Less Datapalooza and More Team Member Support

Datapalooza is a celebration of advances in digitalization over the past decade. It is a chance to promote ideas, concepts, career opportunities, and merchandise. A call for papers could reward the right author with a publication - and even more attention. An academic approach to Datapalooza would critically consider whether the electronics movement has delivered or diverted with regard to the promises of improved health outcomes. There is good evidence that it has increased costs and has adversely impacted access to care where 40% and increasing proportions of Americans most lack access. 

Year after year since 2005 and before, there have been the same promises - lower health care costs, better outcomes, better patient satisfaction, and better team member satisfaction. Year after year it is apparent that there are more costs and complications from digitalization. Health care spending has more than doubled and entirely in areas that have not improved outcomes - subspecialty services and overutilization of subspecialty services, end of life care, administrative costs, CEO and VP salaries, and digitalization.

More for Less and Less for Most

Changes in the US economy, in education, and in health care indicate greater disparities. Few benefit and more are left behind. Health outcomes are worsening - but mainly for those left behind. Sadly there are those that focus on direct outcomes improvements, rather than the root causes - the situations, conditions, environments, local, and personal factors that predominantly shape outcomes. Even worse, runaway health care costs eat up the dollars to invest in people and better outcomes. The focus remains on the few rather than the many. Designs and designers have continued to ignore the many.
The local practices that serve the most vulnerable populations are the most vulnerable. They should be protected from changes that devour budgets and force cuts in delivery personnel as margins turn negative - worsening access to care. Margins have been thinnest where workforce is least, where local resources are least, and where populations are most complex and inherently have lower outcomes. The graphic at the end indicates just how much less is paid to practices in these areas where concentrations of elderly, poor, and vulnerable populations are found - where payment plans are the worst and create the most problems.

It is easy to see why higher costs of delivery and outcomes based incentives can harm.

There is good evidence for increasing costs while adversely impacted access to care
where 40% and increasing proportions of Americans most lack access. 

MedPAC has recommended repeal of the MIPS program - a deeply flawed, complicated, and costly measuring system.

There is good evidence for even greater increases in costs and consequences to come due to data security issues, outdated platforms, cumbersome functions, and difficulties involving the general population readiness.

Most important is that health outcomes are predominantly shaped by local, personal, social, community, family, and similar determinants of health - not clinical interventions and especially not digital clinical interventions 
Subtraction of Health Access By Innovative Design

By using Area Resource File and AMA data for 2010 and 2013, only about 24% of primary care is found in 2621 lowest physician concentration counties with 40% of the US population for about 40 billion dollars. This is about half enough primary care for such a complex population at 50 per 100,000. 

About 7 billion a year has been diverted from team members to datapalooza etc in the past decade. This has rearranged primary care deliver capacity to only 33 billion, 
  1. In counties growing fastest all decades since the 1960s with 
  2. Even more growth to come due to more counties added by closures of small hospitals and small practices plus
  3. Increased numbers of medically and financially vulnerable added due to collapse of affordable housing in higher concentration and more prosperous counties
Internal growth plus in-migration plus stagnant to declining workforce is a formula for much worse by design. Not surprisingly the investments required by digitalization, innovation, certification, and regulation can only squeeze the team members in dollars, numbers, functions, productivity, morale, and turnover for lower or negative margin and movements away from higher primary care functions. Studies document the loss of time, talent, and treasure with meaningless use and datapalooza a major contributor. 

This limited amount of 40 billion for revenue is due to lower payments and lower collections and is far from the requirement of about 80 billion for sufficient primary care for 130 million people that will be growing to 200 million left behind by 2040. No academic or other training intervention can actually resolve health access woes - because of the financial design. Those promising that expansions or special training interventions can resolve various workforce deficits have failed to consider the absolute limitation of too little revenue and too much cost of delivery. What You Will Not Hear in Workforce Discussions is that No Training Intervention Can Resolve Health Access Due to the Absolute Limitations of the Financial Design

The Absolute Limitation of Triple Threat

Those who are academic need to support more revenue for cognitive, office, primary care, mental health, and general surgical specialty services as well as small practices and services paid 15 - 20% less where care is most needed. Instead there is opposition  for this true reform that would provide better balance and distribution in workforce - across MD DO NP and PA. It would also act to improve health, education, and other outcomes in places with lowest outcomes by improvements in health care dollars, cash flow, social determinants, and other local investments - investments prevented at federal, state, local, employer, and personal levels by runaway health care costs to which datapalooza has contributed.

Academics should focus on evidence based practice, not assumption. The Dartmouth to ACA to MACRA assumptions have been many and have been harmful (Sullivan, others). The analysis used to indicate better outcomes in many studies has been misguided and fails to consider patient, population, and local differences and research flaws such as variation within groups compared to between groups (Ashish Jha). It is apparently easy to demonstrate significant improvements - but it is actually hard to deliver real improvements when the efforts of real people to deliver care are impaired.

Academics should focus on efficient practice and support of team members - not meaningless and costly and distracting HITECH ACA MACRA Readmissions Penalties, Pay for Performance, and Value Based designs that are
  • evidence based for costing as much as saved (CBO) and
  • evidence based for inability to shape improved outcomes in major reviews (Annals IM) and
  • evidence based for discrimination against those who care for inherently lower outcome populations - worsening outcomes and disparities in more ways.

Lowest physician concentration counties confirm these adverse changes and the difficulties of addressing care where needed without True Reform. Students and residents interested in family medicine desire Equity. Family physicians Paid Less for Doing More Where Needed are frustrated and they are moving away from primary care as have all other primary care sources for the last few decades. The recent implementations of pseudo-reforms in payment have made matters worse and the designs have moved all the way to Discrimination in Payment.

It is particularly frustrating that family medicine leaders and associations promote innovation and regulation changes that appear to impact family physicians most where payments are already least. In the following graphic the concentrations of elderly coincide with lowest payments and lowest concentrations of physicians. Family physicians at 26 to 30 per 100,000 are equitably distributed. This also illustrates how health care dollars and health care workforce follow concentrations and avoid distribution and improved access to workforce.

Even worse, maldistributions of dollars shape lesser outcomes for those left behind. Billions forced to be shipped out of counties in most need of dollars, workforce, and outcomes improvement - actually shape lesser outcomes.

Transforming Primary Care Requires Fuel and Efficient Design, Not Cost Cutting and More Costs and Complications for Those Delivering Primary Care

True Reform is Needed to Get from Last to First for US Health Care - Equity in Payments for Basic Services and Equity in Payment for Those Paid Least


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