The Ultimate Value in Primary Care Is Most and Best Team Members

The continued decline of primary care is apparently difficult for designers to understand. Those who shape and fund primary care certainly have not found a solution. The original Medicare and Medicaid designs were supportive, primarily with the added and increasing sources of funding. It is hard to see improvements in basic health access for the past 40 years. Revenue limitations, increased costs of delivery, and increases in the team member duties combine to limit primary care delivery capacity. There are many symptoms of systemic primary care failure across the finance, workforce, and practice environment sectors.

"While most Americans think they have the world’s best healthcare, a key distinction must be made. American medicine—expertise, training and technologies for healing—is indeed the best in the world. But the healthcare system used to organize, deliver and pay for care is itself unhealthy to the core." —Sidney Taurel, Chairman, President and Chief Executive Officer, Eli Lilly - thanks to David Dibble for this

Primary care and basic health access are the great examples of best of designs and worst of designs - a tale of two nations.

Does America Specifically Disable Those Who Serve on the Front Lines?

...In human infrastructure areas such as teaching, nursing, primary care, public health, social services, and others. There are increasing challenges and supports are lacking. The population is changing and more Americans are falling behind. Life is more complex. Cuts in support shape fewer to share the load and the complexity.

Examples can be helpful and look no further than what has happened to nurses over 41 years. Designs such as Diagnosis Related Group hospital payments multiply the problems.

Nurses were given more to do of higher complexity despite less time for their interactions (fewer days stay, more distractions) and despite fewer in team member numbers. This is a design ever more disruptive of personal and professional values as well as family. Long ago a reasonable assessment of this design would have tagged this as disruptive of the one on one innovation with each patient, student, or person in need of care and caring. The example of Hong Kong terminating DRG after just 3 years of nursing abuse illustrates the depth of the health care leadership problem in America and their inability to visualize health care from the inside out.

Pre and Post 1980 Designs

From 1965 to 1980 there was the reality of added billions that powered up primary care and basic health access as well as hospitals and practices in 2621 counties forever lowest in health care workforce.

Since 1980, the health care design emphasis has been placed on cost cutting, managed care, insurance expansions, measurement focus, and more specialized care. These have not helped basic health access for most Americans due to failure in revenue design, increased duties, increased complexity of practice and billing, and devaluation of primary care. Burnout, turnover, and turnover costs add to team problems. The payments are smaller via the Resource Based Relative Value Scale, in most states, and in counties with lowest levels of workforce. This is hardly a design that values what primary care delivery team members do.

The standard primary care year measures future primary care delivery for each of 5 sources using years in a career, % active, % in primary care, and a volume adjuster. Only 1970 to 1980 did this improve with a doubling from 125,000 to 250,000. This should have continued up steadily to 400,000 for sufficient primary care but the level has regressed to 200,000 and may even be lower as primary care retention remains difficult to estimate as it continues to fall faster.

As the health professions remain insufficient, so do the delivery team members. There are indications that the team members are even more compromised where the financial design is worse. What happens to delivery team members is apparently not a consideration for those who design health care.

Many Questions Arise

• Is primary care better off with fewer team members and with more complex tasks not related to the one on one care with patients? This can be the case in this tale of two nations as there are providers with survival focus while others have profit as the top motivation.
• Why do we not have designs that place a focus on most and best delivery team members for optimal one on one innovation that matters most with patients? Does anyone grasp how serious this is as most and best are steadily driven away from primary care and basics and where most needed?
• Has movement away from the past design of the MD plus RN dyad in primary care been helpful or harmful as we move lesser in training to various nursing forms to medical assistants?
• What can stop the worsening of primary care retention across all health professional sources? Failed finances, team members and practice environments are not going to help.
• Why do we ignore the evidence of training intervention failure with all sources falling to lower and lower primary care retention even with massive expansions?
• How can special schools, programs, or pipelines help basic health access or most Americans most behind across vast regions of the nation when the financial design is not improving, especially in areas with concentrations of the elderly, poor, disabled, and weakest employers with concentrations of worst paying Medicaid, Medicare, and private health insurance plans?
• Why is primary care not the primary vehicle of health equity along with other basic health access services - mental health, women's health, basic surgical, and geriatrics? Distribution is important for equity and best distribution is possible by more spending on these areas and in 2621 counties most behind with lowest levels of workforce.
• Has the United States lost the ability to deliver complex primary care well? Numbers and quality of team members have changed in key areas such as experience and continuity in the same specialty in the same practice learning more about the same community and resources and working with the same team members and patients.
• Why do we still focus on quality improvement when outcomes are primarily not about clinical interventions - and why base payment designs on outcomes when these will punish practices and hospitals serving in places with concentrations of patients with the worst outcomes inherently along with drivers of outcomes and lower levels of access and supports?
• Why ignore doing studies involving changes in delivery team members and environments as we have gone from primary care physicians with decades of experience to nurse practitioners and physician associates with few years of experience due to rapid departure, churn, lower levels of volume (lower activity, fewer per year), and less continuity with specialty, practice, team, and patients?

• How can lowest financed practices, often with concentrations of Medicaid patients (Community Health Centers, rural, 2621 counties behind), keep their team members when better financed primary care, subspecialty care, and hospitals can easily spirit them away after they gain in training, experience, and expertise? Why ignore the pecking order and the team disruptions of the current financial design with implications of worsening health equity, turnover costs, access to care, team numbers, and team abilities?
• Why ignore the failure of private health insurance in vast regions of the nation with weaker employers with their weaker paychecks, benefits, and health insurance? Is it hard to see that these weaker plans cannot overcome public plans paying too little that together shape permanent deficits of access, jobs, services, team members, and the community contributions of health care employees, their spouses, and their families?

Shaping Quintuple Aim Failure Rather than Success

• Given failures in financing and distributions of dollars and workforce, it certainly appears that the designs are causing Quintuple Aim failure in the health care patient experience, health equity, and population health areas? Team members have long had worsening personal and professional life experiences across numbers of added duties, digitalization, innovation, regulation, retraining, certification, micromanagement, not to mention fewer and lesser team members by design. Lower cost focus with cost cutting is a major problem for most Americans most behind, not an answer. Cost cutting is based on overutilization but harms most Americans most behind who are suffering access issues resulting in underutilization and inappropriate utilization. it is primary example of one size does not fit all (and harms most) in health care. Cost cutting is the worst possible focus for basic health access, especially in the 40% of the nation in 2621 counties permanently lowest in health care workforce with 45% of patient complexity (age, income, chronic illness, behaviors, environments, lack of support, worst literacies and outcomes), higher complexities of practice by design, worsening accounts payable and receivable, and just 23 - 26% of the primary care, mental health, women's health, and basic surgical workforces supported by less than 20% of spending in each basic health access area. These practices must make difficult choices regarding fewer team members or lesser team members. Should practices choose less volume and more interaction with more access limitations for populations or survival focus with more volume, lesser interactions, and more access?

By the way, these all translate to no progress toward sufficient primary care by 2030 as CMS claims. The workforce sufficient by that time would have involved over 400,000 years of primary care already arising from each class year in the NP PA FM IM and PD sources of primary care. This level has been falling from its 1980 peak of 250,000 for some time and is half the level required. Primary care does not capture enough graduates or keep them because there is a total disconnect between the designers and the required finances, team members, team member quality, team member activities, and practice environments required for sufficient primary care.

Bigger Questions Arise and Are Not Addressed Beyond Primary Care But with Huge Impacts on Basic Health Access and Most Americans Most Behind

• Why are hospitals and practices not the largest being forced into these difficult choices about team members, volume, survival, practice environments, and other important areas in health care that should be decided by a nation and by those who are keeping most Americans most behind as a top priority focus?
• Why do we let primary care leaders claim that training is a solution for access failure when the access remains poor despite 50 years of failures involving new types of health professionals, massive expansions, and special training or pipelines? Can Teaching CHC residency programs help CHC workforce with Medicaid payments too low for half of their patients, just tens of billions in HRSA, and 1.4 trillion in annual spending at CMS directed against what they are doing? Rural medical education including pipelines looks good at the program or pipeline level, but the lowest levels of workforce remain much the same. Insurance plan failures involve Medicaid, Medicare, worst employer based plans - and usually public and private plan failure across vast regions or denying care to such patients even in counties with higher concentrations of workforce.

Finances overcome training interventions. A focus on true solutions is required and only major added billions from 1970 to 1980 allowed training interventions to work involving basic health access and distributions of workforce - period, end of story.

• Why are practices blamed for volume focus when the financial design has left them little choice?
• Why is it hard to see that there are consequences when health professionals are forced to develop alternate sources of income (cosmetic, nutrition, emergency room, urgent, and locums jobs) to prop up the failed practices attempting to operate where access is most limited? Why sacrifice personal and family finances and time with family? Why not full time spent not in the overwhelming and underearning and under supported area of primary care as seen for over 40 years?

It is easier to diagnose and treat primary care decline by an examination from the inside out - from the perspective of the delivery team member. The only innovation that matters in primary care, is the innovation one on one with each patient.

Impairments of this ability devalue primary care and what basic health access should be. Team member challenges are increased where primary care workforce has impaired finances and remains with half enough professionals and other delivery team members. Higher payments for procedural, technical, subspecialized, and hospital services certainly impact the career choices and teams

To help understand primary care difficulties, look to the example of the primary care situation in 2621 counties lowest in health care workforce.

• This is where primary care has always been about half enough despite facing concentrations of elderly, chronic illness, worst behaviors and social determinants, and inherently lower outcomes in this 40% of the nation. About 45% of patient complexity is overwhelming for the 25% of the primary care workforce supported poorly with less than 20% of spending. There is discrimination by design as payments are 15% lower and other revenue has been compromised.
• The emergency, hospital, procedural, obstetric, and assistant surgery payments that bailed out low office payments have been closed or compromised for primary care physicians due to hundreds of hospital closures and various insurance changes.
• The private employer-based plans in these counties do not have the 150% Medicare payments to bail out the poor paying Medicare and Medicaid plans. Expansions of the worst public plans is a poor choice when there is a need to have public and private plans that pay their way or a total reform in the payment design.
• Finances have been hurt for these practices not the largest in these 2621 counties that are not able to negotiate the best payments or bargain successfully for discounts and lower costs of supplies and services. Relatively higher costs are likely for each of digitalization, regulation, metrics, measurements, and micromanagement. Team members may be more pushed into multitasking where there are fewer which may not be the case in those larger.

Quintuple Aim Review

Continuing with the 2621 counties and their primary care challenges, we can examine the lofty goals of Triple, Quadruple, and Quintuple Aim. Despite the promises of proponents, it appears that primary care is more of a victim than a beneficiary in this 130 million population most behind. Again, this is best viewed from the inside out - the perspective of the delivery team members.

• The patient experience in primary care would have to be rated as in decline, especially with so much difficulty getting an appointment or keeping a regular site of care. The designers fail to support a better primary care experience, especially for the 40% with half enough primary care workforce.
• Reduction of costs is the wrong focus in primary care with spending that
• Population health is where formal health care delivery has a minor role, but distributions of health care dollars via primary care are the best way to distribute health care dollars. Expenditures on primary care team members are one of the best choices for distributions of jobs, economics, access, income, and community leadership
• The personal and professional lives of team members have been compromised by innovation, digitalization, micromanagement, regulation, certification, and measurement focus.
• Health equity is best served by most and best delivery team members distributed equitably across the population. 1% of the land area in 1100 zip codes with 10% of the population plus 45% of physicians and an even greater share of health care dollars and health care corporate concentrations - is not equitable.

Primary Care Delivery Team Summary

The power of primary care is in the primary care delivery team. How it has been disabled is primarily about two areas. The first is inadequate funding from outside. The second is about the compromises internally in the personnel budget that must power most and best delivery team members.

Budgets, structures, and functions must focus specifically on most and best delivery team members as the top value. With primary care as 50% of health care services, not having most and best delivery team members creates a cascade of consequences across health care delivery.

The top primary care value is difficult to achieve in a health care design that values profit, investment, cost cutting, corporate invasions, consultants, and the big four - procedural, technical, hospital, and subspecialty.

Most of all, a so-called "value-based" design with emphasis placed on metrics and measurements is one of the worst designs of all for practices already suffering most.

• Value-based has not addressed grossly insufficient primary care spending.
• It is a function of cost cutting focus which is exactly wrong for basic health access
• and delivery team member support.
• Measurements are distractions from care and caring.
• And outcomes are predominantly shaped outside of clinical interventions.

Health care designers continue to make poor assumptions that betray their lack of a focus on designing health care for an entire nation - and protecting the vulnerable most behind.

The assumption of overutilization is problematic for all of basic health access in a nation that has failed across primary care, mental health, women's health, basic surgical, and geriatrics. Overutilization is just a rationalization for Type 1 micromanagement cost cutting. The resulting cost cutting has harmed basic health access and particularly primary care for decades of designs. The harm is done to what is most important in basic health access.

The failure to significantly rein in costs while harming most and best primary care team members is one of the major failures of US health care design.

Breaking Up the Concrete to Reverse Basic Health Access By Design

In the 1980s, designers added lines of revenue favorable to those doing well, gave them best payments, and regulations made these difficult to change.

The design was set in concrete with regulatory capture, the Resource Based Relative Value Scale, and budget neutrality. These have not considered the flawed 1980s designs and will continue to worsen team members, practice environments, and American opinions of their health care design. When you specifically compromise the half of US health care services known as primary care, the perceived value of US health care will continue to plummet.

The Lesson of History - Only One Time of Significant Progress

It is important to understand historically when we did value basic health access. Look no further than times when the financial design was significantly improved - in basic health access and where most Americans are most behind.

Only 1965 to 1980 did basic health access improve with the new billions added from Medicare and Medicaid. Only during this time period did primary care capture more future primary care years per class year (less than 125,000 to 250,000 Standard Primary Care Years in the class of 1980). Only during this time did the 2621 counties lowest in health care workforce improve in terms of hospitals and practices.

Since 1980 the focus on cost cutting and crippling micromanagement has revealed the lack of value placed on basic health access.

The US health care design has specifically closed hundreds of hospitals in the 2621 counties resulting in catastrophic losses in access, jobs, health equity, delivery team members, and the community leadership of these health care employed along with their spouses and families.

The deficits of health care make it difficult to recruit and retain better employers - essential to overcome the poor paying public plans. The losses of the health care, education, and government jobs are more devastating where economics are weaker.

Generalists and general specialists were also compromised by hospital closures. The generalists lost emergency, hospital, obstetric, procedural, and assistant surgery services. The general specialists in women's health, orthopedics, general surgery, and urology were largely designed away by these changes.

The Value of Most and Best Team Members

• Best one on one innovation - the only innovation that matters
• Most experienced in local resources and supports
• Change agent ability involving behavioral and other areas
• Higher functions such as integration, coordination, outreach
• Best productivity
• Volume
• Reduction of turnover and best practice environments
• Most and best to share the complexities of care involving patient, practice, family, caregiver, community, and supports/resources
• Cover for each other's weaknesses and facilitate other's strengths - a true team

Designers must remember

• This is a patient
• This is a primary care team member
• The two should interact optimally by design
• This is the only innovation that matters

Another Designed Disruption of Primary Care - The Social Determinant Waiver

Mold wondered why primary care practices were not able to do innovations such as quality improvement programs. His study revealed usual disruptions as a problem and was only the second to look at this area. Changes of key personnel, EHR, billing, location, and ownership hit small and medium size practices hardest. Changes apparently favor the largest by disrupting those not the largest.

MIller and Crabtree had to hunt to find types of primary care that were able to stay with their missions of patient care. They had too look at primary care from the inside out and found best paid capitated, direct primary care, and concierge examples. These were ways to bypass the areas distracting and disruptive to finances and team members.

You cannot see the disruptions and problems of waivers, assumptions, and policy changes unless you view the designs from the inside out - from the perspective of the delivery team members. Attempts to insert technology, micromanagement, or Social Determinant waivers - represent over 3 decades of misguided and harmful assumptions. These can be harm by cost cutting or they can be harm by the assumption that you are helping.

The SDoH waiver is such a design. It appears to violate team members that are already shaped fewer and lesser by the financial design.

• The waiver changes encounter activities from episodic and direct to patient to continuous.
• The team members must work to develop resources and contacts before encounters.
• The encounters will take twice as much time with impacts on other patients and other delivery team members.
• The team members will need to address follow up and revisions.
• The waiver is a 3% cut in Medicaid, already lowest paying of the plans
• The outcomes of the waiver are unknown. Some suggest improvements, but studies are limited. Those who see patients with simplistic deficits in housing or food will be happy. Those who see outcomes as a function of decades of previous life shaping experiences or generations of poverty might be pessimistic - especially given the limitations of primary care team members and social services supports in the US where 40% or more are behind and are worsened by numerous designs.

The SDoH is essentially a 3% cut in Medicaid spending that will harm team members plus it burdens team members substantially.