The Primary Care Transformation Tsunami

Primary care has always been challenging. It is challenging to maintain the energy, the dedication, and the person to person contact required for continuous, comprehensive, coordinated, first contact care. This has been more difficult as the financial design does not support the number and quality of the personnel to interact with patients and families. But the situations have become much worse as numerous disruptions have been added. Digitalization, regulation, certification, and regulation are already too much. And the Tsunami of Transformation is contributing even more to the overload.

Everyone seems to want to change primary care. 

Few are willing to support primary care. Many are attempting to work to improve primary care by new and innovative methods that makes sense to them. Few consider the width, and breadth, and scope of the multiple changes going on.

No Parent would so disrupt their child so much in so many ways and with so many different activities such that they could not accomplish anything. And yet the researchers, government leaders, association leaders, and others that parent primary care are throwing many disruptions at their creation - and with many more to come. 

Even worse, our understanding of the disruptions in primary care and their impact is near zero. Studies have rarely considered disruptions to primary care. A recent article in Annals of FM found only one such article inthe 1990s before adding their contribution. They were able to demonstrate substantial disruptions and disruptive influences in a very limited definition.

Interestingly this article was added when the practices were doing a quality improvement transformation/disruption – or were hoping to do so in areas such as heart health. As noted by Casalino and others in this supplement, there is little that can be transformed with major disruptions. Without "slack" given by better finances or decreased disruptions, attempts at transformation are not only doomed to failure - they are - Disruptive!

This article indicated a tally of basic disruptions due to changes in sites, changes in personnel, and changes in areas such as EHR transformation.

But there are many more that were not considered – various insurance and payer changes, board certification efforts, family tragedies, community tragedies, and losses in other health care areas (changes in local hospitals, other facilities, other practices).

Disruptions in primary care appear to be common, but when you layer in other transformation disruptions – the complexity increases dramatically.

It May Not Be the Economy, Stupid, It May Be the Disruptions and Transformations

Numerous "experts" and consultants and practice facilitators are employed by the Transformation/Disruption process and there are more to come. 

A recent review in the past week indicates transformations for heart disease, prenatal care, opioids, he Silver Tsunami, COPD, preventive medicine, homebound seniors, communications skills training, a new AAFP designed payment plan, and changes in fee scales - and this was not an active or complete listing.

Every organ or system has someone promoting better organ or system care through transformation. The same is true for every preventive medicine area. And some of these are found to be lacking in evidence basis. To these add the more standard disruptions of EHR plus lost key personnel plus lost physicians or clinicians or changes in locations or ownership.

These are all adding to the disruptive events impacting family physicians most of all because of our scope, location, and dedication.

The Transformations have achieved viral status with so many in so many areas. They are only limited by the finances of the practice and the emotional reserve of those associated with the practice.

From the Matrix "You move to an area and you multiply and multiply until every natural resource is consumed and the only way you can survive is to spread to another area. There is another organism on this planet that follows the same pattern. Do you know what it is? A virus."

One key indication of the impact of transformations and disruptions - Only the largest, most organized, and best paid primary care practices serving the patients with the best plans and social determinants appear to have a good chance to survive. 

Even then it is not certain that continuity, comprehensive, first contact, and coordinated can survive. For example, not even family medicine can come up with a reasonable primary care definition. They list 5 different definitions.

I invite you to review the current supplement to the Annals of FM. This was a summary so far of a major federal quality improvement grant program. 

You may not need to do more than review one specific article - The alarming rate of major disruptive events in primary care practices in Oklahoma. Note that the research had a limited view of disruptive events involving key personnel, EHR, losses of clinicians, site location changes.

The situations are so bad that it would be hard to find a practice not disrupted. 

“Our finding that two-thirds of the practices in our sample experienced at least 1 major disruptive event during a 2-year period should be alarming to everyone involved in practice transformation efforts. The fact that the practices in our sample had willingly enrolled in a quality improvement initiative and participated for at least 1 year suggests the actual rate of major disruptive events in primary care practices may be even higher. 

The rate of major disruptive events did not vary across ownership types or geography (metropolitan vs rural). Even though it makes mathematical sense that practices with more clinicians and staff would be at greater risk for personnel changes, medium-size practices in our study reported greater staff changes or loss than did the solo and large practices. Solo practices are less complex and possibly more cohesive, resulting in higher levels of clinician and staff allegiance, thus avoiding certain types of major disruptive events. Medium-size practices, by contrast, may lack the resources and buffers of larger practices and the cohesiveness of small practices, making them most susceptible.

Improvements in care processes are onlybeneficial if they can be sustained. Although sustainability requires morestudy, it is likely that stability of clinicians, staff, and record systems areimportant, because those are the main sources of institutional memory. In theface of major disruptive events, clinician and staff training programs arelikely to be essential. Factors accounting for personnel loss need to bestudied to identify mitigating strategies.”

I was also disrupted. I was disrupted by the number of researchers involved and their past track record. These are people that I respect that have all been moved into quality improvement - and they are contributing to disruptions. Even worse, they are being focused into this area - and away from areas where they could and should contribute such as

• Disruption in Primary Care
• The Impacts of Moving from the Most to the Least Primary Care Experienced Workforce in the History of the US.
• The failed primary care financial design
• Shrinking health access across basic services 
• The impact of shrinking general specialties upon generalists

How Can Primary Care Recover when battered back by Transformations 

before it can get back up off the mat.

Once you understand the disruptions and difficulties and discriminations experienced by primary care practices - you can understand how the only thing that matters is a much better financial design. More personnel, better personnel, reserve funding, and other flexibility or resiliency is all about finances. Casalino indicated the serious problems hitting primary care practices because of the financial design made worse by MACRA and other changes. Yet he somehow indicated that perhaps the practices could pool together to share a care coordinator for "seriously ill patients." There are so many different groups at risk that multiple coordinators would be needed. That is where family medicine comes in - or did. We have the opportunity to develop expertise - or did have, when the financial design kept us in primary care for decades of higher volume experiences. 

What Should We Do to Fight the Battle for Primary Care and for Health Access?

First, we need the disruptors to disrupt their disrupting for long enough to take stock of what they are disrupting. 

Second, we must take demonstrative action. Frankly, we should be out there locked arms with teachers, nurses, cops, public health, and other human infrastructure serving professionals - demonstrating for each other until we have the support, the backup, the team members, and reasonable hope for improvement in the future - not worsening revenue, worsening costs of delivery, increasing complexity in multiple dimensions, and ever more demand.

Dimensions of Disruptions - Patients, Families, Communities, Supports

There are too many practice, community, patient, and family disruptions coming our way to count. For example, the deficit budgets due to tax cuts will force automatic cuts in payments on top of MACRA penalties. 

They will also force cuts in Social Security, disability, SNAP and other population based spending. These changes will hit the patients of 40% of family physicians hardest along with their communities. Tariff wars will hit jobs and economics in key areas such as what remains in manufacturing and agriculture. Environment, forestry, and other government positions are being positioned as few as possible and this will terminate or centralize good jobs along with the associated good people that help shape communities. This will also impact the fewer providers remaining in these communities to care for them.

Lowest Concentration County Impacts

Currently family physicians and others attempting primary care in these counties with half enough primary care (and other basics) - maybe 65,000 who remain out of 70,000 who were there (perhaps 30,000 FM docs of the 65,000) - have about 1 billion a year less to invest in primary care - but somehow are supposed to keep up volume, productivity, prevent turnover, improve quality, document everything, address team member needs, address family changes, bounce back from community hits, and improve satisfaction in all except us.


Ask yourself, why is it that everyone promotes improvements in everything - except the work and home life of those who deliver primary care?