Does the AAFP Truly Support Primary Care?

It would seem that AAFP supports primary care, but is this really true. Does AAFP do all that it can to increase revenue, decrease costs of delivery, and facilitate the work of the team members who deliver the care? Does AAFP support payment designs that result in financial compromise for family physicians? It is harder and harder to make the case that AAFP stands for primary care. 

It is even harder to make the case that family medicine stands for most family physicians. 

Family medicine leaders have sent a message to Congress, but the message was not the most specific message for the Best Future of Family Medicine.

• The message was too long with too many items and poor focus.
• The message did not take the opportunity to align the best interests of family physicians with areas of interest to politicians (designs favorable to Red Counties and the 40% of family physicians in these counties)
• A message to politicians from a primary care leader should address primary care and should not mention the political environment or policies likely to be divisive.

A sailor must know how to stay on course by adjusting rudder and sails
as the political winds change. If you do not know your heading,
it is hard to stay on course or take advantage of favorable winds.

  
Does AAFP Focus on a Best Future for Family Physicians?

If AAFP had the proper priority, it would not stop until the primary care financial design was fixed with revenue greater than costs. Until this was achieved for all family physicians, especially those who make a difference between no access and some access, all floors of the Emerald Palace headquarters should be dedicated to this effort. 

An improved financial design is the one thing that could most make a difference for family physicians and for AAFP. After addressing this, it could do much more. Without a change in course, more family physicians and more Americans will be compromised.

Does AAFP Set the Agenda for AAFP?

Barring specific focus, it is easy to let someone else set the agenda. Recent decades have provided many examples of crisis after crisis For example when there are threats to federal funding for departments, saving these funds becomes the top priority. Other academic leaders have agendas that all too quickly become the agenda of AAFP. Threats to loan repayment, CHIP, Medicare, NHSC, or CHCs draw attention and distract. 

The political firewalls have acted to pit various advocacy groups against one another for a shrinking share of domestic discretionary spending. The constant battles leave little remaining for the most important battles. After wasting all possible political capital, there appears to be little left for specific focus on the failed primary care financial design.

Why not state the obvious? 

If you fail in primary care finances, you fail primary care, and you devastate family practice and care for increasing proportions of Americans most in need of care. Like the designs for economics, housing, and education, the health care design increasingly fails higher proportions of Americans. 

Worse to Come for Most Americans

The 2800 counties lowest in physician concentrations in 2040 appear on course to have 50% of the US population. This half of the US will have half enough primary care and lower levels of all other specialties. Family physicians could have half of family physicians in these counties if it can maintain its population based distribution, but it appears more likely that less than 50% of family physicians will be in office family practice by 2040 - resulting in perhaps 30% of family physicians for this 50%. Family medicine has long had a higher percentage of family physicians in rural practice than US population in rural areas. In the next few years it should slip below this proportion - entirely because of the failed financial design. The 1970s FM graduates had 30% in rural practice. This will soon be cut in half.

Two Financial Failures 

AAFP has failed to bring cognitive vs procedural debates to a successful closure. True payment reform has been denied. In fact, discussions of innovative payment designs have replaced this most important true reform. Equity in payment is also rated as a failure for AAFP. Medicare 2011 data indicated 15 to 20% less for office code payments for lowest concentration county and rural counties as well as counties without a hospital. Most Americans have joined the ranks of those left behind and family medicine leaders have not effectively defended them or the family physicians serving them.

1. Failing for decades to successfully address cognitive vs procedural is the failure that most defeats all that family medicine and AAFP could be. It is the design that unbalances workforce regarding specialty choice as well as distribution. 
2. Failing to get equity in payment for decades (tolerating 20% less) has failed 30% of family physicians in a major way and over half of family physicians in smaller ways.

No Innovative Insurance Solution Addresses Primary Care Failure

Regardless of single payer, universal, Medicare take all, Medicaid expansion, or private subsidy - the designs for payment still discriminate against those who provide basic services. Since most Americans are found where 90% of local services are basic services, the financial design discriminates against most Americans.

This inequitable payment design is why the US has shortages of workforce and substantial access barriers. Dollar maldistributions also contribute to lesser outcomes. Small portions with top concentrations of health workforce and health care dollars do well with current designs. Vast portions of the US with half of Americans receive significantly lower levels of health care dollars, jobs, workforce, and leadership. This is inequity, disparity, and discrimination by design.

Worse with Triple Aim Distraction

And the financial design was made worse. Triple Aim simplistically sounds so good, but is so bad for most Americans and those few who remain to serve them. The AAFP jumped on the Triple Aim bandwagon like all of the others - but still fails to see the folly, assumption, and discrimination that is Triple Aim. Most particularly, blind support for Triple Aim hurts family physicians.

AAFP has apparently accepted the Gruber, managed care, Dartmouth assumptions. Far too much focus has been placed in areas such as overutilization. This is particularly damaging to substantial portions of family physicians practicing where underutilization is a major problem. The micromanagers have negotiated the academic, foundation, and association circles despite critique. The family medicine leadership has good reason to be concerned for the best interests of family physicians, but FM leaders joined the micromanagement bandwagon. Opposing micromanagement does not mean opposing efforts for better quality. In fact, there is good reason to oppose micromanagement to improve outcomes. 

The MACRA Management Reproach

Don't Ignore the CBO

CBO studies clearly indicated that managed care, managed cost, and managed high risk interventions generated as much cost of delivery as was saved by the intervention. Is it so hard for a physician association to understand the problems generated for physicians by micromanagement focus. It appears to be easier to ignore CBO and experienced family physicians. 

It has also been easy to ignore the lack of evidence basis for financial incentives as a stimulus for improving health outcomes.

Triple Aim Is Triple Threat for Family Physicians

Increases in revenue to family physicians to address regulation, innovation, certification, digitalization, and higher primary care functions could potentially improve outcomes, costs, and patient satisfaction. But the implementation of Triple Aim with stagnant or declining revenue and rapidly increasing costs of delivery is a Triple Threat to family physicians.

1. Outcomes - AAFP has bought the deception that outcomes can be changed by clinical interventions - hook, line, and sinker. The truth is that outcomes are fixed in place by the true determinants of health - far beyond the ability of clinical interventions or family physicians to change outcomes. In fact, widening disparities will result in worsening of outcomes as is seen in lowest concentration counties.

Being held accountable without the ability to change outcomes just adds to burnout, frustration, morale problems, and meaningless distraction.

It is sad to see family medicine leaders embrace social determinants but not understand their application. Better investments in people result in better outcomes. Increased disparities across health, education, economic and other designs will worsen outcomes.

AAFP must listen to the family physicians in the field, not compromise them.

2. Costs reduced - Utter failure in cost reduction is higher costs. The costs of health care have been increased via increased costs of delivery. Hundreds of billions of dollars a year have been added by HITECH to MACRA.

Increased cost of delivery has been fully supported by AAFP along with numerous other consequences. AAFP has supported increases in cost of delivery by $10,000 to 20,000 a year each year since 2008. The cost increases have long been unsustainable and for no value whatsoever. Even worse, the costs have increased faster where family physicians most make a difference.

As a subset you can add productivity losses as primary care physicians, clinicians, and team members are all less able to generate revenue or address higher primary care functions. The costs of delivery changes result not only in more costs but more time stolen from those who deliver primary care, more talent distracted, and less treasure.

Time, talent, and treasure stolen away are not value. This leaves less time, talent, and expertise devoted to patients, primary care, and communities of need.

Maintenance of certification is supported by AAFP and also represents costs and revenue losses of over $10,000 a year. MOC is not evidence based for outcomes improvement and therefore lacks value.

The financial design must be improved - not worsened. Why would AAFP contribute to inequity by design? Why does AAFP ignore the gathering chorus of voices to pay attention to what is happening to family physicians?

3. Patient issues - Why would anyone think that patients would be more satisfied due to Outcome focus and cost of delivery increase have guaranteed worse patient experiences. And it is even more difficult to see patients faster or more efficiently or more productively with all that must be done.

The Decline of Family Medicine By AAFP Supported Designs

MACRA has had the full support of AAFP. Even CMS indicated that small practices would be impacted adversely. CMS has continued to develop innovative payment designs that discriminate against providers who care for patients that inherently have lesser health and lesser outcomes. Unfortunately family medicine leaders fail to understand that family physicians are most likely to be caring for the populations behind in outcomes. Prevent MACRA to Do No Harm 

The financial design failure has consequences. Not surprisingly you can count on a lower proportion of family medicine residency graduates doing office based family practice with each passing year and with each passing class year. As with IM, NP, and PA - those departing primary care are not coming back. They are being lost sooner and for longer periods. The second generation of family physicians will have far less impact for primary care, rural health, and care where needed. The third is likely to be worse. The first generation delivered on the promise of family medicine with 85 - 90% in office based family practice for a career for those still active. The second generation is down to 70% and the third may well fall below 50%.

The hospitalist and emergency room conversions may be particularly damaging as they may well represent losses of office based rural family physicians. Indeed the hospital based family physicians are 26% rural compared to 19% for office based - reflecting poor support for office based FM and better support for hospital based.

Real solutions are not difficult to understand. They are actually the opposite direction from the past 40 years.

Taking advantage of the current situation

Family medicine leaders 

• Can team with politicians to address Red County health care failures and frustrations. Substantially more support is needed for the primary care workforce that is half enough in Red Counties. In these counties the primary care services are over 70% of Red County services. provided locally despite grossly insufficient revenue and spiraling cost of delivery increases. 
• Can help politicians to develop a comprehensive plan to address the needs of 40% of the population that has been left behind as well as 50% of Veterans in these counties. This is a design that supports local care, not insufficient access. Local care is needed as populations age and lose mobility. Shipping people to distant sites across counties for care is not going to work out well. 
• Can work with Congress to reduce health care costs by reigning in regulation. CMS also needs to return to focusing on supporting those who deliver care rather than making their jobs more difficult. 
• Can help point the way to balancing workforce by increasing payments for the basic services and reducing spending specific to highly specialized care

Note: The Best Future of Family Medicine involves better primary care payment and lower cost of delivery. This is also the best future for most Americans most left behind in 2700 Red Counties and 60 Blue Counties lowest in health care workforce. 

AAFP should fully embrace this Best Future.