Assertions that Small Practices Can Prosper Are Not Helpful

We need to end disparity by design, not make excuses for it.

First, the South East Rural Physician Alliance is the correct title (not association). 

SERPA + Blue River Valley = Rural Comprehensive Care Network would be a fitting media piece about small and rural practices – but not when used for some other agenda.

Second, our nation needs to hear from family physicians that situations in primary care and especially in small primary care and in rural health care are not prospering - as I did 3 years ago in an AFP Blog. FM leaders may well be surrounding themselves with the wrong influences since family physicians from rural areas or who served in rural areas are all around. 

It has been 20 years since my AFP article - Continuing FM’s Unique Contributions to Rural Health Care. It was a call for family medicine to keep rural health as a priority. Across many key areas, family medicine has not done so.

Most of all, we have been relegated to a failed financial design - and we are not alone. Preventing General Surgery  Preventing Rural Workforce By Design

Their Future of FM Has Failed

The primary care medical home design has been promoted for the past ten years as the Future of Family Medicine in many articles such as those geared to students. Even now the Graham Center calls for more funding for overall primary care (from 150 billion to 300 billion out of 3 trillion in health spending), but the research leaders of FM still cling to the PCMH model. Why cling to the past or send 20% of revenues outside of the practice and away from practicing. It should have been enough to see $105,000 per primary care physician in additional cost or 20% of revenues diverted from what matters most. 

This mode is demonstrated to be a financial failure in Annals of FM despite three forms of supplementation.

The Great Hope of past FM leaders and the focus of the last 10 years of effort - is demonstrated to be a failure. And unless payments are raised, the year after year erosion of stagnant pay and higher cost will take down the most important family practices, primary care sites, and more.

True vision all along would have devoted decades of effort specific to the funding to deliver on a real future for FM. All models of practice and of training clearly depend on a foundation of substantially better payment.

Leaders Lead with Sacrifice 

Leaders are out front. They need to share the risks of those they lead. Our leaders seem to be in a different place. Perhaps those most focused on practice and patients are screened out by the process of becoming a leader.

Do leaders now benefit by developing a close relationship with corporations, government, and foundations. Administrative positions paying well do call to those with leadership experience.

Changes impacting leaders may not be the changes important to half of family physicians and half of the American people. Perhaps they might want to rearrange priorities to focus on these two halves to make a whole for family medicine and their patients and communities.

A Call for FM to Be Much More
My recent blog called for us to put the past 20 years behind us ASAP. Family physicians are still unique in our contributions in rural and nearly all other areas in need of access, since few others remain.   We also need our leaders to address the Six Degrees of Discrimination By Health Care Payment Design

Our FM leaders should be much more because family physicians are so much more.   

In contrast, the current health care policists and designers and innovators have nothing to offer family practice, primary care, mental health, rural health, or care where needed:
  • Their designs have substantially increased the national costs of health care delivery without improvements in quality or other key areas. They have achieved the opposite of value. 
  • Their designs have resulted in major impairments of productivity to the tune of 2 hours of EHR for every hour of patient care.
  • Their payment based on “quality” methodologies are unable to assign individual physician or hospital responsibility. The designs are nebulous at best.
  • Their methods are unable to reliably discern quality as demonstrated by Sullivan and others. 
  • There is scientific evidence for discrimination - for their design sending lesser payments to the critically needed providers that we most represent – those willing to take on the challenges of delivering care where care is most needed. 
  • Their design has been about rapid chaotic change. Such change is not a friend to health care delivery and is most disruptive to small health care and health care at are below margin - by design. Providers kept off balance cannot focus on patients and patient care.
  • Even when failing with meaningful use and across insurance "reforms" and ACOs, the rapid pace continues devoid of reflection, constructive critique, and cessation when failure is demonstrated.

Fight or Fail

FM leaders must fight for true reform - increased payments for small and solo practices, small and rural hospitals, generalists, and general surgical specialties. Without dedicated efforts, Recovering General Surgery Is Impossible and others will not be recovered either.

Do leaders really want a marginalized family medicine torn apart by changes from within and from without by those who least understand us or our patients?

The Future of Health Access

Family medicine continues to have a key role to play. We interface most with the practices and facilities and specialties most threatened. The futures of generalists, mental health, small health, and general specialties are entirely about a completely different payment design. 

No training can overcome the payment distortions. You cannot force workforce. You can only support workforce, or fail to do so. An entire generation of family physicians has had failed support dating from 1980 to the present and beyond. Not surprisingly family medicine has remained at just 3000 annual graduates - the level first reached in 1980.

Even our own family medicine training has been loosing in key outcomes. Every source of primary care that has fallen below 60% in primary care retention (IM, NP, PA, PD, MPD) has rapidly declined to substantially lower levels. Family medicine is closing in on this mark as retention in family practice has counted down from 95% in family practice positions to less than 70% and is still falling. With fewer active in primary care, more distorting influences are generated.

Results Not Excuses
We need leaders that will not excuse the designers from the disparities that they have caused - in health access, in workforce, in jobs, in cash flow, in team productivity, and in more. We must remind them about the people that they are ignoring - people with real and pressing needs - our patients - the patients who have to make up the gaps when Medicaid and Medicare fall short.

Return to Access Focus

Access focus is the primary obligation of every health access association, foundation, and institution. This is a duty ignored for far too long. 

It is the duty of FM leaders to return all of them to their mission and away from misguided innovation and insurance expansion worship.


The health care designers think that situations are OK out there. The situations are not OK for us, for our patients, for our communities, and for 80 - 100 million Americans that are suffering by design.

Assertions that Small Practices Can Prosper are not helpful. 

Such assertions are disrespectful to thousands of family physicians who have been toiling despite a stacked deck for the past 30 years. After a year of "learning" as president and a year as Board Chair, this assertion is disappointing.

We needs leaders that shape US, not leaders shaped by a process that shapes out a priority placed on family physicians and their patients. 

Without an outside perspective there will be little progress towards a solution. As W Edwards Deming noted, 

The prevailing style of management must undergo transformation.
A system cannot understand itself. The transformation requires a few from outside. 

Deming noted that a focus directly upon lower cost was likely to be limited in results. Health care designers should acknowledge the need to design for health care delivery rather than designing for cost cutting.

Deming also noted that quality relies upon "the matrix of relationships,"  and rural health care is a prime example of numerous interacting relationships. When designers fail to include the outside perspective, focus too narrowly upon quality or value, or fail to understand the complex matrix of relationships, progress in rural workforce recovery will remain limited.

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016


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