Fixing American Health Care
Almost weekly there are people who call out for solutions for the sad mess that is US health care. The latest call by Dr. Stephen Ambrose moved me to respond. The foundation of any improvement in outcomes or costs is the understanding that the US population is what predominantly shapes outcomes and costs. The health care designer role to improve outcomes is to substantially redistribute dollars via their health care designs.
The designers would need to change designs from concentrating dollars toward better distribution - the opposite of designs across the decades.
Health care designers can best act to fix health care by changing course 180 degrees
They must boost health care services, dollars, jobs, economics, social determinants, and outcomes where most Americans have lowest levels across all of these most important areas.
Health, education, economic, and social support dollars must be redistributed from the places where they are most concentrated to go to the places where most needed - even if this portion of the population to receive the redistribution is the population stimulated to most protest this redistribution or any such programs.
And somehow the designers must conquer the predators that feed at the government budget trough and steal far too many of these dollars before they can pay for the health care delivery team members needed. This may be the most challenging task of all.
The current designers move through academic institutions, foundations, associations, and corporations that benefit most from these designs. The designs have been stimulated by To Err is Human, Crossing the Quality Chasm, managed care groupthink, the Dartmouth Assumptions to Orsag to ACA and beyond. Each time the focus has failed to consider the impacts upon the populations most behind and those who deliver their care. Even primary care has been changed. The associations focus on marketing (Primary Care Medical Home) and better quality (value based) without understanding the high costs or impacts upon primary care delivery and primary care team members where primary care is most needed.
See how primary care associations make situations worse.
See how primary care fellowships have changed from service to self service.
The basic responsibilities that hold physicians or human subject researchers accountable - apparently fail to apply to health care designers.
- Protection of Vulnerable Populations - To understand consequences to vulnerable populations, you must consider these populations
- Beneficent Intent - To understand harm caused, you must consider that designs cause harm and how they could cause harm.
- Informed Consent - Vulnerable populations have some idea regarding their lesser situation, but they do not understand the designs that shape and maintain this. And they have no consent - no power to modify the design. The consequences are never explained to them.
New designers are required or at least ones that can comprehend the situations facing most Americans most behind and how health care designs make their situations worse.
Outcomes Are Predominantly About Populations, Not Clinical Interventions
First it is important for the designers to understand that outcomes are about populations - not clinical or system or plan interventions. Attempts to micromanage to better outcomes are doomed to even higher costs, more maldistributions of workforce and health spending, greater disparities, and lesser outcomes.
Few look at health policy from two key perspectives - the economist perspective and the perspective of counties lowest in outcomes, workforce, health care dollars, and social determinants. For example, this half of the US ranks about 40th to 60th in these areas when compared to other nations.
The US design fails these populations most and micromanagement of costs makes this worse. You can track billions more stolen from the practices and hospitals where most Americans most need care - billions that go to higher concentration corporations, places, and populations. Metric, measurement, and micromanagement focus is great for those who benefit as consultants, corporations, and CEOs - but the cash distribution changes via policy changes are exactly the wrong direction for improvements in local health care, jobs, economics, and social determinants for those most behind already.
Second, Health Care Costs Are Shaped By Populations Predominantly
Second it is important for the designers to understand that populations substantially shape costs. Americans want everything done and fight any restrictions on their care. This is particularly true for those with some power or authority and those closest to the designers and politicians.
Most Americans have the least, and the access to the least care. They get even less of the most costly areas. Note how telehealth is limited to help. Artificial intelligence and precision medicine would clearly go to those with too much and not to most Americans most behind.
Only one effort ever tried to address this problem by engaging the population in discussions to set priorities of what services would be covered vs not covered. Benefits for most were prioritized and highest cost services were given lower priority. This was sadly only a small segment of the state population in a state with limited health funds (Medicaid, Kitzhaber)
No one wants to have rationing, especially the population most behind. But the fact is that populations least valued have the most health care rationed and prevented - by design. And they appear to be easily manipulated into supporting designs for health, education, economics, and other areas that make their situations much worse.
Redistribute Dollars to Redistribute Outcomes, Workforce, Health Access, Jobs, Social Determinants, Local Health Care Leadership
Third, the designs must redistribute health care dollars from where they are most concentrated to where they are least concentrated. This could be the health care design's most important contribution to fight disparities and increase jobs and social determinants where most needed. These dollars paid would support care of the half of the US population with the least outcomes, least social determinants, least health care dollars, and lowest health care workforce.
But the designs for payment still reward procedural, technical, subspecialized, hospitalized services that are concentrated where workforce and dollars are concentrated. About 1% of the US land area in 1100 zip codes has just 10% of the population and 45% of physicians and generates over 50% of health care costs. More about the priority of distributing health care dollars equitably.
So You Say It is Not Possible to Redistribute Physicians?
Subspecialized care will still need to be concentrated in accessible locations where there are concentrations of workforce and support resources to facilitate this care.
But there is no excuse for deficits in access to the basic services provided by generalists and general specialists that provide 90% of locally available services in these settings. Paid less in these counties and paid less for these basic specialty services and paid less due to penalties via performance based designs - all are a reflection of the lack of
- Valuing basic services
- Valuing the populations most behind
As long as the Values are inappropriate the health care design will be worse. It is particularly tragic that the Value Based design is so inappropriate for the populations most behind and those fewer who remain to serve them. And studies can be initiated and funded by designers to support their value based designs.
America is where the majority of the population is treated like a minority.
Major Increases in Spending for Generalist and General Specialty Services
About 65 - 70% of US health care services are basic services. About 50% of US health services are primary care alone in MEPS data. This was 55% and is shrinking as other services increase and as primary care services decrease - even as population changes dictate much higher levels of primary care demand.
Not that this basic primary care area gets only about 5% of health care spending. And primary care can hold on to less and less dollars to invest locally in primary care delivery due to the predators micromanaging their remaining dollars away.
Primary care, mental health, women's health, and basic surgical services must be paid substantially more and payments must increase to cover the usual cost of delivering care increases as well as any regulatory design changes.
The generalist and general specialty workforces will continue to decline by financial design in ways that training more graduates or other training interventions cannot fix.
Massive expansions of MD DO NP and PA graduates have not improved redistributions of dollars, workforce, or access. In fact, they have increased the dollars, workforce, and overaccess where it already exists. See through promotions to see the truth about training interventions.
The 2621 counties most behind are kept behind by 15% lower payments in Medicare and lower payments via Medicaid and private plans are due to the worst health plans concentrated in these counties (for providers and for patients). And the states fail to address equity or justice. States continue to approve these worst plans - making situations even worse. More about the 2621 Counties Least Understood and Most Important to Understand
The Powerful and Best Paid Who Control the Information Will Fight True Reform
Note that those most powerful will oppose each of the three main areas as they have demonstrated. They have fought hard against new designs with any hint of true reform.
The design for the health care budget basically does not allow more health spending. So any increases in basic health services or services where most needed - would require cuts from those most powerful. So those entrenched already fight and defeat true reform or redirect reform to be even better for them. ACA/Obamacare is a great example. Even the original compromises that set up Medicare and Medicaid have consistently allowed state abuses in Medicaid and other areas.
Digitalization, Hospitalists, Certified EHR, MACRA, and Value Based all reward those who already had these (large systems had EHR), or those looking to fill gaps (Hospitalists, resident work hours limitation gap), or those looking to fill faculty positions (Hospitalists), or those desiring to control hospitalizations (Hospitalists), or those with the best outcomes due to the best plans, patients, and locations (MACRA, Value Based).
These changes have consistently hurt practices and hospitals smaller, doing basic services, with lesser finances, located in states and counties with the worst plans, or least able to address the constantly changing situations. Those must impacted do not have the size to set up a specialized branch to deal with some regulation - so the new changes are forced on those who exist, giving them more to do with fewer to do the work.
Not surprisingly this has shaped deficits in the states and counties most behind. The 2621 counties most behind involve 75% of the rural population, 100% of the rural population in rural counties predominantly African American (Southeast), Hispanic (Border), and Native American (Reservation, and 32% of the urban population most behind with lowest concentrations of health care workforce. These are predominantly Red Counties and bluest of the Blue as mapped in the 2016 election. Black, Brown, Yellow, White, and Red County Lives Matter
Red Counties should know more about the various health, education, and economic policies that worsen their situations - but ... Basic services, Meals on Wheels, Food Stamps, Disability, and Social Services are more important for the cash flow, jobs, economics, social determinants, and outcomes of these counties - but they are constantly told otherwise. Their populations are older, sicker, poorer - and are increasing faster by local population growth an by migration of more people like them that have little choice but to move to places with available and affordable housing.
The Horror Story of Designers Failing to Understand Most Americans and Those Fewer Who Remain to Serve Them
DRGs/PPS designs made this worse by paying less where care was and is most needed and the smaller hospitals suffered most. Elements of this such as reduced payments for new physicians also helped destroy practices where most needed. But mostly the policies continue to fail to address the usual costs of delivering care and add more costs and burdens.
Managed care designs in the 1990s assume overutilization even for these counties lowest in health care workforce suffering from underutilization and this has continued with ACA, MACRA, and value based designs
Primary Care Medical Homes, digitalization, and innovation work out well for consultants, CEOs, and corporations that profit from these changes - but actually steal dollars from primary care budgets. This forces primary care to pay more for non-personnel areas and steal more from the personnel budgets. This results in fewer and lesser team members and declines in caring and care capacity. Direct primary care can address this, except for the half of the population left behind by DPC also.
See how value based design fights against social determinant focus.
Note how health care design has been increasingly taken over by those who are already doing best - with a worsening result specifically for those most behind.
Logical Considerations by the Designers Could Help
People facing a lifetime shaped by disparities with least social determinants and outcomes are not going to have their situations, conditions, or outcomes fixed by a few minutes a year in a primary care office or in contact with primary care team members.
Health care is a particularly bad choice as far as a vehicle to address social determinants. This is seen when considering the limited influence of formal health care with regard to population contact. Primary care is grossly underfunded and impacts few, especially where local populations have half enough primary care professionals and even lower levels of primary care team members. Higher functioning primary care or patient centered primary care demand more and better team members but the financial designs are specific to fewer and lesser where most Americans most need care. Social resources, mental health, and womens health to integrate or coordinate are also half enough or lower where most Americans most need care. See why the innovative designs will not work because the designers fail to understand.
Hospitals contact only 8 out of 1000 people a month of which 800 express some health need (Ecology of Medical Care). Hospitals are focused by design upon readmissions. They can shape some of the outcomes over a month after discharge to prevent penalties for readmissions, but shaping other outcomes over months or years is beyond them.
Americans most behind have many disparities, not just housing or social support. We currently understand that disparities shape poor outcomes but not which ones and not how each one can best address the needs of a particular patient or population.
See How Health Care Costs Are Devouring Our Futures
Note that it will take generations of investments to fix US Health Care
... just as it has declined over generations. Investments in populations should steadily improve Americans generation to generation. The original Medicare and Medicaid designs injected many more billions into the places and populations most behind - and much more where populations were most ahead. Americans demanded and consumed even more as did the largest and most powerful in health care. This resulted in massive cost overruns and consequences. The Era of Cost Cutting dominant in health care today was the result of these accelerating health care costs. This health policy era was implemented in the 1980s with DRGs and PPS - clearly with least focus on small, basic, and most needed services. The pain has consistently been felt by the populations most behind.
And all Americans suffer more and more. The micromanagement has continued to consume more and more at higher cost with little change in outcomes - by design.
Sadly the designs of health care and education reveal that the dollars are maldistributed and the focus on quality makes the situation even worse.
Ratings and Rewards Year to Year can be seen as costly, burdensome to those who deliver care, contradictory, arbitrary, and meaningless.
Why more and more for digitalization, regulation, metrics, measurements, and micromanagements without improvements in cost or in outcomes?
Why would you ever penalize hospitals and practices tasked with caring for populations with inherently lesser outcomes.
Why would you give Star Ratings lower?
Why would you steal more dollars from hospitals with higher readmission levels that are mostly about the local population, areas with half enough generalists and general specialists, and lowest social support resources (and likely most overwhelmed caregivers)?
Those Selected to Be Designers Shape Research that Fails to Consider Consequences
Not surprisingly the medical literature findings tend to support more intervention - until you consider that the outcomes in favor of an intervention are really about comparisons involving one population that inherently has better situations, social determinants, and other factors as compared to the other. Few consider this alternative hypothesis, so the designs continue. More about the Contrived Medical Literature involving outcomes
Why Not Just Increasing Primary Care Spending?
It is easy to see from the above why investing more in primary care alone is not going to substantially improve outcomes or costs as many claim. Starfield and other studies demonstrate clear associations between primary care levels and better outcomes. These studies involve regression equations with serious limitations.
As I was attending workforce presentations by Starfield, I was also paying attention to those who recorded the major differences in health outcomes based on socioeconomic status (Michael Marmot PhD). These helped to explain the differences in outcomes in the US across just a few zip codes.
My studies with regard to distributions of health care professionals pointed out that the counties lowest in primary care were also lowest in social and other non-clinical determinants of health. I have tried to help the primary care advocates to see that their focus on more primary care or better primary care would change outcomes, but so far have failed in my efforts. It is easier to lobby for more funding if you can demonstrate that more funding will improve outcomes, but the actual relationships are far more complex. More about Primary Care Levels and Outcomes.
My read is that:
Nations where the designers value a broader population and support that population have better levels of primary care and better outcomes. Nations such as the US with designers that do not value better distributions have set up designs that favor a few over the many. The populations most behind have lesser outcomes and lesser primary care and basic health and education support.
In the US where primary care is 2 to 3 times greater than the average, the best performing populations, health plans, and health providers are found. Where the US has half enough generalists and general specialists, the populations have concentrations of the worse health insurance plans and inherently lesser outcomes.
Why Primary Care for All will not work either.
Unethical to Distort Patients, Populations, or a Nation Away from True Solutions
If a physician promotes a treatment for a patient that will not work, this is considered unethical or malpractice. If a designer promotes a design change that causes harm to millions or tens of millions, this is considered the usual practice as seen for decades.
Note that Opinion Leaders Promote Many Solutions and None Are Specific to the Major Needs of Most Americans Most Behind. If a "solution" is promoted often enough and has significant financial backing, it will likely be replicated and marketed widely. https://www.dhirubhai.net/pulse/even-clue-fixing-health-care-where-most-americans-need-robert-bowman/
Change the American Population to Change Outcomes
The focus on changing outcomes and costs must involve changing the American population - particularly the half of the American population and increasing that is most behind.
This is also the solution for best addressing health literacy gaps, better utilization of health care, pandemic preparation and modification, optimal vaccine distribution, and a public that demands equity via health and education and economic designs.
Consider that the American population most behind in these areas have suffered most from COVID. Proper studies involving variables specific to these people would move past race or ethnicity or comorbidities to see the relationships, behaviors, situations, conditions, and social determinants that shape outcomes.
HHS Wants Much for Rural Health But Does Little - Notice that those who shape designs must appear to be focused on doing better, but are quite limited in their ability to shape better costs, quality, or access. Also note that associations focused on rural health, support these reports doing little. HHS Secretary Azar indicates that “Our goals for rural health and human services are simple: they need to be affordable; they need to be accessible; they need to be high quality; they need to be sustainable; and they need to be innovative.” NRHA and others may applaud the work, but this does not help to reverse HHS designs that continue to act to worsen costs, quality, and access. This is an examination of the four simple goals of HHS. https://www.dhirubhai.net/pulse/hhs-wants-much-rural-health-does-little-robert-bowman/
CMS Should Be Considered the Major Reason for Shortages and Access Barriers
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/
https://www.dhirubhai.net/pulse/health-care-journals-journalists-need-more-robert-bowman/?
Why Most Americans Most Behind Should Not Celebrate 10 Years of Obamacare https://www.dhirubhai.net/pulse/why-most-americans-should-celebrate-10-years-obamacare-robert-bowman/
The Three Cs of Corporations, Consultants, and CEOs win and we all lose, by health care design. https://www.dhirubhai.net/pulse/three-cs-win-corporations-consultants-ceos-robert-bowman/
ROLAIDS for Relief of Health Care Pains https://www.dhirubhai.net/pulse/rolaids-true-health-reform-robert-bowman/
Cherry picking remains the best plan to shape improved health outcomes. Just exclude those who cost more or have lower outcomes. https://www.dhirubhai.net/pulse/cherry-picking-remains-best-plan-outcomes-robert-bowman/
Why Migration Patterns may shape improving outcomes in cities and states with higher costs of housing and living https://www.dhirubhai.net/pulse/better-city-state-health-outcomes-so-fast-robert-bowman/
Obviously the WOPR Computer in Wargames had to learn about mutually assured destruction. Can health care designers learn this important lesson before it is too late? https://www.dhirubhai.net/pulse/mutually-assured-destruction-health-policy-robert-bowman/
As we spend more on health care, prisons, defense, and debt – we have less to invest in better outcomes for most Americans. https://www.dhirubhai.net/pulse/prison-military-health-spending-puts-us-behind-robert-bowman/