The Essential True Reform Restores Primary Care and Much More

The list of distractions from True Reform are impressive. For decades True Reform has been specifically avoided as primary care worsens within practices and from outside. The demise is most specifically about the financial design. Unless there is a focus on True Reform, there is little hope for Basic Health Access.

This may not make as much sense to those outside of family medicine. Family physicians not familiar with AAFP may also be clueless. If you think that you can fix primary care with more technology, more rearrangements, more types of health professional graduates, or more expansions of training - think again. None of these have any hope of working without financial design changes - major changes.

The following are various concepts that dominate the discussions at AAFP and primary care meetings and media releases of associations and foundations and institutions.

Members, staff, media releases, programs, and personnel have been reviewed.  There is little about True Reform. There is a lot about everything else other than true reform - particularly the various popular bandwagons of the day.

Dedicated, purposeful efforts will be required to achieve True Reform and not have it distracted further away from us. 

It Begins

Single payer health insurance is yet another in a long line of insurance plan distraction from true reform. The health care plan does not matter. What matters is greater revenue over less cost of delivery - the opposite of recent decades.

Medicaid expansion is a distraction from true reform. Pro or anti-ACA are distractions from true reform and the literature is increasingly distorted by politics and attempts to prove one or the other. Perhaps the worst thing that could happen is a partial expansion. After 10 years of Medicaid expansion across the nation - the deficits of primary care would remain. This is because the expanded plans are worthless for primary care where shortages exist. They are already paid less. Paid less than the cost of delivery shrinks primary care. It does not help expand primary care. Numerous bogus studies are coming out to show differences for expanded states compared to non-expanded. These differences are about the populations, not the plans and they have been in place for decades before and will remain for decades - regardless of the plan.

Collaborating with consumer groups is a good idea. The entrenched powers against True Reform must experience most of the nation if not all against them before they will allow True Reform. But AAFP is pushing its value based agenda, even when family physicians are crying out for help. They need True Reform, not consumerism.

Promotion of value based focus rather than True Reform is a waste of great potential. Tell the American people that we family physicians need more time with them, not more time focused on metrics, measurements, and micromanagements - the Three Ms that steal our time with patients, team members, and families.

Training focus, HRSA, more graduates, and special types of graduates are a distraction from true reform. No training intervention can work. 

• The dollars for primary care each year remain flat at 180 to 200 billion. 
• No more dollars, no more workforce, particularly with greater costs of care. 
• Where 40% of Americans have only 25% of workforce, the primary care practices are paid less. They have to be paid much more to expand access. This is true reform and it is not happening.
• These practices where most needed had about 38 billion in 2010 for half enough. They would need at least 60 billion for enough primary care.
• But these practices have had to fork out  1 billion more a year for the Three Ms as seen in HITECH, MACRA, PCMH, and Value Based. 
• There is only 30 billion left to run these practices. They have steadily less to invest in primary care. They cannot hire or keep workforce by design. They cannot do higher functions - by design. The practices are being closed and compromised without True Reform.
• Nothing works to increase primary care levels for any source of workforce other than True Reform

Sadly this is not evident to the associations. More AAFP staff are doing more in more areas not related to true reform. Their hiring, these new positions, and their efforts - are distractions from true reform. 

Until there is true reform there should be a moratorium on new positions, programs, and personnel not related to true reform efforts. 

AAFP has added more to deal with metrics, measurements, and micromanagements. They have added more to address consultants, corporations, CEOs, and CMS - the ones that are worsening our financial design. 

• AAFP, Commonwealth Fundation, and others focused on health access or saying that they are focused on health access need to focus on True Reform.

 The Health Resources and Services Administration HRSA is viewed by many as a solution for primary care. It most definitely is not. HRSA is far too small in budget and personnel to overcome the designs shaped by CMS and payers. More health centers, more recruitment and retention incentives, NHSC focus, more HRSA programs and expenditures are a distraction from true reform. 

• Patchworks exist because true reform does not exist. 
• Fix true reform and patchworks are not needed for practices or hospitals. 
• Patches are held hostage by politicians – enriching them and distracting us from true reform. Every time these come up for reapproval - we loose millions of precious dollars wasted on patches while True Reform is not addressed.

Board certification focus is a distraction from True Reform and is also a distraction stealing time for revenue, time with patients, time with team members, and time with family.  

Not only is it a distraction, but more dollars paid to boards worsen our finances. More of our time stolen to satisfy board requirements is worsening our practice and personal situations plus not being evidence based for outcomes improvements.

Diversity focus is a distraction. Diversity is very popular with associations, institutions, foundations, and the media. Diversity focus is not necessarily wrong. But addressing diverse population needs requires True Reform. The Americans left behind represent diversity unaddressed. Populations across levels of disparities are suffering and need true reform to access care. Equity in payments is required to address diversity.

Diverse types of medical students cannot choose family medicine, stay in family medicine (best distribution to diverse populations) or locate where needed without true reform.

Advocacy is a key characteristic of family medicine. We advocate in so many areas. But for us to be more effective and advocate more - we need a solid financial foundation. 

• Witness who goes to medical association conferences including AAFP - those paid for as in best systems and academic settings and doing best in finances or with practice arrangements such that they can attend conferences.
• Those struggling with finances and support - are focused on their practices. This can result in them being underrepresented.

More well being conferences, more student interest millions, more resident interest millions, more FM departments, more residencies, more FM graduates are a distraction from true reform. True reform has a much better shot at improving these areas.

Assertions of working substantially with CMS are a distraction – when true reform is not accomplished.

Foundations, associations, institutions, research, and media blasts claiming that technology or reorganization of primary care or value based designs are a solution for primary care – are a grand and glorious distraction from true reform. Single issue focus is important – when that focus is true health reform.

AAFP News stories about 60 second surveys about social needs, guide to population health, death from falls, FPs should lead, FPs steer the AAFP are a distraction from true reform.

AAFP leaders claim that members have a voice. But there is a selective group that can attend. Who represents those who are forced to practice longer and harder and cannot attend.

True Reform

True reform puts workforce in place where half of Americans have half enough generalists and general specialists across the basics that are 70% of health care services and are 90% of local services where most Americans most need care. They will still need to travel for more specialized services, but there is no reason for them to go across 1 or more counties to get basic services for primary care, mental health, and women's health as well as basic surgical care. Lack of True Reform focus insures that most Americans are at risk due to lack of Basic Health Access.

True reform values office, cognitive, basic services – even if this true reform forces cuts in the more expensive services, training, recruitment, retention, or other distractions

True reform helps small practice, primary care where needed, FM department finances, FM residency program finances, family medicine choice, family medicine retention, AAFP membership,

True reform supports more team members in our practices to share the load.

True reform can result in more higher primary care functions such as integration, coordination, and outreach. Until we exist as a resource, there is nothing to integrate or coordinate. The same is true for womens health, mental health, and basic surgical services.

True reform distributes health care dollars more equitably – especially if there is a focus on true reform specific to those serving the half of Americans with no or reduced access. The opposite of true reform is happening now with stagnant revenue, continued lowest payments where most needed, more penalties where most needed, and highest cost of delivery increases where most needed.

True reform should not require outside interventions and increased costs. True reform is focused on the team members that deliver the care with increases in their numbers and distributions and supports.

And true reform likely results in improvements in costs.

Women's health requires true reform. Women's health discussions not related to improving revenue for generalists and general specialists doing women's health are distractions from true reform.

True reform requires a reduction of the Three Ms focus of metrics, measurements, and micromanagements and a major reduction in the dollars going to those who do not deliver care as noted by the Three Cs of corporations, consultants, and CEOs.

True reform is a visible, palpable, reliable increase in the revenue over the costs of delivering primary care as well as other generalist and general specialty services.

True reform restores hope to those getting hopeless.

True reform can tip the balance back so that fewer independent, small, and most important practices do not close – and potentially they could expand.

True reform injects enough dollars so that we can cover for patients who cannot pay and those with worthless insurance plans. Access is expanded regardless of insurance or not. Payments less than costs of delivery kill access for those with and without insurance where most Americans most need care.

True reform improves cash flow, jobs, economics, and social determinants for the half of Americans most behind by the designs of health, education, economics, and more. This can also result in improvements in outcomes because the populations are being changed – or at least are not being abused as much by the health care payment design.

True reform could restore the public faith in physicians and in primary care with more time for patients. It can restore our faith with more time for team members and more time for our families.

True reform can stabilize finances and team members to allow opioid interventions, continuity telehealth, focus on mental health issues, expansion of hepatitis C services, support for caregivers, and other more complex areas to be addressed by more team members in more places.

Every day we get claims or blames. We will continue to get these as physicians. But we can expect some improvement with true reform. Without true reform – there will be steadily worse.

Hopefully you will see why True Reform is the most important focus in primary care.

Bob Bowman

Basic Health Access