Why the New Primary Care Eleven Will Be Ineffective

This is another of dozens of such coalitions that have failed since the 1980s to impact on the primary care financial design. Most support policies that run counter to what is most needed in primary care - such as promoting micromanagement. Most continue to support expansions of insurance coverage that have been insufficient in support of primary care - resulting in no financial design improvement. Plans that require more of providers have been disabling to practices and the care that they can give.

The research that Starfield and others have done has the same many limitations. These research efforts consistently fail to disprove the alternative hypothesis that different outcomes are about differences in the two populations compared. There is also a major difference between dichotomous primary care improvement such as none to some as compared to continuous outcomes improvement with increased primary care levels. Starfield's work has reached the level of worship along with micromanagement.

The limitations for each are quite obvious but are ignored.

Yes you can demonstrate that movement from no access to some access does consistently improve costs and quality.

ChenMed and others who move populations from no access (disabled, hospice, homebound) to adequate access are examples of make a difference primary care. Telehealth to those without access can also work. The key to this is "to those without access."

It is very, very, very difficult to demonstrate that incremental changes in primary care are the cause of incrementally better outcomes. The reason for this is that social determinants and non-clinical drivers of outcomes are so highly correlated with outcomes as well as with different levels of primary care.

What part of primary care at 130% for populations associated with higher concentrations that are doing best as contrasted with primary care at 50% or half enough for most of the nation that is doing worst - is difficult to understand?

The literature consistently fails in key areas of outcomes studies

It fails to require the appropriate controls and even leading journals are misleading. The worst ones are easy to figure out - such as the ones that attempted to compare rural to urban hospitals that are vastly different in financing, patient populations, local workforce, local social supports, chronic illnesses, and more.

COVID studies also failed to be rigorous with sufficient controls. This is why the studies overemphasize race and comorbidities except for the few studies that have better controls. This is a consistent problem when we do not have variables such as relationships, home exposures multigenerational, environments, conditions, social drivers, etc. My goodness, we still have data greatly distorted based on billing software. And studies that insert income or education levels based on the zip code location of the patient - are incredibly distorted.

You can see how pushing levels of primary care is a simpler message.

Yes it is easier to influence legislators and others by saying more primary care improves outcomes. But this only hides the problem of vast disparities in the US population dating back to birth and before that have huge impacts. What are you going to do when primary care is ramped up and outcomes do not change - just like CMS Innovation is 5 for 52 in influencing outcomes. Please Terminate Innovation from Above Focus.

Managed care has failed again this time in a randomized study.

Pushing meaningless insurance expansions is also delaying the necessary financial reform that will empower more and better primary care delivery team members.

As Long as We Cling to Solutions That Are Not Solutions, We Prevent the Necessary Changes - such as a transformation of the American population to transform health, education, economic, and other outcomes.

I tire of so many technology innovations or new innovative workforce or new innovative reorganizations all claiming to make a difference as the US outcomes sink into the sunset, particularly for most Americans most behind. We added FM, NP, and PA as new types of workforce - and still have barriers. We massively increased technologies from HITECH to value based and still have problems and poor outcomes that are worsening where they are worst.

Did readmissions penalties help?

• Best financed urban hospitals had 3% with top penalties of 1 to 2% in year 2
• The average for top penalties was 5% of US hospitals
• Rural hospitals had 9% with top penalties
• The fewer remaining hospitals in 2621 counties lowest in health care workforce and inherently worst in outcomes, resources, complexity had 14% with top penalties

Let Us Review the Statements of this Coalition of Eleven with my critique added below each

From the 11 - Our health system must prioritize the role of primary care physicians in promoting patient health and wellness instead of the current fee-for-service framework that narrowly incentivizes "sick" care.

• From RCB - This implication that fee for service primary care incentivizes sick care has little relevance for most Americans with half enough generalists and general specialists. Yes there are practices that increase volume where payments are a problem - but the solution is the financial design. Who really believes that primary care is the route to wealth from health care? This is a basic managed care myth that continues to play out poorly for primary care. (review managed care groupthink to Dartmouth Assumptions to Orsag to ACA to value based to outline the destruction)
• Primary care specific understanding is needed such as from Mold about the Usual Disruptions that impair the middle and smaller practices . Rapid change and higher cost of change is more disruptive where care is most lacking.
• Miller and Crabtree are relevant as well. If you want to transform primary care you must approach from within or from the grassroots level rather than from above. https://www.annfammed.org/content/17/3/250.abstract Those approaching from above are uniquely unqualified to lead transformation where most needed. https://basichealthaccess.blogspot.com/2019/05/why-not-inside-out-empowerment-rather.html
• Is Innovation the Straw that Broke the Back of Primary Care https://basichealthaccess.blogspot.com/2019/03/is-innovation-straw-that-broke-back-of.html

From the 11 - We must improve access to comprehensive and continuous primary care?for patients in underserved communities by removing barriers to care including workforce shortages and health insurance status.

• From RCB - It is the financial design that shapes deficits where the worst public and private plans and employers and patient finances are concentrated. The designers do not value most Americans or what remains of their health care. These 11 want to fix this with training (more or special) and this has not worked and cannot work because of the financial design that sets deficits and shortages in stone.

From the 11 - We must restore growth in the primary care workforce to ensure effective and accessible care for future generations.

• This lack of growth with flat workforce is entirely about the financial design with flat primary care spending. This financial design prevents any and all training from being able to move half the nation from half enough to sufficient primary care and delivery team members.
• No training can fix deficits of primary care or care where lacking - period. https://www.dhirubhai.net/pulse/rural-training-more-graduates-gme-cannot-fix-deficits-robert-bowman/
• We are Not Growing Primary Care, We Are Shrinking It https://basichealthaccess.blogspot.com/2019/03/we-are-not-growing-primary-care-we-are.html
• The Brave New World Facing Primary Care Graduates with decades of class years of overexpansions of NP PA DO and US MD graduates. https://www.dhirubhai.net/pulse/brave-new-world-facing-residency-graduates-primary-care-robert-bowman/
• Mr. Health Care Designer - Tear Down this Wall that prevents basic health access.

From the 11 - The primary care infrastructure must allow for flexibility and innovation to meet individual community needs.

• From RCB - No, No, Never. Innovation focus must be very specific in primary care. Primary care innovation that matters is about designs that facilitate the ability of the physician or team member to innovate with each patient. This is a grassroots relationship. No semblance of innovation from above can be tolerated.
• Empower the relationship and end designs that disrupt the relationship or result in fewer and lesser delivery team members. Stop meaningless and interfering micromanagement. Stop value based focus entirely. Why would you punish the practices that care for the most complex that are found in places lowest in health care workforce and social supports? https://basichealthaccess.blogspot.com/2018/11/real-health-care-solutions-not-value.html
• See what has happened to family physicians that cared for their practice and their community. At some point the part time ER job to prop up your failing practice finances - becomes a full time job. And this rural doc tried to work with AAFP, Indiana health leaders, and CMS leaders https://basichealthaccess.blogspot.com/2018/08/killing-off-caring-docs-that-matter.html

From the 11 - More resources must be allocated to primary care with an increased focus on comprehensiveness of care.

• From me - It is very clear why we do not have primary care for every person and why we have half enough for half of the nation. This is about the finances. Any effective coalition for primary care must force big healthcare to cough up 100 billion in chump change for them to boost up primary care, particularly where half of the population has half enough. An effective coalition will expose them consistently when they say that they support primary care and yet
• You cannot have comprehensive care until you resolve half enough primary care for half of the US population. The National Academies of Sciences also wants primary care for everyone - but totally fails to grasp the relevant facts of primary care finances. Reports dating back decades have not helped and new coalitions will fail also - without a focus on the finances.

When I led the rural medical educators in 2001 and 2002 we approached AAFP and STFM and NRHA desiring to be an accountability vehicle exposing the states and situations that prevented rural health care. We held this in the AAFP emerald palace and STFM And NRHA sent their top execs. AAFP leaders were in the building and they sent a fourth level staff person.

The focus of AAFP is supposed to be about family physicians and the populations that they serve - but the designs have not been changed and clearly abuse family physicians and those they are most likely to serve - the most.

The US Continues to Shrink Workforce in Counties Lowest in Workforce Where Population Growth Is Highest and Has Been for Decades

It is already too late to prevent much of the damage with more to come. https://www.dhirubhai.net/pulse/health-care-designers-shrink-workforce-where-growing-fastest-bowman/

Won't Get Fooled Again Conclusion - "Meet the new boss. Same as the old boss" You might want to review the lyrics of this very relevant song by The Who

• I'll move myself and my family aside If we happen to be left half alive I'll get all my papers and smile at the sky Though I know that the hypnotized never lie
• https://www.youtube.com/watch?v=rtHshBWFRyg

Or you can see how data science is often crafted to fit assumptions. https://www.forbes.com/sites/kalevleetaru/2019/03/24/data-science-has-become-about-lending-false-credibility-to-decisions-weve-already-made/?sh=30c860ae1d87

You might consider how difficult it would be to publish an article that indicated limitations of primary care in improving outcomes or limitations of micromanagement for transforming primary care. Those who are thought leaders and are designers and are editors and are corporations or institutions or foundations have a like mind - that has not stopped worsening of basic health access. CMS even managed to get an article published that indicated that value based designs did not cause harm even though the article indicated that CMS could pull the plug if it did not like the study.