Lack of Accountability for Accountable Care


Is it possible that another era of health reform has been wasted in the 2010s as in the 1990s? Many of the failures have been in the same areas - too much increase in administrative cost, too much for too few for too little in outcome improvement, too much too fast, too much focus on innovation and not enough practicality, and failures specific to access to care. Could it be that designers, their designs, and the implementations all fail to consider local people, local needs, and those who care for people locally?

ACA was squeezed between some of the largest corporations in America (health insurance), those who purchase health care (major corporations), health care associations, and academic innovators. Meaningful reforms were lobbied away before the landmark Accountable Care Act was passed. For an accounting of who is doing well under ACA, try Health Care Who Is it Good For? Not listed are the software corporations that have found their way to hundreds of billions starting with 16 billion in bailout recovery dollars before ACA and many times that since.

ACA may be another example of big spending bent toward biggest corporations. 

Corporations have profited, but can the American people expect an improvement?



Will ACA Advance Health Care?

As ACA has been put into place, CMS has also blown opportunities to advance care. You can only advance care if you carefully define what you want to do, how you want to do it, and what you expect to see as a change before and after implementation. Poor definitions, vague outcome measures, rapid implementations, too much change for too little gain, and too many changes to manage have blown the legacy of what could have been.

There is no way to actually determine an advance, despite substantial investment of time and effort. Bad experimentation is experimentation that can lead to no progress at all and it could lead to future reforms voted down given the waste of past reforms.

The ACA designers blew the opportunity to boost payment for primary care and mental health as procedural vs cognitive reforms were not considered. Local care needs were ignored from the start to the detriment of all. Only a short term payment boost was provided for basic services for CMS patients - and cuts and higher costs and the cost of change eroded any gains. Primary care and mental health practices and providers have been betrayed. Lowest morale levels compete with lack of confidence in government efforts for those hoping to improve basic access. Even worse, they are being held accountable for outcomes that they cannot change - another major failure of accountable care.

Taxation without Representation Looms Large

Those who provide health care have been taxed to do more with less funding and asked to care for more people and asked to care for more complex people.

Substantial portions of the American people feel also taxed for care for little gain. When you expand insurance coverage into the US payment design, you automatically pay more on fewer people with little benefit for most.

Health reform should change health care for the better -
not expand the current problem areas.

Nearly everyone has had some impact from the recent changes as April 15 looms again. Adverse impacts have been common. They are not as likely to be supportive of reform in the future.

Programs that are out of touch are not likely to be successful, lasting, or popular.

Big Plans and Big Failures for Health Insurance and Practice Plans

Half of the Accountable Care Organizations have failed. Even with plan survival, no one will know what these plans have done.  “…There is no “prescribed set of activities or interventions” for ACOs, as L&M put it, we can’t conclude that any particular activity or intervention caused whatever impact on costs or quality our “research” found.”

It is a curse of our time that most scientific studies cannot be replicated. Journals, editors, reviewers, and authors are not accountable. A number of studies involving quality and cost outcomes have serious flaws. Overclaims of benefits, minimization of consequences, studies too short term to report, poor definitions, and poor analysis are rampant. They have been major topics for this blog and others (TheHealthCareBlog, The Incidental Economist)

ACOs and Primary Care Medical Homes share poor definitions, yet somehow there are numerous positive claims.

From a common sense view point, how can you do more in primary care or mental health with a pittance of funding made even smaller with rapidly increasing costs of delivery.

From Meaningful Use to Quality Metric

Health information software was put into place despite not yet being ready for prime time. Health professionals across the nation were forced to adjust to new software rather than having software designed around their tasks. EHRs continue to cost hundreds of hours a year from health professionals. In primary care, EHRs generate 70 - 100 messages a day that must be addressed. There is no major effort to reduce the number of screens, automate to the tasks at hand, or even update speech recognition to what people have on cell phones. Health systems have been forced to change to new software, or suffer through major updates.

Lots of effort on good faith to implement substantial changes seems to not be enough. Meaningless measures and rapid implementation are difficult, but enforcement can be so rigid that those doing 90 - 95% of what is required at great cost get no payment benefit. The American Hospital Association has communicated this to CMS along with other notifications of delays, denials, confusions, and other impediments to payment and care.
  • From DRG to PQRS it appears to this author that CMS has really been about cost cutting with innovation a disguise for a focus on fewer dollars.
The first few rounds of forced higher cost for EHR, HIT, and "quality measurement" have cost many tens of thousands of dollars per primary care physician. The next round is an additional cost of $40,000 more per primary care physician per year with less than a year remaining. Those not implementing these forced changes now face penalties along with stagnant of payment while still trying to figure out how to deal with cuts. Meanwhile the cost cutters get what they always wanted - more costs cut by design. Who cares if the costs are cut most where care is needed most?

The Great Access Squeeze

Some health care endeavors have high overhead. These high overhead areas include primary care and mental health practices where the focus is person to person care. Person to person care is costly, but necessary. Unfortunately support has been failing and costs have been forced rapidly higher. The result is a declining support to cost ratio - the essence of the Great Access Squeeze.

Basic services are suffering - by design. Their budgets are 60% personnel. Supplies, computers, software, office space, insurance, equipment, technology, and other costs are fixed in place and are increasing. Certain personnel are required to function. Many sites in need of care are facing a rapid rise in the costs of recruitment and retention. These all steal dollars that could be invested in health care delivery personnel. The small practices have clearly been left behind and have not been able to invest in innovation. Some have closed and others have merged. Primary care physicians have retired or left for jobs not on the front lines. More are likely to join them after more cuts in pay due to payment design.

As innovation rises, care delivery falls and falls most where needed.

Innovation Incapacitation - We are so focused on innovation that we cannot even take care of the basics

Value-Based Discrimination 

A worse case scenario for health access front line care is even less payment. Medicaid and Medicare payment designs already pay too little and cause shortages of care where needed. But value based payments pay less where care is needed because the populations most complex that will have lesser outcomes are concentrated where care is needed (and where Medicare and Medicaid patients are concentrated). One of the worst legacies of innovation is discrimination against disadvantaged people and the the small practices and hospitals who serve them. Even worse, CMS defends this discrimination by saying that it would not be equitable to make a special allowance or adjustment.

The basis of the discrimination is clear to those who understand health outcomes. Health care outcomes are 60 - 70% about the patient, their situation, their social determinants, their outcomes, their location, etc. There are two choices to avoid discrimination - terminate value based or adjust by situations and determinants. The literature clearly shows that pay for performance discriminates against the underserved (Hong, JAMA) and attempts to adjust for payment are not able to compensate.

The one common element for pay for performance, value based payment, and readmissions penalties is fewer dollars distributed where care is needed – where ACA was actually supposed to help.  In my studies the top penalties have gone to rural hospitals and to facilities in counties with the lowest concentrations of physicians. Failures have been worst for small hospitals and small practices - because of the various ACA changes and challenges.

Long after there is a cry out to end discrimination, the innovation cry continues to drown out the voices of the disadvantaged. Sadly the innovations may add to the numbers and complexities. 

The failures impact local people and ripple effect to others nearby - Domino Decline by Design. 

Failure to Understand Demographics Is Failure By Design

The United States has failed miserably in another measure of access. One of the most rapidly growing populations in America is the population in a county without a hospital. Rural and urban hospital closures and mergers are impacting more counties. The new closures impact larger population counties. Counties without a hospital are also counties growing the fastest in population and in demand for health care. This rapidly increasing population number should fly past 10% of the US population in the next few years on the way to 20% because current designs and designers are so out of touch with local populations, situations, and resource deficits.

The one type of workforce most needed in counties without a hospital is family medicine, also most needed across primary care and primary care where needed. Another measure of workforce failure is failure to change family medicine graduates beyond the 3000 grads a year level first reached in 1980. There cannot be a response from any type of training intervention because training cannot impact payment. Family medicine cannot be produced under a design that so compromises all that family medicine is about while so favoring specialists, technology, and care for the few. Family medicine is local, access, and care for the many where care is needed - the opposite of 45% of physicians found in 1% of the land area in 1100 zip codes with well over half of US health spending. Once again, those doing well appear to be doing better and those falling behind are falling behind further.

These are just a few failures already played out for the last few years with another decade of failure programmed by design. ACA killed off the support for hospitals where care is needed. ACA designers assumed that Medicaid Expansion would fix care where needed. If you pay too little for hospital care for these hospitals, insurance expansion does not work. Political debates  have tended to hide failure by design in this and other areas. Those critical of ACA have also been crippled by the political rhetoric - to the detriment of health care in the US.
  • Researchers have countered that the loss of a small hospital is no big deal. They have compared health outcomes before and afterward and found no change. This is exactly what you would expect. Hospitals and physicians have very little impact upon outcomes - perhaps 10 - 20%. There is a major and fatal flaw to these studies. Health outcomes are 60 - 70% about the population involved, their situations, their determinants, and their relationships. Losses of local jobs, local health professionals, hospital associated physicians, and the organizational role of the hospital and its professionals and employees are difficult to measure because so many dimensions are involved. It is not surprising that those immersed in innovation would not understand the practical reality of care where needed. This is why NP vs MD studies show no difference or PCMH studies or any study that matches up populations well. However if you compare rural to urban hospitals or any disadvantage to advantaged populations - you will show lower quality. This is inherent in the research design.
  • A major failure of ACA and CMS has been the failure to understand the top priority forces shaping health outcomes: social determinants, situations, attitudes, and past learned behaviors.
  • It is difficult for some to understand local impacts, widening ripple effects, and other indications of Domino Decline By Design  

Massive Workforce Failure By ACA/CMS Design or Lack Thereof

The focus of ACA/CMS was payment change to force quality. Payment can barely impact clinical changes which are only a small part of outcomes. Payment focus on "quality" has distracted the nation from the most needed change in workforce - a return of balance between basic services and procedural services.

We produce the workforce that we need for these counties of any type (MD, DO, NP, PA) due to payment too low for cognitive services and so much higher for procedural services. The focus on quality cannot actually be addressed by payment change. ACA/CMS assures us that no expansion of MD, DO, NP, or PA can actually result in more primary care. This requires more dollars to be injected into positions delivering care - something avoided by design.

Payment redesign cannot change quality, but it could impact costs and access. Costs could be cut by decreasing payment for highly specialized services. Of course this would risk the ire of the most powerful corporations and people in the nation. A decrease in specialized payments coupled with an increase in office code pay could actually restore balance and boost primary care, mental health, geriatric, and general surgical services - about 80% of the types of physicians needed for 2161 counties with lowest concentrations of physicians where 40% of the US population remains disadvantaged by design.

A restoration of access and balance between basic services and highly specialized services can be accomplished - because it is payment design that has caused this. 

It is failure to claim success in access while failing to address what must be addressed to result in access to care. 

Expansions of Coverage Fail Most in the Area of Access to Care

ACA ignored workforce needs. The ACA took the narrow focus of expanded insurance coverage. This is one area that actually fails to help the places and populations most in need of care - because the payment design is insufficient to actually pay for the workforce to deliver the care.

Once you understand that these are locations that have higher concentrations of Medicare and Medicaid patients, you can understand that these areas have less people who are uncovered.  Even worse, ACA could not help. The reason for the lack of access to health care services is the lack of health workforce in these areas. This is because Medicare and Medicaid have been paying too little for basic health services for decades. Since private plans tend to follow the federal design, the problem is compounded. New plans also follow along.

Even with 100% of the population covered, the areas already behind will remain behind because they are dominated by Medicare, Medicaid, generalists, general types of specialties, small practices, and small hospitals. The funding will remain concentrated in 1100 zip codes in 1% of the land area with 50% of physicians and the ultimate concentrations of technology and subspecialization - by federal design. 
 

Failures of Innovation and Evaluation


The fact is that much of what the ACA tried to do is compromised by design and implementation. ACA is not alone as the innovation bandwagon of the past few years has been stuffed with vague definitions, arbitrary proxy measures, and poor controls. Despite these major issues, there is already a supportive literature - not surprising given the state of health care quality research.

True reform in the United States must be guided by local needs, practicality, and improvements in basic services. True reform requires a solid foundation of front line access to basic care - a prerequisite for any real improvements in the Big 3 of cost, quality, and access.

The ACA and CMS efforts have not changed the pattern of way too much spent in too few places spent on too few people for too little result.

Recent Posts and References

Health Care Who Is it Good For? - Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation - We are so focused on innovation that we cannot even take care of the basics - Commonwealth Foundation is supposed to be about access. A foundation truly focused upon the access to care foundation could be powerful in shaping needed change. But why does it promote innovations that cost more and divert front line workforce from being able to deliver health access? Why does Commonwealth consider access to insurance to be access to care?

Safety Net Should Sunset and Front Line Access Must Rise - We need a solid foundation for access, not gaps in access and terminology.

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.

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