Ten Points To Understand to Fix Primary Care and Basic Health Access

I have been blessed/curse with 55 years of observations regarding primary care and basic health access.

The great value of primary care has been the one on one continuity, the only innovation that matters. Most and best delivery team members have designs and employers and supports that facilitate

• staying in the same specialty,
• staying in the same practice with the same team, and
• also learning more and more about the community resources and supports
• with the same patients encounter after encounter.

Continuity and experience are to be valued. Instead they have been eroded for 41 years of designs.

Cost cutting and added burdens that force multitasking have cut to the heart of primary care and the only innovation that matters - the one on one.

My mom was an RN and I grew up in two homes

1. the family practice home where she and her doc were most and best and
2. the home with my dad.

I have been teaching, researching, and practice basic health access for 40 years. I truly believe that looking back to beginnings is the key to understanding our failures and discovering true solutions.

The Original Medicare and Medicaid Designs

The 1965 to 1980 time period advanced primary care with new sources of payment created. In addition there were annual cost of delivery adjustments. These were the only major time of significant funding improvements. Not surprisingly this generated a one time doubling of future primary care years, from 125,000 to 250,000 from 1970 to 1980. Since that time, decline by design toward 200,000 and likely below rather than advancing to 450,000 and sufficient primary care.

More and more likely each day considering cuts in revenue, delays, denials, punishment from performance based designs with their added burdens, higher turnover costs, and ever higher costs of delivery not being met by funding.

During this 1970 to 1980 time period a number of research papers claimed that solutions for basic health access were about faculty, curricula, student interest groups, special training, special schools, but....

Success in the 1970s did not hold as these same interventions tanked in the 1980s as the designs of the era of cost cutting ushered in.

This was one of many times that valid workforce research has been done, but the result was meaningless because it did not control for health policy changes or failures to change health policy over time. Pipeline research is valid and demonstrates 10 times greater target locations, but tracking these locations such as 70 Nebraska counties of need, reveals little change.

Financial designs plus training interventions are powerful as in 1970 to 1980. Training without financial design changes will only expand non-primary care maximally with little change in primary care.

But I trusted academics and my worship of medical education and rural medical education pipelines was off the scale.

I was convinced of these academic interventions and wasted 25 years pushing rural medical education and pipelines - until I thought back on what closed my rural family practice. I failed to learn that...

Point 1 - It's the payment design, stupid

Lowest paid in OK, rural OK area 99, in office, in primary care, and 15% less just because I was a new physician told me everything I needed to know

Designers Don't Know and They Do Not Care

Basic health access services that are mainly office services are not the contributors to runaway health care costs. You need designers that allow powerful big health care to push payments up, resulting in cost cutting.

Point 2 - Cost Cutting - the Politically Driven American Discrimination

Those trying to cut costs were unable to balance the need to cut costs with the demands of the most powerful most profitable providers. So what did they choose?

Point 3 - Cost Cutting Policies Target Those Least Powerful

The year 1983 brought PPS and DRG and cuts to new physicians (like me) and the implementations of cost cutting spared those bigger as usual. Or they adapted locations, plans, billing, or other areas to keep the profits coming.

Those not the biggest hospitals and practices were closed by the hundreds and this carnage continues.

Point 4 -Lost hospitals translate to lost local lines of revenue including the higher paid services that could bail out office payments too low

Primary care where most needed for the 40% of Americans most behind suffered the most. The better paid low overhead ER, hospital, OB, assistant surgery, and procedure payments dissolved along with practices and access and local jobs, economics, access, and leadership.

As your cost cutting attempts fail your government payer will need to do more work to individually review health care services and costs to attempt to rein in costs. Not surprisingly you will find that this is far too much cost to pay for the personnel and their benefits etc inside of government programs.

1. You will need to farm out the services to private insurance.

2. You will also need a way to mechanize the cost cutting. DRG and PPS did this with hospitals, so you need a similar cost cutting design for practices.

Both distance designers from the practices, practice environments, team members, and the inside out perspective needed to design. If you have no clue about consequences, you will fail for 40 years of designs - and they have failed for 40 years.

So what was cooked up. Regulatory capture, RBRVS, and budget neutrality.

Point 5 - Voila! the Resource Based Relative Value Scale. If you want to fix in place discrimination in payment design, this is one way to do it.

The RVU changes are ideal for implementing cost cutting on a massive scale. With only a few people involved, there was never a chance to discover that one size fits all is really bad policy. And the probability of figuring this out disappears with the distance increasing between designers and internal practice environments.

Like DRG, the rewards tend to go to those larger and more powerful. Those not the largest or most subspecialized fall behind by design.

Point 6 - Preventing Primary Care from Being All That It Could Be - Best TEAM Members for Best One on One Care

RBRVS and lower payments and least lines of revenue all have significant impact on teams. Team members and practice environments suffer with lower payments because they are relegated to lower value.

Primary care and mental health and geriatric teams suffer and where the payments are lower and the complexity is higher, the practices are unsustainable.

GERIATRICS NEVER HAD A CHANCE

The overall result for basics teams can be seen as fewer or lesser delivery team members (or both) to share the complexity. They fail in revenue and accounts receivable, they fail in costs of delivery and accounts payable, they fail as in MELTED Away delivery team members - more to do in less time of higher complexity with fewer/lesser to share the complexity.

Point 7 - PECKING Order Power and Punishment

Over 15 years of practice in Omaha 1992 to 2007 you could see academic family medicine stealing better team members from CHCs with their weaker finances and we were losing better team members to practices that were a steps up on the RBRVS pecking order. Turnover costs further defeat those already behind.

There is great reward for procedural, technical, hospital, and subspecialized services involving the most lines of revenue and highest payments in each line. The salaries, benefits, team members, and environments are favored by the financial design.

A focus on physician salaries as driving career choice ignores what happens the rest of their lives as far as the patients, team members, environments, supports, and salaries/benefits.

It is easy to ignore the consequences to basic health access and to most Americans most behind

Point 8 - Round After Round of Cost Cutting Creating More Disparities

And of course the designers continued to fail to stop runaway health care costs as more found ways to drain government treasuries.

So you need to implement more cost cutting. Since your plans are operated by multiple health insurance corporations, it is difficult to watch what they are doing to basic services. This allows them to pay less for the basics and they can delay or deny their way.

They can also pay 15% less where most Americans have the lowest levels of county workforce and half enough primary care and basics.

The nurse practitioner and physician assistant graduates with their massive expansions contribute much more to nonprimary care and less to primary care as fixed in place and declining finances translate to insufficient funding as well as fewest/least delivery team members. The massive expansions at 6 to 8% more graduates a year are perfect for facilitating profits from more services, more services paid at higher rates, and lower costs of personnel compared to the most costly physicians.

Doublings of DO and PA workforce result in a temporary 30% increase in primary care and 200% increases in non-primary care. And the temporary increase in primary care melts in the first decade.

Point 9 Enter Micromanagement to Improve Outcomes - WHY?

A number of experts are telling you to focus on innovation, regulation, micromanagement, metrics, and digitalization. There are two major impacts

1. Cuts in personnel budgets - MELTED Away, fewer/lesser
2. Added burdens for delivery team members - MELTED Away, fewer lesser

At the turn of the century there were promises that digitalization would bring lower costs and better outcomes. This has not been the case. Higher costs of delivery and more burdensome micromanagement contribute to higher turnover and ever greater turnover costs. This plays out worse where deficits of workforce and access are worse.

Your assumption that overutilization was the main problem backfires for populations with deficits of workforce and access where cost cutting adds to the harm and facilitates more underutilization and inappropriate utilization.

Point 10 - You never figured out that best health care is about most and best team members so your designs have shaped the opposite.

And in the advanced version, every attempt at Quintuple Aim backfires for what remains of health care for the 40% of Americans most behind.

We are not going forward in primary care. We are back at 1980 levels or worse. We have created so many additional costs and burdens that we are generating less future primary care years, not the doubling from 250,000 to 500,000 per class year needed (red line)

We are not keeping up with purple population growth or turquoise demand increase. Blue lines of primary care years created per class year are flat to declining

The green line indicates declines attributed to 30 billion more in costs tacked on to primary care without revenue to cover these costs.