health care design. It appears that they are losing government, health care, and education jobs with the consequences to jobs, economics, local leadership, and the loss of few better health insurance plans.

While our nation focuses on small portions known as minorities, the great majority of our nation is held back by multiple health care designs - racial, ethnic, origin, rural, and the 2621 lowest. By the 2060s it appears that half of our nation will reside in the 2621 counties - a majority on its own.

The rural portion is stagnant in these counties. It is the urban population that has increased from under 50 million to 90 million from 1970 to 2010 - a rate of growth almost as fast as the Hispanic population.

YOU'RE KILLING US SMALLS

Generalists and general specialists have long been under attack. They have been decreasing by 1 to 3 percentage points per year in active workforce for some time, dating back to the 2000s.

This Mayo Clinical Proceedings graphic is preCOVID in timing. The red zone is % planning to reduce hours and % planning to leave. The imprint of RBRVS RVU would shift generalists and general specialists into the Red Zone.

Pediatrics was the missing link, remaining in the Green zone, but this is changing as Pediatric residencies and fellowships are tumbling down as are pediatric units.