Poor Payment Dictates Poor Training Outcomes in Primary Care

One of the biggest problems in health care is a focus on "my area" rather than considering the overall impact. An intervention in payment or an intervention in training may appear to look good - until you consider the overall impact. For decades various medical educators have pushed rural training or training in Community Health Centers or experiences with minority populations. Few consider that such innovations have not worked to address deficits in workforce for one reason - the limitations in the dollars that go into primary care spending.

No matter what you do to try to influence students or residents or clinicians to choose positions in front line health access practices, the current dollar distribution comes up short compared to patient demand, particularly where care is needed. No practice can expand team member positions or extend to do outreach or other functions, without more payment for cognitive office codes in areas such as primary care, mental health, geriatrics...

I spent decades going to a number of annual family medicine, rural health, government, and foundation sponsored meetings while working to facilitate the training that would address care where needed. It is now clear that what we have been doing for decades is a failure.

A few years ago I would have pushed Teaching Community Health Centers. After all, I helped to start up the medical school at SOMA which was developed to train medical students in CHCs and has the most Teaching CHCs. Specific training such as this is a good idea for the residents training there who want to be front liners. It also can support some faculty who want to stay where needed. 

But no expert or association or government official should claim that Teaching CHCs are able to address shortages of family physicians as AAFP claims. This should be obvious when considering stagnant FM annual graduate numbers at 3000 since 1980 - the last time period when the ratio of payment to cost of delivering primary care was capable of expansion of primary care delivery capacity - and increases in the family physicians most specific to this care. Only during 1965 - 1980 and a brief few years in the 1990s have we had support to build primary care and care where needed because of payment change.  

Innovative Training Impact Pales Compared to Payment Design
Training more in Teaching CHCs will just displace others who would have filled positions of need as the equilibrium is fixed in place by payment limitation. Training more in rural pipelines in a state school only results in self selection impact as the overal medical school and state outcomes are fixed in place by payment. Expansions of training resulting in more MD, DO, NP, and PA graduates has resulted in fewer MD, DO, NP, and PA remaining where needed. Even if an entire medical school trained 100% in primary care, this would also fail. Family medicine did increase from a few tens of thousands to 90,000 after a generation of 3000 annual graduates a year, but all that this has done is to send proportions of other primary care sources ever lower.

This is all because there are limited state, federal, and other payer dollars - the limitation
to hiring and supporting additional primary care team member positions. 

No matter what training intervention you try, you cannot get the optimal result without boosting cognitive payment substantially (99214, office codes, mental health, primary care, geriatric, basic services, etc.), decreasing the cost of delivery substantially, and likely both. A massive boost in the ratio of payment to cost of delivery is what must be done to support more team members that can deliver more care in more places.

The Lesson of Nebraska

The State of Nebraska worked with the University of Nebraska Medical Center to organize coalitions of government, training, and communities around state workforce needs. At Nebraska, Jim Stageman and Mike Sitorius and others tailored graduate medical education GME about as well as possible to the needs of the state - from inner city Omaha Hispanic to rural Panhandle Community Health Centers using hub and spoke rural training tracks. The Accelerated Training program worked to train FM residents in broad scope practice involving procedures to help more locate where care was needed. If you consider the fine men and women, their training, and their distribution - this was awesome. If you consider the overall result in the 87 counties of need in the state, not impressive. 

Two decades of effort raised primary care incrementally from 58 to 61 primary care physicians/100,000.  As a further testament to the importance of payment, Nebraska slashed Medicaid and 13% of the people of eastern Omaha suddenly had no insurance. Not surprisingly practices responded with fewer hired and supported in this area and metro primary care levels plunged.

Yes, the result was a higher proportion of FM docs with FM at 40% of the physician workforce in all but the 6 physician concentrated counties (25% is the national average for FM for these counties). But the concentrations could not change. The payment designs kept a lid on what could be supported. The names changed during my 15 years of visits across the state and on my maps of Nebraska counties and workforce, but the numbers of FM, NP, and PA did not change. And the populations have aged and increased in demand.

Why the lack of change despite targeted programs?

The great majority of counties in Nebraska where care is needed are counties that have concentrations of patients whose insurance plans support local primary care least. Veteran and Native American plans do not help local primary care. High deductible plans tend to discourage primary care visits. Medicaid and Medicare pay too little to support the concentrations of team members needed.

Millions and Billions for Everything Else Other than Team Members

AAFP, consultants, experts, foundations, and government can spend millions on meetings and grants and demonstrations and student interest and new FM associations and new marketing efforts (primary care medical home, Health is Primary) for no gain. CMS can commit more billions to innovative CMS payments. This is also a rearrangement of the deck chairs with no additional funding specific to more personnel to deliver care in more places. In fact, there is often a decline in the funding specific to delivery personnel as new designs send dollars everywhere else (software, hardware, consultants, regulations, technology...).

As long as we can be creative and not constructive, we aid in the failure to address primary care delivery capacity, mental health deliver capacity, geriatric care deficits, rural health delivery capacity, and care where needed in more counties and more settings across the nation. And we can be very creative. 

All we have shown is creativity. Our patients and front line serving professionals deserve more and require more. The battle is not just a few places. We have 40% of the nation living in 2161 counties with lower to lowest concentrations of physicians - because payment design pays too little for local basic care via Medicare, Medicaid, veterans, and high deductible plans. Payment design denies them the family medicine (25% and falling), other primary care (20% and falling), general surgical workforce (20% and falling fast) that is 65% of the workforce needed. Training is incapable of producing the specialties needed for the places of need. And the population is increasing faster in these places and is increasing most rapidly in demand...... 

Note to the Workforce Experts

The next time you trumpet some new innovation, at least think about what you are doing to promote an ineffective alternative treatment while delaying treatment that matters, that supports more of us, that will result in more annual FM graduates for the first time since 1980, that supports more team members to work with us, that can reverse burnout, and that can restore the joy of caring for people that really need care where and when they need care.

Recent Posts and References  

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The Massive Failure that is Primary Care Payment
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
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Innovation Incapacitation
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

Safety Net Must Sunset and Front Line Health Access Should Rise

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Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.


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