The Commonwealth Fund claims a mission for access and yet the various studies supported and reported by Commonwealth fall short in access. There are claims of improvements from the 2010 reforms, but access improvements are more than just insurance expansion and Triple Aim. Access to care requires the primary care team members to deliver care. The failure of access is quite obvious in counties and zip codes where half of the US population has grossly insufficient MD DO NP and PA workforce.
The financial model has long been broken with regard to the workforce to provide access in these counties and other underserved settings. You cannot expand access via expansions of worst paying and least supportive plans. You cannot expect Triple Aim to help when it is most costly and least rewarding for the practices that make the difference between some access and none.
True health reform must involve an increase in the capacity to deliver care – at the national level and especially in the 2621 counties lowest in concentrations of the workforce. Care in these places in most need of access and health care is about generalist and general specialty services, services that are 90% of local services least paid by decades of design. Solutions are not difficult to figure out. Cognitive/office/basic payments must be increased. Equity must also be extended to providers in counties paid 20% less for the same services. Balanced equitable designs are the only route to access improvements for most Americans most behind.
Instead, the designs have suppressed access as seen in lower volume per physician. This is best seen in family physician surveys of a few months ago. Fewer patients per week is not a move toward improving access. Indeed 10 – 20% more family physicians would be needed for the same access delivery.
Failure of Expansions of Graduates and Team Member Consequences
It is not even a given that more graduates will result in more primary care. The designs have facilitated departures of MD DO NP and PA from primary care, even from family medicine residency graduates that used to be resistant to the adverse financial design.
The design changes have caused a distraction, morale problems, decreases in revenue, and decreases in productivity such that fewer team members can be supported to deliver the care. What would you expect when designs force budgets to increase in non-delivery areas leaving less for those who deliver care? What would you expect from more time and energy required for digitalization leaving less for personal interaction? Turnover mechanics are worsened in places in most need of care as the costs of recruitment, retention, advertising, locums, lost revenue, and orientation costs are increasing. This cost is already over $100,000 per primary care physician (or equivalent) per year and represents a more negative margin.
As another wonderful side effect, the revolving door turnover impacting underserved areas has spread to places with half of the US population and now includes the entire MD DO NP and PA workforce.
So few remain in primary care that the primary care workforce continues to move to the least experienced workforce in the history of primary care in the US.
What a wonderful addition to the front lines to move from the most experienced, highest continuity, most dedicated workforce to the least.
The Worsening Perception of US Health Care
Primary care at 55% of services sets the tone for the perception of health care – and not surprisingly the perception is worsening. Only 6% of spending fails primary care, fails US health care and fails perception of US health care.
Expansions of lowest paying and least supportive plans fail for health access except in areas already overpaid and overutilizing – generally in the largest practices and systems.
The Designers Forgot Most Americans, or Do Not Care About Them
Assumptions of the micromanagers regarding their designs to address overutilization have backfired. The consequences of being seen in the situations facing most Americans – the ignored Americans living in areas with underutilization. The consequences are specific to the marginalization of the local workforce to provide access to care.
The designers based their assumptions on just 20% of the population rather than the 50% left behind.
Countdown to Oblivion in Health Access for Most Americans
The 2010 reforms worsened the financial design for primary care, mental health, small practices, and care where needed. Stagnant payments and any small and temporary increases have been overwhelmed by the costs of delivery increases at over $100,000 per primary care physician with even higher increases in small practices.
Over Claims of Benefits and Underestimates of Costs and Consequences
HITECH was $32,500 added per physician and the overall digitization costs are much higher. The literature of 2005 to 2008 is ripe with over claims of benefits and underestimates of costs and consequences – that keep getting worse such as security costs. But this lesson is still lost allowing moreover claims and consequences as seen weekly in the literature of today. As long as the designers believe in micromanagement and fail to understand the social, personal, community determinants of health outcomes – there will be worse designs.
MACRA was $40,000 added. Recruitment, retention, lost revenue, orientation, and other turnover costs exceed $100,000 per year per primary care physician where care is most needed. The design changes did not address 10% greater losses in collections. The biggest, most organized, and most powerful enjoy discounts for supplies, equipment, insurance and other costs of delivery. The smallest end up paying more to cover their discounts and get paid less. The largest enjoy 5% annual escalation clauses. The smallest are sliced by narrow networks and lowest paying Medicaid, Medicare, private, and high deductible plans – take it or leave it plans because there are few or no others.
The financial model for generalists and general specialties is broken and the lowest physician concentration counties should reach 2800 by 2040 with half of the US population in these counties. This is the result of broken designs for access, housing, education, and local support.
Triple Aim Is Triple Threat to Health Access Where Needed
Resistance is futile, but there is a reason for resistance where care is most needed. The financial design is most broken. Investments forced by regulation, innovation, digitalization, and certification are limited by the failed cash flow. The financial design is broken.
The Commonwealth promotional material does not reflect this and actually hides the fact of broken access to care. Triple Aim without the necessary financial and other support where care is needed has been revealed as a Triple Threat – too little revenue, costs of delivery accelerating, while complexity is overwhelming in multiple practices, patient, community, and other dimensions.
Foundations and Associations That Truly Have a Mission for Access … would have environments, behaviors, attitudes, staff training, article sharing, research agendas, and policy designs quite different.
Does AAFP Truly Support Primary Care?
One would think that the most primary care of associations would support primary care, but AAFP support of Triple Aim is a Triple Threat to primary care and to health access.
What You Will Not Hear In Workforce Reform Discussions – Most Americans need an entirely different training design, an entirely different payment design, and most likely both for recovery of their basic access to health.
Failed Academic Scorecard Regarding Social Accountability – Discussions of the social mission are more common, but academic changes requested in 1990 have been ignored. Generalists are not the cornerstone and they have been marginalized by payment and training designs.
Transforming Primary Care Requires Fuel – The transformation of primary care requires payers and players. The payers have said no so the players are too few and are often overwhelmed where the players are most needed. Primary care needs fuel and a more efficient financial design, especially in the small and rural practices and those where care is most needed. The controversies continue to hold primary care hostage, especially primary care where needed where half of Americans will reside by 2040.