What Is Aggressive Family Medicine Advocacy?

AAFP News translates what Family Medicine is doing as a movement, but sometimes more important is what it is not being done. Do the "Families" of Family Medicine focus on what can accomplish the most for family physicians and especially for their patients?

The one thing that sets family medicine apart is service to all of the various places and populations that are most left behind by health care design - rural, underserved, elderly, Community Health Center, lowest physician concentration counties, etc. 

Broadest generalists are the primary means 
to the end of health access where needed.

FM as a specialty has a 3 to 5 times multiplier effect for care where needed - the elderly, the poor, rural populations, CHCs, frontier, and lowest physician concentration county. This is because only family medicine distributions at 30 per 100,000 across the wide range of populations while other specialties are more concentrated where physicians, income, health resources are more concentrated. This is inherent in family medicine.

AAFP News apparently does not understand the things that family medicine has done and has always done. FM docs have not needed special training or special payments like other physicians or more innovations or care rearrangements.


Why Fix What Ain't Broke 
and 
Add to the Fix that Our Nation Is In?

What are all these innovations when considering the hard working front line family physicians who have long worked to integrate, coordinate, and outreach into homes, families, and communities without some special funding or an innovative name or expensive practice consultants and certifications?

Why does AAFP push so much that does not contribute to the support of the teams and physicians to do the care? Please No More So-Called Primary Care Solutions. Please focus on more teams and more in teams and doing more -

Why Payment Matters

Why not focus on what once did result in increases from a few to 3000 annual FM grads by 1980 with no sustained increase since this time? After practicing family physician leaders in the 1950s and 1960s established payment and training and expanded FM, FM has fallen by the wayside. This is largely about a failed financial design.

FM in the first decade was able to push 30% of graduates into rural areas - declining to the current 20% overall due to lack of payment and even lower in the newer graduates.

FM with decent payment was able to care for insured and uninsured even in areas with lower payments by federal designs. Now it is hard to care for insured patients - by payment design.

Why claim benefits for a Primary Care Medical Home when well funded family physicians or even poorly paid dedicated ones have performed many of the functions without having to spend $105,000 more per primary care physician per year - dollars sent outside of practices and communities - dollars that result in less services, jobs, and cashflow where all are needed most?




Special Training Interventions Illustrate Payment Failure and Payment Failure Will Continue to Prevent Any Intervention from Resolving Primary Care Failure

Teaching CHC programs exist because of the problem of insufficient primary care payment. Teaching CHCs are no better at producing family physicians than other programs. No expansion of family medicine or a special family medicine program can actually expand primary care or primary care teams. The problem is the lack of payment dollars - not the lack of some special training.

Teaching CHCs are just the latest of dozens of interventions that have failed to resolve primary care deficits. The new disciplines, expansions of these disciplines, pipelines, and special programs have all failed to do anything other than shrink primary care retention result.


Each failure points to payment failure as the root cause. 

But we continue to think that training interventions will work even when payment designs still fail to supply enough cash to support the local workforce where needed to resolve deficits. Until there are expansions of dollars for more local team members, Teaching CHC or any intervention will fail as special track graduates will only displace others rather than add to delivery capacity.

Rearranging the Deck is not a primary care workforce solution.

Make no mistake, Primary Care is going down by payment design. The total dollars are too few. The costs of delivery are increasing too fast. The accelerating costs of recruitment, retention, locums, and other costs alone prevent the needed workforce and resolution of access barriers. Where payments are lowest and costs have risen the most, access is failing fastest by design. These are also the places where populations, elderly, complexity, and demand are increasing fastest. There is no good news to consider. Even the new so-called sources of revenue require substantial effort - more chaotic change and more disappointments from payment designers that have learned mostly how to delay, deny, or lie convincingly.

No training intervention can work without substantially more dollars to support more team members above the current 150 billion primary care delivery capacity ceiling - minus costs of regulation, administration, productivity losses...

150 billion - 10 billion +2 billion - 10 billion - + 2 billion - 10 billion + 2 billion...

Investing in Primary Care Works As in Special Local Care Intervention Programs

Independence at Home demonstrates the impact of well supported family physicians and team members dealing with complex homebound elderly. It is not a surprise that FM is up to this challenge as 36% are found in locations where 45% of such complex populations are found - a stark contrast compared to 21% of active physicians or 26% of active NP and PA graduates. 

The same improvements were seen when Michigan BCBS fronted primary care to do more. This success also indicates how poor payment prevents integration, outreach, and coordination. Doing more and hoping for more payment is another of many designs burning us out.

Primary Care Is Very Efficient
So Efficient that Investments of Even Small Amounts Work 
But Increased Costs Are Devastating to Team Care 

The Dark Side of Telehealth - Negative Impact on Local Workforce

Web sites and promotional announcements indication hundreds of millions invested in new convenience care designs. It was not enough to show that retail care increased costs without additional benefit. Now the entrepreneurs want to bring the ultimate in convenience.

The dark side of telehealth is about the cashflow. Dollars that would have gone to local primary care to support workforce, services, and team members go elsewhere. The more convenient the services, the more dollars will leave. This process also leaves behind the more complex services and populations for primary care to do. You do not help local physicians by diverting the easier services elsewhere leaving the more complex behind. 

Telehealth replacing primary care is another vehicle for poor local support. The same is seen in the high deductible, Medicaid, Veteran, and Medicare plans that defeat local workforce where these populations are concentrated - in lowest physician concentration counties. These Four Horsemen of the Primary Care Apocalypse have long shaped lowest physician concentrations in 2621 counties and in other areas where the four dysfunctional payment plans are concentrated. Those with or without insurance suffer due to insufficient workforce due to decades of poor payments by design.

When people bypass local care by car or internet or payment design, deficits of workforce follow. The 2621 lowest physician concentration counties exist because of higher concentrations of lower paying plan patients - impacting this 40% of the population. 

How Can Telehealth Be Darker?
On the surface it looks great to indicate telehealth to help support the care in counties with shortages of primary care. Does it make sense to undermine remaining primary care and divert cash away from cash poor counties?

The Bright Side of Telehealth

Telehealth should not compete with local workforce. It should support it as with Project Echo in NM. Telehealth can support primary care and expand primary care rather than undermining local care and local workforce. Project Echo is what happens when leaders design for support. Current telehealth has profit motive across all priorities.

DPC Illustrates the Failed Financial Design of Primary Care

Direct Primary Care shows how important it is to get rid of insurance, regulatory, and all possible overhead to make primary care more efficient and effective, but even with this more efficient design, better payments are needed to rebuild access.

Mental Health Deficits Exist for the Same Reasons as Primary Care Deficits 
Mental health deficits are an even better indicator of the result of lowest cognitive, office, basic payments. Make no mistake, the solution to mental health care restoration is restoration of the team members to deliver mental health care. This requires such services to be paid higher to support more team members to deliver the care.

Reforms Fail for Workforce

ACA, MACRA, and so called mental health "reform" proposals fail the test of true reform. Instead of using existing funding mechanisms to directly increase funding for primary care and for mental health, the funding has been rendered inefficient and ineffective.

The mental health reform bill diverts dollars to "best practices" focus and also to other grants and demonstrations as well to support layers of administration. The "reform" dollars end up in places that are higher to higher in mental health workforce. The dollars fail to flow to 2621 counties with 40% of the population and only 23.5% of mental health providers. 

About the Integration of Primary Care and Mental Health

This is a great proposal. It has worked in CHCs and in family medicine training programs. There is a cost for this. There should also be a great deal of suspicion regarding the distribution of funding.
  • How can we be sure that the funding will go where primary care and mental health remain in deficit?  
  • Why do we spend dollars least efficiently on bricks/mortar or to establish services in a new setting starting from scratch instead of supporting local practices where needed and expanding their ability to do more using their expertise and experience? 
How long does it take to understand that special funding 
rarely makes it to where team members need support,
to where the most complex patient are found,
and to where the lowest payments are found?

We must be efficient and send dollars through existing mechanisms with no requirement for any additional effort.


Best Practices are about Best Supported Practices

We know that changes in behaviors, environments, situations, social determinants, and other people factors are the real game changers in improving outcomes. Why deprive the team members the support to do their important work?

Getting Dollars to the Right People in the Right Places

People and providers most in need do not run in the same circles as those immersed in top concentrations who design policies, payment, and practice. Getting the dollars where they are needed is quite difficult.

Why not be most efficient and increase payments directly through existing mechanisms without additional hoops and other distractions? Without specific designs to support delivery team members you fail to support needed mental health, primary care, and basic surgical services workforce.

MACRA Is Indeed a Tipping Point - the Wrong Way

MACRA is not going to right the primary care ship. If anything MACRA will tip already marginal services and practices over the edge. What is hard about understanding 
  • the impact of distractions from patient focus to measurement focus, 
  • the impact of data collection and lower productivity, 
  • the impact of accelerating cost of delivery
The MU to MACRA costs have adding tens of thousands each year per primary care physician in increased delivery costs plus the consistent Pay for Performance discrimination of paying less to practices and hospitals where care is most needed. This is exactly the wrong approach to building up the workforce to do more in more ways - as is the $105,000 more per primary care physician per year for Primary Care Medical Home (Annals FM)

The best past, present, and future for primary care 

...will always be about time, talent, and treasure devoted to support more people to interact with more patients in more ways and in more places. Dollars diverted anywhere else defeats the people interactions that define primary care. AAFP must understand this reality that faces most family physicians and most of the people of the United States.

We do not need more innovation grants or more primary care training that cannot yield more primary care or support greater primary care delivery capacity. Or more tobacco prevention dollars that fail to get to lowest physician concentration counties where tobacco is most prevalent where 36% of FM docs remain. Or more research that fails to reflect what is going on where half of Americans are falling further behind where half of family physicians are by far the most important local workforce.

These counties need more dollars for more of us and for more of our team members to deliver more care and in the ways family physicians have demonstrated to work best for people in need of care.

The Future of Family Medicine Is Less and Less About Family Medicine

And if more dollars do not get paid out soon, FM grads will be shrinking from 75% family practice yield to less than 55% as more exit to better paid ER (12% 2010 to 20% future), urgent (4% to 8%), hospitalist (4% to 8%), and other positions (5% to 12%). 

It is difficult to claim value from family medicine when family medicine has largely exited the who, what, when, where, how, and why it has been most valuable.

If AAFP does not change payment substantially it will face its own challenges with membership, representation, and more.

Family physicians need Aggressive Family Medicine Advocacy - Associations that are aggressive for their top needs and those of their patients.

Summaries of Recent Blogs

Please No More So Called Primary Care Solutions

Biomedical Focus is Ruining US

More Quality Measures for Homebound Seniors - Not Hardly

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Oregon Primary Care Medical Home Supposedly Saved 240 Million But Spent Over 250 Million - A minimum additional cost of 250 million dollars was required to save 240 million and the actual cost of delivery increases should be much higher.

Blood Clots or How Dr. House Breaks Down the United States - Physicians are pushed to be complete and are pushed to cut down costs. What is needed is much better studies and less media exaggerations

Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children and improved environments, situations, and social determinants. In nations with little or failing support, health interventions can be expensive and fail to work 

Cancer Gets a Moonshot and STDs Get No Shot at All - Disease focus has found new support. Public health and basic services will fall further behind.

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design. 

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

Recovering General Surgery Is Impossible

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with all types of insurance or lack thereof. Medicaid expansion with low payment compromises the workforce to care for Medicaid patients and other patients with or without insurance


Most Visited Early Blogs


Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care  

Finance-me-cratic Constants in the Bureaucratic Universe  

Meeting Primary Care Needs in the Last Half of the 21st Century 

Exploring the Health Consequences of Disease Focus  

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2016

Comments

  1. Hey,
    Really enjoyed reading your post. Thanks for sharing such an amazing and informative post. :)

    Apu

    Medical Case Management

    ReplyDelete

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