COVID Confirms Americans Most Behind in Key Areas Such as Health Literacy and Social Determinants

What set this off was a number of state and national FM communications indicating that primary care does play a major role in improving health outcomes.

COVID is revealing the truth of the matter with regard to what shapes and maintains low outcomes. COVID is hitting the American population hardest - and where Americans are most behind. This is not just race/ethnicity. They studies limited to race/ethnicity are quite limited. They actually distract from factors likely to be more powerful (by using proxy variables, by focus on comorbidities, by failure to including social determinant variables).

We must move to a more mature understanding of social determinant and other non-clinical factors as shaping outcomes in health, education, economics, and more.

Articles have long indicated that the American population moved to another nation with their health care system and providers - would have poor outcomes. Yet we still try to change our health system, hospitals, and practices - and the outcomes remain poor because of our population. Even worse, we hold providers responsible for poor outcomes - that they have little ability to change.

Summary

1. Most Americans most behind have predominantly fixed outcomes that primary care is unlikely to be able to change

2. Americans behind in health outcomes are also behind in education and economic outcomes. The same factors likely shape all three and primary care cannot be seen as changing education or economic outcomes

3. Performance and value based designs are not capable of changing outcomes

4. Performance and value based designs are costly and burdensome and actually hurt cash flow, economics, jobs, and social determinants for the populations most behind. They steal more billions of dollars each year from hospitals, practices, and other health care where most Americans are most behind by design already

4. The designers must be made aware of the discrimination and damage caused by their designs

5. AAFP and other associations and foundations have a mission to support the family physicians, primary care, and populations most abused by design

If it has not been obvious before that we are wrong about value based designs, consider again. COVID reveals the truth as with other health care crises. COVID reveals the near impossibility of shaping health outcomes via value based or pay for performance designs. 

• Because of the health illiteracy of the American population, worse where most Americans are most behind where COVID has been worst
• Because the social determinant factors are lesser for most Americans, also worse where COVID has been worst.
• Because diabetes, obesity, mental health, chronic respiratory problems, heart disease, smoking, and other chronic diseases and conditions are worse for most Americans and where COVID has been worst.
• Because the Americans most behind in outcomes such as infant mortality, longevity, premature death, and maternal mortality are also most behind in health care workforce and in social supports and various outcomes.

Education and Economic Outcomes Are Also Most Behind

These populations or counties most behind also have the worst high school graduation rates, college continuation rates, college graduation rates, and more. These obviously lead to economic issues along with our trade policies, education designs, and health care designs.

Sadly education efforts are also crippled by performance based metrics, measurements, and micromanagements increasing costs and burdens while not changing outcomes.

Any reasonable immersion in county level data with some understanding of correlations and associations reveals these relationships.

Consider that outcomes in health and in economics are behind in the populations behind in health outcomes

• And have nothing to do with primary care interactions with these populations
• And the lower outcomes across the board are closely related to one another and to child well being measures and to social determinant factors

Note to Primary Care Leaders

Please stop saying that primary care is a major factor in changing outcomes. We still have medical school and FM leaders saying this. Why do you want to be held accountable for outcomes that are not possible to change? Why make the situations worse for most office family physicians serving most Americans whose outcomes are fixed in place

• by birth origins
• by living locations
• by years to decades of previous life influences
• by difficult to change behaviors and attitudes
• by economic and education deficits by design

So please stop the value-based support rhetoric.

Do not distract us from the need to change the American population to change outcomes in health, education, and economics.

Note to AAFP and Others

You may think that there is some hope to improve revenue via a new design, but clearly there are designers that continue to compromise our revenue and pay less where most Americans most need care

And the HITECH to ACA to MACRA to PCMH to Value Based design train has run over family physicians and their patients and also the populations that they serve.

Any reasonable economic consideration of these high cost changes indicate

1. Fewer dollars generated and retained by primary care practices where most needed due to penalties and lower productivity

2. Billions more each year in regulatory costs of delivery

3. Higher costs and losses from personnel turnover and higher turnover rates

4. Less cash flow to these populations flowing from their practices - due to fewer dollars in and more dollars out

Attempts to Improve Outcomes Can Make Situations Worse, When the Designers Do Not Understand the Consequences of their Designs

They do not have higher levels of unemployment, but they have the worst employers and benefits and health insurance. They are not lazy, they are abused. They they could use jobs building up the deteriorating physical infrastructure where they live - roads, bridges, pipes, and more - but this is being denied.

They do not have more who lack insurance, but they have the worst public and private health insurance plans - Medicaid, Veteran, High Deductible, and worst private insurance. They do not lack for health insurance and need expansions. They near meaningful health insurance not more meaningless insurance that fails to protect them and that fails to support their local health care and access to care.

AAFP may find it politically useful 

... to work with the government and insurance designers to improve the primary care finances. But it should never indicate that primary care practices can substantially change outcomes. I do not care if a long line of Family Medicine leaders have helped to shape and promote and expand P4P - this does not make it right. I do not care if people give AAFP a hard time about a policy that appears to indicate that family medicine is not interested in quality or better outcomes. The fact is that we are. And that is why we must oppose the consequences to outcomes and to basic health access because of such designs.

Focus on Practice Finances and Economics and Support - Not Meaningless Micromanagement Designed by Designers Far Away

Now more than ever we need to expose the predatory entities that are ruining health care (or running health care). The corporations, CEOs, consultants, and others that do not deliver the care, but leech on their new wrinkles and find more ways to more billions of health care dollars each year - as health care costs increase and as outcomes decline.

It is obviously quite useful to indicate to legislators, staff, and lobbyists that primary care changes outcomes. I will leave it up to your scientific integrity about this one. I would suggest that you carefully review these studies, their lack of limitations, and their biases across design to publication. I cannot help you if you think that the primary care vs outcomes studies had adequate controls and were able to explain away the non-clinical, genetic, and social determinant differences as shaping outcomes.

Many studies involving correlations and regressions look great without considering the alternative hypotheses.

Is It Possible for Primary Care to Change Outcomes?

Yes, moving people from no access to some can change access, costs, and outcomes in positive ways and there are numerous examples (hospice/terminally ill coordinations, homebound telehealth, others).

But to blanket say that primary care offices in a few minutes of time a year can change outcomes substantially in populations that are substantially fixed in place - is not correct.