What Is Stunning in Primary Care Is No Change By Design

Health Affairs has another of a long line of interesting articles that point out the potential of nurse practitioners and other interventions regarding primary care, but with stunning failure to document the primary care situation and what is needed to address recovery of basic health access. 


In this stunning Health Affairs article - the usual promotions of nurse practitioners are noted. The article fails to note the limitations such as fewest active, fewest years in NP careers, highest turnover, lack of specificity of primary care training for primary care outcome result, steady departures from primary care - shaped by NP training design and made worse by payments too low for NP and for primary care.

How Long Do We Tolerate Lack of Primary Care Delivery Capacity Increase Despite 
  • Four new sources of primary care with more proposed
  • Huge expansions of new sources
  • Countless training interventions
  • Countless billions for primary care training that yields less and less primary care
  • Increasing evidence of access failure and destructions of small practices
What is stunning is the lack of increase in primary care delivery capacity since 1980 as the population has increased over 40% and our national leaders in health and government have done nothing. Primary care is over 55% of encounters with 150 billion or less than 5% of health spending. It is this deficit of spending made worse with rapid increases in cost of delivery that defeats any and all interventions in training - including creation and expansion of NP and PA and even special training resulting in family physicians. Nothing can work without true payment reform as is well documented. 

We have had the creation of NP, PA, medicine pediatrics, and family medicine without resolution of primary care woes. Only family medicine stayed 95% in specialty resulting in a natural experiment about primary care delivery capacity set by amount of payment. As FM increased from 40,000 to its maximum of 76,000 - FM grads permanent to primary care displaced all other sources to lower proportions. This demonstrated a ceiling for primary care set by payment. 

This ceiling is confirmed by two doublings of DO graduates without change in primary care production because family medicine choice was cut in half with each doubling.

PA graduates doubled from 1998 to 2008. Unlike NP, PA has tracked specialty changes and entries. PA entry of graduates increased 100%, entry into primary care increased 30%, and entry into non-primary care increased over 200%. And since the PAs melted away from primary care the final result is about 0% growth for primary care and over 230% for nonprimary care as the result of the PA doubling of graduates. Matters are worse since 2008 due to worsening of the financial changes.
The 30% increase in MD resulted in a decline in primary care yet MD associations and experts still cling to expansions of internal medicine - the least likely to impact primary care of all. More IM enter hospitalist than primary care and the 44,000 IM hospitalists will soon be more than the 30,000 to 35,000 general IM docs in primary care - because this is all that 1100 to 1300 per class year can produce as has been present since the turn of the century. 

Where Is the Critical Thinking?
Numerous doublings of Caribbean graduates, a constant 25% for international medical schools, a 30% in MD graduates, a 6 times expansion of PA, and a 10 times expansion of NP with expansion of FM from 40,000 to 76,000 has not resolved primary care deficits. 

The deficits remain where Medicaid, Medicare, Veteran, and high deductible plan patients are most concentrated - and 
  • We expand Medicaid with payments too low for the cost of delivery
  • We expand high deductible plans least supportive for local workforce
  • We send more hundreds of millions to the VA with funds going everywhere but to the veterans in most need of care 45% where VA care is least
  • We tolerate lowest Medicare payments for primary care and even lower payments for services in states in need of workforce and in counties lowest in workforce
  • Countless billions go for training and payment interventions with no chance to address primary care needs but no dollars go to resolve payment discrepancies that cause the deficits
And now we have experts that call for more quality measures where seniors most need care (not measures).

And we still have CMS emphasizing new payment designs that make matters worse with higher cost of delivery, increased burnout, decreased productivity, and lower payments for the small practices most needed.

What is stunning is that NP graduates have increased from 1400 in 1980 to 18000 and will continue to increase far above 20,000 with limited impact upon primary care - because of payment designs paying least for primary care and even less for NP and PA primary care services.

What is stunning is the avoidance of detailed data on NP - such as 40% of NP inactive during their short careers age 41 to 65 with only half active in primary care for a 30% result at best. These are inherent limitations in the design.

What is stunning is the smaller and smaller proportion of NP and PA active and in primary care because payment design pays so much more for the new specialties created and not surprisingly more are added to each new specialty leaving primary care behind and even fewer for the family practice component.

What is stunning is the few point out that only the family practice positions filled by MD DO NP and PA have 36% found in 2621 lowest physician concentration counties - and only when they stay in family practice. This 36% for 40% of the US population is the only population based distribution, but the payment design is moving NP and PA away from family practice, preventing MD and DO from choosing family practice, destroying internal medicine primary care, and moving family medicine to only 70% in family practice rather than 95% as in only 10 - 15 years ago.

What is stunning is health professional associations that support MACRA and Primary Care Medical Home despite evidence of $40,000 more cost per primary care physician in Health Affairs and $105,000 more cost per primary care physician per year (Annals FM) respectively - dollars that are diverted away from the support of team members and communities in need of services, jobs, and dollars. And the Pay for Performance penalties have mainly been demonstrated to discriminate against those who care for the most complex or those living in areas with least workforce and resources or those least in social determinants - which will result in even lower payments where workforce is lowest and most challenged.

What is stunning is the multiplication of "health care reforms" - while we avoid increases in primary care, mental health, cognitive, office, and basic payments to restore the workforces most in demand now and increasing in demand and complexity for the future.

What is stunning is the multiplication of those who benefit from the changing health designs - except the patients in need of care and the team members who care for them.
What should not be surprising is a glut of workforce, resulting in even less payment for primary care and even worse primary care delivery capacity - especially where care is needed. 

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