The Ultimate Government Health Care Paradox

Does government intervention promote or prevent quality in health care? In the areas of health access and EHR quality, it appears that intervention prevents quality. By forcing providers into a few "certified" EHRs that are not efficient or effective for care delivery, CMS prevents market forces from resulting in poor sales for poor EHRs. For decades the payment design shaped by government also prevents market forces from driving up payments for primary care, mental health, and basic services resulting in the serious and worsening deficits in workforce and access that have resulted. 

There are people in government that truly believe that they are helping. Their viewpoints are quite limited because the are focused on innovation or on the health care that they are most familiar with - health care far away from the needs of most Americans. Meanwhile it is more and more obvious to those delivering care that the government interventions are quite limited in the ability to help and can actually make matters worse.
  • Government payments could be revised to restore access and restore a balanced workforce (cognitive/office/basic vs procedural/technical/subspecialized) but designers fail to change payment designs to achieve balance and access 
  • Government could force substantial improvements in EHRs by allowing market forces to take down EHR vendors that do not produce efficient software that facilitates care, but it continues to force "not yet ready for prime time EHRs" down the throats of providers.
Most damaging is that EHR interventions are quite limited for the purpose of improving quality. Even the best quality reporting fails to discern quality. The designers fail to understand that quality is about patient and other factors and has little to do with anything that can be addressed by EHR.
Government Intervention As a Cause of Health Access Deficits

After decades of basic health access decline it should be clear that government payment design has caused health access deficits. This is the result of government action that has keep primary care, mental health, and basic services paid too low.

The evidence has been present for decades. New sources of primary care such as family physicians, medicine pediatric physicians, nurse practitioners, and physician assistants have been created and expanded but access barriers remain along with continued high demand.

It should be obvious that primary care and mental health delivery capacity increase is prevented by payment design as set by government. The shortages of workforce follow concentrations of Medicaid, Medicare, Metallic, Veteran and other government plan patients.

The result of payments too low for decades has been increasing demand above the supply of workforce. Basic services demands are increasing most rapidly for primary care, mental health, and general surgical services while payments are being cut or remain stagnant.

Government suppression of basic payments has created the current imbalance and insufficient access with other consequences such as increased health care cost. With insufficient basic health access workforce, patients are forced into more expensive care or have costly delays in care.

Government even made matters worse by threatening even greater cuts via SGR to get the change known as MACRA – which will make matters worse due to stagnant payment and forced higher cost of delivery.

Prevention of the Quality EHR by Government

Government actions could force improvements in Electronic Health Records but this has not been done. In fact government has acted to prevent such improvements. Rapid implementation before ready for prime time is one reason. The second reason is all about profits. The government forced rapid implementation and has also forced acceptance of the few certified plans even with their quality deficits.

It is obvious that EHRs are fixed in place.  The Editor of FierceHealthcare indicated that Physician EHRs are stuck in a time warp - “Most physicians are about to be channeled from the Meaningful Use program to MACRA and the Merit-Based Incentive Payment System (MIPs), with an even greater emphasis on health IT use. If EHRs are no better now than they were years ago, how can physicians hope to meet the technology requirements? And if they don’t, what does that mean for MIPS? For Medicare? For the doctors?"

Mechanisms that Obstruct Quality Improvement

Perhaps the problem is in the profits - seen as sales dollars over cost dollars. EHR software designs are quite complex. It takes much cost to retool or upgrade or revise. Even the minimal federal requirements have been hard to meet. Changing the archaic platforms used by EHRs would be even more costly. Each change creates a cascade of additional costs to fix the problems created. Changes come with greater risks such as declining sales.

When markets are dominated by a few, profit focus indicates that it makes sense not to do changes until sales declines force the issue. Markets are indeed dominated by a few who appear to profit by lack of change.

The domination is made worse by government certification of the few EHRs that qualify. Once again, government is preventing market forces from forcing change. The government is rewarding the certified and established plans. When sales decline is prevented by government, there is no reason to change. Expansion beyond the ability to address problems is also likely.

Leaders Fixed in Place and Fixing Health Care in Place

Those who might make changes in access or in EHR are not likely to do so.

Digital proponents led the nation into EHR and quickly climbed the ladder at CMS and in other corporations and foundations. Digital dominates foundations such as Commonwealth dedicated to access - led by the original EHR Czar. Those who see all solutions as digital may not have the specific focus on access to care. Commonwealth and others have promoted insurance access as the solution to access to care. Other promotions common are successes in innovations that are questionable or missing. 

Government intervention should be seen as
·      Preventing EHR quality improvement
·      Forcing higher cost of delivery and higher cost of administration
·      Decreasing the productivity of health care personnel
·      Forcing higher cost of EHR maintenance and updates
·      Preventing basic access to care, compromising smaller facilities and practices
·      Increasing the cost of care
·      Decreasing public perceptions of care due to access woes
·      Decreasing clinician morale

There are other consequences but these should suffice.

Questions That Must Be Raised

Why does government design attempt to force quality and value on everyone except vendors? 

Is close association between vendors and government healthy for US?

Why does government attempt to discern quality using EHR focus which has been unable to discern quality if with years of experience and expertise and data and higher costs?

Government could force better quality in EHR but it cannot discern quality in health care, with or without EHR.

Matters now are worse than when the government injected the first 15 billion forcing EHR upon health care before EHR or health care was ready.

The attempt to manipulate quality was always misguided, because people are far too complex and interactions between people are many times more complex.

Why Quality Focus Fails

At best clinical interventions can impact 10 – 20% of “quality.” Digital aspects of health care are a small portion of clinical care and therefore can impact only a small portion of a small portion. The current fixed mindset makes it difficult to understand that  health and health outcomes are shaped by people factors - situations, determinants, relationships...

Digital manipulations can change care and increase the costs of care. Not much more can be claimed.

Real Solutions

Health care is basically care delivered person to person. Real solutions for health care support the person delivering the care as they interact with the person receiving the care. More support specific to deliver allows integration, outreach, more time with the patient, longer hours when care can be accessed, and more access in more places. Costly interventions and innovations act to decrease the funds available to support the personnel delivering the care.

Real Solutions Are People Interacting With and For Patients 

Government should focus on supporting those who deliver care and should avoid compromising support for those who care.

Recent Posts and References  

Government Compromise of Trauma Response - Government could also address compromises of access to emergency care rather than closing down facilities distributed where emergency care is needed  (it also doesn't help that insurers sometimes reimburse patients who then do not pay for the care they received).

Prevent MACRA to Do No Harm

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions


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