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

What patients value most from physicians is our time and attention focused upon them and their needs. The time together has become shorter and what time remains is impaired by technology and data collection. The past 20 years of innovation and modernization have distracted us from what patients value most.

 Reflecting Upon the Ashes
Physicians should reflect upon the declining ability of primary care to deliver the basics, made worse with the new demands added each year plus the limitations of employed practice. Employers are less likely to know you (the employed physician), your team, your patients, or the needs of your community. 

Reflect upon movements away from the solo and small practices, the practices that are most closely associated with patients and communities, the practices noted to be best at preventing preventable hospitalizations (Casalino), the practices that are disappearing at a rapid rate, the practices most likely to involve family physicians. Not surprisingly the quality has been shaped for the worse, not for better. Our capacity to shape patients changes that can change outcomes has been diminished by design.

 The Pittance for Primary Care Made Worse

Situations are worsened with the pittance sent to primary care of 150 billion dollars or only 5% of 3 trillion dollars in total health spending to address 50% of encounters. Even worse, the demand increases are specific to primary care and in areas weak in primary care and even weaker in other specialties. These are places with lower payment as well. It is hard to imagine a worse payment design. This same design has kept primary care workforce stagnant during a period with one of the greatest increases in demand.

Now we realize that it is even worse. The 150 billion limitation on care has been diminished by 5 - 10 billion more subtracted per year for the last 5 years for EHR, HIT, and other digital manipulations. Even with spectacular failures such as meaningful use, the government continues to push certified software clearly not ready for prime time. The dollars and distractions strike at the heart of primary care delivery - the team members to deliver the care. Year after year the primary care delivery capacity is decreased - by design. 

The design also ships scarce health dollars elsewhere rather than investing them locally in care delivery. Year after year more dollars are stolen from local jobs and economics and shipped where jobs and economics are concentrated. These redirections and rapid changes are most damaging to the small practice where care is most needed - adding to the disparities and decreased health outcomes by design.

This year alone will require $40,000 more per doc for MACRA (Health Affairs). Innovation promoters continue to push Primary Care Medical Home despite the cost of  $105,000 more per PC physician for Primary Care Medical Home (Annals FM). The financial future of Primary Care Medical Home is clearly worse as demonstrated in the literature. The financial model fails for PCMH no matter how it is supplemented (current Annals FM). 
How long does it take to expose the empty promises 
of those who are supposed to help the nation 
to deliver more and better health care?

Recent research is not surprising regarding the direction of primary care and the doctor-patient relationship. Reflect upon EHR demanding 2 hours for each 1 hour of patient care (Annals IM).
Why do we tolerate the theft of what patients value - our time and attention?

Reflect upon the past 20 yrs of attempts to change physician behavior to "fix" medical errors with behaviors changed the wrong way - distracted from patient focus and disengaged from continuity, team, community, their own families. 

Our national designers continue to fail to understand quality as a function of the matrix of relationships in and around patients - something that family physicians and team members understand most of all.

Reflect upon the ability of family practices in the past to do much of the high value consumer focused items - the integrations and coordinations and outreaches - before the failure of the financial design.

Note the real cause of loss of value 

Payment designs have failed to value primary care. Those most focused upon care delivery involving access have kept their attention on patient care and have trusted associations and government to support their vital functions. 

Primary Care Associations Fail To Support What Matters Most

Primary care teams have trusted their associations to protect them in their vital work. Their trust has been violated yet they continue to deliver the care. Primary care team members have kept going despite the long term suppression of primary care payments that should have been increasing with increasing demand. 

Government and other payers have clearly compromised primary via low and insufficient payment. The payment design has compromised patient care, teams, and patients. Primary care teams have been asked to do more with less and are unfairly blamed for the failures.
  • Consider stagnant payment.
  • Consider the the accelerations of the cost of non-delivery personnel to manage billing and insurance matters and to address HIT. 
  • Consider the increasing cost of certifications, recruitment, retention, orientation, regulation training, and turnover. 
Note that these all have greater impact in the solo or small practices, the practices most compromised and declining, the homes of half of family physicians, the only ones with population based distribution to the populations left behind by design.

It is hard not to see this as evidence of the long term failure of primary care associations and leaders. The situation has become much worse.
  • MACRA clearly exceeded its parameters
  • Experts have been surprised by primary care associations that have made little protest and indeed have promoted schemes such as MACRA
  • Associations cried for a delay, but cheered when they received "flexibility" but this does not change the compromise specific to primary care payment made worse by MACRA and made even worse where primary care is most needed - and where family physicians are most likely to be found.
  • MACRA will share the inability to discern quality as with other pay for performance schemes and even worse, will pay less where care is most needed. Why would associations and primary care leaders tolerate designs that lack the scientific evidence for anything other than discrimination
  • Primary care team members understand the limitations of pay for performance and the fact that people factors predominantly shape outcomes - not practices or hospitals. Why don't their leaders understand this?
  • Primary care team members understand that primary care has been moved away from integration, coordination, continuity, outreach, and other areas once addressed regularly without paying $105,000 per physician - now it is hard to keep the doors open and do basic functions.
A Best Future for Primary Care - to Rise Like the Phoenix

The best future of FM (or primary care from all MD DO NP PA) is about putting the past 20 years of policies, innovations, increased costs, chaotic changes, and leaders behind us ASAP.

A best future is to have new associations, new leaders, and new payment designs that completely replace the old. 

Primary care needs 
  • Increased fuel to increase capacity as people and demand increase, 
  • Efficiency of operation to expand access (not more regulation obstruction), and 
  • Needs the support to be with patients for the entire time to deliver care and help patients change behaviors, environments, situations, and other determinants - the major drivers of health care outcomes. 

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.        Robert.Bowman@DignityHealth.org

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

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