Family Medicine Leaders Must Move Access Forward Not Backward

The United States remains 23^rd of 26 developed nations in generalists and less than 50^th where most Americans reside. A substantial portion of what exists where care is most needed is a testament to the family medicine leadership that built the original FM design and the graduates that were shaped by this design. Compromises since 1980 that have impacted the entire last generation of health care workforce have been the result of failures in political, health, and family medicine leadership.

Backward is Compromise of Broadest Generalists

The United States continues to require broadest generalists that remain broadest generalists over their careers after training. FM residency grads have been stellar in this role as were the family practice general practice generalists before them.

No others distribute reliably.
No others have resisted the payment design for decades as only family medicine has been retained in primary care across the decades after graduation. Over 95% of active FM graduates have remained in family medicine positions in the past.
Even this has eroded in recent years as more family physicians have departed small practices, independent practice, rural practice, and primary care to go to emergency care (12%), urgent care (4%), hospitalist care (4%), other specialties (< 5%), part time, other careers, and retirement (Graham Center, Masterfile).

The steady declines in primary care retention for all sources and the steady declines in FM grads found in family practice positions should point to the need for substantial payment and other financial design changes – changes lacking since the 1980s and made worse in recent years. Deficits in workforce even where populations have insurance should have pointed to the need to improve the financial design, but leaders have failed to point this out. As a result, health reforms have been poorly targeted.

Backward Is Left Out of Health Reforms

Health reforms only "appear" every 20 or 30 years. This is why it is so important not to be left behind. Family medicine arose by aligning with the 1965 - 1975 reforms and was considered important to the 1990s reforms. FM completely lost out on the 2010 reforms as none of the reforms resulted in

necessary and sustained increased payments to primary care, or
decreases in the cost of delivery of primary care, or
improvements in retention in primary care, or
decreases in the cost of primary care turnover, or
increases in the productivity of team members.

These are all necessary for an improved financial design, and improved function design, and improvements in the higher primary care functions.

Backward Is Burnout, Declines in Productivity, and Team Members Distracted from Care

Burnout has reached an all time high. Collapses in primary care internal medicine, mental health (now 50% delivered by primary care and even greater proportions where most Americans lack access), in public health, and in basic surgical services have placed additional burdens upon remaining care where needed – where family physicians are most essential.

Nurses and more costly personnel are too costly for many primary care practices. It is harder to hire and keep good team members when the financial design works least for primary care, mental health, and basic services compared to more specialized or hospital-based services.

As noted, FM associations have not been able to stop delivery costs and increasing regulation that clearly results in declines in productivity, burnout, and worsening of the financial design. Tragically FM associations have even promoted value based efforts that clearly have added new hundreds of billions each year to overall health care costs without improving outcomes - the opposite of value.

Forward Is More Support Where Challenges Are Increasing the Most

In the places where most family physicians are found, there is worse to come. In these places the population is increasing faster along with elderly populations and the most complex and least healthy populations. These are also the places where health, education, and economics have most failed. Local resources to facilitate better health outcomes are also being compromised – a nasty consequence of state and federal budgets diverted increasingly to health care.

Family physicians along with rural health providers, small towns, primary care practices, mental health, and the half of the nation less organized and most “outside” have been ignored.

Lacking an understanding of the needs of most Americans, the nation’s political and health leaders have lost touch with health access, most Americans, and the family physicians that care most for them. Family medicine leadership is more important than ever in restoring the connections, collaborations, and partnerships that are required to lead the nation to better health, health care, and health outcomes.

Backward Is the Failure to Mobilize the Majority of Americans Left Behind

FM docs contribute the most across the lowest physician concentration counties with 40% of the population. FM dominates workforce where over half of the nation is found – the half that recently expressed discontent with the establishment and with policies that fail to meet their needs. Where the elderly, poor, Veterans, lower income, rural, and underserved populations are found along with concentrations of lowest paying health care plans, family physicians remain as others depart.

FM leadership has missed opportunities to illustrate the incredible work of family physicians - work that has continued despite the incredibly flawed health care financial design. Where health care is most falling apart, family physicians are even more important. As concentrations of physicians, people, income, education, health spending, and local resources go down the proportions of family physicians increase in local workforce.

Forward Is Family Medicine as Is Best Indicated By What FM Docs Do

Small health care across urban and rural settings is reeling from rapid chaotic and often meaningless changes. The 1980s payment designs resulted in hundreds of hospital closures and the compromise of primary care, rural health, and small health care. The 2010 changes took away disproportionate share and failed to support small hospitals, small practices, or primary care. The ACA academic and managed care designers shaped the 2010 reforms in ways that intended compromise of small health care. The closures of small hospitals and small practices have increased. Once again, family physicians contribute the most where care is compromised by design.

Family medicine is most important for access to care in one of the most rapidly increasing populations in the US – the population in counties without a hospital. The last hospitals in counties are closing at a rate of 1 – 2 per month. The rapid growth in this hospital-less population is due to two factors

The closures involve counties with higher levels of population
Population growth is faster in the counties without a hospital

Even worse is the higher demand and fastest increasing demand in these counties - counties that have also lost a major organizing force for local care.

Forward Is Accountability in Care for Access Failures and Failures By Foundations, Associations, and Others with Health Access Missions

Access is an area most important to family physicians, but access failures are becoming worse. Tens of thousands of Americans are dying from access issues. Meanwhile foundations "devoted" to access embrace insurance expansion and continue to ignore the deaths and the lack of local workforce that is most critical for access. Not surprisingly the expansions of the 2010 reforms failed:

Expansions of Medicaid with payment below cost of delivery does not help access
Expansions of high deductible plans are similarly least supportive for local primary care, mental health, and basic access

It is a difficult choice to oppose foundations that can do so much to influence changes in health care and society. But it is imperative to redirect misguided foundation efforts that distract the nation from true solutions - the absolute imperative of much better payment without distracting team members from delivery of care.

Foundation, association, and government leaders should not promote health insurance coverage as a solution for access. Decently funded local primary care can deliver access with or without insurance coverage. Insufficient payments defeat access for those with or without insurance.

Forward Is Focus on the Top Priorities for Health Care Improvement

Leadership in FM should remain focused upon the incredible efforts of family physicians, upon sufficient and reliable access to care, upon the resolution of deficits of workforce facing most Americans, upon true reforms involving substantial payment increases for primary care, and upon the true determinants of health.

Forward Is Overcoming the Real Barriers to Care

FM was restored because FM leaders were successful in convincing Americans of the need for family physicians. Family medicine leaders successfully navigated state and national barriers to accomplish this change. Substantial opposition in medical education had to be overcome. FM funding had to be protected from deans. Family medicine residency programs needed to actually get the funding that was too often diverted by hospitals to other purposes.

FM should once again align itself with the populations that it serves to team up for better health care outcomes. FM should oppose the current misguided focus upon costly and ineffective clinical or digital clinical manipulations. FM teaming up with most Americans and those who truly care for most Americans should return the focus to the personal and community factors that most influence health outcomes.

Current FM leadership is fortunate to have had the incredible legacy of a generation of past family physicians who have been consistent in most needed care. They have also been fortunate to have the example of past family medicine leaders, who rebuilt family medicine despite significant opposition. The lessons learned by the builders still instruct the current leaders.

After exclusion from medical education, formal family medicine was restored by caring family physicians via two specific areas of focus.

First, they continued to care for their patients where care was most needed. Their stellar example was the model for generations to come.
Second, they cared enough about the country to sacrifice even more to bring forward what the nation needed most in health care workforce – family medicine.

That their success was all too brief is a testament to the decades of life that they spent to restore family medicine and to the lack of access focus by the nation and especially by the new FM leaders.

Forward Is a Substantial Contribution to Health Access, Especially Where Most Needed

The time of great success lasted only the first decade of family medicine, a final decade of activity for many restorers. The one time increase to 3000 annual graduates by 1980 remains the one stellar and most specific contribution to health access in the history of the US.

It took hard work by family docs state to state and nationwide to get formal family medicine training established – despite the poor cooperation and even opposition of academia. The original FM leadership never forgot the hard work that it took to practice and also build family medicine.

The 1969 to 1980 growth of family medicine residency graduates was a testament to their hard work as well as a national payment design that supported primary care, family physicians, and care where needed. The original design for Medicare and Medicaid similarly took decades of hard work and worked together with FM to address what the nation most needed and most lacked for most Americans.

The initial decade of FM grads distributed at an unprecedented level above population based distribution with 30% found in rural practice - more evidence of the need for a collaborative relationship between practices and payers for the purpose of access.

FM still maintains 25 – 30 family physicians per 100,000 across the wide range of populations. Even where payment fails most where Medicaid, high deductible, Veteran, and Medicare populations are concentrated, family physicians continue to serve. Where hospitals have closed or do not exist, FM docs are most important.

Expansions of the plans least supportive for local family physicians, Medicaid and high deductible plans, should not have been expected to change access.

Backward is Clinging to the Past, including Obamacare

We cannot afford to cling to financial designs or reforms that have failed to address the most basic requirement to rebuild primary care – funding that remains significantly and consistently above the cost of delivering the care. Clinging to ACA, MACRA, or CMS has been counterproductive for family physicians and could be worse if such a focus keeps us from impacting the designs that are on the way.

Why waste energy on the past? We should focus on key areas and key coalitions. The elderly, rural health, and advocates for those who are poor and underserved. We need to focus on county leadership across the 2700 counties left behind - counties that did make a difference in an election but will need far more than election change to reshape health, education, and economic designs there way after decades of neglect.

Since 1980 the critical support for what family physicians do has melted. Not surprisingly family medicine has remained at 3000 annual grads and other key areas have melted in the areas most associated with FM. These include health access, primary care, rural health, care where needed, and the support of the patients and populations cared for by family physicians.

Forward Is the Promotion of True Value in Health Care, Backward Is Value Based Care in the Opposite Direction of Value (Quality/Cost)

It is the support of the populations and their communities that most shapes health outcomes through changes of behaviors, environments, situations, and social determinants. Improvements in outcomes have been prevented by the last 50 years of health care designs – designs that have added trillions to health care costs for little change in outcomes for the opposite of value. Even worse these increased trillions have depleted spending where communities need economic development, housing, nutrition, public health, police, fire, child development, education, job training and other areas more specific to improving health, education, economic, and societal outcomes.

_Same Quality_   = Lower Value      as seen in US Health Care
Increasing Cost

Slight Quality Increase   = Lower Value as seen in the current quality obsession
Modest Cost Increase

_Same Quality_   = Higher Value as seen in rural health, primary care, FM paid less
Decreasing Cost

But forced higher costs of delivery via obsession with quality compromises access - mainly because outcomes remain the same as they are about the people and populations - not clinical interventions. Attempting to address quality in ways that cannot change quality while driving up health care costs is the opposite of value.

People, places, and populations in need of care do not need rapid costly change, innovations, certifications, and other increased practice costs of delivery - especially where payment is marginal and costs of delivery are high.

Team members need to be focused on their local work to delivery the care and build the community. They are the ones that advance basic access to care and accomplish the advanced primary care functions. These are functions only possible with substantially more funding, better support of team members and communities, less regulatory costs, and fewer distractions.

It is perhaps most troubling that family medicine leaders do not understand that it is the people and community factors that most shape outcomes. Or perhaps more accurately, we see promotions of this concept by various health care leaders, but they fail to integrate this into their thinking or their strategies.

Forward Is Determinants of Health Fully Integrated into Strategy Rather than a Tacit or Politically Correct Awareness of the Determinants of Health

A true understanding of the factors that most shape outcomes also leads to understanding in a number of areas that represent the medical illiterature:

Medical Error Focus has been a costly distraction since To Err is Human. This effort adds tens of billions a year to health care costs with little change in outcomes and some potential for worse outcomes long term. The Primary Care Medical Home effort also fails due to the same high cost, low yield reasons.
Differences in Outcomes Are About Differences in the Populations Served and Not Differences in the Providers. Differences in outcomes across many interventions are explained by differences in the populations served. These include Primary Care Medical Home (populations, providers, level of organization, payment difference), Male versus Female Internists, Urban vs Rural Hospitals, Pay for Performance (Hong, JAMA), High Volume vs Low Volume
Lack of Differences in Outcomes Are About Same or Similar Populations Served as seen in MD vs NP, Resident Work Hours Limitations,

The integration of determinants of health as a function of local spending and other local support also points out the true dangers of quality focused obsession in areas of health and education. The measurement focus combined with stagnant funding can only compromise local team members, local jobs, local economics, and local cash flow. Money received that has to be sent out for software, practice consultants, certifications, brokers, and HIT maintenance are shipped away from the support of team members, local jobs, and local economics. Again and again the real determinants of health outcomes are compromised for efforts that at best are a minimal influence

Forward Is Support for Medical Students and Residents

Family medicine should lead the nation in areas such as better understanding of resident work hours limitations as having no impact upon care outcomes. This is seen in the best quality studies that involve the same populations before and after work hours limitations implementation. This does not, repeat, does not mean that a return to more hours is right. The limitations were correct because they were focused upon establishing better mental and physical health for residents and the physicians that they become. Family medicine once was not afraid to make stands that made sense for medical students - another reason for attraction to family medicine.

Forward Is Evidence Based and Support of FM Docs in their Focus on Care Delivery

The bandwagon has been set in motion by the insurance, academic, and managed care designers. Unfortunately their designs fail in evidence basis and fail most for small practices. The designs act to compromise most family physicians, care for most Americans, and long term outcomes regarding health care.

Pay for performance and derivatives (quality metrics, measurements, digitalization, value based care) have been demonstrated to be costly, distracting, and discriminatory schemes. The builders did not tolerate costly, distracting, or discriminatory and neither should current leaders.

Over a dozen studies specifically indicate compromises in payments via pay for performance for those who care for the most complex patients – older, poorer, less educated, less health literate, more chronic illnesses, more smoking, more diabetes, more obesity, lesser health status, more preventable outcomes, and more premature deaths.

These are all seen and much more across the 2621 lowest physician concentration counties where 36% of active family physicians are found serving 40% of the nation and higher concentrations (42 – 47%) of all of the above. Highest readmission penalties go to rural hospitals (9%) and hospitals in lowest physician concentration counties as compared to urban at only 3%. Providers in the counties with concentrations of the factors most related to lesser health outcomes do consistently have the greatest penalties.

Schemes that lack evidence basis, that lack the full backing of the scheme consultant (RAND), and that discriminate against providers caring for the Americans most left behind should not be supported. Schemes that discriminate against family physicians and hospitals where most needed should be vigorously opposed. Leadership should understand what most impacts family physicians current and future.

Forward Is Focus on True Solutions

Rather than leading academia and designers to the understanding of the real determinants of health, FM leaders promote models of payment and training interventions that distract the nation from real solutions.

FM leaders have tolerated numerous claims of being a primary care solution from those who often did not even enter primary care after primary care training. FM leaders have placed support behind Teaching CHCs.

In a previous life I supported such efforts. I have actively participated in the development of pipelines, rural training tracks, rural faculty development, and the development of Teaching Community Health Centers. I taught medical students and residents in schools focused on such efforts. Specific training has value, but the interventions have no value for resolving access woes. The real solutions involve spending more than 6% of health spending on primary care so that the nation can have more than 55% of encounters as primary care and many more encounters where half of Americans are behind in access.

Specific training is important, but it is more important to understand that there can be no training that results in a resolution for health access where needed – until payment has been addressed substantially and specifically.

Fifteen years of watching 88 counties of need in Nebraska indicated name changes only. There was no change in workforce or access. A stellar design across all levels and residency training in FM matched across the state raised FM to 40% of workforce where needed. This is a level far above the average of 24%. Even so this still did not result in more – only in different. UNMC graduates choosing family medicine found in 88 counties of need at a 12 to 16 times greater level than those not choosing FM is great for the literature, but did little other than change the names.

Those who continue to promote payment plans and training interventions that are not true solutions for health access or for family physicians – are actually delaying the real solutions.

Delay is to deny is to die.

This is something that the builders of family medicine did manage to avoid and the leaders that follow them must avoid this also.

Meanwhile the payment plan fails across primary care, mental health, and basic services with workforce that remains in deficit overall and specifically for half of the nation if not now then within a few years as places of need increase fastest in people, elderly, complexity, and demand.

Forward Is Separation from Academia to Understand Value in Family Medicine

Forward is also avoiding the lure of academia. Despite the years and the contributions, family medicine remains largely outside of academia. Like others left out, they want to belong and sometimes are willing to do academic things not in the best interest of family medicine. One such area is family medicine fellowships - a fourth year added to training. This has been a pet project of some FM leaders. It is a good fit for residencies short on faculty or hospitals short of workforce. It was also easy to do studies convincing FM residents of the need for the fourth year with direct surveys - surveys that did not include information about the increase in their debt, declines in earning potential, and minimal impact on their overall learning compared to a year of practice. Academics clearly value additional years of formal training that mean very little 5 or 10 years later. The proper perspective for workforce is the entire career of a family physician, not a single year.

It is the shrinkage of family medicine workforce that most needs to be avoided. Smaller workforce has even less influence and in the case of family medicine would shrink family medicine contributions where care is most needed.

Looking more academic remains a huge mistake as the available funded family medicine slots are divided over 4 years rather than three. The 9000 slots/4 years results in only 2250 annual graduates rather than the current 3000. This would be a huge blow to access in addition to more financial compromise for FM graduates as well as fewer attracted to family medicine.

Family medicine, of all specialties, should understand that the true learning in family medicine is accomplished in practice in continuity with team, practice, patients, families, and community. This continuity over time is what gives value to family physicians - especially compared to others who turnover more rapidly, fail to enter primary care after training, and depart primary care steadily over the years after graduation.

Family medicine leaders who understand family medicine in the context of family practices, can help the payment designers to understand that valuing longer training or more specialized care has long been one of the greatest design flaws of all.

Forward in academia is more rigor in journals with numerous articles rejected when there are insufficient controls and grossly insufficient limitations sections. Forward may well require a limitations section consisting of half the word count or more. Family medicine has led in critical review and should clearly make contributions in rigor in the areas of quality, cost, and access. Clearly few others demonstrate the necessary concerns.

Forward Is Not Clinging to Past Assumptions and Failures and Especially Interventions that Seemed to Work During Periods of Better Payment, But Not Since

There are important lessons to learn that have not been learned by FM leaders. We still attempt what has seemed to work in the past during the Builder Years when payment and training were focused on care delivery. These include replications of WAMI or WWAMI, rural pipelines, family medicine interest groups, departments in every medical school, residencies in every state, Teaching CHCs, and other efforts that have always required payment support for success and still do.

Selective memory allows us to forget about the studies that linked these to success but have sense been demonstrated not to work - aligning successes and failures with payment rather than programs. A few of us stayed with this and worked 30 years to facilitate such efforts. And even fewer have realized that the success is really about the payment design - not anything training interventions can accomplish.

Family medicine still wastes substantial time and effort promoting academics, training, and innovations. Being "academic" is still more important than health access, family medicine, support of family physicians, and true payment reform.

FM leaders fail to realize that the only area that matters to accomplish all of these areas and more is the firm foundation of a solid payment design that fits the half of family physicians serving where the nation most needs care.

Moving forward requires a solid and substantial financial design. This what is needed to empower family physicians, to produce more family physicians, to retain family physicians in FM, and to accomplish the higher functions of primary care (not regulation, not certification, and not higher cost of delivery and more impairment of team members).

We cannot afford the diversion of doing much more to get slightly more and must avoid doing much more to get less. The US health care design is the ultimate example of much, much more for less result. To change the design will require much more effort and much more focus on what really matters while leaving the past behind.

With continued declines by design in the next decades, it might be possible to once again return to broadest generalists with population based distribution in some future decade. I think it is safe to say that no such effort will come close to what the builders accomplished 1950 to 1980.

Any that hope to measure up would need to double family medicine to the 5000 to 6000 annual graduate level as well as turning back the clock on departures from family medicine after graduation.

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

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.

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.

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

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.

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