The Massive Failure That Is Primary Care Payment

Simple failure is common and involves the failure to perform an action or duty. Massive failure is failing to accomplish what can be done while attempting to do what cannot be done. This is further complicated by distraction from real solutions. If you massively increase the cost of what is done without addressing what is wrong - well...  

The United States has accomplished substantial failure in health care workforce via primary care payment design. Innovations and reforms in payment have been designed around improving quality. Not surprisingly these have failed and for good reason. Health outcomes are mostly shaped by people, situations, determinants, and other factors not possible to address by health care design (clinical means). Efforts to force higher quality have been quite costly in ways that steal primary care delivery capacity in multiple ways.

Payment design has shown the ability to change workforce composition. Primary care has been built up in the 1970s and during the 1990s briefly with better balance of payment as compared to the costs of doing care delivery. The rise of family medicine to 3000 annual graduates was shaped by the 1970s with a peak production in the 1990s when primary care payment was increased and payment to hospital based specialists was threatened. Primary care proportions of clinicians have been preserved or enhanced by payment. Since 1998 the proportions of MD, DO, NP, and PA found in primary care have plummeted. The production of generalists and general specialties (general surgery, general ob-gyn, general orthopedics, etc.) has fallen. Fewer pursue generalist training and few enter practice after their original residency training. Payment encourages them to do more fellowships to get paid more - a process that earns them more salary, more support, more personnel, and better personnel. Generalists, especially in lowest paid settings, are left with newly trained personnel and their better personnel are recruited away by better paid primary care and outpatient departments or hospitals, or specialty positions. The impacts from aberrant payment design are endless.

The attempt to force "quality" upon the nation's providers was misguided at best and will result in massive workforce failure. About 70% of the physician specialties for 2161 lowest physician counties with 40% of the US population are generalists and general specialties. More specialized workforce avoids these locations and are even more likely to do so with rapid closures of hospitals in these counties.

How Do I Fail Thee, Let Me Count the Ways of Massive Failure
  • Huge costs for quality focus
  • No improvement in quality
  • Massive and constant change is costly and decreases productivity and morale
  • Impairment of workforce directly by quality forced activities
  • Worsening access due to closures of small practices and small hospitals and departures of health professionals from health care
  • Distraction of health care reform away from cognitive versus procedural focus - required to balance the workforce, rebuild primary care, rebuild mental health, and restore basic services from general specialties
And by the way, the major increases in demand are rising from older and oldest Americans in primary care, geriatrics, mental health, general surgery, general orthopedics...  Nurse practitioners and physician assistants are also following the payment gradient just like physicians. The specialties needed most are increasing least.

Primary care leaders have done no better than government and insurance regarding massive failure. Internal medicine has discussed primary care decline, but has not stopped the stampede.
  • A primary care generalist workforce over 100,000 at one time will be fortunate to be 30,000 by 2030 - a time of maximum adult and geriatric primary care demand. Over 3300 graduates per class year for internal medicine has eroded to 1000. Over 40,000 have been lost to hospitalist workforce in recent years. 
  • Pediatric gains in residency graduates were completely negated by fewer remaining in generalist pediatrics 1980 to 2010. The Medicine Pediatrics has increased but remains too few in number and has followed the same decline pattern.
Devalued cognitive (primary care, mental health, geriatrics, basics) clearly loses out to overvalued procedural, specialty, subspecialty, hospital care.

For many decades family medicine leaders have been aware that payment compromises primary care.
This results in fewer clinicians entering primary care training, even fewer entering primary care practice, and even fewer retained in primary care in the years after graduation across MD, DO, NP, and PA. Even family medicine is falling prey with 12% now doing Emergency Medicine and about 3% each for hospitalist and urgent care. This is quite a change from just a few percentage points lost only a few decades ago.

Each year the payment gradient established by policy results in more being knocked out of primary care across every primary care source for some time now and for years to come. There are other impacts upon the workforce when primary care is marginalized by payment and punished by massive cost of delivery increases.
Primary Care Is Declining in Continuity, Comprehensiveness, and other Key Elements

Primary Care Is Declining in Experience
  • Previously 100,000 general internal medicine physicians retained in primary care for entire lifetimes are declining toward 30,000. They will have been replaced by new to practice nurse practitioners and physician assistants who stay only a few years before taking their primary care experience with them to other specialty care. NP and PA turnover is twice the turnover of primary care physicians at 13 - 15% a year. Changing from one primary care practice to another or leaving primary care is quite costly for primary care in ways beyond measure. An incomplete estimate 20 years ago was $200,000 to $250,000 in additional cost to a primary care practice for the loss of a primary care physician (Buchbinder). The cost for NP and PA loss may not be as much, but the cost of any loss has increased substantially given so much more to train and orient.
  • Family medicine and general pediatric physicians have been eroding into urgent care, emergent care, and hospitalist care. Rural family physicians become ER docs and hospitalists rather than remaining in continuity rural practices - the lowest paid office codes in the nation.
Studies have long shown the steady decline of proportions of PAs remaining in primary care as the years increase after graduation. (Larson, Hart, AAPA) At least 30,000 NPs and PAs were hired by teaching hospitals to fill the gap left by resident work hours restrictions.

Payment design does have the power to balance workforce, reduce shortages, and decrease access barriers. We know this because payment design has imbalanced workforce, increased shortages, increased barriers, and taken down mental health, geriatric care, and general IM. Payment design has also resulted in physician assistants likely less than 25% active in primary care and nurse practitioners and pediatricians less than 33% active in primary care. Medicine pediatrics is down to 40% with family medicine already below 75%. Even the best estimates of recent years must be constantly revised down due to payment gradient failure.

Payment design does not have the power to increase quality 
because so little of quality as seen in health outcomes can be impacted by clinical means. Payment design does have the power to rebuild access to primary care, mental health
generalists, and general specialties.

Failure is not to do what can be done while attempting to do what cannot be done.


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