Wednesday, September 28, 2016

Time to Burst the HITECH Bubble

Since 1999 the United States nation has been led on a wild chase to pursue solutions to "medical errors." Ever greater promises have been made since To Err is Human regarding the ability of technologies to Bridge the Quality Chasm. Hundreds of thousands of lives per year were supposed to be saved. Despite lack of any such change, new articles are published with even higher levels.

It is time to burst this wasteful and distracting bubble. 

Witness the Findings of a 10 year Effort By Robert Wood Johnson Foundation
"A key finding within the supplement stems from the evaluation team’s efforts to determine if AF4Q improved population health and health care quality measures. The evaluators found no major improvements in these measures within AF4Q communities compared with control regions." After ten years and 300 million dollars, this would tend to point to the need for different investments. 

Not surprisingly there were not significant changes. This was likely because there were no changes in the population or as noted, all populations (study or control) were changing the same. The intervention did not work for the main purpose.

It is a great complement at this time in history to report no difference. RWJF has demonstrated integrity in this reporting. This may not seem like much but it is unprecedented across other foundations, associations, and government. There was success in consumer focus, but not population health or changes in health care quality measures.

Instead of finding a way to report success and jump on the HITECH Bandwagon, objective scrutiny prevailed.

Time to End the Era and Error of Medical Error Focus

Grandiose claims in health care used to be unusual, but no longer. It has become difficult to believe claims of any kind. Even if results look poor, adjustments can be made to obscure the obvious.

Health care quality has not improved. This is not a shocker since the outcomes are predominantly about people and not about their providers, or lack thereof. Because costs have increased and quality has not improved, the nation has moved to lower value - despite attempts at higher value.

Primary Care Medical Home costs $105,000 more per primary care physician with minimal if any gains. This also is the opposite of value.

MU to MACRA has added tens of thousands more in direct costs per team member per year and creates more consequences. Even the best methods used when you can assign a provider to a pateint to an outcome (very rare) cannot discern quality.

Most attempted national quality improvements cannot accomplish the most basic requirement for quality metrics. They cannot even assign a responsible provider to the individual patient to the resulting outcome. Many other factors shape outcomes, especially the patient factors. Even the best of quality metrics cannot separate 80% of physicians from the average even when you can assign a provider to a patient to an outcome (NY CABG).

Grandiose Eras Come Crashing Down

Grandiose advances in science, economics, and industry have come crashing to the ground before. Twice the world economy has been taken down with the aid of new technologies. Grandiose creations have also ended up on the bottom of the sea.

National Geographic has been working diligently to capture the many aspects of the wreck of the Titanic and the lessons that we must learn. The Titanic represented more than an unsinkable ship that sank.

James Cameron has spanned the heights and depths of this planet, and perhaps the heights and depths of humanity as well:

“The Titanic disaster was the bursting of a bubble,” James Cameron told me. “There was such a sense of bounty in the first decade of the 20th century. Elevators! Automobiles! Airplanes! Wireless radio! Everything seemed so wondrous, on an endless upward spiral. Then it all came crashing down.”

Technology is only as good as its limitations.  Physicians must learn what they know and what they do not know, what they can do and what the cannot do. Health care, software, and other innovators have no such focus.
  • Titanic killed hundreds via pick your choice of - full speed ahead, no need of safety devices, calm night without white breakers to see the bergs, cheap materials...
  • But now we have developed massive capability to cause harm by diverting scarce resources to technology, by overcharging for technology, by using technology for regulating health care, by diverting more dollars for care of a few people in a few locations at extremely high cost
We have made more available to few with less available to most - in health care. But beyond health care the impact is also significant. The limitation is that basic access services, basic specialty care, basic nutrition, basic housing, basic child development, and other basics are being marginalized.

And because of all of the wondrous technologies of then and now, the whole world knows about spectacular failure. Unfortunately it seems that this fact is often ignored by the designers.

HITECH Failures from the Start

HITECH was integrated into the Recovery Act - into the trillions of additional debt instantly created. The HITECH component did not actually result in spending our way out of depression since it took much time. The software was not ready either.

HITECH also boosted the careers of many individuals into positions of enormous influence - as seen in Commonwealth Foundation President David Blumenthal MD. It is not surprising that the priority mission of access to care has disappeared in favor of insurance coverage and technology focus.

Dollars do shape new leadership, and not always in the direction best for overall health or health care. This example brings back memories of drug company money that went into cholesterol drugs and research and soon the researchers were department chairs, deans, and other leaders in health care. 

Even worse, when the digital health revolution has fallen short time and again, and even when CMS leaders admit failure as in Meaningful Use, the government has doubled down to even greater cost to providers and to the nation. There was not even a pause for reflection.

How much more can care givers take? They already devote 2 hours to EHR for each hour of care delivery. Innovators are quick to point out that scribes can be hired to do the work, but how is this helpful for negative margin practices or for populations already hurting because of too few team members to deliver care?

The overall result has been even greater declines in health workforce productivity, declines in morale, accelerating burnout, and even greater distraction from delivering care.

Never in the history of the United States has so much time, talent, and treasure 
been diverted from the actual delivery of care and from the support of the team members to deliver the care.

How has it been possible for the focus of Health Care to be diverted away from health care delivery?

A first diversion from health care to other interests involved the cost cutting focus - the invasions of the bean counters and spreadsheet gurus. These are the ones who calculate the savings to be made without consideration of the costs inside or outside of health care. An example is 22 times greater cost than saved due to impacts on mental health patients just because someone figured out how to shave a few bucks per person per month by changing Medicaid from 7 prescriptions per month to 3. This was just the emergency care, hospital care, long term care costs and did not even include the non-health care costs. The experimentation continued with co-pays and approvals of medications and other restrictions - with additional consequences for patients (death, disability) and for providers.

In recent years the cost cutting has been merged with quality measurement focus. This is a difficult combination to crack. If you oppose this, you are painted
  • as against progress 
  • as part of the wrong political party
  • as against quality
  • and worse
What if are for health access, against discrimination, against waste, against unethical experimentation, and against unscientific claims and policies.

The attempts at micromanagement have resulted in a failure to grasp the big picture of what is going on. The cry of "better quality" has diverted attention from the team members who interact most with patients. The incentives to change behaviors have impaired the basic behaviors most important for patient interactions.

To Err is Human Is the Appropriate Theme

Those who have cheered on the worship of technology are human and have erred in their zeal. The result has been rapid and poorly considered massive change. From the very start, the experts have had high hopes, high costs, and high failures. Human individuals are much more complex than can be captured by measures and the endless permutations of relationships are far beyond computation and comprehension. The wreckage is laid out to see just like the ruins of the Titanic. Like the Titanic the effort seemed Too Big to fail and failed titanically.

There is gathering evidence that this
  • has caused harm to those who provide care. The implementation has often resulted in a blame game causing damage that may be irreparable to once respected professions, facilities, and institutions.  The doctor-patient relationship, trust
  • has caused harm to those who take on the greatest challenges. The types of physicians, hospitals, clinics, practices, and institutions that care for the most complex and least advantaged patients are consistently rated lowest - because of the patients that come to them for care that no one else will provide.
  • has caused harm to patients who still need basic access.
  • has caused harm to primary care and to mental health with so much 
  • has caused harm to the scientific community
  • has resulted in a less efficient and effective health care design with rapidly increasing cost of administration and measurement plus declining productivity of team members
Health care has always had been slower in the implementation of change. This is partly due to sheer size. Physicians and nurses also have relatively long careers. It is also due to the "Do No Harm" priority. Rapid implementation of technology linked to payment before a real evidence basis and with inadequate understanding of the consequences has been a bad idea.

Forced Failure of Productivity

Chaotic changes implemented before ready have been a poor fit. Forced sales of software not efficient or effective has allowed poor quality to be supported rather than poor quality technology allowed to decline because of poor fit or lesser productivity - a huge industry cost impacting all delivery team members forced to be less effective and more burned out. 

James Cameron noted after 100 years about Titanic:

"Never have we been able to grasp the relationships between all the disparate pieces of wreckage. Never have we taken the full measure of what’s down there."

We should not wait another 20 years or double down on precision medicine. The results are very clear. Health care outcomes are about people changes, not digital changes.

More and more cost without quality improvement is the opposite of value and results in unnecessary diversions of team members from delivering care.

Monday, September 26, 2016

Six Degrees of Discrimination By Health Care Payment Design

Most family physicians face discrimination, but not as bad as the patients and communities that we serve. This is not so much about FM as it is about the distribution of family physicians - the broadest generalists remaining despite an aberrant payment design.

Family physicians are the only specialty remaining that has equitable population based distribution. The payment design has long chased other specialties away leaving FM at 30 per 100,000 - with more responsibilities because of lack of resources and workforce. In the 2621 counties with lowest physician concentrations with 40% of the population, 36% of family physicians are found. This compares to 24% of NP or PA and 21% of physicians. Only the NP and PA found employed in family practice positions share the population based distribution of FM docs, but these proportions have been steadily declining - also due to payment design.

The discrimination in the nation known as health care payment must be addressed for any workforce to locate where care is most needed.

FM is impacted the most and still has the most to lose by payment design - which is why it should fight most against discrimination by health care design.

Disparities are created by the distributions of revenue. The designs of education spending clearly discriminate against the populations facing disparities. Lower property values shape lower school district revenues in the places that face the greatest challenges to education outcomes - challenges that were shaped long before kids begin school.

Payment Discrimination Number 1:
Geographic Concentrations of Federal Patients

Payment designs for health care also pay the least where disparities exist. Settings with lowest cost of living, lowest property values, and lowest cost of housing often due to environmental issues attract the highest concentrations of poor, fixed income, elderly, disabled, veteran, and other populations most left behind. Their health plans are least supportive for local care, especially Medicaid and Medicare. Veteran and other populations often have to seek care outside of local providers. Barriers to care are shaped where concentrations of lowest paying plan patients are found as in 2621 counties lowest in physician concentrations with 40% of the US population.

True reform boosts the payments for federal patients to provide sufficient workforce instead of forcing other patients and plans to supplement local care by design.

Payment Discrimination Number 2:
Least Paid Cognitive/Office/Basic/Oldest vs
Most Paid Procedural/Technical/Subspecialized/Newest

Where care is most needed, the least paid services are 80% of local services. Lowest payments for primary care, mental health, and basic services creates disparities.

True reform balances payments and shifts more dollars where disparities in access, care, and outcomes are most obvious.

Payment Discrimination Number 3:
Lower Payment in Certain States, Counties, and Practices

Services are consistently paid the least where disparties are more likely in certain states, counties, and cities. Medicare pays the lowest for the basic office code 99214 in counties without a hospital and pays the most in counties that have 10 or more hospitals. Studies indicate largest systems demand the most, leaving smaller to smallest behind.

There has been some small improvement in this area, but more is needed.

The states that have reformed education such that local property values do not shape disparities also shape Medicaid best to avoid disparities. So many disparities exist across so many variables that it is difficult to separate outcomes from pre-existing conditions and situations.

The studies that started Medical Error focus and Insurance Coverage focus failed to consider the lay of the land and the populations involved. This is why Medical Error Focus and Health Insurance Coverage Expansions were doomed from the start. They cannot demonstrate a difference because they fail to improve people - in fact they can make matters worse because of hundreds of billions diverted away from addressing disparities.

True reforms must not pay less where care is already compromised.

Payment Discrimination Number 4
The Most Lines of Revenue and the Highest Reimbursement in Each Line

Those most closely identified with shaping the payment designs are academic institutions and health professional associations. It is not surprising that the most lines of revenue and the highest reimbursements in each line shape the top concentrations of physicians and health workforce and health spending into 1100 zip codes involving 1% of the land area with 45% of physicians and well over half of health spending. Corporate deals, patents, fund raising organizations, foundations, graduate medical education, research funding, and other lines of revenue shape health care design.

True reforms must consider more equitable payment to relieve disparities.

Payment Discrimination Number 5:
Cherry Picking Creates Disparities

A major theme in health care for many decades has been the most success for those serving the fewest patients with disparities. Those most organized are paid the most and face the least complexity.

This leaves most Americans behind where disparities are most common. Lowest payments, lowest resources, and highest complexities are a bad combination.

ACOs doing best fit this pattern and for good reason. The chief models for ACOs such as Kaiser have long been shaping their patient panels. Not surprisingly Kaiser has been highest paid and may well face the lowest complexity. Oldest ACOs and those highest paid did best. The rest have faced challenges (Jha).

Cherry picking was one of the key learning issues involving managed care. Numerous marketing schemes helped to shape the plans who did best and those who fell behind or closed. Not surprisingly the newly created plans have done poorly as they have been forced into less profitable patient populations. Also not surprising is the lack of plans in rural and other counties with challenging patient populations.

True reforms must bust up cherry picking, not reward it.

Payment Discrimination Number 6:
Innovative Payment Designs 

The one consistent outcome arising from Pay for Performance schemes is discrimination. The providers caring for patients and populations with the most disparities are consistently rated lesser in outcomes - outcomes that are mostly about the people factors and populations and not about the care. Over a dozen studies document this discrimination across rural, underserved, and poor populations as well as rural, safety net, and other types of providers.

In my own study, readmission penalties at the highest levels were found in rural areas and areas short of health care. About 9% of rural hospitals had top penalties and the level reached 14% for hospitals in lowest physician concentration counties. This compares to the average of 5% with 3% for urban hospitals.

Overall Health Care Payment Creates Disparities

Clinical interventions receive the most attention at levels nearing 3 trillion dollars a year. These are dollars spent in zip codes and counties with top economics already. The cascade of lower payments shapes least economic impact where economics, health, education, and other outcomes are worst. Cuts in payments, compromises of small hospitals and small practices, failure to maintain higher Medicaid payments, and innovative payment designs make disparities worse. This shapes health and education and societal outcomes the wrong way.

Additionally these innovative designs force practices to send billions away from investment in local care delivery to send to software and other suppliers - the ones that most benefit by design. Mail order pharmacies also shaped concentrations of spending and defeated local pharmacies and the contributions made locally in economics and in helping to change patients to better health.

True Reforms must not divert spending away from places and populations with the most disparities. 

MedPAC Weighs In

This just in - MedPAC has long questioned CMS over the flaws of the payment design and repeated these concerns about MACRA. Now MedPAC has questioned the validity of the rating scale used for hospitals. As is usual, the CMS ratings penalize the facilities that take on the care of the complex and underserved. 

Designs that penalize providers in most need of support are further indication of failure by design.

Why Can't CMS Leave Health Access Alone

Zeal for innovation and cost cutting comes with a price. The price is lesser access where access is already compromised by design. Rural Health, Community Health Center, Small Practice, Small Hospital, and other care where needed suffers because CMS fails at Do No Harm.

It is actually hard to count the different ways that CMS compromises care where needed and the care of its own patients.

Which Discrimination to Address?

At the recent AAFP meeting as is the usual, there was a great deal of attention paid to delegates and resolutions that deal with discrimination and disparity. Unfortunately none of these deal with discrimination by design - the designs that hurt family physicians, their team members, their practices, and their community.

The AAFP positions in support of the payment schemes are puzzling. Why support payment schemes that
  1. Compromise Family Medicine team member efforts by sending hundreds of thousands of dollars outside of the practice for practice consultants, certifications, software, hardware, IT maintenance, and other innovations
  2. Distract team members from care delivery such as with EHR focus for 2 hours for each hour of care
  3. Increase burnout and turnover, costly for staff or physician losses
  4. Increase access barriers, and 
  5. Represent discrimination versus most of us and our patients and communities?
An association, its leaders, and its delegates should support its members - especially the 50% in small and solo practices facing the most obstacles, the 21% of family physicians in rural areas, the 36% of family physicians in lowest physician concentration counties with the least resources, and the overall 50% of family physicians suffering most by design.

These family physicians do not need Primary Care Medical Home designs with greater cost of delivery, they do not need marketing as they are located where fewest others exist, they often do not need quality improvement efforts as they have demonstrated greater ability to prevent admissions, and they do not need outside consultants that often fail to understand who they are or what they do.

Like many of the self-sustaining populations that they care for, they simply need an end to discrimination by design.

Family medicine leaders are not shaping value by what they do. In fact their support is demonstrated to be higher cost without improvement in quality - the opposite of value. Value is consistently demonstrated by practicing family physicians who do the most despite the least support.

Imagine what family medicine teams could do 
with a little more support and a major reduction in obstacles to care.

Have We Come a Long Way, or Not?

As a new physician starting solo rural practice in Oklahoma in 1983 I was paid less for
  1. Being a young, new physician (20% cut)
  2. Being a physician in Oklahoma
  3. Being in Area 99 as with most rural physicians in the state
  4. Having the most Medicaid and Medicare patients
The young physician discrimination was terminated due to court action. Some of the above gaps have narrowed (some). But I could do assistant surgery, deliver babies, and do various procedures - something largely lost. I was also able to boost the function of Nowata Kiwanis, the Chamber of Commerce, increase access to primary care and hospital, organize two health fairs, and help address disparities via the Ministerial Alliance and working with county resources (public health, extension, obesity, teen issues) until all were trimmed away including my practice. 
What worked 1965 to 1980 was largely about lesser discrimination. 
What has not worked since 1983 is about greater discrimination.

Questions and Comments

The recent themes in my posts have resulted in some questions:
  • What discrimination?
  • What do you mean by discrimination by design?
Most are familiar with the lawsuits applied to gerrymandering or discriminatory school funding schemes. Discrimination may be hard to prove or reverse, but this does not mean that it does not exist. 
Clearly in health care, the designs of payment are easily seen as favoring a few associated with highest concentrations of physicians, subspecialty services, and most technologically advanced services. It is not surprising that the lowest payments go to the places, people, patients, populations, and providers that are most behind in other areas as well. 
It is hard for many to grasp the magnitude of the impact. For example, the 2621 counties shaped lowest in physician concentrations by payment design include all but a few counties in each state. Rural counties join counties with concentrations of minority populations as most left behind.
These 2621 lowest physician concentration counties have 40% of the population but the design for payment only allows 21% of physicians to practice in these locations and health spending is an even lower proportion (shaping access barriers, economic discrimination). Lowest payments via Medicaid impact the locations with greatest concentrations of poor, fixed income, disabled, and elderly patients. Medicare and veteran populations are commonly concentrated in these locations. Families caught in the middle without supplementation tend to buy high deductible insurance - also unsupportive of local care, primary care, mental health, and basic services. 
These are places with little or no competition across health care providers or health care insurance. Patient and plan choices matter little to these areas - a concept difficult for designers, foundations, and associations to grasp.
These counties have concentrations of Medicare, Medicaid, least supportive insurance, diabetics, obese persons, sedentaries, fair to poor health status, lowest local resources, and lowest social determinants.  This shapes lowest education and health outcomes to go with lowest concentrations of workforce as well as lowest ratings and most penalties via "quality" measurement.
Shortages force local populations to travel for care (higher cost, access barriers) and they take their dollars with them and spend them where health care is concentrated (magnified economic disparity). The lessons learned from decades of rural research presentations (Dr. Gerald Doeksen especially) apply to many if not most populations left behind by design. Rural Health Works except to the designers of health care.

Others not federal patients in these locations are impacted because of this design that shorts local workforce, access, services, economics, and social organization. 
The same designers trivialize the losses of rural and small hospitals as well as economic and social determinant impacts. Researchers unaware of the full range of influence as well as those trying to prove a point cause problems. Their research attributes error and lower outcomes to rural, underserved, or lower volume providers when it is their research that is flawed. Attempting to compare different locations with different patients, providers, resources, and payment designs should be identified as flawed from the start.
Journals fail to see the flaws and publish these "quality" studies. The zeal of CMS to do "quality" has resulted in distorted penalties and distorted quality ratings. MedPAC has now for the third time questioned CMS. The latest concerns have been raised about the validity of CMS methods used for rating hospitals. The lowest rating go to the facilities caring for low resource patients. CMS and MedPAC also differ about overall payment balance and about MACRA as well. Others in Congress and posting in The Health Care Blog have concerns regarding CMS exceeding the will of Congress and CMS standards for validity. 

Those who train health professionals claim that they can fix the problem, but make disparities worse as seen in GME as only 6.5% of residents are found in 2621 lowest physician concentration counties with 40% of the population - the worst disparity in payment and the major shaping force in physician practice location.

Additional Payments for Special Training Programs 

Of course there is no training intervention that can work - because the payment design does not support workforce where workforce is needed! This was seen in 30 years of working on rural physician distribution to watch no progress across the states and locations where I was working. We could claim great outcomes for the training programs and great fun for us, but no change other than the names serving in a particular county.

Additional Consequences
The one thing that can be counted on is worsening disparities although confusion, low morale, low productivity, higher turnover, and other adverse behaviors and attitudes can be seen arising by the design. And of course these are worst in the states, counties, and zip codes most impacted by the design.

Note that Texas gained the rating of lowest physician morale in the nation as reported in the Austin Business Journal.

Recent Posts and References 

Recovering General Surgery Is Impossible

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

Patients Should Be Changed, Not Physicians

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA - Sullivan

Value Failure By Those Who Promote Value

Bundling or Bungling, Once Again Into the Fray

Solving Mental Health Takes More than Race and Place

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016

Tuesday, September 20, 2016

Assertions that Small Practices Can Prosper Are Not Helpful

We need to end disparity by design, not make excuses for it.

First, the South East Rural Physician Alliance is the correct title (not association). 

SERPA + Blue River Valley = Rural Comprehensive Care Network would be a fitting media piece about small and rural practices – but not when used for some other agenda.

Second, our nation needs to hear from family physicians that situations in primary care and especially in small primary care and in rural health care are not prospering - as I did 3 years ago in an AFP Blog. FM leaders may well be surrounding themselves with the wrong influences since family physicians from rural areas or who served in rural areas are all around. 

It has been 20 years since my AFP article - Continuing FM’s Unique Contributions to Rural Health Care. It was a call for family medicine to keep rural health as a priority. Across many key areas, family medicine has not done so.

Most of all, we have been relegated to a failed financial design - and we are not alone. Preventing General Surgery  Preventing Rural Workforce By Design

Their Future of FM Has Failed

The primary care medical home design has been promoted for the past ten years as the Future of Family Medicine in many articles such as those geared to students. Even now the Graham Center calls for more funding for overall primary care (from 150 billion to 300 billion out of 3 trillion in health spending), but the research leaders of FM still cling to the PCMH model. Why cling to the past or send 20% of revenues outside of the practice and away from practicing. It should have been enough to see $105,000 per primary care physician in additional cost or 20% of revenues diverted from what matters most. 

This mode is demonstrated to be a financial failure in Annals of FM despite three forms of supplementation.

The Great Hope of past FM leaders and the focus of the last 10 years of effort - is demonstrated to be a failure. And unless payments are raised, the year after year erosion of stagnant pay and higher cost will take down the most important family practices, primary care sites, and more.

True vision all along would have devoted decades of effort specific to the funding to deliver on a real future for FM. All models of practice and of training clearly depend on a foundation of substantially better payment.

Leaders Lead with Sacrifice 

Leaders are out front. They need to share the risks of those they lead. Our leaders seem to be in a different place. Perhaps those most focused on practice and patients are screened out by the process of becoming a leader.

Do leaders now benefit by developing a close relationship with corporations, government, and foundations. Administrative positions paying well do call to those with leadership experience.

Changes impacting leaders may not be the changes important to half of family physicians and half of the American people. Perhaps they might want to rearrange priorities to focus on these two halves to make a whole for family medicine and their patients and communities.

A Call for FM to Be Much More
My recent blog called for us to put the past 20 years behind us ASAP. Family physicians are still unique in our contributions in rural and nearly all other areas in need of access, since few others remain.   We also need our leaders to address the Six Degrees of Discrimination By Health Care Payment Design

Our FM leaders should be much more because family physicians are so much more.   

In contrast, the current health care policists and designers and innovators have nothing to offer family practice, primary care, mental health, rural health, or care where needed:
  • Their designs have substantially increased the national costs of health care delivery without improvements in quality or other key areas. They have achieved the opposite of value. 
  • Their designs have resulted in major impairments of productivity to the tune of 2 hours of EHR for every hour of patient care.
  • Their payment based on “quality” methodologies are unable to assign individual physician or hospital responsibility. The designs are nebulous at best.
  • Their methods are unable to reliably discern quality as demonstrated by Sullivan and others. 
  • There is scientific evidence for discrimination - for their design sending lesser payments to the critically needed providers that we most represent – those willing to take on the challenges of delivering care where care is most needed. 
  • Their design has been about rapid chaotic change. Such change is not a friend to health care delivery and is most disruptive to small health care and health care at are below margin - by design. Providers kept off balance cannot focus on patients and patient care.
  • Even when failing with meaningful use and across insurance "reforms" and ACOs, the rapid pace continues devoid of reflection, constructive critique, and cessation when failure is demonstrated.

Fight or Fail

FM leaders must fight for true reform - increased payments for small and solo practices, small and rural hospitals, generalists, and general surgical specialties. Without dedicated efforts, Recovering General Surgery Is Impossible and others will not be recovered either.

Do leaders really want a marginalized family medicine torn apart by changes from within and from without by those who least understand us or our patients?

The Future of Health Access

Family medicine continues to have a key role to play. We interface most with the practices and facilities and specialties most threatened. The futures of generalists, mental health, small health, and general specialties are entirely about a completely different payment design. 

No training can overcome the payment distortions. You cannot force workforce. You can only support workforce, or fail to do so. An entire generation of family physicians has had failed support dating from 1980 to the present and beyond. Not surprisingly family medicine has remained at just 3000 annual graduates - the level first reached in 1980.

Even our own family medicine training has been loosing in key outcomes. Every source of primary care that has fallen below 60% in primary care retention (IM, NP, PA, PD, MPD) has rapidly declined to substantially lower levels. Family medicine is closing in on this mark as retention in family practice has counted down from 95% in family practice positions to less than 70% and is still falling. With fewer active in primary care, more distorting influences are generated.

Results Not Excuses
We need leaders that will not excuse the designers from the disparities that they have caused - in health access, in workforce, in jobs, in cash flow, in team productivity, and in more. We must remind them about the people that they are ignoring - people with real and pressing needs - our patients - the patients who have to make up the gaps when Medicaid and Medicare fall short.

Return to Access Focus

Access focus is the primary obligation of every health access association, foundation, and institution. This is a duty ignored for far too long. 

It is the duty of FM leaders to return all of them to their mission and away from misguided innovation and insurance expansion worship.


The health care designers think that situations are OK out there. The situations are not OK for us, for our patients, for our communities, and for 80 - 100 million Americans that are suffering by design.

Assertions that Small Practices Can Prosper are not helpful. 

Such assertions are disrespectful to thousands of family physicians who have been toiling despite a stacked deck for the past 30 years. After a year of "learning" as president and a year as Board Chair, this assertion is disappointing.

We needs leaders that shape US, not leaders shaped by a process that shapes out a priority placed on family physicians and their patients. 

Without an outside perspective there will be little progress towards a solution. As W Edwards Deming noted, 

The prevailing style of management must undergo transformation.
A system cannot understand itself. The transformation requires a few from outside. 

Deming noted that a focus directly upon lower cost was likely to be limited in results. Health care designers should acknowledge the need to design for health care delivery rather than designing for cost cutting.

Deming also noted that quality relies upon "the matrix of relationships,"  and rural health care is a prime example of numerous interacting relationships. When designers fail to include the outside perspective, focus too narrowly upon quality or value, or fail to understand the complex matrix of relationships, progress in rural workforce recovery will remain limited.

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016

Friday, September 16, 2016

Recovering General Surgery Is Impossible

A complete revision of payment in favor of basic services is required for any hope of more general surgeons, general orthopedists, and other general surgical workforce. Any hope of getting surgical residents to bypass prestigious fellowships in favor of direct practice entry is entirely about the financial design. A fellowship results in a career with services that are reimbursed at much higher levels. Narrowing the differential between basic and highly specialized is required for restoration of all generalist and general specialty careers.


General surgeons are shrinking along with other general surgical specialties. Production is too low to replace attrition. This has actually been going on for some time - General surgery has taken at least a 15% decline since 2005 and more likely close to 20%. The oldest general surgeons are in locations with lowest concentrations of physicians - making shortages worse. These are also the places increasing the most in population, in elderly, in demand, and in complexity - it is a nightmare set to steadily worsen for years to come.

The reason is payment design. The payment design is insufficient to support generalists and general surgery and other general surgical careers. Generalists are also strained as they are forced to pick up tasks from general surgery, orthopedics, ob-gyn, and mental health in the absence of such workforce.

The knee-jerk response is to increase training funds and general surgical trainees, but this would be a waste of funding.

No training intervention can work until there is a fix for the substantial payment disparities between lowest paid cognitive/office/basic services versus highest paid procedural/technical/highly specialized/newest. Special programs can have success, but they just end up displacing others. There is not enough payment to support any increase in the workforce. More production just drives out other sources - as seen in zero changes in primary care and ever lower proportions of MD DO NP and PA in primary care.

There is just not enough payment overall going to general surgical services and this is particularly acute for counties lowest in physician concentrations - counties that only have 21% of physicians despite 40% of the population.

Counties lowest in physician concentration have numerous disparities in physicians including psychiatrists less than 20% (to serve 40%), active physicians 21%, mental health providers 23.5%, and active practicing nurse practitioners and physician assistants 26% (worse for all NP and PA).  The deficits of generalists and general specialties matter most in lowest concentration counties as they are 70% of total workforce.

This decline in generalists and general specialties is about payment - not salaries. Higher payment does allow higher salaries, but payment means much more. Payment means profits to employers and also results in more support to be able to do more services and the highest paid services. This results in more team members to share the load and less complexity for physicians. Higher paid services also allow better team members to be hired and retained as compared to lesser paid services relegated to higher turnover, new staff, and staff unable to move on.

No increase in payment is likely from CMS or from Congress. Congress wants further cuts and CMS wants cuts and more innovation. CMS is falling behind in other functions.

Reform energy has largely been wasted and what remains regarding reform is unlikely to address increases in cognitive/office/basic services at the sacrifice of some payments from procedural/technical/highly specialized/newest.

Needed payment reforms supportive of basic services are prevented as the dominant players do not want cuts in highest paid services. Without increased payments or shifts of funding from higher paid services, there will not be a resolution of workforce gaps. Workforce cannot go where it is not supported.

New payment designs fail to discern quality in services as there is no separation from outcome influences that occur before or after health care encounters or admissions. The patient behaviors, situations, environments, determinants, and genetics as well as deficits of local resources and workforce are much greater influences compared to the provider.

The CMS designs for payment pay less for needed care of patients where disparities are present because the disparities are about people factors with providers penalized unfairly for caring for such populations.

The facilities to support general surgeons where needed are being closed. Small hospitals and practices are failing by CMS and ACA design.

Workforce failures are seen across generalists and general specialties and in the locations where generalist and general specialties are most dominant.

Lowest Paying Plans Promote Disparities.

Patients with Medicaid and Medicare and other lowest paying plans are concentrated around lowest cost of living areas, consequently lowest payments and least local supports (Veterans, Tribal, fragmentation) result in insufficient workforce. Loss of one or two key physicians or practices in a small health location can result in serious deficits.

Powerful Forces at Work Preventing Payment Reform That Matters

The forces that shape health care payment will never allow such a revision. Those who perform the highly specialized services do not want to take a pay cut, especially during a time with numerous other payment cuts impacting hospitals. Getting bigger is really important at the current time and declines in payment impair this priority. The academic and largest hospitals are dominant players in the design of reimbursement. A non-objective participant is almost always a bad idea. This gives those doing well an enhanced ability to oppose reforms in payment - successful for decades. There are a privileged few that benefit by current design including few Americans generally doing well as well as health care entities in a relatively few places with top concentrations of physicians.

Decades of receiving payment from the most lines of revenue (including GME, corporations, and others that they created), and decades of receiving the highest reimbursement in each line has resulted in great power that can be exerted to preserve the current design.

Regarding reforms of payment, the recommendations of Medicare advisory panels have been ignored. Graduate medical education reports have been ignored.

Physicians Held Hostage By SGR More Willing to Settle for Anything Else

At one point there was some reform in reimbursement for basic services in the 1990s, but the benefits were soon eaten up by increased cost of delivery. The reforms of the 1990s were temporary and were quickly reversed with a rebound. The SGR payment was a way to steadily lower costs, but once again powerful forces intervened and made SGR a huge sword of Damocles with huge cuts held off year after year.

In many ways, payment reform was never really considered as SGR played out so badly that anything looked better than what might happen. What negotiating power there was to attempt to narrow the gap between basic and highly specialized services was long gone.

Reform Energy Wasted 

The reform energy of the 1990 and 2010s time periods was far greater than exists now. It also appears that recognition and reform building takes at least 20 years to develop. The 2030s may be the earliest that a change would have the ability to address the challenge. Unfortunately the accelerating demand for generalists and general surgical services plus increasing retirements and insufficient entry will have forced entirely different solutions.

The 2010s leadership had its chance and focused upon insurance expansion and innovative payment - except they failed to focus on the one payment change that matters for 70% of the workforce needed by half of the American population.

Failures in More than General Surgery

The failures are in primary care, mental health, underserved areas, 75% of the rural population, 32% of the urban population. This is seen in 2621 counties lowest in physician concentrations with 40% of Americans. In these counties with least payment support, only 21% of physicians are found. These are counties that have been crying out for what the national design will not produce. Generalists are 46% of the workforce and general surgical specialties are about 25% - general forms of surgery, orthopedics, ob-gyn, urology, ear nose throat, ophthalmology.

Countdown of Physician Workforce in 2621 Counties Lowest in Physician Concentrations
  • FM is 25% of lowest concentration physician workforce. FM once had a role in general surgical services. FM could take up the slack from general surgery, but again the designers have prevented this with certification, liability, and training barriers. Family medicine has long been stagnant at 3000 annual graduates since the class of 1980 - an indication of unfavorable place in the overall design. FM did have top retention in primary care and in specialty, but FM is fading from 95% family practice to 75% as payments, supports, salaries are better elsewhere as seen in Emergency Medicine 12%, urgent 4%, and hospitalist 4% positions. FM docs listed in hospital based settings are 26% rural as compared to all FM at just 20% and falling. FM in the 1970s was 30% rural in location. Failed payment fails most where physicians are most needed. Salaried FM docs are the most squeezed of all by failed payment design. Small and solo practices make up 50% of family physicians and are most threatened. The declines will continue until the last 20 years are put behind with new payment and new leadership.
  • General IM was 13% of lowest concentration workforce but is collapsing to 6% or less. The payment design gives IM residency graduates substantially better choices across salary and support. In the past 15 years the hospitalist workforce has increased to 50,000 total with over 40,000 from IM training. More graduates in each class year pursue hospitalist careers than general IM. Substantial changes in payment disparities are a requirement for any return to general IM.
  • Hospitalist, emergency medicine, and urgent care are the only registered increases for lowest concentration counties - but this may be at the expense of local primary care indicating worse to come. 
  • General surgery is falling fast - over a 15% decrease in the period 2005 to 2013. Payment design takes out production. Small hospital closure takes out needed facilities. Payment design takes out small and solo practices with higher costs and decreased productivity to go with low payments for basic services common to general surgeons.
  • General orthopedics is also falling at a similar rate. In a recent study of specialists by age groups, almost every specialty had higher pay for the older physicians. Sometimes the gap was narrower as in primary care. In orthopedics the youngest and oldest physicians both had highest payment. Taking a fellowship or two appears to be most rewarded by payment design.
Behind By Design in Lowest Concentration Counties with 40% of the US Pop
  • Worst contribution is in physicians with just 21% found where 40% are found. This is made worse because of increased demand from more elderly and near elderly. These are also counties growing fastest. Only 6% of training is found in these counties but even more training would not help as there just is not the payment to support the workforce. The magnitude of the disparity is indicated by 6% of residents (and even less GME dollars) for places with 40% of the US. Reimbursement design constantly shorts care where needed.
  • Mental health providers are just 23.5% where 40% are found. The case can be made that these are places also with behavior issues across alcohol, depression, smoking, drug abuse, and children's mental health. Schools are hamstrung by lack of mental health. Less than 20% of psychiatrists and child psychiatrists are found in these counties - another indication that expansions of training will not resolve shortages. Distance to care makes matters worse. Counties with 100,000 to 200,000 are also without a psychiatrist in some states. Once again lowest payment prevents the support of enough team members in enough places to deliver the care.
  • Nurse practitioner and physician assistant workforce is promoted as a fix for care where needed, but payment less for NP and PA services has been an impediment as with other payments too low. Also NP and PA are among the most flexible, able to transition to more specialties with more added to each specialty. With widespread acceptance the NP and PA graduates are moving away from family practice and primary care to new lower proportions year after year. In the next decade the family practice proportion will be 3rd or 4th behind emergency medicine, orthopedics, and surgery. The last doubling of PA graduates resulted in 100% more entering the workforce, over 200% entering non-primary care, and less than 30% more entering primary care with this falling steadily in the years after entry.

More Dollars for Academic Centers - Even Odds 50:50

This is just the first of the media push. There will be studies and proposals with dollars sent to academic centers - but these dollars will not result in more general surgeons, nor will they replace the aging general surgeons that have shaped 2 - 3 percentage points of decline a year from 2005 to 2013. 

General Surgery Must Rise from the Ashes of the Last 20 Years - but must join the generalist and general specialty crowd in deficit.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016