CMS Fails Rural Health in Access, Support, and Innovative Design

CMS has a long track record of failure with regard to rural health and actually the failure is specific to twice the population in 2621 lowest physician concentration counties. The CMS failures are specific to the emphasis areas indicated by current CMS leadership:

• Improving access to care for Americans living in rural settings;
• Supporting the unique economics of providing health care in rural America; and
• Ensuring that the health care innovation agenda fits rural health care markets.

CMS has been a total failure in these areas except 1965 to 1978. CMS made matters worse since 2010 by exceeding the will of Congress and crafting regulations specifically hurting small providers essential for rural populations and the half of American most dependent upon small health care. CMS continued to implement designs beyond the recommendations of Congress and of RAND - the consultant used to assess the impact of the regulations. 

Three key areas defeat small health, rural health, primary care, access to care, women's health, mental health, and basic surgical services:

1. Revenue designed too low and shaped lower by payers
2. Costs of delivery accelerated by micromanagements of cost and quality, micromanagements not only demonstrated to be failures for cost and outcomes, but also demonstrated to discriminate against those smaller and less organized
3. Complexity increasing in two key dimensions - meaningless/distracting and demographic/inevitable

What is most concerning are the changes of both political parties. Democrats are famous for burdensome regulation, but have increasingly opted for cost cutting or the combination of innovation focused on cost cutting. The Innovation Center is a prime example of the failure of this combination of innovation plus cost cutting. The Republican Party had a chance to dump ACA regulations - but failed to do so in a way that matters for small health and care where needed.

 

Both sides have hurt rural health for years, but now they appeared unified in cutting revenue and increasing regulation - even though the evidence basis is against regulation ability to improve costs or outcomes. 

Cost cutting has impacted all smaller, less organized, and more distant for decades and worse is planned. 

 

Kindig posted on powerful vs powerless as being upstream - and he is right. 
As articulated by Bruce Link and Jo Phelan: “We define resources broadly to include money, knowledge, power, prestige, and the kinds of interpersonal resources embodied in the concepts of social support and social network.” Variables such as socioeconomic status, social networks, and stigmatization, which directly assess these resources, were considered especially obvious fundamental causes of health status. Could it be that these fundamental causes are in fact power in various forms, influencing society from a more upstream position? And, is it possible that power may be accompanied by other similarly fundamental forces affecting health that we have yet to recognize or conceptualize?

 

What I see is more presentations and conferences - that represent more distraction from action - Beyond Flexner, Social Determinant focus, Health Equity, Disparities efforts. 

Review the key areas articulated by CMS

1. Access - 90% of local services are generalist and general specialty in decline by design. Primary care is in disarray and general specialties are each declining by 2 to 3 percentage points a year as measured in active general ob-gyn, general surgery, general orthopedics, general ENT, Urology, others. Mental health is half the level needed where concentrations of mental health issues are found. This has been made worse by the financial design that prevents entering these specialties after first residency and sends residents to one or two fellowships - and away from the careers and locations needed.

2. Support - CMS has continued the unique payment policies and payer behaviors that are specific to worsening of provider economic support. Payment is not increasing and regulation is crippling - and the administration could have claimed a victory by removing the ACA regulations that have contributed - but they did not. There is a long and glorious history of worsening. DRGs was uniquely bad for rural health, nursing, and most needed access. SGR was stagnation but even before that time the worst public and private plans have long abused small hospitals and small practices for decades. Major changes have given them more opportunities - to do worse. Stagnant to declining revenue, worsening costs of delivery, and rapid increases in complexity (meaningless and demographic) are the Triple Threat or Deep Squeeze killing rural health and care for half of the nation.

HITECH, MACRA, and PCMH each cost 50 - 100% more per primary care doctor per year for smaller practices and clearly have tipped the scales toward massive losses of smaller. This is in the literature. This is what I have been calculating out.

You see, you can use the spreadsheets of the bean counters against them. Their micromanagements of costs never worked out - because the costs of micromanagement were as great as the costs saved. Also the consequences of micromanagement of costs were more than just dollars - as we see now written in burnout and worse.

3. Ensuring that the health care innovation agenda fits rural health care markets. As demonstrated above - CMS has permitted revenue deficits, CMS has tolerated payers that are abusive to small providers, and CMS has implemented policies that specifically hurt rural health care even when this impact is known prior to implementation.

Worst of all, CMS is contributing to runaway health care costs. Runaway health care costs defeat state investments critical to improving outcomes 

 

CMS has been unethical in its experimentation. Make no mistake - there is experimentation and not for beneficent intent and with impacts greatest on those most vulnerable who have no say over what has been happening for decades.

 

The case can be made that there is a serious campaign to take down primary care. Even worse, primary care researchers may be a part of this campaign. Even those trained to be critical can fail to understand what is going on as policies

• Destroy the financial design
  Disrupt those who are delivering care
  Make dedicated primary care team members lose heart

CMS and Foundations have made serious mistakes with regard to their assumptions regarding health care design. The Commonwealth Fund claims a mission for access and yet the various studies supported and reported by Commonwealth fall short in access. There are claims of improvements from the 2010 reforms, but access improvements are more than just insurance expansion and Triple Aim. Access to care requires the primary care team members to deliver the care. The failure of access is quite obvious in counties and zip codes where half of the US population has grossly insufficient MD DO NP and PA workforce. The financial model has long been broken with regard to the workforce to provide access in these counties and other underserved settings. You cannot expand access via expansions of worst paying and least supportive plans. You cannot expect Triple Aim to help when it is most costly and least rewarding for the practices that make the difference between some access and none.