How to Destroy Clinical Care Nationally

Thomas Paine MD has illustrated how to destroy clinical care in an emergency room setting. I used his subtopics to illustrate how CMS and others are doing much the same to clinical care in the area of primary care in the United States.

1. Ignore and undervalue clinical experience.

While attention is being paid to value-based, MIPS, and MACRA payments - there is not much change to lowly paid cognitive, office, and basic services. This may also be why experience is least rewarded in primary care as the youngest to oldest salary gap is smallest. In contrast, newer orthopedist are paid most similar to oldest. The payment design rewards the most subspecialized - where the most income can be generated.

CMS physician payment design rewards longer training and more technology but ignores factors such as experience, continuity, and retention in a needed career - factors important in primary care and mental health delivery. Where the patients are most complex, the clinical experiences prior to the care episode can be most valuable - but value based payment is not based on such value. Actually the new design is not really new. It is a patch of a patch of a patch.

There is no payment adjustment for care where needed, for practices that invest in more delivery personnel, for those investing in more RNs or more experienced personnel, or for those with more integrated services. Low payments actually move practices away from all of these areas.

A great hypocrisy is promoted by panels, researchers,
primary care associations, and CMS as they support many
of these areas by words as they continue insufficient payment

CMS does not see that they drive people away from primary care and mental health - shaping deficits in workforce. Not surprisingly they fail to see that they have made matters worse MU to MACRA. What is surprising is the primary care associations such as AAFP have not seen this.

Experienced MD DO NP and PA move away from primary care by design. CMS does not see that decades of underpayment results in consequences.

The consequences also include staff in primary care practices. Those most valuable often move on to higher pay, different employment, different specialties, or different careers. Where payment support is lower the practices can support fewer personnel
and have difficulty keeping the best personnel.This was seen in Nebraska where Community Health Centers had rookies and lost their better personnel to primary care practices who lost to hospital or subspecialty practices. The payment gradient shapes the teams. High turnover defeats primary care ($300,000 lost per lost primary care doc) and also investments such as Primary Care Medical Home as personnel move on rapidly

Where have all the RNs gone?

Many can remember back to a long term continuity RN working with their primary care physician. The RNs are apparently too costly now. Instead of assessing and checking in each patient while providing direct support to the physician, a few RNs per clinic are in the back rooms doing triage phone calls or negotiating with insurance companies for coverage for patient needs or managing the clinic as an administrator. Lowest cost drives the personnel in underfunded primary care. Lowest payments for underserved primary care and for primary care as compared to other care shapes a pecking order in practice personnel.

Underserved primary care suffers the most

with lowest payments,
with the most complex patients,
with the least experienced personnel (and some quite dedicated and frustrated),
in areas with the least resources,
with a number of additional challenges to payment, productivity, personnel, and outcomes.

The case can be made that underserved primary care needs the most experienced and those that stay the longest building up the awareness and expertise specific to team, patient, community, local resources, and more. A complete reversal of the current payment design would be required for this.

The CMS design that results in lesser payment for primary care results in fewer staying primary care as flexible types of clinicians (internists, physician assistants, nurse practitioners) have other options for higher pay, better support, and less complexity). Where there is the greatest career flexibility, turnover is higher and continuity is shaped lower.

If you understand the need for experienced continuity personnel - Loan repayment and other short term incentives fail to work well due to insufficient cognitive/office/basic care payment by design.

2. Don’t ask clinical staff what they need, tell them what they get.

CMS does not support primary care or mental health and now tells them how to run practices while forcing them to pay more to deliver care while shrinking productivity.

3. When the ER is showing signs of distress, address it by creating more administrative positions.

ACA/CMS efforts have increased administrative and management and other non-delivery costs. This has been the major shaping force in health care for decades. Primary care and public health and mental health remain flat just as with other basic services. Specialty and subspecialty costs accelerate with new services and technologies rewarded most. This is also why workforce accelerates. Administrative costs have increased the most.

Cost cutting efforts have succeeded to shift costs to populations less able to cover the costs and to primary care which is least able to defend itself or its patients.

CMS has demonstrated time after time that is is disconnected from care and caring and those who deliver the care. CMS apparently has little awareness of the access, cost, and quality problems that CMS is causing. You can find great quotes verbalizing their awareness, but these have been words only. To find these promoted in primary care, rural, and health access focused association media pieces is disturbing.

4. Automatically turn down any request from clinical staff in the name of saving money.

CMS has been guided by cost cutting primarily since the 1980s. The contrast in policy direction has been substantial. CMS rebuild health care and health care where needed from 1965 to 1980. The priority has changed from investing in health care to chopping health care. Not surprisingly those paid the most that are also the most organized have managed to preserve payments and help create new lines of revenue. Payments for basic services have steadily deteriorated relative to higher paid services, making matters even worse in areas most dependent upon basic office services such as primary care and mental health.

CMS has taken the most narrow interpretations possible. More times in recent years the hospitals, systems, and practices have had to bring lawsuits to recover millions or billions diverted by CMS.

The latest developments promoted by the Center for Innovation are focused primarily upon cost cutting. Often the efforts combine cost cutting with quality focus - quite difficult to accomplish unless you target patient populations that have the most advantage (and therefore the best outcomes already) and that pay too much for care. Attempts to focus on cost, quality, or both have devastating impacts upon access as more dollars are taken away from being spent on the team members to deliver the care. Primary Care Medical Home Fails Natural Experiment Innovation Incapacitation

5. No one knows the unique struggles, challenges, and problems that your emergency department faces like an outside consultant.

CMS, primary care associations, and foundations promote innovations such as Primary Care Medical Home with consultants that tell experienced practices and personnel what to do while taking $105,000 perprimary care physician away from the ability to deliver primary care. The testimonies of former PCMH physicians confirm the costs and distractions of outside management consultants.

Quality focus, reporting, data collection, software, Meaningful Use, MIPS, and MACRA add tens of thousands per primary care physician each year in ways that can only marginalize primary care and destroy small practices and facilities. Quality Metrics Cost

6. Make sure your EM physicians are constantly reminded that they have no negotiating power.

CMS and insurance payers and those who employ physicians are constantly reminding physicians that they have little control over what they do - other than to depart. There is often some measure of deception present when hiring. Many recruiters know that if you can get the candidate to bond to people (clinic, community, patients) then they can stick them there for awhile - but this is another reason for burnout. When candidates are attracted to well supported teams and environments, they will stay and serve even the most complex patients.

When primary care associations fail to defend primary care or primary care when needed, there is little power at all. Health access foundations support technology and innovation over consequences such as lost access

7. All of the many EDs in your system are doing exactly the same thing, so it is fair to directly compare them to each other.

CMS in published data, in quality measures, in penalties, and in other areas compares vastly different hospitals and practices serving a variety of populations with a variety of resources. The publications and penalties result in greater confusion and worsening of situations

Major journals are not much better as they publish research that allows researchers to commit major errors such as apples to oranges comparisons. Why would any journal allow lesser paid small hospitals to be compared to biggest facilities (JAMA) with differences in funding, personnel, patients, community resources, and more.

CMS clearly does not understand the variety of interactions of patients with those who deliver care in a variety of situations with a variety of local resources. CMS clearly does not understand how these line up in advantage and better measures for some while others have few of advantage and lesser measures along with lower payment.

8. Create an environment where it is impossible for your clinical staff to succeed, then blame them for the failure.

CMS pays too little for basic services while forcing front line practices to pay higher cost of delivery while assigning penalties that makes their job even harder - and this is magnified where care is needed and where CMS patients are more concentrated. CMS designs such as DRGs have been a primary reason for marginalization of nursing with ratios too low, burdens too high, experienced nurses driven off...

CMS is a primary reason for low morale among nurses and physicians.

Senators and others are blaming primary care for a number of societal woes, even when they fail to fund primary care, mental health, child well being, early education, nutrition, and programs directly related to social determinants, local resources, health literacy, and other patient factors important to health and health outcomes. Senator Who Do You Think You Are Fooling

Primary care needs partners - political, primary care association, insurance payers, and government partners to work with them to change environments and situations of people in favor of better health and health outcomes. Primary care working with local resources, groups, and individuals is the progress that must occur. This cannot happen when payment undermines and overwhelms local primary care, paralyzes practices with rapid change, and drives off local health professionals and established and connected team members.

These all require decades of partnering to address recovery and expansion of the team members to sufficient levels to deliver, facilitate, integrate, and coordinate care across all the populations and places in need of access.

Nothing less than a Moonshot effort for decades is required to recover health access for the American people. Sadly the Moonshot was directed the wrong way.

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