Patients Should Be Changed, Not Physicians

Patients should indeed be engaged, educated, and changed in behaviors, situations, environments, and supports because this is 60 - 70% of health outcomes. The failure to influence patients, families, homes, communities, resources, social determinants, and child well being will continue to shape lesser outcomes in health, health status, and health outcomes. These most important areas are currently outside of our current design for health care spending. 

Reformers and innovators hoped to influence improved patient outcomes by changing physician behavior. The most consistent finding in the efforts to improve quality - is no change. The outcomes have not been changing because people are not changed or being changed. Their behaviors, environments, situations, resources, relationships, and social determinants are the same.  

Apparently health care and education fail to learn from study after study. Over and over Pay for Performance is attempted with the same failed result. Teachers and physicians and others dealing with people are not going to have changed outcomes because the outcomes are about the years or decades of other influences that have shaped the student or patient.

The pressures upon teachers and physicians have become enormous. There is increasing awareness of the consequences.


The new regulations have resulted in highest ever levels of burnout, higher turnover, early retirement, closures of small practices, and disengagement behaviors - from participation in teams, family, community, and more. Such is the result with so many more hours for EHR, documentation, and meaningless messages with less time remaining to what really matters: patient engagement and optimal team and family function. Never have health care team members been asked to do so much more with little or declining support. Physician practice changes are at an all time high. There is little doubt as to the reason why.


Pressures To Do More With Less are Counterproductive

Why Would Any Designer Take Down the Team Members That Most Influence People, Behaviors, Environments, Situations, and People Factors That Most Influence Readmissions, Preventable Admissions, and Local Care Outcomes?

Those who could influence behavior change and other people factor changes have been marginalized. Nurses are the most important hospital ingredient after patient influences. DRG bundling design took down nursing as a means to the end of people change with nursing ratios too low, nurses too busy, too few hospital resources, and time of hospitalization too small to influence patients or families.

Lowest payments for cognitive, office, basic, primary care, and mental health insure the least opportunities to influence people factors from within health care. Lowest payments for primary care and mental health with 60% of the US health encounters marginalizes the value of the encounter for people change. Encounters have been shaped to be too short and too superficial by design. This is but one area where attempts to change behavior for value (more for less cost) have resulted in adverse results.

Only from 1965 to 1978 did the US design increased support for the team members to effect needed people change. The 1960s and 1970s were about the only time that we invested more in other key areas such as education. The US invested steadily more in primary care, mental health, and basic services during this period of time. It spent substantially more on more to most specialized care to break the bank, but at least it did spend more to build up health access for a time. 

The benefits of the investments in health access and basic education are running out just when we need more from both.The problem with long term investments is that few understand them and even fewer support them.

Access Barriers By Design

The team members that could change people and outcomes have all been marginalized for the past 30 years by national and state designs. In 2621 counties lowest in physician concentrations due to payment design with 40% of the population, the fewest team members face the most complex patients in locations with the least resources and social determinants - by design. The shortages and access barriers are the result of concentrations of federal patients with their lowest paying plans. Innovations and expansions of insurance coverage fail to send more dollars to places suffering from cost of delivery too high and getting much higher with payments too low by design.

Plenty of Health Spending But the Wrong Places

We spend enough in health care that we could impact cost, quality, and access for rural, inner city, minority, Native, elderly, and poor populations - but we tolerate designs that spend the most via highest cost areas needed by few and accessed by few and provided in fewest locations. Not surprisingly there is little gain overall. 


Our nation has chosen to invest 17% of GDP substantially in clinical interventions 
that shape 10% of health outcome influence.

What Is the Real Story of Medical Error Focus?

The real story is that 20 years of medical error focus has resulted in countless tens of billions added each year in increased administration and regulation costs. Since there has been no improvement in health outcomes, this represents the opposite of value.

The real story is that Medical Error Focus works out very well for the institutions, corporations, associations, and consultants that benefit most from measurement focus.

The real story is software corporations and practice management consultants with a larger and larger share of health spending. More are needed to address numerous changes during this time period of rapid and chaotic change by design.

The choice of the digital "revolution" as a change agent has been misguided and costly. Digital reforms represent a small influence within the small influence of clinical intervention - too small to register among much greater influences and "noise." The software has been costly and has not been tailored to efficient and effective use. Now that physicians spend twice as much time with EHR as compared to time with patients, the error is becoming more obvious along with the increasing realization that physician and clinician behavior has been shaped the wrong way.

Failure of People Change Agents in Health Care By Design

Areas such as primary care and mental health are failing by design and with them the ability to shape people factors. In the 150 billion a year area of primary care, another 10 billion will be required for MACRA in 2016 alone. This can only come from cuts in the numbers and support for the delivery team members The 10 billion a year for multiple years without increases in payment plus the loss of productivity for EHR is more than can be sustained. Encounters will continue to be less engaged, shorter, and more difficult to obtain. Good luck finding basic services where they have been most limited by decades of designs made worse.

Did Medical Error Improvement Result in Less Support Where More Is Needed?

Readmission penalties and MACRA have failed to demonstrate significant success. They have been consistent in one area - discrimination against providers caring for patients less advantaged (12 studies). The payment design has helped to create disparities, but the newest wrinkles will send even fewer dollars where dollars are lacking while sending more to those who already get the most. The Mess that is MACRA - Sullivan   Prevent MACRA to Do No Harm

Cherry Picking Is Even More Important

This is also seen in ACOs. Studies indicate the same for the new bundling of physician payments.
Bundling or Bungling, Once Again Into the Fray Insurance companies, systems, and practices must avoid the most complex, lowest paying while maximizing the most advantaged and best paying. 

Training Fails By Design

Even the most innovative training designs designed for care where needed cannot result in improvements in access because the payments remain limited by designs that will send even less where needed. Poor Payment Dictates Poor Training Outcomes in Primary Care

Physician Behaviors Made Worse, Not Better

One can make the case that physician behavior, unfairly vilified as the reason for medical error, has not been changed for the better. In fact the changes have been for the worse. Physicians are deciding to leave practices (costly due to higher turnover $300,000 per primary care physician), leave medicine or retire (decrease in workforce), leave primary care for hospitalist or Emergency Medicine (defeat access), or disengage from patients, teams, employer, community (numerous quality, cost, access issues here). Physician behavior is dominated by EHR focus that occupies 2 hours for each hour of patient care. Physicians are marginalized by EHR, loss of personal time, incredible debts, and loss of control. Physicians spend 1 - 2 hours of personal time on health care (Sinsky, Annals IM).

Other behavior changes include career choices. MD, DO, NP, and PA graduates continue to move away from health access careers following the payment design to higher paid hospital, procedural, technical, subspecialty positions. With the continued micromanagement from above plus more required with less support, primary care will occupy fewer of each type of graduate. Less support for the most complex patients in areas with least resources will make matters worse for cost, quality, and access where needed.

The Case for Worsening of Quality By Mergers and Consolidations of Practices

Physicians have been influenced to give up private practice for employed larger practices. Larger practices and employed practices are associated with lesser quality as measured by preventable hospitalization (Casalino).

Time for Real Change - Away from Error Focus and Toward Delivery Focus

Medical error focus has dominated the last 20 years with designer, academic, government, foundation, media, software corporation, consultant, and association promotion. Unfortunately the nation is no better off with costs too high, quality too low, and continued access compromise.

But we do have more insurance coverage.

And Pay for Performance Has Another Nasty Side Effect - It Can Backfire and Shape Work Behaviors the Wrong Way - In education and health care it is important to learn that outcomes are about the students and patients and their environments and situations. Paying teachers or physicians more for improved "standardized measures" is ineffective.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric


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

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.
Copyright 2016

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