Showing posts from April, 2015

More Confirmation of Small Health Value and Small Health Neglect

No small part of America is impacted by designs and information sources that disadvantage small hospitals and small practices. In turn, this continues to disadvantage and damage the people that depend upon small health care.Over six months ago this first small health review indicated substantial problems. More evidence has been added regarding the value of small health and further neglect of same. Studies have indicated improved outcomes for small practices and a new one from BMJ demonstrates the same for low volume hospitals. The chief actuary for CMS has indicated that increases in the cost of delivering care are too much compared to stagnant payment. Remember that primary care and small practices are paid less and have more difficulty making all of the regulation adjustments.The Paucity of Awareness Continues Paucity used to be a favorite AAMC word. Sadly it is our health leaders that often have deficits of awareness. The impact of lack of awareness continues to damage an…

Heroes for a Few or For Tens of Millions

We no longer tolerate discrimination in research design. We still tolerate discrimination in the designs of payment and training.

Almost any day in the New York Times there is some death of someone's hero. A recent health care death stimulated some comment. A cardiologist who was one of few to expose the Tuskegee syphilis experiment died recently. For the past 65 years it has been a struggle to expose and address discrimination against vulnerable populations and other abuses of human subject research experimentation. Hundreds and sometimes thousands have died in each episode. Actually we are still only aware of the tip of the iceberg as prisoners, nursing students, medical students, people in other nations, and many others were subjected to abuses.

It can be difficult to find critique in health care where my way or the highway is far too common. Critique is too often missing when it comes to damage or death to vulnerable populations. Health systems fail, states fail, and federal de…

A Bridge Too Far to Cross the Quality Chasm

Pursuit of quality is an ultimate good thing in health care, right? But what if the current pursuit of quality decreases the financial viability of the practices and hospitals that are on the front lines of health access? Where care is threatened, populations are more complex
Should Providers Be Held Accountable For Situations Beyond Their Control: Health Literacy BarriersSelection Bias Due to Geographic Location, Transportation, Age...High Acuity from Presenting Too Late for CareCommunity Resource Deficits (lack of local, state, federal investment)Lesser Social Determinants Numerous Dimensions of Patient Complexities Across Situations and Relationships Accountability continues to creep up on cost cutting as a top CMS priority. CMS needs to pay attention to research findings as summarized by the government - important research demonstrating the ways that patient outcomes are limited by patient factors. 
The following comes from the Agency for Healthcare Research and Quality AHRQ - …

The History of Good Deal Bad Deal Payment Designs

The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent.

Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially for primary care and all physicians paid on the lower end of the payment scale.
Good Deal Start Bad Deal End Number 1  was the original Medicare and Medicaid falling behind in about a decadeGood Deal Start Bad Deal End Number 2 - 1990s "reforms" - falling behind in about 5 yearsGood Deal Start Bad Deal End Number 3 - MACRA - few if any years ahead (but better than a 21% cut?) The AMA actually rented out the auditorium where Kennedy announced what would become Medicare and Medicaid to lodge its protest. Fifty years ago there were at least some leaders raising concerns regarding what would happen. Now with Medicare and Medicaid so much of the payment design, matters are worse.
By the 1980s, primary care payment w…

Oops We Did It Again for Too Little Payment By Design

The one major problem that has faced primary care for the past three decades has been cost of delivery rising faster than payment. Each "fix" has not really been a fix as steadily fewer enter and remain in primary care from all six sources. 

MACRA is the new design and CMS has already projected the impact for decades. Here is what the Chief CMS Actuary says in his April 9, 2015 report:

"While H.R.2 avoids the significant short-range physician payment issues resulting from the current SGR system approach, it nevertheless raises important long-range concerns that wouldalmost certainly need to be addressed by future legislation. In particular, additional updates totaling$500 million per year and a 5 percent annual bonus are scheduled to expire in 2025, resulting in a payment reduction for most physicians. In addition, this bill specifies the physician payment update amounts for all years in the future, and these amounts do not vary based on underlying economic conditions,…