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.

Thursday, May 26, 2016

Senator Who Do You Think You Are Fooling

The minute the Senate calls your name, in this case about the alleged lack of family physician response to the opioid crisis. This is the response of a family physician

We family physicians invite you Senator, to visit us in our practices.

We ask you to explain to us how we will be able to address growing opioid and other addictions, mental health deficits, expanding geriatric demands for care plus screening for hepatitis, depression, suicide, nutrition, health literacy, resources, medication access, and other complex areas that we must integrate and coordinate.

We would like you, Senator, to reflect upon the impact of deteriorations in situations, income, jobs, education, housing, and other determinants of health and health outcomes. 

We ask how we can do more with less since we are already paid least and CMS will pay us even less because we care for these more complex patients. Also we will be having to pay more for HIT, EHR, MU, MIPS, MACRA, PCMH - efforts that will worsen matters due to declining productivity.

These are the complications that front line family physicians must address despite least pay, most complexity, highest penalties, and shrinking cash to pay for team members.

We need an understanding national leader to partner with us to restore necessary care – one who will invest in front line basic health access to restore the team members in primary care and in mental health specific to access to care.

We need a leader who will participate constructively in rebuilding health care - one who will avoid participating in blame and shame campaigns popular in the media at this time that often distract us from our common health care goals.

To lead our nation well you must understand key areas such as human infrastructure and physical infrastructure - areas that can help our nation to be more efficient and effective. Investing in teachers, nurses, public health, public servants, primary care, and basic services is important. Distractions from these key areas are important to avoid - for a better nation.

I can assure you that you do not know what is going on on the front lines just as I know that those on the front lines know very well what you are not doing. The evidence is all around them and makes their jobs more difficult, day after day, year after year.

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.

Wednesday, May 25, 2016

Are New Departments of FM Necessary?


A story out of Boston (or New York, or...) brings attention to a long term dream of academic family medicine - having a family medicine department in every medical school. Not surprisingly the latest article or blog is soon promoted and passed around by FM associations. For decades the Family Medicine journal has listed family medicine results once a year and has categorized by department - keeping this focus alive. The question remains...

Are new departments helpful for family medicine or not? 



Payment Design = Workforce, Regardless of Training

Can departments of family medicine boost family medicine? Apparently not since the most rapid increase in family medicine residency growth from 1970 to 1980 was the period of fewest family medicine departments. What really fueled the rapid growth of family medicine was substantially more payment going to increase primary care. Since family medicine is the most dependent upon primary care payment (cognitive, office, basic services), family medicine is most shaped by payment. Others not specific to primary care (IM, NP, PA) have many other options and have taken them - away from primary care, family practice, and care where needed - all lowest paid by design.

Since the 1980s, the payment design has been most about cost cutting with those least organized losing out the most (small practices, small hospitals, care where needed).

Payment shapes workforce. Payment and workforce shape training and all work together to shape training outcomes. Unfortunately payment design shapes all factors and in ways away from local, primary care, family medicine, care where needed, and support for those who care. Federal Cause of Shortage Areas and Access Barriers

So once again - Why should family medicine push to have departments in every medical school such as top ranked (US News) schools that may only have less than 10% primary care result due to
  • one to three family physicians produced a class year for maybe 2 in primary care
  • three in internal medicine PC out of 25 choosing IM training 
  • three in pediatric primary care out of 14 choosing PD training
per 100 in a class for actual results of 8 to 10% for primary care. These are outcomes consistent for many class years of graduates - more evidence of the power of payment design impacting all. 

Isn't this another distraction away from real growth of FM - that requires substantial increases in payment, decreases in cost of delivery, and especially both?

Only One Historical Period of Real Progress for Primary Care and for Family Medicine

The period of time most associated with advancement of family medicine was the period with the fewest departments of FM. From 1950 to 1978, family medicine made progress fueled by the hard work of FPGPs state to state to establish the need for FM, training programs, and payment. There was success in attention and in needed action. There was widespread awareness of the need for family doctors. This was supplemented by National Health Service Corps NHSC expansion and funding specific to FM training. These additional interventions all looked good too, as long as there was expansion of payment supporting more positions in more places. Sadly these interventions do not seem to do much other than rearrange the deck chairs because of the limitations of payment that place a ceiling upon primary care delivery capacity.

The initial building period was the initial and only major growth of FM to 3000 annual grads by 1980 and FM has stayed at 3000 except for a few years in the 1990s when payment was temporarily changed and when medical students feared to enter hospital careers. 

What Happened to Family Medicine Leadership?

The leadership of FM changed substantially during its early years. The leadership that built FM was family practice experienced. The rapid growth of FM resulted in the next generation of leadership that was often not practice experienced except for academic practice exposures. The initial building leaders acting across this period of time 1960 to 1980 shaped FM to what it is today at 90,000 active family physicians. Since this beginning period of time, academic focus has been limiting for family medicine and health access.

What Happened to the 1960s and 1970s Medical Schools?

Once upon a time there were even primary care medical schools that were funded with family medicine as a major focus. These efforts have essentially been marginalized and only one small school (Duluth) remains somewhat effective for primary care, family medicine, and care where needed. 

Mercer has been a glaring example of payment plus academization taking out the best health access medical school in the southeast in just a few years with FM choice plummeting from 30% to 3% - and despite an active department of family medicine and a family medicine dean. Top health access results in the Southeast US where deficits have been greatest made Mercer a top choice for care where needed (along with West Virginia School of Osteopathic Medicine). But care where needed is predominantly about family medicine choice and less than 5% for FM lands schools in the bottom for health access result.

Osteopathic expansions have doubled graduation numbers twice since the 1960s graduates, but each doubling has been accompanied by half as many choosing family medicine - for no gain in FM despite two doublings of family medicine departments. DO schools in the northeast and most urban areas have had particularly poor showings in family medicine despite departments and numerous activities and a key role in DO schools - in contrast to MD schools.


The Academization of Family Medicine

The time of academic focus has resulted in more departments and more families of family medicine (Family Medicine Associations). The growth has provided a number of opportunities for consultants, association staff, and those developing products, services, and marketing opportunities. The Family Medicine board has required more from family physicians to keep board certified, despite the lack of an evidence basis for the Maintenance of Certification process. The time, effort, and cost to member family physicians has been substantial. The Real Kerfuffle

Only the recent government regulations have disrupted family physicians from care to a greater degree than distractions created by family medicine leaders. 

If you are a family physician aware of what really matters, every time you see the word quality you should expect more cost and more distraction without any real hope of making a difference in local care and care where needed. Quality translates to higher cost of delivery, payment cuts, and more costly regulation. The failures in recent CMS Innovations are numerous and specific to family medicine, small hospitals, small practices, and care where needed.

In the last few years, family medicine associations and academics have led the charge to innovation, rearrangement, consultation, promotion, marketing - and away from care that matters. CMS Innovations consistently detrimental to most family physicians are promoted as soon as announced.

Killing Off Primary Care Delivery Capacity

Stagnant revenue in primary care chopped up by staggering increases in the cost of delivery - this is what is defeating family medicine, primary care, mental health, geriatrics, care where needed, and care for rural or underserved or minority populations. This is what is hurting most family physicians. This is the reason for the rise of Concierge, Urgent, Retail, and Direct Primary Care for better payment, decreased costs of delivery, or both.

There has not been growth in graduates or payment as cost increases have continued to negate whatever incremental increases in payments were provided. 

M & M Focus - Marketing and Meeting

Marketing and meeting focus compromises the focus upon increased payment. Family medicine has hitched its star to marketing - the reason for overemphasis on Primary Care Medical Home and Health is Primary. PCMH has been a way for larger more urban practices facing competition to market their services - a reason for support from pediatric and family medicine leaders. Sometimes associations promote areas not in the best interest of a majority of members. For example the Primary Care Medical Home focus of family medicine leaders is not a good choice for small and solo practices - practice types that are over half of family physicians.

The growth of associations and their activities is linked to consultants, advertising, and meeting revenues. Associations sell information and member access to recruiters and many others that make money off of family physicians. So much is generated from M & M that dues are a small portion of association revenue. 

This takes associations away from a focus on members.  In fact the ACA/CMS plan has been called the attack of the aggregators 


Money talks and the needs of most members walks. 

Such is the tradition of physician associations. 


Family Physicians and Care Where Needed in the Crosshairs

Value based payment has become a favorite of FM leaders, perhaps eager to appear to be the best proponents of quality. Apparently they did not get the memo about evidence basis for real quality shaped by patient factors such as situations, determinants, relationships, and barriers. And apparently they have forgotten that family physicians are serving the populations with all factors shaped toward lower quality metric measurements. Studies have indicated advantages for caring for the advantaged and disadvantages for the rest. Hong did one of the better studies published in JAMA:

Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non–English-speaking patients were associated with lower quality rankings for primary care physicians.

To the extent that health systems reward physicians for higher measured quality of care, lack of adjustment for patient panel characteristics may penalize physicians for taking care of more vulnerable patients, incentivize physicians to select patients to improve their quality scores, and result in the misallocation of resources away from physicians taking care of more vulnerable populations

A payment design that will pay less to primary care and to care where needed will impact family physicians more than any other type. Are We Moving Away from Achieving Value in Primary Care? 

There have been a constant stream of distractions from what is most specific to FM.

Family Medicine as a Poor Fit for Traditional Medical Education

Academic focus has resulted in substantial funding for research, graduate medical education, and highly specialized care. As academic influences became ever stronger, generalists and general specialties have been marginalized. Academic, association, and corporation interests have dominated payment design - a design that pays according to how much academic training you have. The end result has been less local, primary care, and health access - by design.

Outcomes shape the training. Medical schools produce so few for primary care that they cannot possibly prepare well for primary care. The hospitalist movement not only stole 50,000 primary care trained physicians, it also now plays a large role in primary care training. Numerous workforce influences continue to marginalize FM and primary care in the practice, research, and other areas. 


New Departments or a New Model for FM Training?

There is no logic to the focus on family medicine departments in a few remaining schools. The only logic to family medicine medical education is replacing aberrant preparation, selection, and medical school. The new design should be the best fit with FM residency training and practice - 9 years of specific FM preparation and training can replace 11 or 12 years of costly and nonspecific training.

FM has always been specific to local - not medical school, state, regional, or national. FM associations have lost this focus, but we should not. Most of us are still in small practices working locally. We innovate with each patient - a contrast to the mess of national level innovation that fits few or none. The academic mentality is why we have the insurance coverage focus and the forced quality - doomed from the start because of local failure in access and integration and coordination and comprehensiveness.

True reform begins and ends locally with patients and local populations. This requires universal access to basic care - local care arising locally and focused locally.

Traditional medical education will never get it with total lack of local focus and a top priority focus on just a few years of training rather than preparation for a lifetime of learning. There will never be more than student interest rather than the involvement before, during, and after medical school that really matters.

Sadly it is FM associations that have also bought into the same scenario. Instead of reshaping medical education, medical education has reshaped them.

Payment Shapes All Clinical Workforce

This is not surprising because the same process has absorbed nurse practitioners. Those truly delivering access have long been marginalized. An opportunity to be entirely family practice has been missed - and now only 20% will be active in family practice for a career as every other career has consumed more graduates into new training and new specialties and subspecialties. This is also about payment design plus academization.

The care of most Americans depends upon an entirely different process - one that fits them and not the needs of a few, not the needs of 1100 zip codes with half of physician workforce, not the needs of corporate medicine, not the needs of association medicine. Bigger and more academic is better for bigger and more academic, but not local, personal, efficient, and effective.




Fighting Against the Payment and Training Designs Is Most Difficult When Funded By Same


Academic family medicine is funded by the same payment and training excesses that help to defeat primary care, family practice, and care where needed. When you understand that multiple lines of revenue with the highest reimbursement in each line go to academic and largest centers, then you understand inequities, lack of access, and distractions. With this understanding, you see the socialization process of health leaders, especially physicians, who proceed across institutions, associations, corporations, meetings, and similar screenings to become ineffective for local, health access, and care where needed. Why would you want family medicine departments speaking out against what is best for family physicians?


Bigger and more academic is better for bigger and more academic, but not for local, personal, efficient, and effective.



We need more promotions of family docs of the year, those in the field on the cutting edge of health access. FM docs, FM research, and FM payment should be focused locally and on access. The same should be true of FM training and associations.



Family physicians need local preparation, local training, and support for local practice. The opposite focus is a distraction from what is needed.

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.

Sunday, May 22, 2016

No Positive Spin for the Innovator Tailspin

In health care delivery, reflective practice is considered a best practice. There is apparently no reflection at CMS or across the innovation whirlwind. Instead of learning or pausing to reflect, there is only acceleration of the chaos we call American health care. 


How many failures in how many ways should be tolerated?

Insurance Expansion - The failure of insurance expansion for the purpose of access to care has been exposed. Denial will not help Medicaid, Medicare, and new plan patients to actually get the care that they need - poor payment long ago prevented the workforce that they needed and in the places of most need.

Accountable Care Organizations - This attempt can be considered a failure as half of ACOs have fallen with more to come. It is likely that a real effort in this area would cost far more, but the costs have already been substantial.Why would you think that you can create competition when you main direction is to aggregate more into bigger plans, systems, practices, etc.?

Primary Care Medical Home - PCMH has become a fantasy land of promotions and numerous claims - unrealized. Foundations and primary care associations jumped upon this bandwagon hard. But they apparently lost their objectivity or the fact that half of their members cannot afford the costs and other consequences. Even worse are the lack of cost savings or quality improvements. 



Quality Metrics - Quality metric efforts turned into marathons and quagmires. Meaningful Use efforts to hold practices accountable have been meaningless and menial but this did not stop implementation or expansion. Those delivering care have suffered all across development, implementation, and consequence. Instead of learning from their errors, the CMS Innovation Experts are doubling down with MACRA - 954 pages of more torture that experts have difficulty with. 

The EHR Community built by the 30 billion from HITECH may have one of the best takes on this as well as the lack of understanding of family medicine associations regarding the serious threat of MOTHRA   err MACRA: Massachusetts General Hospital's and Harvard Medical School's John Goodson, MD, foresees troubles ahead for small physician practices in particular JG: There's an implication in there that everyone needs to be aggregated — I call this the attack of the aggregators. You really do worry about the little guy practices and how they are going to perceive this. I don't think it's gotten to them yet. And if you look at what's coming out of the professional societies, particularly family medicine, it's not quite clear that they see the alarm quite yet, but I promise you they will.   (no indication at all)

The Board Chairman of AAFP asked CMS whether there would be a chance to delay the rapid implementation of MACRA. After all, the CMS leaders had just pledged in front of 300 family physician leaders to listen and to attempt to decrease the burdensome regulation. But there was no listening, reflection, or attempt to change. There was a mention of a tight time line and so it is still damn the torpedoes and full speed ahead. The recent rounds of hospital, primary care, and rural health meetings by CMS officials apparently only helped CMS to learn the language to express while continuing what they planned to do.

Why would we want more "progress" when the previous progress attempts were failures?

Why would we want acceleration of chaotic change?

Why would we want to bundle services, creating more winners and losers? The example of DRGs is plain that it takes decades to realize all of the consequences and yet we accelerate into more bundling?

Why would we want to force much needed front line primary care, mental health, and basic service practices to shell out more tens of thousands each year per clinician for each new innovative wrinkle, regulation, or certification when these practices are already at or below margin? 

Is there no understanding that cash diverted to everything else other than paying for more team members is what prevents integration, coordination, outreach, and innovation one on one between team member and patient - real innovation that matters most?

Why is it hard to understand that access to care requires more team members in more places supported by more funding for cognitive, office, and basic services - the ones paid least by decades of designs made worse by forced higher cost of delivery?

Why would any practice, hospital, or system want more Medicaid patients or more lowest paying plan patients when those with the most such patients are declining by design. The impact spans the largest systems to the smallest practices resulting in changes from positive (survival) to negative margins. An 80 million decline resulted from too many California Medicaid patients served by Dignity Health - the difference between a positive and negative margin. 


Designs that fail from smallest to largest and for most Medicare and Medicaid patients 
need serious restructuring - not more rapid innovation.

There is no positive spin for the innovator tailspin and apparently no positive margin where care is needed by most CMS patients and the others deprived of local care via CMS.

The three most important areas of health care are cost, quality, and access. In the haste to cut costs and to force quality, access gets blown away by design after design.

And more bad news for CMS regarding basic functions such as keeping names and billing straight - CMS is Lambasted for failure to Control Fraud and Abuse.


A number of legitimate health care providers would indicate abuse by bounty hunters hired by CMS and paid based on how much can be recovered - for more abuse potential. 
 
Primary care can be recovered and should be recovered,
but cannot be recovered when moving the wrong directions

Population Health from Above or Below

The innovation gurus have declared population health to be a key factor in health outcomes. As usual there are those who plan to help others while helping themselves. Can Big Data approaches make a difference? Are there other approaches? Do we trust consultants and corporations from afar to help diagnose and treat community wide health problems? Is there another approach that does not involve distant, different, and shipping scarce dollars elsewhere?


Those who truly want to improve the health of populations might want to consider approaches local in focus, lower in cost, and of no benefit to anyone outside of the community not to mention decades of previous development. 

Community Oriented Primary Care and Asset Based Management are approaches that have been around for over 50 years. The history of COPC is quite revealing as Sidney Kark tried to go to South Africa to address trauma - but found what was needed was sanitation and public health. Such problems are common when those far away attempt to address local care needs without really understanding the people or the who what when where and how of engaging people for change.

Advantages of local population determined approaches include 
  • Engagement specific to local priorities and preferences 
  • Full utilization of local resources plus needs assessments for the development of more
  • Local organization of health care efforts rather than disintegration as in current health care
  • Specific data development and utilization for specific local application (not shotgun approaches of too much collected with little used and even less relevant)
  • Development of interventions specific to desire to change
  • Skipping decades of mistakes, local resources, local desire to change, and other specifics that big data from above cannot hope to address. 
Local approaches are not one size fits all as in top down approaches. The proper approach is one size developed by one community fits one community.
One former proponent of primary care medical home eventually saw the light as there was little that a distant and different part time consultant and coach could do. What really matters is often the culture, the organization, the understanding - all local.
Local also might avoid the major folly of the US health care design - more layers of administration and management added in ways that accomplish less for ever higher cost.

Why not try the opposite of top down or more local dollars shipped elsewhere for nebulous reasons.


Family medicine represents the worst and best. Many family physicians have participated in local approaches and some teach these approaches. But the family medicine leadership fully embraces the latest innovations including those that are a poor fit for most family physicians. FM leaders like to talk about leading change, but do not embrace the local led change that family medicine has to offer. FM like many others are still waiting for solutions from above rather than facilitating local care. It is maddening for FM to ignore the decades of experiences of local family physicians while jumping for the latest innovation.


FM leaders want to promote primary care in Health is Primary. Many hours from many people go to promotional pieces. There is much ado but no focus on the way to do what is promoted. For example point 4 of 6 points in Health Is Primary is "Integrate public and mental health into the Patient Centered Medical Home (PCMH) and add care managers, health coaches and population health professionals to the primary care team." Of course there is nothing in any of the six major points about increasing payment so that family practices can do any of this, particularly the solo and small group half of family medicine going away by payment design and made worse with higher cost of delivery.

This is another one of those Americans can always be counted upon to do the right thing areas (Churchill quote) and more will be tried expensively and ineffectively until Americans do the right thing or exhaust the US treasury sending money to corporations to try everything else.

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