Medicine

For Better or For Worse in Quality

For decades we have had stagnation in important areas such as health access and in quality. Meanwhile, costs have skyrocketed. The opposite of value has become the norm for health care in the United States.

A worst case scenario in health care would be

More funds to those already with the most and more payment to those with the simplest and briefest tasks of care - the traditional US payment design
Less funds to those providing care for those most need of care because of least funding plus higher cost of delivery resulting in even less that can be done
Cuts in resources making social determinants, jobs, and situations worse.
Vague measures of performance and vague definitions of interventions making it easy to claim benefit and hard to actually improve (ACO, PCMH, value-based payment) or easy to exaggerate (NC Primary Care Medical Home, Milliman) such that advocates and consultants can continue to expand while primary care contracts
Rapid change without regard to the consequences of rapid change and damage done by interventions implemented before adequate testing - or any testing (multiple)

As a nation we have achieved the worst case scenario and the impact is greatest upon the locations and the populations where care is most needed.

More for Fewer and Less for More - Hospital and practice payment designs pay less for those smaller where care is most needed and have done so for decades. Pay is less for the basic services that are best distributed. Pay is most for the highly specialized and briefest services used by few and these specialists are most concentrated where payments are most concentrated. The largest entities have demonstrated the ability to game the new payment designs much faster than the smaller. Biggest also means the least cost of supplies and insurance because they are larger and can command discounts while the smallest have to pay more and make up the discount for the largest. The biggest entities, through mergers or acquisitions (health plans, systems, practices), also demand and get higher payment resulting in higher health care costs.

Support Declines for Social Determinants and Situations - Most of what happens to people in health outcomes is determined by social determinants and situations. It is more difficult to influence individual outcomes by interventions that involve entire populations, but it is only in such changes that outcomes in health and education and other areas can change.

National, state, and local resources to support people, populations,
and better outcomes are becoming more limited.

Sometimes states even refuse to distribute such resources. Various entities manage to divert funds intended to address real and pressing needs.

Disparities continue to widen across the nation, especially in the populations and places in most need of care. The impact expands beyond lower to ever higher middle income populations.

Vague Plus Vague Equals Vague

The majority of Accountable Care Organizations are failing, the definitions are vague, and the purpose has been defeated. This is because mergers continue to result in even less competition with pressures toward even higher costs.

Primary care medical home fails to demonstrate improvement, the costs are too high, the definitions are vague, and overclaims are common.

Using a Problem Solving Design for Improvement

Problem solving starts with assessment followed by intervention and then re-assessment. It can take two or three years for even a small scale problem. Ideally this is local in initiative, in selection of the problem to solve, in implementation, and in reassessment.

The major failure of our time is the one size fits all health care problem solving. This is why it is so easy to claim that innovations will work - innovations that have little relevance.

Assess Performance - Assessment is quite limited. There are many reasons for outcomes, but often only a few are measured or studied. The equations used for assessment fail to contain variables specific to social determinants and situations. They fail to include deficits of local resources, access barriers, and workforce deficits.

Gaps in Care - Gaps primarily exist because of insufficient payment for basic services making matters worse for the small practices and small hospitals that depend upon basic services. This is also why deficits exist in primary care, mental health, and other basics. This will get worse due to payment design plus required higher costs such as $105,000 per physician per year for PCMH and $40,000 PPPY for quality metric focus. It is not possible for training to fill the gaps because the gaps are determined by payment.

Engage Patients - Progress that matters for cost and quality requires substantial investment in basic services of $70,000 or more per physician as seen in Vermont to improve cost and quality - and even more to be able to reach out and engage. How is this possible when EHR alerts take an additional hour a day to address?

Improve Performance - requires coordinated state, federal, and local investments in people to improve social determinants and situations which are 60 - 70% of outcomes as compared to clinical which are 10 - 20%. Insurance access fails, innovations fail, investments in people matter.

Problem solving can solve access, cost, and quality but not in the current worst case scenario.

Real progress requires investments in patients, people, and especially in children.
Real progress requires investments in basic services to build up basic access to care.
Real progress requires local focus and local investment, not one size fits none.

The Shaky and Shady Primary Care Medical Home

Lack of Support for Primary Care Medical Home - Schwenk, Abrams, Jackson and Williams References

PCMH cost $105,000 per physician per year

Critical review of Primary Care Medical Home, proposing ways to actually measure value - something not measured well so far.

A Rough Guide to Spotting Bad Science

Pressures Mount for ACA Changes

The Real Kerfuffle - How much chaos can family physicians stand?

IOM Panel Calls for Training in Social Determinants (But Needs Such Training)

Which is worse, IOM calling for training or family practice leaders? Front line family physicians do their work because they are local and have continuity with patients and families to deliver care that integrates social determinants and situations.

Is the IOM Waking Up?

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Overcoming Barriers to Health Access Including Portions of ACA

Best of Basic Health Access

Primary care can be recovered and should be recovered,
but not when moving the wrong directions

Robert C. Bowman, M.D. [email protected]

Basic Health Access Web Basic Health Access Blog World of Rural Medical Education

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