Considering the Consequences of Micromanagement
A JAMA Health Forum has been created and a recent episode was absolutely on target calling into question so much of the micromanagement that has been accepted and continually expanded from 2005 to at least 2025 and from HITECH to value based and beyond. https://edhub.ama-assn.org/jn-learning/audio-player/18617056? Although this posting questioned the quality measurement focus, it did not go far enough to ask for full investigation or termination of this misguided movement profitable for few and punishing for so many.
Now that we understand more and more that outcomes are shaped by non-clinical factors such as the drivers, determinants, and life experiences since birth, it is time for the meaningless micromanagement madness to end.
Why consider changing or new measures when there is so little indication of benefit and more indication of disruption and higher costs of delivery?
It was very important during this JAMA Health Forum discussion to point out that the quality measures are not well targeted, and are gamed by practices, and may well be meaningless for true quality improvement. Well Done. Notice that higher costs can force cost increases to others or they can force practices to cut personnel or other costs.
Why measure if
Clearly the costs of micromanagement go up per physician as noted and the consequences are higher in practice for those medium and smaller in size.
Much the same is found by Mold with regard to usual disruptions that impact small and medium size practices most (Mold, Annals FM suppl, changes of billing, EHR, ownership, location, key team members).
Also those smaller and medium size are more likely to be found where the worst finances exist - as shaped by patient populations with the worst Medicare, Medicaid, and private insurance plan concentrations (and high deductible, and worst plans for local providers).
Cherry Picking Is Rewarded and Population Fixated Practices Are Stuck with Accountability and Punishment Despite Least Support and Greatest Challenges
Cherry picking has become the most important strategy to bypass any health care outcome design. Note how biggers may also be able to cherry pick the right locations and plans and patients while those smaller are stuck with populations that not only have lesser health insurance plans. Note how those smaller to medium size have lesser employers, benefits, income, environments, situations, health access, and outcomes - as shaped by these over decades of life influences.
Higher costs and distractions with no change in outcomes is the opposite of "value based" -
But that is exactly what the value based, performance based, MACRA, MIPS, ACA, HITECH bandwagon (backwards for a reason) has shaped since 2008. Ever since 2005 the promises of digitalization, innovation, regulation, and reorganization have been made - but have largely not materialized.
But the bandwagon continues. Also note that these costs specifically transfer more billions each year from the places lowest in workforce and access to places with higher concentrations of health care dollars, health care economics, workforce, and more. This creates disparities that can eventually worsen outcomes.
The designers appear to be unwilling to consider the consequences of the designs and changes. The designers are unaware of the consequences of the impacts of micromanagement on most Americans most behind.
The designers appear to be unwilling to consider the consequences of the designs and changes. The designers are unaware of the consequences of the impacts of micromanagement on most Americans most behind.
An example can be reviewed. The 2621 counties lowest in health care workforce are moving from 40% of the population in 2010 to 50% by 2060. They already have concentrations of elderly, poor, chronically ill, worst health behaviors, and worst outcomes. Lowest access matches up to poorest finances and most closures and compromises by design.
These 2621 counties have more smaller and medium size practices along with the worst employers (and their insurance plans), the worst Medicare plans (Medicare 2011 data), the worst Medicaid plans (dating back to the compromises that created Medicaid), and the worst patient finances. They had only 38 billion in primary care spending in 2008 or 20% of such spending to support 25% of the workforce (AMA MF, ARF) and 25% of office visits (Medicare 2011) for this 40% of the population. Stagnant revenue since that time, increasing usual costs, and increasing micromanagement costs of delivery can only shape even fewer and even lesser delivery team members.
These map out as Red Counties in 2016 plus rural minority counties, or 130 million or 40% of the total population including 75% of the rural population (but not all) and 32% of the urban population (that is not even recognized as abused by design.)
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Consider the true consequences of HITECH to value based.
Consider that so many factors shape worse, that improving outcomes is less possible and more costly.
Will we finally halt the micromanagement bandwagon with all of its poor assumptions and discriminations, especially against most Americans most behind and what remains of their health care?
And we did not even discuss burnout, higher costs of team member turnover, lower team member productivity, and movements away from more and better team members as required by higher functioning or patient centered primary care. Turnover costs alone are about $300,000 per primary care physician with a loss each 3 years for $100,000 per fte per year or about 15% of revenue generated per fte.
Micromanagement costs, turnover costs, and usual disruption costs are not even considered in the financial design yet clearly are significant in many ways. Most importantly they act together to worsen basic health access where most needed.
Health care used to be discussed in terms of quality, cost, and access.
The overemphasis on the first two has completely taken our designs and designers away from considering the consequences on access - particularly where it is already most compromised.
Access is poorly studied and is often abused and misused by those who claim to be a solution for access when they are clearly not.
The financial design absolutely prevents training interventions from working - all of them. More types of workforce have failed. So have massive overexpansions of MD and DO and NP and PA.
This is very clear from my 30 years of study of pipelines. You can generate studies indicating higher proportions of graduates or odds ratios advantages, but you cannot demonstrate improvements in health care workforce capacity over time without a population change to better employers and social determinants and health plans. By the way, these shape higher levels of workforce and primary care in ways that prevent primary care levels from being considered as shaping outcomes.
Until we understand micromanagement and training interventions as incapable of changing access or outcomes, we will continue to make the situations worse for most Americans and what remains of their health care.
Expansions of the worst Medicaid, Medicare, high deductible, and private plans cannot help basic health access deficits for most Americans as these have caused the deficits. These Americans never lacked for health insurance more than others, they have always had the worst plans. https://www.dhirubhai.net/pulse/myth-insurance-coverage-expansion-solution-basic-health-robert-bowman/
Physicians and human subject researchers must follow evidence basis, avoid harm, and protect vulnerable populations. Health care designers do not. https://www.dhirubhai.net/pulse/ahrq-foundations-who-support-research-must-stop-harm-health-bowman/
New types of health professionals, more schools and programs, and bigger class sizes have not fixed health access deficits and cannot, because of the financial design. They can create a massive glut of workforce, however. https://www.dhirubhai.net/pulse/your-favorite-new-medical-school-fix-deficits-workforce-robert-bowman/
In order to understand the abusive health care, education, economic, and other designs, you can begin by understanding more about the counties most behind in areas such as health care workforce, health care spending, health care access, and health care equity. https://www.dhirubhai.net/pulse/count-down-2621-counties-most-behind-understand-why-health-bowman/
The United States is unique in that the design for health care walls off most Americans with half enough generalists and general specialists – by design. https://www.dhirubhai.net/pulse/mr-health-care-designer-tear-down-wall-stop-killing-robert-bowman/
Enough is enough. Stop saying that insurance expansions can fix basic health access. Indeed, expansions of the worst health insurance plans can worsen access and outcomes for most Americans most behind.
Micromanagement is suspect for Value and May Worsen Outcomes – By Design?https://www.dhirubhai.net/pulse/micromanagement-suspect-value-may-worsen-outcomes-robert-bowman/
https://www.dhirubhai.net/pulse/why-health-professional-training-cannot-fix-shortages-robert-bowman/
https://www.dhirubhai.net/pulse/predators-profit-off-health-care-problems-punish-team-robert-bowman/
Faculty member UCLA Fielding School of Public Health : Health, Policy and Management
3 年Medicare advantage has 43% of the population and that will only get bigger Following the global capitated model works well in integrated health systems and we will see growth in these systems Good outcomes have been reported in these organized systems Physicians don’t go into private practice but join organized multi or solo specialty groups to gain peer satisfaction, effeciencies of scale and more and better care coordination Larger systems and medical groups negotiate better contracts with insurance companies Not much negotiating with government plans The problem with fraud, although a small part of our wasteful system has been show with upcoming on HCC by physicians and systems to get more money out of Medicare in the advantage system Kaiser just got hit with a huge penalty Upcoding is historical in our FFS system hence the need for audit and trained coders…physicians are not always that good at coding and often leave money on the table so it goes both ways Moving money to address social determinants is not possible with the FFS system, as there is no money left over after overhead and paying the physician (whose incomes have not suffered) Capitated systems can address SD
Dermatology & Dermatology Mobile Apps
3 年Toss the failed models …. Trim it down tell CMS and HHS ignore their corporate and political kickback. I still like simplicity. Use existing billing and fee for service and EFT systems (but cut out then2% EFT companies steal from physicisns), cut out the failed CMS experiments (MA, Medicaid HMO, ACO and DCE) and install crushingly good anti fraud software much like the credit cards use. Use the bureaucrats to process the fraud ex post facto with meaty penalties instead of prior authorization rationing of access which delays, changes or fixes the abandonment of care and associated increases in morbidity and mortality with only the physician responsible. . Use the money the middle men conglomerates steal to insure more citizens. Of course that’s a dream. Bismarck would work well also enabling all access to quality affordable private care
Faculty member UCLA Fielding School of Public Health : Health, Policy and Management
3 年Waiting to hear about the solution Look forward to to hear about your design
Dermatology & Dermatology Mobile Apps
3 年American Medical Care is unique. Insurers and not physicians manufacture and and produce preventive, medical, surgical and palliative outcomes with patients, yet, physicians still take full responsibility for these outcomes managed and produced by non-physician conglomerates.