Another One Bites the Dust - Micromanagement Fails Again

Another micromanagement has demonstrated costs of micromanagement as much as what might be saved. This is of course what CBO indicated a decade ago about such interventions. This time the CMS Comprehensive Primary Care Initiative failed to demonstrate much - in the practices that survive in the US. 

Higher costs without changes in outcomes - this is not value-based. Once again it appears that the personnel used up in micromanagements of costs and of quality could have better been used to address care delivery.

Words like comprehensive and continuity mean little in primary care where turnover of patients and plans has increased along with turnover of team members, clinicians, and physicians.

So little has been added to offset increasing costs, so many areas of increased delivery costs have been added, and complexity has markedly worsened due to demographic changes in the population as well as changes in the practice due to "innovation."

A return to the support of the team members who deliver the care would be nice, but it appears that innovation worship will continue despite the evidence base.

Note also that these initiatives require increased investments in personnel that may not be sustained when the demonstration is over - as those with Primary Care Medical Home grants have found out.

The usual obstructions remain. Disruption is a common reason for lack of transformation and lack of outcomes. Disruption is common in small and medium practices. 

Small practices have been hurt more by innovation, regulation, digitalization, and certification.

The Waves of Health Care Cost Increases Past, Present, Future

The sad fact is that the waves of health care cost increases all have good intentions, but they result in too much cost for too little gain for too few. None of them are inherently evil, but instead of going only as far as fits good value (outcomes vs costs), the decisions are made to go many times farther. This increases the costs for little increase in outcomes - consistently poor in value. Too much expensive workforce, overutilization of most expensive services resulting in even more workforce, increases in nondelivery costs, and massive increases in complexity defeat the delivery of health care in the United States. This Triple Threat has come about in Waves of increased costs and complications.
  • First Wave cost increases for 100 years have been due to biomedical focus - as demanded by academic, largest corporations, and the public. The power of the biomedical is illustrated by the power of the "Death Squad" rhetoric. We all want more dollars for the futile attempt of preventing death as is most evident in over 25% of Medicare spent in the final year of life. Note that health care formal and public health split from each other a few decades ago. One exists to work for few while public health focus has been the many. The few are winning and the many are losing - by design.
  • Second Wave is about micromanagement of costs. These have increased costs substantially for no gain in outcomes and perhaps some worsening - the opposite of value. Classic graphs show the substantial increases in administrative, management, and non-delivery costs derived from micromanagement of costs and increasing with micromanagement of quality.
  • Third Wave cost increases are about micromanagement of quality. These have also increased costs for no gain in outcomes. The promises of micromanagement have not materialized and are not likely to do so since health outcomes are about the patient and local factors - not clinical manipulation. Many if not most of the quality study results showing a difference involve studies that compare two populations that are different - higher vs lower volume studies and rural vs urban studies and studies by ethnicity and race clearly involve many such differences. The Medical Error studies that shaped the quality micromanagement failed to include proper controls. Billions more a year spent on "quality" has no changed deaths due to so-called medical error. These studies are based on the assumption that clinical interventions dominate the determinants of health
  • Fourth Wave cost increases are already on the horizon. The lobbying has successfully reached the highest levels. The moonshot fourth wave for the future is about precision medicine. This has the greatest potential to improve outcomes for few individuals and at tremendous costs. It may well be the culmination of the entire last 200 years of scientific advances - but it will cause incredible stresses on everything not precision medicine. Any who believe that these costs will come down or that these benefits will be available to more than a small portion of Americans are those who have not paid attention for decades or are those who choose to ignore policy, policy impacts, design consequences, and much more.

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