Unprecedented decreases in morale and productivity have been seen across primary care in recent years. It is very clear that team members have faced rapid changes and increasing care demands along with declining support while patients and situations have increased in complexity. Health care leaders are not paying attention. There has been no progress to improve support or to decrease the challenges.

Even worse, primary care leaders get poor ratings as they spend their time and effort and scarce resources on areas that will not reverse marginalization, burnout, turnover, and productivity problems.

A recent RAND study was very relevant and indicated increasing concerns regarding the ability to best care for patients and have been sent through formal family medicine channels. Studies document the proliferation of additional work hours before and after patient care. Numerous studies indicate the higher costs from HITECH to MACRA and for primary care medical home. These are designs that can only marginalize the team members that are forced to comply.

A recent interview of the CEO of Geisinger promotes how they are changing health care while rearranging incentives for physicians.The following is what was printed with my numbering:

  1. “take great care of patients; 
  2. treat patients like they are your family; 
  3. help us with same-day access, so occasionally that means staying late, 
  4. occasionally that means coming in on a Saturday; 
  5. help us with recruitment and retention, because we want to 
  6. make it a great place to work; 
  7. be engaged in our teaching 
  8. and research, 
  9. talk to patients about the genome study; and finally, 
  10. be a good citizen— run on time, don't use foul language, volunteer for committees, that kind of stuff. 
If you do those five things, we're going to pay you.”

http://www.modernhealthcare.com/article/20170304/MAGAZINE/303049958/qa-lets-stop-complaining-about-social-determinants-of-health-and?

CEOs are great on statistics regarding profit but are short on counting ability such as counting the additional duties and the additional hours. There is an obvious discounting of time for family and personal life.

Substantial replacement of physicians is also indicated in reviews of county workforce 2005 to 2013 where Geisinger is dominant. 

Primary Care Marginalization


Primary care once depended upon a physician-nurse team. Now less costly and less trained personnel are all that primary care can afford - as per payment design. Turnover impairs continuity across primary care team members. 

Departures of physicians and clinicians from primary care to better paid positions (urgent, emergent, hospitalist, specialties, administrative) all shrink the primary care workforce by turnover impacts. Another problem result is the decreasing experience levels of those who interface one on one with primary care patients.
 
Hospital, subspecialty, and outpatient care are all paid at higher levels and this allows delivery of such services with more personnel that have more training and more health care experience along with better support. This is inherent in the payment design. 

DRG design had a substantial impact as patients were dumped from higher resourced hospitals to lesser resourced primary care. The design resulted in the rise of hospitalist workforce to send patients home faster using less resources and now 50,000 primary care trained physicians are hospitalists.

It is the payment design that most interests CEOs, deans, and others. Departments, divisions, programs, and practices mired in lowest payments and higher cost of delivery will be marginalized. 

The factors that decrease productivity and increase burnout have become institutionalized as seen in the thoughts and statements from CEOs, CMS officials, government, associations, foundations, and politicians. 

Primary Care Must Be Valued By Primary Care Leaders

How can you claim to have value for health access or for primary care when your graduates are falling away from primary care before, during, and after training? 

Even family medicine leaders appear to be misguided. They are fiddling as family physicians fall from 95% employed in family practice positions for active graduates is down to just 70%. The rural outcomes have dropped from 30% to 20% over past decades. Family medicine has remained mired at 3000 annual graduates for 37 years and many millions of dollars and dozens of efforts have not changed what better financial design could change in only a short time. Family medicine, NP and PA graduates remaining in family practice positions remain 36% found where 40% of the population resides in 2621 lowest physician concentration counties - but fewer remaining in family practice positions is concerning as this is a direct threat to all that primary care can be. 

ll sources have declined to fewer and fewer who are active and found in primary care positions. Family practice positions filled are by far the most important and NP and PA move steadily away from family practice positions as dictated by design. The massive expansions of nurse practitioners and physician assistants have replaced the collapsing general internal medicine workforce, but more and more graduates are required to produce the same primary care. Stagnant primary care delivery capacity coupled with failing mental health and general surgical specialties is exactly the wrong result at a time with demand increasing most in these areas and most of all in the lowest physician concentration counties with greatest growth of population, elderly, complexity, and demand.

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

The blogs represent the opinion of the blogger alone.

Copyright 2017