True Reform is Needed to Get from Last to First for US Health Care

Health care in the United States is notable for being the worst when comparing health care among wealthy nations. A Commonwealth article was published in NEJM highlighting four areas that need to improve. Interestingly an improvement in primary care finances would address all four areas, but this discussion was avoided. Fitz Mullan had another article promoting the social mission just published in JAMA. Once again addressing bankrupt primary care finances would contribute to the social mission. Lofty ideals are easy to discuss, but the hard work is missing when it comes to addressing access barriers, disparities, and most Americans falling farther behind. You cannot get from last to first by failing to address areas that must be reformed - areas that actually shape insufficient access, insufficient primary care, insufficient team member support, and disparities. 

Goals, Aims, and Missions must be replaced with specific actions.

True Reform Is the Beginning

The foundation, institution, association, government-associated authors can begin to address four areas and the social mission by a true reform focus - equity in payments for basic services compared to most specialized and compared across the nation.

The authors fail to indicate the one most important area for improving primary care, mental health, and basic access services - 

more payment for cognitive, office, basic services. 

This must be the top priority even if less goes for procedural, technical, subspecialized. This is the only way to balance generalist MD DO NP and PA vs non-generalists. 

Primary care is the best distributed of all workforce and therefore is the best route to distributing health care dollars.
  • About 70% of local services where needed in 2621 counties lowest in physician concentrations are primary care services. 
  • Lowest paid basic services are 90% of local services. 
  • Only 6% of spending goes for primary care which involves 55% of services and also covers 50% of mental health services.
  • Where hospitals are missing, are threatened, or have closed - primary care is even more important.
  • Distributions of dollars also help to distribute improved outcomes as outcomes improvements require dollar improvements in areas such as education, economic development, housing, local resources, and other areas. Designs that concentrate create disparities. Designs that distribute can help address disparities.
Procedural, technical, subspecialized services are rewarded the most and are most concentrated where physicians are most concentrated. These are also the places where the institutions, largest systems, corporations, foundations, and associations are most powerful and are most willing to oppose this top priority reform. Primary care and basic services are a small proportion of local services and workforce where there is immersion in highest concentrations. The academic/research/workforce consultant/payment policy gurus are not going to support true reform.

Will academic, foundation, association leaders identified with social mission, access barriers, primary care, and disparity reduction stand up - perhaps at the risk of their jobs and reputations?

Authors that move in the most powerful circles have to stand up and promote this true reform even if other academic, association, foundation, institution colleagues oppose this reform. 

Other nations have better balance involving higher levels of generalists. Higher concentration counties in the US rank well among other nations. Half of the US population ranks far below all developed nations in generalist to population ratios. 

Despite the wondrous and expansive rhetoric regarding training interventions as a solution for generalist deficits, it has long been clear that generalist MD DO NP and PA workforce has been prevented by payment design. Few enter and even fewer remain - by financial design. The primary care design also results in a less experienced primary care workforce that may not perform as expected. Higher functions such as integration, coordination, outreach, and community partnerships are more likely with better designs that result in better retention and improved continuity.

No MD DO NP PA school or program or special training design can address gaps in primary care, mental health, and basic surgical services until this true primary care payment reform is addressed.

Once again this is about the limitations in primary care with revenue too low overall and specifically in places where half of the US population most needs care.

The US Health Care Design Is Specific to High Cost and Low Yield Outcomes

The runaway health care costs have been fueled by overutilization of highest cost services. These are services typically provided in higher to highest physician concentration counties. These services offer the least improvements in outcomes for the highest costs.

Expansions of subspecialty, administrative, and micromanagement costs continue to drive lowest yield for highest cost. These changes over the decades have acted to increase disparities.

Disparities are widened by overspending where services are concentrated and by underutilization involving most Americans.

Expansions of MD DO NP and PA workforce have been successful in one area - increasing non-primary care workforce. The expansions of the NP and PA programs have been ideal for a more efficient financial design - for non-primary care practices. Replacing as many most costly subspecialist physicians as possible is essential to lowering costs of delivery - of non-primary care services. This also boosts profit margins for higher to highest concentration providers.

True Reform Needs a Solid Financial Design
  • A universal coverage for primary care with 20% higher payments would be a start. Universal coverage for primary care is more palatable and more affordable. It is already a best value at 55% of services for 6% of spending.
  • Universal coverage for primary care with a 20% boost would be a 25 or 30% improvement for places with lower collections and greater challenges in billing, delays, and denials of payment. There would also be benefits in terms of less turnover and productivity losses.
  • A universal payment scale paying the same for office codes across the nation would bring equity to primary care payments for another 20% boost for those paid lowest - where services are most impaired by the current design.
The recommendations above would likely provide 45% more revenue for primary care where primary care is lacking - especially in lowest concentration counties. This redistribution of dollars would be a best match to the counties and practices most in need of workforce. Efforts specific to It also avoids the very costly and compromising issues of the current overproductions of MD DO NP and PA graduates.

Best Timing for True Reform

The time to do this was 2010 to allow at least 30 years to be able to address the populations most left behind that are increasing from 40% to 50% of the population by 2040. Sadly the US has not been moving from 40 to 60 billion to expand access as the insurance expanded pays too little and requires too much innovation, regulation, and certification cost. Economic improvements have also avoided these counties resulting in further deficits where turnover costs are highest and are increasing most.

Basic health access deficits bad and worsening are about patients with lowest paying insurance plans concentrated where deficits of workforce are greatest, where costs of delivery are increasing fastest, and where complexity is increasing most in multiple dimensions.

A reasonable understanding of the social and other non-clinical determinants of health that dominate in shaping health, education, and other outcomes...

...leads to the conclusion that billions taken away from lowest concentration counties by each of HITECH, digitalization, MACRA, and Primary Care Medical Home results not only in a decline in access but also a decline in health outcomes - as the non-clinical determinants are worsened. Education has a similar discriminatory design and a similar loss of billions from these counties by measurement focus. Measurement focus is ridiculous when these are counties that need to retain dollars to retain workforce and improve outcomes.

The designers underestimate the disparities caused by the health payment policies including worse outcomes due to dollars 3 times greater spent in 79 top physician concentration counties with over $30,000 spent per capita and 3 times less or less than $3000 per capita spent in lowest physician concentration counties that should have 50% of Americans by 2040.

Further Decline By Design Impacting More Americans

Demographic and other changes insure worse to come. This is because of housing collapse, closures of small hospitals, and meaningless costly micromanagement and other non-delivery costs accelerated. Housing collapse drive more financially and medically vulnerable populations to lowest concentration counties, closures of small hospitals add 10 - 12 counties a year to the ranks of lowest concentration counties, and micromanagement steals billions more each year from areas such as primary care that only get a minimal 35 - 40 billion for primary care. 

This is officially half enough in raw numbers of dollars required and only one-third enough given the higher concentrations of poor, elderly, fixed income, disabled, veteran, poor child, diabetic, obese, smoking, and mentally ill populations in these counties.

You can add the latest research indicating concentrations of populations with lower health care literacy, nonadherence, high risk, and high cost.

Runaway health care costs are fueled by overutilization in higher concentration counties, highest payments for the highly specialized services that do the least for health outcomes, decades of increasing administrative costs, decades of increased profits distributed to a few Americans. Runaway health care, military, and prison costs together with austerity focus compromise the personal, state, federal, employer, and local investments needed to change outcomes. Better investments in people, local resources, environments, and situations is required for better outcomes. This was noted but was not emphasized.

Much of the recent confusion, distraction, and inefficiency added is about the insertion of micromanagement into health care design - a bandwagon assumption that cannot improve outcomes as noted in evidence based reviews.

If you stand for access then you must stand up for true payment reform. If we cannot get foundations with a mission for access to support access improvements specific to the needs of most Americans, we will not make progress in access, costs, or outcomes.


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