Every day there are articles, blogs, and speeches proposing a fix for primary care. The latest to cross my desk comes from Health Affairs. Another value based plan is proposed to address the needs of patients with dementia. We can agree that individuals with dementia do have complex health care needs and their caregivers are often overwhelmed. We can agree that primary care is the most appropriate care venue for such patients. But I would argue that primary care is currently not capable of the challenge. Before additional proposals are considered such as those involving innovation, digitalization, reorganization, regulation, integration, coordination, or outreach – the financial design must be addressed.
How Does Innovation Hurt Where Practices, Towns, Health Facilities and Resources are Small
- Innovation Is a Distraction from Real Primary Care Solutions
- Innovation Focus Forced on Team Members Contributes to Overload
- Innovation Is More Likely Where Primary Care Is Better Supported
- Innovation Is Least Likely Where Financial Designs for Primary Care are Worst
- Innovation Specific to the Care of Each Different Patient is the Heart of Primary Care
- Innovation, Integration, Coordination, Outreach, and other Higher Functions Are Prevented By the Financial Design
Compromise By Design
Primary care is currently overwhelmed with too little support after years of stagnant or declining funding plus worsening costs of delivery, especially the worsening costs of regulation. This comes as primary care is forced to deal with major increases in the complexities of patients and of practice. The financial design for primary care is not helping. Stagnant revenue with forced increases in the cost of delivering care impacts primary care budgets. This has resulted in fewer primary care team members, less skilled team members, and more burdens placed upon the fewer that remain (the formula for burnout). Focus on the Financial Design to Address Burnout in Doctors, Nurses, Others
A new financial design is needed that results in more and better team members who can engage in more specific areas – such as the care of Alzheimer’s patients. They can share the load with each other and take on some of the burden of caregivers - but only with better support. Others would claim the need to address social determinants to aid those with various illnesses. But this also requires investments at the community level - time, talents, and treasures. Like the dementia caregivers and the primary care team members, the people in these communities are burned out from too much burden faced by too few as complexity increases in number and demands.
The situation is even worse where those with hundreds of the most complex conditions and diseases and situations are concentrated. This has developed as they have always lived there and cannot afford to move elsewhere or prefer not to do so. They are joined by those who are forced to move there due to worsening finances, the need for less costly housing, less costly living locations, and the need to find housing that is actually available. Often the financial decline of such patients and their families is about their health situation. Tragically they are forced to move from places with higher concentrations of primary care, transportation, and supports to places lowest in such concentrations.
Indeed, this is the design of the United States health care system with few receiving the most at highest cost and most Americans receiving the least.
An example of highest complexity, least support, and lowest concentrations of workforce can be found in 2621 counties with 40% of the population. These counties have higher concentrations of elderly, oldest of the elderly, veterans, diabetics, patients with COPD and asthma, mental health issues, and much more. This is 75% of the rural population and 32% of the urban population united by lowest concentrations of MD DO NP PA primary care mental health women's health general surgical workforce and even less of more specialized care. These deficits are specific to the county and adjacent counties. These are vast regions of the US with deficits while only a few counties jammed together have the health care workforce.
This 40% in general has over 45% of the most demanding diseases, situations, and conditions. Not surprisingly these populations have inherently the worst health outcomes - mortality, longevity, premature death. In these counties the primary care levels are lowest with just 25% of the workforce that is generalist or general specialist. In these lowest concentration counties about 23.5% of mental health providers are found along with 15% of psychiatrists and 12% of geriatric psychiatrists. This is the consequence of lowest payments for the most basic generalist and general specialty services – paid 15% less according to Medicare 2011 in these counties. These counties are where the worse public and private health insurance plans are concentrated. Office, cognitive, basic, and serving where needed all translate to lower payments and stagnant payments – by design.
The primary care practices in these counties do not need more innovation – they need support from better funding. They would like to integrate and coordinate – but need the team members to help integrate, coordinate, outreach, and otherwise engage outside of the office, with caregivers, with local community support, with specialists, with schools, etc. Because these are smaller practices that are more likely to be a part of the community, they are painfully aware of the overwhelming needs, but they are overwhelmed by the designs that fail to support them to do what is needed. Concentrations of Medicaid, Medicare, high deductible, and worst private plans are shaping their shortages, and the lack of Basic Health Access.
So, most important before discussions of innovation, integration, coordination, outreach, telehealth, or other higher primary care functions – is a better financial design.
These practices do not need more regulation – they have had to pay 30 – 80% more per primary care physician for HITECH, MIPS, MACRA, and PCMH. Digitalization, regulation, innovation, and usual costs of delivery are conspiring to kill off what remains of the primary care workforce in these areas. They also do not get any compensatory funding as they deal with these new disruptive areas just as they have not had additional funding in the past to deal with higher cost areas such as higher turnover and usual disruptions (losses of key personnel, change in EHR, billing, owner, location, Mold Annals of FM)
These practices do not need special programs or special payments to better care for the half of the nation behind by design – they need real funding to support real people to deliver real care to people in need – who are increasingly ignored by our nation.
Dementia Is Not the Only Disease To Address
Dementia is one of hundreds of diseases, conditions, and situations more prevalent where our nation supports generalists and general specialists least. It may make sense to form some special service, program, or payment design in places with higher concentrations of workforce. These proposals mean little for most Americans and the 25 – 30% who continue to serve them – despite the flawed financial design.
Better Revenue, Decreased Costs of Delivery, More Team Members
The path to improvement in their health care is very specifically about a much better financial design involving public and private health insurance or whatever replaces them. The greatest flaw of health reforms 1990 to 2010 to the present – is that lack of help for the fewer generalist and general specialty team members that serve most Americans as shortages get worse, complexities increase, and supports decline.
And more meaningless debates about what primary care should be or what health insurance should be - should not distract from the focus on a better financial design to support the people who actually deliver the care.
We Are Not Growing Primary Care, We Are Shrinking It - Not only is primary care delivery capacity declining, we are shrinking primary care from within by compromising team member functions.
Real Health Care Solutions, Not Value Focus
The CMS Contribution to the Demise of Rural Health - CMS leads by example - the wrong way
You're Killing Us Smalls - Small health is being killed off by design.
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