Necessary Rather than Disruptive Transformations
The timing is excellent for significant learning regarding what works and what does not work to improve health care delivery. The distractions need to end. We need to return to more efficient and less costly. In other words, we need to transform away from recent transformations. This opportunity could be missed by those clinging to the past, reviving past assumptions, or past beliefs or those distracted by politics rather than relying upon evidence based studies.
The timing is excellent with several major works just published or distributed in the last year.
Disparities Creating Barriers to Outcomes
There is the opportunity to grasp the incredible costs of disparities. We can take stock of what we are doing with designs in health, education, economics, and other areas that worsen disparities. This National Academies work goes a long way to helping to understand just how far we have to go to change outcomes in the nation by changing outcomes in most Americans falling most behind. This sets the stage to understand the distractions of Transformations for Quality, Triple Aim, Quadruple Aim, ACA, PCMH, MACRA, HITECH, and more.
More for Quality is Less for US
The Robert Wood Johnson Foundation helped us to understand the limited impact of 300 million to advance disruptive change with Aligning Forces for Quality over a 10 year period. More dollars for limited change is the opposite of value.
We are beginning to understand that tens of billions more each year added to health care costs for medical error/quality measurement/digitalization focus are moving us in the opposite direction from value - little improvement at steadily higher costs. And speaking of value...
Pay for Performance Has Been Reviewed and Has Again (and Again) Been Found Lacking
“In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clear evidence to suggest that they improve patient outcomes.” from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 1/10/17.
The past year also revealed the lack of evidence basis for board certification activities. More dollars and more distractions for no improvements in outcomes is another wrong way transformation
Clinging to the Past Low Probability Solutions or Moving to Real Solutions
It could be a new era in health care, with transformations consistent with the evidence. Clearly we can move away from disruption and toward collaboration.
The transformations that must occur are
1. An incredibly important return to the support of the team members that deliver the care rather than continued disruption and "us vs them" divisions made worse with Pay for Performance.
2. A greater understanding of the true determinants of health as shaped in people long before health care encounters, during encounters, and after encounters.
3. A return to collaborative care across facilities, practices, communities. administration, and those who deliver care. Divided by design is far too costly and yields little result. (This is not the same as the collaboration of CMS and AMA - the subject of the next blog)
4. A resolve never again to embrace disruptive change involving human subjects or human populations without substantial evidence of beneficent intent, without protection of vulnerable populations, and without informed consent or reasonable understanding regarding the benefits and consequences.
It is very important avoid setbacks for most Americans already behind in health, economic, education, and other designs.
We must invest in people to improve health outcomes. We cannot and should not force health care team members to do what must be done predominantly outside of health care settings.
We must invest in the people who most invest in people to improve outcomes. Community and health team members that can influence behaviors, situations, environments, and social determinants of health must receive greater support to advance this important work across health, public health, child development, education, public service
We must not spend so much upon clinical interventions and digital clinical interventions that we fail to invest in people.
Disruptive and Not Necessary or Evidence Based
Pay for Performance has been disruptive
Readmission Penalties and MACRA lack an evidence basis. CMS itself indicated the consequences specific to most small practices.
Kip Sullivan captured Sloppy Risk Adjustment and Attribution Guarantee MACRA Won't Work as well as the discrimination of P4P. He also tracked the assumptions that led to ACA and MACRA in his Open Letter to President Obama Series all at The Health Care Blog.
Over a dozen studies clearly indicate the discrimination of Pay for Performance against providers who serve less advantaged populations such as the 40% found in 2621 lowest physician concentration counties. About half of family physicians are in small practice or are in practices that serve less advantaged patients with lesser outcomes.
Insurance Business Methods Disruptive, Payment Disruptive for Small Practices
Primary care practices have been forced by payers to hire additional staff just to do work that benefits insurance and government payers. This impairs practices.
Additional studies indicate lesser payment for smaller vs larger practices and lesser payment when health insurer market share is higher. Market Share Matters: Evidence Of Insurer And Provider Bargaining Over Prices Eric T. Roberts, Michael E. Chernew, and J. Michael McWilliams Health Aff January 2017 36:141-148; http://content.healthaffairs.org/content/36/1/141.abstract
I had Five Degrees of Payment Discrimination, MACRA made Six Degrees of Payment Discrimination, the insurance market share is Seven.
Lack of Necessary Payment Transformation in 2010 Reforms
The reform most needed in the 2010 reforms was higher payment for cognitive, office, basic services. The opportunity was wasted as is quite evident now. Primary care, mental health, generalists, and general surgical services - those most increasing in demand and most needed where care is most lacking - are in even worse shape due to stagnant payment and much higher costs of delivery via regulation, recruitment and retention costs, declines in productivity, turnover, and more.
Transformations Disrupting Family Medicine, Small Practices, Rural Health, and Care Where Needed
MACRA and P4P derivatives were never going to work for FM because of the patients that FM doctors most serve. Delaying real solutions is not a proper approach.
FM leaders must return to evidence basis (against P4P, against board certification that is not evidence based), must stand against discrimination, and must stand with most family physicians who have faced the worst by national design.
The performance metric for risk-standardized 30-day readmission rates for MI is not associated with quality of care, long-term mortality risk, or long-term readmission risk beyond the first 30 days following discharge.
Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.
The timing is excellent with several major works just published or distributed in the last year.
Disparities Creating Barriers to Outcomes
There is the opportunity to grasp the incredible costs of disparities. We can take stock of what we are doing with designs in health, education, economics, and other areas that worsen disparities. This National Academies work goes a long way to helping to understand just how far we have to go to change outcomes in the nation by changing outcomes in most Americans falling most behind. This sets the stage to understand the distractions of Transformations for Quality, Triple Aim, Quadruple Aim, ACA, PCMH, MACRA, HITECH, and more.
More for Quality is Less for US
The Robert Wood Johnson Foundation helped us to understand the limited impact of 300 million to advance disruptive change with Aligning Forces for Quality over a 10 year period. More dollars for limited change is the opposite of value.
We are beginning to understand that tens of billions more each year added to health care costs for medical error/quality measurement/digitalization focus are moving us in the opposite direction from value - little improvement at steadily higher costs. And speaking of value...
Pay for Performance Has Been Reviewed and Has Again (and Again) Been Found Lacking
“In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clear evidence to suggest that they improve patient outcomes.” from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 1/10/17.
The past year also revealed the lack of evidence basis for board certification activities. More dollars and more distractions for no improvements in outcomes is another wrong way transformation
Clinging to the Past Low Probability Solutions or Moving to Real Solutions
It could be a new era in health care, with transformations consistent with the evidence. Clearly we can move away from disruption and toward collaboration.
The transformations that must occur are
1. An incredibly important return to the support of the team members that deliver the care rather than continued disruption and "us vs them" divisions made worse with Pay for Performance.
2. A greater understanding of the true determinants of health as shaped in people long before health care encounters, during encounters, and after encounters.
3. A return to collaborative care across facilities, practices, communities. administration, and those who deliver care. Divided by design is far too costly and yields little result. (This is not the same as the collaboration of CMS and AMA - the subject of the next blog)
4. A resolve never again to embrace disruptive change involving human subjects or human populations without substantial evidence of beneficent intent, without protection of vulnerable populations, and without informed consent or reasonable understanding regarding the benefits and consequences.
It is very important avoid setbacks for most Americans already behind in health, economic, education, and other designs.
We must invest in people to improve health outcomes. We cannot and should not force health care team members to do what must be done predominantly outside of health care settings.
We must invest in the people who most invest in people to improve outcomes. Community and health team members that can influence behaviors, situations, environments, and social determinants of health must receive greater support to advance this important work across health, public health, child development, education, public service
We must not spend so much upon clinical interventions and digital clinical interventions that we fail to invest in people.
Disruptive and Not Necessary or Evidence Based
Pay for Performance has been disruptive
Readmission Penalties and MACRA lack an evidence basis. CMS itself indicated the consequences specific to most small practices.
Kip Sullivan captured Sloppy Risk Adjustment and Attribution Guarantee MACRA Won't Work as well as the discrimination of P4P. He also tracked the assumptions that led to ACA and MACRA in his Open Letter to President Obama Series all at The Health Care Blog.
Over a dozen studies clearly indicate the discrimination of Pay for Performance against providers who serve less advantaged populations such as the 40% found in 2621 lowest physician concentration counties. About half of family physicians are in small practice or are in practices that serve less advantaged patients with lesser outcomes.
Insurance Business Methods Disruptive, Payment Disruptive for Small Practices
Primary care practices have been forced by payers to hire additional staff just to do work that benefits insurance and government payers. This impairs practices.
Additional studies indicate lesser payment for smaller vs larger practices and lesser payment when health insurer market share is higher. Market Share Matters: Evidence Of Insurer And Provider Bargaining Over Prices Eric T. Roberts, Michael E. Chernew, and J. Michael McWilliams Health Aff January 2017 36:141-148; http://content.healthaffairs.org/content/36/1/141.abstract
I had Five Degrees of Payment Discrimination, MACRA made Six Degrees of Payment Discrimination, the insurance market share is Seven.
Lack of Necessary Payment Transformation in 2010 Reforms
The reform most needed in the 2010 reforms was higher payment for cognitive, office, basic services. The opportunity was wasted as is quite evident now. Primary care, mental health, generalists, and general surgical services - those most increasing in demand and most needed where care is most lacking - are in even worse shape due to stagnant payment and much higher costs of delivery via regulation, recruitment and retention costs, declines in productivity, turnover, and more.
Transformations Disrupting Family Medicine, Small Practices, Rural Health, and Care Where Needed
MACRA and P4P derivatives were never going to work for FM because of the patients that FM doctors most serve. Delaying real solutions is not a proper approach.
FM leaders must return to evidence basis (against P4P, against board certification that is not evidence based), must stand against discrimination, and must stand with most family physicians who have faced the worst by national design.
The performance metric for risk-standardized 30-day readmission rates for MI is not associated with quality of care, long-term mortality risk, or long-term readmission risk beyond the first 30 days following discharge.
Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.
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Managed
Care to Dartmouth to ACA to MACRA innovators have failed to focus on
the patient factor changes that could improve outcomes but the
innovators have managed to change physician behavior - the wrong way to
turnover, retirement, closures of practices, larger practices,
avoidance of complex patients, disengagement, lower productivity
Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care
Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care
Robert C. Bowman, M.D. Robert.Bowman@DignityHealth.org
The blogs represent the opinion of the blogger alone.
Copyright 2017
Copyright 2017
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