You're Killing Us Smalls

What does it mean when someone says you re killin me Smalls?
Line from the movie "The Sandlot," meant to show extreme frustration towards someone's ineptitude or clueless-ness, sometimes both. You're killing meSmalls definition by Urban Dictionary.Nov 27, 2014   Urban Dictionary



Those that design health care are indeed killing us small practices, small hospitals, and small health care - and we let them do it.

The health care financial design is toxic to small practices. Only those with extremes of ineptitude or clueless-ness could do so. Or perhaps they are so dominated by those larger, more organized, and most powerful that they cannot see the damage being done. More confirmation of small health value and neglect

AAFP has no excuse. Half of members are in small practices and have consistently been paid the least for family practice and are paid 15% less where they practice and suffer the most cost of delivery increases. In fact AAFP supports the innovations in the misguided belief that these can help improve outcomes - which are clearly about the patient and population and not about a tiny portion of waking minutes (0.6%) spent in a primary care practice. Does AAFP Support Primary Care Delivery?   All AAFP Initiatives Should Be Focused on the Triple Threat to Financial Design.

The smaller practices are documented to suffer the most with usual disruptions but this is not enough. These practices are forced to pay the most for meaningless change - rapid meaningless change. They pay the most per primary care physician (or NP or PA) for each.

The impacts remain and multiply for small practices, rural practices, practices in counties lowest in workforce, practices serving half of Americans with half enough generalists and general specialists,

You're killing us Smalls. Sandlot was right - about family physicians. 

  • You are killing our small practices where half of us practice. 
  • You are killing our relationships with patients - most important to us. 
  • You are killing us. We are most impacted by the burnout, lower productivity, higher complexity, and fewer team members supported to share the load.

In fact, you are contributing to the demise of family physician careers and people. 

Stop pushing meaningless innovation, digitalization, certification, and regulation and start supporting those who deliver the care - care that is most complex and is worsening by usual changes and disruptions made worse by new designs.  



Smallest/Least Organized/Neglected
Largest/Most Organized/Protected
Most Needed Primary Care Location
 Most Concentrated Primary Care
Worst Paid – 15% less for office codes
Best Paid via Best Negotiation Power
Worst Cost of Delivery Increases
Least Cost Increases per PC doc
FM is over 20% of local physicians and dominates local primary care
FM is less than 10% of local physicians
Least Powerful and Least Understood Punished By Design
Most Powerful and Most Understood Protected By Design

There is only one route to Thriving at the current time. If you were in a smaller and lower paid practice and you have been taken over by some larger or better paid entity - you now have the financial means to better support your team members, care, and caring. This is a very small portion of primary care practices as few larger entities want to take over those smaller who have more complex and costly patients with lesser outcomes - because of the current design.

Isn't it interesting that the only route to Thriving is a lowest value transition. These favored practices taken over are paid more for delivering the same care to the same patients with the same outcomes. More paid for no change in outcomes is lowest value - a great fit with the US health care design. This also includes impacts on small portions of the population and avoids care where most needed to complete the themes of US health care design.

To Recover from Burnout, Lower Productivity, Overload, Poor Morale...

Stop pushing training that cannot result in more team members for increased health access and shared complexity - cures for burnout.

You have two choices - 
1. Devote all effots to change the financial design
2. Or join the other side killing smalls

More team members is the cure for 
1. Deficits of health access
2. Relief of burnout
3. Higher functions in primary care such as outreach, integration, coordination
4. More dollars flowing to places with least dollars, social determinants, and outcomes


  • The design creates deficits
  • The design creates burnout and kills those who matter most in health access where needed
  • The design prevents higher functions across primary care, women's health, mental health, and general specialties
  • The design results in additional costs of massive graduate expansions (MD DO NP PA) and special training, grants, and incentives (rural, primary care, pipelines, special schools, special preparation, recruitment, retention, more) - all wasted. HRSA and state funding is no match for the overwhelming disparities in payments arising from CMS leadership across the last generations of workforce.

When the smalls that most serve most Americans are supported rather than wasted away - we can have a foundation of health access.

 #primarycare #regulations #financialanalysis #digitization #design #healthpolicy

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