Innovation Incapacitation

Americans Can Always Be Counted Upon to Do the Right Thing...
Churchill knew us well. He knew that we would eventually do the right thing, but knew also that it could take forever to get to the right thing.
There is no deficit of innovative proposals to help address primary care delivery capacity woes. It is as if the deficits have helped to multiply the numbers and types of innovative proposals. Medical schools for over 50 years (all failed save 1), NP and PA programs, payment designs, types of specialties, rearrangements, consultants, measurements, definitions, determinations - all are just a few of the innovations.
Does anyone really want to address access barriers for those with low or no access?

If it has not yet become obvious, primary care does not need more distraction from what must be done. Yet we have created more foundation proposals, more government innovations, more primary care associations, more sources of primary care workforce - and we still have 80 to 100 million that have fallen behind in basic access to care. 
The Commonwealth piece is a nice review of what could be done in population health management. The question remains, does this address the top priority of payment. Will this result in much higher payment, much lower cost of delivery, or both? There are many ways to do this, but none of the above is the usual result from innovation.
To Review the Primary Care Decline By Balance Sheet
 
Innovation in primary care is quite costly. Payers would have to come up with over $200,000 more per primary care physician per year for those who need it most and have payment least. This is the starting investment of $105,000 per primary care physician per year to ramp up to primary care medical home plus quality metrics at $40,000 PPCPpYr plus at least $50,000 more per primary care physician per to begin to address some of what is proposed. This is a cost of 6 billion dollars more for 30,000 primary care physicians at $200,000 more. 

This 6 billion not for more primary care workforce to improve access to care. This is for enhancements of care delivery for the sites of these 30,000 where care is most needed. There is also no guarantee that this will be dedicated to areas and populations in need of primary care. Those with the right connections get the grants and those lease organized, generally where care is most needed, fall further behind.

Money Money Everywhere in Health Care But Not in Primary Care

There is no source for all of this funding or any indication how to get CMS or Congress to pay for anything. After all, more spending requires cuts in other areas to compensate. The steady marginalization of primary care leaves very little that can be cut, but more cuts to primary care continue.
The new proposals are commonly demonstrations. More small scale innovative demos are not the answer to sustainable access where needed for the 80 - 100 million left behind in basic care. 
There is only one source for primary care delivery capacity increase and that has to do with ramping up primary care payment. Anyone talking about anything else is only distracting and delaying what most be done. A total revision of payment is required with more taken from specialized care and given to primary care, mental health, and other access deficit settings. It is important to understand that Government and Insurance Payment designs result in the location and distribution of true shortage areas.

The main question all along has been how to pay for the additional primary care team members to actually deliver the care - and pay enough to help them build local workforce, outreach, integration, and coordination. This requires far more support than Medicaid, and more than Medicare, more than "decent" insurance which does not exist for most Americans, more than the $70,000 more per primary care physician per year to make innovation work, and more than the additional tens of thousands of other added costs. 
And you cannot get this from areas in need of care (taxation, required insurance coverage) as you would shrink social determinants or impact housing or other choices that disadvantaged people have to make every day.

More paid for consultants and managers and data (purchase and input) and other innovation shrinks care where needed. Remember these are small practice and small center budgets already at or below margin that are having to pay more for recruitment, retention, supplies, and other areas. More pay for everything else shrinks pay for the personnel to deliver care. 

Primary care is mostly people delivering care to people. Personnel costs are the most expensive. Delivery team members are the most expensive at all. Higher costs in other areas always pressure practices to cut back on delivery personnel.

Improved Outcomes to Support Better Payment - Not Likely

Innovators also cannot be allowed to claim improved outcomes for more value or better Pay for Performance. Outcomes are 60 - 70% about situations and social determinants and at best are 10% derived from clinical interventions. They are proposing to make substantial changes in outcomes in populations that have been fixed in place by multiple dimensions and degrees of dimensions for decades. 
It is accountability time for the innovators.

Top Down Vs Grassroots
Top down is a poor choice for care where needed - but a common one for the clinicians, consultants, and managers for local care. Origins, training, and experiences are often exactly opposite from what is needed.
How can people from elsewhere understand local needs, situations, and patients. These are sites that need substantial care that is empathetic, service oriented, and contextually guided. This requires local origins. local training, and decades of local experience. The solution for population based improvements must include local people with local skills and abilities who understand local people, and can deliver continuity care.

Population health management companies could join the ranks of misguided and costly care management from afar or mail order pharmacy interventions with destructions of local pharmacists, jobs, access. Mountains of big data and other innovations add to administrative costs, and help divert local funding away from local expenditure, and often fail to meet the very specific and individual needs of dozens of places in each of 1400 to 1800 counties across the US, not including portions of the most urban settings. 
We do not need more jobs in more Innovation and Administration Centers. We need more jobs supported where care is needed - the direct and indirect solution to care that matters.

Recent Posts and References

Safety Net Should Sunset and Front Line Access Must 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

Are We Moving Away from Achieving Value in Primary Care? - Quality is over 60% about the patient, situations, relationships and has very little to do with clinical intervention - but this does not prevent serious exaggerations of "so-called value."

Time for Quality in Quality Studies - The Best Studies from the best institutions and journals have led the nation astray in quality studies and we continue down this pathway.

Pressures Mount for ACA Reforms or Revisions - It has taken too long for critical voices to be heard about the consequences of experimentation plus change that is too quick, too costly, and impairs access to care. Compromise may be most specific to small practice and small hospital settings and those that they attempt to serve.

IOM Should Learn About Social Determinants Not Preach Them - Too many IOM studies fail basic research design tests and often for failing to understand important influences of health care outcomes - like social determinants and patient situations and relationships.

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.

The Real Kerfuffle - How much chaos can family physicians stand? Why do family medicine leaders avoid the evidence regarding MOC? 

Wrong Way Mental Health - Exploitation and insufficient access have been tolerated far too long.

Medicare and Medicaid at 50 and Beyond - A program that once built workforce, facilities, and health access where there were concentrations of poor and elderly patients now compromises workforce, facilities, and access where needed.

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 costs of $105,000 per physician per year  - too much to achieve success in access

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

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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