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Triple Threat Destroys the Essence of Who We Are in Primary Care

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Triple Threat is what creates, maintains, and worsens burnout - and the essence of what we are in primary care.

Threat 1. Insufficient revenue
Threat 2. Accelerating cost of delivery
Threat 3. Complexity increasing in multiple patient, practice, and community dimensions

Complexity is inherent in the life of a primary care physician. 

Complex primary care delivered with sufficient revenue and support to cover the costs and complexities of delivery is highly satisfying. A bad financial design made worse is what erodes margin as well as time - time with patients, team members, colleagues, and family as well as personal time.


Value based designs tear at the fabric of who we are. 

We know that outcomes are beyond the ability of our practices. This is actually supported by the literature in major reviews of pay for performance. Even worse, these schemes discriminate against those caring for the most complex with the least resources - with lesser pay and added complexity.

Tragically foundat…

AAFP Initiatives Should All Be Focused on Triple Threat

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New initiatives by medical associations can help patch up wounded members, but are not solutions for the systemic dysfunction impacting tens of thousands of members. AAFP gains high marks for wonderful resource materials and this will likely be the same to address burnout, but their efforts to address burnout will not prevent burnout. To prevent burnout, AAFP must go upstream. Triple Threat is the cause of burnout.

Burnout is due to the Triple Threat challenges of 1. insufficient revenue, 2. increasing cost of delivery, and 3. worsening complexity.

Stress is not the problem. 

Stress is inherent in the life of a medical student, resident, and family physician. We were taught about ratios of stress over support. Stress must be balanced by support in patients, in physicians, and in team members. Too little

in dollars, in other support, in numbers of team members, in numbers of physicians and clinicians, and in satisfaction with regard to what we do drives our problem areas.  Lack of suppor…

Will the New AAFP President Worsen or Improve Triple Threat?

As Michael Munger MD takes over as AAFP president he indicates "One of my real concerns is around payment reform. And it's a multilevel concern. Will we really see meaningful payment reform?" Your responses at the AAFP site indicate that you are asking the right questions...

But under your leadership will AAFP work effectively and successfully to combat the Triple Threat -
Revenue too little, Accelerating costs of delivery (including the shift to value based), and Complexity increasing in multiple practice, patient, community, and other dimensions? Who will help AAFP to see through innovation, digitalization, certification, and regulation as adding to costs of delivery and worsening Triple Threat? How many more dozens of articles are needed to be added to the evidence basis that indicates that performance incentives fail to change health outcomes. Even worse, they discriminate against the patients and populations that best fit the description of those cared for by famil…

The Ultimate Shared Principles for Primary Care and for Most Americans

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The Shared Principles documents have attracted much primary care attention. Primary care associations are signing up to support the principles. These are principles that have existed for generations of general practice and family medicine physicians. They are good principles as with other areas supported by such associations. But it is important to remember that the power for primary care principles is the financial design.


Each of the primary care principles requires a better financial design. Each principle has long been compromised by the Triple Threat. The primary care Triple Threat is too little revenue, acceleration of cost of delivery, and complexity increasing in multiple dimensions (practice, population, community, higher functions). This limits what we can invest in practice, patients, team members, and the people of our communities. The same Triple Threat is taking out mental health and general surgical specialties - thrusting even more burden upon the family physicians who…

Does Commonwealth Support Health Access for Most Americans?

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The Commonwealth Fund claims a mission for access and yet the various studies supported and reported by Commonwealth fall short in access. There are claims of improvements from the 2010 reforms, but access improvements are more than just insurance expansion and Triple Aim. Access to care requires the primary care team members to deliver the care. The failure of access is quite obvious in counties and zip codes where half of the US population has grossly insufficient MD DO NP and PA workforce. The financial model has long been broken with regard to the workforce to provide access in these counties and other underserved settings. You cannot expand access via expansions of worst paying and least supportive plans. You cannot expect Triple Aim to help when it is most costly and least rewarding for the practices that make the difference between some access and none. True health reform must involve an increase in the capacity to deliver care - at the national level and especially in the 2621 …

Does the AAFP Truly Support Primary Care?

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It would seem that AAFP supports primary care, but is this really true. Does AAFP do all that it can to increase revenue, decrease costs of delivery, and facilitate the work of the team members who deliver the care? Does AAFP support payment designs that result in financial compromise for family physicians? It is harder and harder to make the case that AAFP stands for primary care. 

It is even harder to make the case that family medicine stands for most family physicians. 

Family medicine leaders have sent a message to Congress, but the message was not the most specific message for the Best Future of Family Medicine.
The message was too long with too many items and poor focus.The message did not take the opportunity to align the best interests of family physicians with areas of interest to politicians (designs favorable to Red Counties and the 40% of family physicians in these counties)A message to politicians from a primary care leader should address primary care and should not mention …