Attempts to Address Overutilization Leave Most Americans Behind

Four decades of attempts to address overuse have not only failed to rein in overuse, the efforts have contributed to under-utilization and more Americans left behind by design.

Overuse has long been 2 to 4 times higher in highest physician concentration counties. Overuse supports too much workforce for few and results in too little for many. Overuse steals the workforce needed elsewhere and makes it appear that there are deficits of workforce with the need for more graduates - when the problem remains overutilization.
Payment Design Plus Profit Motive Plus Political Power
Overutilization is largely the result of the payment design and profit motive and political power. The payment design results in too much paid for highly specialized services and too little for the basic services (primary care, mental health, basic specialties). 
Profits are best supported by the march to ever more types of procedures and technologies that are paid the most because they are newest and most subspecialized. The profits by those most organize pave the way for political power - power that prevents true reforms such as more for cognitive, office, and basic services as well as services where most needed for those smallest and least organized. 
Too much for too little result, too much profit over the basics, and too much power vs too little - these are what drive the US health care design the wrong way.

Payment Design Diverts Workforce
Nurse practitioners and physician assistants have followed the higher payments to new specialties with more added in each specialty. The dollar distributions shaped by payment policy would not allow more primary care physicians, clinicians, or team members.
The effects of payment upon the physician workforce are obvious - and this pattern is being repeated in the rapid changes seen in NP and PA workforce. For decades NP and PA were promoted as solutions for primary care, care where needed, and efficient care. 
  • It is obvious that there is no solution for care where needed as the deficits remain despite massive expansions. 
  • Primary care similarly remains stagnant by design.  
  • The NP and PA "efficiency" advantages claimed in primary care did not work out in lowest paid primary care paid even lower. 
NP and PA advantages have best been seen in non-primary care. As the specialty and subspecialty barriers all fell away, the NP and PA advantages shaped new career options. The NP and PA graduates helped highly specialized practices 
  • to capture more market share, 
  • to handle the basics with NP and PA graduates
  • to shift highest paying procedures and services to subspecialty physicians for maximal revenue generations, 
  • to allow care delivery in multiple sites (office, different hospital sites), and increase utilization of existing testing equipment and personnel. 
This has allowed largest systems and practices to cut expensive subspecialty physician costs to the minimum while maximizing services, testing, and billing.

Expansions Facilitate Increases in Workforce, Services, and Overutilization
Massive expansions of PA from 1500 to 9000 annual graduates a year and NP 1500 to 20,000 a year since 1980 have substantially contributed to increasing utilization, higher costs, and overuse. 
Recent doublings of NP, PA, and DO graduates have not contributed to more primary care as expansions are negated by fewer remaining in primary care.  MD primary care results are shrinking despite expansion - as fewer remain in primary care. There is no other choice. The numbers of positions are limited by the revenue - minus the other costs of delivery and more limited by delivery costs that have been increasing.

Blocked from primary care by the annual revenue limitation of 160 - 180 billion for primary care or 6% of spending (minus expenses), NP and PA and DO and Caribbean and MD expansions have fueled the massive increases in non-primary care workforce.

The workforce design compliments the increased utilization of highest cost services and penalizes basic services. Expansions of graduates cannot improve access as the basic services are all prevented from expansion by payment design. 
Suppressing the Basics Accentuates the Highly Specialized
Even worse, the deficits of primary care and access facilitate greater utilizations of higher cost services - emergency care, specialty care, subspecialty care, urgent care, and convenience care.

More graduates translates to more workforce and more highly specialized workforce - leaving the basics far behind.

Ever Higher Health Care Costs Are Unopposed

Runaway health care costs have followed 
  • From rapid ever purer expansions of non-primary care workforce
  • Plus rapid expansions of administrative costs 
  • Plus digitalization costs
  • Plus micromanagement costs
The increases in administrative and non-delivery costs have been significant. These include more personnel in administration and management, managed care efforts, managed cost interventions, and managements of high risk patients which have added about the same costs as would have been saved by management efforts (The CBO was right)
The consequences of spreadsheet cost cutting have been significant. Physicians have often told the cost cutters of the consequences, but they are long past listening. The cuts look good on paper but translate poorly to the real world where complex interactions between individuals, groups, and society are difficult to capture. The CBO was right, the White House and Steven Brill Were Wrong by Kip Sullivan.
Additional and substantial tens of billions a year have been added by HITECH to ACA to MACRA to value based. The Pay for Performance additions are some of the worst, adding higher cost of delivery for no significant change in outcomes (Annals of IM review) while discriminating against those who provide care to more complex patients with inherently lesser outcomes as noted in increasing numbers of studies past 15 already. Pay for Performance has delayed needed reform - especially cognitive vs procedural.
The obvious result of so much more for little or no gain in outcomes has been failure in value. The US has obviously been moving the opposite direction from value. This is another reason why attempts at value basis are misguided at best.

Consequences of Cost Cutting (Caused by Overutilization and Costs Too High)

Overutilization has been bad, but innovation and regulation and certification efforts have made the situation worse. Cost cutting has been a very non-specific tool with a four decade history. The collateral damage has been greatest 
  • in primary care with 55% of services delivered
  • in basic services care where needed where margins are thinnest
  • in small practices where cost of delivery increases are most
Those largest, most organized, and most powerful are in the best position 
  • to prevent adverse legislation
  • to reshape regulation is desired ways
  • to influence implementation 
Those doing best are the largest and most organized in places where workforce is most concentrated.

Good business decisions require that essential areas not be cut and may even need to be given increases because they are essential - but this has not happened. Even worse the basics have continued to fall relative to those highest paid and overutilizing - dragging more team members, clinicians, and physicians this direction.

Those smallest, least organized, and most basic have steadily been left behind as overutilization, overregulation, overadministration, and overcertification have continued while costs have worsened, outcomes have worsened, value has worsened, and access has worsened - with the worst impacts on increasing proportions of Americans - your choice of 30 to 50% and increasing.

Closures and compromises of small practices and small hospitals continue where care is most needed, where populations are growing fastest, where fewest health care dollars go already, and where more dollars are required to be shipped to higher concentration settings - by each new permutation of the health care design.

Only those immersed in higher concentrations could fail to see the situations, conditions, environments, and compromises.
Research Immersed in Concentrations Results in Policies Rewarding Concentrations
The research base has long been immersed in the places and practices and systems that are largest and that most overutilize. The latest designers from managed care to Dartmouth to the present have continued to base their assumptions on this top 20% most concentrated. The research has long ignored those who fail to access services. The data is also distorted when the populations involved have difficulty accessing care in places where insufficient workforce and other access barriers exist - where underutilization is a major problem.
The research differences promoted widely have largely been the result of comparisons of different populations - not the various clinical interventions that have gained press.


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