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 Barriers
  • Selection Bias Due to Geographic Location, Transportation, Age...
  • High Acuity from Presenting Too Late for Care
  • Community 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 research arm of HHS. This is titled,  “Why Should Practices Implement Health Literacy Universal Precautions?”
  • "Experts recommend assuming that everyone may have difficulty understanding and creating an environment where all patients can thrive. Only 12 percent of U.S. adults have the health literacy skills needed to manage the demands of our complex health care system, and even these individuals' ability to absorb and use health information can be compromised by stress or illness. Like with blood safety, universal precautions should be taken to address health literacy because we can't know which patients are challenged by health care information and tasks at any given time."
To repeat: 
"...Because we can't know which patients are challenged 
by health care information and tasks at any given time." 

Only 12% of adults (adults not elderly) who are health literate enough is just the tip of the iceberg. We know that older and oldest adults are less health literate. We know that they are concentrated together where social determinants and patient situations are more challenging, where health literacy is less, and where more barriers to care exist. 

Concentrations of the Complicated

There is not a level playing field when it comes to the most complex and complicated populations. Those that inherently because of who they are and because of their past decades of life influences have the lowest outcomes are concentrated together.

In the new wave of innovation, this translates to even lower pay for those geographically associated with complex populations or the providers that remain to be chosen by such populations or those selected out by insurance or other payers. Movements toward narrow networks and other fragmentations can make matters worse. In each case, the divisions shape the advantaged and best paid and best covered one direction and those less to least in the other along with their providers.

Policies, pay, regulations, training, access issues, and complexities all align to shape

A Bridge Too Far to Cross the Quality Chasm 

For decades the designers have been creating an access chasm. This Access Chasm has not been addressed and may be worsened by efforts to Cross the Quality Chasm - particularly when cost cutting is an even higher priority compared to quality.

The very foundation of the Bridge to Cross the Access Chasm is being eroded by efforts to Cross the Quality Chasm. There is also an increasing awareness that unless patients and their situations are changed, the Quality Chasm will not be crossed.

It has not helped that the innovators innovate based on their awareness of populations that have care, while the United States still has tens of millions with low or no access and little or no health information. Where we know the most involves the most specialized conditions and facilities while we know the least about populations, basic conditions, and resources where care is needed.


 When access is worsened:
States and counties short of workforce combine low pay, rapidly increasing costs of delivery, higher complexity of patient, and least support. Forty per cent of the US Population is found in 2621 counties lower to lowest in physician concentrations along with lowest health spending, health workforce, and health access:
  • Medicare and Medicaid populations are higher proportions along with those with low insurance coverage (such as high deductible). This is a reason for insufficient pay and insufficient providers. The decades of insufficient payment design have acted to help create health care problems.
  • Obesity, smoking, poor activity, fair to poor health, premature death, and other characteristics associated with poor health outcomes are more common (data from U of Wisconsin County Rankings).
  • Lesser political and social organization
  • Lesser resources for health care
Studies of readmission penalties and pay for performance document the problems created for providers where care is needed – where patients are more complex, less health literate, and have more diseases, conditions, and situations that limit care outcomes. Instead of reflective consideration of the consequences, there is acceleration of change.


A Bridge Too Far to Cross the Quality Chasm

Apparently CMS cannot see the problems it is creating by its implementations of "accountability focus" far beyond the ability to be accountable. Lack of awareness remains a problem for government, foundation, and association leaders. Paying less to providers who care for patients in most need of care represents a substantial problem. Failure of care where needed would seem to be the opposite of any true design for health reform.

Elderly populations are among the least health literate, receive the most care, need explanations the most, and yet have primary care supported at lowest levels. Numerous factors coincide in ways that make payment for performance impossible. 

CMS designs are holding practices and hospitals responsible 
for areas that are difficult or impossible to address.

Applications To Workforce and To Quality
With reasonable awareness, one can understand how rural hospitals, primary care workforce, and geriatric workforce are threatened.

High Complexity + Low Pay + High Delivery Cost + Low Resources = Failure By Design
Restricted to the most complex and time consuming patients with multiple overlapping health and other problems plus low pay by design translates to little or no expansion of workforce. 
  • Geriatrics remains tied dependently upon other institutions or training. Without the contributions of those associated with training (pharmacy, faculty, teaching hospitals) Not surprisingly the distributions of geriatricians fail for the purpose of geriatric care. Where elderly are concentrated, they are more complex and have less support. This is the domain of family medicine, the only specialty that has population based distribution to serve all of the various populations more complex and lower paid.
Family medicine has also had little or no expansion due to high complexity, lower pay, and a distribution pattern quite the opposite from the choices of medical students born, raised, and trained in top concentration settings. Family medicine delivers substantial care for the elderly and poor as well as others limited in finances, education, and local resources. 

Family medicine is the physician specialty most associated with care where needed – at 2 to 4 times other specialties. The graduates of state medical schools in Kansas and in Nebraska that choose family medicine are 16 to 22 times more likely to be found in a county with lowest concentrations of physicians in Kansas or in Nebraska. 

Family medicine has long managed higher volume despite a mix of the most complex populations with the least resources. This has been an expectation turned reality for general practice long before family medicine. This is a formula for practice viability for frontline health access across private practices, rural health clinics, FQHCs, and community health centers. It is also a reason why family physicians are the top choice of these front line access sites. 

The new focus on "higher quality" may not accomplish higher quality for many reasons, but the attempts can limit volume and health access and payment and support and more.

Interestingly there are studies that demonstrate that small practices are associated with improved quality with regard to preventable admissions. This was not specific to family medicine, but family medicine is most specific to small practices. Decades of working with the same people in the same practice with the same team and community may have advantages.

Family physicians have developed expertise in working with people. This is not necessarily about training because family physicians stay in their practices long term. With 3000 - 4500 encounters a year specific to health care team, patient, family, and community resources - substantial learning is possible most relevant to care including care of the most complex. 

Why would anyone think that they could determine or define quality 
far away and separated from where quality needs to occur?

Many aspects of the innovative designs are in the opposite direction from the needs of people in need of care and especially those who deliver care to them.

What nation would design the most obstacles for the small practices, the small hospitals, and the family medicine specialty at the heart of care where needed – rural, small urban, underserved, lowest clinician concentration counties – however you want to define need for 20% to 40% of the United States population.

One reflection to consider: How is it that the United States has consistently developed designs for the past 50 years that pay more for the care of advantaged populations and that pay less for care where needed?

The method of payment may be changing, but this one truth of payment continues.

In the only developed nation without universal coverage, it appears that the inevitable result is persistent divisions created by health care design.

Other Problems with Forced Quality Under MACRA

Spiro makes the case that the Alternative Payment Model side of the Medicare reform bill really is a step forward — if that program is designed well, and gets lot of doctors to sign up, it really could move the needle on value-based payments.

 But if doctors stick with the MIPS program, Spiro has a compelling case that this new reform bill would have Medicare taking a step backward. (Topher Spiro at the Center for American Progress)

The APM is obviously tailored for those largest and most integrated. MIPS is most likely for those smaller in many ways including the ability to take on huge risks with populations that may not pay off.


Coming Soon: Is It Possible to Measure Quality When People Just Want Basic Care?
  • Does volume cause a problem when more patients can be seen when and where they want to be seen?
  • Does quality matter when taking more time to input more information can inhibit the when and where of care? 
  • Does the recent designer preoccupation with innovation really matter when it comes to sore throat, cough, skin conditions, red eye, ear pain, urinary complaints, basic care for chronic disease, and numerous aches, pains, or injuries?
One Caution About Health Literacy

It is entirely possible to attempt to assess health literacy and create a barrier to care. This is a sensitive area and cookie cutter approaches can backfire. When you ask patients about sensitive areas, care is needed and experience with care. As with all that we do, it is important to adapt to patient and situation. Those experienced in primary care must apply this every day. Those not experienced or aware can design more barriers in ways that they do not understand.


Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health

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