The Real Future of Family Medicine Is the Financial Design

Yet another large health system has decided to shut down family medicine residency positions, this time in Ohio. There are consequences to come for the surrounding populations and perhaps some complications in Ohio. Family medicine advocates inside and outside of Ohio are spending a great deal of time and energy on an area outside of their control. Time may be better spent shaping real future for family medicine in Ohio and across the USA. This is about a much better financial design and not training.

It is easy to spend a great deal of energy fighting off FM residency closure. The Bartlesville program closed not long after I became a faculty member and despite stellar contributions to Oklahoma. It did not matter that Oklahoma was in need of family physicians nor did it matter that Bartlesville was in need of the contributions of a family medicine program.

I continue to be amazed when stellar FM programs are closed  including those addressing the higher primary care functions for the most challenging local patients. The list of stellar FM programs closed extends across decades and across the states. Even programs such as  Mad River in Ohio and FM programs in smaller sites have been closed. As with other closures of small hospitals and small practices, there is no consideration of higher priority or importance for access.

But Should We Waste Energy on Another Closed Program
When Even More Will Close Without a Better Financial Design?

Resistance may be futile until family medicine has tied together most Americans left behind into a coalition that does understand more about why they have been left behind and what can be done to fill the gap.

Spare the Closure Focus and Focus on the Better Financial Design To End Closures

Family medicine has always suffered from those thinking short term and not long term. Being reactive does not work to prevent illness and it works even less with regard to program closure.

It is easy to submit closure calculations with loss of graduates to analysis. It is easy to do regressions and demonstrate a 20 times multiplier for instate location when residency graduates are trained instate (based on AMA Masterfile 700,000 active graduates in 2013). You can also multiple by 1 million in economic impact a year per graduate (AMA).

I had a fun and satisfying career doing rural visits, developing rural programs, and doing hundreds of thousands of databases, regressions, and variable manipulations some time. it is astounding what you can do when combining geography, history, policy, and databases. But truly making a difference is really about support for those who deliver the care. I am tired of lazy calculations, regressions, and generalizations. It is time for specifics. We need to move from the Tyranny of the Current Era of Health Research back to the support of what really matters regardless of gender, race, ethnicity, geographic location, or type of policy. It is time to understand the limitations of academic focus.

Family medicine must return to the roots of family medicine - a return to the power of practice and coalitions involving most Americans - as with 1950s to 1960s family practice and those who built family medicine while running their practices and fighting for better state and federal designs.

To stop the closures of FM programs, it would seem that an improved financial design would boost the value of FM - just as it has resulted in an imbalance in specialist focused training and workforce.

Rearranging the Deck Chairs

Decades of watching names change on maps without increasing primary care delivery capacity indicates that a different approach is needed.

• If there are no additional dollars entering a county lacking primary care team members, there will be no more primary care team members. 
• If there are more dollars required to leave the county or pay for costs not supportive of team members, there will be no more primary care team members. 
• If the costs of delivery are increased by regulation for EHR or digital or measurement or certification or practice consultant or team member training expenses, there will be no more primary care team members.
• If the morale and the productivity of team members is decreased by the financial design, revenues will be impacted and there will be fewer primary care team members.
• If the costs of delivery are increased by higher recruitment, retention, and turnover costs, there will be no more primary care team members. 
• If primary care practices where needed are paid less due to pay for performance, there will be fewer primary care team members. 
• If insurance payers continue to get fewer and more powerful, there will be decreased payments and fewer primary care team members. 
• If policy designs specifically target small practices and small hospitals due to assumptions that bigger is better, there will be fewer primary care team members. Designers that do not understand Small Health Care cannot help but undermine care for most Americans. Small Health Care Fights for US
• If policy designers assume that volume is bad and do not understand that volume in primary care is access and do not understand that Office Primary Care Does Not Break the Bank, there will be fewer primary care team members. The nation only pays 6% of health spending for the 55% of services delivered by primary care and is already 23rd of 26th among nations in generalists (worse than 50th where most Americans are most behind).
• If policy designers are willing to support rapid implementation of designs that lack evidence basis such as pay for performance despite the known discrimination against those that provide care where most needed, there will be even fewer primary care team members where care is most needed, where primary care is even more important because little else remains. Ending the Disruption of Pay for Performance
• If designers expand insurance plans least supportive for local primary care where needed, there will be fewer primary care team members where needed. Four Horsemen of the Primary Care Apocalypse
• If policy designers desire the higher primary care functions and better outcomes, they will go the opposite directions because of their designs that compromise the team members that are needed for primary care function. The designs that send scarce dollars out of counties in most need of dollars, access, workforce, services, jobs, economics, and social determinants are compromising outcomes in health, education, economics, and other areas. Necessary Rather than Disruptive Changes

Family medicine is at the center of these changes
and any Future of Family Medicine consideration
must begin with a much better financial design.

More Dollars for More Family Medicine Positions and More Team Members

Ohio and other states must be brought to the reality of greater support of the specialty most important for most people in the state. This requires a design that provides supported positions for graduates in the state, keeps graduates in primary care, and keeps graduates in the state.

But this also requires that Ohio supports existing plus future graduates in practice as well as retaining past graduates. Such a design does not exist due to limitations in revenue and accelerating costs of delivery

The future of family medicine in Ohio and across the nation requires a different support design.

It takes more than 6 billion dollars a year on primary care spending in Ohio (160 billion nationwide x 11.6 million / 320 million) to result in success for any primary care training intervention to work. States that have more primary care have invested more in primary care. This is not a "build more graduates" matter. It is a support more positions commitment.

The one time expansion of the newly created specialty of FM to 3000 annual graduates by 1980 required the substantial increased payments from the new and expanding Medicare and Medicaid programs to result in more family physicians and more primary care across the nation from 6 sources. Payments directive through elderly and poor were ideal for supporting more FM grads - especially in rural and underserved areas where payments increased support for more positions. The first decade of graduates had 30% rural distribution, declining over time to less than 20% - yet another indicator of payment dictating positions and distributions.

The Case Against the Designs Shaping the Last Generation of Workforce Is Solid.

• An increase to six sources of primary care has not helped.
• Massive expansions of primary care sources have not significantly increased primary care delivery capacity. 
• The 7 times expansion of NP graduates since 1980 and the 6 times expansion of PA have simply replaced the collapse of internal medicine primary care while pediatrics and family medicine have remained stagnant (1400 grads a year for PD, 2800 grads a year for FM).
• The last PA doubling did not result in any increase in primary care. This 100% expansion resulted in 200% more entering non-primary care with only 30% more entering primary care - a figure completely depleted in a few years of departures after training. 
• DO primary care contributions have not changed since the 1960s as the family practice contribution has declined from 60 - 70% to 18%. Each time DO grads doubled the FM contribution was cut in half for no change. As with NP and PA, only the family practice positions filled matter most in primary care for these three. More specialties added with more added to each specialty has steadily depleted the family practice result as more leave following the financial design to better support.
• Increases in MD grads have also not changed the 3000 annual graduates from FM. 
• The payment design has completely collapsed internal medicine primary care with assistance of 40,000 IM graduates lost to hospitalist workforce - that now claims more IM grads per class year than primary care. 
• Pediatric graduates have increased 30% but this did not change 1400 general pediatricians per class year.

Then there is the decline in the legendary family medicine retention for decades of class years from 95% retained in family medicine positions down to less than 75% due to 12% in ER, 4% each in urgent and hospitalist, and additional losses to other specialties and activities. What Is Stunning in Primary Care Is No Change By Design

Please No More So-Called Primary Care Solutions



The great problem with a focus on more academics, more FM departments, more predoc, more residency programs, more NP programs, more PA programs, more primary care schools, more international graduates, more COGME Reports (25th Anniversary of COGME Third Report and No Change By design),


A Better Financial Design Is Required for...

• More family medicine graduates. More FM grads require a different financial design with greater revenue compared to cost of delivery. No other specialty faces so much with such little support while being disregarded the most Valuing the Crucial FM Care Role in the Crucible 
• More primary care delivery capacity with more primary care team members
• Higher primary care retention for all sources of primary care
• Lower turnover of primary care up to over $300,000 per lost primary care physician and about $1 to $2 per person in a state more in costs of recruitment, retention, locums, and brokers - or about 1 million more dollars a year in a state such as Alaska not to have more primary care, but to place an ante to have the opportunity to deliver primary care
• Increasing continuity of team members to help accomplish the higher primary care functions as well as more efficient and effective care
• Primary care team members to make a difference by looking forward to practice every day rather than decreasing morale, decreasing productivity, and increasing burnout especially in the last decade
• More mental health team members
• More general surgeons. Recovery of General Surgery Is Impossible as payments are too low for basic services and fellowships result in positions with substantially more payment support. The same is true for all general surgical specialties declining at 2 to 3 percentage points a year for over a decade. All have been declining for the past decade because of payment design. 
• More workforce in all of the specialties that family physicians and their patients need most now and in the future. The payment design prevents the nation's workforce from addressing the increasing people, elderly, complexity, and demand - especially in 2621 lowest physician concentration counties increasing the most in all of these areas with stagnant to declining health revenue, workforce, and access to go with more dollars shipped out for meaningless uses.
• Better outcomes in health care. Clinical interventions substantially fail. Real health outcome improvements require a different design. Dollars need to be redistributed to places in need of dollars, jobs, services, economic impact, and social determinants. Housing, nutrition, fire, police, economic development, child development, elderly services, and other investments can make a difference in addition to facilitating the process of care and caring. In health care spending, the opposite design is required with at least the same payment for the same service 
• Better payment support of the generalists and general specialties that provide 90% of local services in the counties where 40 - 50% of Americans are found. Clinical interventions cannot accomplish the changes that improvements in local spending, jobs, cash flow, and social determinants can do. Reversing decades of increasing concentrations of health spending where few Americans are found is the route to addressing disparities. Health, education, and other basic support spending are the routes to improving outcomes not only in health, but also in education, economics, and other outcomes in places where such outcomes are lowest.

The outstanding family medicine contributions to rural practice, underserved practice, and practice in 2621 lowest physician concentration counties can only be increased by a much better financial design. The 35 years of expansions have indicated a ceiling effect such that increases in graduates from primary care sources actually cannot work to increase overall US primary care capacity.

No Pay for Performance or Value Based Design can resolve these deficits in workforce and access because P4P actually results in even less payment in these places where patients are more complex and have less resources and are more likely to have us giving their care. The impact is worse for family physicians who are the most likely to be found serving the populations with inherently poor outcomes.

Family Medicine leaders continue to believe that CMS and other designers will send more dollars their way. These hopes have been in vain. Matters are even worse. What increased dollars are available require costly efforts. The designers have no clue regarding the complexity of patient care involved. This is why geriatrics has failed without outside funding support or care involving better paying patients or plans. If designers understood complexity and impacts such as insufficient local resources, why have they paid less and increased the burdens of those few who remain to serve the most complex?

The future of past, present, and future residency programs as well as their outcomes requires a different financial design - as does the Future of Family Medicine.

It is true that better functioning counties, states, and nations have higher levels of primary care - but it is a mistake that you can produce more primary care and resolve gaps in outcomes. Counties, states, and nations that invest in people and community have better functioning in many areas and also tend to support more basic services in health, education, etc.

The future does not look good for primary care where needed. There has been no departure from marginalization across the past 35 years of payment designs. Block grants, hundreds of billions in cuts from Medicare and Medicaid, and high deductible plans all have common ground in being least supportive for local workforce, generalists, and general specialties. Obtaining higher payments is likely to be more difficult, but is more essential for FM and for our patients. Reductions in costly regulation may or may not come. Most assuredly we will have to fight for a better financial design and not be distracted by promises that promise more and deliver even less. What Is Aggressive Family Medicine Advocacy?

Our allies in family practice have always been our patients and those across 2800 counties where we are most important. We are most important for the elderly and numerous other populations. All together we are most important for greater than a majority of Americans left behind. Coalitions with those who represent most Americans represent a better future for them and for family medicine.

Working with true allies is far more important than agreeing with those who design against us and against most Americans.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Martin Luther King, Jr. 

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Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

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