It's Still the Economy Stupid

Once again Americans are rallied to fight against the result (high prices) rather than what caused the high prices. More money is thrown at the diagnosis leaving less remaining for prevention of high health care costs and prices. The process is great for those who write the articles, capture the attention, and enrich themselves. It is also the easy choice. Exposing high health care prices as evil takes no effort at all. The real harm is done by those who promote what seems to be popular as they distract Americans from the real causes of high health care costs.

The Biomedical and Micromanagement Waves that have long shaped runaway health care costs are the result of the same influences that shape higher prices and less for more Americans - by design. Higher costs are the result of advantages of designs that favor those bigger, those most organized, those who prepare to profit from the newest designs or implement them to their advantage, and those in the right locations serving the populations with the best insurance and best outcomes. 

What Do High Prices/Runaway Health Care Costs Have to Do with Basic Health Access?

There is some element of truth with regard to those who promote high prices as the enemy, but the relationships between costs, prices, cost cutting, and consequences demand more complex understanding. It is far easier to blame doctors, hospitals, drug companies, or the scapegoat of the week or month or year.

Journalists, social media, and various trade magazine articles are causing serious harm to health care. These entities are not bound by "Do No Harm."  There is a danger that they can influence worse outcomes for half of Americans. The knee-jerk reactions of DRGs and managed care as well as the assumptions of Accountable Care to MACRA are evidence of such reaction. The divisions in our nation result in decisions based on popularity or political party - rather than what works best for most Americans. Clearly the path of health care so far has been more spent for fewer. Some consideration needs to be given to the half of Americans most behind and fading fast.

Those who desire to slash and burn health care costs really do not care to discern the damage that has been done to Basic Health Access for decades, and made worse during this Health Policy Era Defined by cost cutting since the 1980s. The cuts do not impact all equally. The cuts are most commonly deflected by those largest and most organized - who often design the changes or influence them before, during, and after regulation. The policy changes that force more personnel to be devoted to innovation and regulation do not work well for those smaller who have personnel who must multitask rather than specialized personnel dealing in one area of regulation.

The changes continue to result in the worst impact upon smaller providers, providers where most needed, and those who serve the half of Americans facing the discrimination of underutilization - with worse to come as in decade after past decade since the 1980s. 

 A Center for Health Journalism article began stimulated this response by indicating "It's the Prices, Stupid.

A better play on words remains "It's the economy, stupid."

It is the Economy
That Has Been Decimated
by Runaway Health Care Costs

Creating and Worsening Health Care Costs By Policy 

Waves of reactions have been stimulated by runaway costs - and they have managed to actually increase costs and make health care less efficient, less effective, and less accessible.
  • The 1960s and 1970s changes did increase health care costs. One major difference now and then was that the initial Medicare and Medicaid designs were specific to increasing the health care dollars for basic services and for services where needed - where Medicare and Medicaid populations were concentrated then and are still concentrated now. The increasing dollars in rural locations and lowest concentration counties helped to support and expand small practices and small hospitals.
  • The 1980s changes and adjustments worsened care where most Americans need care. The 1980s with Prospective Payment and Diagnosis Related Groups had one clear purpose - to decrease health care costs. Rural health, nursing, small practices, and primary care have all been impacted and costs of health care have continued to rise.
  • The business and government coalition that became managed care and managed cost emerged in the 1990s. These changes became a platform that have catapulted the health care giants and their subsidiaries into greater control. Bigger insurance and bigger corporations continue to win. CBO reports indicated that managed cost and managed risk interventions ended up costing as much as saved. So we have bigger but not better and larger taking down smaller again and again. 
  • The 2000s brought recession and the micromanagers once again had their chance. They placed their proposals into economic recovery packages. Their inflated and assumed claims that digitalization would improve quality while also decreasing costs were published in academic journals without much critique. The same journals are still silent while the same claims are made and the costs have increased even more and in more areas such as security and the massive costs of security breaches.
  • The 2010s expanded insurance coverage and forced more micromanagement across health care - for the purpose of quality improvement. This was continued despite the evidence that outcomes are linked to patient, local, social determinants most of all and least in clinical intervention areas. And the micromanagement was doubled down by CMS despite its own published data about the discrimination specific to small practices (Table 64 MACRA) and dozens of other studies indicating discrimination in payment arising from financial incentives. 
The Waves of Health Care Cost Increases Past, Present, Future

The sad fact is that the waves of health care cost increases all have good intentions, but they result in too much cost for too little gain for too few. None of them are inherently evil, but instead of going only as far as fits good value (outcomes vs costs), the decisions are made to go many times farther. This increases the costs for little increase in outcomes - consistently poor in value. Too much expensive workforce, overutilization of most expensive services resulting in even more workforce, increases in nondelivery costs, and massive increases in complexity defeat the delivery of health care in the United States. This Triple Threat has come about in Waves of increased costs and complications.
  • First Wave cost increases for 100 years have been due to biomedical focus - as demanded by academic, largest corporations, and the public. The power of the biomedical is illustrated by the power of the "Death Squad" rhetoric. We all want more dollars for the futile attempt of preventing death as is most evident in over 32% of Medicare spent in the final year of life. Note that health care formal and public health split from each other a few decades ago. One exists to work for few while public health focus has been the many. The few are winning and the many are losing - by design.
  • Second Wave is about micromanagement of costs. These have increased costs substantially for no gain in outcomes and perhaps some worsening - the opposite of value. Classic graphs show the substantial increases in administrative, management, and non-delivery costs derived from micromanagement of costs and increasing with micromanagement of quality.
  • Third Wave cost increases are about micromanagement of quality. These have also increased costs for no gain in outcomes. The promises of micromanagement have not materialized and are not likely to do so since health outcomes are about the patient and local factors - not clinical manipulation. Many if not most of the quality study results showing a difference involve studies that compare two populations that are different - higher vs lower volume studies and rural vs urban studies and studies by ethnicity and race clearly involve many such differences. The Medical Error studies that shaped the quality micromanagement failed to include proper controls. Billions more a year spent on "quality" has no changed deaths due to so-called medical error. These studies are based on the assumption that clinical interventions dominate the determinants of health
  • Fourth Wave cost increases are already on the horizon. The lobbying has successfully reached the highest levels. The moonshot fourth wave for the future is about precision medicine. This has the greatest potential to improve outcomes for few individuals and at tremendous costs. It may well be the culmination of the entire last 200 years of scientific advances - but it will cause incredible stresses on everything not precision medicine. Any who believe that these costs will come down or that these benefits will be available to more than a small portion of Americans has not paid attention for decades or chooses to ignore policy, policy impacts, design consequences, and much more.
Worsening of Health Outcomes Due to Runaway Costs

Runaway health care costs increasingly impact budgets at all levels - federal, state, local, employer, and personal. As previously discussed, greater proportions of budgets for health spending leave less for investing in people including areas that shape the determinants of health. Health care dollars diverted to the most costly areas that impact the fewest result in less investment in the societal expenditures that most shape health outcomes.

Over 50% of health care dollars concentrated in 1% of the land area with 10% of the population

Health care dollars are closely associated with economic dollars. Places or people with concentrations of economics have concentrations of health care dollars. Health care acts to shape increased economics in concentrations. Health care designs have specifically reduced economic activity where most Americans are found with lowest payments for basic services, lowest for primary care, lowest for practices in lowest concentration counties, and reduced due to penalties because of the populations that they serve. 

High levels of local economic activity shapes highest levels of workforce, health care costs, best insurance plans, and best access to care. The opposite is the case for half of Americans behind in these areas and more. In many ways the waves of health care cost increases have made matters worse where health care is smaller, more personal, and lowest paid with higher relative costs for regulation and adjusting to policy changes. Regardless of political party, neither seems to understand how they both contribute to decline by decide.

Three waves of health care costs have continued to build up on each other to overwhelm our nation. The overall impact has been true to the American health care design (and economic design) as dollars are concentrated into fewer hands. More millions of Americans are added each year to those left behind in health care delivery, health care access, and health care outcomes. 

The First Wave Biomedical Tsunami - Procedural, Technical, Academic, Centralized, Subspecialized, Overutilized 2 - 4 times Where Health Workforce Is Most Concentrated
The first wave of runaway costs is still going strong after 100 years of impact. This wave remains highest payments for procedural, technical, subspecialized services. The earliest interventions remain the most important for our best health - but we have forgotten just how important these basic infrastructure areas are. Public health, vaccination, sanitation, clean water, and basic health care services have always provided the most bang for the buck but the health care designs have changed in ways that impact fewer and at much higher costs. 

Science has moved from the most common maladies impacting most - and it proceeds to smaller and smaller areas that need clinical interventions. This guarantees higher costs that benefit fewer.

Even worse, the basics most important for health outcomes improvements are being compromised by runaway health care costs. Workforce is shaped by payments. Workforce tells this tale and reveals little to no growth in primary care or in dollars for care where needed despite more sources of workforce and massive expansions. This has resulted in exclusively expansions of nonprimary care and ever higher concentrations of workforce. This is best seen in 1% of the land area involving 1100 zip codes with 45% of physicians and just 10% of the population. 

This first wave of runaway costs has continued to shape MD DO NP and PA to add more new specialties with more added to each specialty while leaving primary care, women's health, mental health, and basic services behind. The media helps to play a role by pitting various factions against one another. Also the advocacy groups, real or created by those defending highest payments, use the media to prevent death squad impacts - allowing ever more for less result. Blame the doctorCost cutting has been the dominant policy construct since the 1980s because of runaway costs from the first wave.

Second Wave Cost Micromanagement Costing More and More

The second wave has been costly micromanagement directed to cut costs, but also for little gain in outcomes at high cost. The CBO report says it all about managed care, managed cost, and managed high risk as the costs of such micromanagement eat up any savings. With more emphasis outside, there was more increase in dollars for those managing from outside of the person to person health care delivery. Administrative, CEO, VP, stockholder, and other non-delivery costs continue to spiral upward.  but not in these highest cost lowest value first two waves as they roll on and over the US. The spreadsheet led to micromanipulative cost control efforts - and the marginalization of those who deliver the care. The marginalization of nursing via DRGs is most evident and has continued for decades. The assumption that the one on one interactions that define health care can be dictated from outside has been most expensive in costs and in distractions for those delivering care. Apparently the micromanagers thought that their studies demonstrated great success, so they were encouranged on to a the third wave of runaway costs by failed attempts to micromanipulate quality.

Third Wave Clinical Micromanagement - Costly, Distracting, and Demoralizing
The basic assumption of this third wave is that health outcomes are about clinical intervention, especially clinical digital intervention. These assumptions are wrong. The same problems exist in education where micromanipulations of teachers and classrooms are costly and distracting. Outcomes are about outside of schools and practices and hospitals - not inside. 

These wrong assumptions that has been most costly for no gain in outcomes - the opposite of value based as in the first 2 waves. After 12 years it is apparent that the nation has had higher cost of delivery because of attempted improvements of costs and quality and without outcome improvements. Outcomes are about people - social, local, community, and other non-clinical factors. More corporations and consultants and non-clinical costs continue to be added.

The adverse impacts have been seen across nursing and all of the team members that have to deliver care despite micromanagement and despite meaningless use. They watch as those associated with the highest paid services do best and have the most support to share the load while they get more patients, more complexity, and more manipulation from the outside impacting their lives and their best efforts.

Triple Threat is negated for those with highest payments - payments that buy the most support and the best support. Triple Threat is magnified for those with lowest payments where micromanagement makes the duties and directions more complicated. Turnover, morale, and productivity are decreased by design.

Bigger Insurers, Systems, and Practices
Are Most Organized and Provide the Best Paid Services
Demand the Most Discounts from Suppliers
Receive the Most Attention from Government
Have the Most Influence Regarding the Designs, Legislation, Regulation

The three waves have shaped health care into entities larger and larger and able to demand higher prices and get paid more while they help shape highest payments for the most subspecialized, procedural, technical services. The design helps shape even larger and more organized entities that are more able to demand discounts from suppliers and more able to demand and get annual escalations in payments from payers. The three waves have increased their revenues most while decreasing their load relative to those smaller. They have benefited most from the glut of MD DO NP PA resident and fellow workforce - working to keep their costs low as they capture the most dollars by design.

The largest, best paid, and most organized do well because of the first wave. They have also been able to shape the financial design influencing more lines of revenue to be created. These lines have been expanded and maintained while receiving the highest levels of payments..

The largest have been impacted the least by the cost micromanagement second wave and some elements of the academic and biggest have merged with the micromanagement movement. The third wave of quality focus has also been influenced if not initiated by the largest, most academic, and most organized. The movements arising from Dartmouth assumed that 20% of the nation's population represented the nation. They assumed overutilization as a major problem and indeed the parts of the nation most concentrated in highly specialized workforce have 2 to 4 times greater utilization. However, the assumption of overutilization has worked out poorly for half the nation facing underutilization.

The natural reaction from prices too high is that prices must be cut and this impacts payments, but this too works out poorly for the 55% of services known as primary care paid at 6% of private insurance spending and 10% of public. Only 160 to 170 billion goes to primary care and only 25% of the primary care workforce is found in 2621 lowest physician concentration counties. The unadjusted estimate is 40 billion in revenue but this must be reduced due to 15% less paid by design and by 5 to 10% less in collections. This 36 billion has been reduced by micromanagement and innovation to leave only 30 billion to invest in the care delivery component of primary care. This supports have enough primary care where 132 million people or 40% are found. Micromanagement has resulted in less at more cost with additional costs added for turnover, lower productivity, and other consequences.

The third wave has helped the largest and most organized to do better compared to those smaller. They grow by adding those of their choosing. Cherry picking remains the best strategy for payers and for those who deliver care. The largest have benefited greatly from the greater adverse impacts upon those smaller from the third wave. The higher costs of care delivery are eliminating their competition just as primary care, women's health, mental health, basic services, small practices, and small hospitals are being eliminated where most Americans most need care.

So you can listen to those who talk about high prices, but the real problems resulting in declining health outcomes are runaway health care costs as well as military and prison costs many times that of other nations. Health outcomes can only be improved by investments in children, child well being, child development, parenting, housing, nutrition, environments, situations, behaviors, and social determinants. The three waves of runaway health care costs and additional waves of military and prison spending continue to steal that investments that help shape improved health, education, economic, and other outcomes. We are a nation of people and health care is about basic person to person interactions.

Health care is about do no harm and those who promote spreadsheet cost cutting and technology worship and Triple Aim have forgotten the priority of "do no harm," just as they have forgotten the consequences of their innovations. They have also lost touch with health care so much that they have forgotten the importance of supporting those who deliver the person to person care.

Revenue, Cost of Delivery, and Complexity All Worsening Are the Triple Threat

The Triple Threat is what creates shortages by location and by specialty. Triple Threat so impairs the financial design and so adds complications such that workforce layers out by Triple Threat.

The three waves have created the Red Zone Specialties. In Mayo Clinical Proceedings the Red Zone is defined by those in the quadrant most likely to plan to depart their practices and those most likely to plan to reduce their hours of work in a week. This is most associated with burnout and other consequences. The Red Zone specialties are generalists and general specialties - family medicine and internal medicine primary care, women's health, general surgery, general orthopedics, general urology, and others who enter practice straight from residency instead of taking one or more fellowships. Emergency medicine is also a Red Zone specialty. This may well be the result of breakdowns in generalists and general specialties sending greater loads and more complex patients and situations.

Red Zone Specialties are most likely to plan to leave their current practice and are most likely to plan to reduce hours. This is linked to burnout. The Red Zone specialties are the most numerous, the most basic and lowest paid, the most important for health access,  and are about 85% of services where lowest concentrations of physicians are found.


Higher Costs Via the Biomedical Wave

  • Procedural, technical, subspecialized designed to be highest paid services 
  • Overutilized specialty services where workforce is concentrated (at 2 to 4 times)
  • More care later because of earlier interventions (chemotherapy)
  • People live longer (some populations)
  • Last year of life health care costs (32% of Medicare)
  • Drug prices
  • Patient demand for "everything" even in futile situations
  • Unrealistic expectations
  • Too little preventive and basic care resulting in too much cost
  • Too little spent to address patient factors that shape health and health outcomes resulting in far too much spent and dollars spent for little or no gain. Research done on populations with resources also may not apply to populations without resources that can have more adverse events and reduced outcomes from chemotherapy, biologic agents, and other treatments that require best ability to rest, best home support, best nutrition, most supportive employers - the best investment is once again investment in people - so that they do not need health care and so that health care actually work
Physicians and other get the blame and the bashing as consequences of the waves. Lost confidence in providers can result in repeat visits, second opinions, or delays in needed care.

Divisions between various health care factions are the consequences of the waves that tear at the foundation of health care delivery.

Journalists and social media feed off of the controversies - adding to distractions (primary care versus specialist, high versus low volume, inconsistencies, differences in outcomes that are shaped by differences in the populations involved - not differences in providers.

Those outside who do not understand practice are the ones that claim that it is physicians that do not want to change, when the appropriate response is

"My job is access to care. Your promotion is hurting access to care or is not demonstrated to protect access to care. You must do more than just promote. Demonstrate that your innovation works without causing harm or hurting vulnerable populations that are soon to be half of Americans. Do not base your work on the estimates and assumptions of others who have also failed to work through all of the major areas that must be addressed to take care of patients. You might want to actually interact with those who provide the care where needed before you go off on some crusade. When there are twice as many team members where most Americans have half enough, then we can talk about higher primary care functions. But your design fails to provide the basic levels of primary care, mental health, women's health, and community resources to be able to integrate or coordinate much. Also when you talk about quality being shaped by clinical interventions, the"


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