CMS Payment Design

Valuing the Crucial FM Care Role in the Crucible

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The latest FM blog joins a chorus indicating the difficulties in mental health. The FM version is that FM plays a major role. Family physicians play the crucial role. This role goes far beyond mental health to most of the areas where people need care. The FM role is even more important where most Americans are left out of care. 
Distribution Matters for Access Even if Designers Forget About Distribution
 
Designers assume that people can transport for care. Designers most consistently associated with top concentrations of people, income, education, and professionals do not see the transportation barriers by their design. Huge populations are forced to travel for care because 45% of physicians and health resources are concentrated in 1100 zip codes in 1% of the land area where only 10% of the people are found. These are already the most congested areas and situations are worsening – especially when care is needed most.
Distribution will matter even more as the elderly multiply fastest and consume more health care and grow older and are less mobile and are less able to transport. 
New designer wrinkles include narrow networks, more high deductible plans, practices that say they are accepting federal patients but do not (GAO), and lesser productivity due to regulation impacts.
FM Distribution Against Payment, Income, Education, Resource, and other Gradients
A major value of FM is about the distribution of family physicians and their broad scope. All other specialties fall to lower concentrations as payments, resources, income, and education decline. This leaves family medicine to cover more areas and more complexities where physician concentrations are lowest – where only family practice positions exist for MD DO NP and PA. 
The inability of other specialties to distribute should illustrate the value of family medicine and others who fill family practice positions – but even those who represent family medicine fail to understand this. Since 1980 when the family medicine leadership transitioned away from the hard working, broad scope practicing family physicians, the key value areas of family medicine have suffered.

Broadest generalists distribute most and are most important when distributed. Family physicians distribute at 30 per 100,000. As concentrations of physicians overall diminish, family physicians remain at or near the same concentration. This results in higher proportions of family physicians delivering care as other specialties drop away. This results in more burdens across more areas where care is most needed. In addition as the concentrations drop off, family physicians are more likely to be the small or solo family physicians that are 50% of family physicians overall.

Challenges Mount for Care Where Needed

Counties with lowest physician concentrations are all but a few counties found in the 35 states most left behind. Access is even more limited due to higher concentration counties far away in only a small portion of a state. Within these counties, physician workforce is even more concentrated in a few Super Center or Major Center zip codes – zip codes that receive multiple lines of payment and the top reimbursement in each.

The counties associated with lowest physician concentrations have numerous challenges across social determinants, behaviors, situations, chronic diseases. They also have only a few basic services and the lowest reimbursements for each service.

Cuts in social security, disability, nutrition, and other across the board cuts hit hard where care is most needed and where care is most prevented by payment design. Closures of small practices and small hospitals make local challenges even greater.

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Lowest Physician Concentration Counties with 40% of the US Population    n = 2621 Ratio
Low Education Counties 97.40%  
One Hospital Counties 84%  
Diabetics (42 – 48% for Smokers, Obese, Sedentary, Lesser Health Status) 50% 1.25
Disability Payments 47% 1.175
Premature Deaths 45% 1.125
Social Security Pay 2010 43.4% 1.085
Children in Poverty 43% 1.075
SNAP Payments 42.2% 1.055
Persons in Poverty 41.6% 1.04
Uninsured 40.7% 1.0175
Population 40% 1
Active Family Physicians 36% 0.9
NP and PA in FP 36% 0.9
General Surgery 27.2% 0.68
NP and PA with NPI 26% 0.65
Mental Health Providers 23.5% 0.5875
Active Physicians 20.8% 0.52
Psychiatrists 19% 0.475
Non-FM physicians 18% 0.45
Resident Physicians 6.5% 0.1625

Only 23.5% of mental health providers and 19% of psychiatrists are found in the lowest concentration counties. There are indications that psychiatrists are shrinking away from care where needed. Administrative and supervisory roles are increasing. Substantial deficits have been created by insufficient payment acting over decades.

The tragedy for over one hundred million Americans is that it will take decades after payment reforms to rebuilt the workforce and access. This is lost upon those who maintain and advance the cost cutting agenda that most undermines care where needed – not to mention jobs, cash flow, and other areas associated with payment design.

More Burdens Upon Generalists

Insufficient payment for mental health forces more patients to go to primary care for care. This has resulted in at least 50% of mental health care delivery found in primary care. The design also increases the strain upon underfunded primary care, especially primary care where needed which is mostly about family physicians. Mental health is not the only increasing burden stacked higher by “innovative” design and cost cutting designers.
Mental health access may be suffering to a greater degree since the proportion of mental health via primary care has increased from less than 47% to over 50%. Of course this could be because mental health consumption is increasing. More than likely it is about both of these. 
And it gets worse where care is already most compromised as in 2621 lowest physician concentration counties where 40% of the population are designed to have only 21% of physicians and 23.5% of mental health providers – a nasty consequence of payment design. 
The 36% of family physicians to serve this 40% of the population is just one indication of more burdens places upon all who remain and serve where lowest payments and local resources meet highest complexity.
Suffering Across Deficient Cognitive, Basic, Office Services
It should be more obvious that true payment reform requires more payment for cognitive, basic, office, primary care, and mental health. The political situation requires this additional funding to come from higher paid services. Too much cost of delivery for the revenue compromises the care along with increasing complexity.
  • The sad situation of geriatrics is a key indicator. Low payments plus high complexity have defeated geriatric numbers and distributions. Geriatrics largely exists where it can find other payments or supports. 
  • Primary care sources continue to fall away from primary care positions to ever lower levels of primary care retention. 
  • Family medicine graduates have declined from 95% to 75% remaining in family practice. Soon 15 – 20% will be in emergency medicine with 6 – 8% each for urgent care and hospitalist care. Higher paid specialties draw more graduates away. Internal medicine was once 13% of the workforce where care is needed but this will be moving to 8% or less and increasing demand centrally could well eliminate IM as a source for 40% of Americans most left behind. 
  • General surgical specialties have been declining at 2 to 3 percentage points average per year from 2005 to 2013 using the AMA Masterfile. Those few remaining where needed are the oldest.
  • Recruitment and retention costs are accelerating along with the cost of primary care physician turnover. It is not possible to hold to primary care intentions, primary care as an initial choice, primary care practices, or primary care as a career. The poor support for primary care results in substantial hidden costs across training, practice, and care where needed.
Why Ignore the Obvious About Health Access?
It should be obvious that care where needed is becoming more complex in more ways that any understand – especially those who design health care who seem oblivious to the consequences of the designs.
  
It should be obvious that that population is increasing most, the complexity is increasing most, and the demand is increasing most for 2621 lowest physician concentration counties – counties that are losing more billions shipped outside of the cash poor counties to satisfy the new regulations
It should be obvious that the designers have not crafted payment that would support 75% of the workforce where 40% of the American people remain left behind. These 2621 lowest physician concentration counties care most need the generalists, mental health providers, and general surgical specialties that are paid less under the past decades of designs. 
  • Producing more primary care graduates, more general surgical graduates, more general orthopedic graduates, more from urology or ENT or Ob-Gyn is just not possible when substantially more payment is associated with one or more additional fellowships.
  • More fellowships result in even greater concentration and lesser access.
It should be more obvious that the experts appear to understand far less than those delivering the care. Experts in health care who understand health care delivery are quite valuable. Experts  with little understanding of health care delivery and with a poor understanding of the limits of digital technology have moved the nation to higher costs without improvements in outcome – the opposite of value.
The MDs leading CMS and various foundations need to do a few hundred home visits in the counties where their designs most compromise care to see whether innovation, digitalization, or constant chaotic changes are helping or hurting access.
It should be more obvious that small practices are important in addressing needed access and are also successful in areas such as preventable hospitalizations.

It should be more obvious that the practices most in need of resources are facing the greatest shortages of primary care, mental health, local resources, dollars, jobs, housing, health habits, cash flow, and support.

It should be more obvious that these practices will receive lower ratings and more penalties and less support for team members in addition to greater distraction and lower productivity – as set in motion by the new designs.

At least it should be obvious to those who are reasonable and objective and focused on what matters and the support needed. 

Family Medicine Distributes Equitably and Others Concentrate in Concentrations
  
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Active Physicians Per 100,000 Ratio Top to Lowest Top Physician Concen-tration County Higher Middle Lowest Physician Concen-tration County
% of US Population   10% 20% 30% 40%
County Number in Category   79 152 286 2621
Best Distributed  
Family Medicine 1.18 30.77 33.08 29.19 26.03
General Surgery 2.75 11.69 7.82 6.12 4.25
Gen Orthopedics 2.86 9.08 7.19 5.57 3.17
Average Distribution  
Emergency Med 3.32 19.04 14.24 11.17 5.74
Ob-Gyn 3.42 20.48 15.21 10.99 5.99
Medicine Peds 3.44 2.58 1.75 1.01 0.75
General Urology 4.08 5.41 3.63 2.67 1.33
Gen Pediatrics 4.13 32.55 22.16 15.79 7.88
All Active Physicians 4.14 468.12 304.77 222.06 113.05
Otorhinolaryngology 4.20 5.42 3.42 2.57 1.29
Internal Medicine 4.31 64.79 42.72 30.85 15.03
Gynecology 4.38 1.22 0.72 0.57 0.28
Ophthalmology 4.93 11.20 6.98 5.03 2.27
Concentrated  
Hospitalist 6.03 0.98 0.77 0.43 0.16
Gen Pulmonary 6.22 7.91 4.63 3.16 1.27
Gen Preventive Med 6.89 1.79 0.74 0.55 0.26
Gen. Neurology 7.19 9.57 4.92 3.39 1.33
Internal Med Geriatrics 7.46 2.81 1.63 0.98 0.38
Hematology Oncology 7.83 10.33 5.14 3.46 1.32
General  Psychiatry 7.85 26.49 12.68 8.65 3.37
Geriatric Psychiatry 9.25 0.80 0.32 0.27 0.09
Child Psychiatry 9.60 6.36 3.05 2.11 0.66
Most Concentrated  
Endocrinology 10.09 4.84 2.38 1.54 0.48

 

View the above tables to help understand how family physicians must address care of the elderly, those with chronic diseases, mental health, women’s health, and other functions in addition to greater complexity, challenging environments, and unhealthy behaviors. Nutrition, public health, sports medicine, community organization for health, and many other areas must also be considered. 
Someone must stand in the gap when others are not even around. 
Promotions of Family Medicine Need More Value – from the Health is Primary Site
Health is Primary is a communications campaign to advocate for the values of family medicine, demonstrate the benefits of primary care, and engage patients in our health care system. Our aim is to build a primary care system that reflects the values of family medicine, puts patients at the center of their care, and improves the health of all Americans. Family Medicine for America’s Health launched the campaign to help strengthen the primary care infrastructure and make America healthier.
 
Teaching Community Health Centers Fail if not 3 for 3 – Training in Family Medicine Plus Training in a State in Need of Workforce Plus Training in a Lowest Physician Concentration County – only 11 of 63 Qualify for All Three  But without payment reform, Teaching CHC grads only displace others to rearrange the deck chairs as payments have not been increased to the counties in need of payment.

Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals

Wall Street Hears of Obamacare Large Practice Emphasis Mistake  “What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care. 

Casalino indicates the value of small practices in preventable hospitalization.

Small Health Complexities and Demographics

Open Season Upon Small Health Care

Do Not Assume that All Small Practices Are Doing Well

Reference Links
  • Small health care (< 5 physicians in a practice) is 45% of primary care in America as noted in the recent Robert Graham Center one pager. 
  • The common assumption that bigger is better should not be accepted without question
  • Before readmission penalties, the adverse impacts upon Small Health and others with more complex patients were known
  • Small practices do better in preventable hospitalization
Preventing Rural Workforce By Design

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access

The MACRA Test – Can You Survive the P4P Discrimination?

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA – Kip Sullivan at The Health Care Blog

Scientists Fail at Science involving Physicians and Politics

Selling and Swelling a Bigger HITECH Bubble

Time to Burst the HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Assertions that Small Practices Can Prosper Are Not Helpful

Recovering General Surgery Is Impossible

Primary Care Must Rise from the Ashes of the Last 20 Years

Outcomes are Changed by Changing Patients, Not Physicians

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Value Failure By Those Who Promote Value

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 

Finance-me-cratic Constants in the Bureaucratic Universe 

Meeting Primary Care Needs in the Last Half of the 21st Century

 Exploring the Health Consequences of Disease Focus

 

Basic Health Access: Does Primary Care Experience Matter?

 

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

Copyright 2016

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