Real Health Care Solutions, Not Value Focus

The Value Based Movement lacks Value. It is important to understand how AAFP, Commonwealth, and others have arrived at their misguided focus about what is value.You will hear the various promotions constantly in journals, policy papers, and in the media. The following are more critical evaluations via Jha, Soumerai, Sullivan, CBO, Annals of IM, and others with my comments, critique, and assumptions regarding the real influences on outcomes.

I still have hope for associations and foundations, but they need new leadership and a return to missions such as health access – real health access.Their staff need to be re-educated regarding the true value of family physicians and others serving in teams on the front lines despite that greater challenges of the value-based focus.

Value, P4P, Performance Based Evidence Is Lacking

Annals of IM 1/17 in a comprehensive review did not indicate value for performance based incentives. Only process was improved.   It is hard to stop a Bandwagon, but a Bandwagon rolling the wrong way needs to come to a halt. Pay for Performance has had its 15 years, and has been found lacking.

"In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clearevidence to suggest that they improve patient outcomes." from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of InternalMedicine 1/10/17.  

This and more at

Many studies appear to indicate value – but consider that these are not randomized or high quality studies. Often the so called quality studies compare two different populations that are different in many ways.

We know that different populations have different outcomes based on social and other determinants.

In many ways the quality of research has regressed. More new tools tend to hide the flaws in research techniques known for 100 yrs

Finally an article that is on target in the key area of clinical operations. These rare articles with proper critique and voices of reason are drowned out by the sea of other bandwagon articles promoting false and costly interventions. Only a few consistently have the proper critique down - Casalino, Sullivan, Soumerai, Jha. 
  • "Current performance improvement programs have several fundamental flaws. These programs have emphasized narrow financial incentives over broad nonfinancial rewards and relied on distant, centralized accountability instead of local culture and organizational responsibility. Future iterations of performance improvement programs should aim to capitalize on physician professionalism by emphasizing nonfinancial rewards, resources for quality improvement, team-based assessment, continuous learning, locally-determined targets, and organizational culture ."
Professionalism, Performance, and the Future of Physician Incentives

Casalino started out doing research somewhat the usual way, but began discovering that the usual way was not right. Small practices had better outcomes in some areas with the smallest doing best. He also raises questions regarding quality improvement, and this is one of his most thought provoking works.

Quality is not a good descriptor for current so-called quality studies  

About the Quality Claims of More Primary Care or Better Continuity

Many of the claims of more primary care being better for outcomes follow the same correlation is not causation defects. If you understand the maldistribution of social determinants and similar factors that parallel the distribution of workforce, you can understand more about the flaws of outcomes studies. Studies of hospital quality and comparisons of types of physicians (male vs female, young vs old, US vs IMG) have been particularly flawed.

Commonwealth and AAFP both share this misguided faith

... in performance or value based incentives despite major missions for health access. This is sad because access has been hurt by financial designs with revenue too low, costs of delivering increased by the innovations, and complexity increased by the innovations as patients and practice are both more complex. This is the statement of the Commonwealth president

"In health care, as elsewhere, information is power: not only the power to heal, 
but also the power to improve quality, efficiency, 

reliability, safety, and value." David Blumenthal MD

This stunning quote is another example of solutions that will "come from above." There is no basis for such claims. The assumptions and claims were implemented as policy long in advance of evidence. These have done harm - a major violation of Do No Harm.

The claims indicate great faith in innovation. The claims indicate that something that can be done in health care will improve outcomes. But we know more and more that outcomes are shaped by forces outside of health care.

This leadership perspective from above and far away from health care delivery is quite the opposite of what is needed. We need a return in health care to a focus on the top priority of the challenging labors at the local and individual level where health care and other needs are most complex.

Similarly the fix for health, education, and other outcomes must occur at the individual and community level - not just in practices or schools

In family medicine and nursing and other venues, we understand that solutions come from innovative interactions with patients when we are supported for such interactions. The changes impacting the last generation of workforce have clearly acted against the support of this workforce - by taking away the finances for their support, by taking away their numbers, by taking expertise (RNs) away from areas such as primary care, and by markedly increasing the complexity and challenges of care.

Clearly the pattern of the past generation of workforce is a movement away from such support.

Choice of Technology Focus Indicates Technology Focus, Not Solutions

Commonwealth chose a President who started HITECH for the government. Commonwealth reports consistently misrepresent access, claiming that insurance access is patient access to care. It is not.

The 2621 counties lowest in MD DO NP and PA workforce are an important example to understand. In these counties growing fastest in population, demand, and complexity already, there are half enough generalists and general specialists. This is primarily because they continue to have the worst plans. About a third of family physicians are found in these counties along with only 25% of general specialists across mental health, women's health, basic surgical services.

These counties demonstrate that the lack of health insurance was not the major problem. In 2010 these counties had 40.2% of the population and 40.6% of the uninsured population – essentially no difference. They had plans at the same rates as other places, they just had the worst plans and still do. These plans are the reason for half enough generalists and general specialists - the ones who provide 90% of existing local services in these counties (for the ones that still exist).

President Obama bought the promotions and assumptions spawned by Dartmouth and others – resulting in a misguided approach to health reform. Again, the outcomes are worse in these counties where primary care and other workforce concentrations are worse. It is important to understand distributions of people, workforce, and social determinants to understand outcomes.

Other works by Kip Sullivan help track the development of these esoteric designs based on assumption and a desire to "tinker" around. Open Letter to President Obama About His JAMA Paper   is a series tracking the origins of the ACA and the flawed assumptions. Sullivan notes to President Obama - "Just because you're leaving office doesn't mean you must sit on the sidelines and watch the ACA take a slow nose dive. If you set aside some time after you leave office to immerse yourself in health policy, and if you give high priority to finding the truth and low priority to making the ACA look good, you will conclude as I have that the ACA has little cost containment in it. You'll conclude, as I have, that Peter Orszag, Zeke Emanuel, Jeanne Lambrew and the other advisors who told you "accountable care organizations" and other pay-for-performance fads could cut costs were merely regurgitating groupthink developed over the last half-century by the managed care movement."

Regurgitated Managed Care Groupthink

And more recently Sullivan reviews  Curb Your Enthusiasm   "Lawton Burns and Mark Pauly, economists at the Wharton School, just published an article that should be required reading for all policy makers and health services researchers. The article,  entitled "Transformation of the health care industry: Curb your enthusiasm," appears in the latest edition of the Milbank Quarterly.
Burns and Pauly undertook an enormous task and executed it well. They first sought to explain the assumptions underlying Managed Care (MC) 2.0 – the proposals promoted by the managed care movement in the wake of the HMO backlash of the late 1990s. Then they evaluated the probability that the MC 2.0 proposals will work as advertised. To do that, they looked at the relevant research and then at the social conditions that are impeding the implementation of those proposals. That's a lot to bite off."

I cannot find the reference to the EHR deficits, but EHRs have been found lacking and costly. Also the costs of additional security, fraud, connectedness, updates, and innovations have far exceeded the projections of a decade ago. Little help added with the addition of lots of cost and complexity has not been valuable. Once again the added costs tend to result in budgets more lean for the personnel who deliver the care.

The Tyranny of Value-Basis

It is a time of promotions across consultants, corporations, magazines, software, hardware, and others hoping to capture more health care dollars, research dollars, government dollars, foundation dollars...

Health care is hard, challenging work. 
There is no Technology Wand to Fix Health Care

"We" know that. "They" do not. The designers continue to be misguided. Physicians in surveys have little faith in value based as noted in the 9000 physicians responding to the newly released Physicians Foundation survey. About 47% noted that at least some of their compensation is tied to value based but only 18% believe quality/value payments will improve care or reduce costs.

In contrast, physicians are 26% in favor of single payer and 35.5% in favor of single payer with a private insurance option. 27% favor a market driven system. Physicians appear to understand the real problems are about insurance and finance and EHR and disruptions - areas less studied and less promoted.

Higher Health Care Costs Are Not Valuable

We do know that micromanagement of costs has been a failure as evidence by cost increases and CBO reviews. The micromanagements cost as much as saved via CBO reviews. These did not consider other costs or the increasing cost of security or fraud. The EHR promotions have also been found lacking

Family physicians in smaller practices bought out by those larger are among the few happy ones. they are caring for the same patient's but they get a 15-25% increase in reimbursement and that supports them and their team members better.  This is also an area where there are higher cost for no change in outcomes. This is a best definition of lack of value.

The worst case situations are seen where rural and small practice family physicians are being taught about value based. The 100 million dollar grant goes to consultants and corporations - not to the rural and small practice physicians. These are practices paid 15% less that have the same or similar outcomes. The fact is that these fit the definition of high or higher value. These are also practices most valuable because they are in places that take populations from no access to some and from some access to better. This is best for access, but does little for other outcomes (Because Outcomes Are About the People, Not the Practice).

We do know that micromanagement of quality is costly - a negative with regard to value. Also costs are worse for the small practices which are half of family physicians. The smaller, less organized, and most needed practices have had to pay 30 – 80% more for each of HITECH, MACRA, and PCMH. These are a factor in the demise of practices where needed.  (reviews of Health Affairs articles involving cost comparisons between largest and smallest, generally about $40,000 for each major change for the largest and much more for those smallest) Disparities in workforce distribution, access, and social determinants are facilitated by design.

Value Focus is Bad for Rural, Underserved, Small, Cognitive, Basic Services Already Facing the Worst Financial Designs

The damage is most specific to family physicians (and fewer others) who are most distributed to these populations. Family physicians achieved population based distribution with about 24 to 30 per 100,000 across the range of populations. They are not concentrated in concentrations as with non-family practice positions of all types).

Family physicians are distributed to populations with the worst public and private health insurance plans and the most onerous treatments of providers. Their pleas for help are acknowledged, but little has been done.

Ginsberg has also done work to illustrate the failure of Graduate Medical Education to meet the needs for primary care

Brookings had a review of this area. 

High cost, high need patients drive consumption of health care services and costs. 

This fact has been known for decades. In a masterful job of marketing, this fact has been lost completely. What we now see promoted constantly is that physicians and other providers are the reason for overspending. All we have to do is reign in physician behavior and we will save costs. Right????    

The Managed Care/Dartmouth designers that have shaped ACA have developed a series of flawed assumptions as pointed out by Kip Sullivan in The Health Care Blog. The Dartmouth assumptions were based on Medicare patients - a small 20% that has consumption driven by age and chronic disease.  President Obama bought these promotions and assumptions, sadly distracting a chance for equitable payments and improvements in health care for half of Americans.

It is my hope that Commonwealth and AAFP 
will see the evidence and listen to members 
and stakeholders and providers and team members – 
to end these higher costs and abuses.

Primary care in these lowest workforce concentration counties once had about 38 billion in revenue to use to deliver primary care and may have had 1 or 2 billion in increase since 2010 (minus practice closure losses). These practice have had to ship 8 billion dollars to cover HITECH, MACRA, and PCMH adjusting for their lower penetration rate due to poor margin. They had 15% lower payments for the same services in Medicare 2011 data. They have the most complex patients with the worst concentrations of diseases and outcomes across infant, maternal, longevity, premature death, diabetes, asthma, COPD, sedentary, and more

These practices are caring for the most complex with the least support and lowest collection rates. The discrimination against them has yet to be addressed. The dollars forced out of their hands to consultants and to corporations and to their innovation promotions are dollars stolen from the practices, the team members who deliver the care, and the communities most in need of access and social determinants.

Fight the financial design. This is the most important fight 
for family physicians and for any who truly support access to care.

And if you understand social determinants, you can understand why P4P, value based, or performance based payments would make matters worse for family physicians, small practices, 30% of the practices where most needed, practices in 2621 counties with 40% of the population most underserved, and others who care for the underserved.

Payments Adjusted for Complexity of Care - Nope

No adjustments in payments are coming for the care of the complex or for practices most disrupted by usual or innovation disruptions. Hong in JAMA long ago demonstrated that you cannot adjust payments. CMS has refused to adjust payments (or any real increases). Mold in Annals of FM ( )indicated that small and medium practices have the most usual disruptions. Because of worse finances and complexity, these hit hardest.

Innovative disruptions have also hurt FM, primary care, and care where needed hardest. Except for this study, this 117 million dollar effort was wasted and also distracted primary care researchers from important work.

This year there would be progress if Commonwealth and AAFP 
just stopped promoting innovations – if that is possible.

What Primary Care Researchers Should Be Researching Instead of Quality Improvement

April 17, 2018
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 AHRQ 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.

Researchers in primary care should focus on practices, team members, relationships, conditions, supports, disruptions...

Small Health Attacks

CMS recently claimed to be helping rural health – they are not helping rural health. They are causing rural health problems by their designs and have been for decades. By permission from Shane Avery MD    There are certain people who pay attention to salaries and benefits as shaping physician specialty choice. There is a correlation, but correlation is not causation. I look at these are great distractions. What's behind the salaries and benefits is more important. And what drives this from upstream is even more important. The real force, the major influence, is the financial design - revenue, cost of delivery, complexity. Behind this is powerful vs powerless.  When you pay so much more for health care costs as seen in Massachusetts - you deplete child development, early education, mental health public health, higher education, environmental changes, housing, nutrition, and public security. The US is among the worst

Draining the Primary Care Medical Home Swamp

June 08, 2018
All three primary care home demonstrations have failed as noted by Kip Sullivan in a recent thehealthcareblog. Kip Sullivan is a voice of reason in an insane policy period. This is only one of many appropriately critical pieces that make sense.

In another sad twist of fate, a major reason for the failure was the promotion by medical associations - including family medicine. Even more important in reading his works, is the discrimination specific to those smaller, where needed, caring for the most complex, and most ignored. Family Medicine has long had the best track record for all of these areas.

Sullivan and Soumerai have noted that these innovations and regulations have taken on a life of their own.  Pay for performance: a dangerous health policy fad that won't die   includes graphics from the primary care home demo failure

MACRA Fails and discriminates by design

Studies often make it to publication, but there are major flaws. Some guidelines with regard to physician responsibility are helpful.

This is a nice review by Kip Sullivan in The Health Care Blog of what it takes to demonstrate that the findings are due to a particular physician. 

[H]ere are several important determinants of validity of physician performance measures:
Is the measure fully controllable by the physician?
Is the measure properly adjusted for variation in the case-mix of patients among physicians?
Is the measure partially controlled by some other level of the system?....
Reliability assumes validity as a necessary preconditionAlthough the reliability calculations can still be performed for measures that are not valid, subsequent interpretation is problematic. [p. 17] 

The original document is with the RAND Corporation as a basic tutorial with regard to assessing provider contributions regarding outcomes.

I think that we can safely say that there are very few if any studies that fit the above reasonable criteria to attribute responsibility to health care providers. More about the assumptions that have driven health policy and including the newer ones misguided about social determinants. from

You will see the assumptions in the following expert writings, followed by my comments. This is From The Commonwealth Fund's David Blumenthal, M.D., and Melinda Abrams highlighted six key opportunities in this JAMA "Viewpoint."

Policy Options for Improving HNHC Patient Care By Commonwealth (Italics, my comments in non-italics

  • Promote value-based payment. The prevailing fee-for-service payment system-which incentivizes the delivery of more services, even when fewer may be needed-represents a major obstacle to improving HNHC patient care. Value-based payment strategies will give providers a stake in optimizing, rather than maximizing, the delivery of health services.  
  • Improve value-based payment design and implementation. Authorities need to ensure that clinicians working under value-based payment arrangements do not continue to be reimbursed on a fee-for-service basis, which sends mixed messages. Equally critical will be developing risk-adjustment formulas that account for social and economic factors that complicate care for HNHC patients. Failure to do so may discourage physicians from treating these individuals.

My Comments
  • Note here the managed care/Dartmouth dogma that claims that all designers and designs need to do is to make physician behavior in high use areas of the nation change to resemble physician behavior in low use areas. This is absurd as the consumption or lack of consumption is about patient factors, community factors, and other influences not involving providers.
  • Blame the physician has played well for twenty years but has not resulted in improvements in cost, quality, or access. What has resulted is a massive increase in administrative and non-delivery costs. It was time to burst this bubble 2 years ago and yet it continues.
  • Risk adjustment means that those who deliver care may face decreased revenue and consequences - set up by designers far away that mainly want to cut costs regardless of need to cut or not.
  • Physicians and providers have reacted strongly to the changes. Prominent has been the rapid expansion of digitalization and EHR. These are not necessarily the problem. 
  • The real problem is about the designers that have exceeded the limits of these technologies with regard to the ability to measure and the validity and reliability of the measurements. Sadly this focus at all costs and despite the distractions has impacted the core of what health care is all about - the team members that deliver the care. The designs have specifically marginalized the team members.
  • What this has done is to increase health care costs while decreasing team member productivity - and also changing physician behaviors the wrong ways. Physician Behavior has been changed  -  the wrong way
Allow payments for nonmedical services. Meeting the housing, nutritional, and personal care needs of HNHC individuals is important to improving their care and reduce their health-related expenses.

My Comments
  • Finally there is some acknowledgement of the importance of people factors. But it takes more than talk. Practices are reeling from all of the billions that now must be spent upon EHR, HIT, and other non-delivery areas forced by regulation.The health care designers cannot even find a way to send a few more dollars to primary care, mental health, or basic services, much less housing, nutrition, or other areas.
  • Designers like to talk about social determinants, situations, and environments but this is just talk. They have a Hope Chest and they hope that more dollars will be spent on people factors, but they are not willing to set this up, nor are they willing to lobby for this and risk their political support. 
Commonwealth Continues
  • Assist clinicians in adopting best practices. Practices should be directed and assisted in adopting proven strategies for addressing the needs of HNHC patients, including: grouping patients with similar needs into cohorts, using multidisciplinary care teams, leveraging health information technology, and promoting patient engagement.
  • Prioritize health information exchange. Removing the political and economic obstacles to health information exchange-that is, the exchange of electronic health records between providers-would pay particular dividends for HNHC patients, whose complex care must typically be coordinated among multiple physicians. 
  • Support ongoing experimentation. The efforts of the Center for Medicare and Medicaid Innovation and the Patient-Centered Outcomes Research Institute to develop, monitor, and evaluate efforts to care for HNHC patients should be supported and extended. 

My Comments 
  • The designers are asking the impossible, perhaps even insane behavior by health care providers. Practices have been stripped of support for team members and face lower morale and productivity. And they the designers state that they should hire more people just to handle the few high cost high need patients - and ignore the remaining flood of patient care demand and complexity. 
  • More time and effort and cost spent on few seems attractive, but this remains a wash. The Congressional Budget Office indicated that special management could save costs, but these efforts had cost equal to what was saved. 
  • All of the above including Health Information Technology were utilized by the Robert Wood Johnson Foundation Aligning Forces for Quality project with 300 million in additional spending over ten years for no effect on population health or quality measures.
  • Trying the same things over and over and expecting a different result is insanity. 
  • Rapid implementation of change is also insanity

What we now known from insurance plans, ACOs, practices, and hospitals is that they cannot achieve their quality or cost goals if they have concentrations of most complex patients. The managed care plans that were successful taught us this in the 1990s using various schemes to keep from having to sign up the high need high cost patients. 

The designers have no clue with regard to the entire spectrum of health care consumption with most urban, highest income, most complex, chronic care, and better paying plans resulting in the most spending while rural, lower income, less educated, less health literate, lower property value, lower resource populations have insufficient workforce, access barriers, and people factors that prevent technology and other interventions from working.

Bob Bowman
Basic Health Access


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