Innovation Is the Problem Not the Solution for Worsening Health

Innovation is good. Innovation worship is not good. Innovation application without scientific testing or clinical trials is unethical regarding clinical interventions and should be just as prohibited with regard to health policy. Clinical trials can harm hundreds or thousands. Innovative policies can harm millions.

It takes a reasonable understanding of health care, health care outcomes, social determinants, and the investments that most improve social determinants to understand the consequences arising from the innovative nightmares past, present, and future.

If you review the information sources with a critical eye, you too may find that the innovative policy designs have been disruptive to care, have hurt health care where health care is most needed, have reduced access to care, and have resulted in distortions in the literature. Indeed what is accepted and published in journals seriously lacks consideration of alternative hypothesis, lacks inclusion of many pages of limitations, and can be seen as closer to jump on the bandwagon assumption rather than scientific in nature.

At stake are

• the health outcomes of a nation 
• the support of the nurses and other team members that deliver the care
• the perception of the United States as a just nation

Health outcomes for most Americans can be worsened by so much spent on so few for so little result. Cost overruns can result in cuts in payments. This results in changes in providers that often involve decreases in personnel budgets. Nurses and those involved in basics such as primary care and mental health are often compromised by changing designs. When Americans have an increasing perception of "something is wrong" this can contribute to unrest. They can also be directed away from what is really wrong to what others think that they should think is wrong - worsening divisions and resulting in more delay rather that movement toward solutions.

The following is a compilation of state reports, foundation reports, the New York Times articles, and workforce distribution.

Health care costs are clearly remaining in runaway mode and these runaway costs have contributed to many consequences including those that can worsen health outcomes - defeating a primary purpose of innovation. Innovation itself has massively increased the cost of delivery and has redistributed health care funding in ways worsening disparities and likely to worsen outcomes. Innovation is very hard to stop - in clinical advances, in drug promotions, or in policy implementation. On the horizon is precision medicine which is the epitomy of biomedical excesses - highest costs of health care expended on few and limited for many and mainly benefiting a few corporations, institutions, practices, and locations.

The United States Had the Most Fertile Field for Expansive Health Care Innovation

As seen in the New York Times - "The last third of the 20th century or so was a fertile time for expensive health care innovation. Sherry Glied, an economist and a dean at New York University, offered a few examples: “Coronary artery bypass grafting took off in the mid-to late 1970s. Later, we saw innovations like drug treatments for H.I.V. and premature babies.”  These are all highly valuable, but they came at very high prices. This willingness to pay more has in turn made the United States an attractive market for innovation in health care.

Ms. Glied speculated. “The most efficient way to improve population health is to focus on those at the bottom,” she said. “But we don’t do as much for them as other countries.”

The effectiveness of focusing on low-income populations is evident from large expansions of public health insurance for pregnant women and children in the 1980s. There were large reductions in child mortality associated with these expansions. “Those reductions were much larger for poor children than for richer children,” Ms. Currie said.

Note that medicine is very much a trickle down venue

...with those at the top substantially out of touch with the situations facing most at the bottom. Note also that the improvements noted in the Times article can be linked to times of increasing access to health care.

• Due to the improvements in access for pregnant females, their families, and their children
• Due to the original Medicare and Medicaid designs specific to populations most behind and impacting the poor and elderly as well as those living in these counties with concentrations of the elderly and poor. This involves about 2000 - 2500 counties with least access to care. 
• Since the 1980s, this has been designed away as revenue stagnated, costs of delivery increased, and access no longer improved. In fact hundreds of hospitals and thousands of practices were closed by design changes involving payers - public and private.

As noted, other nations have adapted more successfully to aging populations and prevention of disparities. The United States can be seen as suppressing such efforts.

Serious consequences can result for failure in certain societal investments. For example lack of investment in infants, children, child development, and early education can span future generations.

• "A report by RAND shows that in 1980 the United States spent 11 percent of its G.D.P. on social programs, excluding health care, while members of the European Union spent an average of about 15 percent. In 2011 the gap had widened to 16 percent versus 22 percent." (quote from NY Times)
• Although this is a modest divergence over time, Mr. Anderson says it could be significant nonetheless. “Social underfunding probably has more long-term implications than underinvestment in medical care,” he said. For example, “if the underspending is on early childhood education — one of the key socioeconomic determinants of health — then there are long-term implications.”

As nations begin to separate within, outcomes worsen as the lesser half continues to grow to more disparity and greater proportions of the nation. Health access changes in the United States demonstrate exactly this result.The numbers of counties with half enough primary care are growing - to 2621 counties lowest in concentrations of primary care, women's health, mental health. This is growing past 2661 by 2040 or soon given the rates of population growth in these counties, more counties added due to financial changes (closures of small hospitals and small practices), and fewer dollars going to these counties for health care. This also impacts social determinants via changes in cash flow, jobs, etc.

The New York Times article implicates disparities involving income and other social determinants.

• Slow income growth could also play a role because poorer health is associated with lower incomes. “It’s notable that, apart from the richest of Americans, income growth stagnated starting in the late 1970s,” Mr. Cutler said.

 

• Even if we can’t fully explain why the United States diverged in terms of health care spending and outcomes after 1980, one thing is clear: History demonstrates that it is possible for the U.S. health system to perform on par with other wealthy countries. That doesn’t mean it’s a simple matter to return to international parity. 
• A lot has changed in 40 years. What began as small gaps in performance are now yawning chasms.
• And, to the extent greater American health spending has spurred development of valuable health care technologies, we may not want to trade away all of our additional spending."

In other words, American health care took the path to most dollars and least resistance. Everyone wants the promise of a longer life and everyone believes that more innovation, more technology, more procedures, and more health care is the way to a longer life.

If you think that we have the ability to rein in the highest cost services that benefit few, consider the "death squad" rhetoric that is easy enough to pull up and promote to keep from cuts involving the big ticket items - the continue to get ever more costly. Precision medicine offers the most costly benefits of all that will benefit the fewest for highest costs - truly the direction of the American health care design.

In the rush to "eternal life" the designers have gained the upper hand. They have been able to shape designs that have resulted in ever greater health care dollars while depleting more of the dollars to invest in children and social determinants across federal, state, local, employer, family, and personal budgets. The middlemen - insurers, suppliers, and pharmacy benefit plans - are more that willing to pass on their costs to others while doing little to decrease costs. To understand how the waves of health care cost increases have proceeded, consider the biomedical, administrative, micromanagement of cost, and micromanagement of quality waves - building wave upon wave for greater runaway costs in more dimensions. More players have been added and they are powerful enough to demand and get their share of the health care pie - making the pie expand in more dimensions.

More than Runaway Health Care as Military/Defense and Prison Overspending Continue

Health care spending excesses did not occur alone. Military, prison, and health care expenditures have substantially increased and far beyond nearly every other nation.

Changes in Societal Investments in Human Infrastructure and in Physical Infrastructure

The United States recovered rapidly from WWII due to little worldwide competition for American products. The war debt was paid off rapidly. There was room to invest and we did. The 1950s (GI Bill, Interstate) and 1960s (education investments, War on Poverty, Medicare, and Medicaid) were specific to the physical and human infrastructure important for improving outcomes. It is possible that these investments prevented worse situations that were developing.

This did not last as the funds to invest were limited by higher spending on defense, inflation, higher debt, prison, and health care plus less ineffective societal investments.

This ineffective investment deserves some explanation. Republicans and those focused on the short term can point to social program failures. Failures of interventions are not simplistic in nature. These can occur

• because the intervention was wrong or poorly suited
• because the spending was too little, or 
• because the intervention was poorly coordinated with other needed investments. 

This in itself is too simplistic but is far more detailed than Slash and Burn for any reason.

Often program outcomes are minimal because of too few dollars. For example, HeadStart funding for only half of the children in need leaves the other half behind - who interact with the other children in ways that negate the gains overall. Rebuilding a generation and the next also requires coordinated investments. Failures in housing and nutrition can negate gains due to child development or education investment.

Perhaps most tragic is that many Americans have been convinced that investments in Human Infrastructure are not worth making. They have been brainwashed that all social program interventions are worthless. Once again there are many reasons for the appearance of failure - including the requirement for generations of coordinated investment to begin to demonstrate progress.

So we are back to the major limitations

• Overspending in health, military, prison (and likely in debt)
• Underinvestment in children and social determinants
• Half enough funds and poorly coordinated interventions

The targeting of CHIP funding almost as soon as deals were reached about CHIP may well be confirmation of additional underinvestment in children and social determinants to come. Who would hold a segment of the population hostage, children, to obtain concessions in other areas?

In more recent years, the nation has had polarization of policies into right and wrong instead of a focus on efficient investment. Conservatism, critical thinking, evidence based process, and the "common good" focus are all out of balance. All of these elements are essential for policies to work well with minimal consequences.

Even worse, the worst characteristics of each party have been adopted by the other.  

Obamacare was a choice to increase spending in come areas but it also resulted in slash and burn focus in other areas. For example Disproportionate Spending and other supportive health care spending were replaced by insurance expansions. Unfortunately the insurance plans were not paying enough to replace the lost funds as has been consistent across high deductible and expansions of other worst public and private plans.

Slash and burn has been a typically Republican strategy. The ACO efforts, expansions of bundling, financial incentives, and the innovation center have had cost cutting as their prime directive. Frankly no one questioned the very real likelihood that cost cutting and innovation are mutually exclusive.

How is it possible to cut costs, improve outcomes, and
keep patients and delivery team members happy? It is not possible, period. 

Once again some level of overinvestment is required to be sure that the innovation works in clinical trials, in policies, and perhaps even in life.

Indeed, Obamacare did not really take on the most important reforms and underspent in key areas - such as primary care, basic services, and health access.

Even worse, ACA to MACRA also massively increased regulations, a Democratic staple.

The Republicans have also promoted Democratic overregulation. In Trumpcare (or CMScare, your choice) the Republicans did not deregulate health care even with their hatred of ACA. In fact they have adopted increased regulations that appear likely to go beyond ACA. CMS has of course exceeded the will of Congress before. Perhaps having one of the largest budgets in the world allows this. Unfortunately CMS sets the tone for

Unfortunately the spending has been diverted to fewer people and fewer places - leaving most Americans more behind by design. Race and ethnicity may not work out well to determine the discrimination in various studies. This is because African American and Hispanic populations are concentrated in the counties with higher concentrations of health, education, economics, and other spending. They face segregation in many areas, but also benefit from the overall prosperity in concentrations. In lower concentration settings, the cumulative impacts of failed health, education, economic, housing, and other designs can be seen.

Social Determinants Matter, But Who Is Responsible


More Indications that More Americans Are Falling Further Behind - The ALICE study

Note the shift to the right or more orange in the Red Counties and the 60 Blue rural counties. Income, health, and economic disparities are concentrated in lower concentration counties.