Family Medicine Must Move Beyond the 1960s Design to Address the 2040s

The designs for training and for payment that worked so well to improve health access during the 1960s and 1970s gave the illusion that training alone could make up the workforce gaps. Such is not the case. The financial design fueled the 1960s and 1970s improvements. The failure of this design since the 1980s prevents further gains - continuing to leave most Americans behind. The family medicine leadership still clings to the 1960s design, but must embrace a 2040s design to continue to lead in family medicine, in primary care, and in health access.

It is quite revealing that family medicine associations and leaders have embraced the innovation/regulation/certification bandwagon. There is a willingness to embrace the academic, association, institution, and association designs. But do these designs match up to family medicine now - or in the future?

Past family medicine graduates that were active were 90% committed to office family medicine for decades. More recent tracking indicates 70% and the rate of decline suggests even less for newer graduates.

As family medicine graduates fall to 65% or 55% in office family medicine, will family medicine leaders consider the flaws of their 1960s model?

Voices of concern have become a chorus. There is also little indication of a rise of public support - the kind that brought family medicine into existence.

The initial family medicine design 

...was based on a desire for acceptance into the academic community.

• The decision for 3 years of residency instead of 2 was guided by this desire. 
• FM came close to a four year design recently - a really bad design for numbers of FM graduates, for graduates in debt, and for delays in income generation. 
• FM claimed successes from FM student interest groups, departments, and other interventions during the brief periods of increased FM choice, but fails to understand that these do little as demonstrated in many more class years and primarily due to the financial design.
• Family Medicine journal still eats up pages each year promoting departments in every medical school. 
• Similarly family medicine leaders have gone along with the academics in areas such as innovative payment models and Primary Care Medical Home.
• Maintenance of certification is no longer evidence based for outcomes improvements, but FM leaders still cling to this model and to the substantial overcharges for such certification. The initial claims of being "more academic through recertification" persist now as back then.

FM Is a Mismatch for the Academic Design

Family medicine is community based, population based, accessible, distributed, and service devoted. The academic design is isolated, concentrated, inaccessible, focused on few people, and is devoted to itself. Even the best intentioned medical schools of the 1960s and 1970s have been remolded into the academic design. Mercer is an outstanding example of one of the best for Southeastern counties in most need of physicians led by over 30% FM choice but declined below 5% and lost distribution - during the reign of a family physician dean. The academic design is more prosperous and hard to resist. The preparation, the admissions, and the training all reward the most exclusive at the expense of the most normal.

The academic design is what has concentrated 45% of physicians into 1% of the land area in 1100 zip codes with 10% of the population. Meanwhile 40% of Americans in 2621 lowest physician concentration counties have 22% of physicians and less than 13% of health spending.

The academic designs and designers fight against true payment reform. True payment reform is about increases in basic, cognitive, office, primary care, and mental health services with decreases in the more to most specialized services. Academic designs create more lines of revenue and result in the highest payments in top concentration settings. Even lower payments go where care is most needed and penalties are most likely because of the least healthy patients.

Family medicine cannot prosper in places that fight the very reforms needed for family medicine and what family medicine does best.

The designs pay less where family medicine is more important and where Medicare populations are concentrated and where physician concentrations are lowest. This is seen in the table below categorized by the proportions of family physicians in a county from least to most.

Family Medicine Was a Miracle Event

The Flexner Design nearly wiped out generalists. More dollars for fewer in fewest locations made matters worse. There was little hope for basic care for most Americans until...

Family medicine was restored by family practice general practice physicians that fought hard state to state - using the popular support of Americans for a restoration of a personal family physician.

The restoration of formal family medicine in training and in practice has been the one major positive change in health access since the 1970s. It was not accomplished by the new type of training alone. The major lesson of the 1960s and 1970s was not innovative training. The message was a redistribution of dollars. The dollar distributions required permanent generalists. The permanent generalists required the dollars.

Family Medicine, Medicare, and Medicaid

July 30, 1965 or 52 years ago, Medicare and Medicaid were signed into law. The dollars represented a redistribution in the initial design. Changes in the design from more to less supportive for primary care, family medicine, and care where needed are important to understand.

Family medicine timing was a great match for the increasing revenue via new sources (Medicare and Medicaid). Training that could distribute matched dollar distributions.  As more family physicians graduated, there were more dollars to support them and in the rural locations and lowest physician concentration counties where Medicare and Medicaid are concentrated.

• The training models of the 1970s were worshipped - including the WAMI (now WWAMI) design and others. These models have largely failed with the decline of the financial design and the decline of family medicine choice in graduates

Numerous examples of "success" can be seen including the dramatic 12 to 20 times multipliers of distribution where needed with choice of family medicine in the graduates of the U of Kansas and U of Nebraska. But the overall capacity in lowest concentration counties in these states did not change. FM wiped out other primary care in a rearrangement of the deck chairs. The problem remains insufficient health care dollars - by designs steadily changed 1980 to the present.

Family Medicine Reached the Limits of the Initial Design by 1980

Since 1980 the financial design has changed from support for team members to cost cutting.

• Training outcomes follow the financial design and family medicine has eroded from 90% of active family physicians in office based practice to less than 70% with newer graduates at lower levels.
• This was also illustrated by 30% of the 1970s FM graduates found in rural locations - a level that has declined to less than 20% steadily over time. Now hospital based FM docs have 26% rural location rates - powered by hospital spending which is much better than office services design.
• By 1980 the family medicine graduates reached 3000 graduates. Since this time there has been little progress in what matters most in family medicine, in the primary care financial model, and in health access for most Americans. The linkage between these areas is undeniable. 
• All sources of primary care are failing, falling to steadily lower levels entering primary care and steadily lower remaining in primary care.
• All sources of care for lowest concentration counties are failing despite more dollars to prop up incentives.  
• Billions more have been added to costs of delivery in lowest physician concentration counties - sent further behind by design.
• Greater proportions of the population and family physicians are falling behind by design.

The 1960s financial design has failed and with this failure the training design has not been able to make up the gaps.

 This leaves choices:

• Do nothing and allow family medicine to become something else not associated with primary care, health access, or care where needed (seems to be the current choice).
• Expend all available association, department, residency program, and family medicine physician resources on improving 6% spending for primary care to 12% (not happening)
• or
• Develop a 2040s model that delivers on health access regardless of the payment design.

Value-based designs appear to be the favorite of family medicine leaders. There is no evidence that this will power up the financial design. There is evidence of discrimination against those who provider care for the most complex and least healthy - and family physicians fit into this category.

How Can Family Medicine Embrace Social Determinants and Not Understand Discrimination in Payment Design?

Full understanding of social, personal, community, and local resource determinants of health indicates the futility of clinical interventions for improving health outcomes

• Particularly in primary care with so many other influences before, during, and after encounters
• Particularly where 40% of family physicians are found in places with lowest concentrations of workforce, resources, and determinants of health.

These two major areas for the 2040s family medicine design can be addressed by

• Locally focused preparation, selection, training, and obligation
• Health access specific training
• Health outcomes improvement focus
• Change agent focus across preparation, selection, training, obligation, and practice

Moving from Academic Mismatch to Family Medicine Match

"One size fits all" preparation, selection, and training has not been a good fit for most family physicians serving where most Americans need care.

Family medicine and primary care subservient to payers, large systems, and large practices will continue to result in compromises for family physicians and for their patients.

Lesser payments for primary care, mental health, cognitive, office, and basic services fails most where most need care.

Family physicians should embrace a model that will continue to focus on health access and lowest concentration settings.

When Visualizing the 2040s Model, the Wrong Way Designs Are Exposed

Triple Aim has been a Triple Threat to primary care where needed. Outcomes are fixed by population situations and conditions. Cost of delivery increases have impaired the financial engine that drives access and motivates team members. Patients cannot be satisfied without substantial investment in primary care - not anything that the Triple Aim/micromanagement/innovation crowd is willing to do. 

It has been hard to see the family medicine leadership embrace Triple Aim and ignore the consequences on family medicine physicians, teams, and health access. This has helped to understand that the 1960s model is still dominant. FM leaders still want to belong more than they want family physicians to make a difference.

The 2040s model is specific to reducing costs, improving outcomes, and matching up family physicians to the populations that they serve. There is no need for rural origin or minority origin – which may not include the origins specific to care where needed and certainly not the careers needed to match up to populations similar to origin. The 2040s model does not care if trainees begin at age 14 or age 40. The design is specific to a lasting commitment to integrate with the community and practice and health outcomes.

The 2040s Design Is Specific to Facilitating Team Member Work in Health Access

The key to health access, the keystone of family medicine, is facilitating the work of team members. There should be little separation between those preparing, those selected, those training, those under obligation, and those practicing. Each facilitates and mentors the others for an efficient and effective model reaching far beyond offices and deep into communities.

More 2040s and Moving Beyond the 1960s Model

Establishing the model visualized in the 1950s and 1960s has been a laudable goal. But the academic partners in this model have other agendas. The payer partners continue to fail by sending  only 6% of spending for primary care for 55% of services. The payer partners have become opponents via cost cutting, neglect, denials, delays, and meaningless increases in the costs of delivery to match meaningless distractions for team members.

The players and payers are not going to accomplish true reform. They are not going to change the payment design that results in ever higher concentrations of health care workforce in fewer locations leaving increasing proportions of Americans further behind by design.

The 2040s model works best with better payment, but it can also accomplish what it must without a payment change. Ideally the major increases in primary care revenue would occur by significant reductions in procedural, technical, highly specialized, and hospital based care. This is best for returning balance in workforce in terms of spreading out workforce and restoring primary care, mental health, and basic surgical services.

In bed with academics also has been a reason for family medicine to be attached to regulation, innovation, and certification - all to the detriment of family physicians and especially those in FM delivering on the promise of health access where most Americans need care.

The focus on the original model (academic, department, centralized) has resulted in FM trying to be more in ways that FM should not be. It is the best at health access and it should focus on being more in health access and changing most Americans left behind to better health outcomes.

The past focus has prevented visualizing the model that has to exist in 2040 when 45% of Americans and 50% of the most complex populations will reside in 2700 lowest physician concentration counties. Will they be ignored from just 1980 to 2020 or 1980 to 2040 with still another 20 class years of graduates needed to begin to make a difference.

This could easily be 2800 counties

• As more counties lose their last hospital. The loss of a hospital is a major contributor to loss of specialties other than family medicine, setting the county behind in dollars, workforce, access, and health outcomes. You cannot cut jobs and dollars without worsening local outcomes.
• As urban and rural populations grow in these counties.
• As natural or man-made disasters occur in higher concentration counties.
• As housing collapses in higher concentration counties. The housing debacle sends more Americans and the most vulnerable to lowest physician concentration counties - the have lowest workforce and lowest local resources. It also sends more to become homeless or depend on other family, but the available and affordable housing as well as a lower cost climate forces a move to lowest physician concentration counties.

Why No More Funding Despite Growth in People, Complexity, and Demand?

How will local health access clinics deal with these areas unless they become the focus of preparation, selection, training, change agent development, and change agent family physicians?

How will the nation deal with disparities under a health care payment design that worsens disparities?

Discovering the Discrepancies

This blog began after photos appeared regarding the early FM leaders that were present at the creation of the annual family medicine student/resident meeting. Those of us around in the late 1970s were able to meet some of these men and women. We learned to respect what they did. But they were human. And they were focused on the issues of the time.

My experiences in rural practice and in organized medicine, taught me to question. Were these efforts helping or hurting? It was clear that the AMA and state associations were certainly not helping health access, primary care, or care where needed. The staff and the leadership had agendas different from what I considered the best interests of family medicine, rural practice, and primary care.

This critique was sharpened in academic efforts including immersions in physician databases, the workforce literature, and county demographics.

Promoting and then Demoting the Pipeline

For 30 years I helped to develop, maintain, and expand the pipelines to family medicine and health access careers. It was obvious that family medicine was limited. FM needed to continue to reach down to medical school year 1 and 2 and down to the summer before medical school and then down into college. Rural and minority programs have long worked their way deeper and earlier. But even these efforts are limited.

These pipeline models are fun to create and maintain, and appear to make a difference. However they are limited by their academic connection many times stronger than the community connection. The lessons of community projects, Community Oriented Primary Care, and Community Friendly Training all point to earlier and more comprehensive efforts at the community level.

An entirely different process of preparation, selection and training is required to blast beyond 3000 annual FM graduates and beyond practitioner to change agent. This is beyond the multiple claims of health access success as the design is specific to health access where half of Americans most need care.

The residency programs remain an awesome contribution – but the movement away from academic connections should have continued. The FM residency needs a better preparation and training before residency – as well as an obligation and health access contribution after residency.

This is a commitment model – a model lacking in the current design.

The process of preparation should begin when students reach the age when they desire to improve their social interactions – in middle school. The health access change agents are not the same as the best and brightest in scores. Those who demonstrate the ability to relate, work in teams, and accomplish change are the preferred selections. Rich in personal, group, and community interactions is assessed via personal, group and community interactions.

Health outcomes changes require changes in people and communities. Family medicine has the only distribution capable of facilitating change where needed. FM has always needed the teens and twenties working within their communities on the way to becoming change agents in FM, other health careers, and teaching. Meetings at the state and regional level should reinforce local activities such as needs assessments, assessments of readiness for change, and interventions driven by the community, revisions, and continued progress. Students need mentors and change agent activities.

Communities can afford to invest in a graduate who will spend medical school, residency, and 7 years of practice facilitating health access and health outcomes. Current designs that send dollars and graduates into higher concentration counties are poor value for most Americans.

• How else should we measure value in health access medical education?
• Is there any other better training for health access other than a community-based continuity model that begins and ends immersed in the community? 
• What will work in disasters or with worsening of situations in major metro areas or with a further deterioration in academic support for health access?

About 200 million people will be looking for basic care in their communities in 2040. These are places with half enough care. They are already most dependent upon family practice. They receive the least payments and try to deliver the most services to the most complex patients with the least local resources.

There is no movement toward meeting their needs. Family medicine leaders are the only ones positioned to make a difference for this half of the nation. They cannot help by clinging to a 1960s design.