Saturday, August 20, 2016

Maternal Mortality Increase in Texas - People Factor vs Clinical Intervention Influence

As an advocate it is tempting to look for "evidence" that supports your "side." An example is maternal morbidity in Texas. Advocates are happy with articles that link poor maternal outcomes to declines in reproductive funding. They are claiming the clinical intervention card. The same advocates would likely be the ones that identify disparities as a problem. This is a people factor claim. Which influence dominates? 

Is it People Factor Influence or is it Clinical Intervention Influence?

It is not acceptable to play the people factor/social determinant card for some studies and claim clinical intervention as a major influence at other times. You may or may not be an advocate for reproductive services in Texas. You may want to believe that cuts in funding for clinical services directly impacted maternal mortality, but this disregards the disparities that often tend to shape outcomes to a much greater degree. 

People factors should consistently be dominant as health outcomes influences, as much as 60 - 70% of outcomes. Clinical interventions should remain a a minor player at 10% - 15% of influence. 

Clinical Intervention Equals Distraction from Better Outcomes

Over forty years of clinical intervention focus has resulted in minimal impact on health outcomes. The quality intervention focus 1999 to the present has made matters worse with substantially higher administrative and other costs - returning clinical intervention focus to highest distorting influence. Meanwhile the important people factors that can change outcomes remain minimized.

After decades there is finally some recognition that Maximizing clinical interventions is what deprives us of the funding needed to address people factors.

People Factor Influence for Health Outcomes Improvements

Behavior changes can have substantial influence. Some behavioral changes (education changes, situation changes, smoking, substance abuse, obesity) can impact outcomes in a relatively few years.  Applied over decades for populations, behavioral changes can substantially prevent the need for clinical intervention (smoking). Minimized people factor focus is the rule rather than the exception. Even in the clinical arena, the cognitive services are paid least, keeping primary care and mental health care from influencing people factors.

There are a number of alternative hypotheses to explore in studies about health outcomes. Texas may be one of the only states with declines in maternal mortality this year, but declines have been seen across states with more disadvantaged populations for a number of years. Texas is not alone in poor outcomes and may just be behind others in timing. 

Texas and People Factors

Texas shows up poorly in a number of studies across health, education, and other outcomes - which indicates the populations that are concentrated in Texas. The people factors drive outcomes - situations, social determinants, behaviors, attitudes. The outcomes of these women have been shaped over the last 15 - 25 years and may also represent 2 or 3 generations of influence. Poor outcomes are common to hundreds of counties where lower cost of living concentrates populations with many different people factor issues.

Beginning a New Era of People Factor Focus - Closing Clinical Focus

It is really sad to see short term influences given blame or credit for changes in outcomes. Recent political changes are too soon for much of anything other than distraction from action.
  • Medicaid expansion has at best an indirect impact tied to other changes. 
  • ACA did not suddenly improve Kentucky or make Texas worse. 
  • Primary Care Medical Home fails for influence but you can compare different populations of patients and have differences.  
  • Resident work hours limitations in teaching hospitals cannot change patient outcomes because the populations are the same before and after
  • Physician vs nurse practitioner studies should indicate the same "quality" as noted in JAMA if the patient populations are the same or similar.
What is consistent in studies of quality is lower outcomes for populations more closely associated with disadvantage (Pay for Performance via Hong in JAMA, Urban vs rural hospitals, Readmission penalties higher for underserved counties). This is why quality measurement, pay for performance, readmission penalty, and other manipulations fail most where care is most needed.

There are 2621 counties where 40% of the US population is clustered around lower cost of housing/living with lowest concentrations of physicians, physician assistants, and nurse practitioners due to insufficient Medicaid, Medicare, and other lowest paying plans. These are populations left behind by federal, state, corporate, association, and other designers. They are the most complex populations with the least resources and the worst outcomes across health, education, economics, and more. They existed before ACA, before Red vs Blue, before Medicaid expansion, etc. Improvements in their outcomes requires investments in these people and the people that can best invest time and effort addressing behaviors, situations, environments, and other people factors. We have tolerated distraction from real interventions to change outcomes far too long and especially 1999 (To Err is Human) to ACA to the present. 
We must stop the focus on clinical interventions and focus resources
on people factor influences.

Advocates for populations left behind should not play the clinical intervention card and contribute to more decades of populations behind by design.

Thinking Through Insufficient Studies

In the case of obvious bias as in my people factor bias above, there is another consideration. Cuts in reproductive funding could impair the team members to deliver behavioral and other people factor interventions. The real problem is that studies rarely consider people factors. It is much easier to do simple studies. It is also much easier to get published if your study is a nice fit with current controversies.

Of course there is a people factor explanation for worsening maternal morbidity.

This brings up the real debates that we should be having. How do we best support people factor change
  • Directly within practices reaching out to people 
  • Directly within communities on people factors
  • Or both
Prying dollars away from disease focus will be most difficult in any case.

The plot thickens. Turns out Texas has not been alone in mortality rates, with a little research. Texas went from 18 to 37 per 100,000 in Texas in recent years. For some perspective:
Scientific American also indicated the problems with different data collection: 

So why not check as to when Texas implemented changes in the forms... 

ACOG had an interesting slideshow indicating a decline in the rates from nearly 1000 in 1920 to less than 10 in 1990 before beginning to rise again. Note the disease focus and lack of people factor focus
  1. Better ascertainment – still underestimated
  2. Delayed childbearing
  3. Obesity
  4. Rising C/Section Rate
  5. Cardiomyopathy
  6. Multiparity
  7. Immigration
  8. Death Certificate change
  9. In Vitro and other technology
More clinical interventions were proposed by ACOG ...

Sunday, August 14, 2016

Solving Mental Health Takes More than Race and Place

Articles illustrating the problems of minorities in areas such as mental health care access are quite popular. The authors and editors often chose such comparisons to gain attention, readers, and advertising as seen in black vs white, male vs female, physician vs nurse practitioner, and comparisons of good vs bad quality.

Such studies illustrate disparities, but a major question must be asked? Is a focus on race or ethnicity the best way to actually help America address mental health disparities?
Analysis Issues But is this difference or disparity about one specific area such as race/ethnicity? With additional factors included in the equations, race/ethnicity would decline in influence.

Patient and Population Factors Is this difference about social determinants such as income and education that are known to be different. This is also seen in rural populations and populations in different states or counties. Family structure (single parent, multiple children, working parents, grandparents raising children) can make it difficult to access mental health care. Studies note the lack of evening availability for appointments. Situations, relationships, and environments shape outcomes.

Behaviors, Attitudes Is this difference about attitudes, lack of trust, or stigma as also seen in rural and other populations? Do white populations, especially of higher income level, overutilize mental health as seen in other health services?

Workforce and Payment Design  Is this difference about lack of workforce in certain locations with minorities, difficulties finding a mental health provider, insurance process barriers, or the ultimate cause of lack of workforce - lowest paying insurance? 

Race, Ethnicity, or Place
Demographic data may be useful to illustrate reasons for deficits to exist. It is also useful to remember that the Kaiser reported study indicated mental health provided by mental health and primary care since half of mental health is provided by primary care.

County health and demographic data can be merged with physician databases and Area Resource file data. Counties can be stacked from top concentrations of physicians to lowest concentrations. Top concentration counties have concentrations of resources, physicians, and social determinants. These counties are often clustered together in one portion of a state or region leaving most counties with deficits.

Counties with lowest concentrations of physicians also have lowest concentrations of mental health providers (2013 data). 

The 10% of the population in the Top 79 Counties with highest physician concentrations had 19.9% of mental health providers (2 to 1). The Higher Physician Concentration 152 Counties with 20% of the population had 25.3% of mental health providers. The middle 286 counties with 30% of the US population broke even with 31.3% of MHP. The lowest 2621 counties by physician concentrations with 40% of US had 23.5% of mental health providers or almost 2 to 1 against. 

These lowest physician concentration counties with 32% of the urban population and 75% of the rural population have higher concentrations of elderly, poor, children in poverty, most complex health issues, and least healthy populations to go with lowest concentrations of health workforce and fastest growing populations. 

These counties did not have a larger share of uninsured (1.01 index) but their lowest paying insurance already defeats access having shaped lowest workforce and least access to care for decades. Additions of insurance with payments too low to offset accelerating cost of delivery and declining productivity are not helpful to resolving access barriers, particularly where lowest paying plan patients are concentrated.

And don't forget that the payment design insures that training outcomes fail to produce the generalists, mental health professionals, and general specialty careers that are over 70% of local workforce for these 2621 counties. Training does not have the ability to overcome overall deficits nationally and especially local constraints of payment.

Basically about 50% of the US population is found where all types of health workforce is lowest in concentration - and for the same reason.

Access Barriers Due to Payment Design
The places with lowest concentrations are found in close association with lowest cost of housing and lowest cost of living. These places concentrate the US patients with lowest playing plans - Medicaid, Medicare, metallic, and others. 

Places with concentrations of lowest paying insurance plans
cannot resolve workforce deficits without dealing with payments too low.
Fragmentation By Design Frustrates Local Access

Veterans are also concentrated in these counties. This is another population least supportive of local primary care and mental health because of fragmentation of the US design. Where deficits exist, it is important that all local populations can access local providers. Narrow networks add to the fragmentation.

Payment Deficits Defeat Access Many Ways
Payment for mental health is so low that many mental health providers cannot participate, choose not to participate, or participate on paper but not in reality. Government investigations have confirmed the lack of participation for those listed as participating in plans such as Medicaid.
Low cognitive/office/basic services payments shape workforce and access barriers many different ways all along the patient pathway to mental health. 

Final Questions

Can you address race or ethnicity as an intervention as compared to different approches such as improvements in cognitive payment, community resources, integration of mental health with primary care, or changes in the various attitudes and behaviors of insurers, providers, and patients?  

Our nation needs a focus on what can make a difference. Comparisons are useful with regard to awareness of disparities, but solutions require specific actions.

We need to focus on low cognitive payments to mental health. The same low payments also defeat primary care which provides 50% of mental health care (up from 47%). As mental health sunsets, it is likely that primary care is being more burdened directly from mental health care and indirectly with unmet mental health needs. Overutilization in costly emergent, urgent, and specialist services is also a function of poor mental health access. 

Statistical Questions

As an editor for a journal, there were times when studies were rejected or had to be substantially modified because the original submissions needed work in design, analysis, or interpretation. For example cancer data does have a location for a patient and their race/ethnicity, but not the income or education of the patient. Income or education or other data points from the location of the patient are often inserted as proxy variables based on zip code, census tract, or county location. This tends to magnify the influence of race/ethnicity as the differences involve more dimensions and degrees of differences that are not included. 

No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016


Saturday, August 13, 2016

Health Access Professional Training Should Avoid Medical Schools

As long as we continue to focus 70% of spending upon clinical interventions that can only influence 10% of health outcomes, we will fail to focus attention on the 70% of health outcomes that can be addressed via people factors. Situations, environments, behaviors, relationships, and other people factors are the dominant influence in health care outcomes (and education outcomes, and economics...). Health access professional training needs people change focus far more and clinical intervention focus far less. The reality of true health reform awaits discovery. True health reform must have health professionals with people and people factor focus. The preparation and training and payment designs fail to support the cognitive or person to person interactions that can best change health outcomes.

Health access professionals should understand the people that they serve. This seems obvious, but what is not obvious is substantial movement away from people understanding.

Health access professionals are not likely to pick up people focus or people skills during training. They should have people awareness and people skills focus before, during, and after training. It should not be surprising that it is difficult to change health professional attitudes, behaviors, and actions after a first 30 or 40 years of immersion in something quite different. 

The Flexnerian design is widely praised as the foundation of modern medical education. Unfortunately this design was implemented by zealots that wanted to extinguish anything that looked like the past such as preceptorships and apprenticeships. The zealots were so focused on academic, university, science, and technology that they removed local, people, and health access focus.

Physicians arose from the people and distributed where people needed physicians prior to 1910. Yes, there remains a need for formal training, but formal training should not result in compromise of local people focus and health access. Zealots have added new characteristics such as subspecialized, centralized, high volume, and quality measures focus. Sadly these have moved health care further away from what really matters in health outcomes.

It will take redesign to re-establish a priority of local, people, and health access focus.

The 30 or more years prior to a health access career should be immersed in local situations, patients, families, and community. There are people skills, background fit, and geographic arguments to explore. Payment designs should reward careers involving people interactions (cognitive), experience, team focus, and continuity.

It is safe to say that we have the wrong designs for preparation, selection, training, and payment with regard to solving health access woes. 

People Investing in People for Outcome Improvements

Preparation for medical school rewards those who invest in themselves rather than those who invest time and effort in people and people change. Changes in behaviors, situations, relationships, and environments have far greater potential for outcomes improvements as compared to clinical interventions. Preparation, selection, training, and support of health professionals should be re-oriented to maximal influence rather than minimal.

College-based preparation for health access professional education has all the wrong influences
The colleges that shape future medical students are over 70% from the top income quartile and have most urban origins. These are only a few of the social determinants, environments, upbringing, and multiple other dimensions that separate the elite from the entirely different patients they will see.

Future physicians have exclusive parents, schools, and other environments.  Immersions in exclusive environments and exclusive groups are not conducive to the attitudes, behaviors, and skills needed for health access. Those raised by the school of hard knocks have a chance to grow in awareness regarding the condition of most people. Those protected from hard knocks by their parents and others in their environment do not. This may be one reason for physician suicide rates to be so high.

Medical school training and testing focuses physicians to focus on basic sciences while avoiding people skills training. Studies of empathy and service orientation demonstrate the resistance of medical students to such training unless these existed previously (O'Connor). These are linked to primary care, mental health, and behavioral changes (Newton, Madison).

Medical school and residency training sites illustrate the disconnect between most Americans and their physicians. Training is stacked over 60% in 1100 zip codes in 1% of the land area where 10% of Americans are found (shrinking atypical populations at that). Highest income, most urban origin, children of professionals are trained in similar most exclusive settings by faculty with the same origins. The problems of past medical school environments have not completely been worked out.

Less than constructive attitudes and behaviors shaped in training persist in medical careers and in the groups and associations that involve physicians.  Top academic bodies and journals continue to overemphasize clinical interventions while minimizing people factors – behaviors, attitudes, environments, situations, social determinants, etc. For example, To Err is Human is widely regarded as a major influence toward quality focus and reduction of medical errors. However nearly 20 years later the outcomes have not substantially changed and the costs of administration and quality focus have accelerated - eroding support for the team members to deliver the care. The impacts may be greatest on the small hospitals and small practices most in need of support - support that is less likely under past designs and made worse by the new innovative penalties.

True health reforms require different thinking and different thinkers. 

Solving health problems in the United States is a task that requires entirely different solutions. The current political, economic, and health leadership is far too immersed in the exclusive. Ideas and innovations are implemented without prior testing and even despite known consequences.

Geographic Inequities By Designs of Preparation, Selection, and Training

Medical schools fail for health access across many areas. The easiest argument to address is geographic. Medical students in the US are an extremely poor fit with the health care needs of most Americans. Most urban, highest income, most educated parents and similar influences before, during, and after training is a poor fit with 2621 lowest physician concentration counties where 40% of Americans most need care. Medical school and the most important influence of residency training location shape physicians away from these counties. Only 6% of training is found where these 40% need care. Concentrations of preparation and training shape future concentrations of physicians. 
  • Concentrations by design may also shape overutilization. As physicians pack in to highly concentrated areas, more health spending is required to support them. In counties lowest in physicians, current cuts and costly regulations are a poor fit with the need for more services and more workforce – especially in these counties with more rapid growth of population, elderly, and complexity.

Specific Career Choices - Generalist and General Specialties

The US produces the wrong specialties.  The US needs broadest generalists and general specialties. This is the result of demographic shifts to more elderly, more complex care, and more people interactions such as integration, outreach, coordination, navigation, and facilitation. Many patient care needs could be met by less expensive generalists and general specialties – but only if we can produce and support these careers. For an entire generation (30 – 35 class years), we have not done so. Now we face substantial deficits getting worse.

The US specifically needs more family practice positions filled by MD DO NP and PA. The designs of payment and training and regulation insure that these careers are avoided or are temporary. Payment is least for cognitive or people focused interactions. Training minimizes these areas. Regulations allow graduates to depart family practice for numerous other careers. This is particularly seen in NP and PA graduates as “success” is seen as more specialized graduates. Clearly those with specialty and subspecialty positions have the most support and the most salary. For those who enter primary care, turnover to other primary care practices or away from primary care is substantial at 11 – 13% a year or twice the primary care physician turnover. Turnover in all sources is facilitated by poor support and greater burdens with designers, payers, and employers failing in support and adding greater burdens.

Training designers seem to have a poor understanding of the consequences of their actions. Because they do not understand that outcomes are about people factors (not training), they are surprised when clinical interventions fail to demonstrate results. They expected resident work hours limitations to improve the quality in teaching hospitals. No such expectation should have existed for those who understand what shapes outcomes (patient factors before, during, after). Unfortunately actions have consequences. What did happen is that about 20,000 to 30,000 NP and PA graduates moved over to fill the teaching hospital workforce gap created by resident work hours limitations.

The innovative designers continue to implement without regard to the consequences. DRGs or bundling payments by diagnosis was chosen for cost cutting in 1983 after very little testing. The drive to get patients out of the hospital faster was bad enough but higher cost personnel such as nursing was marginalized. Lower quality may have been facilitated by DRG design. These are not the only consequences. Hospitalists were promoted as solutions for getting patients out of the hospital at least a half day sooner. The promotions have so far diverted 50,000 primary care trained physicians to hospitalist positions. As is common, the designs were a good fit for some who promoted the idea with their studies. This hospitalist design was ideal for academic centers short of workforce and faculty. NP and PA hospitalists have also increased. The studies arising out of such academic centers resulted in distribution nationwide, including distribution to settings that may not benefit. 

Generalists have consistently been diverted to new specialties that often have hospital, disease, technical focus – the wrong directions from health access. Now hospitalists train substantial portions of primary care physicians - the wrong faculty for health access.

Family physicians have been resistant to departure from family practice positions until recently. As family physicians increased, other sources flexible for primary care have declined (IM, PD, NP, PA) with fewer entering and fewer remaining in primary care over their careers. Eventually family physicians reached saturation after 35 class years of 3000 annual graduates. The numbers overall for primary care were too much for the limited support for primary care positions. Even a relatively permanent workforce will respond to insufficient payment. Workforce follows the dollars and payment design shapes the workforce.

Previously a physician departure to another career required retraining in another field or a fellowship. Over 20% of family physicians have found ways to depart family practice positions. Now about 12% of family physicians practice full service emergency medicine with another 4% in urgent care and another 4% as hospitalists. Care where needed may suffer most. Rural family physician careers lose out to those leaving for rural hospitalist and emergency room careers. FM grads in office based care are 20% rural in location. This rises to 26% for hospital based FM docs in the AMA Masterfile 2013.
Family medicine remains most important in counties in counties lowest in physician concentrations. 

About 24% of physicians in 2621 counties lowest in physician workforce are family physicians. About 13% were general internists but this is moving to 7% or less as few IM trained physicians remain generalists. Pediatrics is about 6%. General surgical specialties contribute 3 – 5% each across surgery, ob-gyn, orthopedics, urology, ENT – but are rapidly decreasing nationwide at about 2 percentage points a year. The older physicians are found in these counties – another indication of too few remaining in these general specialty careers after residency training. Payment design dictates one or more fellowships – training that insures locations in highest concentration counties rather than lowest. FM remains the top specialty in demand but fewer choose FM. Medical students are well aware of the poor support, especially with higher medical education debt. The 8 times expansion of PA graduates and the 10 times expansion since 1980 is also evidence of the failure of training to overcome payment design.

Counties without a hospital or losing their only hospital are particularly dependent upon family medicine. But payments for office services are lowest in these counties. These gaps are often in states and settings with the most concentrations of Medicaid, Medicare, and other lowest paying plan patients. The threats to small practices and small hospitals include the designs for training and the designs for payment.

Very specific career choices are required for resolution of health access. Only family medicine has 36% of its physicians found in 2621 counties with 40% of the US population for a 0.9 ratio – a population based fit. These counties include 32% of the urban population and 75% of the rural population. Family physicians remain at about 26 to 34 family physicians per 100,000 across the wide range of populations. FM is over 1.0 for rural locations or 20% found where 18% of the population is found.

Nurse practitioners and physician assistants have limited distribution. Those departing family practice to more specialties also depart population based distribution. Psychiatrists, geriatricians, and internists tend to avoid these lowest concentration counties. This is not surprising given lowest payment for cognitive services and higher complexity with increased cost of delivery. The payment model fails most where care is needed most. These are counties with the most population growth over recent decades and they have greater proportions of near elderly, elderly, and oldest of the elderly.

Most Failure for the Most Americans

The US designs for payment and for training fail most where needed most and at the worst time in history given demographic changes. More cuts specific to these populations, more consolidations, and more attention paid to the largest and most organized almost guarantee widespread deficits during this time of no increases in payment, rapidly increasing administrative and other costs of delivery due to regulation, and declines in productivity forced by regulation. The small practices and small hospitals are facing the most problems but continue to receive the least attention and the least payment.

Recent Posts and References 
The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016

Thursday, August 11, 2016

Why Not a Behavior Change Moonshot?

For forty years Americans have been convinced that cancer can be fixed. It fits with our quite impossible dream of living forever. We have constantly been told that all that we need is more of each of the following
  • highly specialized and costly research, 
  • highly specialized and costly tests, 
  • highly specialized and costly scans, 
  • highly specialized and costly physicians/staff/systems...
Can this be done without collapsing health care or the national economy? Is this a good expenditure of dollars? Can our bodies endure the treatments?

In more recent times we have a call for a cancer moonshot. Is this a fit with what can be done, what science dictates, and at reasonable value?

What is highest probability - is that we will not be able to afford it. President Kennedy understood this with his original moonshot claim and indicated that we could not do this, unless we focused on keeping costs reasonable. Science, innovation, and discovery costs in health care have no such restraints and have gone way out of control since the 1960s.

It is quite interesting that we hear talk of value in health care every day, but no one raises the question of value in the many areas where we are pouring billions into care with little return on investment.

The science required is daunting.

Spending more for fewer Americans is indeed the American way - but this is not value.

Not mentioned are areas with substantial impact upon Americans.

Behavior Change Is Where Complex Disease, Best Outcomes, and Value Coincide

Whatever happened to behavior change? The science studies have long demonstrated that the major impacts upon cancer are about behavior changes such as stopping smoking. This one behavior change was worth forty years of drug, scanning, and technical advances from 1960 to 2000 (NCI researchers). It has taken a massive infusion of dollars to finally tip the scales in favor of a technological solution. 

Patients who present with chest pain with mental health problems are more likely to die in the next year compared to those with cardiac reasons. 

Behavior Change Advantages
  • Behavior change is scientific. Patient factors are most important in health outcomes and behavior change is perhaps the most important
  • Preventing complex disease is the best approach for least cost and best outcomes
  • Completing a full course of treatment for best outcomes requires behavior change as many do not understand how to maximize benefit/minimize consequences
Since 1999 and To Err is Human we have been even more focused on the clinical area - the area least likely to influence outcomes with highest costs. The massive buildup due to technology and subspecialty focus has only been dwarfed by the administrative cost acceleration. 
We are even cutting and compromising the mental health, primary care, and community sources to address changes in behaviors, determinants, situations, and other patient factors that shape most of health and health outcomes.

Cancer Is Not the Only Moonshot Area

Cancer is just one area and a late comer at that. What about sanitation - failing fast? What about clean water, immunization, public health, primary care? What about community interventions, nutrition, housing, security, child development, early education, and other human infrastructure and physical infrastructure to make our society more efficient and more effective.
And then we wonder at all of the different destructive behaviors that dominate the headlines... And we cannot even get cab fare to address them.

And by the way, the Mental Health Reform Bill, is no design to replicate for a moonshot. More funding for best practices, administration, demonstration, and distribution (dollars to agencies) is everything but rubber meets the road one on one behavioral impact.

Recent Posts and References 

Burying More Americans By Health Design

The Mystique of Medicaid Expansion

Rallying One Hundred for Health Access Not MACRA

The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016

Tuesday, August 9, 2016

Burying More Americans By Health Design

Each new day brings more promotions of health care influence by ACA or CMS or various institutions or foundations supportive of innovation focus. Despite numerous claims of patient centered focus, there is more movement away from the support of the people to address people and patient factors.  

A phone survey (goodness) is promoted in the New York Times with claims that Obamacare Appears to Be Making People Healthier. Even the worst of study designs about changes with the least potential to change health manages to find publication and promotion. Meanwhile most Americans await meaningful change because of health care design.

DRG to ACA for Better or for Worse?

A better case can be made for past decades of DRG to ACA designs making people less healthy. When designs slash the team members to address people factors and slash the cash needed to address social determinants to really influence health, lesser health is far more likely for more Americans. 

Burying People Influences Can Bury More People

The policies of 2010 to the present have continue to bury more Americans by burying the top influences on health outcomes – the 60 – 70% of influence due to people factors. Mountains of studies and their promotions tend to bury the fact that we fail to invest in better environments and situations. The people factors are clearly the most influential for better health. Payment design marginalizing cognitive services for decades has defeated any move toward more team members to invest in people. Behavior change is people helping people to change behaviors via mental health and in primary care (50% of mental health care). 

Driving People Influences Away By Design

Decades of poor support via Medicare and Medicaid have resulted in deficits of workforce 
  • at the worst time in history and in the worst places 
Cognitive and basic services dominate health care delivery in the places where care is most needed. These are the places most increasing in population, elderly, and complexity. Failures in payments for 60% of the workforce to deliver care in these places is a major reason why insurance coverage expansions have no influence.

If you are in places with health care workforce because of the design and gain insurance, you might gain access. If your are in places without health care workforce because of past decades of design, insurance access is not going to address your barriers to care.

Where Americans are concentrated by lowest cost of housing, there are more people who are older, more complex, and less healthy. These are the places where providers are fewest and are most penalized by ACA and CMS designs. Multiple factors influence health and health outcomes and the span from advantaged to disadvantaged layers out the outcomes in ways that clinical interventions are powerless to address.

Shifting Influences to Lesser Outcomes

ACA took away Disproportionate Share and other special payments to address the needs of providers left behind by CMS designs. Even worse ACA and CMS designs now cut more payment where resources are lowest and patients are increasing fastest in numbers, complexity, and demand. 

Payment Failure Results in Training Failure Results in Disparities 

Payment failure has shaped a generation of training failure despite expansions to more sources of workforce and massive expansions of graduates since 1980. Payment design insures that deficits of primary care and mental health and basic surgical services will remain. 

Designs that concentrate 50% of physicians in 1% of the land area with 10% of the population insure lesser access and additional deficits from half of Americans behind by design.

Place and Population Based Decline By Design
The demographic changes reinforce the payment failure. The payment designs discriminate against 2621 counties with 40% of Americans that receive lowest payments from Medicare and Medicaid, shaping lowest concentrations of health workforce and reinforcing lesser determinants of health – a much more likely influence on true long term health outcomes.

Marginalizing People Who Could Promote Better Patient Factors

People interacting with people can have great influence. Designs should support the team members to facilitate changes in behavior, situations, and other patient factors. Health care design has been discussed as an inverted pyramid with far too much invested in areas with little influence while the foundational areas are marginalized.

The huge expenditures for academic/hospital/subspecialty/technical/largest system/corporation influences have continued. They defend themselves best from cost cutting. Rapid change also favors those who can adapt. Chaotic change most favors those best supported by previous designs who are most organized and can take advantage of changes.

DRGs ushered in the Era of Cost Cutting. Across the nation some simplistic calculations have allowed slash and burn to proliferate across Medicare, Medicaid, insurance, hospital, practice, prescription, and other areas. Studies are crafted to demonstrate simplistic cost savings, but the studies fail to consider impacts upon other health care or additional costs outside of health care. For example closures of mental health facilities are considered cost savers, until the entire cost to law enforcement, people not mentally ill, and other health care areas are considered. 

Those most organize defend from cuts while cuts proceed in the people that could impact people factor change. 

Administrative Excess Diverts Health Spending Away from People and Care Focus
More cost from managed care or managed cost was a start. New layers of more cost for less influence were ushered in by To Err is Human.  This has reinforced administrative excess for even less investment in the team members to deliver the care. True health reform was prevented in 2010 because these distractions were reinforced rather than replaced.

The dollars have followed administrative, hospital, subspecialty, technology focus while avoiding investments in people, behaviors, situations, and determinants. We continue to allow claims of clinical influence - even with the most minor of clinical interventions such as EHR and insurance coverage.

True reforms such as increased payments for cognitive services or investing in people to address people factors are avoided. Even worse the attempts at quality divert funding away from dollars spent on local care delivery, especially where care is most needed. Dollars are ever more concentrated along with the health impacts that follow. 

From DRG to ACA we have failed to invest in people and thus fail to improve health.

Note also the recent lawsuit settled by CMS that indicated too little was paid using underestimates of the numbers and overestimates of those who had some payment.

Recent Posts and References 

Rallying One Hundred for Health Access Not MACRA

The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.
Copyright 2016