The Designers Ask the Impossible from Primary Care Practices That Are Already Compromised By the Financial Design

New recommendations from the US Preventive Services Task Force indicate that counselling with regard to changes in diet and activities can reduce the cardiovascular events. A number of studies indicate that 30 min to 3 hours of counseling can result in 1 less serious event per 100 people counseled - maybe. The task force did not consider the challenges attempting to provide these services or the consequences to practices that are already compromised and on the brink of closure.

The editors raised some important concerns as they gave a critical review:

1. Will the recommendations result in better outcomes in the real world?
2. Are the recommendations practical?
3. Can the recommendations be done?

These are very important questions that require much more study, but there are already some answers when you consider the situations already facing the Americans most behind in health care design, outcomes, and access. This can be illustrated by using the example of the costs and consequences for the 2621 counties lowest in health care workforce.

Using physician databases, Area Resource File data, and county level data on diseases, behaviors, and outcomes - I have previously categorized the US by health care workforce concentrations. Counties were stacked from highest to lowest concentrations of physicians and arbitrarily divided into a top 10% of the population of 79 counties, a higher 20% in concentrations involving 152 counties, a middle concentration 286 counties, and a lowest concentration 2621 counties. These map out as the Red Counties in the 2016 election and the rural counties bluest of the Blue with a majority that are Native, African American, or border Hispanic.

These counties have long been the lowest in concentrations of health care workforce, health access, health care spending, and all types of health professionals and their specialties. Generalists and general specialists represent 90% of the locally available health services, services paid the least by past, present, and future design. The closures of over 800 hospitals since 1983 PPS/DRG changes have been predominantly in these counties - another factor in low levels of health care workforce. Most specialists and many general specialties depend upon the existence of local health facilities - the ones that have steadily been designed away since 1983.

The practices that remain in these lowest concentration counties are paid the least for the same services by 15% as seen in Medicare 2011 data. They also suffer the lower payment consequences of the worst health insurance plans, both public and private, that are concentrated there. Similarly the population enjoys the worst employers and paychecks and benefits, including the worst health care insurance.

• Clearly these counties have not been valued by the US at the federal and state levels

For years I have been trying to raise awareness with regard to the abuse - of the people and of the remaining health care, particularly the primary care practices in these counties. Not only do they have the worst finances by design, they care for the populations that inherently have the worst outcomes. Clearly they have deficits of workforce cannot be fixed by training more graduates, as we have massively expanded training without impact on primary care or care where needed for decades.

You can easily see that the various pay for performance and value based schemes will make their situation worse where health access is already least – by design. These schemes add to the costs of delivering care and compromise health care team members to lower productivity and limitations in care and caring.

• Many of these physicians are near retirement or are near to closing their practices. Avoiding a large cost in these situations with significant disruption of the practice is advisable.
• Others are unable or unwilling to address the costly regulations, decisions that can result in penalties and exclusions from some of the health insurance plans.

These all impact the practices and the populations negatively.

Even worse the HITECH to ACA to MACRA to Primary Care Medical Home to value based designs have depleted their finances and their delivery team members as we will review.

Now we have the latest recommendations from the US Preventive Services Task Force. This raises questions.

1. Can these practices hire and maintain the necessary counseling workforce or any additional workforce?
2. Would the counseling recommendations work for these populations that have not been studied and are different from those previously studied?
3. Do the designers have a clue with regard to the practicality and relevance of their recommendations?
4. Do the designers understand the consequences of constant policy changes, regulations, innovation, and digitalization?

The short answers are

No, these practices cannot hire more personnel, period. Their finances have been decimated and they are already forced to compromise to fewer and lesser delivery team members. The cost of over 30,000 counselors represents 2.3 billion more in cost for practices receiving less than 30 billion a year. 

1. It is unlikely that the recommendations would work for this 40% of the nation due to lowest health literacy, worst health behaviors, most chronic conditions, worst employment and employers, traditional diets, worsening of sedentary lifestyle, declines in vigorous exercise, and continued declines in their education, economic, health, and societal outcomes.
2. The designers and researchers should not speculate that their recommendations have relevance for this population.
3. The designers clearly do not understand this population or their situations and conditions and health care environments.
4. The designers clearly have not considered the consequences of their micromanagement assumptions for this population or for the American population.

The 130 million people in 2621 counties lowest in health care workforce this are a population with higher concentrations of elderly, poor, smoking, diabetics, obesity, sedentary lifestyle, lack of vigorous physical activity, heart disease, premature death, COPD, asthma, mental health issues, health literacy issues, and more.

Unable to Afford the Required Number of Counselors

A ballpark estimate would be that this population has 30 million at risk of cardiovascular events spanning the ages from young adult to elderly

Counseling could prevent 300,000 cardiovascular events with 2 hours of counseling

This would require 33,333 more primary care team members dedicated to counseling at 1800 hours a year.

An average cost would be about $70,000 for salary and benefits for this team member.

This would require about 2.3 billion dollars from primary care in 2621 counties lowest in health care workforce that have less than 30 billion remaining to spend on primary care delivery. These practices had 38 billion to spend in 2008 but finances have deteriorated due

1. due to rapid increases in the costs of delivering primary care from usual cost of delivery increases
2. due to rapid increases in the costs of delivering primary care due to disruptive innovation
3. due to stagnant primary care revenue (or declining). https://www.dhirubhai.net/pulse/four-decades-steady-declines-primary-care-delivery-across-bowman/

In 2008 when HITECH began and the micromanagement bandwagon moved to ACA, MACRA, Primary Care Medical Home, and value based designs the financial situation was much better.

Primary care spending was about 5% of total health spending or about 200 billion dollars. These counties had 25% of the primary care workforce for a raw calculation of 50 billion, but corrections for lower payments and worst health care insurance reduce this to 38 billion for 2008.

These counties have 40% of the population and only 25% of the primary care workforce supported by 20% of primary care spending. A similar situation exists in women’s health and in mental health.

Note that the deficits in these areas also tend to stretch primary care to cover these and other broader scope areas. This makes it more difficult to address new areas such as integration, coordination, counseling, prevention, public health, or outreach.

The Sources of the Increased Costs of Delivery from HITECH to Value Based

Health Affairs articles were used to input the cost per regulation, innovation, or digitalization change per primary care physician. These costs added have been in the range of $30,000 to $50,000 per primary care physician. The calculations of the total cost were based on 60,000 primary care physicians in these counties in 2013. Since rural practices have had low adoption rates, a figure of 30% penetration was inputted.

This results in about 1 billion less remaining for these practices to invest in primary care delivery with each passing year. The practices that remain only have 30 billion to invest when considering just stagnant revenue and increasing cost of disruptive innovations.

• Worsening finances shape fewer and lesser team members – also a direction away from higher functioning primary care or patient centered primary care.

The situation is likely to be much worse

1. The added duties of micromanagement would shave productivity and revenue generation by a few percentage points - perhaps $500 million to a billion less, not cumulative.
2. Increasing turnover cost and frequency hit these practices hardest at $300,000 per lost primary care physician with a loss frequency each 3 years for $100,000 per FTE per year. Turnover costs for physicians alone in these practices is a 5 billion dollar cost a year out of the less than 30 billion remaining. These impact the practice budget most directly and reduce what can be paid for the remaining delivery team members - another factor in fewer and lesser team members.
3. The figure for recruitment, retention, and locums cost for Alaska alone goes up by 1 million a year past 12 million a few years ago. Based on this figure for this lower concentration portion of Alaska, the application to the US total lower concentration counties is about 300 - 500 million more in such costs each year.

Mold also did studies that illustrated additional problems when small and medium size practices attempted quality improvement.

The usual disruptions from changes in key personnel, ownership, billing, EHR, and location hit these practices hardest. The practices in these counties have always been smaller. Also there are other usual disruptions in these counties with changes in employers, employment, mining, manufacturing, agriculture, trade policies, and disease patterns that Mold did not consider in his survey. After all, his was only the second paper published in this area. Seems that quality improvement gets 117 million and attracts the remaining primary care researchers, but detailed studies of practices from the inside out are lacking - as Miller and Crabtree illustrate.

The designers have never considered the unique challenges of these practices and hospitals or the consequences of their constant changes and manipulations. Research that actually focuses on the challenges faced by the delivery team members would be nice, but the designers are focused on justifying their designs. Seems like this is quite the usual with regard to data science.

The above all support some of the concerns raised by the editors with regard to the preventive task force recommendations.

"In conclusion, the data to support optimizing dietary patterns and physical activity to promote cardiovascular health is robust, rigorous, and spans the life course from in utero to older adulthood. Yet effective translation of these available data from randomized clinical trials to implementation in clinics, communities, and individuals is lacking." https://jamanetwork.com/journals/jama/fullarticle/2773250

In other words,

• we do not know if the recommendations will work on the usual population and
• we certainly do not know if they will work on the largely unstudied 40% of Americans most behind in health care design
• we do know that the financial design prevents implementation of this massive increase in counseling just as it prevents adequate basic health access, higher functioning primary care, and patient centered primary care. 

Why Do These Constant Promotions of Successes Bother Me So Much?  - They cannot work for most Americans because the resources integrated and coordinated - do not exist. Many of the interventions promoted by those in higher concentrations - make the practice of basic health care more difficult in lower concentration practices and hospitals. These so called "successes" are not really successful, they raise the costs of delivering care, they distract those who do care and caring, and they defeat basic health access.

https://www.dhirubhai.net/pulse/ignoring-most-americans-behind-across-housing-health-education/?

Medicare designs and dollar distributions are important to understand. Not only does Medicare design distribute dollars poorly, its design influences private insurers to do much the same. These plans act together to defeat Basic Health Access where most Americans most need care.

https://www.dhirubhai.net/pulse/same-future-medicare-great-few-worse-most-americans-robert-bowman/

Fight Design Discrimination to Restore Basic Health Access - and Our Nation  There are 3 very important reasons to fund basic services to a greater degree where they are most needed. We should fight for this even if the dollars must be taken from highly specialized care to be budget neutral. We have to fight for the basics and for those most in need, even if those doing well by the current designs fight back and oppose us.

Why?

1.      BECAUSE THOSE PRACTICING WHERE MOST AMERICANS MOST NEED CARE NEED THE SUPPORT – and our nation fails them, and they deserve not to face discrimination by design

2.      BECAUSE MOST AMERICANS MOST BEHIND MOST NEED THE SUPPORT– and our nation fails them, and they deserve not to face discrimination by design

3.      BECAUSE OUR NATION CANNOT IMPROVE HEALTH, EDUCATION, ECONOMIC, AND SOCIETAL OUTCOMES – because the designers are making choices and shaping designs that make disparities and outcomes worse.

https://www.dhirubhai.net/pulse/fight-design-discrimination-restore-basic-health-access-robert-bowman/

What must happen to change outcomes is a change in communities, populations, and who is valued. Most of the American population is being left behind along with the family physicians that serve them. If we are not up front about this to students and residents, how will they learn what is most important.

https://www.dhirubhai.net/pulse/which-future-family-medicine-designs-from-outside-empowered-bowman/

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

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.

https://www.dhirubhai.net/pulse/covid-confirms-americans-most-behind-key-areas-health-robert-bowman/

The story of US health care design is the story of concentrating dollars, health professionals, and facilities. The designs benefit few people while prospering those doing best already. The places and populations doing better are a contrast with most Americans doing worse. Health care costs defeat the lives of current and future Americans. Health care designs actually contribute to disparities, declining access, and declines in health outcomes. It is way past time to hold health care designers accountable for their designs.

https://www.dhirubhai.net/pulse/harming-tens-millions-americans-health-policy-design-robert-bowman/

A toxic culture now dominates primary care. Lesser support for the work, lesser pay, more goals to meet, and more tasks spread over fewer team members hurt the primary goals of primary care - care and caring. It is ironic that the value over volume mantra influences primary care to higher volume focus to attempt to make up for the higher costs of delivery forced on primary care by a decade of micromanagement-focused designs. There is a serious question of value and values that involves the basic generalist, general specialty, and hospital services in the United States.

https://www.dhirubhai.net/pulse/toxic-primary-care-environment-robert-bowman/