Triple Threat Destroys the Essence of Who We Are in Primary Care

Triple Threat is what creates, maintains, and worsens burnout - and the essence of what we are in primary care.

Threat 1. Insufficient revenue
Threat 2. Accelerating cost of delivery
Threat 3. Complexity increasing in multiple patient, practice, and community dimensions

Complexity is inherent in the life of a primary care physician. 

Complex primary care delivered with sufficient revenue and support to cover the costs and complexities of delivery is highly satisfying. A bad financial design made worse is what erodes margin as well as time - time with patients, team members, colleagues, and family as well as personal time.


Value based designs tear at the fabric of who we are. 

We know that outcomes are beyond the ability of our practices. This is actually supported by the literature in major reviews of pay for performance. Even worse, these schemes discriminate against those caring for the most complex with the least resources - with lesser pay and added complexity.

Tragically foundations with a mission for access (Commonwealth), and even primary care associations support the design changes that have worsened Triple Threat. This is particularly true for the 36% of family physicians serving the least healthy counties that also are lowest in concentrations of physicians.

The current design fails for support and worsens finances and complexity via regulation, certification, digitalization, and innovation. This worsens burnout, morale, productivity, frequency of personnel turnover, cost of turnover, and retention of MD DO NP and PA in primary care. This combination most hurts those serving the 40% of the population most in need of care, most complex, and least supported - the same lack of support as those who provide care for them.

Payments are least for the specialties most needed and their services are paid 20% less by the worst public and private insurance plans where access to care is most needed. Pay for Performance schemes guarantee greater complexity and even less payment - because of the patients cared for with inherently lower outcomes. The Triple Aim magnifies the damage of Triple Threat. Six Degrees of Discrimination in Payment Design   Primary Care Medical Home adds to cost of delivery and complexity and time demand without improving finances or outcomes.

Supply, demand, and demographic changes continue to worsen access, disparities, and outcomes.
Demand for basic care is worsened by demographics and by dysfunctional designs other than health designs. 
This will shape greatest increases in demand (met and unmet) for these settings.The lack of sufficient workforce will drive unmet demand, increasing burnout, and other consequences.

Outcomes Compromise

Runaway health, prison, and military costs plus austerity focus will continue to make matters worse as federal, state, local, employer, and personal budgets are stripped of the ability to invest in local housing, transportation, environments, support personnel, social determinants, and other factors that make health care delivery less complex. Even worse, the changes defeat health outcomes improvements.

The Family Practice Multiplier

Family practice MD DO NP and PA are 3 to 7 times more likely than other specialties to be found in rural, underserved, or lowest concentration settings. All other specialties concentrate amid higher concentrations. The consequences of Triple Threat are most evident in the lives of the ever smaller percentage of MD DO NP and PA remaining in family practice positions. The specialty that distributes equitably suffers the most because it distributes with 36% found where 40% of Americans are found in lowest concentration counties.

Another consequence is primary care moving from the most experienced workforce to the least as fewer stay in primary care. The financial design offers better support, better salaries, better benefits, and less complexity outside of primary care.

Business Models Demonstrate the worst cost increases and compromises for small practices versus larger primary care practices. 

The 25th Anniversary of COGME 3 and still no change by design.

Time to Burst the HITECH Bubble

True Reform Is Needed to Get from Last to First

Too Little Support and Too Much Required also contributes to The Dark Side Killing Doctors

The Academic Medicine Scorecard on Social Accountability

Worsening of Costs Quality and Access with Telehealth - local practices outreaching to patients always makes sense, but outside Teleprofiteering is likely to damage local access.

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