Soon No Specialties Left to Limit Family Medicine Scope

Recent meetings of family physicians brought up the age old question of expanded scope. Some raised concerns about threats to this scope. As is the usual, what is most important is the context. Where half of Americans are found, there is not a reason to be concerned about scope. 
Only in highest concentration settings are family physicians limited - since all specialties other than family medicine concentrate in higher concentration settings.

The competition is less and less of a problem regarding broad scope for family physicians in lowest physician concentration counties. Few of the other specialties remain and many are in decline. 
This places more burdens upon the remaining family practice workforce. This comes at a bad time as the practices require more time for documentation and there is less time for expanded scope such as hospital and procedural activities.
As discussed previously in recent blogs, the payment designs continue to be the major limitations for all of the above workforce types. Generalist and general specialty services are 90% of the services in these lowest concentration counties. The overall payment design pays less for the basics and the basic services are paid less in these counties. This is a poor design where care is more complex and resources are more limited.
Notably the attacks on scope have proceeded from insurance and payer designs. 
  • Liability premium costs put the brakes on many procedures - and a key route to better revenue generation in practices sent the least revenue by payment designs. This forced full scope obstetrics beyond many family physicians, unless they predominantly did such work to support the liability premiums. Hospitals are closing and obstetrical services are closing in these 2621 lowest concentration counties also a consequence of payer designs failing for the basic hospital services of these smaller facilities.
  • Government and insurance payers have also dumped assistant surgery - once a key expansion of scope and another revenue generator.
Countdown Workforce in Lowest Concentrations
  • FP positions filled by MD DO NP and PA distribute best at 36% to match up to this 40%. FM is 24% of local workforce where needed and reaches 38% when counties do not have a hospital or in the states such as Nebraska and Kansas. 
  • General internal medicine was 13% of local workforce where needed but is collapsing to 30,000 or below. The 4 times greater multiplier for top concentration settings will substantially reduce this contribution to 5% or below. 
  • Contrary to many studies indicating the need for geriatricians, they fail for distribution where the elderly and most complex elderly are found. Only 13% of geriatricians are found in this 40% of the population where 45% of the elderly are found. Geriatrics fails for financial design reasons - basic services paid too low and complexity too high. Inkind contributions from academic centers, nursing homes, rehab centers, and large hospitals insure that geriatrics remains concentrated along with the physician origins most closely associated with higher concentration settings. 
  • Pediatric workforce is only 6% and stable but pediatric physicians are stacked toward concentrations along with every other specialty other than family medicine. Gender changes, origin changes, and payment changes will further limit distribution. 
  • Mental health fails for lowest concentration counties where this 40% of the population easily has 45% of mental health problems. Only 23% of mental health providers overall and 17% of psychiatrists are found in these counties. 
  • Shrinkage of public health has long complicated care in lowest concentration counties and has also expanded scope. 
  • General surgeons were 27% with general orthopedics at 24% and general obstetrics gynecology at 22%. These and other general surgical specialties have been shrinking at 2 - 4 percentage points a year from 2005 to 2013 in the AMA Masterfile. There has been no sign of stopping. This should not be a surprise since these are the lowest paid services. These are also some of the oldest physicians - an indication that training of these basic surgical types is incapable of addressing care where most Americans are found and are increasing most in elderly, demand, and complexity.
All physician types who could act to reduce family practice scope are concentrating and contracting. This should result in lower physician concentrations overall and higher proportions of family medicine in the lowest concentration county physician workforce. 
In addition to challenges of scope, the challenges from patients are also significant - and are substantially increased in these places with lowest resources and workforce.

US Population 40%
SNAP/Food Stamp Spending 42%
Poor Americans 43%
Elderly Americans 43%
Obese Americans 43%
Social Security Spending 43%
Smoking Americans 45%
Preventable Deaths 46%
US Veterans 46 - 48%
Poor Children 47%
Social Security Disability $ 47%
Diabetic Americans 50%
40.7% Uninsured 2014 (so much for health insurance expansion as not that much different than the 40.2% of the population in lowest concentration counties)
  • 40.2% Population in 2010
  • 38.6% Population in 1990
  • 36.6% Population in 1970
The lowest concentration counties are fastest growing in numbers (30% faster than US average), in elderly, in demand, and in complexity - only the finances remain stagnant, miring these counties at 115 physicians per 100,000 and likely less.
Combinations such as Dual Eligible patients, homebound elderly, poor children, those with more mental health days, and those with poor to fair health status are more likely to be seen in these settings. The permutations that add to complexity are endless but the support has been limited by past, present, and future designs.
Housing and other lower cost of living factors shape patients with lowest paying plans into lowest physician concentration counties. Those stuck cannot leave and those driven out of higher concentration counties (financial reasons, lack of affordable housing) accumulate. The health payment plan failures shape the workforce failures.
Family physicians increase in proportion as local determinants of health decrease. The payments also decrease for the same office codes. The new Pay for Performance designs place additional limitations with higher costs and more penalties because of the populations in lowest concentration counties. The discrimination has been documented, but the bandwagon of Pay for Performance Rolls On.

The major battle remains the financial design that rewards non-basic services and penalizes those who most serve where needed, their patients, the communities in need of services, and basic health access in the United States.
But the new health care law, if enacted, will make matters worse. The impact will be substantial upon Red Counties already hurt by cuts in the supports noted above, with more to come.



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