Not Even a Clue About Fixing Health Care Where Most Americans Most Need Care

America divides into a small portion doing extremely well and most Americans behind by design. From their perspective what seems to be a solution is not and may cause them and their providers more problems.

Robert Pearl MD collected top 3 health care fixes from the experts and opinion leaders that he interviewed. They were ranked in a top ten format at fixinghealthcarepodcast.com/2019/08/09/survey-results

1. Eric Topol wanted universal insurance - BUT Insurance coverages and expansions are not valuable when these involve plans that pay less than cost of delivery as is most common where care is most needed. True reform supports more team members where access is limited by half enough team members supported – by the financial design.

2. ZDogg listed Performance based incentives as important - BUT these incentive type designs (P4P, value based) actually make matters worse for care where needed. These practices where most needed are already paid 15% less. They are least able to purchase the certified EHR resulting in a penalty. They are more likely to be penalized because they care for populations with inherently lower outcomes - populations that reside in counties with half enough local generalists and general specialists and with half enough local support resources. These practices have to pay more for each disruptive innovation and they are likely to get less returned to them. Studies document this discrimination by performance based design.

3. ZDogg listed hiring more for primary care – BUT hiring more requires more primary care spending – prevented in the current design. More primary care team members is a solution for 40% of the US with 25% of the primary care workforce, but this would require 80 billion instead of the 30 billion going to primary care in these 2621 counties lowest in primary care concentrations. They would have to make up for half enough as well as compromises because of the poor financial design. Higher functioning primary care requires support, not regulation. And by the way, these primary care practices paid least and penalized most - have already had about 8 billion diverted from their budgets and team members to pay for HITECH, MACRA, PCMH, and other disruptive changes. They once had 38 billion in revenue to invest each year – but what remains to invest keeps declining as more billions go to consultants, corporations, and CEOs for meaningless metrics measurements and micromanagements. Their local populations have also been more depleted of the ability to pay by the designs for health, education, and economics.

4. Halee Fischer-Wright indicated that removing red tape would help, but we are far from that. A requirement to remove red tape would require enforcement. States fail to hold payers accountable for the numerous abuses to patients and providers.

5. Eric Topol wanted physicians paid by salary to eliminate wasteful care. Physicians are employees and are largely paid by salary. Fewer are independent, perhaps 20%. The employers are larger and more powerful and dictate much of what occurs. Some physicians do have productivity designs but these are set by employers. The employers base their decisions upon the financial design. Once again what is assumed to be a problem for those in higher concentrations, tends not to be a problem where care is most needed. Where needed most, primary care has too much to do and lowest payments. Those choosing this career and location are not the ones that selected for most lucrative gains.

There are also problems with salary designs. Salary designs have been abusive for employed primary care. Salaried physicians are given more to do with fewer support personnel – adding to burnout

6. ZDogg wanted more convenient care access - BUT... It would seem that more convenient care would help – but generally it adds to the costs without changing outcomes. Also patients are increasingly diverted from use of local primary care, undercutting the primary care that remains.

7. Eric Topol speculated that machine learning would reduce hospitalizations. If reductions in these area are the desired goal, we can look at the literature. Hospitalizations have been reduced by small practices, particularly the smallest (Casalino). Supporting small practices has literature to support reduction of hospitalization. Speculation is not helpful. Improvements in access are a good idea for addressing cost and quality – but our nation is going the other way.

8. Don Berwick wanted a 75% reductions in measurements. Thanks to Dr. Berwick and others, Pandora’s box was opened and we now have runaway costs and distractions to care delivery. The various CEOs, consultants, and corporations plus related marketing and publishing have taken over health care - and opinions about health care. Measurements have numerous problems with many more to come.

9. Ian Morrison wanted more physician leaders. BUT this is not necessarily a solution. Physicians do not necessarily need to lead health care. There are many others in health care such as nurses and techs. We need leaders to listen to all of those who deliver the care. But instead, the designers appear to be doing all possible to disable those who deliver the care – stealing their time with patients, other team members, and their families. Those delivering the care are less likely to influence health policy, because they are so busy with care – further reducing their influence and the awareness of the designers.

10. Don Berwick is still focused on his version of Triple Aim that he helped to distort. Most important for health care delivery past, present, and future is Access. This is common sense as health care delivery does not exist without access. Cost and quality improvements have been seen with improved access. New disruptive designs have acted to reduce access where needed. The focus on micromanagement of cost has been costly, distracting, and disabling – as has the focus on micromanagement of quality. Access is the foundation destroyed by US design.

When these are the opinion leaders shaping designers and perceptions – we have far to go to get to anything close to Basic Health Access