What would it take for CMS to actually have sufficient primary care by 2030. Spending in primary care would need to go up, not down as in 5.8% to 4.6% of total spending as indicated by the Milbank Scorecard 2010 to 2020 (purple squares at bottom). Flat lined 250 billion in primary care spending with cuts and new types of costs added can only decline capacity by about 20 - 30 billion or 10% of capacity year after year due to less workforce and other team members supported (green line). Worst case orange line reflects cuts, higher turnover costs, even worse retention, and higher costs of delivery. Primary care delivery capacity should have continued to increase slightly faster than population growth (purple line), ideally at 2% annual increase (turquoise) to cover population increases and increases in a number of complexities. Fewer and fewer primary care years per class year indicate declines, not advances. Primary care retention would need to increase. It continues to decline for all 5 sources decade after decade. CMS would have to prioritize delivery team member numbers and quality while decreasing metrics, micromanagement, and team member burdens. CMS would have to focus on volume increases rather than volume to value. In primary care, volume is what enhances access. In particular the cost cutting and overutilization focus must go away for 40% of the nation with half enough primary care and basics where underutilization and inappropriate utilization worsen by the financial design. The nation would have to address the fatal flaw of employer based health insurance - payments lower than cost of delivery where the weaker employers are concentrated. CMS would have to increase payments to 110% of the cost of delivery, up from 60 - 85% CMS would need to audit its plans and discipline them such that lower payments are not associated with lower levels of workforce - as in 15% lower office payments for primary care where it is half enough for 40% of the population in 2621 counties across vast regions. Primary care year production since the class of 2010 needed to exhibit regular annual increases in the numbers of primary care years from IM NP FM PA and PD (blue line) CMS would have to look back historically and see that the only major increase in primary care was 1965 to 1980 with the new billions from the original Medicare and Medicaid design (blue line left) CMS would need to understand that no training design, especially graduate medical education funding, can address deficits of primary care and basics where the public plans and worst private employer based plans are concentrated. CMS would need to see that its designs prevent improvements in PC delivery capacity including regulatory capture, RBRVS, budget neutrality, and better payments and more lines of revenue for those larger - especially when CMS votes its 1.4 trillion annual budget against basic health access.
Robert Bowman
6mo
The Standard Primary Care Year can create an artifact as some class years may have less primary care and some with more with abrupt impacts - as in the managed care panic when medical students avoided hospital based careers for a few class years. The overall impact is the same when smoothed for adjacent class years as would be expected - since thie primary care result is entirely about the financial design. Notice that all sources are driven away from primary care with those rewarded most by RBRVS and most lines of revenue departing faster (IM NP PA).
I used to think that CMS could do this, but believe it’s far more complex, probably involves HRSA, and most likely requires Congressional action. I believe that a lot of this has literally been set in concrete since the founding of Medicare in 1965, via the GME and other processes, such as the AMA & the RUC. Not to mention the AMA & CPT, which has the impact of allowing the AMA to spend tens of millions of taxpayer dollars on lobbying to maintain the status quo. It’s a mess!
Andrew Serio
6mo
Very informative!
Basic Health Access
6moThe internal medicine component was 150,000 strong built up by 5000 per class year for over 30 class years. Over 60% were retained in primary care. There were general practice docs in place that had to stay in primary care. The designers gave them much better reasons to depart primary care and they did - via fellowships and later 55,000 to hospitalist careers Few realize that PA and NP follow the finances away from primary care and basics and also away from areas with deficits. Both have also moved from over 60% to less than 20% primary care It is all about the financial design and finding the best private employer based plans by location, employer, or contract.