Paul Buehrens’ Post

When you combine limited insurer panels, prior authorization of access with geographic segregation of practices per capita, all specialties and subspecialties are difficult to access.

What would it take to generate sufficient primary care for about 85% of the US population? The Standard Primary Care Year calculates the years of primary care delivery specific to each source and each class year - the product of Years in a career % active % in primary care and a Volume Adjustment. The 1975 FM grads could have efficiently been the source for primary care with 350,000 divided by 25 or 14,000 annual FM grads. The design would have required staying in office FM. Better opportunities in urgent, emergent, hospitalist, and other careers has helped to shrink family medicine to 10.7 Standard Primary Care Years which would require 33,000 annual grads to get the 350,000 But we have a mix of primary care types. Based on their proportions, what would it take to produce the 350,000 per class year? We would need to graduate 6025 family physicians - a boost of 1925 and 4188 pediatricians - up 1338 12563 internal med grads - up 4013 64947 NP grads - up 30747,15000 more than currently produced a year 18367 PA grads - up 5867 and also 6000 more than produced Not having a permanent broad scope primary care source (34 years at 90% active and 90% retention and top volume) - makes it difficult to get to sufficient primary care. The fact of no indication of improvement in primary care retention indicates CMS failure by design Only 250 billion in primary care spending that is eroded by higher costs of delivery year after year makes progress in primary care impossible Expansions of NP and PA with the addition of more new specialties that have better financial designs will continue to defeat NP and PA primary care while building up non-primary care workforce. This will also contribute to the least experienced primary care workforce in our history as the proportions with no or low experience increase and as experienced primary care NP and PA depart. The spending required to get to 350,000 Standard Primary Care Years per class year would need to reach 400 to 500 billion dollars due to 30 billion a year in uncovered increases in the cost of delivery. This would need to get by regulatory capture, RBRVS, and budget neutrality and worst public and private health insurance plans in the 2621 counties. Doubling the investments across each basic health access specialty specific to the 40% of Americans most behind in 2621 counties lowest in health care workforce would be 1. the best health access investment 2. the best health equity investment 3. the best increase in jobs economics where most needed 4. the best increase in local health care and community leaders (team members and spouses contribute) where most needed 5. the best investment in health care where the population is growing fastest 6. penance for 41 health care killing years from CMS 7. the only way for any training interventions to work, just like 1965 to 1980

Advancing Health Equity in a Primary Care Practice The 2021 NASEM report “Implementing High Quality Primary Care” posed the research question, “By what mechanism does primary care achieve health equity?” In response to that question, I was honored to do a presentation at the “Inaugural Meritus Health Equity Summit” hosted by the visionary Dr Maulik Joshi (CEO) and Dr Chante Richardson, Associate Dean of Equity, Diversity and Inclusion at the Meritus School of Osteopathic Medicine. The presentation described a program that achieved equity in a primary care practice serving a largely Hispanic and African American population (Menocal Family Practice). The purpose of the presentation was to provide a model for others to establish scalable and sustainable equity focused programs in primary care that produce measurable equity results. The following is a brief summary of the key elements and a few representative results: 1. Begin with standardized social needs screening tools. Use the screen for all patients to avoid bias and to normalize the process. The PRAPARE screen is a good example of a widely used tool that is readily incorporated into EMRs. 2. Employ and support a Community Health Worker (CHW) team to assist patients in addressing social determinant barriers by linking to Community Based Organizations, government programs, navigating the healthcare system and developing longitudinal support relationships.   The CHW services are reimbursable by many insurance companies including Medicare and Medicaid (in most states). 3. Provide a simple provider to CHW referral workflow for consenting patients facing social challenges. Encourage first contact for the CHW at the time of the visit. 4. Provide a framework for consistent communication between providers and CHWs. 5. Maintain a registry of patients in the CHW program in order to track health quality, outcomes and resource utilization. 6. Track and analyze health quality measures (eCQMs) and outcomes through an equity lens for the overall practice population. Disaggregating quality measures into distinct demographic groups reveals insights that are not apparent from the average practice performance and provides opportunities for tailored equity initiatives. The presentation also included an example of primary care equity in action. Disaggregated eCQM quality data revealed a significantly worse diabetes control in the Hispanic patients compared to whites. In response the CHW team focused attention on 100+ Hispanic diabetic patients with defined social needs and implemented culturally and linguistically relevant programs in nutrition, diabetes education, and assisted with medication access. Within the span of one year the good control eCQM measure for this group improved by 6% and the average sugar (A-1-C) control improved from 9.6% to 8.2%, (lower is better). This is an example of the Health Equity return on investments through primary care. Yours in health equity Howard

What Is Medicare and How Does It Work? Medicare is a federal program that provides healthcare coverage in “parts.” Medicare Part A provides coverage for hospital insurance, and Medicare Part B provides coverage for outpatient services. When people refer to Medicare, they usually mean Original Medicare, which consists of both Part A and Part B. Medicare Advantage, also known as Medicare Part C, covers everything included in Original Medicare and bundles Part A and Part B into a single plan. These plans usually include additional benefits that Original Medicare doesn’t offer, provided by private insurers who follow guidelines set by the federal government. Who Is Eligible for Medicare? People at least 65 years of age who are U.S. citizens or permanent residents are eligible for Medicare. Most people eligible for Social Security are also eligible for Medicare. People who are younger than 65 with certain disabilities also qualify, as well as those who are on dialysis or have had a kidney transplant. What Does Medicare Cover in Parts A, B, C and D? Original Medicare covers hospital stays, skilled nursing, home health care and hospice care (Part A). It also covers doctor’s visits, preventive care, mental health services, physical therapy, occupational therapy, lab services and other outpatient services (Part B). Original Medicare doesn’t cover prescription drugs, eyeglasses, hearing aids or dental care (unless performed in the hospital under Part A). People who choose Original Medicare can buy prescription drug coverage with a standalone plan known as Part D. Medicare Advantage covers everything included in Original Medicare. Most Medicare Advantage plans also include prescription drug coverage and frequently offer dental and vision coverage, hearing aids coverage and fitness benefits. These coverages vary by plan.

The Centers for Medicare & Medicaid Services recently released the "Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule" and the "Ensuring Access to Medicaid Services Final Rule." There is *A LOT* going in the 2 rules but here are a few quick highlights I found interesting-- 1️⃣ Max appointment wait time standards, including 15 business days for routine primary care and ob/gyn services and 10 business days for outpatient mental health and SUD services. States must conduct yearly enrollee experience surveys and implement remedy plans if access standards are not met. More member surveys! 2️⃣ Scope of in lieu of services was better defined to address health-related social needs, stating in-lieu of services can be used as immediate or longer-term substitutes for a covered service. Get ready for state plan amendments! 3️⃣ All FFS Medicaid fee schedule payment rates must be publicly available. Then every two years, the FFS Medicaid payment rates for primary care, ob/gyn care, and outpatient mental health and SUD services must be compared to Medicare rates. This will shed a lot of light on inconsistencies! https://lnkd.in/gHN2P9D8 https://lnkd.in/gUz9PeCn

Palliative care is poised to be a game changer for public health. Nearly 50 percent of states now include palliative care services for eligible Medicaid recipients, according to C-TAC. And in California and Hawaii, two paths are being forged toward wider palliative care access. New York State is on track for the next innovative expansion of access to palliative care.

Understanding the Continuum of Home Care. Navigating the spectrum of home care services can be complex, but it’s crucial for ensuring patients receive the personalized care they deserve. Here’s a snapshot of the key aspects from the Continuum of Home Care Worksheet (feel free to download!). I will also include some great vetted and dedicated people/partners in care to consider for each service line: Personal Care: Tailored for individuals needing assistance with activities of daily living (ADLs), personal care allows people to maintain their independence at home. No medical prescription is necessary, and services continue as needed, covered by various funding sources (often private pay, long term health insurance, or VA benefits). Capital City Nurses: Melissa E. Koppal, CDP and Peter Clopton SmithLife Homecare: Andres Arrazola Diaz, Erika Chavez, and Renan Augusto Cherished Hands Home Health Care: Abby Sakariyah CRNP FNP-BC Advanced Nursing & Home Care: Mark Asch and Steve Lahn, CASP, CDP BrightStar Care: Catherine Reyes Home Health Care: Requires skilled services that are ordered by a physician and may include physical therapy or speech language pathology, among others. Typically covered by Medicare Part A, Medicaid, or private insurance, these services are for those classified as "homebound" under Medicare. LHC Group Homecall Rockville: Bryce Chase and Ally Chowbay Palliative Care: Designed for those with serious, life-limiting illnesses needing symptom relief. It can be provided alongside some home care services but is not used with hospice care. Palliative care is adaptable and changes according to medical necessity. Bills to Part-B of Medicare, Medicare Advantage plan (requires prior-authorization), or commercial insurance. Empatia Palliative Care a part of Heartland Hospice: John Webster Hospice Care: Focuses on comfort for individuals with a life expectancy of six months or less if the disease follows its natural course. Hospice care includes a wide range of services, like pain management and spiritual care, and requires certification by physicians that the patient is terminally ill. Care involves nurses, aides, social workers, spiritual care, and bereavement. Hospice coveres related medications and durable medical equipment. Medicare Part A covers the Hospice Benefit at 100%, most Medicare Advantage plans fully cover as does MD or DC Medicaid. Heartland Hospice: Tyler Lloyd #HomeCare #PalliativeCare #HospiceCare #HealthcareProfessionals #PatientCare

How to find Medicare Providers using the Medicare Lookup Tool The Medicare.gov website has a very useful "Find & compare providers near you" tool that allows you to easily search for providers by location - nearest to you in the following categories: Doctors & Clinicians: Find general information about doctors, clinicians, and groups enrolled in Medicare. Hospitals: Find and compare information about the quality of care at over 4,000 Medicare-certified hospitals. Nursing homes, including rehab services: Find and compare Medicare-certified nursing homes based on a location, and compare the quality of care they provide and their staffing. Home health services: Home health services treat an illness or injury to help people recover, regain their independence, and become as self-sufficient as possible. Hospice care: Hospice provides care and support for people who are terminally ill. Inpatient rehabilitation facilities: An inpatient rehabilitation facility is a hospital, or part of a hospital, that provides intensive rehabilitation to inpatients. Long-term care hospitals: Long-term care hospitals serve critically ill and medically complex patients who require extended hospital care. Dialysis facilities: See your area's quality of care and patient survey ratings for Medicare-certified dialysis facilities. Reach out to Justus Jay Gray at Just Us Insurance Services, Inc., your local Medicare agent in San Marcos, CA!

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.

I have seen considerable growth in the area of Program of All-Inclusive Care for the Elderly (PACE). PACE makes sense for the program participants. It allows them a one-stop shop for a variety of services to meet their needs. PACE allows participants the ability to live in their homes longer as they age which is a really good thing! The real problem with PACE will impact the entities who become providers. Providers can be home health care agencies, hospices or even adult day care entities. They are often drawn into the program by the opportunity to improve their business offerings and increased revenue. Some key factors needed to be a PACE provider highlighted in this article include having a physical plant where the care is provided. To be a PACE provider you must have a space for a variety of services including adult day care, primary medical care, nutritional counseling, occupational and physical therapy, social work counseling, just to name a few. Now, let's take a closer look at the participants. To qualify for the care, a participant must need intermediate or skilled level care. The CMS.gov website defines a participant as one who is "frail, elderly". That translates to individuals with more substantial medical conditions, often with enhanced fall risk. Providers are taking on these new exposures, often without thinking of the potential consequences that could come from increased incidents that lead to claims and lawsuits. There are some healthcare programs out there that qualify under the Federally Qualified Health Centers (FQHC) Act, which provides government protections from medical malpractice claims. Unfortunately, at this time, PACE providers do not qualify so they must rely upon their current insurance carriers for this coverage. Many carriers are not aware of the enhanced risks associated with being a PACE provider. As the amount of PACE providers and participants grow, so will the likelihood of significant casualty losses. I suspect this will eventually mean that PACE services will no longer fit eligibility under most policies in the standard market. Those exposures will eventually be forced into the E&S marketplace where premiums will be much higher. Entities considering PACE now should be mindful of this likely development and consider the potential future financial ramifications.