What Primary Care Researchers Should Be Researching Instead of Quality Improvement

It is clear from the recent Supplement to Annals of Family Medicine that some of the best and brightest primary care researchers have been focused on a specific area. They may not have much choice as primary care research is poorly supported. They have millions of reasons to do "quality improvement" research - 117 million ARHQ dollars. But is this a good choice?

AHRQ continues to follow the Bandwagon of quality micromanagement - disappointing for an evidence-based entity because of the evidence basis mounting up against quality improvement efforts set in motion with To Err is Human and accelerated by the Dartmouth Assumptions, ACA, MACRA, CMS, and various associations. Even when primary care association members are hurt, the Bandwagon rolls on and over them.

Particularly distressing are the various for-profit entities cashing in on quality improvement claims - often claiming to do it all or improve costs, quality, and more. What is most clear is the transfer of dollars from primary care practices to these entities to the detriment of those delivering primary care. Primary care needs less of a Deep Squeeze or Triple Threat - not More.

If you have been following this blog and the studies involving quality in health care, it seems that the continued focus upon quality improvement, micromanagement of practices, and practice transformations is associated with
  • higher costs of delivery, 
  • distracting burdens upon delivery team members, 
  • discriminatory payments involving those caring for the most complex with the least resources where care is most lacking,
  • some limited ability to influence the process of care,
  • and the inability to significantly change outcomes
Why Not Research These Areas?
The Apparent Keys to Productivity and Financial Viability

Is the research community so averse to the business aspects of medicine that it fails to consider researching the business aspects? Researchers have certainly not been shy about accepting millions to do research that has done little for those who deliver primary care.

Now that primary care has moved substantially into the for-profit focus of health care, who is left to defend those who are facing disruptions in their lives and livelihoods - as well as the needs of patients for those who care for them and also care?

Disruptions Past Present Future

A common theme regarding the new and old changes impacting primary care across the decades since 1980 is the impact of disruptions.

It is important to point out that transformations are disruptive - even if those who design disruptions fail to see this. Not only are the disruptions increasing by design, they appear more likely to impact the practices serving Americans in most need of care.

In fact, the study of these disruptions may be the story in primary care.

Foundations, government programs, and associations that promote innovations, digitalizations, certification, and related regulations may mean well but they are not seeing the forest beyond their particular tree. Primary care is a vast forest of scope, ages, conditions, workforce, locations, and more. One size clearly does not fit all, but one focus clearly does not help the rest of primary care outside of that measurement or transformation focus. The loss of macro focus as seen in areas such as MACRA is just one of many increasing disruptive influences that are contributing to the failure of primary care. The Primary Care Transformation Tsunami

As usual the failures are occurring where it most matters in

Those who claim to be the good guys who are trying to improve health care appear to oblivious to the possibility that they are in hurting primary care by increasing disruptions.

Once again health care leaders have failed to place a top priority on areas most important for Basic Health Access.

What Should PC Researchers Research Instead of QI

Those critical of quality improvement should also be willing to indicate what areas should be given a higher priority in primary care - far above more focus on quality improvement.

A short list of areas to consider as a higher priority for primary care researchers includes qualitative and quantitative studies of
  • disruptions to primary care including innovations and transformations and regulations
  • primary care financial failure due to limited revenue and increasing costs of delivering care including declines in services, small practices, and decreases in the proportion of health spending going for primary care
  • the role of the financial design as a cause of burnout and improved finances as a means to the end of decreasing burnout. 
  • the role of affordable housing collapse in increasing the population growth, demand, and complexity where primary care capacity is lowest and is not increasing - partially due to disruptions and worsening financial designs.
Primary care researchers should also test the assumption that more primary care leads to better outcomes since numerous alternative hypotheses exist - especially the substantial variation of primary care levels with social, local, personal, and community determinants of health outcomes. It could well be that the only way for primary care to improve outcomes is due to better distributions of health care dollars. Indeed, if this is the case, then 70,000 primary care physicians serving where the nation has half enough primary care should be paid 15% less for office services and all of those providing basic services should be paid more across primary care, women's health, mental health, and basic surgical services - where workforce has been in decline.

As each of these areas fails, the ripple effect can be seen in the others. How can you transform practices to coordinate services when the pieces to coordinate keep dying, declining, or changing? General specialty workforce is declining at 2 to 3 percentage points a year across the nation with the oldest in places serving the half of Americans most behind. These indicate more disruptions to come.

Quality improvement appears doomed to failure in primary care. 

This is because outcomes are predominantly not about primary care and because primary care itself is also failing.
  • Outcomes are predominantly about patient factors not amenable to primary care transformation - why would someone think the few minutes that we call a primary care encounter has any power to do much of anything
  • Transformation requires stable practices, personnel, and settings and disruptions of all these basic areas are getting worse - and transformations of practices, personnel, and settings are accelerating disruptions. These disruptions, instabilities, and failures of transformation are documented in the Annals of FM Supplement.
  • The tactics used for quality improvement have a failed track record except for discrimination against the small practices most critical for health access for half of the US population.
  • Primary care itself has been disrupted - moving to fewer and services. Attempted quality transformations have stolen 8 billion of the 38 billion a year that was once invest in primary care where there is half enough for 40% of Americans. 
  • Primary care is being undermined by numerous competitors offering more in convenience, price, access, satisfaction, time with health care teams, and more. Teleprofiteering, retail care, urgent care, emergent care, substitution of specialty care for primary care, and poor quality health advisors via the internet all work to undermine primary care.
Retail and urgent care are considered responsible for taking business away from primary care, perhaps 30% of what could have gone to primary care.

Teleprofiteering alone has the potential to reach as many encounters as primary care by steal 30 encounters per month per 1000 people from each of 1. did not consider I had a health problem 2. have a health problem but did not think of seeking care 3. have a problem and would have seen primary care but did telehealth (with many of these having to be seen later anyway)

Back to Focus on the Future

At some point in the history of health policy, there has to be a return to the necessary support of the care of the Americans most left behind and those who serve them. Perhaps this will even involve consideration of the team members as they attempt to deliver care. How disruptive has it been when slash and burn and regulatory excess have both been the most disruptive to the hospitals and practices where most needed? How much more disruptive will hundreds of billions in cuts be? Sequestration and state changes will make the situation much worse - this you can guarantee. Perhaps it is not the major disruptions easily identified but the slow steady wearing away of support increasing the probability of disruption - and worsening the probability of any transformation.

Annals of FM supplement has reviewed the AHRQ quality improvement progress. But you need read no further than the articles about disruptions. When we are talking about the

Physicians are commonly blamed about the lack of transformation, but transformation delays and failures may be much more about disruptions. What else can be expected other than disruption when numbers, demand, and complexity are increasing and the dollars to support practices where needed are not increasing. When you subtract $40,000 to $80,000 a year per primary care physician for each of HITECH, MACRA, and PCMH - there will be more disruptions and less support of the team members - transformed or not. About 1 billion fewer dollars a year for 40% of the population of the 30 billion a year that remains is the right way for more disruption and the wrong way for Basic Health Access.

Usual, innovative, and transformative disruptions abound - and are facilitated by government and foundation grant programs. Everyone loves innovation and reform - but few take the time and effort to consider the impact where it matters most - impacts on patients and impacts on those who provide the basic care where most needed.

In the Annals of FM supplement, Casalino documents the disruptions via regulations as sell as the lack of slack or the capacity to make changes.

Mold has just the second paper published about the usual disruptions to practice. Other articles in the supplement note the difficulty if not the impossibility of transformations of practices that are disrupted practices. Usual disruptions are overwhelmingly common - losses of key personnel, EHR changes, billing program changes, changes of locations, and changes of ownership. Not assessed or measured were disruptions due to changes in the family members of the team, changes in other local practices, changes in local facilities, or changes in the community. The quality improvement transformation disruptions are substantial.

Even worse, the disruptions for quality improvement tend to involve small areas - the small fish in the Big Pond Broadest Scope of Primary Care. What is the impact upon the rest of the primary care practice when the practice goes for cardiovascular transformation? What happens to cardiovascular when the focus is prenatal, maternal, premature death, COPD, homebound elderly, or any of hundreds of the components that are found in broad scope primary care - the care specific to 40 - 50% of Americans most behind. 

A Four Part Series Regarding Productivity – Lack of Disruption y


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