Care Coordination Is Prevented By Health Care Designs
Jon Warner asked for advice regarding needed improvements in the care of vulnerable populations. The short example of a model is SERPA - local physicians organizing together with local hospitals and employers for community-wide changes. But sadly such a situation is rare. Inside out works to address local community needs. Regulations and innovations forced from outside - just do not work for the practices and people in most need of support. This is because the designers fail to understand - thus their designs make the situations worse.
If you understand the people and practices and hospitals most closely associated with vulnerable populations, then you might understand this. If you understand that those who claim to be a solution - are promoting themselves mostly, then you move a step closer to understanding how the problem is getting worse.
Do Gooder Foundations and Associations Push Do Gooder Innovations - Gone Bad
Commonwealth loves to ride the bandwagons. It pushes insurance access - which is not the same as access to care. Commonwealth pushes innovation - which makes the situations worse for care and caring at the local levels. Commonwealth has chosen leaders from those who support metrics, measurements, and micromanagement. It is not surprising that they fail to understand the people in most need of care, their plans, and their providers. It is quite tragic as Commonwealth has a mission for health access. But then so does AAFP who also supports designs that disable family physicians and those they serve.
To understand the failure of coordination, you must understand the designs that fail practices, hospitals, and populations.
The designs for Medicare, Medicaid, and Duals support these populations and those who care for them poorly. An example is the populations in 2621 counties lowest in health care workforce with 40% of the US population. Their deficits of local workforce are largely due to worst public and private plans concentrated in these counties - the ones with the worst financial designs.
- The last decades of regulatory changes plus usual costs of delivery plus stagnant revenue have made deficits of workforce worse.
These counties did not lack for health insurance in 2010 more than others as they had 40.6% of the uninsured to go with their 40.2% of the population. But they clearly have the worst health plans for the people, places, and practices. Readmissions designs also send the worst penalties to the remaining hospitals in these counties. Their sin was caring for populations that inherently have lesser outcomes. Star ratings, MACRA, and other designs hurt them more.
To Follow Access, Care, and Caring Follow the Health Care Dollars or Lack Thereof
For example the 60,000 primary care physicians in these counties
- have had stagnant revenue while
- they have had to come up with 1 - 2 billion more a year to cover usual costs of delivery that increase year after year plus
- an additional 1 billion more added each year to cover the costs of HITECH To MACRA to Primary Care Medical Home (which only 30% can afford or have implemented. This does not include later implementation, security, updates, or value based costs, or losses of revenue from the above).
So what was once 38 billion as their share to deliver primary care in 2008 has been reduced below 30 billion to spend on primary care delivery - resulting in fewer and lesser team members and difficulties implementing any change much less attempting to hold on to care and caring.
Designs and Designers Discriminate and Benefit Those Doing Best By Design
Experts have long warned CMS and insurers that performance and value based designs teach providers to avoid patients who inherently have the worst outcomes. But then the better plans are just not available where they are needed. And when you can find a Medicare Advantage plan, it is important to document any possible condition to boost revenue - plus you have the lack of local access to aid in cutting costs paid out.
Larger entities want to extract the higher paid specialty and hospital referrals that must travel distances to get care, but they do not want the responsibilities for caring for such populations under current designs. So it works best for them to compromise local practices, emergency rooms, and hospitals.
The Situations Are Made Worse for Vulnerable Populations, Not Better
These counties lowest in workforce are lowest in social supports and community resources. They have also been growing fastest for over 5 decades - joined by more who move their for lower costs of living and housing as Americans get older and poorer and sicker. These escalating costs drive them away from the counties higher to highest in concentrations of workforce to join others like them in these counties. Any decent review would indicate massive problems where practices and hospitals are being closed as the local population increases rapidly.
And these counties have long had only half enough primary care and generalists, they have half enough general specialists – mental health, women’s health, basic surgical services. This is likely true for over half of the US population - not just rural or minority.
Mythical Beliefs About Resolving Deficits of Workforce
Any decent workforce study would demonstrate no improvement in local workforce despite massive expansions of nurse practitioner, physician assistant, and medical school graduates. These expansions for decades of class years expose the myth that more graduates or special training programs or schools can resolve deficits - they cannot.
Only the financial design can fix this problem - and those in charge along with those doing best vigorously oppose declines in revenue to pay for basic and for care where needed. These are practices which are paid less and their local hospitals are also paid less. The office codes are most important for them and they are paid 15% less as seen in Medicare 2011 data. There is not likely any better in the payments of the worse insurance plans concentrated in these counties. Studies consistently demonstrate that those bigger win and those smaller lose in the practices, systems, and insurance designs.
Studies also demonstrate flat primary care spending and workforce despite the massive expansions of annual graduates and numerous reforms since the 1990s – but this does not stop nursing leaders or physician assistants or medical education leaders from claiming to be a solution. After 30 years of pushing rural and primary care pipelines, I realized the futility of training as a solution. You should too.
You should laugh when people talk about integration and coordination where the practices, delivery team members, social resource, and general specialists are all half enough.
- How can you add scribes or coordinators or outreach – when your finances dictate cuts not expansion? Primary care finances are mostly about the people doing the primary care. When you finances fail, you fail the people and the practice and the local population.
To Understand Failure of Coordination and Innovation, Understand the Practices
The practices tend to be smaller, independent, and most disrupted by the constant churn of innovation and regulation. Mold (Annals FM) could teach about the usual practice disruptions that prevent needed changes- but the researchers are more interested in promoting quality improvement rather than understanding the patients, people, populations, and practices. Fortunately physicians such as Mold are more aware and explore why innovations do not work or face issues in implementation – not so other designers.
Patient centered care and higher functioning primary care demand more and better team members - but the financial design shapes fewer and lesser. Pharmacies, grocery stories, nursing homes, hospitals, and practices are also being designed away from these locations and have been for decades.
Has the United States Ever Changed the Financial Design in a Meaningful Way
The evidence indicates growth in workforce and health access only during the 1960s and 1970s when the designs were better. Practices multiplied and grew along with small hospitals. Family medicine grew significantly only during this period - reaching 3000 annual graduates by 1980 and growing only by 1% a year since that time.
From the 1980s onward there is little evidence that anything has helped. There are good indications that draining these counties to the tune of tens of billions more each year to pay for meaningless health insurance, metrics, measurements, and micromanagements - is making the situations and outcomes worse.
Only 1965 to 1978 did these counties receive increasing billions that supported local health care via Medicare, Medicaid, and Duals. But the big systems and practices abused these plans - resulting in the Era of Cost Cutting dominant in health policy since the 1980s - with the worst impacts upon these practices and hospitals and populations left further behind.
Advocacy Groups and Special Designations Can Distract from Solutions
Rural definitions and shortage definitions are also a distraction. They give the impression of small portions of the US behind in health care access and workforce and dollars – when the deficits are widespread and massive.
Rural is not pure for deficits as 25 to 30% are doing quite well. Rural is based on concentrations of people - which are not the same as concentrations of health care dollars and workforce and access. Physician concentration coding does follow these important markers.
Shortage area designations do not represent concentrations of physicians well. There is a widespread understanding of the need for reforms, but reform attempts have failed at least 3 times and reflect shortages poorly. The 32% of the urban population in these 2621 counties has no advocacy group at all. No one is illustrating their needs or increasing awareness with regard to the designs that make their situations worse.
Real, necessary, and sufficient change starts with a substantially better financial design for basic services along with a massive decrease in the regulatory and innovative costs of delivery.
For Care Coordination, you must establish and support those in primary care (office, home, community) who do the care and caring - not half enough
For Care Coordination, you must establish and support social resources and not tolerate half enough.
For Care Coordination, you must establish and support the general specialists needed with reasonable local access.
Care coordination requires designers that understand the populations, the providers, care coordination, and local resources.
The Glut of Workforce Exposed But Ignored from January 2019
Think Twice About a Medical Career
Seasons of Distortion Rather Than Accountability and Social Responsibility
Too Many and the Wrong Clinicians from 2014
Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care July 30, 2011
The Glut of Health Workforce Exposed But Ignored January 2019