Triple Threat Destroys the Essence of Who We Are in Primary Care

February 5, 2018 | By | Reply More

Triple Threat is what creates, maintains, and worsens burnout – and the essence of what we are in primary care.

  • Threat 1. Insufficient revenue
  • Threat 2. Accelerating cost of delivery
  • Threat 3. Complexity increasing in multiple patient, practice, and community dimensions.

Complexity is inherent in the life of a primary care physician.

Complex primary care delivered with sufficient revenue and support to cover the costs and complexities of delivery is highly satisfying. A bad financial design made worse is what erodes margin as well as time – time with patients, team members, colleagues, and family as well as personal time.

Value based designs tear at the fabric of who we are.

We know that outcomes are beyond the ability of our practices. This is actually supported by the literature in major reviews of pay for performance. Even worse, these schemes discriminate against those caring for the most complex with the least resources – with lesser pay and added complexity.

Tragically foundations with a mission for access (Commonwealth), and even primary care associations support the design changes that have worsened Triple Threat. This is particularly true for the 36% of family physicians serving the least healthy counties that also are lowest in concentrations of physicians.

The current design fails for support and worsens finances and complexity via regulation, certification, digitalization, and innovation. This worsens burnout, morale, productivity, frequency of personnel turnover, cost of turnover, and retention of MD DO NP and PA in primary care. This combination most hurts those serving the 40% of the population most in need of care, most complex, and least supported – the same lack of support as those who provide care for them.

Payments are least for the specialties most needed and their services are paid 20% less by the worst public and private insurance plans where access to care is most needed. Pay for Performance schemes guarantee greater complexity and even less payment – because of the patients cared for with inherently lower outcomes. The Triple Aim magnifies the damage of Triple Threat. Six Degrees of Discrimination in Payment Design Primary Care Medical Home adds to cost of delivery and complexity and time demand without improving finances or outcomes.

Supply, demand, and demographic changes continue to worsen access, disparities, and outcomes.
Supply of workforce is prevented by Triple Threat across generalists, mental health, and general specialties. Before, during, and each year after training, supply is compromised. No training intervention can resolve shortages of care where needed, because of Triple Threat.

Support is weakened by Triple Threat that is also compromising mental health, public health, women’s health, and general surgical specialty services. Recovery of General Surgery is Impossible This adds to the burdens of primary care physicians serving most Americans most left behind by design.

Support from small hospitals has long been required to support primary care where the financial design fails. This support can only decline as hospitals are closed and compromised by their own version of Triple Threat. Not surprisingly they too are penalized the most by readmissions. Declines in support weaken supply to an even greater degree. The primary care finances fight is THE FIGHT for vulnerable populations.

Demand for basic care is worsened by demographics and by dysfunctional designs other than health designs.
Small Hospital Triple Threat – As small hospitals and small practices face additional closure and compromise, more counties are being added to the 2600 counties lowest in health care workforce. Too little revenue for basic services plus costs driven too high compromise all on the front lines. This increases demand specific to those who remain as well as decreasing support.

Dysfunctional Housing – The collapse of affordable housing in higher workforce concentration settings will send even more of the most medically and financially vulnerable to these lowest workforce settings.
Lowest physician concentration counties with 40% of the population have had the most complex patients as well as the patients with the most chronic diseases including mental health, the worst behaviors, and the most difficult situations.

These lowest concentration settings have had the greatest rate of population growth decade after decade since 1970, growth that housing changes will likely accelerate.

This will shape greatest increases in demand (met and unmet) for these settings.The lack of sufficient workforce will drive unmet demand, increasing burnout, and other consequences.

Outcomes Compromise

Runaway health, prison, and military costs plus austerity focus will continue to make matters worse as federal, state, local, employer, and personal budgets are stripped of the ability to invest in local housing, transportation, environments, support personnel, social determinants, and other factors that make health care delivery less complex. Even worse, the changes defeat health outcomes improvements.

The Family Practice Multiplier

Family practice MD DO NP and PA are 3 to 7 times more likely than other specialties to be found in rural, underserved, or lowest concentration settings. All other specialties concentrate amid higher concentrations. The consequences of Triple Threat are most evident in the lives of the ever smaller percentage of MD DO NP and PA remaining in family practice positions. The specialty that distributes equitably suffers the most because it distributes with 36% found where 40% of Americans are found in lowest concentration counties.

Another consequence is primary care moving from the most experienced workforce to the least as fewer stay in primary care. The financial design offers better support, better salaries, better benefits, and less complexity outside of primary care.

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Category: Health Care

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