Major Journals Fail Primary Care Once Again

Major journals have slipped in another article that apparently was designed for controversy and for widespread distribution to media outlets. The title of this Health Affairs article is not original or easily misunderstood - "Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services as Compared to Other Countries." Health Affairs published the bait. Media outlets such as the NY Times were hooked.

Controversy will once again divert the nation from addressing real problems such as deficits in primary care. The American Medical Association has chimed in for a defense. Once again too much focus on physicians with the most highly specialized services will defeat basic health access.

What is common to major journals, media outlets, and the past 30 years of political administrations is a poor understanding of primary care. Errors of perspective and analysis are far too common. It is not a surprise that one of the Health Affairs authors is a member of the Obama health care team (written prior to joining the team). The current administration has made little progress and various reports and appointments may move basic health access the wrong directions. (The Health Resources Services Administration still has primary care projections for 2020 that are impossible to reach).

The nation's leadership still has little clue what goes on day after day for most Americans in areas such as basic access to health where they are left behind by US designs of health spending and health workforce. Special programs are not the real solutions. The solutions require understanding the reason for most Americans to be left behind. Steady work over 100 years has shaped the current design favoring those in top concentrations with steady and progressive declines in basic health access and primary care over this time. 

The Health Affairs article indicates that primary care physicians in the United States are paid more than in other nations. Those reading the article will first of all be confused as the article is not an easy read or one easily accessed. Entire books have failed to capture primary care differences as well as national design differences. It is not surprising that the media repostings of this article have emphasized the controversy without much indication of substance.

The authors wanted to compare other nations and physician fee differences and apparently chose the most dramatic examples to further their plan. Health Affairs allowed them to cherry pick their analysis from a huge volume of possible data that could have been chosen. Their discussions of orthopedics and primary care are actually minimal compared to their plan to do nation to nation comparisons. But primary care will be even more confusing to those reading the article. And interpretations by those in Congress could result in serious consequences for most Americans.

The title stands alone and needs little supporting evidence - Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries – the journal could have saved the 9 pages by just posting the title alone - we get this already. But primary care gets caught in the crossfire and the controversy.

One can also figure out that the US might just need to pay more for primary care because it pays way too much for non-primary care. With voluntary choice dominating health professional education, once students are admitted into training the designs drive lesser supported primary care to become non-primary care. Design flaws require more pay to keep primary care retained in primary care. This is especially indicated in flexible primary care workforce designs (nurse practitioner and physician assistant sources). Those most flexible that can go to primary care or not require higher pay to remain within primary care.  This point could have been made in a few paragraphs, but the article goes on to compare all manner of data across various nations – those who are very different than the atypical US situation.

The article and the inevitable media reports imply that primary care is either well paid or paid too much. This is confusing and distracting. Authors, health care designers, current political administrations, future administrations, and national designers need to understand much more about the current situations facing primary care and basic health access for most Americans.

There are many indications of insufficient primary care spending in absolute dollars or primary care spending relative to non-primary care spending:

• The United States has inadequate and declining primary care workforce, particularly in 30,000 zip codes with 65% of the US population – locations left behind with lower to lowest concentrations of total health workforce, primary care workforce, and health spending. The US design favors top concentrations of health workforce with top concentrations of health spending. This shapes top concentrations in all facets, including primary care. Over 60% of primary care is stacked in 3400 zip codes clustered together in zip codes with 75 or more physicians where 72% of US physicians are found with only 35% of the US population. Over 70% of internal medicine and pediatric workforce is also found in these top concentration zip codes. Only family medicine with 50 - 55% of workforce outside of concentrations has anything resembling needed distribution and persistent primary care by design
• Even greater concentrations of workforce are found in over 1000 zip codes that have absolute top concentrations of primary care with 150 – 250 primary care physicians per 100,000 in only 1% of the land area with 11% of the population. These are clearly the sites with the most lines of revenue and the highest reimbursement in each line - and top concentrations of workforce and support personnel.
• Deficits of primary care facing most Americans are an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support. This is complicted by insufficient health spending in 30,000 zip codes with 65% of the population as compared to zip codes with top concentrations of workforce and spending.
• Primary care not supported by grants or by capitated methods of payment or by private insurance has been in trouble for quite some time with increases in the cost of delivering primary care and insufficient reimbursement from Medicaid or Medicare or those with low or no health insurance coverage. The article does point out that primary care successes where populations are wealthy and are well covered with private insurance.
• Every one of 6 primary care sources (NP, PA, IM, PD, MPD, FM) has been impacted by fewer graduates remaining in primary care during training, at graduation, and each year after graduation. More are found in hospital and subspecialty and non-primary care areas. Primary care graduates deliver less and less primary care during their careers with each passing class year. This is also an indication of inadequate absolute primary care support or relative deficit compared to non-primary care support.
• Primary care graduates matched to their class years indicate gains in primary care only 1965 to 1980 with a slight short gain in the 1990s. At all other times, primary  care delivery capacity has been in decline. Primary care numbers only doubled from 1965 to 1980. Non-primary care numbers have doubled from 1965 - 1980, from 1980 to 1995, and from 1995 to 2010 and will double again from 2010 to 2025. Primary care graduates are now two-thirds non-primary care in workforce result, but perspectives have so far not allowed this discovery. Primary care can be counted on to be stagnant for decades to come. Non-primary care cannot even be counted with three dimensions of expansion simultaneously progressing.
• Only family medicine remains with 80% or greater retained in primary care over a career. All other sources have 15 – 45% of graduates found in primary care. Substantially less primary care delivery is the result. The steady year after year decline indicates more declines to come although internal medicine, physician assistant, and nurse practitioner decline rates have to slow as so few remain in primary care and proportions approach zero.
• Family medicine itself is an indication of inadequate primary care support. Family medicine is the only career recognizable as a permanent primary care source at the current time. Students choosing family medicine must integrate past influences, training experiences, and future perceptions as they make this decision. Family medicine remains at 3000 annual graduates and has not increased in annual graduates for over 30 years. This is zero growth or no expansion at all. One would not expect a permanent primary care source to expand without better support for primary care in absolute dollars or relative dollars for primary care compared to non-primary care. The specific solution for rural, underserved, primary care, elderly, poor, CHC, and near poor populations is the one road not taken - an indication of little or no US emphasis upon basic health access - by design.

Solutions: more basic health access spending specific to locations and populations and more spending upon primary care where needed

Solutions specific to health access would require diversion of a few percentage points of hospital and academic and subspecialty spending from 3400 zip codes. This small percentage would result in 10 – 20% greater spending upon 30,000 zip codes with 65% of the population. Such is the concentration of health spending as compared to the small proportions spend in rural or underserved settings.

Solutions specific to primary care would require a few percentage points taken from non-primary care to provide a 10 – 20 percentage points to primary care. Critical Access Hospitals have taken rural hospitals off the critical list because CAH funding captures a few percentage points from all other hospitals to resuscitate rural hospitals. This change was required because cost cutting designs for health spending after 1980 resulted in massive rural hospital closures. The design changes defeated rural health gains 1965 to 1980. Once again those in charge at the top failed to consider basic services needed by most Americans. Rural primary care is clearly facing the greatest possible crisis at the current time with declines in primary care workforce and continued declines in sources of rural workforce. 

Given those in top concentrations in charge of the health care design, the result will be the same as in the past 30 years

• Stagnant spending in primary care with stagnant to declining primary care workforce
• Stagnant health spending in 30,000 zip codes with 65% of the US population
• Increased health spending in a variety of non-primary care and hospital settings (and crippling increases in the national GDP spent upon health care)
• Increased health spending in 3400 zip codes that already have top concentrations of workforce which will shape even greater concentrations of workforce. 

Articles that imply primary care doing well will not help address the major health access problems facing most Americans. A similar problem is announcements of grants for a few million here and a few million there while hundreds of billions poor into just a few zip codes under the dominant design for health spending.

The practice settings with the most lines of revenue and the highest reimbursement in each line are able to take workforce from any other settings.

In the past decade alone teaching hospitals have already claimed tens of thousands of primary care nurse practitioners and physician assistants to replace resident workforce lost (work hours restrictions).

Hospitalist workforce has claimed over 20,000 internists and 30,000 total physicians in addition to more non-physician clinicians.

The US designs are crafted by teaching hospitals and hospitals and associations. The designs allow those in top concentrations to prosper with even more consequences for those left behind. Also design changes tend to shift greater responsibility elsewhere as in hospitalist workforce with hospitals discharging patients and responsibilities onto lesser paid primary care settings and already overburdened primary care nurses - increased work and responsibility for little or no increased revenue. This is another example of errors of perspective where one action has a number of consequences.

Again and again lower paid primary care workforce has been tapped to address non-primary care areas over and over – emergency, geriatric, sports medicine, hospital, teaching hospital, urgent, and hospitalist with more to come. Primary care nurses, nurse practitioners, physician assistants, and physicians are paid less and this results in higher levels of turnover (loss of continuity) as well as departures from primary care to non-primary care careers.

Designers fail in specific primary care training, fail with departures of primary care graduates from primary care, fail to consider important areas such as experience in primary care that result in continuity, and fail to design policies that retain primary care or assist in the delivery of primary care. Innovative solutions are still associated with NP and PA workforce that were created for primary care and basic health access, but articles fail to point out that NP and PA workforce have been diverted over two-thirds to non-primary care workforce. Articles and experts fail to illustrate these failures. By working steadily for what works for a few, most are left behind steadily and progressively - by design and by those who are supposed to critically appraise designs.

Pay for Performance is another innovative design that works for those in top concentrations. It is not a surprise that this reward originated in top concentration circles. Physicians caring for patients in top concentrations receive top quality ratings by caring for those that have top socioeconomic status. For once JAMA got this one right. The Hong study in JAMA indicated physicians rated low quality just for caring for the underserved. Unfortunately it is rare for journals to consider the more global perspective just as it is rare for authors or workforce experts to capture this perspective. State designers interested primarily in cuts and cost savings have little or no understanding of the increased future costs or health care consequences that they are shaping year after year. Only recently with the Medicaid Randomization study (Baicker) have we had any clue regarding just how much having health care coverage matters. Health Affairs has been exposed to the right perspective, but how many booster doses are needed? 

Primary care personnel are more difficult to retain due to designs that pay more for hospital, subspecialty, and non-primary care areas. The US designs insure shortages of personnel, less experienced personnel, and higher costs just to obtain personnel for locations with the least workforce that often have the most complex populations. The past, present, and future reimbursement designs have shaped these outcomes by resulting in steadily less paid for low primary care billing codes relative to non-primary care code. Pay for Performance has demonstrated no major benefit as well as harm to underserved settings that have lower quality specifically because they care for patients left behind by US designs for education, economics, jobs, and health care.

Health Affairs has dedicated entire journal issue contents to primary care innovation and reinvention without including a hint of how the US would actually have the primary care workforce to address primary care delivery, much less innovation in primary care. This tends to distract from solutions rather than contribute to solutions.

Designers have all contributed to substantial dysfunction in primary care from fragmentation in care and from more competition from sources with much better revenue (urgent, emergent, non-primary care) and from policies that convert primary care trained graduates to non-primary care workforce.

Primary Care Practice Internal Design Failures

Primary care has continued to require more and more personnel (more overhead) at a time when primary care is more difficult to deliver. And the next 20 years of aging and other changes will make this even worse.

Within primary care sites, the practice dynamics represent serious problems. More and more personnel are required that are not actually involved in primary care delivery. Two new modes of care delivery have been created because the costs of overhead are too high (collaborative care, boutique care). Both modes are a fit for certain providers and patients, but result in even less primary care delivery arising from the primary care workforce that is already too few.

Primary care has multiple more barriers to efficient care. Billing for primary care is way too complex with way too many sources with way too many requirements. Receptionists must screen for fraud and collect ever more information. Primary care nurses direct clinics, insure compliance, train staff, keep on top of new weekly care care requirements, take calls, make important care decisions regarding triage, gather ever more fragmented health information, and spend countless hours dickering with insurance companies so that patients can get appropriate care. Government and insurance company efforts force every more innovative technology and equipment and personnel uses that are increasingly expensive with little help for what matters

• primary care volume sufficient to overcome health access deficits and
• primary care quality.

More cost for less care delivered to fewer is not a good plan when half of the nation is being left behind by design.

Specific and SMART Solutions for US Health Care Woes

• Universal health insurance coverage specific to primary care (not all care)
• Single payer specific to primary care (also separates primary care spending from the chaos and marginalizations of current US payers).
• Primary care specific training for primary care workforce that remains specifically in primary care for a career. MD, DO, NP, PA, and RN students in this plan would be admitted with requirements to serve the careers and locations needed. Instead of grossly inadequate selection and training specific to primary care, the US would be specific. Current training is one size fits none made worse by voluntary choice plus aberrant policies. These result in concentrations of workforce and inadequate primary care. Also junior or senior students dedicated by obligation to primary care should spend a year as a health care team member in a primary care setting helping to provide care for people in one of the 30,000 zip codes in need of primary care
• Primary care should be steadily sent more revenue with non-primary care sent less, until US workforce is back in balance and US health spending decreases rather than increases. This results in less loss of primary care workforce as well as primary care workforce with greater experience and greater continuity. Does Primary Care Experience Matter? This also forces higher volume from non-primary care that will also help address shortages of non-primary care.

Or we can all wait another year or two or a decade to see what happens as non-primary care expands in three dimensions and primary care remains flat by design.

SMART designs for health access and primary care will be opposed by existing designers using major journals, government reports, and the media to make their points - to keep the typical policies intact and to keep top concentrations of spending flowing to locations with top workforce concentrations - with few or no responsibilities - and with the usual guarantees of high profits. Finance-me-cratic Constants

Additional Major Journal Failures

What Do Medical Home Studies Indicate?

Another publication, this time from Pediatrics, indicates the value of a medical home. But is this value about the term “medical home” or is this value about the concepts that are associated with “medical home”- concepts that any number of providers and clinics can address.


In addition, this is a poorly conceived study with a major failure to consider the real reasons for differences - social determinants that shape access, continuity, and better outcomes.


Why Are HRSA Projections of Primary Care So Wrong?

Why are 2008 HRSA Projections of Primary Care Workforce indicating substantial increases when the reality is decreases in primary care?

Primary care workforce is substantially less than annual graduate numbers depict due to departures from primary care during primary care training, at graduation, and each year after graduation.

The Health Resources and Services Administration projection of 2020 physician primary care was last posted in 2010. This document indicates increases in primary care that are impossible for internal medicine and family practice. To properly guide the nation, HRSA must not wait for new data or studies. It should remove the erroneous projections. This major document represents much good work tainted by the primary care projections.

	Family Medicine	Internal Medicine	Pediatrics
Annual Graduates since 1980	3000 and steady for zero growth for 30 yrs	About 1% annual growth to 7200	About 2% annual growth to 3200
% Primary Care Entry	85% - surveys, office based retention, COGME 91%	20 - 25% for senior resident surveys and COGME	44% for senior resident surveys and COGME
2010 Primary Care	100,000	80,000 – 90,000	45,000 – 50,000
2020 Primary Care	100,000	60,000 – 70,000	45,000 – 50,000
2030 Primary Care	100,000	40,000 – 50,000	45,000 – 55,000
Steady State 30 yr Entry	3000 per year	1400 per year	1400 - 1600 per year
HRSA 2020 Primary Care Projection Exhibit 18	143,350 family/general practice	155,330 IM Primary Care	72,730 for PD Primary Care
Past Entry into Primary Care in recent years	2500 - 3000	3000 – 3500	1200 - 1400
Annual Primary Care Entry 2010 to 2020 to reach HRSA 2020 Projections	Double from 3000 to 6000 FM Grads 2010 to 2020	Five times entry requiring all 7000 IM Grads to stay in PC	Double the current annual entry to 2600 each year 2010 to 2020

Family medicine has not changed and given 30 years of zero growth, is not likely to change. Internal medicine primary care retention has been cut in half in primary care entry in the past 15 years and 20,000 internists, typically those younger, have entered the hospitalist workforce in recent years. The decline in primary care internal medicine is a worst case scenario for the elderly doubling 2010 to 2030. Any increase in annual graduates in family medicine would have been most specific for the elderly, poor, near poor, rural, CHC, and other populations in most need of primary care.

Pediatric experts have indicated saturations of pediatric primary care in the locations where pediatricians locate primary care practices (Cull, Committee, Freed). Because PD primary care is saturated, increased pediatric annual graduates have resulted in lower proportions remaining in primary care. Expansions of PD annual graduates have demonstrate lack of an ability to increase primary care via expansion. 

Government and foundation reports indicate nurse practitioner and physician assistant contributions to be made in primary care. It is true that primary care contributions have increased, but it now takes 2 to 3 times more graduates for the same primary care, rural primary care, and underserved primary care delivery since 1980. This is because fewer remain in family practice employment – the predominant primary care, rural, and underserved delivery vehicle.

Government and foundation reports also are not specific and the media reports of these efforts are even worse. The reports imply indicate "nurse substitution for physicians" or "nursing as a solution" or "nurse practitioners as solutions." Generic solutions such as more nurses or more nurse practitioners are not specific primary care solutions. Specific solutions for primary care are only 1 in 50 nursing school graduates and only 1 in 4 nurse practitioner graduates that are specific to employment in family practice as a direct care clinician.

Retention in family practice for MD, DO, NP, and PA graduates

is the only significant primary care, rural primary care,

and underserved primary care solution.

Retention in primary care is required

for any source of primary care to result in primary care workforce.

How can viable workforce discussions proceed if major association, foundation, and government reports are in error? Getting beyond agendas to people in need of basic health access is the specific requirement for primary care to be able to address basic health access.

Projection methods for primary care fail when graduates fail to remain in primary care. Projection methods fail when assumptions intercede and displace reality. Common sense tests must be applied to be sure that projections during rosier times (such as the 1990s for primary care) do not result in inflated projections.

Studies must encompass entire careers of contributions using realistic estimates such as those based on years in a career, primary care retention, and activity levels. With only 30% of primary care graduates serving in primary care careers and wide variations in activity and years in a career, the folly of depending upon annual gradutes is quite apparent.

SMART measuring tools are required that assign future workforce to the class year of graduation. This is illustrated in the Standard Primary Care Year – a method that can Specifically Measure Achievable primary care in a Realistic and Timely way.