These Are A Few of My Favorites For Better Basic Health Access
If you want ready access to the most relevant works that point out why most Americans have half enough generalists and general specialists plus the low down on the worsening health care designs of our nation, these are my go to sources.
Under construction
Micromanagement Failure
For decades CMS and other designers have attempted to micromanage for cost savings. They have failed to rein in costs. They have spectacularly failed to rein in costs of the big health (academic, largest) systems. They still include these prominently as major influences regarding the health care design. The designers still tolerate more lines of revenue and the highest levels of reimbursement where workforce is concentrated.
Micromanagement has not only failed to rein in costs, it has increased costs and can act to worsen basic health access where the workforce is lowest and has the worst financial designs already.
Why studies often support micromanagement
Data Science Has Become About Lending False Credibility to Decisions We've Already Made - Kalev Leetaru?Contributor?AI & Big Data
Quality improvement studies are funded to show benefits of interventions by funders that want to show benefits and those doing the research also want to find benefits as do those who publish journals and those who read journals and those who report about journal articles.
The Lack of Quality of Quality Improvement Studies - especially controls and rigor in analysis and explaining away the hypothesis that outcomes are about population differences and not interventions
Reflect on this series of publications about a clinical intervention to improve COPD outcomes. The first publication indicted that the outcomes were improved by an intensive clinical intervention. To their credit the authors explored their work and findings and found that they did not have the proper controls and approach. This took an incredible amount of work and some difficult reflection as well as improvements in their research and analytic ability. This is not a lazy study as with far too many quality focused studies. These studies take much more work. They take much more data about the non-clinical factors. Studies using the large convenience data sources are too easy and are too distracting because they have so few patient factors.
COPD hospital based intervention retraction demonstrates how the relevant outcomes may be reversed by the choices of researchers regarding data, who to include, controls, and other variables. To their credit, the republication corrected the previous publication errors. https://jamanetwork.com/journals/jama/article-abstract/2752467
By KIP SULLIVAN JD?Review of The Tyranny of Metrics by Jerry Z. Muller,? . You will not see a better description of the micromanagement madness than at this site via Sullivan and Muller. If you are promoting managed care, micromanagement, cost cutting, quality improvement, or value based designs, this is a must read. You must consider the many assumptions and flaws and harms and potential harms that this does to those who deliver the care, particularly where care is most difficult to access.
Study the Tyranny of the Mean and understand the errors introduced by inserting mean values for income or education instead of actual data specific to the patient.?"What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands that feed it."?SAURABH JHA, MD (associate editor with The Health Care Blog)
Micromanagement Fails Over and Over
Exhibit 1 is the Epitome of Micromanagement and Innovation - the CMS Innovation Center. They are apparently so confident in micromanagement that they publish their results and indicate 5 for 52 or 47 failures out of 52 attempts. Some were spectacular failures including some up front investments in primary care - but if you understand how badly primary care is underfunded - you can understand how this happens. And if the boost in primary care is small and incremental, you are not going to see cost or quality changes.
CMS Innovation Center at 10 years of failures https://www.nejm.org/doi/full/10.1056/NEJMsb2031138
Instead of reigning in innovation, CMS decided that it needed more skin in the game. Seema Verma Hyperventilates About Tiny Differences Between ACOs Exposed to One-and Two-Sided Risk
How Can You Address the Real Triple Aim - cost, quality, and access
In contrast are movements from little or no access to superior access as seen in ChenMed, Southcentral Foundation, hospice, homebound, and disabled via coordinated team efforts and telehealth. The reductions in cost and in quality for these are about the major boost in access for those without - not some "value based design." These are about more and better delivery team member to be able to do integration, coordination, outreach, and other higher primary care functions - functions denied by CMS and other designs where the financial design shapes fewer and lesser team member and worse.
The Impossibility of Resolving Primary Care Deficits By Training, Innovation, or Technology
Flat lined primary care???The Health Resources and Services Administration projects a 17?percent increase in primary care physician demand yet only 11?percent net growth between 2013 and 2025.2
Health Resources and Services Administration.?National and regional projections of supply and demand for primary care practitioners: 2013–2025?[Internet]. Rockville (MD): HRSA;?2016?Nov [cited 2021 Nov 18]. Available from:?https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/primary-care-national-projections-2013-2025.pdf?Google Scholar
Even my most conservative estimates of primary care retention from a decade ago were too rosy. Retention has declined much more. See how NP PA and IM generate the least primary care delivery per graduate at 2 to 4 or far below the ideal at 35 SPCYrs or the best at 24 for 1975 FM graduates. There are too many options and these are all supported by better financial designs resulting in fewer entering primary care, fewer staying in primary care, less and less experience in primary care, etc.
It is impossible for training more graduates to address primary care deficits
First, the massive expansions of MD DO NP and PA for decades of class years has not worked.
Second, primary care spending and workforce are both flat lined
Third, payments are lower where concentrations of workforce are lower.
The fewer family practice positions filled by MD DO NP and PA are most important for distribution such as 36% found in the lowest health workforce concentration 40% of the population, but where it is more important it is most abused.
Finally, the declines in primary care have been reducing the primary care delivery across all graduates, even the best sources such as family medicine. Using FM as an example for all primary care and setting parameters at 80 - 90 primary care physicians per 100,000 or about 350,000 Standard Primary Care Years required from graduates to meet this level
You can see that the number needed to treat deficits is higher than can be reached and is increasing fast - too fast to ever resolve deficits of primary care. Also remember that primary care remains concentrated in higher concentration areas - reducing what can resolve deficits. No training intervention can work. Only a financial design can shift more to enter and remain in primary care.
Primary Care Research That Matters and Should Be Increased Instead of Quality Improvement
"The 3 illustrative cases reveal it is possible for some primary care practices to seize ownership of their care and prioritize their craft of family medicine. These practices began with their founders' realization that matching their practice to their values was impossible, given the conventional financing system and commercial EHRs designed to serve it. They came to this conclusion differently but took similar action by developing business models that circumvented the limitations of fee for documentation and pay for performance.
Although their clinical care and business models differed, all 3 practices succeeded in shifting the source and directional emphasis of change from outside-in to inside-out.
Shifting Implementation Science Theory to Empower Primary Care Practices
William L. Miller, Ellen B. Rubinstein, Jenna Howard and Benjamin F. Crabtree
The Annals of Family Medicine May 2019, 17 (3) 250-256; DOI: https://doi.org/10.1370/afm.2353
领英推荐
Small and medium size practices are more likely to be disrupted by changes in key personnel, EHR, billing, location, ownership, and other changes. These can be costly and can contribute to inability to adapt to any number of changes.
The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma
James W. Mold, Margaret Walsh, Ann F. Chou and Juell B. Homco
The Annals of Family Medicine April 2018, 16 (Suppl 1) S52-S57; DOI: https://doi.org/10.1370/afm.2201
Casalino comment at https://www.annfammed.org/content/16/Suppl_1/S12
Casalino LP, Pesko MF, Ryan AM, etc. Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood). 2014;33:1680-1688. https://content.healthaffairs.org/content/early/2014/08/08/hlthaff.2014.0434.abstract
?Accessed September 22, 2014.
Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings??Clemens S. Hong, MD, MPH; https://jamanetwork.com/journals/jama/fullarticle/186551
Association Between Patient Social Risk and Physician Performance Scores in the First Year of the Merit-based Incentive Payment System
Conclusions - In this cross-sectional analysis of physicians who participated in the first year of the Medicare MIPS program, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with other physicians. Further research is needed to understand the reasons underlying the differences in physician MIPS scores by levels of patient social risk.
In the Introduction - Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect.26
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Value Based Care – no progress since 1997?https://thehealthcareblog.com/blog/2020/10/12/value-based-care-no-progress-since-1997/
About Nurse Practitioners - Too Many, Least Experienced, Failure for Primary Care as with all sources
As noted above, massive increases in NP at 6% more a year doubling annual graduates each 12 years or 10,000 to 40,000 from the 1990s until recent class years - have not touched primary care deficits. The financial design deflects any and all would be Basic Health Access workforce.
Policy Evaluation Of The Affordable Care Act Graduate Nurse Education Demonstration - The limitations are specific to faculty, teaching interactions, clinical material and more. These are documented, but they ask for even more millions. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2021.01328
And finally from Kip Sullivan via Muckrack
The “medical home” concept has become counterproductive. It is muddling the debate about how to improve medical care without raising costs, and it is punishing primary care clinics. A recent paper by Ricardo Mosquera et al. illustrates both problems. At the beginning of the paper, the authors assert there is no solid evidence for the claim that “patient-centered medical homes” (PCMHs) cut costs. That assertion is correct.
UncategorizedJun 22, 2016? By KIP SULLIVANOne of the privileges of being a managed care advocate is that you never have to discuss the unpleasant question of how much your proposed intervention will cost. Whether your proposed intervention is HMOs, report cards, pay-for-performance, ACOs, “medical homes,” or electronic medical records, you never have to estimate what your bright idea will cost.
By Kip Sullivan for PNHP –The people who brought us the “public option” began their campaign promising one thing but now promote something entirely different. To make matters worse, they have not told the public they have backpedalled. The campaign for the “public option” resembles the classic bait-and-switch scam: tell your customers you’ve got one thing for sale when in fact you’re selling something very different.
By KIP SULLIVAN JD?Review of The Tyranny of Metrics by Jerry Z. Muller,? . You will not see a better description of the micromanagement madness than at this site via Sullivan and Muller. If you are promoting managed care, micromanagement, cost cutting, quality improvement, or value based designs, this is a must read. You must consider the many assumptions and flaws and harms and potential harms that this does to those who deliver the care, particularly where care is most difficult to access.
By KIP SULLIVAN JD?On the morning of December 21, I opened my copy of the New York Times to find an op-ed?that said almost exactly what I had said in a two-part article The Health Care Blog posted two weeks earlier. The op-ed criticized the Hospital Readmissions Reduction Program (HRRP), one of dozens of “value-based payment” programs imposed on the Medicare fee-for-service program by the Affordable Care Act.
By KIP SULLIVAN JD?The Hospital Readmissions Reduction Program (HRRP), one of numerous pay-for-performance (P4P) schemes authorized by the Affordable Care Act, was sprung on the Medicare fee-for-service population on October 1, 2012 without being pre-tested and with no other evidence?indicating what it is hospitals are supposed to do to reduce readmissions.
By KIP SULLIVAN JD?Egged on by the Medicare Payment Advisory Commission (MedPAC), Congress has imposed multiple pay-for-performance (P4P) schemes on the fee-for-service Medicare program. MedPAC recommended most of these schemes between 2003 and 2008, and Congress subsequently imposed them on Medicare, primarily via the Affordable Care Act (ACA) of 2010 and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
There is no meaningful difference between the performance of Medicare ACOs that accept only upside risk (the chance to make money) and ACOs that accept both up- and downside risk (the risk of losing money). But CMS’s administrator, Seema Verma, thinks otherwise. According to her, one-sided ACOs are raising Medicare’s costs while two-sided ACOs are saving “significant” amounts of money. She is so sure of this that she is altering the rules of the Medicare Shared Savings Program (MSSP).
Pay for performance, a dangerous health policy fad that won't die
Pay for performance, the catchall term for policies that purport to pay doctors and hospitals based on quality and cost measures, has been taking a bashing.