The Primary Care Finances Fight Is THE Fight For Vulnerable Populations

Family physicians are the most likely to encounter vulnerable populations. Addressing the needs of these populations requires more team members with better support. The team members are the ones most compromised in the past three decades of payments too low and cost of delivery too high made worse by rapid chaotic change.

Family medicine leaders have set up a series of meetings. The track record of these large gatherings is not stellar.  The first of these meetings addressed access. The second of these meetings focused upon vulnerable populations. There is a third planned to address primary care workforce. The result will be more panels, reports, centers, and initiatives. But this will not address access, vulnerable populations, or primary care workforce.

When a single area is important to all of the core missions of family medicine associations, this should be the dominant if not the only focus.

Reports, Panels, Centers, and Grants are what CMS does when it cannot take care of health care delivery. Family medicine associations support more of the same.

"Continuing a long history of tackling disparities in patient care head on, Julie Wood, M.D., M.P.H., AAFP senior vice president of health of the public and science and interprofessional activities, announced the launch of the AAFP Center for Diversity and Health Equity, an initiative that will focus on addressing the social aspects of health care.
"The AAFP has developed its Center for Diversity and Health Equity to take a leadership role in addressing social determinants of health, nurturing diversity and promoting health equity through collaboration, policy development, advocacy and education," Wood told AAFP News."

Expanding access is a requirement for addressing vulnerable populations. 

Vulnerable populations were once considered a small population. Austerity focus and the 21st century addition of 2 trillion more dollars to health care (past 3 trillion now) have conspired to compromise domestic discretionary spending and many if not most of the supports for vulnerable populations.

Austerity focus at the state and federal level and worsening health care costs both act to compromise health care, education, economic, and other outcomes. 

Within health care, the changes also compromise the financial designs for primary care and basic services - the generalists and general specialties that are 90% of local services where care is most needed and where vulnerable populations are most likely to be found. The basic services, especially those delivered where most needed, are the ones that are provided by those least organized. Those most organized will continue to protect their interests. This will send an increasing burden to those who remain to deliver basic services - more patients, more added to vulnerable populations, more elderly, more with mental health needs, more with chronic illnesses, more complexity, less support, fewer team members, and more regulations. Vulnerable populations have no place to go other than to multiply. Family physicians are most prevalent where health access is in greatest need and this is where vulnerable populations are concentrated. Family medicine must fix the financial design for any real hope of addressing access, vulnerable populations, and primary care workforce.

The dominant US designs assure the rapid expansion of vulnerable populations to become the majority of Americans due to
  • Widening disparities in children in multiple outcomes shaping increased numbers of vulnerable populations.
  • Cascades of future impacts due to US children being last or next to last across child well being factors among developed nations.
  • Disparities in education and other spending at the state level with impacts upon health, education, and economic outcomes
  • Disparities in health spending 9 to 1 in favor of 79 top physician concentration counties as compared to lowest physician concentration counties
  • Lowest payments for primary care and basic services services that are 90% of the services where needed
  • Highest population growth (twice the average for decades), highest growth of the elderly, increasing complexity, and greatest increase in demand in 2621 lowest physician concentration counties - making populations more vulnerable (Red counties and a few dozen rural counties with a majority that are minorities and some of the worst disparities)
  • Forced migrations of vulnerable populations (fixed income, disabled, elderly, lower to middle income, Veterans) to lowest physician concentration counties where housing costs are lower and where climate is better for health conditions (43 to 48% of these populations are found in this 40% of the nation's population, The ranks swell to include 45 to 48% of diabetics, those with preventable deaths, smokers, and obese Americans.
  • The tripling of the elderly in the US by 2040
  • Rapid increases in minority populations
  • Closures of rural and small hospitals shaping populations in counties without a hospital and with subsequent declines in local workforce as one of the fastest growing populations in the nation due to more counties added and higher populations in the counties added
  • Cuts in payments to providers serving vulnerable populations from ReaganCare to ObamaCare.
  • Pay for performance (value based, readmission penalties, MACRA)) penalizing providers who serve vulnerable populations as outcomes are more likely to be lower because of the local, resource, patient, community, and other factors present
AAFP should save the dollars for the final forum on primary care workforce.

The promises of CMS and primary care associations and various expert gatherings will not address vulnerable populations, health access, or primary care workforce. This requires more specific efforts. Every dollar that AAFP can generate should be focused upon what will actually address beleaguered primary care team members, vulnerable populations, and health access. There must be no rest from this labor until the payment designs are improved for primary care, for mental health, and for basic services. This critical change must occur where vulnerable populations are more likely to be found - where access and primary care workforce are most compromised.

It is time for True Primary Care Advocates to wake up to historical fact. The only time of progress in these heavily conferenced areas was
  • During the one period of time from 1965 to 1978 
  • When more dollars were being injected into primary care and 
  • When more dollars were being injected to support more team members where health access was most needed via
  • Expansions of Medicare and Medicaid spending, 
  • Spending closely associated with vulnerable populations.
  • It also helped that this was a period of relatively less increase in cost of delivery
  • with increases in payment rates helping to cover the costs of inflation.
The Era of Cost Cutting Since 1980 With Rapidly Increasing Costs of Delivery

Since 1980 the payments have been stagnant and have at times have been cut. In addition, the cost of delivery has gone up due to regulation, turnover costs, higher than inflation costs of supplies and other practice essentials.

The largest practices and systems demand and get higher payments for the same services and even annual escalation clauses. The smallest practices and providers get take it or leave it least paying contracts from payers.

The largest practices and systems demand and get discounts from suppliers - leaving the rest to make up the difference.

The one sure thing since 1980 has been disparities worsened by numerous designs that shape health, education, economics, and children.

Clinging to Past Glory Is Misguided as Only Payment Has Mattered

Appearances have been deceiving. Numerous family medicine interventions looked good at the beginning but have not worked since. Family medicine and primary care associations and leaders still cling to the past. This time of great success when everything worked is the period of 1965 to 1978

The 1965 to 1978 policies are why so many "interventions" appeared to work
  • FM departments and student interest groups in every school, 
  • Student resident conferences, 
  • Primary care schools, and pipelines to primary care and rural practice. 
  • FM reached 30% rural practice location rates by 1980 only to shrink below 20%. Only the hospital based (emergency, hospitalist) remains 26% rural because of better financial designs for hospital based FM grads.
  • All primary care sources have fallen away from primary care - as dictated by the financial design.
  • These all required steadily increasing injections of dollars to support the positions - the positions that once expanded primary care and care where needed. The financial designs fail for the positions and the team members to address health access, vulnerable populations, and primary care delivery capacity.
No training interventions can actually work because of failed payments. Decades of data support the same findings across the vast stretches of America where most Americans fail most in access - then and now. Tracking confirms little change other than names changing, or initials changing behind the name. Rather than patting people on the back for the success of their program or pipeline, it is important to examine what is actually happening nationwide, or across counties left behind, or regarding the practices that address vulnerable populations.

We still have 2621 lowest physician concentration counties that are persisting due to the same lowest paying, least supportive payment plans - compromised to lowest paying levels by those who take advantage in higher concentration settings and those who set payment policies based on their immersion in higher concentration settings.

A better financial design is the major requirement
for access and vulnerable populations and primary care workforce.
Why do family medicine leaders avoid what is critical
to all of the major family medicine missions?

The Primary Care Financies Fight Is THE Fight
For Vulnerable Populations 

Punishing Primary Care with Medical Homes - Higher Costs without Outcomes Improvements

The Least Healthy Counties Across the United States - There Are Many Least Healthy Counties That Share Insufficient Health Workforce, Insufficient Health Spending, Greatest Patient and Population Challenges, and Least Support By Design

The Academic Family Medicine Mismatch - Is family medicine better off under the restraints of academic medicine or would it be better off with control of the entire process of preparation, training, and practice?

Two Forces Shaping Declines in Outcomes in Health and Education - Austerity Focus and Cost Cutting Due to Runaway Health Care Costs

 Mastering Well Being for Residents Physicians and Patients Takes Time - Residents, Physicians, and Patients All Need Time for Sleep, for Learning, and for Reflection

Match Hype Hinders Health Access Solutions - the tiny increase to 3200 for the FM match will yield record low levels of family medicine positions as FM grads have declined from 90 - 95% to less than 70% result over a career. FM needs more grads and a return to 90% remaining in family medicine 





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