The Federal Cause of Shortage Areas and Access Barriers

In the United States, it is the Centers for Medicare and Medicaid Services (CMS) that leads the nation with regard to payment design. CMS has a direct impact as more patients are added to CMS control each year. Insurance company payers for private and other insurance follow the example set by CMS. The past decades of payment policies have impacted an entire generation of 35 class years of workforce. What we see is what we get as shaped by CMS. It is CMS that is responsible for the locations truly short of basic health access services.

Distortions of Workforce - Payment Design = Training Outcomes

Within medical services there is a great divide between lowest paid basic service office codes (routine office visit 99214) and higher to highest paid specialty services. This differential is what has shaped many of the serious problems in the Big 3 characteristics of our health care system. Lack of access is shaped by decades of deficit payment design. In turn insufficient access results in costs too high and quality issues.

Insufficient payment results in too little revenue for primary care practices and helps prevent hiring of primary care team members to deliver care. It is also harder to retain primary care team members where care is needed resulting in additional costs. Specialty facilities can hire away the primary care personnel that they desire. Meanwhile the specialty and subspecialty dollars pile ever higher shaping higher concentrations of workforce along higher health care costs. The result has been
  • Too few entering primary care training for MD, DO, NP, PA
  • Too few staying in primary care after primary care training for MD, DO, NP, PA
  • Turnover issues for primary care where needed and primary care vs specialty care
  • More new specialties with more added to each specialty leaving family practice behind 
  • Too few remaining in general surgical careers after initial residency training in surgery, ob-gyn, orthopedics, urology, ENT...
More specialist and subspecialist positions are filled for MD, DO, NP, and PA resulting in higher costs and more health care dollars spent in fewer areas of the nation where workforce is already most concentrated.
The result is that no matter what training is attempted, the wrong specialties are created for the wrong locations leaving basic services, primary care, mental health, and areas of need further behind. For example, primary care contributes 45% of the physicians in lowest physician concentration counties and general surgical workforce is 20%. These are physicians dependent upon the lowest paying codes.

Internal medicine graduates face the greatest differential between basic pay and subspecialty pay and have dissolved the most to only 10 - 15% remaining in general internal medicine. Pediatric graduates have melted to 33% primary care retention. Family medicine has slipped the least to 80% primary care as graduates have few options other than primary care. The general surgical specialties have declined about 2 - 3 percentage points a year from 2008 to 2013. Internal medicine by 2025 to 2030 will be less than one-third the primary care workforce that it was in 2000. This is the result of a decline from 3300 per class in general internal medicine to less than 1400 per class year.

There are deficiencies of primary care, geriatrics, mental health, and basic surgical services by CMS design.

Special programs, special schools, new disciplines, and expansions have all failed for the result of basic services because of the design. Training outcomes are shaped almost entirely by the jobs and positions created by the payment design.


DRG Design and Primary Care Decline

CMS also has contributed to the demise of primary care internal medicine with the DRG payment design for hospitals. Under this design, it is important to discharge patients as fast as possible and hospitalists have been hired for this purpose. The rapid growth of hospitalist workforce will shrink primary care even lower than noted above as over 40,000 internal medicine graduates have taken this option in the past 12 years. A realistic outcome for internal medicine is less than 1000 per class year for only about 25,000 to 30,000 by 2030. This deficit in adult primary care could not come at a worse time as the elderly triple and overall primary care deficits mount.

But wait, there is more:
  • Office payment for 99214 and other codes is even less in states in need of primary care and in locations in need of primary care.
  • Office payment is less for physician practices compared to hospital outpatient payments which are greatest in counties that have over 10 hospitals and least in counties without a hospital - counties lowest in workforce.
  • Medicaid patients have lowest paid services and are concentrated where care is needed. Cuts in Medicaid payment have made matters worse. Not surprisingly Medicaid patients are concentrated where deficits of workforce are found.
  • Medicare payments have been too small and have been cut. Medicare patients are also concentrated where care is needed.
  • Payment to small hospitals is less by CMS design and special support payments have been removed.
Disparity By Design

Where CMS patients are concentrated, deficits of primary care and basic services are going to be concentrated as these are the places most dependent upon lowest paid basic services, lower paid Medicare, and lowest paid Medicaid. This helps create disparities in jobs, economics, income, and education. In turn, these disadvantages in determinants help shape lesser outcomes. Declines in Social Security payment, declines in SNAP nutrition payments, declines in day care and child development funding, and other across the board cuts have greatest impact on the areas of the nation facing the most deficits. It is not surprising that situations are declining for young adults, middle aged adults, and the elderly - those who are lower to middle income and falling further behind.
Discrimination By Innovation
  • Readmission penalties worsen payments to small and rural hospitals because of the complex, less healthy (smoking, obesity, sedentary, health status), and less advantaged patients concentrated in these settings
  • Payments to small practices will be even less by CMS so-called value based designs because of the complex, less health, and less advantaged patients concentrated in these settings
  • Small hospitals and practices pay relatively more for software, hardware, maintenance, recruitment, retention, and other costs related to care delivery. The costs have been $100,000 or much more for each practice or hospital. Recruitment and retention adds $1 more per year per visit to the cost of delivering care. When you add several dollars a year to costs and fail to increase reimbursement, primary care is compromised by design. With cuts, compromise is hastened.
 Big Bang vs Little Clout
  • Small results in inability to negotiate for discounts for supplies and other cost areas of care delivery. The big players get cuts in costs while the smaller players and mid-size players are forced to make up the difference for suppliers, insurers, and others. 
  • Payment negotiations with insurance payers go well for the biggest and poorly for the smallest. This is seen with higher payments to locations with largest systems and fewer competitors. The smaller players are less organized and lose out. The nation's health care cost differentials are shaped by lack of competition and small practices and small hospitals lose out in this process.
Higher payment allows larger facilities and larger systems to buy up those smaller. By doing so the payments are raised resulting in the same services at higher cost - the opposite of value based. Less competition also the big players to demand and get higher insurance payment for the same services. The nation has long been moving away from value based payment and designs that for small practices and hospitals to close or merge make matters worse.

Before the designers promote value-based, they should recognize 
the situations that have been shaping the opposite of value-based. 

The Family Medicine Situation
  • Family physicians are over 50% found in small practices. These are the practices that have had the most difficulty with chaotic rapid change, Primary Care Medical Home, rapidly increasing cost of delivery, and stagnant to declining reimbursement.
  • Family physicians provide 25 - 45% of the physician workforce in the counties most in need of workforce - counties with highest concentrations of low paying, complex, less advantaged patients. As income, education, and health care dollars decline, family physicians increase in proportion basically because FM remains 30 FM docs per 100,000 across these locations. 
  • FM docs are particularly important for care in one of the most rapidly growing populations - the population in a county without a hospital. Dozens of counties are being added each year with ever increasing tens of thousands added per county. Once again these counties have the fastest growing populations and demand for services.
  • Clinics and practices with family practice MD, DO, NP, and PA are the most vulnerable under value based payments. They will be most likely to be penalized because of the patient populations at these sites.
  • Populations are increasing most where FM docs are more likely to be found.
  • Demand is increasing fastest where FM docs are more likely to be found.
  • Complexity is increasing fastest where FM docs are more likely to be found.
  • Payments are not increasing where FM docs are more likely to be found.
  • FM residency graduates have been most solid in primary care retention over a career, but the assaults of lower pay, higher complexity, lesser support, and new opportunities are taking a toll. There are about 12% in emergency care and another few percentage points are found in each of urgent care and hospitalist care. This translates to a 1 percentage point decline each year for 15 years.
Family Medicine Needs 99214 Focus, But FM associations and leaders have devoted substantial resources elsewhere
  • To an FM department in every school or an FM residency in every state - interventions notoriously unreliable for any primary care result given the payment design
  • To student interest groups that have looked good for production of primary care only when payment has been supportive - and millions have gone for generating interest without generating more revenue to actually support more family physicians.
  • To thousands of meetings all unsuccessful for payment improvement.
  • To Primary Care Medical Home and other marketing attempts. PCMH has been demonstrated as too costly for small practices that are 50% of family physicians. PCMH also leaves even less revenue to support the team members that actually deliver care.
  • To value based reimbursement as a way to value family medicine. Why would any FM leader think that new designs would favor primary care after over 30 years of CMS devaluing primary care. There is no indication of what must happen for real change - more payment to primary care with less to specialty and other types of care. This is the only way that primary care will help restore actual access to care and have a chance to help address quality and reduce costs. Apparently family medicine has lost touch with the increasingly difficult situations facing most family physicians.
  • To generic promotion of "primary care" with dozens of meetings across the nation - all spectacularly not focused upon 99214 
  • To generic promotion of primary care training that does not result in primary care. Why should an 80% source of primary care recognize a 10% source or a 30% source as primary care when internal medicine and pediatrics are 90% and 70% not primary care in result over a career.
  • To special training schools or programs such as Teaching Community Health Center residency programs or a fourth year for FM training. Without an increase in support for more primary care team members, no training intervention can work. Also even the Teaching CHC design has just 11 of 62 sites with the specific combination of family medicine, residency site in a state in need of workforce, and residency site in a county in need of workforce. The addition of a fourth year to FM training actually would shrink family medicine from 3000 to less than 2500 graduates a year as the limited slots would have to be divided by 4 years rather than 3. 
Our nation needs more family physicians as it needs no other, but it will take specific focus upon office code payments and minimizing cost of delivery. It is an increasing ratio of revenue over costs that will fuel health access improvements. The funding must actually support more primary care team members where care is needed while facilitating there work with patients, communities, and integration of resources.

The decades long Era of Cost Cutting most damaging to basic services must come to an end.

Family Medicine Must Conflict with HHS, but...

It is difficult to conflict with HHS as family medicine is perhaps the most dependent upon CMS, HRSA, and other HHS funding. This also is about lowest payment for 99214.

FM leadership must lead family medicine and primary care to the logical focus while holding CMS accountable for its actions - truly accountable care.

CMS leaders must put their money where their patients are and where care should be: 

"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt (acting administrator for CMS).  

CMS must do more than talk. CMS must pay for the primary care team members to build the primary care capacity to address rapid increases in population, elderly, demand, and complexity. 

Those who value health access must also do more than talk. Office code payments are the route to rebuilding health access, improving costs and quality, and distributing health care dollars in ways that can reduce disparities. Family medicine associations and leaders should support what family physicians do throughout their entire careers - despite CMS.

Other Blogs

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

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Blogs indicate that primary care can be recovered and should be recovered.


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