Why Care Still Fails Despite the Claims of 153 Studies

The debates over health care have continued to draw the attention of the entire nation. It is a time of difficulty understanding the truth or the consequences. Even those who promote reform may not understand the truth or the consequences impacting most Americans that most lack access. This is how the "experts" can point to 153 studies that indicate improvements when most Americans are falling further behind by design.

Most apparent should be that access is not improved by insurance expansion where access to local workforce is the dominant reason for access barriers. Who would think that expansions of plans with neutral or negative margins would help increase primary care, mental health, and basic services - services that are 90% of local services where most Americans most lack care.

Slash and burn involving insurance or Medicaid is not likely to help, but neither are costly regulations. Designs resulting in the worst of both are designs that impact basic care for most Americans.

Expansion of Regulation Is Bad for Health

The savvy crowd should be up on evidence basis as they drive us toward better outcomes. But sadly primary care is not the vehicle to better outcomes. Outcomes are shaped almost entirely outside of primary care offices.

It should also be apparent that the regulation expansion crowd is also making health access worse. You cannot force practices desperate for revenue and burdened with high overhead to ship billions more dollars away. These are the practices paid the least with the most complex patients. The impacts of regulation, digitalization, innovation, and certification include consequences to team members and the capacity to deliver care.

Does Anyone Listen to CBO?

CBO has done pretty well with estimates of costs and consequences of various policies and proposals. But those designing ACA, micromanagement, MACRA, and value based designs have apparently not paid attention.

The CBO has demonstrated the futility of managed care and managed cost, yet these solutions have become the law of the land. Dozens of studies regarding pay for performance incentives have had major reviews indicating no significant benefit from such incentives for the purpose of health outcome improvement. The additional costs clearly result in no gain in outcomes - for a negative value based result.

A Bridge Too Far to Cross the Quality Chasm

The Consequences of Bad Policies Are Multiplied Where Access Is Most Needed

Policies designed to address overutilization where physicians are concentrated and too many specialists are found are not a good fit where most Americans underutilize care and have half enough primary care, mental health, and basic services available locally. This adds to disparities

Even worse, the additional costs act to shrink health care delivery capacity by changing primary care, mental health, and small practice budgets.

As with any large scale change, there are certainly some who benefit and others who do not. But the pattern is easier to read for health care for the Americans that have spent the last three decades behind in local workforce and this should continue for at least another three decades. Journalists, politicians, foundations, associations, and health care leaders should ask the age old questions of who, what, when, where, how, and why.

They Stand in the Way

Three problems (and those who make these three worse) stand in the way of claims of health access improvement where Americans have had decades of insufficient access.

• Too Little Revenue - The 2010 reforms did not deal with the financial design that sends too few dollars such that only half enough primary care, mental health, and basic services are locally available for your choice of 35%, 40%, or 45% of Americans. Geographically the access barriers are likely to remain for 50% of the population in 2800 counties lowest in physician concentrations by 2040 or sooner.
• Costs of Delivering Basic Care Accelerating - The 2010 reforms actually resulted in higher costs of delivery due to regulation, innovation, digitalization, certification, turnover, and usual practice costs of delivery 
• Complexity of care delivery increasing due to the above, due to rapid changes, due to changes in the US population, and due to changes in communities.
• The changes all suggest that leadership is ignorant with regard to the way most Americans live, breathe, thrive, and survive - especially with regard to their health care or lack thereof.

This Triple Threat hits hardest in the 2621 counties lowest in physician workforce 

• Where payments are lowest for basic services and are even lower in these counties are are made even lower by pay for performance. 
• Where costs of delivery for innovation, regulation, digitalization, certification, and turnover are increasing faster and relative to the limited finances of the practices involved
• Where the complexity of delivery is increasing fastest as rapid changes hurt the smallest most, hurt those with the fewest and least specialist personnel most, and hurt practices the most where patient aging and chronic disease is most prevalent along with least local resources and least support from public health, mental health, women's health, and basic surgical workforce.

Does Anyone Remember Do No Harm?

Claims of health access improvement face the stark reality of failed financial designs that are not only closing small hospitals but are also impacting small practices and care where needed. The generalist, mental health, women's health, and basic services that are 90% of local services where care is most needed are all being compromised by design.

Expansions Did Not Deal with Triple Threat. HITECH to ACA to MACRA have worsened the situations facing practices where most Americans most need care.

But the Data Used, Reviewers, Editors, Journals, and Media Paint a Different Story

Convenience data helps distort the findings. The most information is found from the largest practices and systems.

New reviews use the most rosy presentations to indicate 153 studies supportive of positive changes in costs, quality, and access - but clearly do not address the situations facing providers struggling most where designs most compromise their function.

• Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion positively affects access to care, utilization of services, the affordability of care, and financial security among the low-income population. Studies have also shown improved self-reported health following expansion, and one new study demonstrated a positive association between expansion and health outcomes. However, further research is needed to more fully determine effects on outcomes.
• How is it possible to do Triple Aim when Triple Aim worsens all three components of Triple Threat - revenue generation, costs of delivery, and complexity of care?

Triple Threat defeats Generalists and General Specialty MD DO NP and PA 

• where 40% of the nation is found in 2621 lowest concentration workforce counties
• where payments are 15% lower for the same services
• where local colleague supports are least
• where mental health and public health are least
• where primary care levels are half enough
• where local support resources are least
• where complexities of patient, population, and community are greatest

AAFP Initiatives Should All Be Focused on Triple Threat

Higher to highest physician concentration counties have many ways to make up for the deficits of primary care and basic services. They have the concentrations of ERs, urgent cares, primary care, mental health, womens health, retail clinics, public health, and surgical specialties. Even primary care is concentrated in these counties due to higher contributions of internal medicine and other non-family practice primary care.

The 2010 Reforms and More Recent Reforms

• Did not address Triple Threat
• Worsened Triple Threat
• Resulted in greater morale, productivity, revenue generation issues 

There was no lasting change in revenue plus forced higher cost of deliveries and great increases in complexity. Triple Aim and micromanagement have worsened Triple Threat.

The 2010 Reforms Did Not Re - Form Health Access Where Needed 

They did not address the true reforms needed for access improvements - the financial design was not changed for generalists and general specialties - 90% of the MD DO NP and PA workforce where 40% if not most Americans most need care.

Counting Down the Revenue Lost and the Costs Gained HITECH to MACRA to PCMH

Insurance Expansions Are Not Specific to Access Improvements

Expansions can only work for access where workforce is already most concentrated, most overutilized (2 to 4 times) and most overpaid. This is where higher paid specialists steal services that should have been supplied by lower paid primary care. Outpatient care and primary care gets highest payments where hospitals and physicians are most concentrated. Biggest systems and clinics get the highest payments and smallest and least get the least.

Revenue too low, accelerating costs of delivery, and multiple dimensions of complexity defeat access in primary care, mental health, women's health, basic services, office services, small practices, and small hospitals - all those most important where 40% if not most Americans are found.

The Financial Design Is the Problem - Countdown to Oblivion

This design prevents any MD DO NP PA RN assistant pharmacist pipeline teaching CHC or other training intervention from working. Improving workforce capacity requires more dollars and lower costs - not the opposite.

These counties with stagnant revenue of about 40 billion for primary care from all sources have had to deal with a subtraction of 6 - 8 billion due to the increased costs of regulation innovation digitalization and certification.... plus higher cost of turnover.... plus declining productivity.... plus continued departures of MD DO NP and PA from primary care.

What new math allows any calculation other than declining access and declining outcomes 

due to billions more each year shipped out of these counties 

for measurement focus in health and education - 

while stealing the dollars and personnel that matter?

There is no financial indication of anything other than shrinkage of dollars specific to the team members who deliver the care. This can only result in shrinking primary care delivery capacity and access where 40% of Americans are found in 2621 counties lowest in health care workforce.

The Perfect Storm Is Here Now

The Perfect Storm this week includes threats to safety net hospitals, CHCs, and CHIP. Delays in addressing these areas have already impacted health access as it is too late to stop the hiring freezes and cutbacks. This also results in lost jobs, cash flow, social determinants - the factors that actually do shape health, education, and other outcomes.

Failing the Tests of Common Sense

We should be tired of studies that fail the tests of common sense. How can expansions of plans paying less than cost of delivery help access in these places? Expansions of high deductible plans also do not help local primary care practices. These are places where it matters that 50% of veterans are neglected in their basic needs or that the few public or private plans that exist are the worst for patients and for providers. Morale problems, burnout, and other issues involving team members are worsening.

It apparently does not matter that payment is even less due to the discrimination in payment arising from pay for performance schemes, or that productivity and revenue are down due to regulation, innovation, rapid change, turnover, and more time stolen by EHR - time for patients, colleagues, team members, family, community, and self. The very fabric of health access is being destroyed.

Triple Threat also closes remaining hospitals in these areas and this increases deficits of local workforce plus adding more counties to those lowest in workforce. These counties were already growing fastest in population decade after decade since the 1960s. They are well on the way to 2800 lowest physician concentration counties with 50% of the population by 2050.

Housing Collapse Adds to Health Care Collapse

More burden is more numbers and higher complexity. Lower support is fewer colleagues and team members to share the load. The US design is consistent in overloading places with highest loads already.

Housing costs have rapidly escalated across places with higher concentrations of people, dollars, and health care workforce. This has resulted in more homeless, more living in more crowded homes with family, and more forced to depart these counties. Even worse, those forced to live in these lowest concentration counties because of the collapse of affordable housing in counties with higher concentrations of workforce tend to be medically or financially vulnerable or both - adding to the complexity of populations that already have highest concentrations of complexity, lowest local resources, and lowest workforce levels. Democratic regulation and Republican austerity focus can only worsen access and outcomes in these counties.

Local health care is also most lacking in mental health, women's health, and basic surgical services - services that are still shrinking because of the same Triple Threat. Too little revenue, accelerating cost of delivery, and rapidly increasing complexity of care in multiple dimensions has overwhelmed local care, and stolen the time and talent needed to address patient, team, community, and other health needs. Primary care in these counties, particularly family practice MD DO NP and PA is set for worsening by design.

Hospitals are also closing according to Triple Threat and the smallest with the most complex populations have worse impacts. This takes out local outpatient, emergency, and primary care as primary care is more dependent upon local hospitals.

Fiddling around for decades while 35% of the population falls behind, then  40%, then 45%, and soon 50% is bad enough, but claiming success in access with lowest levels of MD DO NP and PA still found in these counties is damnable.

Very specific areas must be addressed very specific to focus, awareness, Triple Threat, and care of most Americans most ignored and least cared for.