The Ultimate Shared Principles for Primary Care and for Most Americans

The Shared Principles documents have attracted much primary care attention. Primary care associations are signing up to support the principles. These are principles that have existed for generations of general practice and family medicine physicians. They are good principles as with other areas supported by such associations. But it is important to remember that the power for primary care principles is the financial design.



Each of the primary care principles requires a better financial design. Each principle has long been compromised by the Triple Threat. The primary care Triple Threat is too little revenue, acceleration of cost of delivery, and complexity increasing in multiple dimensions (practice, population, community, higher functions). This limits what we can invest in practice, patients, team members, and the people of our communities. The same Triple Threat is taking out mental health and general surgical specialties - thrusting even more burden upon the family physicians who must do more for more people with less support - an overwhelming design my any true measure.
Patient Centered Primary Care Collaborative
 The power for patient centered care is financial. Continuous, comprehensive, and equitable care requires a much better financial design to retain patients, practices, team members, and family physicians. Team based care is made more difficult by designs that shift dollars away from team members and the care that they deliver. Higher functions are impossible to address without powerful support. Access is what is failing most by financial design.  

Some Want to Polish Primary Care But Fail to Realize
That They Are Helping to Polishing Off Primary Care 
Moving Up the Scale from Most Needed Primary Care Practices 
to Involve Greater Proportions of the American Population
Some want to drive primary care practices to greater health outcomes, but fail to realize that primary care and other clinical interventions are small compared to the personal, local, and community determinants of health
Any hope for more polish and better outcomes is linked to better investments in the populations and this includes better distributions of health care dollars via a better primary care financial design.
 
Designs that best work for those doing well are compromising care where most needed directly, and indirectly through misguided attempts to reign in costs that play out worst for health access across legislation, regulation, implementation, and revisions.

Fighting the Nothing - the Triple Aim Adds to Triple Threat
We must address revenue too low, costs too high, and increasing complexity. We must ignore the many distractions and diversions - the nothings - that consume our resources and prevent us from addressing the Triple Threat to our existence. Rural practice teaches how to focus on the somethings while ignoring the nothings. A movie comes to mind that captures the battle between what we most believe in and what represents nothing.

The Neverending Story has a deeper message. 
It teaches us about the top priority of belief. We must fight the nothings in this life to focus on what matters. We need to believe in the things that matter most. Atreyu had to confront his enemy just as Bastian had to confront himself and his enemies. We have to confront the nothings and focus on the financial design
G'mork: Foolish boy. Don't you know anything about Fantasia? It's the world of human fantasy. Every part, every creature of it, is a piece of the dreams and hopes of mankind. Therefore, it has no boundaries.
Atreyu: But why is Fantasia dying, then?
G'mork: Because people have begun to lose their hopes and forget their dreams. So the Nothing grows stronger.
Atreyu: What is the Nothing?
G'mork: It's the emptiness that's left. It's like a despair, destroying this world. And I have been trying to help it.
Atreyu: But why?
G'mork: Because people who have no hopes are easy to control; and whoever has the control... has the power!

Because People Who Have No Hopes Are Easy to Control
Whoever Has the Control Has the Power!
The Nothing has consumed all,
but it only takes a tiny speck of belief...
Many events since the 1984 release of this movie have illustrated the problems regarding lack of hope, control, the power to distract, and power itself.
I will forever remember The Neverending Story for its medical contribution. It gets credit for curing my chest pain. As a solo rural family physician, I experienced worsening pleuritic chest pain over the 1980s. It was bad enough that I had to suppress any and all coughing and laughing. My wife and I had a chance to escape and chose to go to this movie. It was painful but I kept laughing. I started laughing so hard that I could not stop. 
Suddenly there was a pop deep in my left chest. Since then there has been no more pain.  It is likely that scar tissue formed from multiple past episodes of pneumonia - and my lung finally broke free. 
Breaking Free of the Blinders
It would take me decades to break free of my thinking that the academic solutions for rural health would work. My decades of academic focus, my rural medical education experiences, and my advocacy efforts kept my blinders on. I remained focused on the nothings rather than focusing on what really matters.
I should have learned Triple Threat from my solo rural practice - since it drove me out of practice with payments too low and payments 15% lower in Area 99 where I practiced. The new policies of 1983 threatened the local rural hospital and paid me 20% less because I was a new physician. Although this new physician cut in pay was short lived, it indicated the lack of awareness of small practices, small hospitals, and rural health - and it was the beginning of understanding of the nothings for me.

Tracking no change in Nebraska across lowest concentration counties for over a decade eventually reveals the truth. Despite an optimal pipeline and the best GME plan for a state, there was insignificant change in delivery capacity. UNMC students choosing family medicine reached 16 times more likely to be found instate in primary care where needed - but the level of primary care remained at the 50 - 60 per 100,000 level. Massive expansions of MD DO NP and PA sources have not fixed primary care deficits - and clearly they never will.
Questions Must Be Asked.
  • Why is it so hard to focus on the financial design that means so much to all that we do?
  • Why do we shy away from confronting the nothings to focus on what matters most?
  • How do we combat social media dominated by those promoting the nothings? 
  • We need leadership and staff that understand us more, understand the nothings less, and focus on illustrating what we do to foundations, associations, designers, and politicians?  
  • Why is it so easy to go along with the academics, the innovators (those who assume), the marketeers and their promotions, the consultants, the government designers, the bandwagons, and others that claim to be improving health care that are actually distracting us from the solutions that matter?
Lessons for Health Access Warriors from The Neverending Story
  • Every part of what we do is about the dreams and hopes of our patients and what we hope to accomplish with them. 
  • We are beginning to despair - to lose our hopes and dreams.  Morale is fading with productivity. We must not despair or we will sink into the muck as Artax did.
  • We have to face our true selves and focus on the very nature of what we do - or do not do. 
  • We have to realize that we have the power to work with our patients and communities and most Americans to overcome the nothing to realize the full potential of primary care. 
In Family Medicine We Must Believe in Family Medicine
Family physicians have long believed in family medicine despite the inferior treatment, payments, and conditions. We have cared enough to disregard lower salary and the many challenges that we face. We have endured the partialists and aberrant research that implies that we are inferior when in fact we are the most valuable for most Americans.

Often paid less and yet with the same or similar outcomes, we represent the greatest value even if CMS is spending 100 million to teach value to those most valuable in outcomes vs cost and in how we move patients from no access to some - an infinite improvement most valuable.
As family physicians, we must believe enough to do whatever we can to fix the threats to family medicine. We must address revenue too low, costs too high, and increasing complexity.

If We Believe, We Will Fight the Triple Threat
It is important for individual, state, and national family physicians to focus all attention on the Triple Threat that is destroying all that we believe in. 
Addressing the financial design is the real solution for family medicine, for primary care, for health access, for rural health, for associations representing these areas, and for most Americans left behind by health care design. 

The Triple Threat Hurts Most Americans Behind By Design
 
One-third of the US population was behind but it has grown. It has become 40% of the population left behind in 2621 lowest physician concentration counties. Our nation is adding more counties to this total as small hospitals and small practices fail - by the financial design. The population left behind is increasing
  • As the counties added have greater population
  • As the population in these counties is increasing fastest
  • As more Americans are forced away from higher concentration counties as affordable housing collapses and sends them to lowest concentration counties where they can afford to live
  • As lowest concentration counties increase in numbers, demand, and complexity. 
These are all progressing at the most rapid rates in US history without the awareness of the designers of health care or our nation, without recognition of the broken foundation of health care, and without the necessary increases in support. 
It is likely that over 50% are behind. The lowest physician concentration figures are geographically reproducible, but fail to capture tens of millions more hidden in small pockets of higher physician concentration counties.
Triple Aim and the 2010 "Reforms" have made the financial design worse while distracting us from true solutions. 

Most Americans Need Allies - Association and Foundation Support


Most Americans working together with all of the foundations and all of the associations that are supposed to be dedicated to health access should be able to accomplish a financial design solution.

Sadly the association and foundation support is going for Triple Aim, meaningless use, higher cost without improved outcomes, and expansions of insurance plans that pay too little and worsen care delivery costs - adding to Triple Threat rather than helping.
Focus, Focus, Focus Is Required for a Financial Future for Family Medicine

Too Little and Too Late for 2040
A sooner rather than later financial solution is better since it takes 30 years of a sufficient financial design to result in the necessary and sufficient workforce. A generation of workforce is shaped by a generation of cumulative financial design. Generations of past workforce were shaped to inadequate levels by generations of policies with failed financial design.
Future generations will suffer because we have failed to act. We are already 7 years behind to address half of the population with half enough primary care. This is the situation being shaped for 2800 lowest physician concentration counties by 2040. Shortages are already designed to exist until 2050 but only if 2020 is the beginning point of 30 years of superior financial design.

Without the understanding that access can be created and sustained, despair can cloud our thinking and result in us grasping for straws. But we can resist the nothings to make a difference for most Americans.
Training Interventions Are Costly and Distracting
Training interventions are designed by those who believe in training interventions. They believe so much in training interventions that they are not seeing the limitations of the financial design. As they graduate more graduates or special types of graduates, they can demonstrate success. But this success is only about the program or special intervention.  This does not increase the dollars going to support more team members so it cannot increase health access. Why is this so hard to understand?

I admit that it was hard for me to understand this for too long, but we must change.
Health access capacity improvements require substantially more dollars to support the team members where access is needed and is most needed. 
  • The payment design pays least for health access workforce.
  • The cost of delivery design forces health access practices to pay higher costs of delivery in nearly every new or old category.
  • The complexity drains the revenue and increases the cost of delivery with even greater impact upon lowest concentration county practices.
More Belief in Primary Care Demands Less Belief in Training
We need to have more belief in primary care while moving away from belief in training. It took me 30 years as an advocate of rural training, pipelines, and underserved training to realize that none of these could actually improve health access. More just resulted in others displaced. Financial designs favoring higher concentration locations, careers, team members, and specialties have absorbed the expansions of graduates. 
The financial design prevents any success involving training interventions. The Triple Threat prevents the production, support, and retention of generalists and general specialties that provide 90% of services across lowest concentration counties and other zip codes left behind in higher concentration counties.   
Please consider the impossibility of addressing massive deficits of primary care by graduating more. Special training is not wrong, but it can be distracting.

A top priority placed on special training by AAFP (In the Trenches, Shawn Martin) prevents AAFP from focusing on the financial design.
IT IS NOT POSSIBLE TO RECOVER WORKFORCE
BY TRAINING INTERVENTIONS
Standing Up for Most Americans
At some point those of us who believe in the priority of health access have to stand for something different for most Americans

Those out delivering care where needed for the least organized and least healthy and most complex populations need to be recognized and supported - not punished. The financial design continues to send them less revenue for basic services and 15% less for the services they provide. Penalties are being added where the populations have long been least healthy with least local resources and workforce.

These are the places where family physicians are most likely to be found. All other specialties concentrate at ratios 3 to 7 times higher in the 79 highest physician concentration counties with 10% of the population as compared to 2621 lowest physician concentration counties with 40%.
  • MD DO NP and PA all concentrate in concentrations - except when filling family practice positions. But fewer remain in family practice positions with each passing year and each passing class year of graduates.
  • Only family physicians are matched up to need with 36% of active family physicians found serving this 40%. But family physicians are shrinking from 85% of active graduates in office family medicine to less than 70%.
  • Family medicine could shrink as these lowest concentration populations grow fastest or it could rise to greater importance. Family medicine could remain at 36% for this 40% or it could increase to 55% serving the expanded population of 50% of the nation in lowest concentration counties in 2040.
All of the above will be shaped entirely by the financial design. There is more.
  • Internal medicine could hold at 45,000 serving in primary care or it could melt away to 25,000 or below. Already 45,000 are hospitalists - a ready escape for the 15% of IM graduates that started out in primary care.
  • Physician assistants have demonstrated no increase in primary care delivery across the last two doublings of annual graduates. It is possible that further increases will result in even less primary care.
  • Shrinkage is also seen with expansions of graduates. This is seen in US MD graduates with a 30% increase in graduates and a 10 - 20% decline in primary care delivery. 
  • The last two osteopathic doublings demonstrated no gain as the predominant primary care result, family medicine, was cut in half with each doubling.
A Better Focus for a Better Future
A better financial design contributes to improved access, improved cash flow where needed, and improved outcomes. More health care dollars even more concentrated as in the past 100 years and worsening in the past 40 and made even worse in since 2010 will worsen disparities in primary care, access, and health outcomes for most Americans.

For Shared Principles, for power to the true primary care associations, for primary care workforce, for the teams that deliver primary care, for rural health, for lowest concentration counties, for better health outcomes, and for half of the American people - we must address the primary care financial design.

Better Access By Dedicated Policy Designs

It will take 30 years of vastly improved financial design to result in adequate health access. This is how long it takes the financial design to improve, increase, recruit, retain, stabilize, and support the current level of workforce. A generation of about 35 - 40 billion spent for primary care in lowest concentration counties must be increased to a level over 70 billion to support the necessary health access workforce instead of half enough - or worse. 
Even more billions will be required if a few billion dollars a year are forced out of lowest concentration county primary care practices to go for more innovation, digitalization (6 billion), regulation (4 billion), and certification (PCMH costs over $80,000 per primary care physician in these locations). Each of these costs are higher in the small practices and in the practices where care is most needed, just as they are smallest in the highest concentration and largest practices.

Most Americans Should Not Be Penalized By Billions Diverted 
from Lowest Concentration Counties

Those designing health care are immersed in concentrations of workforce. Those immersed in places dominated by massive costs, multiple lines of revenue, the top reimbursement in each line, fraud, waste, abuse, and overutilization have forgotten about the half of the population facing underutilization, most access barriers, and worsening situations across environments, social determinants, local resources, and other determinants of health outcomes.

In highest concentration places the specialized workforce takes services that should go to primary care. In lowest concentration places, primary care is stretched to address its own deficits and deficits of others specialties, mental health, public health, women's health, and support services.

It should be our top priority job to remind them about top priority areas such as access and basic care for most Americans. 
We must ask foundations and associations to cease and desist in efforts that do not address the financial design and that often make the financial design worse. The primary care delivery capacity is riddled with thousands of leaks with more added and greater losses from each leak. Our associations and foundations cannot plug them all and sadly are facilitating more leaks and greater losses of primary care delivery capacity.

We must stop plugging thousands of leaks all getting worse and build a real foundation for an optimal health care design. The patchwork diverts our necessary focus.
  • Teaching Health Center training
  • Primary Care Medical Home
  • CHIP funding
  • Medicaid funding
  • National Health Service Corps
  • Community Health Centers
  • Meetings - Annual, Numerous Groups, Student/Resident, Other
  • Marketing Consultants
  • Family medicine research
  • Departments of Family Medicine
  • Family medicine programs
  • Agency for Health Care Quality and Research
  • GME Reform
  • ACA to MACRA to Value Based Designs - it is rare to see much from AAFP except materials promoting these areas
  • Preserving membership
  • Raising funds for FM associations
It is possible to defend each of these as important, but their importance pales compared to the financial design of primary care. In fact a better financial design can largely replace each of these or facilitate their better impact. A better financial design would have prevented the need for most if not all of these.









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