Major journals have slipped in another article that apparently was designed for controversy and for widespread distribution to media outlets. The New York Times rapidly picked it up. As the nation enters the final months before 29.5% fee cuts for Medicare physician services, there will be many more of these that reach the light of day – too many if this is an indication.

What is common to major journals, media outlets, and the past 30 years of political administrations is a poor understanding of primary care. It is not a surprise that one author is on the Obama health care team.

The 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. It is not surprising that the media postings have little substance.

The article does not indicate internal flaws specific to primary care and those dependent upon Medicare or Medicaid or populations with little or no coverage. The authors wanted to compare other nations and apparently chose the most dramatic examples to further their plan.

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 not what is needed. 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 complicated 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.
•  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.
• 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.
• Family medicine itself is an indication of inadequate primary care support as family medicine has not increased in annual graduates for over 30 years – 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.

More spending specific to primary care where needed or more equitable distribution of existing health spending. This would require diversion of a few percentage points of hospital and academic and subspecialty spending from 3400 zip codes to add 10 – 20% greater spending upon 30,000 zip codes with 65% of the population. This would require a few percentage points taken from non-primary care to provide a 10 – 20 percentage points to primary care.

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 and in 30,000 zip codes and increased spending in 3400 zip codes that already have top concentrations of workforce. Articles that imply primary care doing well will not help address the major health access problems facing most Americans

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. These designs allow teaching hospitals and hospitals to prosper with even more consequences for those left behind – and also there has been a shift of greater responsibility for lesser paid primary care and lesser responsibility for those with greater pay.

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 to consider departures 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. By working steadily for what works for a few, most are left behind steadily and progressively – by design. Pay for Performance is another innovative design that works for those in top concentrations and fails for those behind. Innovative NP and PA workforce creations were created for primary care and basic health access but are 70% solutions for non-primary care workforce.

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 to non-primary care.

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 practices, the dynamics represent serious problems. More and more personnel are required that are not actually involved in primary care delivery. One new mode of care delivery has been created because the costs of overhead are too high (collaborative care). 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 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 or primary care quality.

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 (see, 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.

Robert Bowman is a physician who blogs at Basic Health Access.

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