Open Letter to Family Medicine Leaders Regarding Expansion of FM

Please reconsider your plans to devote major resources to expand family medicine graduates. We must work together for FM, but we must be effective. Effective efforts must be specificity to address the problem. The problem in primary care cannot be solved by training. More reports, conferences, staff resources, and association resources would waste time, effort, and energy.

It is meaningless to attempt to expand any primary care, generalist, or general specialty workforce without the dollars specific to support more delivery team members. Only a major improvement of the financial design can support more team members in more locations - especially where most Americans have the least by design.

The lack of effectiveness of more graduates is obvious and has been for decades. New sources of primary care and massive expansions of four sources have not resolved deficits of primary care or workforce where needed. The glut of workforce created will make matters worse.

The financial capacity for primary care has been and remains the limiting factor. This is best seen where workforce is least concentrated.

Lowest Workforce Concentration Counties

The 40% of the population in 2621 counties lowest in workforce had an estimated 38 billion for primary care. This is based on 180 billion for primary care in 2010. There is only 25% of the primary care workforce in these 2621 counties (AMA Masterfile, Area Resource File). The collection rates are lower in these counties (by 5 - 10 percentage points). The Medicare 2011 payments were 15% lower for office services in these counties.

What is most obvious is that these counties have concentrations of patients with the worst public and private plans. They did not lack health insurance more than other counties as 40.6% of the uninsured were found in this 40.2% of the population. The problem was and is - the financial design. The worst plans are the most obvious contributor to the situations facing these practices.

Expansions of the worst plans, declines in economics in these counties, and closures of small practices and hospitals have not helped. Each of these contributes to additional limitations upon the primary care workforce.

The Losses of Primary Care Delivery Capacity via Digitalization, Regulation, and Innovation

Lower workforce concentration counties tend to have smaller practices - the practices that have 30 - 80% higher costs of delivery for implementation of each of HITECH, MIPS/MACRA, and PCMH. This worsens the financial design. Using Health Affairs and other publications indicating the greater costs per primary care physician, the costs of delivery for these three have resulted in 8 billion going to consultants and corporations rather than staying in these practices and communities where dollars are most needed.

Since 2010 the revenues have remained stagnant, subtracting 8 billion or about a billion a year in higher costs of delivery, this leaves only 30 billion where 38 billion once was there to invest. Other costs of practice have gone up above inflation and these practices also have higher rates of turnover and greater losses from turnover.

It is possible that a small increase of 1 or 2 billion in revenue has been realized, but the losses are greater than the gains. The finances dictate fewer and less effective team members - by financial design.

•             Turnover, productivity, morale, and burnout issues arise from the financial design.

•             Retention issues arise from the financial design - in primary care, in a specific primary care practice, in an area of need.

•             Choice of primary care and family medicine is suppressed all along the pipeline - more leaky due to the financial design.

Please demonstrate to me how graduating more FM, DO, MD, NP, PA, Caribbean, or newer types will help the problem of half enough primary care for half of the nation - by financial design.

Rearranging the Deck Chairs Is Not Improvement in Primary Care Delivery Capacity

Rural programs, FQHC programs, and pipelines can result in higher proportions of graduates entering practices where needed - but once again the financial limitations do not allow an increase. These special program graduates only displace others. It is a rearrangement of the deck chairs on the Titanic.

I tracked outcomes on the Nebraska map for over a decade. The names and initials associated with the names changed, but the capacity never changed in the 70 counties in need of workforce. UNMC graduates choosing FM were 22 times more likely than those not choosing FM to be found in one of these Nebraska counties - BUT the county levels of workforce did not change. Others also tracked a decline in primary care capacity due to changes as tens of thousands lost all forms of insurance. Eastern Omaha was critically impacted. The reason was the financial design change.

So you can demonstrate numerous relationships to more workforce - but not an actual increase in workforce.

Increases in Workforce Delivery Capacity Require More Revenue, Lower Costs, and Better Support for the Team Members Delivering the Care.

The US designs have resulted in stagnant to declining revenue, much higher costs of delivery, worsening complexity of care and patient, and less support for the team members delivering the care.

Do you want more graduates to face more adverse practice conditions? Is that fair to graduate more without dealing with the real problems facing primary care?

Recognizing True Improvements in the Financial Design

It is not possible to improve finances if the costs of delivery are increased - limiting any increase in revenue.

There are four states that have set up some increase in primary care spending by payers - but they have embraced high cost of delivery value-based designs.

Even worse, the practices that care for patients that inherently have lesser outcomes and greater complexities - would get even less by so-called value based designs. The hospitals in these 2621 lowest concentration counties, the fewer that remain, had the highest rate of readmission penalties at 14% compared to 9% of rural hospitals, 5% overall, and 3% of urban hospitals.

Providers behind by design need more support - not more punishment and discrimination.

Yet to Be Considered in the Financial Design

The financial design does not compensate for rapid change, meaningless change, or usual disruptions (losses of key personnel, changes of location or ownership or EHR or billing, Mold in Annals of FM). Other disruptions are present, are likely to impact small and medium practices most, and are not considered (major illnesses in team members or families, impacts on personal family time, local economic setbacks, impacts on private practices of nearby public supported practices).

Recognizing the Lies About Training as a Workforce Solution

The Dean's Lie about medical school production of primary care is widely recognized. We should face up the the lies about training as a solution for workforce deficits.

Obvious Setbacks to More FM Graduates

• Fewer recent FM graduates remaining in FM 
• Face up to a nationwide move to declining primary care visits.
• Face up to practice compromises and closures

States such as Alaska have long realized that retention was the main problem. Each year Alaska has to spend 1 million more on recruitment and retention (Office of Rural Health). This projects to about 200 - 400 million a year more in additional direct costs to primary care practices where needed. The losses of productivity, orientation costs, and other adjustments are much more.

Retention within primary care has long been the problem for MD DO NP and PA. This is also predominantly about the financial design. Turnover has always been more rapid for NP and PA. PA studies document movements from one primary care practice to another and out of primary care. Recent expansions have been negated as the expansion has almost entirely gone to non-primary care workforce.

Massive, massive expansions have not solved deficits and cannot - because the dollars remain the same. Nurse practitioners are one of the best examples. More NP graduates are in primary care, but not as many as have been produced. About 45% - 50% train in family practice, but obviously the nation does not have this half as a primary care workforce. The financial design does not allow it. 

If expansion worked, NP would have long ago erased deficits of workforce. NP are past 33,000 annual grads and still increasing at 14 times annual population growth rate. US MD DO and PA annual graduate expansions are at 7 to 10 times the annual population growth rate that has slowed to 0.6%

So it is folly to consider expansion as a means to the end of addressing deficits of workforce.

Losses of Generalists and General Specialists Will Continue

The financial design limits nationwide primary care, mental health, ob-gyn, general surgery - across lowest paid generalists and general specialists.

Primary care levels nationwide remain stagnant over the decades while non-primary care workforce continues to increase.

It should not be a problem to recognize the real problem.

There is a close relationship between primary care, mental health, women's health, and basic surgical care. These are all in decline by design. This places more burdens upon those who remain. Each of these workforce segments only have about 25% of national workforce in these lower concentration counties with 40% of the US population. 

Accelerating the Workforce Deficit Problem

Even worse, decade after decade these counties have had  populations growing at the fastest rates in numbers, demand, and complexity. 

You could also consider that more counties are being added to this lower concentration county segment as hospital and practice closures are specific to this financial design. The US should have 50% of the population in 2661 lowest concentration counties by 2035 or 2040. Housing deficits in higher concentration counties could accelerate this change. 

A Plea for Sanity

It is hard to stop focusing on more graduates as has been the case since the 1970s. But the only time FM truly increased in annual graduates was during the first decade, when the financial design (Medicare, Medicaid) added substantial dollars to primary care and where primary care was most needed in these counties with concentrations of poor and elderly.

More primary care or family medicine schools did not work. Departments for all medical schools did not work. Family medicine interest groups have not worked. They only worked when the financial design changed interest in family medicine.

Our graduates across all decades of graduation need your help. Those yet to come are also an important consideration. 

If you plan to get more graduates to choose family medicine, then it is even more important to assure them the support for lifelong rewarding careers.

I implore you to examine the evidence – and focus the resources upon the financial design. There is nothing else that comes close to this top priority for family medicine, primary care, general specialists, and most Americans that have the least – by design.

Bob Bowman

Basic Health Access