AHRQ and Foundations Who Support Research Must Stop Harm By Health Care Design

Very few consider that foundations could be causing harm or that researchers could be causing harm or that health care designers could be causing harm. Harm is possible directly by design. It is also possible to cause harm by distracting our nation or its leaders away from true solutions.

For decades we have moved away from what matters most in health care design - the support of the team members to deliver the care so that they can best innovate with each patient for the best solutions. The trillions of dollars in health care can be shaped for profit and higher concentrations, or they can be distributed so that most Americans most behind might enjoy the same benefits of basic health access.

This was stimulated by an AHRQ posting promoting one of its researchers and projects. Some have made contributions, a few. Most have been distractions. For example:

AHRQ has sponsored quality improvement projects including 117 million dollars to help facilitate better cardiac outcomes via primary care practice. An entire issue of Annals of Family Medicine was dedicated to review of this project. One article was relevant. Almost as an accident, a study by Mold examined the reasons why primary care practices did not fully participate. This was the Usual Disruptions study indicating changes in key personnel, billing, EHR, ownership, and location as problematic for smaller practices and even medium sized practices. This is one of few studies to look from the inside and see how change and rapid change and change from outside can be difficult - and can even be harmful.

This is what you would expect when

• The designs are from outside and above
• The designers are out of touch
• The focus is on cost cutting
• The assumption is that primary care can change outcomes even in populations with relatively fixed outcomes after years or decades of previous life influences, behaviors, environments, situations... (and lowest levels of education, health literacy, and more)
• The few minutes a year of primary care contact is placed in the context of the past year or years of experiences
• The designers fail to understand that they have designed fewer and lesser delivery team members, half enough primary care, higher turnover, more burnout, and worse - for the practices serving most Americans. Even if higher functioning primary care could work for integration, coordination, and outreach - there are not enough in primary care, women's health, mental health, social supports, and other key areas to do higher functioning primary care.

The Problems Are the Same, or Worse, Under the New Financial Designs

I have been disappointed with the continual focus on yet another major change - from volume to value. It is hard to find primary care where most needed as focused on profit - since so many are financially failing. And it is easy to see how volume focus is how these practices attempt to cope with failing finances by design.

The problem with the new payment designs are still the same as in fee for service. These new designs fail to improve upon 20% of primary care spending to support only 25% of the primary care workforce in 2621 counties lowest in health care workforce with 45% of disease, environment, behavior, and situation complexity. This is based on county level data for these counties and 15% lower Medicare payments (2011 data) for office services in these counties not considering worst Medicaid and other insurance payments or the higher concentrations of the worst plans in these counties - that shape deficits and access barriers.

How Micromanagement Shapes Practice Failure

And the performance or value based designs make the finances worse. Each year since 2008 they capture $500 million to a billion more from these remaining primary care practices that only had 38 billion as their share of primary care spending in 2008. This is the result of innovation, regulation, micromanagement, and digitalization.

Note that this moves more billions from places in need of health access, health care workforce, jobs, economics, and social determinants to go to places of higher concentrations - acting to increase disparities and worsen outcomes.

Now an immediate response might be, well too bad their health care is failing. They can just move. But the problem is that they cannot move. It costs too much for living and housing where there is health care. In fact these forces are driving more Americans to move to these 2621 counties lowest in health care workforce. They want to live there and they also have little choice. The designers can learn this and improve their designs, or not change the designs and contribute to more unrest and populations even more vulnerable to political manipulation.

AHRQ Did Make an Important Contribution

These declines by health care design are made worse by the usual disruptions as seen in the Mold AHRQ study in the Annals of FM supp. The impact is greater

• on these medium and smaller size practices concentrated in these counties,
• because of rapid change,
• because of relatively higher cost of regulation and innovation and supplies and services,
• because of higher turnover, by lower productivity and by fewer and lesser delivery team members as dictated by the financial design.

Volume Increases Shape Increased Access, Value Based Shapes Decreased Access

Also researchers and policists fail to consider that volume to value movement has reduced volume. As the bandwagon as rolled on to value based design with stagnant revenue, the impact is inevitably volume reductions where access is limited. This acts to reduce access where most needed.

Designers and Researchers Must Discard the Myth of Small Minorities Behind in Health Care Design.

They have failed to consider that most Americans have underutilization of many basic services because of the financial design shaping fewer and lesser delivery team members in places with lowest levels of workforce.

This exposes the micromanagement focus on overutilization as not only wrong but discriminatory and a source of increasing disparities (and likely reductions in outcomes).

How Long, Not Long We Have Been Promised - But Far Too Long So Far

https://www.dhirubhai.net/pulse/how-long-basic-health-access-most-americans-behind-robert-bowman/?

More at https://www.dhirubhai.net/pulse/so-much-ahrq-hrsa-primary-care-researchers-could-do-reverse-bowman/

One day those who sponsor research will try to understand health care design from the perspective of 2621 counties lowest in health care workforce and then the designers and researchers and health care leaders can begin to understand the destruction of DRG/PPS to ACA to value based, the failure of medical homes, the consequences of fewer and lesser delivery team members, and how these leaders and agencies and foundations make the disparities worse - even when they think they are doing good. Count Down the Characteristics and differences in the populations in these counties to understand how health care designs can make their situation worse.

• Why would you expect any intervention to work to improve basic health access when the designs from 1983 to the present when the designs have not substantially increased the dollars going to generalists and general specialists specific to half of the US population?
• How can you continue to pay 15 - 30% less to hospitals and practices where most needed and fail to change stagnant finances and add on ever higher costs of supplies, services, and micromanagement - and not expect failure by design?

We are only now beginning to understand the carnage from DRGs nearly 40 years later and with only about 15 years of understanding of the consequences. Managed care now has randomized studies illustrating no improvements. CMS Innovation is 5 for 52. And eventually ACA will be exposed as great for big health, big insurance, and counties with concentrations of workforce with most Americans and their remaining health care left behind by design.

Beneficent intent, protection of vulnerable populations, informed consent, and evidence basis must guide physicians, researchers, and health care designers. Hopefully it will not take 50 years to accomplish this as with human subject research protections.

Why Most Americans Should Not Celebrate 10 years of Obamacare. They are not getting good insurance and their local finances and health care are being designed away. Again you must understand from the perspective of most Americans most behind - and not listen to micromanagers and their assumptions from above. https://www.dhirubhai.net/pulse/why-most-americans-should-celebrate-10-years-obamacare-robert-bowman/

Stop Health Insurance Preoccupation https://www.dhirubhai.net/pulse/stop-insurance-coverage-preoccupations-start-basic-health-bowman/

The United States has never had a financial design that would support a primary care physician for every person. It has never come close. It has only had progress toward this goal from 1965 to 1978. Since the 1980s each passing year or fad or bandwagon has moved the US away from this personal primary care physician goal. https://www.dhirubhai.net/pulse/what-prevents-americans-from-having-personal-primary-care-bowman/

Micromanagement is suspect for Value and May Worsen Outcomes – By Design?https://www.dhirubhai.net/pulse/micromanagement-suspect-value-may-worsen-outcomes-robert-bowman/

How Long for Basic Health Access for Most Americans – the Ones Who Remain Most Behind Why do we tolerate health access focused associations and foundations when they fail to put their mission areas as the top priority – or when they support micromanagement focused policies that make basic health access worse. https://www.dhirubhai.net/pulse/how-long-basic-health-access-most-americans-behind-robert-bowman/?

It could be considered a major problem in a few decades when the health care has been decimated by designs that close hospitals and practices where most Americans most lack care. The fact of the matter is that the US design has always compromised basic health access for large portions of its population. In the graphic you can clearly see the faster growth of the US population in the county categories middle and lowest in concentrations of physicians. The slowest population growth is in counties with top or higher concentrations of physicians. This 30% of the population in higher concentrations is favored. The middle to lowest concentration counties with 70% of the population have had the fastest population growth decade after decade. This is also where hundreds of hospitals have been designed away along with thousands of practices. These tend to be smaller to middle sized and least organized. https://www.dhirubhai.net/pulse/health-care-designers-shrink-workforce-where-growing-fastest-bowman/

Everything that You Know is Wrong About So-Called Primary Care Solutions?There are many who claim that their graduates are primary care solutions. They are wrong. The only solution for primary care deficits is a better financial design. We must get to the truth before we can actually address primary care deficits and basic health access deficits specific to most Americans most behind. https://www.dhirubhai.net/pulse/everything-you-know-wrong-primary-care-workforce-solutions-bowman/

Our recovery as a nation must be generation to generation and this greatest battle for civilization can only be one when each new generation has a greater and greater proportion of its children growing up in thrival mode rather than in survival mode. – RCB You cannot regulate or micromanage health care or education to improve outcomes. You must improve the population. https://www.dhirubhai.net/pulse/only-true-solutions-health-education-outcomes-robert-bowman/