Family Medicine Does Care - FMDC

We have been advised by AAFP leaders of the purpose of the Family Medicine Action Network. Apparently there have been numerous complaints. Some of us are considered to be a pain in the rear, or worse. Imagine that.

If you are a family physician, I urge you to belong to this list serve so that you can hear and speak for yourself.

This was my response – too long as usual, but I felt it better fit in one piece so that those upset can delete it in one document and be done with it. For those who want to review and reflect and see what might be done rather than the same approaches, there is plenty of material.

In some ways, this is a "what I would do as an FM leader" type of piece. But leader or follower, something must be done as what we love is being destroyed right in front of our eyes.

Some of this you may not necessarily agree with. Some I am not sure about, but the reasoning follows from decades of life experiences.

 There is no harm in discussion.

A discussion group such as Family Medicine Action Network should respect discussions on policy, even if contrary to the current policy efforts. There is no harm in opposing the status quo. It is our duty to oppose the status quo when it does not facilitate what we value as family physicians.

• Yes, family physicians have clearly made decisions different than most physicians involving schools, residency training, and practice. Considering all physicians to be alike is a mistake.

Policy proposals specific to the family physicians that are most threatened, should receive the most careful attention and top consideration of the Families of Family Medicine. If the current health policies worsen their situation, worsen health access for their patients, and worsen the social determinants and therefore the outcomes of the populations that they serve – we should react strongly and explore all possibilities of reversing this horror story. Those who think that they are doing good by their policies (CMS, health insurers, managed care consultants, software corporations), need to know the harm and consequences of same.

Policy proposals suggesting new lines of attack should also be considered since the old lines of attack have not resulted in important changes specific to family medicine and family physicians as well as basic health access.

I have divided the following into Go Areas that we should consider as a top focus. I have also listed stop areas that we should minimize. We are limited in resources. We must focus. You may disagree, respectfully. But you should consider.

If you see some area to discuss among these or other areas, why not? If you don't agree, then point this out.

Go Areas Highest in Priority and More Likely to Have Impact Favorable to Our Values

·         Go Area Point of Attack – The Elderly Increasingly Left Behind

·         Go Area Point of Attack – Go Forth on Protection of Future Health Professionals

·         Go Area – Focus on the Urban Populations Left Behind That Have No Advocate and the 2621 counties with 40% of the population falling behind rapidly by design

·         Go Area – Go Forward By Rallying Patients and Practices to File Health Insurance Complaints

·         Go Areas – All of the Above Areas Could Help Us with Media Attention Directed to Advocacy for Patients

·         Go Areas – All of the Above Areas Could Help Us with Media Attention Directed to Advocacy for Patients - over a decade of media attention has shifted opinion away from drug companies and the horrors of their pricing. It will take many years and many types of efforts to improve basic health access.

·         Go Area – Health Care Dollar Distributions Result in Disparities and Worsening Outcomes -

This is a research economic impact approach. This approach points out how the designs for health care dollars favor practices, systems, and populations with higher concentrations. This focus exposes discrimination against those with less. Social determinants and health outcomes will be worse for the 40 – 50% of Americans designed to have the least health care workforce, the least health access, and the least generalists and general specialists. In particular the lowest payments where workforce is short and billions more a year diverted from these practices and hospitals to pay for metrics and measurements and micromanagement – are likely to cause worsening outcomes because of greater disparities.

Stop Areas to Terminate or Minimize So that We Can Focus Attention On Higher Priority Areas Where We Can Make a Difference

·         Stop Area – Stop Promoting the Managed Care Groupthink by Those Unaware of the Damage Done to Us and Our Patients and the Populations We Serve

·         Stop the Rural Focus - Why focus on rural deficits? – I am not deserting my solo rural family medicine roots or my decades of rural medical education. We have higher priority areas involving more of the population and more family physicians.

·         Stop Areas – Stop Saying That Training Can Fix Deficits of Workforce, Primary Care, Generalists, General Specialists, Mental Health, Womens Health, or Basic Surgical Services - Training is far too weak to reshape NP PA MD and DO away from the most specialized and costly services that have the best financial design.

·         Stop Areas – Stop the focus on temporary fixes such as loan repayments and much of what is done in HRSA. (As a background, many family medicine departments and residencies are dependent upon government funding sources such as HRSA. NP and PA training, NHSC, and CHC funding is also in HRSA)

Family physician leaders may not want to stop this, but consider that nearly all of what HRSA does can be addressed by improvements in payments to generalists and general specialists – particularly Medicaid. Medicaid paying 30 – 40% more on par with better health plans would be enough to cover the costs of caring for Medicaid patients plus some margin to invest in more and better team members (imagine that, patient centered care and higher functioning primary care, currently denied by Medicaid design).

Cling to HRSA if you want, but consider that payment options favor all across primary care, especially primary care where most needed.

Why continue to go along with the current status quo? Why focus on areas better for others and not good for family physicians or family medicine?

Why continue to retreat and be defensive or apologetic?

Why not attack, especially when we know so much of what is going on is wrong for our patients, our nation, and us?

Why not listen to those lifetime dedicated to family medicine and relatively free of the secondary internal family medicine interests and the outside bandwagons that both distract us?

If they kill off more of us on the front lines of service considered in many ways to be most valuable (moving more Americans from no access to some), how can our values hold? If our leaders do not value access for most Americans with the least, they will never come to value us and what we add to value in out nation.

Why not listen to those of us dedicated to databases, analysis, and health access research for over 20 years – one who has taken a critical view of the usual research involving workforce and outcomes?

There are others also that we have brought up, and there is evidence based literature, but this is not changing our course?

Why continue to support the past two decades of managed care to Dartmouth to Orsag to ACA to Value-Based groupthink which has consistently worked against those who do the most prevalent and most basic care – and suffer the most harm by constant redesign?

1. Tired of losing, then try a different approach.
2. When your "enemy" is strong and entrenched, do you attack or do you find vulnerable areas?
3. Do you win by encouraging students and residents to go along and become one of us as we have become with worse to come,
4. or should we help medical students and residents and nurse practitioner students and physician assistant students to understand what horrors lie in wait for them with a glut of workforce and continued poor support of basic, cognitive, office, most prevalent, and most needed services – where the team members will turn over the most and have the least experience – by design?

There are some Go Areas of Attack and there are some Stop Areas of Attack - policy areas where we should minimize or cease our activities.

Go Areas

Go Area Point of Attack – The Elderly

The elderly are increasing rapidly in numbers, in demand, and in complexity. Our nation has actually been shrinking support for the elderly in key areas such as nutrition, housing, social support, and health care. Americans are aging and getting poorer and more vulnerable. The challenges of providing health care to the elderly are enormous and are getting worse.

Even worse the elderly are increasing most in population, numbers, and complexity where the bankrupt American health care design is shrinking generalists and general specialists - by far the most important for care of the elderly. And the elderly with their worst paying plans (Medicare, Medicaid) will lose out even more by selection bias. CMS plans and state government plans are insufficient, burdensome, and disabling to primary care, especially where most lacking.

Family physicians have long been documented as more likely to care for the elderly. These past studies were done before the collapse of internal medicine primary care. The internal medicine geriatric workforce is only 12 – 13% found where 45% of seniors are found – in the 2621 counties lowest in health care workforce. Office family physicians are 36% found in these counties – matching up best to this 40% of the population and 45% of seniors. But services to seniors are limited because there are half enough generalists and general specialists in these counties – by financial design.

MEPS data indicates declines in primary care visits, particularly for the elderly. Lower income counties are also losing. Clearly the counties behind already have the worst designs financially and there is little reason to expect anything other than the most massive declines in primary care visits in these counties.

This is a vulnerable area to attack. The senior advocates have been set back but are rallying.

Go Area Point of Attack – Go Forth on Protection of Future Health Professionals

Go Forward with Informing Students and Residents in Training.

Do we get anywhere by pushing family medicine on students and residents given the continued deterioration of the financial design, especially where family physicians are most needed, most valuable, and most important?

Many of us know the pain suffered by family physician forced to move out. They have long been married to their practice and communities. They have endured personal, community, and practice stresses and sacrificed to hold these together, but the financial designs make this more and more difficult. Should we marry family physicians to practices, people, and communities that they will have to leave?

The situations may be worse with nurse practitioners. Finally there is some recognition of their unprecedented massive expansion. Nurse practitioner students need to know the results of uncontrolled expansion of annual graduates by 6% or more a year or 10 times the annual population growth rate and 5 times any increase in demand. They are not hearing about the consequences that will impact their health professional career for their entire lives.

Physician assistant students and medical students need to know the coming glut of workforce also as their expansions continue at 5 to 8 times population growth rates. MD DO NP and PA students all need to know the truth of poor support and high turnover and less experience in health professionals and team members in areas such as primary care, urgent care, retail care, and emergency care.

• The bubble will burst and the MD DO NP and PA graduates not near retirement will feel the impact - throughout their careers.

If you think that us old family physicians are upset about how we are treated and how our patients, communities, and colleagues are treated, wait till you experience the anger of those younger with more debts and their dreams shattered.

Do family medicine leaders want to continue to encourage them to do what is becoming difficult or impossible to do?

Isn't it concerning that we have spent millions of AAFP dollars and significant portions of our association and political capital on a better Future of Family Medicine – when our national designs threaten all future health care professionals and the team members that all provide the care and caring in our nation?

We focused our Future on the Primary Care Medical Home reorganization of family practices – often costly, distracting, and difficult to achieve because of our financial design.

More and better team members should be the focus, but this works by improving the financial design, not worsening it with metrics, measurements, process improvements, reorganization, pay for performance, and value based care.

• Focus on the team members
• Focus on those who deliver the care
• Support those who deliver the care
• Facilitate the work of team members to improve access where most needed - do not impair their work

We listened to the promotions of primary care medical home – and now we see the consequences. Yes, the marketing people were involved in the Future of Family Medicine - and we got a marketing solution.

• But most family physicians do not need to market their practices. They have little or no competition. No other specialty can survive because of the financial design, but this is also killing us off finally.
• Most family physicians cannot afford costly medical home consultants, software, certifications, etc.
• Once again what family medicine leaders pursued could work out for those in counties and places with higher to highest concentrations of workforce with lots of competition - but no in lower concentration settings where most Americans are found.

We in Family Medicine must return to be the voice for those who serve our nation in the most prevalent and most needed and most deprived services.

This is also the start toward unification of primary care and a powerful force to prevent the fewer and larger corporations from some of the more serious abuses.

As long as they (big insurance and other foundations, government) can play us off against one another, they will do so. So we must

• Inform NP and PA and DO and MD students so that they know what exists and what is coming.
• Call for a moratorium on training expansions, or at least no more than 1% annual growth.  

Stop Areas to Terminate or Minimize So that We Can Focus Attention On Higher Priority Areas Where We Can Make a Difference

Stop the Rural Focus - Why focus on rural deficits?

There, I said it. This family physician who started as a solo rural family physician and continued as a lifelong rural medical educator is telling you to minimize this area.

• Has this advanced our situation after decades of work?

Why focus on rural situations when counties lowest in concentration are the ones growing fastest in numbers, demand, and complexity as their practices and hospitals are designed out of existence?

Why focus on 16% of the US population with one third of the rural population doing quite well in workforce – leaving only about 11% of the population as the rural focus area? Rural populations

• are vague in definition,
• are not universally behind,
• have advocacy, and
• are stagnant to shrinking.

Populations consistently abused by design are

• Medicaid,
• much of Medicare,
• the elderly with lower to middle income
• most rural populations,
• 32% of the urban population lowest in health care workforce,
• inner city populations, and
• populations unduly restricted by their profit minded health insurance plans.
• Family physicians are also a most likely abused population because of their distribution and their care and caring for the populations most behind and because they remain and serve and prefer to focus on practice rather than protest - to their downfall.

Family Medicine can no long consider government their friend. They do not have our backs. Government must be reshaped to support all who serve the front lines in health, education, development, and social support.

A question to FM Leaders

Why encourage rural family medicine when the financial design is resulting in frustration, fewer and lesser team members, turnover, burnout, and fewer to share the load?

I still assert that there is nothing better than complex primary care well supported, and nothing worse than complex primary care poorly supported.

Fixing the support is the key.

Acknowledge the truth in family medicine residency graduates - that half or less will remain office family physicians and primary care because they are departing - like NP PA and other physicians.

Go Area – Focus on the Urban Populations Left Behind That Have No Advocate

About 32% of the urban population is falling behind with half enough generalists and general specialists via decades of past designs. 32% of 200 million is 64 million people that have deficits of workforce, health care dollars, and health care access.

About 28 – 30% of office based family physicians are found in these counties left behind – and are paid less and penalized more because of it - just like rural family physicians.

County based advocacy could help inform these counties about their financial deficits much as Rural Health Matters has done for rural populations and their local leaders to understand the key elements of the economy that matter – health, education, social supports in particular.

There are national associations of counties to consider and work with in partnership.

Would it be bad for AAFP to help unify opposition to changes in payment, insurance, or social supports that are taking these counties and their health care down by design?

These populations are already upset – you see it in the way that they vote.

The 2621 counties most behind are essentially the Red Counties in the last election.

But they were not always Red and they will change again as seen in the past. (Yes the NY Times and others get this wrong.) But what you can get from the NY Times is migration patterns, and more are moving to these states and counties - forced out by housing and cost of living designs. They will continue to grow fastest and be more disgruntled.

They need voices to help inform them rather than brainwash them. Their problems are largely about the various state and federal designs – and there is worse on the way

Go Area – Go Forward By Rallying Patients and Practices to File Health Insurance Complaints

Work with state family medicine and primary care associations to pressure state government to hold big insurance accountable.

Go Areas – All of the Above Areas Could Help Us with Media Attention Directed to Advocacy for Patients

Work with the Center for Health Journalism to educate future health journalists about critical review of various policies, claims by the managed care media, etc.

Why do we allow the managed care and info tech journals to constantly promote their "successes" and consultants and corporations and distortions of micromanagements of cost, of quality, of social determinants, of hotspotting?

Stop Areas – Stop Saying That Training Can Fix Deficits of Workforce, Primary Care, Generalists, General Specialists, Mental Health, Womens Health, or Basic Surgical Services

More family physicians will not solve the problem of fewer family physicians remaining in office primary care with rates that continue to decline as family physicians follow careers with better financial support.

More types of health professionals added (FM, NP, PA, nurse specialists, MPD, others) and massive expansions in each have not worked.

More medical schools is contraindicated as there is documentation of less primary care result and worse distribution as graduate numbers go up.

Pipelines are still popular with a rural or primary care outcome focus, but they do not impact the financial design. Success in a particular school or program or pipeline can demonstrate higher proportions meeting the target location or career – but not improvements in the concentrations of workforce that remain in deficit. The particular area can only support the workforce that is dictated by the financial design.

• 200 billion a year defeats primary care expansion.
• 30 billion a year for primary care in 2621 counties lowest in health care workforce shrinks primary care in these counties with 40% of the US. They will increase to 50% but their share of primary care is likely to go down to 20%, given recent decades of changes.
• Half enough generalists and general specialists for half of the US population is not going to improve without a change in the financial design and the designers are making this worse with increases in the costs of delivering care via designs that disable the team members that do care and caring.

 Special training is good for specific training, but is powerless to overcome too little revenue as the costs of delivery go up, usual old costs and abusive new ones in more dimensions.

Most Americans Could Benefit from Family Medicine Local Only Training - the only option with the current bankrupt financial design.

Only an entirely local preparation, admissions, and family medicine training with at least and 8 year obligation can work to resolve deficits – and it has other benefits given the $100,000 per FTE of primary care per year costs – because of the financial design.

No one is even talking about a total commitment design.

Anyone NP PA DO and MD given options to change – will follow the financial design to better support, more and better team members, a better practice environment, and better salaries/benefits. For us in family medicine, the latter is less important than the former. We are environmentally sensitive within our practices and are growing frustrated with out environments as they grow more toxic and intolerable by design.

Stop Areas – Stop the focus on HRSA Programs

Remember that there is nothing that HRSA can do in training grants, in loan repayment and other graduate incentives, or in Community Health Center areas that CMS cannot negate by its constant appalling redesigns of 1 trillion a year and influencing more trillions.

• HRSA Fails Because of CMS Design
• Health access efforts fail because of CMS and state designs
• Care for the elderly and poor fail because of CMS and state designs
• Care for the populations with concentrations of poor and elderly fail because of CMS and state designs. If CMS and states paid their share, then others with and without insurance could receive care. Since they fail to pay their share, local generalist and general specialist care fails for others. How ridiculous to talk about higher functions, opioids, expanded mental health services, and more - when the ability to keep a practice viable is being destroyed by design.

Every time various HRSA programs come up for renewal, it takes an enormous amount of our political effort to fight off those who hold these programs hostage

Think about this. Loan repayments and other recruitment and retention incentives and bonus do not directly support the delivery of care by the long term health professionals and team members that do the care and caring.

• Support those who actually do the care and caring long term, not those who might do it or who temporarily do it.

If the practice is not good enough to facilitate recruitment and retention, then fix the financial design to help the practice add more and better team members.

Alaska Office of Rural Health reported that it was costing 1 million more each year in recruitment, retention, locums, and brokers fees to help fix deficits in primary care workforce – about 10% per year in increase. This could be translated to 300 million more a year for the nation involving the states in most need of workforce.

We pay more and more and get less result. We pay more and more to those who do less and less. How can this continue?

Practices in need of workforce need long term continuity family physicians. Why send someone who will be there temporarily? The practice and the community need the physician and their leadership in practice and in the community.

Turnover costs at $100,000 per fte of primary care physician per year defeat the financial design to an even greater degree. Fix the finances to reduce turnover and turnover costs and to improve continuity and value for the practice and the community.

Consider that nearly all of what HRSA does can be addressed by improvements in payments to generalists and general specialists – particularly Medicaid paying 30 – 40% more on par with better health plans and enough to cover the costs of caring for Medicaid patients plus some margin to invest in more and better team members.

Cling to HRSA if you want, but consider that payment options favor all across primary care, especially primary care where most needed.

There are reasons to oppose many of the current bandwagons and other policies that fail for basic health access.

 These also include moral and ethical issues. As human subject researchers and as physicians we attempt to the best of our ability to

• Do No Harm, focus on beneficent intent
• Protect vulnerable populations
• Give informed consent – best explanations and advice in a way that makes sense to our patients or research subjects

Our health care designers have demonstrated that they

• Cause Harm to people by design, particularly with the constant hammering of cost cutting that almost always works out worse for the populations behind and the fewer who remain and serve them
• Cause Harm by constant and costly changes most deadly to smaller practices and those most needed. 
• Cause harm to the doctor patient relationship by inserting more and more obstructions and situations that result in health care professionals being blamed – even though they are only the expression of designs failing from above.
• Cause Harm to health professionals and health care team members who are being marginalized by designs with less support and more to do that adds little meaning. Clearly their lives personal and professional have been made more difficult.
• Damage vulnerable populations by taking down their basic health services and supports

And they may well be worsening outcomes if you track the changes in cash distributions via

• meaningless and costly health insurance expansions that had increased profits for these corporations already doing quite well
• metrics, measurements, and micromanagements – leaving fewer and fewer local dollars where populations most need dollars. Tens of billions more each year extracted from practices and places in most need of dollars - will worsen social determinants and outcomes.

Old Guy History

I started thinking about payment issues and policy matters in the mid 1980s as a solo rural family physician. It was very clear that I was most valuable to my community and patients along with so many others that were underpaid and under supported in the area. I poured my life and concerns out on my Apple IIE.

I have not stopped, even when in my best interest to do so.

This frustration also drove me to seek medical association positions in an effort to change the design. Sacrificing significant income and time away, I pursued this goal in Oklahoma and nationally.

I was the first delegate elected from the newly created Young Physicians Section of the AMA. I did represent the protests of young physicians at the time and this was recognized in my election.

I soon found out that the AMA staff and leaders had other agendas – very obvious in the reference committee actions. I have continued to see difficulties with medical association staff efforts in other associations – including the AAFP. Some would say that the staff are too few and have too much to do. I would say that priority areas have not had the proper focus in areas such as rural health, basic health access, and health policy specific to the financial design.

There is often a disconnect with what is going on in practice across government, associations, foundations, and institutions – basically the route to leadership positions in health care.

You need to understand what is going on and how much trauma is being designed upon those who serve where most needed.

Most of all we need to act.

Those of us who have taken a different life course, have a duty to restore awareness of what is going on. It is our duty as physicians, as family physicians, as policy researchers, as workforce researchers, and as decent human beings.