Experimental Innovation or Basic Infrastructure?

Almost daily we see some promotion of health care innovation - a foundation grant, a research study, a primary care association communication, a government statement... 
Wouldn't it be nice if we actually funded infrastructure and basics
instead of trying to substitute innovation or other distractions? 

Innovation focus has actually caused significant dysfunction in health care and beyond.

Why not value basic nutrition, housing, clean water, sanitation, public health, and basic health services? When we fail to achieve the basics, we ignore the most important contributors to health outcomes. Current estimates by civil engineer experts indicate that our water supply alone needs over 1 trillion to return to a basic infrastructure. 
  • No one appears to value infrastructure until it is lacking
  • No one does anything until the privileged feel the pinch of lack of infrastructure
In other words, Flint Michigan is only the tip of the iceberg. Health care designs are just as bad.
 

Why value expanded insurance coverage that fails to cover basic services and shrinks access to care with payments insufficient to support the basic workforce to do basic access to care? Expanded insurance coverage to universal coverage still equals poor access with underfunding primary care, mental health, and basic services. Underfunding compared to procedural specialties has long undermined the workforce needed to deliver access. 

Infrastructure such as primary care, public health, and mental health must be funded.
This is a requirement for a functional health care system, the one that we lack.
Primary care cannot be innovated without sufficient funding for the
primary care team members to deliver the care.

Distortions in Value


Why do we have value measures that fail to value the basics - such as caring for the complex and those where care is most needed? Why would we ever think that paying less where more workforce is needed would help? Why lower pay where patients are more complex and where people fail to have basic care and many other basics (pay for performance, readmission penalties, value based)?

Why do primary care associations value the marketing, consulting, and distorting of primary care instead of valuing those who deliver primary care? Why would primary care leaders support innovative new payment designs after three decades of failed payment designs? Why trust government and insurance payers when they have failed to value primary care with the additional payment required to accomplish more access, improved quality, and decreased costs, and for decades?

Cover Ups in Primary Care

Why tolerate claims of primary care workforce solution from five sources of training that only manage to produce 10% to 45% of graduates active and in primary care practice during their career after training? No source can actually result in more primary care without more funding injected specific to support of more positions to deliver the care.

Why did we stop exposing The Dean's Lie (overclaim of primary care result) when The Dean's Lie results even lower in primary care result than when The Dean's Lie was first exposed? Why do we have primary care rankings for schools that promote schools that have lower to lowest primary care result in graduates? Has the media helped deans and other leaders to lie? 

Accountable Care Designers, Agencies, and Insurance Payers Remain Unaccountable

Why support more software, audits, and accountability demands from those who remain unaccountable for the final product?

Why screen all adults for depression when we have insufficient primary care and mental health to care for current patients much less millions more? Why screen for Hepatitis C in certain populations when we cannot afford the exorbitant cost? Could it be that drug companies have a direct route to the CDC and other government agencies? Why overwhelm primary care even more on the way to billions more in profits?

Many questions need to be asked, but few are being asked.

This blog piece started out as a review of another smokescreen - the smokescreen of more innovation announcements. Witness failing rural health and what is the response? Foundations and government grants are announced for innovation with just a pittance of dollars for a few that can muster the resources to get grants. 

The New Rural Innovations that matter are the same as the old innovations that matter - family practice and rural facilities. Why do we reward innovation from above when it is the daily innovation and adaptation of care givers that matters most to patients? How can they do their job innovatively if they have levels of funding that are insufficient to meet demand, not to mention coordination, integration and outreach.

Real innovation within primary care practices has been denied by payment design for decades. The basics are not sexy but they continue to serve where needed generation after generation even with deficits of revenue.

The new innovations have killed off access. 

This is what happens when forced innovations require higher cost of delivery resulting in even less support for the delivery of care. This is how we have had more distractions away from the real health access solutions - more team members, more coordination, more outreach, more continuity.

Innovation focus is a primary reason for failure in primary care where it matters - primary care delivery capacity and primary care delivery capacity across the nation where 2000 counties most depend upon primary care (50% of workforce) and general surgical specialties (20%) requiring more than a pittance of payment for office code work.
Just imagine what could happen with truly innovative spending - spending more instead of a level that remains grossly insufficient cut more each year with higher cost of delivery.

This was stimulated by one of the latest of the innovation explosions. Instead of real hope for rural health, we have the distraction of innovation.
  • Recent Rural Health "Innovation" Awards have gained a lot of rural and underserved media attention    (Kate Reynolds Innovation - Why Not Value the Basics? CMS Rural Innovation Grants) 
  • CMS - Keep Your Innovation Dollars and Pay for Primary Care and Rural Hospitals beyond Survival to Thrival Level
Why would we think that increasing the cost of delivery by $40,000 per primary care physician and requiring hundreds of hours away from care delivery would help to improve primary care delivery capacity?

Health Affairs Casalino US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures - Each year US physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures. While much is to be gained from quality measurement, the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report. --- With over $40,000 cost per physician, access will suffer further.

The Shaky and Shady Primary Care Medical Home

Lack of Support for Primary Care Medical Home - Schwenk, Abrams, Jackson and Williams References

PCMH cost $105,000 per physician per year 

Critical review of Primary Care Medical Home, proposing ways to actually measure value - something not measured well so far.

A Rough Guide to Spotting Bad Science

Pressures Mount for ACA Changes

The Real Kerfuffle - How much chaos can family physicians stand?

IOM Panel Calls for Training in Social Determinants (But Needs Such Training)

Which is worse, IOM calling for training or family practice leaders? Front line family physicians do their work because they are local and have continuity with patients and families to deliver care that integrates social determinants and situations. 

Is the IOM Waking Up?

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


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

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