Wednesday, April 27, 2016

Poor Payment Dictates Poor Training Outcomes in Primary Care

One of the biggest problems in health care a focus on "my area" rather than considering the overall impact. An intervention in payment or an intervention in training may appear to look good - until you consider the overall impact. For decades various medical educators have pushed rural training or training in Community Health Centers or experiences with minority populations. Few consider that such innovations have not worked to address deficits in workforce for one reason - the limitations in the dollars that go into primary care spending.

No matter what you do to try to influence students or residents or clinicians to choose positions in front line health access practices, the current dollar distribution comes up short compared to patient demand, particularly where care is needed. No practice can expand team member positions or extend to do outreach or other functions, without more payment for cognitive office codes in areas such as primary care, mental health, geriatrics...

I spent decades going to a number of annual family medicine, rural health, government, and foundation sponsored meetings while working to facilitate the training that would address care where needed. It is now clear that what we have been doing for decades is a failure.


A few years ago I would have pushed Teaching Community Health Centers. After all, I helped to start up the medical school at SOMA which was developed to train medical students in CHCs and has the most Teaching CHCs. Specific training such as this is a good idea for the residents training there who want to be front liners. It also can support some faculty who want to stay where needed. 

But no expert or association or government official should claim that Teaching CHCs are able to address shortages of family physicians as AAFP claims. This should be obvious when considering stagnant FM annual graduate numbers at 3000 since 1980 - the last time period when the ratio of payment to cost of delivering primary care was capable of expansion of primary care delivery capacity - and increases in the family physicians most specific to this care. Only during 1965 - 1980 and a brief few years in the 1990s have we had support to build primary care and care where needed because of payment change.  

Innovative Training Impact Pales Compared to Payment Design
Training more in Teaching CHCs will just displace others who would have filled positions of need as the equilibrium is fixed in place by payment limitation. Training more in rural pipelines in a state school only results in self selection impact as the overal medical school and state outcomes are fixed in place by payment. Expansions of training resulting in more MD, DO, NP, and PA graduates has resulted in fewer MD, DO, NP, and PA remaining where needed. Even if an entire medical school trained 100% in primary care, this would also fail. Family medicine did increase from a few tens of thousands to 90,000 after a generation of 3000 annual graduates a year, but all that this has done is to send proportions of other primary care sources ever lower.

This is all because there are limited state, federal, and other payer dollars - the limitation
to hiring and supporting additional primary care team member positions. 

No matter what training intervention you try, you cannot get the optimal result without boosting cognitive payment substantially (99214, office codes, mental health, primary care, geriatric, basic services, etc.), decreasing the cost of delivery substantially, and likely both. A massive boost in the ratio of payment to cost of delivery is what must be done to support more team members that can deliver more care in more places.

The Lesson of Nebraska

The State of Nebraska worked with the University of Nebraska Medical Center to organize coalitions of government, training, and communities around state workforce needs. At Nebraska, Jim Stageman and Mike Sitorius and others tailored graduate medical education GME about as well as possible to the needs of the state - from inner city Omaha Hispanic to rural Panhandle Community Health Centers using hub and spoke rural training tracks. The Accelerated Training program worked to train FM residents in broad scope practice involving procedures to help more locate where care was needed. If you consider the fine men and women, their training, and their distribution - this was awesome. If you consider the overall result in the 87 counties of need in the state, not impressive. 

Two decades of effort raised primary care incrementally from 58 to 61 primary care physicians/100,000.  As a further testament to the importance of payment, Nebraska slashed Medicaid and 13% of the people of eastern Omaha suddenly had no insurance. Not surprisingly practices responded with fewer hired and supported in this area and metro primary care levels plunged.

Yes, the result was a higher proportion of FM docs with FM at 40% of the physician workforce in all but the 6 physician concentrated counties (25% is the national average for FM for these counties). But the concentrations could not change. The payment designs kept a lid on what could be supported. The names changed during my 15 years of visits across the state and on my maps of Nebraska counties and workforce, but the numbers of FM, NP, and PA did not change. And the populations have aged and increased in demand.

Why the lack of change despite targeted programs?

The great majority of counties in Nebraska where care is needed are counties that have concentrations of patients whose insurance plans support local primary care least. Veteran and Native American plans do not help local primary care. High deductible plans tend to discourage primary care visits. Medicaid and Medicare pay too little to support the concentrations of team members needed.

Millions and Billions for Everything Else Other than Team Members

AAFP, consultants, experts, foundations, and government can spend millions on meetings and grants and demonstrations and student interest and new FM associations and new marketing efforts (primary care medical home, Health is Primary) for no gain. CMS can commit more billions to innovative CMS payments. This is also a rearrangement of the deck chairs with no additional funding specific to more personnel to deliver care in more places. In fact, there is often a decline in the funding specific to delivery personnel as new designs send dollars everywhere else (software, hardware, consultants, regulations, technology...).

As long as we can be creative and not constructive, we aid in the failure to address primary care delivery capacity, mental health deliver capacity, geriatric care deficits, rural health delivery capacity, and care where needed in more counties and more settings across the nation. And we can be very creative. 

All we have shown is creativity. Our patients and front line serving professionals deserve more and require more. The battle is not just a few places. We have 40% of the nation living in 2161 counties with lower to lowest concentrations of physicians - because payment design pays too little for local basic care via Medicare, Medicaid, veterans, and high deductible plans. Payment design denies them the family medicine (25% and falling), other primary care (20% and falling), general surgical workforce (20% and falling fast) that is 65% of the workforce needed. Training is incapable of producing the specialties needed for the places of need. And the population is increasing faster in these places and is increasing most rapidly in demand...... 

Note to the Workforce Experts

The next time you trumpet some new innovation, at least think about what you are doing to promote an ineffective alternative treatment while delaying treatment that matters, that supports more of us, that will result in more annual FM graduates for the first time since 1980, that supports more team members to work with us, that can reverse burnout, and that can restore the joy of caring for people that really need care where and when they need care.


Recent Posts and References  

Thanks Obamacare No Thanks - The sickest in America have had insurance coverage. ACA does not need claims of benefits that are not benefits and lack of attention from serious consequences

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.

Feeling Bad About CMS Feeling Good
It takes more than a feeling to lead in health care. Health care design must work for Do No Harm rather than I Feel Good - especially when it comes to constant changes.


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
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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, April 9, 2016

Stop the Promotion To Restore Mental Health Access

Critical attention is needed to address claims of "value" for any number of recent health innovations. Enough is enough. It is about time to turn from distraction to needed action.

Rapid Change Is Costly and Distracting

In this health policy period of incredibly rapid change, it should be apparent that change comes with high cost and often accomplishes nothing at all. Half of ACOs have fallen by the wayside. Meaningful Use is being left behind. Medicaid expansion was held hostage and even with expansion it still fails for primary care and mental health due to payments too low. Medical homes have finally gained the close examination required of such a costly endeavor at $105,000 per primary care physician more in cost of delivery per year. Physicians now spend hundreds more hours a years on EHRs leaving less time for patient care and for generating revenue to support care delivery.

A narrow focus upon "quality" can be very costly - especially when "quality" is difficult to define.  Substantial dollars can be spent for no change in quality at all. Such is the case when primary care or mental health or geriatric outcomes are about factors that cannot be addressed by clinical means. It is not the clinical focus that matters when situations, relationships, determinants, and other patient factors dominate the outcome influences.

Mental health care is clearly understood as a major problem in the United States. There is one major reason: insufficient mental health team members. Is this workforce even on the agenda to rebuild? From the above, it appears that we are going the wrong way by spending more dollars on everything except more team members delivering care.

Common sense demands the answers to a few basic questions:
  • How long will it take before more dollars are invested in building a mental health workforce that is reasonably sufficient for 15 years from now - a minimal amount of time required for rebuilding such a workforce?
  • How long will it take before more dollars are invested in sufficient primary care - a key requirement for mental health recovery since 47% of mental health care is delivered by primary care?
  • How long will it take to reverse policies that have put small practices and small hospitals in decline - the front line of access for mental health and primary care?
  • How does spending tens of thousands per physician for digital changes, $105,000 more per physician for medical homes, and $40,000 more for quality changes this year help when the top priority should be supporting more team members to rebuild primary care and mental health care delivery capacities?
The cost cutting focus across our nation since 1980 has infected every area of society - schools, health care, roads, bridges, pipes, etc. Teachers, nurses, public health, primary care, and mental health team members are human infrastructure - essential for an efficient and effective nation but compromised by payment designs. Physical infrastructure is also compromised by lack of payment support. Each year or two our nation falls behind a trillion dollars in rebuilding and maintenance costs.

But somehow our leaders seem to believe that there is some magic potion that can be applied to make bargain basement infrastructure work better. They are more willing to spend more on the head, but not on the arms and legs to do the work. The time for head games has long passed.
 
While some focus on innovation, others are still attempting to provide primary care and mental health for tens of millions of people despite payment sufficient for only millions of people and bare bones care at that. 

A top priority should be placed on the people who need care and those who care for them - not the largest corporations and the latest innovations.


Grassroots Local Focus Is Required

Mental health care needs more support to fuel more outreach into homes, families, and communities - not more different sources inreaching into their pockets stealing access to care.

The stimulus for this piece was another Commonwealth posting that Medical Homes May Help Improve Mental Health Issues. "We found that in the U.S., the patient-centered medical home model appears to be associated with better care experiences for adults with mental health issues." Not that "patient centered' or "medical home" or "mental health" have specific outcome definitions or approaches



Recent Posts and References  

Thanks Obamacare No Thanks - The sickest in America have had insurance coverage. ACA does not need claims of benefits that are not benefits and lack of attention from serious consequences

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.

Feeling Bad About CMS Feeling Good
It takes more than a feeling to lead in health care. Health care design must work for Do No Harm rather than I Feel Good - especially when it comes to constant changes.


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
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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.

Wednesday, April 6, 2016

Thanks Obamacare No Thanks

Policy changes have all good intentions, but they have good and bad results. The value is not about innovation. The value is about implementation. Denial and distraction only work temporarily to hide poor implementation.

At the very start of ACA there have been massive promotions and massive protests - but both sets of claims were quite uninformed and politically motivated. In many ways, CMS seems to move rapidly to new innovations perhaps to cover up problems with the past innovations.

Sadly the claims of benefit continue in the face of known adverse consequences. In Think Progress the headline screams that Obamacare helps the sickest to gain insurance. This author is taking some liberty with his reporting (like so many others). A more detailed examination reviews those sickest, the role of insurance access, true access barriers, and what is going on where care is compromised by design.

Who Are the Sickest in America?

The sickest in the United States are the oldest people with the least resources who live in poverty and have Medicaid and Medicare due to disability or age. These have two forms of insurance - Medicare and Medicaid. In some ways they have lesser health outcomes because of their insurance plans do not pay sufficiently for their care - shutting doors, erecting barriers, and changing the types of providers that they can access who can provide less because they care for more Medicaid and Medicare and other disadvantaged patients. 

Do the Sickest Have Insurance Access?

Dual Eligibles, Medicare plus Medicaid, have been granted insurance since 1965. The sickest patients have long had ways to get Medicare (disability) as well as Medicaid  insurance have been present for those discussed. 

Do the Sickest Have Access to Care?

Multiple blog posts have dealt with the flawed reasoning that insurance coverage equates to access to care. Basic health access workforce is required, something poorly supported by payment for decades. New ACA wrinkles in implementation include narrow networks. GAO criticized CMS for lack of sufficient supervision of innovative programs such as Medicare Advantage and expressed concerns about access for those with chronic conditions. 

This summer a Dual Eligible patient suffered delay and eventual death as he was shipped to different hospitals. His neighborhood reels from the worry that the same will happen to them. Some patients must travel 50 - 100 miles and fill out paperwork for practices - that are likely to reject them as patients because of their situation. Word gets around helping to suppress access to care to an even lower level. The good news is the insurance coverage. The bad news is the continued access barrier.

What Has ACA Done to Hospitals and Practices Serving Disadvantaged Patients?

Providers serving a disproportionate share of Medicare, Medicaid, low pay, and no pay patients once had significant special funding - before ACA killed it. Hospital boards for small hospitals and the few remaining small practice owners have to look realistically at the future - a future of declining payments, increasing regulation, and across the board cuts. The writing on the wall has closed dozens of facilities with dozens more closing each year. 

Sadly, many still point to the lack of Medicaid expansion as a reason for small practice and small hospital decline. Insufficient payments for Medicare, Medicaid, and ACA generated plans still result in small practice and small hospital decline.


Who Is Worst in Cherry-Picking - the Media, insurance corporations, biggest practices?

Cherry-picking works well for research studies and for insurance plans. Cherry picking works best for hospitals and practices that care for the most advantaged. Not only do they get the best paying insurance, they will get paid even more by value-based CMS payment designs. Forbes had an article today pointing out the value of "cherry picking" by cultivating the favor of all of the elite patients that they can get. 

God help the plans, practices, and hospitals serving those disadvantaged as they will be paid even less and deteriorate more - under ACA/CMS design.



You cannot overcome access to care barriers by health insurance expansio

because the plans and the payers fail to pay enough to primary care, mental health, and other office payment dependent (cognitive services) providers. 

ACA as implemented by CMS is killing off small practices and small hospitals - the ones where care is most needed. Where care is most needed is where Medicaid, Medicare, low pay, high deductible, and veteran populations are concentrated together in lower cost (poor quality) housing. 

The payers create the shortages, barriers to care, higher costs of delivery, and higher costs while impairing access.
When infrastructure falls apart, it is time to invest in infrastructure - not innovation, rearrangement, cost cutting, reorganization, consultation, and more research.

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.
 
Feeling Bad About CMS Feeling Good
It takes more than a feeling to lead in health care. Health care design must work for Do No Harm rather than I Feel Good - especially when it comes to constant changes.


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
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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, April 2, 2016

The Consequences of Innovation Procrastination

There is a Queen song that will have greater and greater play in future years,"Another one bites the dust." This should be in your head now as sung by Freddie Mercury as we all chime in. Another one bites the dues will continue to apply to
  • Physical infrastructure decline such as water pipes, roads, bridges, public buildings
  • Human infrastructure declines in teachers, nurses, public servants, primary care, public/mental health
If you want, you can replay the song with images of bridges falling down or Flint Michigan replayed a thousand times across the nation. There will be more infrastructure failures this year and next year... We are just seeing the poorer areas and situations where public investment has fallen behind the most. We will also only see the dramatic and not the usual as these are far from media or public attention. We have not chosen to pay attention yet, but we will have our chance as these failures impact more people and in more ways.

Innovation as Procrastination

Perhaps this is why we have Innovation Centers draining more dollars, distracting more people, and promising more for less. We may like procrastination so much that we are willing to create centers to distract us from real solutions. After all we can throw around millions or billions in grants and look like we are doing something - when real change in health, education, economics, efficiency, and effectiveness as a society requires trillions in investments.

One of the first lessons of Public Health 101 was - if you have insufficient resources, be sure to innovate or rearrange or reorganize. That way you can get your next job somewhere else before they blame you for the poor outcomes that were already shaped by lack of investment.

If you pass out enough money to primary care leaders or rural health leaders or their associations, you can even help them to buy in to innovation focus. After all, I was convinced that grants could actually make a difference in the pipelines to rural practice or primary care - but now I see more clearly that these were innovative spending distracting us from real solutions. Family medicine associations clearly have lost their focus on what matters while throwing millions after departments in every medical school, student interest groups, marketing, primary care medical home, and other innovations - without accomplishing any improvements in primary care payment impacting 80% of members.

Family medicine associations must create more jobs, more positions, and more support for primary care team members. This is also the way to more members for family medicine associations - or does this not matter?

Procrastination Is Devastation
  • Why delay needed investments in children from the earliest ages before the window of opportunity closes as the velocity of learning slows down about age 8?
  • If teachers were relieved from the burden of grading and other administrative tasks, they could actually have time to help children learn. 
  • If children had a better start, they would be well on the way to improvements in education, health, economic, and other outcomes.
Infrastructure is the ultimate if, if, if question. If only we had done this, by this time, to prevent this, to make this work better...

In health care we have had failure of investment in public health for decades. Primary care issues have helped to defeat health reform as we see now. The promise of health access offered by health insurance coverage expansion has been defeated by insufficient team members and other consequences of poor primary care payment support.

We know that these areas need to be addressed but still we delay. It takes time and money and effort to rebuild physical and human infrastructure. Most of all it takes a strong desire to make our nation better for future generations

Infrastructure must rise and innovation focus must fall.

True advocates of primary care must support payment specific to the support of team members - payment that can actually result in human infrastructure where it is most needed and most neglected.

In health care we truly appear to be willing to try everything else possible - other than investing in the basics such as team members to deliver primary care, public health, mental health, etc.

When infrastructure falls apart, it is time to invest in infrastructure - not innovation, rearrangement, cost cutting, reorganization, consultation, and more research.

Recent Posts and References  

 

Feeling Bad About CMS Feeling Good
It takes more than a feeling to lead in health care. Health care design must work for Do No Harm rather than I Feel Good - especially when it comes to constant changes.


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
We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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.


Feeling Bad About CMS Feeling Good

Amy Bassano, incoming deputy director of the CMS Innovation Center, said, “We feel good that hospitals are ready to start (bundling payments) on April 1.” Those of us in health care delivery would all feel a lot better in health care if CMS knew that hospitals are ready - but CMS doesn't know what or who is ready and they have not known so for some time. This is more evidence that we need more health care engineers in health care and fewer innovators, researchers, and entrepreneurs at the controls.

Why do we feel bad when CMS says they are feeling good about something?

Unlike other innovations sent our way in rapid order, there is some potential to estimate the impact for this new innovation in payment. Diagnosis Related Groups bundled hospital payments by diagnosis. What were the results?
  • There was some impact on cost control.
  • There were big winner hospitals, winners, loser hospitals, and lost hospitals. The bigger ones won and those smaller lost with closures of hundreds of hospitals paid too little for the care demand. Special legislation was required to repair the damage, but ACA and CMS have taken these out - resulting in dozens of hospital closures with more to come.
  • The marginalization of nursing was inevitable under bundling as nurses were caught between patient care demand and hospital needs to cut costs via personnel cuts.
  • There has always been a potential negative impact upon quality due to nurse to patient ratios too high. The adverse impacts of DRGs may have lowered quality in ways that help explain recent "improvements" better than innovation focus.
  • Infrastructure suffers and the capacity for care during epidemics declines.
  • Forced mergers and closures have resulted in a decrease in competition with potentially higher costs.
DRGs were the only cost control available to CMS in 1982 and only had a 1 year test in New Jersey, a most atypical state as far as the nation's hospitals, populations, etc. There was no time for study, nor was there a critical look as to how to prevent consequences. Consequences have continued for decades with rising divisions between primary care and facilities, increased loads places on low resourced primary care, theft of 50,000 primary care trained physicians to become the hospitalist workforce.

CMS and ACA designers actually knew about many of the consequences of innovative payment, but have still moved full speed ahead.

What will happen under bundling? Almost certainly bigger combined with smaller in bundling such as hospitals and physicians will result in hospitals and systems winning and physicians and personnel losing. Once again CMS has assumed that there are cuts that can be made after decades of cuts. CMS assumes that something clinical inside of health care can be done to improve quality while shaving costs - ignoring the fact that the patient and situation and other patient factors are 60 - 70% of outcomes with clinical limited to 10 - 20%

Bundling will leave winner and losers. Winners will profit as they will get paid and have lower costs. These are likely to be systems in locations with advantaged patients, higher resources, and better situations such as intact families, housing, transportation, etc. The biggest always find a way to game the new scenario faster and better - a huge advantage in a time of constant chaotic change.

Another adverse impact will be seen in the losers. CMS has not shown the ability to adapt to the demands of more complex patients, nor is this possible to do in a way that does not create more winners and losers.

Front line health access has been losing by CMS design for decades.
Not surprisingly this pattern will continue.

The real design of the innovation center has always been clear. Innovate to save, rearrange to save, integrate to save, consultants to save. Show CMS the money saved and we will give you money. Bundling is designed first of all to save CMS first and foremost without regard to patient or provider considerations.  "The Centers for Medicare and Medicaid Services, or CMS, estimates the program will save $343 million on the $12.2 billion that Medicare will spend on the procedures over the next five years."

It is safe to say from the last ten innovations implemented in rapid succession that the US health care system has not been ready for the individual changes, much less the combination of combinations of change. The innovation center has continued its focus upon innovation regardless of the adverse impacts upon care and the adverse impacts upon those who deliver care.

I tried to describe my frustration with health care designers to my chemical engineer dad. I noted, " Imagine that the researchers were in charge of chemical plants. Would it surprise you that there were cost overruns, infrastructure problems, workforce issues, failed processes, and even a few blow ups along the way?"    Engineers or engineering thinking is needed with materials, logistics, infrastructure, personnel, and outcomes constantly integrated in an efficient and effective manner.

Tossing it in to see if it sticks does not work well beyond making spaghetti. We need to know what will work, not how to manipulate the next design to see if it does or does not stick. We must know more before implementation. We owe this to tens of millions of people impacted by these changes and perhaps an entire nation.

A chance to cut is a chance to cure is as outmoded in health policy as it is in surgery.

Recent Posts and References 


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 - We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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.

The Real Kerfuffle - How much chaos can family physicians stand? Why do family medicine leaders avoid the evidence regarding MOC? 

Wrong Way Mental Health - Exploitation and insufficient access have been tolerated far too long.