Value Failure By Those Who Promote Value

These are many areas of concern for those attempting to deliver health care. There are even more areas of concern regarding those in rural and smaller practices and facilities where growth is most in population, in elderly, in complexity, and in disparities. The concern list has been growing more rapidly since 2010.

Ten Concern Areas for Populations Behind By Design and Their Providers

1 Chaotic, rapid, meaningless change is making it difficult for practices and facilities to support the team members to deliver care. Such change favors those bigger and more organized. 
  • These are design changes that marginalize the teams that are supposed to deliver the care, especially for small health care. Populations already behind experience the changes most - along with most adversity.
2 Designs for payment increasingly lack clarity and overlap in confusing ways.  This raises serious concerns. In recent years, providers have had to sue the government or payers to get proper payment as they attempt to deal with delays, denials, and government interpretations marginalizing providers 
  • The designs and resulting situations accelerate costs of delivery and administration as well as forcing declines in productivity. Simplified designs allow more dollars to flow to team members to deliver care. This is especially a requirement in places where care is limited due to lowest payments.
There are well-documented adverse consequences of so called quality measurement or value based payments including less payment/more penalties for providers caring for rural, underserved, less advantaged patients and others with patient factor reasons for lesser outcomes as seen across over a dozen studies. Even worse is the documented inability of quality measurement to discern a quality provider from the average. There are too many other influences - people factors, genetics, community, resource deficits, other providers, too much interference 
  • The payment changes to shape penalties lack the evidence basis for the claims that have been made. 
  • CMS has made a claim that the measurement is valid even where numbers are small even though the CMS consultant (RAND) did not indicate that it was valid. 
  • The dollars for penalties are dollars diverted from care where needed. 
  • The dollars for software, hardware, maintenance, data collection, reporting, and other costly quality metric areas are stolen from places that desperately need the dollars. 
  • The dollars are shipped to locations with concentrations of dollars, jobs, and health care. This is true for many of the recent designs such as mail order pharmacies that change economics, jobs, and dollars where needed.
4 Being forced to make decisions to get bigger or collaborate or sign over or cut back in ways that are likely to result in marginalization of local services and supports for the community 
  • There are often no good decisions to make for those in charge of small practices or small facilities. Decisions can result in closures of services, decreased access, loss of jobs, or other changes that sell out people you know and love - people who depende upon you for jobs or health care. 
  • Designers far away have no clue regarding the divisions that they have created and accelerate. They really ignore the divisions, diversions, and harm that they do by their designs.
5 Inability of the US design to produce the generalists and general surgical specialists (surgery, orthopedics, ob-gyn, urology, ENT) needed to do basic surgical services 
  • Payment reform that matters was avoided. For decades government leaders and CMS have long avoided true health reform to address Big vs Small, Urban vs Rural, Cognitive vs Procedural, Basic vs Specialized. Payment remains too low for basic, cognitive, office, rural services and care where needed.
  • Primary care spending was estimated at about 150 billion nationwide per year. This spending has not been increasing. About 6 - 10 billion more each year has been diverted from primary care to pay for digital changes with hundreds of hours per team member diverted from care to digital devotions. 
  • General surgical specialties are avoided due to payment designs that pay so much more for those who do fellowships, procedures, and highly technical care.
  • Over 75% of the workforce needed where care is lacking is prevented by payment design.
  • Closures of small hospitals, emergency rooms, and labor & delivery units continue as dictated by low payments, higher costs of delivery, and marginalization of team members
  • Even family medicine graduates, once 95% found in family practice positions, are being diverted with about 12% doing emergency care and 4% each in urgent and hospitalist care. Rural family doctors do much better by converting to urgent, emergent, or hospitalist careers. They also have better life balance and do not have added responsibilities each year with more added to do with too much to do already. Burnout causes drive productivity declines and higher turnover - a cost of $300,000 per lost primary care physician.
  • Populations suffer when basic access suffers 
6 Steady erosions of state and federal funding to support health and social resources in rural and other underserved counties and populations. Together with erosions of health spending and education spending, these cash, job, and support changes will result in lesser health, economic, education, and societal outcomes in rural areas
  • Health care spending cuts have not been alone in their discrimination. Austerity focus has resulted in cuts in education, nutrition, and social services. Cuts in Social Security and nutrition represent cuts in two of the most equitable spending remaining in federal government. 
  • The Older Americans Act was intended for expansion to help prepare for the Aging of Americans to help prevent the need for costly long term and other care. These funds were marginalized and failed to be increased over time. America is not prepared for rapid aging. The efforts to prevent higher costs and greater disabilities have nearly all been diluted (local agencies, local resources, primary care, mental health, geriatric care, community organizations).
  • Federal funding is also diluted by state efforts that can divert funds away from populations in need to privatization, consultants, and other uses.
  • Property tax based education clearly discriminates against places with lower property value. Special funding for areas with government land and less of a tax base have been cut. Corporations have also walled off boundaries to prevent their funds from being used by school districts.
  • Federal formulas allow places with 30% child poverty rates to have a lower priority for federal funding support as compared to places with 7% child poverty who happen to have greater concentrations of poor children. Such is the discrimination that results from those more organized versus those least.
  • Quality metric focus is not limited to health. Education has faced numerous rounds of diversions of funds away from teachers and assistants to pay for software, hardware, maintenance, special curricula, and other efforts. In addition students are tested more leaving less time for learning interactions. Health centers, schools, and other entities are diverted to the pursuit of grants and special funding - and away from their mission areas. The end result is a massive increase in administration with funds taken away from those who deliver health, education, child development, etc.
7 and 8 Additional costs to find and keep good staff and good physicians remain a problem when payments (Medicare, Medicaid, other payers) are too low to compete with urban and larger settings 
  • Nurses and other skilled staff needed for small practices and facilities are challenging to recruit and retain and keep up on skills and continuing education, etc.
  • Based on studies in one of the 30 states most behind in physician concentrations, the increasing cost of recruitment, retention, and locums in just primary care alone is 1 to 2 dollars per person in the state for more cost each year. This translates to 300 million more per year for clinician expenditures for primary care. This is just for primary care to survive.
  • The actual cost is higher due to primary care turnover. Base on the previous figure of $225,000 per primary care physician (Buchbinder) and not considering all costs of replacement and orientation plus changes in the past 2 decades, primary care turnover is easily $300,000 in overall costs and losses in revenue.  Flawed payment designs are a major contributor to higher turnover. Once again the costs higher where care is most needed results in dollars diverted from those who deliver the care.
  • The deficits are also seen in small hospitals. Medicare formulas regarding labor costs have long resulted in payments too low where care is needed.  
  • Costs can be significant when hospitals find an orthopedist and update other staff and equipment - only to lose the orthopedist. Large facilities can count on having multiple specialists. They can even replace some of the very expensive specialists with NP and PA clinicians at substantially lower cost. Highest reimbursement, steady levels of clinicians, lesser cost of recruitment and retention, lesser costs through NP and PA, lesser costs of supplies and equipment as volume buyers get the discounts and smaller providers have to pay for the difference
  • Rural and smaller hospitals could once depend upon local physicians to staff the ER and care for patients in the hospital. The academic and larger hospitals came up with a plan that fit their needs well as well as the dictates of DRG based payment. Rapid assessment and rapid discharge work well for largest hospitals who can afford to pay more for ER and hospitalist workforce. Other hospitals have been forced to go along, not because of financial benefits, but because this became the expectation. Lower volume and smaller hospitals cannot make up the costs by keeping ER and hospitalists busy enough. Academic facilities used ER and hospitalists to address longstanding faculty shortages. The design was a win win win for the biggest and a lose lose lose for the rest. The plan added 10 billion in annual costs to hospitals and has stolen 50,000 primary care trained physicians - and will end internal medicine as a significant primary care workforce - the result of 30 years of payment designs.
  • Payment and workforce designs are a poor fit for small health care and care where needed.
9 Journal and media articles have been based on flawed assumptions. What people read can shape their impressions and guide them toward or away from various health care choices. For two decades researchers have assumed the value of bigger facilities with higher volume. Their works have been biased regarding other types of health care. The studies have failed due to insufficient consideration of people factors and other influences that most shape health care. A great example has been studies of hospital quality. Journal and media articles claim lower quality for rural hospitals. This is not different. Rural hospitals are different, not better or worse. Attempts to compare them have the most basic of research flaws - attempts to compare apples and oranges. Their interpretations have not considered the vast differences between hospitals - differences in patients, payments, personnel, situations, and more. 
Rural hospitals and hospitals found where care is most needed have the obvious problem of caring for more patients with lowest paying plans such as Medicare, Medicaid, Metallic, and high deductible plans. The payments are less due to Medicare formulas. Medicaid payments are insufficient. The support for staff is different. The services are different. 
Care outcomes are shaped by patient factors before, during, and after hospitalization. Patient factors shape most of the outcomes - this is why 30 days was chosen (and may be too long) for readmission measurements. With longer time periods, even more is shaped by people factors. With lesser periods of time the patient condition at admission and their diagnosis shapes outcomes. The thirty day period is also inaccurate by type of condition as the figure should be moved shorter and longer. 

Higher volume may have some influence in some procedures, but not in others. 

The assumptions have been allowed to remain. This has promoted bigger and higher volume and marginalized rural, smaller, and lower volume.

10 Low priority areas have been addressed in "health reform." The designers focused upon insurance coverage expansion rather than true reform. Regression studies dating back to the 1990s have shaped substantially higher administrative cost hoping to improve medical errors and increase health outcomes. In both areas, the studies gave far too much credit to clinical interventions and insurance interventions while ignoring the factors that shape outcomes - the people factors that shape most outcomes. 
  • This is why much has been done for 20 years resulting in substantially higher costs and little improvement in outcomes. 
  • Even worse, the result has been cost cutting and rapid change favoring those biggest who can fend off costs and rearrange priorities. Those smallest can least afford the costs and have predominantly basic services paid least - and can only marginalize or close services.
Common sense indicates that problem of access and insurance coverage. 
  • Expansions of insurance with payments too low to support the costs of running small hospitals and small practices still cannot support care where needed. 
  • Higher payment required from existing insurance (Medicare, Medicaid, private plans) have allowed small practices and small hospitals to care for patients with or without insurance. The current designers have forgotten the lessons of 1965 to 1978.

The basic assumptions regarding insurance coverage expansions were flawed.
The solution has long been obvious for health access recovery, for workforce balance, for primary care workforce, for mental health workforce, and for a workforce that can care for populations increasing and aging in the places where they reside. 
  •  This has always been about substantial increases in basic, cognitive, office payments and reducing payments that are too high for highly specialized services. 
The medical-hospital-system-academic-industrial-corporation-association complexes have long made and shaped other designs and designers. 
Payments raised for the basic services that are most prevalent where disparities exist is the way to minimize the inequities caused by the current health care payment design. It is the best way to improve access and restore this basic foundation for care.


Value Failure By Those Who Promote Value
Designers that fail to value the team members who deliver the care, especially where care is most needed, are designers that must be replaced. Designers must not value innovation, quality measurement, or digital information in ways that compromise care. Designs efficient and effective result in more team members in more places when and where patients need care. This is how you accomplish outreach, coordination, integration, and care improvements - by working on people factors, changing behaviors, improving environments, and addressing the basic requirements for better outcomes. 
Designers also need to avoid designs that most divide our nation - insured or not, bigger vs smaller, outpatient vs inpatient, primary care vs specialized care, corporate/profit vs patient care, most concentrated vs the rest of US. 
Do No Harm By Design
Designs in health care should Do No Harm. The same standard should be observed we demand of those who deliver care. It is the responsibility of those who deliver care to point out that designs are doing harm. The very designs that we have force those who manage and deliver care to make choices that can cause harm directly or indirectly.

Of all the forms of inequality, injustice in health care
is the most shocking and inhumane.
Martin Luther King, Jr.

Discrimination By Design
  • Less than 20% of health spending goes to 2621 counties with 40% of Americans under the current design. 
  • Counties and populations behind need generalists and general surgical workforce - those who provide services that have the lowest paid codes. The payment design actually prevents the training design from supplying generalists and general surgical workforce.
  • Medicare data on office code 99214 and other office codes indicate that these codes are actually paid less in these counties. The providers are paid less for the same services. This is true despite 3 decades of protests.
  • The cost of delivery has been worsened for small hospitals and small practices under the new design. The patients and the providers have the most difficult times adjusting. 
  • Premature deaths in the counties and populations left behind are higher and team members to help change behaviors are needed more but supported less. 
  • The counties left behind are more likely to be in states with lowest paying Medicaid and Medicare plans. The counties left behind have many deficits, but not necessarily in insurance coverage. The Medicare and Medicaid proportions of patients are higher, filling the gap. Insurance coverage was never going to do much for such counties. Indeed the new plans are failing most in these counties as insurers leave them behind. 
  • Medicare plans, Medicaid plans, Metallic plans, Medicare Advantage plans, high deductible plans, Veteran plans that fail for local support, and other plans fail most for those left behind by design.
  • Academic institutions, specialty associations, and health professional associations are constantly claiming that they are a solution for health access - resulting in further confusion, additional failure, and lack of focus on the real cause of payment failure
These were counties and populations left behind before Medicare and Medicaid - decades before, and decades since. From 1965 to 1978 dollars did flow more freely through the elderly and poor under Medicare and Medicaid (and to these counties and to small health care), but this was cut off in the 1980s along with many programs designed to address the inequities.

In recent years, the various populations and locations left behind have even been divided into smaller pieces by media, political, and other approaches - Black,  White, Rural, Inner City, Minority, Native. Dividing those who are behind is one of the best ways to continue to marginalize those already behind. It also helps if they have to fight between each other for the small morsels remaining for basic health or basic education or other basics.

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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