A Few Hundred Million More is 8 Billion Less for Primary Care

A few hundred million more dollars for primary care is small change compared to 8 billion dollar annual increases in the cost of delivery.

The various ACA and CMS proponents have been feasting on JAMA articles by CMS and President Obama. Primary care advocates hoping for any good news also pass around these pieces despite what the real message is about. It is important to read the fine print. Rather than the promotion of the new math, we need more who can calculate the damage being done to access and to primary care delivery capacity year after year for decades.

Primary care is about people taking care of people. The main cost of delivery of primary care should always be the cost of the employees that deliver the care. The design of primary care should add more support for the team members that deliver primary care. The innovative designs have found ways to subtract from care delivery.

Primary care delivery capacity is about the magnitude of support specific to primary care team members. It is quite obvious that the real story past, present, and future is not addition. MD DO NP and PA streaming away from primary care across selection, training, and years of practice has long been enough evidence of compromise.

New math may claim that the addition of insurance coverage adds to care, but adding more patients to lowest paying plans paying below cost of delivery is quite obviously not the solution for insufficient primary care delivery capacity.

Why would anyone believe that paying less for primary care

and paying even less where care is needed

plus compromise of the small practices where care is most needed

would add up to anything other than health access failure?

Primary care stories are about subtraction

• The subtraction of funding cuts, delays, denials, and lack of payment - There is no funding increase planned for primary care. At best there is a rearrangement of existing funding.
• The subtraction of increased cost of delivery - No funding increase plus increasing cost of delivery subtracts from primary care delivery capacity
• The subtraction of productivity loss - There is also a productivity loss involving hundreds of hours a year that physicians, physician assistants, and nurse practitioners (the MD, DO, NP, and PA that choose to remain PC) must spend to address paperwork (electronic paperwork, Health Affairs).
• The subtraction of morale and motivation to deliver primary care - After spending more time before and after practice to address the paperwork, it is difficult for clinicians to care for patients in the way that they feel patients should be cared for. The subtractions include loss of the will to practice, loss of the ability to practice independently, or loss of the will to practice primary care at all.
• Subtracting small practices is a poor choice to address access as the small practices are the most important when remaining viable to practice

It is obviously difficult for payers, politicians, and pundits with short term members to understand the changes

• from good payment prior to 1980 (with much lower cost of delivery) that allowed Medicare and Medicaid payments to expand care to cover those with low paying or no insurance
• to the cost cutting years of the 1980s with more rapid increases in the cost of delivery
• through the short years of slightly better pay in the 1990s
• to the rebound against primary care plus higher cost of delivery with less ability to care for patients without insurance or with low paying insurance
• to the current stagnation in pay with accelerating cost of regulation and other costs of delivery with patient volumes too high and inability to care for low pay or no pay patients.

Isn't it ironic

• that insurance coverage expansion is accompanied by the inability to care for patients in need of care?
• that high volume in health care is considered abusive in physician practices but is important for access to care in primary care? Sadly the impacts of declines in payment, marginalized margin, and productivity declines are not seen as impairing access.

Could it be that the fervor to flatten physicians has resulted in little more than flattening primary care, mental health, and basic services paid least by design?

Government and Insurance Payers Face 3 Basic Choices

• to support primary care more with additional funding (avoided for decades),
• to choose to cut specialized or hospital care and shift funds to revalue primary care team members (best choice),
• to choose to allow cuts and compromises to continue as since the 1980s

The last choice has been the best slippery slope choice to keep the steady declines in primary care, in mental health, in access, in continuity of care, and in are where needed under the radar.

Meanwhile this gives politicians, associations, and foundations free reign to claim new solutions for all of these areas - solutions impossible due to the subtractions of cost of delivery relative to stagnant funding.

The Case Against A Few Hundred Million More

Even though CMS, HHS, and President Obama indicate "more pay" for primary care practices, there is actually less on the way. Substantially more is being taken away in cost of delivery and productivity loss while very little is being added. Adding also costs more time and money and delivery distraction.

Small change is small change

Primary care was held hostage by the previous payment design and MACRA allows only small increases less than 1% annually and far below increasing cost of delivery. Other specialties have many routes to escape cuts and small increases by focusing on higher paying codes or different locations.

Since primary care has only a few office codes/cognitive services, there is no way around lowest payments remaining lowest.


CMS may send more to various demonstrations and grants compared to what is paid out in increases - and these grants and demonstrations are not specific to care delivery.

A few hundred million more in various "increased" payments is a tiny portion of the 150 billion a year spent on primary care.

Does the term strung along come to mind?

But the Real Story is not Addition, the Rest of the Story is Subtraction

The few hundred million in "additional pay" or grants or demos widely promoted by CMS and dependents is a stark contrast from the bleak reality facing primary care as indicate by another 8 billion dollar loss due to the increase in the cost of delivery ($40,000 per primary care physician for quality metrics, Health Affairs)

Mental health is also failing due to lack of cognitive payment design reform. Failure in primary care is also failure in mental health. Overburdening primary care used to do 46% of mental health and now has a 50% share. This indicates that the most cognitive and complex services may be compromised the most.

Don't expect help from the Mental Health

The Subtraction from Primary Care Could Not Come at a Worse Time

Primary care

• Needs to be expanded above the current annual limit of 500 million primary care visits as set by inadequate primary care payments
• Needs to be expanded in places of need with half of the workforce concentration due to payment deficits (worsening cost of delivery worst where care is needed is a worst case scenario)
• Is increasing in demand due to demographics such as more people and rapid increases in the elderly and patients with high complexity
• Is increasing in complexity due to the additional requirements of integration, coordination, and outreach (and at a time when communities are facing cuts in resources applicable to health)
• Faces significant productivity problems due to poor morale, adjustment to rapid change, and burdensome EHR requirements
• Faces turnover of staff, team members, and clinicians due to changes in the workforce and payment insufficient to the challenge

How can you retain in primary care when all other positions for MD, DO, NP, PA, RN, and other team members pay better?

Payment = retention = continuity = outreach = coordination = social determinants

Primary care change that matters is specific to more team members and requires a 30 billion dollar boost (20%) just for the team member component to attempt to deliver the care.

As with the 1990s "reforms" the lack of primary care delivery capacity substantially negates the health reform result. Note for example that poor Medicare, Medicaid, Metallic payments negate the impact of health insurance expansion.
President Obama promoted the "proven health reform ideas" of ACA in his JAMA article but avoided discussing winners and losers - the result of all health policy changes. Not mentioned in his article were the words primary care, community, rural, underserved, access, cognitive, integrate, and outreach. These appear to be the loser areas - areas I consider most important for true health care reform involving improved access, improved distribution of workforce and the economics of health care spending, reducing divisions caused by health spending, and improving the true shaping forces of health outcomes - social determinants, behaviors, environments, and other patient factors - factors ignored by CMS resulting in the aberrant designs. Also not mentioned were accelerating administrative and non-delivery costs, productivity and morale changes, and decreasing competition due to mergers of health corporations, insurance companies, systems, hospitals, and practices. Local care is losing and megacare is winning - by design.


To understand US health care, one must understand the pecking order as seen in payments

• Highly specialized dominate over basic services
• Procedural services rule while cognitive and interactive are marginalized
• Care for higher income, most advantaged patients is most valued while care for most Americans falls behind
• Urban dominates and rural falls behind by health and many designs for funding distributions across health, education, jobs..

Cuts in care can be avoided or minimized by those at the top of the pecking order. Those at the bottom face closure, compromise, and worse impact of rapid changes.

Recent Posts and References  President Obama and His "Proven Health Reform Ideas" President Obama indicated in JAMA "We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since." More Geriatricians Will Not Solve the Geriatric Care Crisis The Great Folly of Health Care Quality Studies Rallying One Hundred for Health Access Not MACRA The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them. Government Compromise of Trauma Response Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed... Prevent MACRA to Do No Harm Poor Payment Dictates Poor Training Outcomes in Primary Care No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric The Consequences of Innovation Procrastination - Distractions due to innovations result in harm to millions who need care delivery, but we have more rearrangements, confusion, reorganization, rapid change, and worse. It is time to stop exhausting possibilities and support those who do the work of front line health access. The Federal Cause of Shortage Areas and Access Barriers - The Federal Design for payment shapes the breadth, depth, and locations of shortage areas due to lowest payments for Medicaid and Medicare and other plan designs that pay least  Primary care can be recovered and should be recovered,  but cannot be recovered when moving the wrong directions Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org The blogs represent the opinion of the blogger alone. Basic Health Access Web   Basic Health Access Blog   World of Rural Medical Education