Saturday, June 18, 2016

Government Compromise of Trauma Response

In the wake of another gun tragedy there have been many calls for change. Trauma experts have asked for better trauma response preparedness. The advocates for change are taking advantage of this narrow window of opportunity, 

but their calls for changes will not do much. 

How can I be so sure? First of all, calls for greater preparedness for disasters or traumas have been made for decades. The calls have been made by those logical in their thinking as well as those passionate after disasters. But most importantly, there is no design to support change. The funding designs, training designs, and locations of health care would need to be changed in the opposite ways of the last 30 years.

It only takes common sense to understand that responses have become more limited with ER closures, mergers, and movements. The personnel to respond to disaster are fewer and are less linked to ERs than ever. The on call systems that backed up emergency rooms and disaster responses have long been marginalized. Surgical centers allow many surgeons to avoid hospital and ER environments. Trauma Centers are quite costly and often depend upon state decisions regarding Medicaid payment as well as federal support through special funding such as graduate medical education. Some of this federal funding to compensate for low federal health care payment (disproportionate share) has been taken away by recent "reforms." A critical review of the last six years of reforms reveal failure after failure - failure in new insurance plans, failures in coverage, failures due to confusing rapid change, failures with designs that cannot possibly discern quality or cut costs. The failures with most specific import to access are about payment failures. Medicaid expansion fails even in states that expand Medicaid because of payment too low. 


Where concentrations of Medicare and Medicaid populations and other federal patients are found, you will find deficits of front line health access due to payments too low. 

From 1965 to 1980 the M & M design injected funding where there was no funding and increased fees for services regularly. Since 1980 the M & M design has paid relatively less for basic services and pays less for care where needed. The same basic services are paid less and practices and hospitals where needed do no have the more expensive services or more exclusive insurance payments or more exclusive businesses to bail out their lack of support. The impact is greatest upon those smaller and less organized and less able to demand discounts from suppliers or the required higher payments from insurance and government payers.

Rebuilding Response and Responders - a Matter of Funding

For any health care delivery where care is needed, it takes blood, toil, sweat, and tears. Mostly it takes lifeblood. Lifeblood in health care delivery is money. Governments only want to pay less for health care. This is a problem as disaster response requires spending enough to be ready for a disaster or trauma victim or victims. 

For any rebuilding of trauma response, it will take funding. This funding change will need to be led from the top. It is government designers at the federal (CMS) and state levels that will need to send funding to the facilities that must stand ready 24/7/365.

Designing Access for Trauma Patients Means Matching Up Facility Distributions to People Distributions

Payments most for those biggest and most centralized has resulted in emergency response that is limited by design. The responders are concentrated away from those in need of response. Across urban and rural America this has been going on. Once again, hospital systems compete for the local closest to the advantaged and as far away from the disadvantaged as possible - and lowest paying Medicaid, Medicare, Metallic, and other plans.

For decades CMS has caused massive closures of small hospitals. This is a function of payment too little for the cost of deliver plus the increased cost of burdensome regulation. Add to this the rapid change - difficult for the largest and impossible for the smallest. 

To address response to trauma and disaster, designers must stop closing small and rural hospitals and ERs by payment designs that pay too little for Medicaid and Medicare services. 

Leapfrogging to Survive in American Healthcare

Compromises of emergency rooms are guided by bottom lines as hospitals follow the dollars and avoid lower paying populations - the populations that tend to live in areas at higher risk for gun deaths, motor vehicle accidents, industrial, recreational, and other traumas. 

Over the decades you can see what transpires. In Waco in the 1980s, Providence was closest to care where needed and soon decided to move past Hillcrest to the advantaged side of town. Within a few years the entire environments of both hospitals changed. Hillcrest almost failed due to payments and leapfrogged in location, which resurrected the hospital via different location, structure, and function - and more distance from care where needed. 

Hospitals in Omaha have leapfrogged farther away from East Omaha where payments are lower due to patient mix. When primary care is also taken down, there are more consequences. Loss of primary care means loss of a buffer against higher cost patients with lower paying plans. The loss of primary care is a 1 - 2 punch on facilities where care is needed. Academic and other hospitals have long learned to manipulate the system to find ways to get federal shortage facilities to buffer their hospitals. This is why you can find them in close proximity to such high concentrations of workforce, usually rationalizing the high numbers of Medicaid patients without access. Note how lack of payment in Medicaid causes the barriers and creates the opportunity to manipulate the current design. The biggest also help protect the shortage programs in their area. Of course this still results in a doughnut of shortage around their concentrations of workforce.

But overall the hospitals have been forced to move away from central city areas - leaving them more vulnerable to disaster and trauma. The trauma and disaster potential arising from central city highway, industrial, sporting event, recreation, and entertainment concentrations are not considered.

Designs that shape responders are not consistent with need for response.

Failed Primary Care and Overwhelmed Emergency Care Shapes Profit Opportunity

The sad fact is that failures in primary care, mental health, and basic services have compromised basic access to care. Emergency rooms were overwhelmed. Entreprenuers have responded to the opportunity with convenience care siphoning off the higher paying patients. Stand alone emergency centers, urgent cares, and retail clinics have stolen ER volume and have taken less complex care away from emergency rooms. These new designs target the advantaged with better paying plans. The overall design results in the more complex and lower paying patients for emergency rooms. 

If want to see another rapid change in your hospital, watch as your ER converts to a Level I trauma center. This is an incredibly complex change as you must be ready for major changes in operations, waiting room environment, personnel cost, and equipment utilization. You can also expect impacts as certain patients decide not to go to the ER or to this ER.

Freestanding ERs and Urgent Cares and even Surgicenters could take up some of the trauma and disaster response - except they are located where retail business is concentrated - away from trauma, disaster, and needed care where lower paying patients are found.

Supplies and Supplier Readiness 

Orlando ran short of critical supplies. This is not surprising as various respiratory or GI epidemics have overwhelmed even basic supplies such as IV fluid. The new cost cutting designs with supplies provided time on target have no leeway for sudden demand. Hospitals with thin margins have cut deals with suppliers to provide a minimum of supplies. Learning from Walmart and others, some facilities do not even own the supplies until they are used even.This does reduce waste and allows a reduction from 20,000 different items to 11,000 but there is no disaster preparedness. 

CMS designs pay even less where access is most needed which is generally where such patients are concentrated. Cost cutting does not allow for key medical supplies to be stockpiled for even a flu epidemic much less for a local disaster. 

As the risk for disasters increases, our transportation deficits are magnified. 

And in the case of transportation disruptions, resupply can be difficult or impossible. Power failures, floods, hurricanes, tornadoes, earthquakes, transportation strikes, construction events, civil disturbances, or high demand for services can cut off most of the people from access to the facilities needed.

In epidemics and disasters, the media can cause more problems.

Ever since the CNN started highlighting various epidemics, the public has been encouraged to crowd into overcrowded facilities - thus exposing the worried well to those who are spreading the epidemic. The push to bring the latest information adds to crowds and crowding in disasters. How many times have you wondered by someone didn't act to help someone instead of filming their trauma?

Poor Payment Design Kills off General Surgical Specialists

Payment designs have been killing off general surgical specialists. More have continued to do one or more fellowships to specialize for better jobs and for better support. General types of specialists are the professionals most important in the 2161 lowest physician concentration counties with 40% of the US population, especially for response to trauma. General surgical workforce used to be 25% of the physicians in these counties but fewer graduates entering the workforce after initial surgical training plus retirements result in a rapidly aging surgical population. The oldest and nearest to retirement depart as forced by age and by national policy direction. As small hospitals are closed, the workforce linked to hospital and general specialty care also fades - as does access to care.

Nationally in the AMA Masterfile 2013 compared to 2005, the various general surgical types (general surgeons, orthopedists, ENT, eye, ob-gyn, urology) were all decreasing by 2 to 3 percentage points a year. New regulations with greater physician frustration, ER closures, surgical department closures, Surgicenter competition, and small hospital closures are making this workforce deficit much worse. 

Sympathy and Empathy Are Distractions from Symphony

The calls for trauma access reform are well-intentioned, but a very different health care design is required to actually have a health care delivery system that can respond to trauma. Battlefield Lessons To Advance National Trauma Care     Up to 1 in 5 trauma victims may die unnecessarily

Articles address a piece of the problem and are usually written from the point of someone who is promoting their side as a solution, but true solutions required a much more comprehensive awareness.

We have numerous innovative people, advocates, groups, disciplines, programs, or institutions that are willing to benefit from their claims of being a solution. They are doing more harm than good.

When designs or articles or programs are not specific to focus on the team members to deliver the who what when where how and why of needed care, they actually move the nation away from solutions. This is not a training or workforce problem. It is first of all a payment problem. No training design or special grant program or other intervention can work if the payment does not support the intended changes. 

Design Failure is Compounded By Failure in Implementation - Deficits of Engineer Thinking

We do not have the leaders that function like engineers to put together the teams to deliver the care, and the supplies, and the workforce, and the training, and the funding, and the administration... to support the facilities in the locations needed. We just have enough of a health care design to allow manipulation to result in care for a few at high cost while leaving behind most Americans.

Bloated Administration

What is also apparent is that the administration generally has become excessive and unresponsive, in ways that preventing action from the local to the national level. Review How to Destroy a Great ER or How to Destroy Care Nationally with the same framework as used in how to destroy an ER.

Designs focused first upon cutting funds and forcing quality have failed to cut funds or improve quality although they compromise front line basic access to care and front line trauma response. The evidence based reviews of MACRA confirm the failures as well as the serious consequences forced upon those who attempt to deliver care where needed.      Prevent MACRA to Do No Harm


Recent Posts and References  

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
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





Wednesday, June 15, 2016

The MACRA Management Reproach

It is a sad day when something can be implemented that is so wrong for health care delivery overall as demonstrated by the evidence and is also so discriminatory across access to care where needed. 

MACRA cannot measure and discern performance. MACRA methods are known to punish smaller practices, raise costs of delivery, and distract from care focus. Inability to discern and sloppy methods plus wide variations (between practices, patients, year to year) will result in inaccurate feedback. The impact will likely be greatest to compromise care where needed. 


 “Outside the bubble where Congress and CMS live, there is a widespread recognition that CMS cannot measure physician “performance” accurately.” KS backs this up with evidence from Journals and MedPAC.

"CMS’s failure to say a word elsewhere in the rule about the disproportionate punishment meted out to smaller clinics, and CMS’s refusal to admit it will be dishing out this punishment on the basis of crude measurement, is appalling!"


“The feedback doctors will receive from CMS under CMS’s proposed MACRA rule will arrive in two forms: Money (more or less of it) and data. Neither form of feedback will be accurate. For that reason, the behavior desired by Congress and CMS – “smarter care” (as CMS puts it) producing lower costs and higher quality – will not materialize.”

“In this installment I review the risk-adjustment problem and CMS’s irresponsible claim that it can measure physician “merit” even with sample sizes as small as 20 patients.”

“The purpose of risk adjustment is to adjust cost and quality scores for factors doctors cannot control. The patient’s health, socio-economic status, and quality of insurance coverage are the three most important confounders that must be accounted for in any pay-for-performance scheme (MACRA is, of course, one great big P4P scheme) or any report card that could steer patients toward or away from a clinic or hospital. If risk adjustment is not done, or is done poorly, the signals doctors receive from the P4P scheme or report card will be useless, and even worse than useless if doctors who treat sicker and poorer patients are punished unjustifiably. Dozens of studies have shown that P4P schemes and report cards are already harming sicker and poorer patients (see, for example, Werner et al. ), Dranove et al.. , Chien et al. , and Friedberg et al. )."

The blog goes on to review the best quality report card with years of experience – and notes that it falls far short despite high cost. Medicare Advantage is another scheme that has much evidence of too much variation and discrimination against those associated with the sickest and poorest. 

“My purpose in examining the CABG report card and CMS’s HCC method is to give you a sense of how primitive even our most sophisticated risk-adjustment methods are and how unfixable that problem is. CMS, however, gives the readers of its MACRA rule no hint that risk-adjustment is still in its infancy and will never grow out of its infancy. To the contrary, CMS conveys the impression that CMS has already created risk adjustment methods sufficiently accurate to punish and reward physicians.”

CMS Implies Validity and Reliability in MACRA - Not So

“In a report entitled, The Reliability of Provider Profiling: A Tutorial, the RAND corporation said exactly what I’m saying. CMS is well aware of this report: I found it in a document on CMS’s Physician Compare website (see p. 25). RAND made it crystal clear CMS has no business conflating its “reliability” test with accurate risk adjustment. RAND stated:  Validity is the most important property of a measurement system. In nontechnical terms, validity is whether the measure actually measures what it claims to measure. If the answer is yes, the measure is valid. This may be an important question for physician profiling. For example, what if a measure of quality of care is dominated by patient adherence to treatment rather than by physician actions? Labeling the measure as quality of care measure does not necessarily make it so.”

The measures are not fully controllable by the physician or practice.The measures are not properly adjusted for variations in case-mix, year to year, or other wide variations.

“I think we can go beyond “problematic” in criticizing CMS’s proposal to use patient pools as small as 20. I believe “reckless” is the appropriate word.”

Bad feedback is worse than no feedback. “In fact, CMS’s feedback could be worse than useless. It could have the net effect of raising costs and lowering quality, especially for the poor and the sick.”


The statements implicate MACRA as an attack of the aggregators and note the many problems of short time line, long term impact, weighing every practice down with reporting requirements, and rapid acceleration of penalties four, five, seven, nine percent in just 6 years. The penalties are noted as chilling to those who might try to stay in practice despite the costs and penalties and to those who might start up or join small practices.

There is also a notation of surprise at the lack of action to address MACRA critically by those most threatened such as in family medicine.

What we actually can point to for best evidence about quality measurement demonstrates the inability to discern plus a consistent discrimination against those smaller, caring for more complex, caring for those with less resources, caring for those with more difficult situations…


Increasing cost, decreasing quality, and reducing access are exactly the wrong ways to go in health care and clearly the small practices, small hospitals, and front lines of access are impacted most - especially family practices.

In other words, there is little benefit to MACRA at all unless your job is related to the billions going into this new business (or your position in government which is your future position in business).

Over and over the programs and policies that compromise people in need of care also compromise family medicine and all on the front lines of health access. 

Recent Posts and References  

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
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




Lack of Accountability for Accountable Care - Roll on regardless of consequence




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

Wednesday, June 8, 2016

Prevent MACRA to Do No Harm

Do no harm is still considered a top principle in health care - especially for physicians. Physician associations should advocate for their patients and should not advocate policies or practices that cause harm - especially harm to vulnerable populations by commission or omission.

Harm can be caused in a number of ways in health care. Harm can be caused by cost too high or by quality problems or by access to care barriers. 

  • MACRA claims to be focused on quality but studies question whether quality can be achieved by clinical interventions. Failure regarding the ability of electronic interventions is already documented. MACRA cannot even discern differences in "quality."
  • CMS agrees that excessive costs due to regulation must be addressed and then minutes later CMS officials promote the burdensome MACRA implementation without possibility of delay
  • MACRA has a focus on cost cutting with no better than break even regarding payment change overall for areas such as primary care and mental health. 
  • MACRA does not redistribute payments from higher paid to lower paid or address other inequities in the current payment design
  • MACRA continues payment too low for cognitive/office/basic services with payment too high for procedural/technical/specialized - the design that defeats generalist and general specialty careers that are needed most now and are increasing fastest in demand
  • MACRA continues to defeat the major causes of access barriers - insufficient payment to sustain workforce where needed (where CMS patients are concentrated) and insufficient workforce by type and location
Access harms have become so common that they may be outside of the ability of many designers and health care leaders to comprehend them. This has been made worse by a focus on special programs to address access barriers. Of course the amounts set aside for special programs are too small and fail to help most of the practices on the front lines not to mention the administrative excesses of such programs and the ease of cutting them out entirely.

MACRA will cause harm

  • MACRA is essentially fee for service with a continuation of fees too low to sustain many small and solo practices that provide lowest paid services such as primary care and mental health. Many still do not understand that primary care and mental health are paid less and that practices bigger and where care is concentrated make more per service while practices smaller where care is needed make less. MACRA continues this disparity.
  • MACRA continues to pay less where access to care is most needed. Elderly, poor, Medicare, Medicaid, fixed income populations and populations with low paying plans are in harm's way under MACRA because the payment design plus penalties will result in even less payment, less viability, fewer team members to deliver the care.
  • MACRA will particularly single out practices where family practice MD, DO, NP, and PA are the dominant health professional - small group and solo, practices on the front lines of health access. Family practice professionals are the only ones that can be shown to have population based equitable distribution such as 36% found in 2161 counties with lowest concentrations of physicians where 40% of the US population is found (0.9 ratio or above is population based compared to other specialties 0.2 to 0.6) This will make it even harder to obtain and sustain family practice recruitment and retention - the number one demand for many years because of payment design deficits. This will result in worsening of the vicious cycle of more paid for recruitment, retention, brokers, consultants, and other administrative costs with less remaining for care delivery.
  • MACRA payments have already been shown to pay less by government investigators for many if not most primary care practices (disputed of course by MACRA designers). Harm caused to primary care harms people through access barriers, access barrier deaths and disabilities, increased overall health costs, and worsening of local economics. Places where practices are closed or compromised lose out in local income, jobs, education, transportation costs, outflow of local citizens for other services, and decreases in organization for care.
  • MACRA payments force an increase in the cost of delivery due to software, hardware, maintenance, update, and other additional costs. There is no design in MACRA for a compensatory increase in revenue to cover any of the recent forced increases in cost of delivery due to regulation. 
  • Payments for the last decades have continued to compromise primary care and mental health to the breaking point.
  • MACRA diverts attention from the necessity of restoring access to care in two ways. It focuses attention away from paying more. MACRA diverts funding away from the team members delivering the care via regulatory burden.

MACRA is worse than the previous patches prior to MACRA.

MACRA is about harm to basic health access. MACRA will worsen shortages of workforce where workforce is most needed and where demand for care is growing fastest.

MACRA should be opposed by those who truly champion "Do No Harm" - physicians, physician associations, and especially those who advocate for patients, primary care, and care where needed.

Those who promote MACRA are responsible for the declines in access to primary care and mental health that result from MACRA.


MACRA will make each of these problems worse by impairing access, increasing cost of delivery, increasing regulatory burden, increasing pace of change, increasing access woes, decreasing productivity, and decreasing morale.

MACRA = Harm by Design

For prevention of harm, for population based health, for primary care, for mental health, for care of the elderly, for care where needed - PREVENT MACRA

Recent Posts and References  

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
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




Lack of Accountability for Accountable Care - Roll on regardless of consequence




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

Friday, June 3, 2016

Talk About Unpaid Stressed and Abused For Decades

When a journalist wakes up the the real world, there are great opportunities. But can the journalist manage to capture the perspectives needed to truly understand the reality of health care delivery?

I enjoy the variety of information that I allow to access me. Sometimes there is amusement. At other times I see the best of humanity or try to turn off the worst. In the health care area, I am usually frustrated with what rises to the surface, particularly from health care journalists.

A few years back I tried to do more work in this area. I found that there was not much interest from the perspectives that I embrace - local care, health access, care where needed, and preparing health professionals for these areas. I thought that the experiences of 30 years of teaching, researching, and delivering health access would be valuable - since the nation has long been drifting away from health access, local, care where needed.

It took years for the decades of habits and experiences to peel back before I could see more clearly. Those attempting to pass on the information that we seek, do not have decades of experiences or much reflective thought.



Vox has been informative and a new piece describe the challenges of those attempting to care for a troubling and persistent condition. This is not new as the New York Time has had a number of provocative pieces including some where the journalist let passion get beyond journalistic sense.

This author sees herself and others as unpaid, stressed, and abused. I do hope that she resolves her problems.  I hope that she can learn beyond her situation to see the situations facing many if not most Americans now or in the near future.

I see much of primary care, mental health, and basic service delivery as much the same. It will even get worse because of the numerous journalists that help foundations, institutions, and government promote their solutions - solutions that are not a fit with the reality facing most Americans.

Underpaid Stressed and Abused Primary Care

There are many questions that arise in this area. Decade after decade we have allowed basic health access to deteriorate - primarily due to lowest payment for primary care, mental health, and basic services. These are the services provided by generalists and general specialists - the ones going away by payment design. So much more paid for technical, procedural, and highly specialized care is a major reason for cost of health care increase. Someone with a somewhat different perspective could tell us whether the payment design or the rapidly increasing administrative costs killed off more care delivery. I suspect administrative costs have increased the most with payment distortions to highly specialized care a major reason. Not surprisingly this has resulted in compromise for primary care, generalists, mental health, geriatrics, and other basic services destroyed by little or no increase in payment, inflation of usual costs, and new added costs of delivery.

Despite this obvious reason for health access failure, more and more innovators, organizers, advocates, deans, program directors, and associations claim to be a primary care solution. Even worse, government grants and foundation dollars go to support their innovations, consultants, and corporations.

As soon as these blogs, social media pieces, or journal articles are published and as soon as government promotes some new innovation - the band wagon process rolls on and in a direction away from the reality of care delivery where needed.

The One Specific Solution to Health Access Is More Funding

The only effort specific to health access recovery, more funding, is the one that is avoided as "everything else" is attempted. What is worse is that these efforts distract from the real solution and diffuse the organization needed to make the solution a reality - a solution demonstrated 1965 to 1980 and a few years in the 1990s and denied since that time by payment policy. Not surprisingly these have been the only gains in graduates most specific to primary care, geriatric care, health access, care where needed, rural health, and population based care - family physicians. FM rose from restored to 3000 annual graduates 1969 to 1980 and has had little change since other than a few years in the 1990s when 3300 - 3500 graduated from FM residencies.

Why Don't Associations Specific to Primary Care Support More Funding?

Even family medicine does not get it. FM associations and leaders and media pieces promote meetings, conferences, training, retraining, departments of FM, residencies in every state, and the marketing known as Primary Care Medical Home even when these matter little to most family physicians.

What matters most to most members is more support for what they do, more team members, more colleagues, more replacements, and more support for their patients - denied by the reality of payment design. (same reflection for teachers and students)

Can a health journalist experiencing health care for a first time aid in progress toward a solution? Can we get some perspective here?
  • At some point age 15 - 35, some sort of chronic condition will strike many of this age. Instead of the usual episodic illness and rapid recovery, much more care will be needed. 
  • This is usually quite frustrating due to the visits required, the uncertainty, and the logistics. 
  • Also there is the realization that a person is not immune to chronic health problems and sometimes there is the beginning of the understanding that death is inevitable, as are numerous limitations.

The example of a health journalist "experiencing" health care delivery gives numerous lessons for those willing to reflect

Why do we tolerate the care delivery that we have, or don't have? (perhaps her point)

How much worse is it to have Medicaid, or Medicare, or Veteran care, or live hours from needed care? And why do we only pay attention to Veterans (some) when Medicare, Medicaid, rural people, minorities, and other tens of millions have been putting up with many times this for decades?

Would she have written hundreds of previous health care articles the same way if she had her new realization long ago?

What would she do differently if she had the training and practice experience of a physician?

How different would her writing be, if only...

One of the problems of our current time is a serious level of misinformation arising from blogs, social media, and often from major journals.
 

What If (my personal reflections from career experiences)

What if she had the 60,000+ patient care experiences of a family physician?

What if she had 400 encounters with Medicare patients and patients with Medicare and Medicaid in their homes last summer - low cost of housing homes in low cost of living locations because this is all that they afford - with health care deficits that make matters worse even with insurance coverage?

Will a journalist see beyond self to tens of millions of others who have even fewer options lasting back decades in time and decades of life? 

The Treasure Trove of Reflective Rural Practice

How would her perspective change if she saw the best of rural practice for 2 years and then the most difficult times as friends, families, patients, neighbors, businesses, and more fell apart with declines in agriculture, state cuts in education and social services, centralization of state services away from your town, and decreases in payments for local health care? Would she understand the deficits of designs that allowed school districts with great taxable property to steal the teachers and resources that they need from schools without low taxable land? Would she try to save the local daily rural newspaper, one of the last existing? How would she feel with the demise of a practice and then hospital and local Walmart and more?  Would she feel that she wasted countless hours of work organizing local care, writing legislators and Congress, working with the chamber of commerce and local clubs and the ministerial alliance and social services locally, and sacrificing thousands attempting to find a way to keep practices, communities, and care afloat?

These lessons and more were learned but took time to set in. And it is even more frustrating that we think that we can address primary care and mental health - doing everything other than sending funding specific to the team members who actually deliver the care.

Why would we think that those without front line experiences (journalists, health policy researchers, consultants, experts, Congressional or legislative staff) could comprehend what has been going on?

The above experiences over the last decades, and especially the most recent years, have been my experiences.

The personal experiences of a family physician can be important to the reality and the context of care. Sadly until many highly specialized physicians have the experience of care, they never have the chance to learn where care matters most. But sometimes the awareness of care can be overwhelming - a real reason for burnout levels high in primary care physicians.

The experiences of other family physicians can be informative...

What if she had been forced from her primary care practice by payments too low and cost of delivery made too high for the 50% of family physicians in small and solo practice? Imagine what if feels like to see meaningless regulations making matters worse and forcing unpleasant decisions to cut personnel or spend substantially more despite making less, with the risk of being paid even less.

How do FM docs feel when the association that is supposed to represent them embraces each new innovation - primary care medical home, value based, MACRA with all of these adding $40,000 to $100,000 per year per primary care physician to a practice that already is an neutral or negative margin?

Imagine the final blow when you come to the reality that you can no longer sustain the life you love or the patients you love - patients that have care demands that are less and less likely to be met. Others work outside jobs to sustain their practices. The journalist has experienced a few hours of frustration. Imagine the frustration of a life spent in service, often poorly supported, with great demand and sacrifice required, and clearly not valued by those who design payment and distribute the ability to survive elsewhere and to thrive for a privileged few.

I hope that all of you get past the barriers to care - and find your way to realization of the care delivery conditions in this nation, or lack thereof.
 
When you see the health information, see past the information to the reality.



We will remain victims of our perspectives,
unless we reflect and allow reality to change US.

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


Recent Posts and References  



The Consequences of Innovation Procrastination - Delays in indicated care result in harm to patients. Distractions due to innovation result in harm to millions who need care delivery, not rearrangements, confusion, reorganization, and rapid change.

The Massive Failure that is Primary Care Payment 
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
Health Care Who Is it Good For? Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation
Safety Net Must Sunset and Front Line Health Access Should Rise

Experimental Innovation or Basic Infrastructure? Wouldn't it be nice if we actually funded infrastructure and basics instead of trying to substitute innovation or other distractions? 

For Better or For Worse in Quality - More for fewer and less for more - thus continues the new innovative designs - same as the old designs

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.

Saturday, May 28, 2016

How to Destroy Clinical Care Nationally



1. Ignore and undervalue clinical experience.      

While attention is being paid to value-based, MIPS, and MACRA payments - there is not much change to lowly paid cognitive, office, and basic services.

CMS physician payment design rewards longer training and more technology but ignores factors such as experience, continuity, and retention in a needed career - factors important in primary care and mental health delivery. Where the patients are most complex, the clinical experiences prior to the care episode can be most valuable - but value based payment is not based on such value. Actually the new design is not really new. It is a patch of a patch of a patch.

There is no payment adjustment for care where needed, for practices that invest in more delivery personnel, for those investing in more RNs or more experienced personnel, or for those with more integrated services. Low payments actually move practices away from all of these areas.

A great hypocrisy
is promoted by panels, researchers,
primary care associations, and CMS as they support many
of these areas by words while ignoring their cost as they continue insufficient payment


CMS does not see that they drive people away from primary care and mental health - shaping deficits in workforce.

Experienced personnel move away from primary care by design. CMS does not see that decades of underpayment results in consequences in the personnel retained. Those most valuable often move on to higher pay. Where payment support is lower the practices can support fewer personnel and have difficulty keeping the best personnel.

Where have all the RNs gone?

Many can remember back to a long term continuity RN working with their primary care physician. The RNs are apparently too costly now. Instead of assessing and checking in each patient while providing direct support to the physician, a few RNs per clinic are in the back rooms doing triage phone calls or negotiating with insurance companies for coverage for patient needs or managing the clinic as an administrator. Lowest cost drives the personnel in underfunded primary care. Lowest payments for underserved primary care and for primary care as comparef to other care shapes a pecking order in practice personnel.

Underserved primary care suffers the most
  1. with lowest payments, 
  2. with the most complex patients,
  3. with the least experienced personnel (and some quite dedicated),
  4. in areas with the least resources,
  5. with a number of additional challenges to payment, productivity, personnel, and outcomes.
The case can be made that underserved primary care needs the most experienced and those that stay the longest building up the awareness and expertise specific to team, patient, community, local resources, and more.

The CMS design that results in lesser payment for primary care results in fewer staying primary care as flexible types of clinicians (internists, physician assistants, nurse practitioners) have other options for higher pay, better support, and less complexity). Where there is the greatest career flexibility, turnover is higher and continuity is shaped lower.

If you understand the need for experienced continuity personnel - Loan repayment and other short term incentives fail to work well due to insufficient cognitive/office/basic care payment by design.
           

2. Don’t ask clinical staff what they need, tell them what they get.       

CMS does not support primary care or mental health and now tells them how to run practices while forcing them to pay more to deliver care while shrinking productivity.
           

3. When the ER is showing signs of distress, address it by creating more administrative positions.

ACA/CMS efforts have increased administrative and management and other non-delivery costs. This has been the major shaping force in health care for decades. Primary care and public health and mental health remain flat with other basic services while specialty and subspecialty costs and workforce accelerate and administrative costs increase the most.

CMS has demonstrated time after time that is is disconnected from care and caring and those who deliver the care. CMS has little awareness of the access, cost, and quality problems that CMS is causing. You can find great quotes verbalizing their awareness, but these have been words only. 
           

4. Automatically turn down any request from clinical staff in the name of saving money.     

CMS has been guided by cost cutting primarily since the 1980s. The contrast in policy direction has been substantial. CMS rebuild health care and health care where needed from 1965 to 1980. The priority has changed from investing in health care to chopping health care. Not surprisingly those paid the most that are also the most organized have managed to preserve payments and help create new lines of revenue. Payments for basic services have steadily deteriorated relative to higher paid services, making matters even worse in areas most dependent upon basic office services such as primary care and mental health. 

The latest developments promoted by the Center for Innovation are focused primarily upon cost cutting. Often the efforts combine cost cutting with quality focus - quite difficult to accomplish unless you target patient populations that have the most advantage (and therefore the best outcomes already) and that pay too much for care. Attempts to focus on cost, quality, or both have devastating impacts upon access as more dollars are taken away from being spent on the team members to deliver the care. Primary Care Medical Home Fails Natural Experiment     Innovation Incapacitation
           

5. No one knows the unique struggles, challenges, and problems that your emergency department faces like an outside consultant.   

CMS, primary care associations, and foundations promote innovations such as Primary Care Medical Home with consultants that tell experienced practices and personnel what to do while taking $105,000 perprimary care physician away from the ability to deliver primary care. Quality focus, reporting, data collection, software, Meaningful Use, MIPS, and MACRA add tens of thousands per primary care physician each year in ways that can only marginalize primary care and destroy small practices and facilities. Quality Metrics Cost
           

6. Make sure your EM physicians are constantly reminded that they have no negotiating power.   

CMS and insurance payers and those who employ physicians are constantly reminding physicians that they have little control over what they do - other than to depart. There is often some measure of deception present when hiring. Many recruiters know that if you can get the candidate to bond to people (clinic, community, patients) then they can stick them there for awhile - but this is another reason for burnout. When candidates are attracted to well supported teams and environments, they will stay and serve even the most complex patients. 
           

7. All of the many EDs in your system are doing exactly the same thing, so it is fair to directly compare them to each other.      

CMS in published data, in quality measures, in penalties, and in other areas compares vastly different hospitals and practices serving a variety of populations with a variety of resources. The publications and penalties result in greater confusion and worsening of situations  

Major journals are not much better as they publish research that allows researchers to commit major errors such as apples to oranges comparisons. Why would any journal allow lesser paid small hospitals to be compared to biggest facilities (JAMA) with differences in funding, personnel, patients, community resources, and more.

CMS clearly does not understand the variety of interactions of patients with those who deliver care in a variety of situations with a variety of local resources. CMS clearly does not understand how these line up in advantage and better measures for some while others have few of advantage and lesser measures along with lower payment. 
           

8. Create an environment where it is impossible for your clinical staff to succeed, then blame them for the failure.

CMS pays too little for basic services while forcing front line practices to pay higher cost of delivery while assigning penalties that makes their job even harder - and this is magnified where care is needed and where CMS patients are more concentrated. CMS designs such as DRGs have been a primary reason for marginalization of nursing with ratios too low, burdens too high, experienced nurses driven off...

CMS is a primary reason for low morale among nurses and physicians.

Senators and others are blaming primary care for a number of societal woes, even when they fail to fund primary care, mental health, child well being, early education, nutrition, and programs directly related to social determinants, local resources, health literacy, and other patient factors important to health and health outcomes. Senator Who Do You Think You Are Fooling

Primary care needs partners - political, primary care association, insurance payers, and government partners to work with them to change environments and situations of people in favor of better health and health outcomes. Primary care working with local resources, groups, and individuals is the progress that must occur. This cannot happen when payment undermines and overwhelms local primary care, paralyzes practices with rapid change, and drives off local health professionals and established and connected team members.

These all require decades of partnering to address recovery and expansion of the team members to sufficient levels to deliver, facilitate, integrate, and coordinate care across all the populations and places in need of access.

Nothing less than a Moonshot effort for decades is required to recover health access for the American people. Sadly the Moonshot was directed the wrong way. 

Recent Posts and References  



The Consequences of Innovation Procrastination - Delays in indicated care result in harm to patients. Distractions due to innovation result in harm to millions who need care delivery, not rearrangements, confusion, reorganization, and rapid change.

The Massive Failure that is Primary Care Payment 
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
Health Care Who Is it Good For? Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation
Safety Net Must Sunset and Front Line Health Access Should Rise

Experimental Innovation or Basic Infrastructure? Wouldn't it be nice if we actually funded infrastructure and basics instead of trying to substitute innovation or other distractions? 

For Better or For Worse in Quality - More for fewer and less for more - thus continues the new innovative designs - same as the old designs

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.