Why Is Value So Hard to Recognize in Health Care?

Family medicine leadership supports a coalition that claims that it can cut costs and improve quality by a movement to value based payment. This coalition wants to convince the incoming government to continue to support continued innovations and transitions to value based payments. This would be a continuation of the last decade of experimentation.

"While not fully scaled, the new payment models have made great progress in promoting transparency, reducing cost and improving quality," said the letter. "Many organizations are nearing the tipping point for realizing permanent change." 

As has been common in these experimentations, the efforts have involved more concentrated organizations, practices, businesses, and locations - those least associationed with family physicians and basic health access needs.

In the 34 years since Prospective Payment and DRGs the dominant focus has been on cost cutting. This period, The Era of Cost Cutting, continues to dominate thinking. There has been no consideration of investment in team members to deliver needed care such as in primary care or mental health. The constant cuts have plagued primary care, mental health, basic services, rural health, and care where needed. This is because far too little is spent and team members are most challenged to deliver care. Often the outcomes have been the same - a remarkable achievement given marginalization by payment design. 

Instead of seeing value where it exists and where it could likely be improved with more support, value is seen in constant changes, rearrangements, and innovations - changes that add to cost but not to quality or value.

Another consistent theme in health care for decades is seen in the places and types of care with greater value. These have been the places where family medicine has been found most consistently. These are the places where services are underpaid and most complex and often have the same outcomes. Rural health, family medicine, and primary care have had great value for decades.

A Major Question Would Be

Why would family medicine leaders support efforts that are not likely to increase revenue, that have increased costs, and that have marginalized family medicine and those that they serve? Why play along with people that have agendas not consistent with value, especially when they claim to be value focused?

Because of FMs unique population based distribution and long term stellar retention in primary care, family physicians have had been given the best chance to approach with a balanced perspective - critically important due to the unbalanced health care design. FM has had to overcome all federal and state obstacles for decades. Because others fail in distribution and in services where needed, family medicine is even more important.

Family Medicine Is About Restoring Health Care of High Value

General practice and primary care were largely forgotten - yet family medicine restored generalists. No other specialty is more important as needs increase and resources decrease.

Why has family medicine forgotten the broad scope of its family physicians as they take on more tasks - or have to do so as there is no one else. Primary care provides 50% of mental health as mental health also fades. Where mental health most fails such as in 2621 lowest physician concentration counties, family physicians take up the slack. This is seen as other specialties fade and in places where urgent care, retail care, and emergent care do not exist.
Value for the Least Valued and Least Appreciated Populations

In previous postings the 2621 lowest physician concentration counties have been illustrated - the counties most dependent upon generalists and general specialties for 70% of workforce and over 90% of services. Family physicians dominate with 24% of local workforce and are even more important as internal medicine collapses from 13% to less than 7%. These counties are even more important to understand as they contributed the most to the last election results. The case has been made that these counties and the 36% of active family physicians that serve them are being left behind steadily.

Politicians, the media, and experts were surprised at the election results. This should not be a surprise as they fail to understand the people just as they fail to understand those who provide care for them. About half of the population and half of family physicians are falling behind by design. Studies indicate half of family physicians in small group or solo practices - the ones that have been most adversely impacted by the changes. The question has to be asked,

Does Family Medicine Understand Most Family Physicians 
or the Populations Where Family Medicine Contributes the Most?

Out of Control Because of Being Out of Touch and the Wrong Bandwagons

The medical and health literature paints a rosy picture of steady progress toward addressing all of the ailments of health care - out of control costs, persistent medical errors, insufficient patient satisfaction, and more. Progress is lacking in all despite hundreds of billions added per year to health care costs.

Noticeably missing are discussions of access to care. Even worse are promotions of health insurance expansion as the solution for access. Meanwhile those most associated with access where care is most needed, are marginalized further by "progressive" designs. Those who say "show me first" or ask for evidence are marked as regressive.

Who is more regressive, those who spend more and more for less 
or those who ask for evidence?

Is it a good thing to bait your "important work" by selling it
as a way to reduce costs when it raises costs of delivery?

After the last election, is there more evidence needed regarding how jumping on a bandwagon works even though it may not work for most Americans?

Accelerating Non-Delivery Costs for All Except Health Care Delivery

There is extensive evidence of ever higher cost of administration arising from management scheme after micromanagement scheme. Some of these schemes can save money in narrowly defined areas but also cost as much as is saved (CBO). Even worse, the narrow measurements fail to include areas outside of health care involving community resources, legal, and other costs.

A continuation of the rapid rise of health care costs confirms the inability to control costs, especially when additional new types of costs are added. There is still more to come as comprehensive health info tech effort was predicted to add a full 2 percentage pts to health care costs. What we have is not comprehensive, well-connected, efficient, or effective.

The savings from EHR/Digital manipulations have failed to materialize and damage from fraud and security breaches (338 in 2015) have been greater than anticipated. People are finding more ways to make millions off of health care in the United States while those who deliver health care suffer the consequences.

Consistency in Overprediction and Underperformance

Over and over our nation has suffered from overprediction and underperformance. CMS has been most consistent in this area with a 2 - 3 times overprediction of health insurance expansion, claims of ACO success, and consequences for health care of value. No single entity has done more to impair the productivity of the team members that deliver the care, to increase morale problems, to worsen burnout, and to facilitate higher turnover. Primary care offices may be suffering most of all in the fallout and replacement of a primary care physician costs over $300,000.

Independent physicians driven out of practice and prevented from establishing their own practices are left at the mercy of employers. These employers are squeezed between regulations, increasing administrative costs, and higher costs of benefits such as health care. Not surprisingly they are squeezing the team members that deliver the care.

Primary care physicians and clinicians are becoming suspicious of salary-based paychecks - as well they should. Employers are working them longer and harder without increasing payment - as dictated by the ever changing health care designs, designers, and coalitions.

Fantasies are created in the literature 
that are not backed up in the reality of health care. 

Studies illustrate the magnification of the literature by the media with many of the innovations taking on a life of their own. The areas of value in the literature such as primary care and primary care where needed may have suffered the most. Promises of primary care solutions have become some of the worst. Overpredictions have been believed and have made it difficult to present the reality - or real solutions.

Compromising Basic Services and Basic Access

Another common theme is that the changes have hurt basic access to care for most Americans - the portion of America already marginal in access. Rapid change, unpredictably higher costs, and deliberate attempts to eliminate small practices and hospitals in favor of larger have impacted most Americans and those who serve them.

In economics, in health care, in education, and in other basic societal contributors - true progress in outcomes are about consistent steady efforts - not wanton experimentation where outcomes are difficult to understand and easier to exaggerate. Rural areas have long been examples of areas that benefit from the long haul without the rapid chaotic ups and downs that leave them behind.

Why Promote Compromised Payment Designs That Lack Evidence Basis?

Despite over a dozen studies indicating that pay for performance discriminates against those who serve where most needed, this has been expanded into value based payment.
It is difficult to understand why pay for performance is promoted by family medicine when even the best measurements (NY CABG) - the rare ones where you can actually match physician to procedure to outcome - fail to discern physicians from the average 80% of the time.

Family medicine supports CHCs and Teaching CHCs but apparently does not support CHCs in payments via pay for performance that are known to discriminate against CHCs and those who serve the complex underserved. How much worse is it to support payment designs that pay less to family physicians and to the small hospitals where family physicians are most likely to be found?

The applications of pay for performance to primary care, geriatrics, and mental health are impossibly complex as FM docs know well. Quality metrics are contrived at best and misguided and costly at worst - adding $40,000 or more each year per primary care physician to the cost of delivery.

Even worse, family physicians with population based distribution are the most likely to care for the patients most complex in behaviors, situations, environments, and social determinants. This care exists in places with the least health spending, the least health resources, and the least workforce.

There is no better example of programmed consequences across burnout, low productivity, morale decline, and turnover increase. The health care designs ask for more and more, ask for more that is irrelevant to care, and steal needed support.

Moving Beyond Measurement to Discrimination by Payment Design

The evidence basis for quality discernment is poor and over 12 studies have demonstrated the discrimination inherent in pay for performance. Hong demonstrated the discrimination in Community Health Centers in one of the best studies.

MACRA is appropriately described as Wacky and a coverup for previous failed designs. 

CMS committed both types of errors – exaggeration and denial – in its first rule, and it committed identical errors in the final rule. (Kip Sullivan on MACRA)

The assumptions of Pay for Performance are why high readmission penalties go to only 3% of urban hospitals, 9% of rural hospitals, and 14% of hospitals in lowest physician concentration counties where 40% of Americans are losing small hospitals, small practices, and additional resources already.

Six Degrees of Discrimination in Payment will apparently continue and worsen.

Should Family Medicine Support Coalitions and Designs That Discriminate?

FM should consider carefully a role in a coalition that continues efforts that can marginalize those who deliver care - especially family physicians and their teams.

The truth of the matter is that PPS/DRG to managed care to Dartmouth/To Err is Human/SGR/ACA/MACRA have helped to double the cost of care (1.5 trillion to 3 trillion) at no increase in outcomes. The so-called value based efforts have helped to move the nation away from value - while collapsing local spending that can improve health outcomes.

President Obama and his team were captured by the assumptions of Dartmouth and Company and even used the same flawed examples of places where care supposedly costs less, but actually costs more. Open Letter to President Obama by Kip Sullivan

Does AAFP want to be associated with zombie legislation or zombie ideas that have worked badly while raising costs and compromising access?

Facing the Reality of a Failed Primary Care Financial Design

It is even more obvious that increased spending in areas such as primary care and mental health are unlikely. Promises of more revenue for primary care have resulted in a few hundred million - a drop in the bucket for 150 billion. Informatics and measurements alone continue to consume 4 - 8 billion more each year.

Organizing a coalition of associations and groups focused on changes not in the best interest of health access is not a good choice.

The AAFP needs to refocus on health access and primary care - what family physicians do best and most need help to do better.

More than membership is threatened as AAFP may lose its muscle as representing primary care - as FM docs trickle away from 95% FM result for those active to the current 70% while moving toward less than a majority like all other primary care sources - as dictated by payment designs 1980 to the present and worse in the future.

What Coalition Member Can Match the Immeasurable Contributions of FM?

The challenging work of restoration of family medicine across the 1950s and 1960s and the growth of family medicine to 3000 annual graduates by 1980 with the achievement of a stable population based workforce of 80,000 active graduates is perhaps the most remarkable achievement in health access.

This growth and distribution of family physicians against the overall design of American health care is a testament to all involved.

The lack of improvement since 1980 is evidence of lack of payment support, weakening of the family medicine movement, and likely both.

All other specialties concentrate among concentrations of physicians, income, and health resources. FM distributes at 25 - 30 per 100,000 across the broad span of American populations. FM is still the specific solution for all locations and populations, especially the fastest rising population of all - population in a county without a hospital. FM docs serve even where health payments discriminate most.

Family physicians had even better outcomes when supported to do so such as 30% rural location rates for the 1970s graduates when payments were better relative to costs and when the original Medicare and Medicaid plans were more focused upon health access instead of everything else. Declines to 20% and below are a direct impact of failed support for health access, family physicians, and primary care.

How is it possible to have quality or save costs when there is low or no access by health care designs supported by coalitions such as this, or CMS, or other payers?
Yes to Coalitions, But Yes to the Correct Coalitions - not politically correct but correct for family physicians and those that they serve like no others.

Roll On the Family Medicine Bandwagon, Not Those of Someone Else

Our history is that playing along did not work for us or for those who depend most upon FM. Real dollars are needed, not promises. These dollars must support delivery team members and enhance the higher primary care functions that are impeded by discriminatory designs. Paid least and doing the most is value - what we have been about all along.

AAFP is making a weak attempt to appeal to the New Political Powers. Once again why play to the prevailing wind when you already do what needs to be done and supported. The 2700 Red Counties most need us and our teams and the dollars and jobs that we capture for their communities.

Why not empower them to change insurances, and spending, and politicians?

Why not a coalition with most Americans and the bring those who desire the votes of most Americans around to the support of us - and them?

It is hard to understand that you are on the right side, when you join those that are on the wrong side.

Stand for Family Physicians By Standing with Family Physicians and Those that they Serve.

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.



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