Saturday, November 19, 2016

The 25th Anniversary of the COGME Third Report and No Change By Design


Hardly a month goes by without some new proposal for more study regarding physician workforce. New studies funded and implemented and reported will not do anything but cost much more and do even less. There are reports from the 1990s that outline concisely what is needed. There has been little progress as the nation has not acted on the recommendations. 

New reports only allow those with their own agenda to add their own spin. At one point in time the experts were more in tune with workforce needs in the nation. The COGME Reports such as the Third Report have been on target - and they have been ignored.






There is really not much need to comment as the report speaks to past, present, and continued failure.

Generalist failure 

...is worse and in more places and will continue to worsen past 2020. Internal medicine will be less than 30,000 as a workforce by 2025 - 2030 or one-fourth of its previous contribution. The last PA graduate doubling resulted in no additional primary care result. This is why we should not even mention the so-called primary care solutions.

Access to care problems 

...continue although the experts of the time did manage to underrepresent the populations with problems as the rural or inner city populations are just the tip of the iceberg with regard to access woes.

Too few underrepresented minority physicians

... are also the tip of the iceberg as it would be hard to design a physician workforce that was more different than most Americans in background, careers, specialties, and locations. The process of medical education tends to defeat needed specialties, service orientation, empathy, and the ability to communicate with patients. 

The results of the last election indicate 

  • Just how little various leaders in America understand the needs of most Americans and 
  • Just how little the experts understand about most Americans and 
  • Just how little the media understands, and obviously makes matters worse. 

Shortages have worsened across needed specialties. 

From 2005 to 2013 there was a 2 to 4% average annual decrease across general surgery, general ob-gyn, general orthopedics and other general surgical specialties - specialties of critical need across 2621 counties lowest in physician workforce where 40% of Americans need basic services.

Primary care, mental health, and geriatric failures in numbers and in distribution exist. Just producing more medical students has clearly failed. Matters are worse for locations with rapidly increasing complexity and least paid services.

Runaway costs due to specialization and subspecialization 


...have been bad enough. Unfortunately additional waves of increasing cost of health care have followed. The initial specialization was followed by subspecialization and has been surpassed by administrative cost increases. Attempts to manage care or high risk or high cost patients have added as much cost as has been saved, with expansions of administrative costs in other areas. Medical error focus since 1999 has added more hundreds of billions a year closely associated with the massive increased costs of EHR/digitalization. The result is of course across the board cuts and continued underfunding of primary care, mental health, and basic services.

Each of these changes have diminished the basic health access that can be delivered - by design. 

Never in the history of the United States has so much support been diverted somewhere else and away from the team members delivering the care. The burnout, recruitment, retention, productivity, turnover, and other costs continue to tear at the fabric of care delivery.

Regional Needs Cannot Be Met

Medical education and graduate medical education as well as nurse practitioner and physician assistant education cannot address regional needs. All physicians and clinicians are far too valuable for generating revenue for the largest systems, academic systems, and others competing for care domination in the top concentration settings.

Those with top concentrations find ways to control more and more workforce. Resident work hours limitations presented 25,000 opportunities taken by NP and PA graduates. Thousands of hospitalists were hired to replace resident losses and long standing faculty shortages. Over 50,000 primary care trained physicians now occupy hospitalist positions. No one even gave a thought to the substantial impact upon primary care and care where needed.

It is not possible to address regional or local needs when more positions are created and supported where workforce is already concentrated.

The 1992 to 1996 changes did attempt to address these areas and did so for a few years. Internal medicine class years did increase back to primary care for a time and so did physician assistants. 

With the end of the decade, the small change gains were replaced such that the US has had a steady decline in access, care where needed, primary care, geriatric care, mental health care, and basic surgical care that will continue to at least 2020 and likely beyond. 


There were a few in academic medicine that realized the need for a change, and for regional focus in planning and coordination of workforce. These leaders were also ignored.

A good read from 1992 is Academic Medicine's Season of Accountability and Social Responsibility by Butler. The headlines that Butler quoted from 1991 still apply today. 
  • Newsweek: The Revolution in Medicine
  • Fortune: Taking on Public Enemy No.1
  • The New York Times: Ringing: The Health Care Alarm
  • The Wall Street Journal: Medicine Appears Costly, Researchers Say
  • Business & Health: Physician, Cut Thy Costs
  • Nation’s Business: Curbing Costs of Health
  • The New York Times: Demands to Fix US Health Care Reach a Crescendo
  • US News and World Report: Doctor’s Dilemma: Treat or Let Die?
  • Business Week: Driving Down the Costs of an Aging America
  • Newsweek: The Antibodies that Weren’t: Federal Investigators Find Fakery in Biology LabTime: Scandal in the Laboratories
  • Newsweek: The Big Business of Medicine
  • The New York Times: Medical Technology Race Adds Billions to the Nation’s Bills
  • The Washington Post: Medical Care: How Much Health Care Can We Afford?
  • The New York Times: Why Emergency Rooms are on the Critical List
  • Newsweek: Can You Afford to Get Sick?


Butler recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research. Next, he focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. He describes models of existing, successful programs. The author concludes by proposing to create a "National System of Regional Medical Care." 


What Are the Consequences of an Entire Generation of Workforce Concentrated Away from Most Americans By Payment Designs?

By 2020 the nation will have lost an entire generation of workforce (30 class years) to designs that send the most (or all) lines of revenue to the most concentrated settings in 1100 zip codes in 1% of the land area while 2621 counties lowest in physician concentrations (and many other concentrations) fall further behind by design. 
  • The top concentration Super Center zip codes have just 10% (shrinking) of the population and 45% of physicians and well over 50% of health spending. New lines of revenue supporting these zip codes are still being created. 
  • Over 30000 zip codes fight for just 30% of workforce despite 66% of the population.
  • Another comparison is 2621 lowest physician concentration counties with 40% of the workforce, 21% of active physicians, and less than 18% of health spending. Only the 36% of family physicians matching up to this 40% of Americans has any real distribution where needed. About 75% of the rural population and 32% of the urban population is found in these zip codes.


Even worse, 
  • the new designs ACA to MACRA send even less dollars where care is needed
  • the new designs ACA to MACRA steal even more dollars away from those who deliver most needed care
  • the counties in greatest need are growing fastest in numbers of people
  • the counties in greatest need are growing fastest in numbers of elderly
  • the counties in greatest need are growing fastest in complexity
  • the counties in greatest need are growing fastest in demand
  • the counties in greatest need depend upon generalists and general specialties that are shrinking by payment design
There can be no response to address primary care recovery or basic health access improvements because payment is missing and what little is sent to counties of need is also forced to be sent out of these counties by design pushed by government agencies in charge of access, by foundations with a mission for access, by primary care associations dedicated to access, and by health policists claiming to focus on access. 

Perhaps someone will begin to understand that payment design defeats the best of intentions, missions, innovations, and rearrangements. 

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.

Primary Care Must Rise from the Ashes of the Last 20 Years of Policy

Recovering General Surgery Is Impossible

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work 

Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind. More STDs with more resistance to treatment and more risky behaviors and public health funding slashed and little or no access to care - What Could Go Wrong?

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance



Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2016

The Four Horsemen of the Primary Care Apocalypse

Payment is easily established as the dominant reason for primary care deficits. Primary care has been paid less, far too little, for decades. Basic services paid less than specialized care is the reason for an unbalanced and too costly workforce in the United States. A nation 23rd worst of 26 developed nations clearly is not investing in generalists, primary care, basic access, or care where needed. Decades of poor primary care payment has shaped deficits of primary care workforce. There are indications of worse, not better in the past decade and at the worst possible time in the history of the United States.

The pattern of the deficit reveals payment as the source. Deficits are greatest where payments are lowest - by state, by county, by population, by practice (smaller size 1 - 9 physicians), by lowest physician concentration counties. Few have not seen the map of red counties and blue counties in the last election. With the exception of a few counties with substantial minority populations, the blue counties have the highest paid services, specialties, and concentrations. The red counties have the lowest paid services, depend upon lowest paid generalists and general specialties,  and have only about 26% of workforce for counties with half of the population of the US.

The counties lowest in physician concentrations are largely the result of payment design.

A close examination of the counties lowest in physician concentrations indicates the four major players producing the deficits by design - Medicaid, High Deductible Insurance, Veterans Administration, Medicare. 

Four Horsemen of the Apocalypse via Wiki

Medicaid - Famine

Medicaid is the dominant deficit determinant. Consequently Medicaid offers the most opportunity for impacting needed payment change. Medicaid payments are indeed lacking, creating workforce famine or workforce deserts. 

Medicaid populations are most concentrated where payments are lowest, where workforce is lowest, and where basic access is most impaired. Increased payments for primary care, mental health, cognitive, basic, least technical, least procedural, and oldest services - this is the best way to improve access, they are the best way to balance workforce, and inject jobs and cash into areas in most need of social determinants - the true route to improving health outcomes. 

Medicaid payment is a major driver of disparities. The only thing less is even less payment through Medicaid to counties with the most disparities already. If Congress does not continue CHIP funding expiring in 10 months, the 47% of children in these 2621 counties with 40% of the population will have even more difficulty along with all in their counties.

Payment below cost of delivering care helps to shrink care for Medicaid patients - and every other patient in the counties where Medicaid patients are concentrated. 

Medicaid payments are so low that many providers fail to accept Medicaid patients. Some places with highest concentrations of physicians have managed to facilitate the flow of  federal dollars to nearby sites in zip codes adjacent to highest physician concentrations - using the fact that few in the area accept Medicaid payment. The solution is better payments - not more dollars abused by those already receiving the most. Federal designations can be part of the problem instead of part of the solution - because of payment design.

Medicaid expansions were not specific to the local problem facing these counties. The counties with the most access barriers have the least workforce - but do not have higher deficits of uninsured. They have the Four Horsemen instead.  

High Deductible Insurance Plans - Pestilence

High deductible plans are catastrophic plans. They work with high cost services as in emergency care or surgery or critical care. They support primary care less. They represent Pestilence or a torture of local care where needed. The plans also torture those with asthma, high cost medications, and those forced to sign up for insurance.

In the counties lowest in workforce, generalists and general specialists dominate. There are few hospitals and those hospitals cannot handle trauma or major catastrophic illnesses. The catastrophic care plans have always helped to impair payments and workforce to rural counties and other counties where lower income Americans are found. Expansions of High Deductible Insurance Plans support local care where needed least.

Veterans - War

Veterans also gather around lower cost of living areas and have to bypass local primary care. Over 45% of Veterans are found in the 2621 lowest physician concentration counties. Many argue that veterans need special care. Those that prioritize special care for few in few places are compromising local and accessible care for 45% of Veterans by workforce that already has to address the needs of the most complex populations in the nation. The lack of support from Veteran plans helps to compromise care for all in the local settings where Veterans are concentrated.

Medicare - Death

Medicare has a chance at break even relative to cost of delivery, but one must also consider the complexity of Medicare and Dual Eligible and oldest Medicare patients. Over 30% of Medicare payments are associated with death or near death as paid for the final year of life.

In the lowest physician concentration counties
  • The payments are less
  • The complexity is greater 
  • Recruitment, retention, locums, turnover, and supplies are more costly 
  • The new regulations are crippling physicians that still take Medicare in more ways that can be counted. 
The maps of the voting patterns of recent elections are a reasonable representation of the lowest physician concentration counties. Those in red counties have long known that they were falling behind - but they do not know the specifics.

The Runaway Stampede

This brings up one more element - a close associate of these Four Horsemen of the Primary Care Apocalypse. This element is increasingly important - the rapidly increasing cost of delivery. Some would say that non-delivery costs are more like a stampede. 
  • The substantial sum of $40,000 more added this year per physician for quality metrics via MACRA (Health Affairs) or about 8 billion added this year alone - is subtracted from the 150 billion in primary care payments. 
  • Tens of thousands a year per primary care physician have been added for regulatory costs via EHR, hardware, info tech maintenance, certifications, practice consultants, and administrative costs. Year after year the design is what destroys primary care.
  • Recruitment and retention costs have also accelerated. Without the payment design to support primary care with sufficient payment, primary care is unable to recruit and retain physicians, clinicians, and other team members. Nurse practitioners, physician assistants, nurses, techs, and other personnel can follow the payment design to health care settings with better pay, more personnel, and greater resources. 
  • As situations worsen over time and in places shortest in workforce, even greater costs are encountered. 
Is it Aggressive Family Medicine Advocacy for the Families of Family Medicine to support substantially higher cost of delivery? Is there any evidence basis for a Future of Family Medicine with crippling higher costs of delivery?

The 400 or 500 million overall in increased annual costs for recruitment and retention and locums (perhaps increasing to 700 million due to higher turnover) is small change compared to $40,000 more per physician for quality metrics (Health Affairs) or 8 billion more for 200,000 in primary care. Then you can add $105,000 per primary care physician per year for those with a primary care medical home.

Each of these only subtracts from the 150 billion ceiling for primary care resulting in a steady erosion of primary care delivery capacity just when the demand and complexity are increasing fastest and in the places lowest in primary care.

I would estimate that perhaps a few billion are added to primary care revenue and about 10 - 12 billion is lost to additional costs.


Why Are Lowest Physician Concentration Counties Lowest?

What concentrates the Four Horsemen plans in certain counties? Lower cost of living and lower cost of housing are important - even if health care is more difficult to find. Veterans in particular are found in these counties with 75% of the rural population and 32% of the urban population. 

These counties have concentrations that are lower to lowest income, or have fixed incomes, or have chronic illnesses. About 40 - 43% of Disability, Social Security, and Food Stamp spending is sent to these counties with 40% of the US.

Lower property values also help shape lower support for schools and education. The states with counties furthest behind also tend not to make up the low property value inequities. 

Lower health care payments and lower education payments result in lesser economic impact - and health and education are a substantial economic impact in these counties - usually in the top 3 or 4 employers and first and second in many counties. 

Highest Complexity Shape Lesser Outcomes - and Lower Payments

Over 47% of poor children are found in the 2621 lowest physician concentration counties - a large concentration for places with just 40% of Americans. The population demographics reveal higher concentrations of poor, rural, disabled, Social Security, Dual Medicare/Medicaid, fixed income, least mobile, lowest transportation, least healthy populations. Diabetics, smokers, and obese people are more concentrated. In other nations, greater complexity results in greater levels of payment. In the United States the hospitals and practices caring for the most complex are paid less - and are paid even less by ACA to MACRA designs paying even less where outcomes are less - because of the local population demographics.

Readmission penalties are more likely for hospitals in these counties, three times as likely. The demographics of the counties insure lower payments for those stuck with MACRA or other pay for performance designs. Once again those who have the better locations will do better by payment designs and those who have lesser payment will be paid even less.

The designs shape consequences that cycle into future generations. Highest levels of smoking, diabetes, obesity,  and health status issues are found in these counties. There is greater potential to address the higher levels of preventable illness, but this is about far more than clinical interventions and requires far more than a decade of effort.

Recovery of Primary Care

Shortages are seen across the nation in primary care because of lowest payments overall and lowest local primary care support where there are higher concentrations of Medicaid, high deductible, Veteran, and Medicare populations. Not only does this impact the patients that are uninsured or lowly insured, it also impacts those who are insured who live in these cities, counties, zip codes... 

Demographics and payment designs make matters even worse. Lowest concentration county hospitals and practices face the lowest payments care for populations that have the most complexity and the least resources. These are counties growing fastest in numbers, in age, in complexity, and in demand. Payment prevents the generalists and general specialties needed for 75% of local workforce. Recovery of primary care, mental health, general surgery, general orthopedics, and other general specialists cannot occur for MD DO NP or PA without true payment reform.

True Payment Reform

The four horsemen of the primary care apocalypse could be different across Medicaid, highdeductible, Medicare, VA - Designs for Medicaid could add dollars. Incentives could shift patients away from high deductible plans or include primary care benefits. Medicare could revise payment for basics up and subspecialized down (required to have any balance or increasing in the primary care ceiling). 

The VA did not choose to support local care where 50% of Veterans are found in lowest concentration counties. No, it sent 200 million down their pipeline leaving less to go for care - and instead of spending this via local established primary care offices that are demonstrated to be the most efficient - the VA will be spending on bricks and mortar and establishing new personnel and office equipment and trying to recruit and retain.

Think Local, Plan Local, Act Local

When the Southeast Rural Physician Alliance (SERPA) in Nebraska was starting out - they did not know the payers or those designing the local health insurance plans. They soon figured out who was setting up the plans and they helped benefit managers and employers to revise the plans such that local primary care and local hospitals were supported. Employers benefit when using less costly local services and employees also benefit as they save time and dollars due to less transportation. This also results in fewer dollars leaving the county as those leaving the county shop in more concentrated counties as they go to health care in more concentrated counties.

This basic lesson seems lost upon national leaders, state leaders, and leaders in primary care and in family medicine. Family medicine needs to promote what is good for family physicians and the patients of family physicians.

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

Biomedical Focus is Ruining US

More Quality Measures for Homebound Seniors - Not Hardly - why not improve access for the 45% most left behind rather than making care more complicated and measure focused

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.

Primary Care Must Rise from the Ashes of the Last 20 Years of Policy

Recovering General Surgery Is Impossible

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work 

Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind. More STDs with more resistance to treatment and more risky behaviors and public health funding slashed and little or no access to care - What Could Go Wrong?

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance



Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2016

Friday, November 18, 2016

Please No More So Called Primary Care Solutions

The numerous and increasing so-called primary care solutions have largely been a waste of time. Even worse, these so-called solutions have been a distraction from real solutions. The claims made by a variety of nursing, physician, primary care, foundation, and government leaders are often well-intentioned. They often believe passionately that they represent a solution. 

In fact, it is not possible for primary care innovations, training interventions, and rearrangements to work to restore primary care or basic health access at the current time or in the foreseeable future.

The solution has always been about payment. There will be no future of primary care or future of family medicine or future of care where needed or future of rural health or future of health access without real payment reform.

There is a formula for success in all of these important areas.
  • Payment needs to be substantially increased 
  • Above any increased cost of delivery and 
  • Must also be adjusted for the higher complexity that also add to costs plus
  • No, repeat no, additional hoops need to be jumped through to receive this payment. 
This is the primary care solution that works - and it also works for basic services, mental health, general surgery and other workforce behind by payment design.

How long will we tolerate so called solutions for mental health, general surgery, etc. that are not really solutions?

Graduate Medical Education Expansion deserves particular mention as it cannot work to restore any target specialty set by ACGME. Payment defeats each and every desired workforce and practice location. In particular, family medicine choice is prohibited across preparation, admission, training, and retention. Only 6.5% of residents are trained in the 2621 counties lowest in physician concentrations. Payment actually overcomes the deficit of GME design since 21% of physicians are found in these counties - but this remains small compared to the needs of this 40% of the population left behind.

Primary Care Success Requires Investment in the People That Are Primary Care Delivery

It has become so common to see attempted interventions involving consultants, software, rearrangements of practices, academic expansions, pipelines, high risk patient focus, innovations, or payment incentives - but the fact of the matter is that primary care is broken. None of these are wrong, but they all distract from the true primary care solution.

An investment must be made in what primary care is all about - 
the team members to deliver the care. 

Why is it so hard to see that the team members are most of the cost because they are most of the action? Why did we ever tolerate a design where primary care practices are forced to pay for personnel who do the work of insurance companies and government - leaving little left to deliver primary care? Why is it hard to see that dollars stolen for rearrangements, innovations, software, hardware, constant chaotic changes, measurement focus - all steal from primary care itself, from the team members to deliver the care?

More team members supported to do more and in more places is the solution for primary care, basic health access, and care where needed. Anything that impairs people interacting with people to help change their behaviors, situations, environments, conditions, and other determinants - is impairing the proper focus upon changing health outcomes.

The managed care/Dartmouth innovation gurus have assumed that physician behaviors can be reigned in to result in cost savings - with manipulations to greater quality. This application is most destructive to primary care, rural health, and care where needed where lower payments, increasing demand, and higher complexity have forced them long ago to be most effective.

In fact, it is the lack of payment support that kills off primary care - as seen when there is investment in primary care in Michigan and in Home Care demonstrations - that do have good claims for cost, quality, satisfaction, and access benefits. Squeezing hurts and more squeezing hurts more.


After decades of "primary care solutions"

the problem of insufficient

primary care delivery capacity remains. 
Stop the Insanity

Over and over again is not working. The decades of failed primary care promotions stand testimony to the failure of the so-called "solutions." We must stop the insanity of continued failed interventions. No demonstration or grant or special program or school can address the ceiling for primary care shaped by 150 billion, with further decimation by increasing cost of regulation.

In health care involving patients there are ethical considerations. If your alternative treatment is not really a solution, then it should not be adopted or even attempted. Treatments require an evidence basis and alternative treatments that delay effective treatments are unethical at best. 






Payment Designs Punish Primary Care

Many in primary care can testify to the substantial pleasure of delivering primary care in well-supported situations. At the current time many testify to the burnout and other negatives accelerating across the last decade of designs. This is entirely about increasing what must be done and the complexity while decreasing the financial and other support.

The solutions for burnout, primary care, mental health, basic services, and basic health access are one and the same. Entirely different designs are needed.


Misguided Interventions Made Worse with "Innovation

New sources of primary care, graduate medical education expansions, expansions of new primary care sources, innovative training models, and pipelines to primary care have failed.

Even worse we have measurement focus and primary care medical homes costing 5 - 8 billion more added each year. These are costly billions spent without an evidence basis for care improvement. Not surprisingly the most challenged small practices and practices where care is needed have not adopted the new innovations. Margins have been too low to tolerate the additional costs.

One can even consider that interventions forcing larger practices or closures of small practices are doing harm. There is an evidence basis for small practices as doing better in areas such as preventing admissions. But small practices are being collapsed and swallowed by health care design.

The designers out of touch with the needs of most Americans and those who care for them have designed away health access. They have added billions more in cost of delivery that result in negative margins or unpredictable futures. Their designs have overstressed primary care team members, decreased productivity, have distracted team members from care focus, and have acted to diminish overall primary care delivery capacity with the impact greatest upon the locations in most need and increasing the most in demand and complexity.

Payment needs to be substantially increased above any increased cost of delivery and must also be adjusted for higher complexity. This is the primary care solution.

A Journey of Discovery

Decades ago I began to track medical school primary care mission statements, and graduates, and county distributions of graduates, and primary care graduate outcomes. I kept maps of the counties in need of workforce and workforce changes over time. I was fortunate to have a job that supported teaching, researching, and delivering health access and also attending the various primary care, rural, and underserved meetings across the nation. 

Over time I lost my enthusiasm for the job as it became apparent that the workforce was not changing, no matter what was being done. Across Nebraska counties mapped by name of physician, the names would change, but not the capacity for delivering care. After 30 years of being paid to improve access, my conscience would no longer let me keep taking money for outcomes that could never be changed.

My passion for health access has continued. But we need real solutions, not more failures.

Although many continue honest effort to resolve primary care woes, careful reflection regarding the evidence leads to the conclusion that there cannot be a solution because of the current financial design - a design that dictates all of these outcomes, the results of training, and even greater disparities.

No one contests the effectiveness of special training regarding the graduates of these programs. The problem is that 150 billion for primary care in annual spending remains a limitation - a ceiling. 150 billion for primary care limits US primary care. Only 5 billion or 10 billion in your state limits state primary care. More graduates from a special source merely displace those from other sources. There is no funding increase to grow capacity. The funding does not increase and therefore the workforce cannot increase. The funding is particularly limited in the states and counties lowest in workforce, that are also lowest in payment support.

Witness the long and growing list of failed interventions

  • The US has created 4 new sources of primary care since 1960.
  • The US doubled US MD grads from 1960 to 1980 and has added 30% more in the past decade.
  • The US quadrupled DO grads 1960 to 1980 without primary care result as each doubling was accompanied by half as much primary care result from graduates.
  • Special primary care medical schools established in the 1960 - 1980 era
  • The 12 times expansion of NP graduates since 1980 from 1400 to 17,600
  • The 8 times expansion of PA graduates since 1980 from 1400 to 9000 with documentation of no primary care result from the last doubling of PA graduates.
  • The 10+ times expansion of Caribbean graduates at over 60% primary care trained illustrates more futility.
  • Family medicine was created and increased to 3000 annual graduates by 1980 but the doubling of the FM workforce to 80,000 has only displaced other sources not permanent to primary care. This is great for FM outcomes, but overall primary care remains the same. 

Training in primary care is a smokescreen long used by medical and nursing leaders to be able to claim primary care result. This is good for funding academic settings. But payment shapes fewer entering primary care and fewer that remain. This is not about salaries so much as it is about the support or lack thereof.

International graduates continue to supply 25% of US physicians but 45% choose IM - the most unreliable of all primary care sources even with primary care training. Few choose family medicine, the most reliable source. This is not surprising given their origins and early training, their experiences in the few years in the US, and the institution chosen.

The Natural Experiment of Family Medicine Expansion

Family medicine was one of the new sources of primary care. From 1969 to 1980 family medicine increased to 3000 annual graduates - a steady state level maintained even in 2016. The expansion of family medicine was most specific to primary care recovery as FM grads have remained 95% in family medicine positions - until recently. During the 1970 to 1980 class years, FM was tracked to distribute 30% of graduates to rural areas. In the 1980s, payment expansions ended as the nation entered the current era - the Era of Cost Cutting. 

Stagnant payments set limits upon primary care. The increase of family medicine from 40,000 to 80,000 as a workforce from 1980 to 2005 was accompanied by a decline in the proportions of all other sources found in primary care. The family practice component of physician assistants dropped from 54% to less than 25% from 1984 to 2010. Internal medicine collapsed as a primary care sources. Pediatrics declined from 70% to 45% result for primary care. Despite substantial primary care training for nurse practitioners, only about 30% are active and in primary care. NP results in about 60% active over a career and those active are half in primary care - for 30% active in primary care result. 

There simply is not enough financial support for primary care positions and there is substantially more support for non-primary care positions. Each year there are more specialties and subspecialties added and more MD DO NP and PA add to these new specialties. This leaves primary care and family practice behind by design.

Massive Expansions Have Failed for Primary Care Result

The 12 times expansions of NP graduates since 1980 from 1400 to 17,600 and the 8 times expansions of PA graduates since 1980 have done little more than replace collapsing internal medicine primary care result. PA leaders have been the most honest and track new graduate career choices. Their choices indicate that even a doubling of annual graduates is not capable of increasing primary care delivery capacity. Workforce centers have tracked PA deteriorations in the years after graduation.





Special Training Has Great Outcomes - for Special Training Graduates Only

Most deceptive are the results of special training programs in all disciplines, pipeline designs, pipeline designs with gaps filled, bonus programs, loan repayments, and retention and recruitment bonuses. 

These all seem to be effective when considering the outcome of the program or track, but the graduates are still subject to the same distortions in payment in the years of practice and special track graduates merely replace and displaces others rather than increasing primary care delivery capacity. More dollars are required to be injected at all levels for success - when what is required to seal the leaks in the pipeline at all levels is higher primary care payment.

What is most consistent about primary care proposals is their benefit for those making the proposals and receiving payments. It is a sad fact that the CMS branch of HHS creates the shortages via payments tens of billions too low for primary care and the HRSA branch attempts to clean up the mess with tens of millions. 


Adding a few billion to CHC payments does very little compared to 150 billion in annual primary care spending and is small change compared to 6 -10 billion a year in added costs of delivery.


The Astonishing Lack of Evidence Basis for Primary Care "Solutions"

The recovery of primary care is also the result of substantial impairment in our evidence basis regarding primary care, access, and services where needed. Even with a sustained increase in primary care payments, it would take at least a half a generation of workforce or 15 class years to recover the workforce - 2030 at the earliest. Demographic changes alone have already overwhelmed basic health access and there is worse to come. 




Demand is increasing most where populations are increasing fastest and where complexity is greatest across the elderly, disabled, poor, and those with lesser health status, habits, and outcomes.

We have 2621 lowest physician concentration counties with 40% of the population that depend upon generalists for 50% of workforce and general specialties for 30% with primary care stagnant and general specialties in decline. At each level lower payment shapes less workforce across the states with lesser concentrations of workforce, the counties, the zip codes, and the practices. We have even paid less for services provided by NP, PA, young physicians, rural practices, small hospitals, and rural hospitals across years or decades. Across places with concentrations of more complex patients and patients with lowest paying plans, we have lesser concentrations of workforce and more challenge and we pay less.

Then in a further act of discrimination, Pay for Performance Designs have been implemented - a design with over 12 studies most consistent in indicating lesser payment where the care is most complex and where care is most needed.

The deficits are shaped by lower payments for primary care, mental health, cognitive, office, basic services, and care where needed and much higher payments for procedural, technical, specialized, newest services, provided in places with higher concentrations of physicians, income, people, education, and outcomes.

Where workforce is most needed the most needed specialties are failing by payment design. Where primary care is most needed, graduates fail to enter or remain in primary care even if "training" in primary care across MD DO NP and PA.

Family practice result has taken the most grief from payment design. Each class year MD DO NP and PA graduates fall to new lower proportion records each year due to expansions and fewer found in family practice. Each new specialty and subspecialty created adds more MD DO NP and PA graduates and leaves fewer remaining in family practice - by payment design.

As goes family practice, so goes access. Only family practice MD DO NP and PA are found in the population based distribution (36% of FM in 2621 counties with 40% of the US) where population is growing fastest in numbers, complexity and demand.


You cannot succeed in access by failing to support generalists and general specialists that are 75% of the workforce where most Americans most need care.

The only way that any of the above will be more successful is by increasing US payments to support primary care, decreasing the cost of primary care delivery, and likely both. The biggest providers get the best breaks and the smallest end up getting paid less and face the challenges of chaotic change and rapidly increasing costs. 


Instead our nation cuts primary care payments or keeps them stagnant while the designers increase the cost of delivery (administration, regulation, EHR, digital, recruitment, retention, turnover).

There can be no recovery of primary care, mental health, general surgery, general orthopedics, or other general surgical services until there are increases in payments.


Compared to Other Nations

"In comparison to adults in the other 10 countries, adults in the U.S. are sicker and more economically disadvantaged. The resulting challenge to the U.S. health system is compounded by higher health care costs, greater income disparities, and relatively low levels of spending on social services." 

In the counties where 40% of Americans are clearly most left behind, the US does not even rank among developed nations and appears to be 50th to 60th at best.

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

Biomedical Focus is Ruining US

More Quality Measures for Homebound Seniors - Not Hardly - why not improve access for the 45% most left behind rather than making care more complicated and measure focused

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.

Primary Care Must Rise from the Ashes of the Last 20 Years of Policy

Recovering General Surgery Is Impossible

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work 

Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind. More STDs with more resistance to treatment and more risky behaviors and public health funding slashed and little or no access to care - What Could Go Wrong?

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance


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Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2016