Pounding Poverty Providers with Pay for Performance

United States designs for health spending consistently result in less for those who already have the lowest health spending. This is accomplished by designs that send less to those that attempt the responsibility of their care. Design changes and even reforms that are supposed to send more spending to those who care for most Americans left behind can also fail.
Because more Americans are joining those at or below poverty, particularly children, the nation should spend far more time understanding the inequities of the current and future designs.
Proposals for bonus funds were supposed to send more funding to those who care for underserved patients, family medicine and rural associations had to exert additional time and energy and research to insure that the programs actually send funding to those who deliver the needed care. Studies from North Carolina indicated that previous bonus program funding were commonly accessed by those that were not supposed to receive the funding.
Hong in JAMA demonstrated that Pay for Performance punished practitioners caring for the underserved. See comment in AFP Community Blog.
Pediatrics just published an article about the value of a continuity medical home – an article that actually demonstrated that continuity was really about advantage and discontinuity was about disadvantage. The real driver of better quality was social determinants, not the medical home concept in this study that did not really even study outcomes of actual certified medical homes.
Now Kaiser indicates much the same for Hospitals that care for those left behind. Readmission rates are much higher for lower income Americans. This is of course a function of any number of social determinant and similar demographic characteristics that add up to difficulties that lead to hospitalization and difficulties that are far more likely after hospitalization.
It is hardly possible to keep up with all the ways that funding is diverted to care of those with easier care and naturally better outcomes.
Not much comment is needed other than indicating that until designers understand most Americans and their basic needs, the designs will continue to favor few. Design changes also may insure even greater divisions.
Potential Impact of Pay-for-Performance on the Financial Health of Critical Access Hospitals (Policy Brief)    Author(s): Robert Town, Ira Moscovice  Sponsoring organization: Flex Monitoring Team
Pay-for-performance (P4P) incentives likely reduce the financial status of CAHs already in financial stress. However, P4P incentives are likely to have only a modest impact on the financial stability of CAHs.  Date: 02 / 2010

Providing Underserved Patients with Medical Homes: Assessing the Readiness of Safety-Net Health Centers  Author(s): Katie Coleman, Kathryn Phillips
Sponsoring organization: Commonwealth Fund
Surveys safety-net health centers (public hospitals and clinics, federally qualified health centers, rural health centers, and free clinics for the medically underserved) to determine their potential to become patient-centered medical homes (PCMHs). Date: 05 / 2010    A summary would be that those caring for Americans left behind have an uphill battle to qualify as medical homes. They have a major battle just trying to keep up with increasing demand.

Basically even to become eligible for increased pay, there is substantially more investment required to get where needed. Also the outcomes will be less not due to lack of effort, but due to care of underserved patients. Government designers and reformers do not understand the people most in need of care or the type of care they need or the funding required to meet their needs.

A true approach to build quality requires far more understanding and awareness and substantial time and effort to process a real design. Cost cutting focus results in rapid implementation and designers are most familiar with what works for a few rather than what would work for most.

Arizona has delayed six months beyond the required July 1 2011 federal deadline to set up their electronic verification site so that Medicaid providers can recoup their tens of thousands invested in patient management software and hardware and consultants in the past 2 years. There are only 10 days left in the year. It appears likely in at least one state that investments required to gain incentives will not even be paid as indicated. Other states short on funds and Medicaid funds may also play the delay game. This is a catastrophic event signaling to those who care for patients in need that they need to stop caring for Medicaid patients or leave the state. This is another way to Pound Poverty Providers.

One thing is certain. Taking the "safety-net" for granted is guaranteed to result in greater divisions between Americans in income, health, employment, productivity, and other measures.

Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog
SMART Basic Health Access     World of Rural Medical Education
Basic Health Access Blogspot 2011 - Summaries and Links for 2011

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

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