1. What is the decision or change (e.g. clinical topic, practice guideline, system design, delivery of care) you are facing or struggling with where a summary of the evidence would be helpful?

It is very common for experts to promote higher functioning or patient centered primary care. They discuss integration, coordination, and outreach. But what is the situation in 2621 counties lowest in health care workforce with half enough primary care, women's health, and mental health?

2. Why are you struggling with this issue?

The financial designs clearly favor procedural, technical, subspecialized, hospital services and locations in counties with higher concentrations of workforce. Big health care demands and gets higher payments and those not biggest are left with lower payments. In 1983 I was a solo rural family physician and was paid less in primary care, in Oklahoma, in area 99 Oklahoma, and was paid about 15% less as a new physician . For 30 years since that time I have been trying to get doctors into rural and underserved areas in various academic positions, but I keep going back to the lessons of the financial design. I could make it on the low revenue from office practice because I did get revenue higher paid from hospital, ER, assistant surgery, procedures, and obstetrics - but these have mostly gone away as have most of us.

The numbers translate to about 45% of patient complexity in 40% of the population lowest in health care workforce with just 25% of the primary care workforce supported by less than 20% of spending (reductions from lower Medicare payments and other worst Medicaid and private plans in these counties).

This translates to fewer and lesser delivery team members. The deficits can be worse given increasing costs of micromanagement, much higher costs of turnover, and the impacts of Usual Disruptions (Mold, Annals of FM, AHRQ study).

Without more and better delivery team members and with deficits of local workforce, higher functioning care would appear to be most difficult.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

I want health care leaders to understand that it is difficult to do higher functioning or patient centered primary care when there are deficits of the workforce and social supports to integrate and coordinate - plus addressing the needs of more complex patients.

I want designers to understand the difficulties faced in their common solutions such as more technology, more data, more consultants, or more personnel such as scribes or care managers.

I want some understanding that there are reasons not to innovate or digitalize or disrupt that are very logical and are not related to local physicians being against "progress."

4. When do you need the evidence report?

Mon, 01/01/2024

5. What will you do with the evidence report?

Hopefully AHRQ and others who shape health care will refocus on the team members and their most important innovation with each patient. Hopefully the designers will rethink the financial and team member impacts of their designs. Most important appears to be a better financial design that actually adjusts for revenue too low, costs of delivery accelerating from usual inflation costs, more costs of micromanagement, more increases in each micromanagement cost, and relatively higher costs for small and medium size practices.

Supporting Documentation

Higher functioning Primary Care (Word, 74 KB)

Optional Information About You

What is your role or perspective? Basic Health Access researcher

May we contact you if we have questions about your nomination? Yes