Reforming the Reforms of the Reformers

Numerous documents indicate the reasons for increasing US health care costs. Most are written by the designers of health care. This puts them in the unique position of not understanding health care cost, quality, and access from the perspective of most of the American people as they care so little for them - by design. 

The Seven Drivers are listed from Kaiser Health News (KHN) which use the Bipartisan Committee as a source. The numbered statements are from them. The rest is from RCB.

1. We pay our doctors, hospitals and other medical providers in ways that reward doing more, rather than being efficient

The KHN says fee for service is bad. It certainly is the way that non-primary care manages to find ways to generate more revenue and bypass any cost saving reforms. Fee for service has been the way to build services and workforce – with the consequence of high costs.

Fee for service is a way to reward volume and development of services and workforce, along with better fees for the services - this is why non-primary care has grown rapidly along with the health care servies in 1% of the land area with 50% of workforce and the greatest numbers of services and the most expensive services. The designers in these zip codes have designed health care their way.  Finance Me Crats     To Follow the Money, Follow the Workforce   Health spending patterns shape health workforce and vice versa.

Health care systems get bigger with less competition and the most exclusive services are unregulated with runaway costs. Meanwhile those employed in health care, including doctors, are forced to do what employers and stockholders want – more profits.

Primary care is in need of growth, more volume (not less), and has a limited number of services. Primary care should have the incentive to grow of fee for service or at least not the cutbacks for 30 years as issued by health insurance, Medicare, and Medicaid.

Revised fees, flat rates, and bundlings are innovative ways that can help reduce costs for specialty services, but are not a good choice for primary care that ends up with the short end of the stick. Innovations turn cooperative health provider efforts into competitive and primary care loses in the mix.

KHN says electronic records help. The evidence is mixed and the cost of increased information access drives health care costs up and also occupies more time, reducing primary care volume. This sends more millions to less or no access. HIT has also resulted in closures of primary care offices and services to people most in need of health access. The true intent of cost reduction has been seen rather than supposed improvements. Health info also is used to increase revenue generation with no improvement in care or access or it can be used to commit fraud or what is mostly fraud but legal. These generate increased revenue and higher health care costs.

Perspective of health access primary care - each change ends up cutting primary care out even more along with most Americans left behind by design. No change passes the test of no harm in cost, quality, or access to those already most vulnerable - most of US.

2. We're growing older, sicker and fatter.

While this is true, mostly the nation is dividing into a few with the keys to national and personal treasuries, and most Americans left behind. The nation is dividing toward a very few who rule who are ever less aware of America and Americans and most Americans who fall behind with poorer health, less health care coverage, less access to care, lesser jobs, and little economic impact benefit from the health care design. Most are being marginalized by politicians, health care designers, and economic leaders who are out of touch with most Americans. Politicians realize they can gain more with glitz, innuendo, and personal attacks. All the way to the top there is realization that intellectual discussions of the issues are not the way to get elected. Health care discussions, especially in primary care, are more about promotion rather than solutions.

3. We want new drugs, technologies, services and procedures.

We do want advances, but what are promoted as advances rarely are advances as studies are showing. We get tests that result in more tests and more expensive tests and no better health information. We get tests that lead to procedures that harm or kill. We get promotions directly to us for “advances.” We suffer from the side effects of advances and this results in more health care services and costs. We also have corporations that get laws passed so that they can have greater markets – such as digital mammography that is not an improvement but has much greater cost, or CT scans marketed for any number of conditions, or non-communicable diseases – a new way of marketing disease drug technology focus. We have software, marketing, drug, device, and other corporations expanding their claws on health care dollars and their hold on your wallets and our government treasuries.

And yes, as KHN points out the new are much more costly than the old with little or no help. A Nobel prize winning physician recently pointed this out in cancer care. He also continues to focus his research on interventions that work, rather than marketing those that fail to work. He had to go to another country to get the cooperation needed to do this work. The US market is too lucrative to attempt to develop real improvements as there are so many that generate so much for so little gain - the real US health design.
4. We get tax breaks on buying health insurance -- and the cost to patients of seeking care is often low.

Very few have such health insurance. Most have health insurance that has so many hoops and holes that we are all disgusted – and get less needed care as a result. Many have high deductible health insurance (the only thing that they can afford) which prevents basic health access – care that could prevent higher costs.

But why does this article ignore health insurance as a factor driving up the cost of health care as they just pass on the costs, increase rates, force government and business to cut employees to balance budgets. Could it be that both parties in the Bipartisan want to avoid making powerful insurance companies angry?

Also this article ignores Basic Health Access with maldistribution of health providers and barriers that prevent care. This is a huge problem impacting most Americans, but not those that write articles about health care.

5. We don't have enough information to make decisions on which medical care is best for us.

Well the real problem should be evident now more than ever before. We have way too much information thrown at us and those that finance the information can process their way to money, fame, power, government treasuries, and more. They move far faster than we can investigate and prosecute. Meanwhile we have little real education and human development - requirements for processing information. The loudest voices and those that sound the best win, even when a bad choice for most.

More health information would be nice, but comes at great cost – driving costs up more. Also the information is slanted like this article – away from specific solutions such as less non-primary care workforce (fewer MD, DO, NP, and PA specialists) and more primary care that remains 90% in primary care and distributes best to serve most Americans (family medicine).

As an example of information and promotion rather than solution - Note that nurse practitioners and physician assistants are promoted as primary care solutions, but only the 25% that end up employed in family practice are much help to primary care or to half of Americans in locations with lower to lowest workforce.

Two thirds of NP and PA help promote non-primary care workforce and more profits for health care and higher costs. This is because the US health care design pays more for non-primary care services and NP and PA can help increase revenues with more services, tests, technologies, and procedures with lower employee costs and higher profits. This is no reflection poorly on NP and PA, who benefit from the non-primary care employment. As long as designs reward the designers, the MD, DO, NP, and PA workforce will grow their way and result in much higher health care costs. A major reason for NP and PA not found in primary care is tens of thousands hired by teaching hospitals to fill gaps in workforce left by their own rules and regulations. This moves NP and PA where needed to where health care costs the most. Three Dimensions of Non-Primary Care Expansion Driving Higher Costs - Increase in annual graduates, increased proportions entering non-primary care training, 70% of primary care graduates as non-primary care workforce.

6. Our hospitals and other providers are increasingly gaining market share and are better able to demand higher prices.

Market share is a good example, but see who is buying up the market share. Insurance companies are doing even better as they use their information to buy up the most profitable to shape their control for decades to come. Insurance companies shape confusions such as government control as noted as the Politifact Lie of the Year. Confusion leads to inaction and continued profits - because of the current designers benefitting from the designs. Academic centers also do well under our design, but want even more dollars sent to their zip codes that already receive by far the most health care dollars per person under our design.

7. We have supply and demand problems, and legal issues that complicate efforts to slow spending.

This article was far too vague and confusing and failed to implicate the designers of our current designs – the real reason for spiraling health care costs in the way they influence government and US.

Americans need designs for basic health access, workforce that serves them where they are located, and health spending that make sense for most Americans not just a few.

Robert C. Bowman, M.D.
SMART Basic Health Access


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