Another Fine CMS You Have Gotten Us Into

Perhaps we are indeed back to the time of Another Fine Mess (Laurel and Hardy). In a mad rush to implement innovation and to save all possible costs, CMS is creating complications for people that it is most responsible to protect.

As PBS and Ken Burns celebrate the legacy of The Roosevelts, it is tragic to see what has become of over a century of effort involving Social Security, Medicare, Medicaid, and health care equity.

The United States has one of the most complex health designs and clearly the various designers often know not what they are doing to others. More cartoons and comedians would find this a ripe area for material if not for the suffering involved.

Health and Human Services has a huge role across Social Security and US health care. CMS or the Centers for Medicare and Medicaid Services has a dominant role to play in the design of health care in the United States. 

CMS can be progressive or regressive. Interestingly CMS has chosen to appear to be progressive and innovative (or has been forced into this role) while often being regressive when there are consequences that must be addressed. Instead of a time honored role to help out those less able, CMS has implemented policies and programs that can disadvantage those most in need.

There is certainly an increasing awareness of CMS' inflexibility and poor attention to the consequences of its many actions and rapid changes. 

Since HHS has more money than all but a few nations and corporations, few appear willing to risk losing their small piece of this pie by attempting to press home their critique of this behemoth. Also the outright political attack upon "Obamacare" may make it easy for HHS to dismiss critique rather than giving proper attention to efforts to improve health care design and delivery.

Regardless of the reasons, CMS appears unwilling to ignore the advice of experts who have urged caution in the implementations of so many changes, many of them not completely ready for prime time as indicated by delays and a number of consequences. Requests for important changes are ignored or appear to result in a defensive posture - clearly not the collaborative approach required for improving health care at the local, state, or national level.

From the perspective of this author, small health and health access has suffered the most by rapid change and poor consideration of numerous consequences.

Regardless of the political administration over the past 33 years, dominant themes at CMS have made it harder to deliver health care.
  • Cost cutting above all - government should be about investment for optimal result. Cost cutting is essentially a focus upon a minimal investment for tolerable result. This is bad enough in business but should be in intolerable when this involves the health of people. Populations still behind in health should be intolerable, especially in a nation that spends by far the most on health care, but the very design fails to expose the designs that continue to leave substantial Americans behind.
  • There is too much focus on change for the sake of change and without the proper study of the consequences. Rarely are the interventions studied before full implementation in violation of human subjects protections that should apply to health care designers just as they apply to health care researchers.
  • CMS has a role to promote solutions that have worked for decades (like family practice) but instead promotes new and untried interventions, even when known to be dilute for the desired results such as primary care or care where needed. Simple payment designs are abandoned in favor of the increasingly complex.
  • Insurance companies, health associations, and others have been able to promote their own special interest needs shaping national designs favoring few with substantial Americans falling further behind.

CMS and HIT - Health Information Technology was not yet ready for prime time when billions were injected into software. The delay in spending "Bail Out" spending and the beneficiaries of such spending did not aid in the nation's economic recovery where needed. Obviously the software corporation sales force was willing to sell, but the pressures to sell and the relatively sudden opportunity may have actually delayed needed updates and developments. Clearly the implementations have been far too difficult and the interfaces haphazard.

Largest providers appear to be favored with such changes as their health information investments have often been ongoing. Smaller providers suddenly are faced with massive change and massive costs. 

The AMA says changes are needed in health information technology - but our nation plunges on with far less efficient HIT. The software still takes far too much time and effort.  Experts in HIT and those representing rural health care (National Rural Health Association) have encouraged more caution. AAFP experts also agree that the Meaningful Use regulations are ridiculously complex.

Numerous problems have been created in the most important and most forgotten area of health care delivery - the clinicians and teams that deliver the care. Distractions from their duties limit the services that can be provided at a time with too few clinicians and rapidly increasing demand.

In the 3 days spent preparing this, more continues to be added (5 paragraphs). CMS has a glitch just announced that will again cost physician practices millions more dollars. As has happened before, CMS will not be ready to fully service the physicians just added to the program in the past year. I would not be surprised to find that these will tend to be small health practices.

And there is more - While it might be considered important to add online personal access to medical records (considered important for digital innovation), people don't perceive the need to do so.

Stop the HIT Glitches and Delays for Better Care

We would never allow high tech to be suddenly practiced upon patients via high tech surgery or high tech medicines without substantial testing and development and careful application -

but we allow HIT to be implemented and promoted in a way 
that has resulted in complications and consequences in a
way not consistent with "Do No Harm." 

CMS and overzealous auditors and excessive delays in appeals/denials resolution - Those in charge of payment have not been efficient. They have paid many billions to those who have committed fraud. For many yearsOverzealous auditors have been paid according to how much they can save CMS - essentially Bounty Hunting. They have done what would be expected - caused problems for those attempting to deliver care. Major disruptions of care have resulted - so much for addressing the prime directive of health care - do no harm! The American Hospital Association and the American Medical Association and others have pleaded for CMS to address this problem.

Medicare Advantage Formulas - CMS was too cozy with insurance companies and ended up paying 12 billion in excess yearly for the past 6 years - because the insurance companies learned to manipulate severity of illness (Medicare Advantage Money Grab, Center for Public Integrity and CMS investigations). CMS makes headlines exposing fraud and waste of funding, but has somehow allowed overpayment by design. Sadly this overpayment generally goes for those already doing well - insurance, higher income patients, urban patients, patients where care is readily available. Too much for some means too little for many others.

Too much for few leaving too little for most others is an all too common CMS theme.

Small Health Payment Formulas - CMS has not been able to properly assess the revenue needs of small/rural hospitals as well as small/rural practices - perhaps because such locations are too far away from where CMS lives and breathes? The design is flawed. Small Hospital Closures Accelerate, Finances Weaker for Stand Alones Practices in the counties without a hospital demonstrate lesser pay, just as they demonstrate lesser concentrations of clinicians. Where care is dominated by hospital outpatient departments as in counties with top concentrations of physicians, pay is greater for the same service - by design. The primary care and basic services most prevalent in small health and where care is needed continues with lesser pay resulting in lesser support and care falling behind for most Americans.

Primary Care Payment - For Decades CMS designs have resulted in too little support for primary care and too much support for non-primary care - distorting US MD, DO, NP, and PA workforce away from primary care and family practice and care where needed. There can be no recovery of health access with current designs of payment and training - designs that appear set in stone.

Pay for Performance - Studies repeatedly show that providers rated "lower quality" under pay for performance are providers that are more likely to care for disadvantaged, complex, older, and sicker patients. The logical conclusion of Pay for Performance or Value Based payment is the elimination of care for patients in need and in locations where needed. CMS disagrees with the need for reform saying that to be fair it should continue the same payment design regardless of the consequences. Regarding the Flaws in Pay for Performance

Insurance Company Design - A major reason for costs too high and services provided too few is the current insurance company based payment design. This design appears to added only a small 5% paid to insurance companies for their work, but actually the design is far more costly. Insurance companies acting on their own or as intermediaries force health care providers to do their work. Employees in hospitals and practices must screen patients, bill patients, beg for prescriptions, beg for referrals, beg for hospitalization, beg for other services or goods, monitor high cost or high complexity patients, and other costly activities.

Preventing Rural Workforce - Prevention of Rural Workforce by Design is a review of many problems arising from designs and designers

CMS and Meaningful Use - Electronics experts and those representing small practice have cried out for delays in the rapid implementation of MU - to no avail. It is a primary reason why there is Open Season on Small Health Care

CMS and Disproportionate Share Rollbacks - Designs for more revenue for providers caring for patients where Medicare, Medicaid, low pay, and no pay patients were more likely. The Supreme Court did the most damage when allowing states to opt out of the national insurance reform plan, but CMS has not done enough to prevent declines in services, clinicians, and hospital facilities where care is needed arising from rollbacks in Disproprotionate Share.

CMS and Readmission Penalties - Readmission penalties at the top level of 1 to 2% are more likely for rural hospitals (9% vs 3% for urban) and 10% of hospitals in 2621 counties in most need of workforce.

CMS Failure in GME Design - Failures in the states in need, in primary care, and where clinicians are needed.


Health and Human Services has other limitations
  • Funding to boost primary care training that only results in 30% primary care result.
  • Funding distributed to locations that have higher concentrations of clinicians as those who can manipulate the system do manipulate the system
  • High administrative cost for Community Health Center programming
  • High administrative cost for low result from loan repayment programs. Loan repayment results in minimal changes in practice location. Generally those taking the loans are those who would have distributed (family physicians, prior commitment) or those that intend temporary benefit - not what helps long term. Loan repayment is another patch, not a fix such as more family physicians or others permanently committed to primary care for a career or permanently committed to locations of need. 
HHS must stop band-aid repairs and must have designs that truly result for primary care and care where needed.

HHS has made a number of mistakes and defensiveness and cover-ups have not helped. It might be nice to hide errors from politicians poised to exploit any error, but 

The design is such that it is not a surprise that Commonwealth has asked the question -  Do Health Care Costs Fuel Economic Inequality in the United States?

Continue on to Open Season on Small Health By Big Media

Summary of Small Health Complexities

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...



Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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