Innovative Health Care Designs Do Not Support Patient Centered Care and Value Based Designs and Will Worsen Outcomes, Not Improve Them

This began with an JAMA Network article that states that fee for service is not compatible with patient centered health care. As a fellow family physician I agree that Americans deserve such care. She claims that fee for service is not compatible with patient centered care. My work indicates that no financial design is compatible with patient centered care and the newer designs are actually worse when you consider the compromises to patient care and caring in value based and performance based designs.

I am pretty sure that she supports more and better team members in the primary care delivery team. I assert that the financial design past, present, and future proposed - all result in fewer and lesser delivery team members. The impacts of policy changes for decades indicate that the real problem is that the designers do not value basic services or most Americans most behind. Design changes make their situations worse and this will continue until we have new designers that value all Americans and, in addition, they understand the situations, conditions, environments, and health care for the half of Americans behind by design.

There is so much about health care in higher concentrations involving data and studies. There are too may policies rammed into implementation without considering Americans in lower concentrations or their health care.

New Designs Have Not Meant Help for Most Americans or their Basic Health Access Across Decades of Design Changes

Newer has been consistently worse, not better. The author is a family physician and writes from her perspective attempting to address complex patient needs. The author appears to equate a new design for health care with better opportunities to address these complex needs. This is an incorrect assumption. Perhaps the author has health care experiences in places that already have what it takes to do higher functioning primary care

• average to higher levels of primary care
• average to higher levels of women's health, women's health, and basic surgical workforce and services
• few impediments raised by health insurance plans
• ready access to average to higher levels of social supports
• more health care personnel, possibly due to academic or other funding support or in-kind contributions of residents or health professional students or volunteers.

But most Americans do not have the above and this is particularly true where most Americans have half enough of each of the above to go with concentrations of the worst public and private health care insurance and the most complex patients.

Continuity of Care Has Not Been Valued by the US Health Care Design

What the author illustrates very well is the continuity primary care relationship lacking in health care design. This requires adequate primary care and team members and both of these are prevented by the health care design. Insurance churn turns over patients by design. You also need long term stable primary care instead of constant turnover.

Optimal Primary Care - Denied By Design

Basic Health Access has long been denied to most Americans across decades of policy changes. Regularly almost weekly some new innovative proposal is made - that will not work for most Americans most behind. I have previously discussed

• Medicare for All https://www.dhirubhai.net/pulse/medicare-all-premature-until-groundwork-laid-robert-bowman/
• Primary Care for All https://www.dhirubhai.net/pulse/primary-care-all-nice-d-robert-bowman/
• Value based care - most of my posts

There is clearly no indication that in these design changes that there will be a boost in the financial design for primary care. Such a change is needed to finance what is most important for patient centered care - more and better delivery team members. The root of the problem is the lack of valuing basic services and valuing most Americans most behind.

Why should teachers get blamed for education outcomes that are shaped predominantly outside of teacher or school influence? Why should practices get blamed for health outcomes predominantly shaped outside of clinical influence? The real problem is that way most Americans are treated. COVID is a primary example of a nation that has failed to create and support a well-educated highly health literate population that can avoid or modify the course of basic illnesses. We have had a chronic problem made more evident by the latest acute pandemic problem.

It is time to move beyond the illusion of helping to improve outcomes when in reality new and innovative designs are meaninglessly impairing the delivery of care, are not improving outcomes, and are creating disparities by design. Consider this problem of health care design that ignores three key perspectives

1. Economic maldistributions arising from health care and other dollar designs
2. Impacts within practices and hospitals to those who deliver the care - particularly the delivery team members - These include direct impacts of more burdens to address and indirect impacts as budgets are depleted to pay for new innovations - leaving less to support the delivery team members
3. And consequences specific to most Americans most behind. Understand the rise of administrative costs and the decline of health access and outcomes where most Americans most need care. https://www.dhirubhai.net/pulse/stop-designers-from-making-health-care-delivery-worse-robert-bowman/?

Also changes in health policy have consistently failed to reduce health care costs or significantly improve health outcomes – and sadly have been compromising Basic Health Access by design. https://www.dhirubhai.net/pulse/valuing-basic-health-access-over-value-based-designs-robert-bowman/

If you really want to improve outcomes, start with infrastructure investments.

Nations must invest in the Human and Physical Infrastructures to hope to have a viable Spiritual Infrastructure. Child development, parent education, early education, change agent armies of teens and young adults working in health, education, and community projects are required. https://www.dhirubhai.net/pulse/infrastructure-failures-across-america-robert-bowman/

If you continue to increase the administrative costs, continue to distract the delivery team members from a focus on care and caring, defeat health access where it is weakest, and design for even lower cash flow, jobs, and economics for areas in most need of these - your designs are the major problem. Not only are they not addressing the real problems, they are distracting our nation from real solutions to health, education, economic, health access, and other major problems.

• Is it hard to understand that those who prosper during health care crises - are the ones who promote the crisis and benefit by design changes to address the crisis? Much the same is true with economic bailouts. Meanwhile the powerful and nearest the trough win and most Americans lose. It is the American design, sadly.

Higher Functioning or Patient Centered Primary Care Requires More and Better Team Members But the Financial Design Shapes the Opposite

All of the advances in primary care that are proposed demand more and better primary care delivery team members. The design changes have consistently shaped fewer and lesser where most Americans most lack Basic Health Access.

The Problem is Lack of Value and the Solution Is NOT More Health Care Emphasis

The author appears to claim that primary care can address many of the high need patient care areas. But the examples used reveal a nation that does not value its people – their housing, nutrition, safe water and environments, education, development, just legal practices, and more.

Health Care is Massive in Cost But Minimal in Influence

It is a great mistake to think that health care is in a position to fix the number and degree of disparities that impact 30 – 50% of Americans – particularly as they grow older and poorer and more in debt, often because of the health care design.

The Ecology of Medical Care demonstrates the problem of health care out of position to address health outcomes. These studies are based on 1000 people per month with regard to health care issues. About 800 consider some health care issue. About 200 visit a physician, about half in primary care. Only 8 are associated with hospital care. Note that primary care visits are shrinking also.

Now Reconsider Most Americans Most Behind

Most of all consider that half of the US population has half enough generalists and general specialists and half enough social support resources – and each of these three are shrinking in the face of increasing need.

Even worse, these are the populations with inherently the lowest health, education, and economic outcomes. This indicates that performance based designs will be more likely to result in penalties to practices and hospitals already paid less and facing greater challenges. 

It is time to move beyond the illusion of helping to improve outcomes when in reality your designs are meaninglessly impairing the delivery of care, are not improving outcomes, and are creating disparities by design. Consider this problem of health care design that ignores three key perspectives – economic distributions, impacts within practices and hospitals to those who deliver the care, and consequences specific to most Americans most behind. Understand the rise of administrative costs and the decline of health access and outcomes where most Americans most need care. https://www.dhirubhai.net/pulse/stop-designers-from-making-health-care-delivery-worse-robert-bowman/?

The 2621 Counties Lowest in Health Care Workforce By Design

A critical review of the path of micromanagement from DRG/PPS to value based care from 1983 to 2018 indicates that the primary care practices remaining in the 2621 counties lowest in health care workforce will be moved farther away from higher functioning or patient centered primary care.

This 40% of the population with 130 million people in 2010 had only 25% of the primary care workforce (Masterfile, Area Resource File) supported by only 20% of primary care spending due to reductions for 15% lower office payments (Medicare 2011 data), lowest collections, and worst public and private insurance plans. This financial baseline already translates to fewer and lesser team members to deliver the care, chronically. It is possible that the volume focus in many of these practices is an attempt to survive because of the abusive financial design. More about these counties most behind for background https://www.dhirubhai.net/pulse/counties-lowest-health-care-workforce-40-population-get-robert-bowman/

There are indications that they will lose, because of the financial design. This 40% of the population is not valued and neither are their providers. Each policy change since the 1980s has had consequences and more challenges, not that these practices need more. They already have the most complex patients and the fastest population growth rates.

This is likely due to local populations that must stay while others must migrate to these counties. Those with lesser finances that cannot leave these places with lower costs of living and housing. Meanwhile more Americans in the higher concentration counties face increases in these costs that drive them to migrate to counties lower in costs. They are also leaving counties higher in concentrations of health care and social resources to go to counties lowest. They are leaving places with 100 – 150% of the national levels of primary care to places with 50% across generalists and general specialists. These counties have physicians that are oldest, nearest to retirement, paid least, and abused most – much like their patients and communities.

These are essentially the Red Counties and the rural minority counties linked by generations of neglect by the designers. These counties have 75% of the rural population and 32% of the urban population.

Counties lowest in concentrations have higher concentrations of chronic diseases, mental health issues, older age groups, and adverse behaviors to go with lesser social determinants. Census data by decade for over 50 years indicates the most rapid growth rates in population numbers, demand, and complexity. Meanwhile the financial design dictates declines in team members and movement away from patient centered primary care, higher functioning primary care, and Basic Health Access where most needed.

Primary Care Finances Are The Worst Where Challenges Are the Most

Revenue remains flat for primary care in these practices. The usual costs of delivering care continue to increase. The micromanagement costs are also increasing, likely at higher rates per primary care physician because the practices are smaller and independent.

Estimates of the costs of HITECH to Value Based run about $30,000 to $50,000 for each per primary care physician. A minimal cost for 60,000 primary care physicians is about 1 billion more a year. These counties only had about 38 billion to invest in primary care in 2008. The amount remaining to invest in local primary care is less than 30 billion.

This also suggests fewer and lesser delivery team members as more paid for budget areas other than personnel, depletes personnel spending. Other personnel have had to be paid for non-delivery costs of regulation. And delivery team personnel have had impacts on their personal and professional lives - because of micromanagement. Lower productivity and higher turnover further impair the practice finances, care, and caring capacity.

Consider that higher costs of delivery hurt health access where generalists and general specialists depend on lowest office payments and deliver 90% of the remaining locally available services. Consider that the powerful opposition to true reform exists and prevents equity in payments for the same service as well as increased payments for the basics that would only come about if the most powerful gave up their procedural, technical, hospital, and subspecialized overpayments.

Consider that expansions of health insurance only work when the local population has workforce and can get meaningful insurance. These counties are a negative in both areas.

When you begin to understand the consequences of health, education, economic, agriculture, and housing designs specific to most Americans most behind, they you are in a position to be a more effective leader or designer.