Health Outcomes Are About Populations and Basic Health Access - Not Value Based
Our nation is about as far from improving health outcomes as it can be. It fails to invest in the two areas that can improve outcomes - Basic Health Access and the American people. Even worse, the health care designers compromise Basic Health Access by valueless constant change, valueless micromanagement of costs, valueless micromanagement of quality, and valueless insurance designs.
Primary care is right in the middle of the catastrophe known as US health outcomes. Half of US health encounters are primary care - but these continue to fall to lower proportions as other more costly encounters continue to increase. The decline in primary care is primarily the result of inadequate revenue with forced increased costs of delivery.
Those who design health care are not merely reshaping primary care and access. They are destroying it - and its primary value which is Basic Access to Care.
Designers Neglect the Foundation of Access
The primary value of a primary care practice is access. Access once had a place of value. Access, costs, and quality used to be the Big 3 in health care design. Now access is not even a part of the Triple or Quadruple Aims.
The managed care focused designers have designed away access - in their designations of what is important and by their designs that defeat access. Not surprisingly their attempts at reducing costs, improving quality, and increasing satisfaction fail. The interventions and innovations involving health plans, practices, or hospitals fail. If you defeat access it is unlikely that you will improve outcomes.
Health Outcomes Are About People, Populations, Conditions, Environments, Genetics - but not health care delivery
Complicating failure of cost, quality, and access is a nation that does not value investments in its people - made worse because health care is consuming budgets at all levels - national, state, local, employer, family, and personal.
Where most Americans most need care, generalists and general specialists provide 90% of local services (65 - 70% for the nation). Academic institutions, professional associations, foundation, government, and insurance companies neglect basic access. Those who shape the designs continue to focus attention on what fits them best. They value their own and fail to value health access where needed or most Americans most behind in access and other areas.
The Consequences of Neglected Basic Health Access
By neglecting basic access, our nation causes access barriers, causes workforce deficits (CMS in particular), and causes disparities. The designs send fewer dollars to support jobs, economics, and investments in people where most Americans lack dollars, jobs, economics, and investments.
Restoring Access Requires True Reform
True reform is not about expansions of insurance meaningless to access such as plans that fail to pay for primary care or pay below costs of delivery. True reform sends sufficient revenue for twice the workforce and team members to places where most Americans have half enough. CMS and other designers oppose increases in the basics - and therefore oppose access and continue to cause shortages and access deficits.
A true reform would redirect dollars away from concentrations of dollars, jobs, workforce, and health spending to places in most need.
Access can improve outcomes, economics, jobs, and social determinants where they are most lacking for most Americans. Expansions of child development and early education can do the same. These are avoided by the designers. Even worse, the designers are focused on metrics, measurements, and micromanagements that divert more billions each year from the support of schools, teachers, assistants, practices, hospitals, and delivery team members.
And of course these billions more each year go to higher concentration settings - acting to worsen disparities via the designs of health and education. Dollars are more concentrated in concentrations along with jobs, economics, and social determinants. The spiral of decline is continued by the designs of health and education where most Americans are already behind.
Health Care Failures Act to Fail Other Societal Areas
Many more billions spent in the places with top concentrations fails America by design. on the last days or years of life -And since the most powerful demand and get the designs that they want, they oppose true reform and oppose access for most Americans.
The designers also lack awareness of the populations most deprived of access. Without access there is no data about health care delivery. Many Americans and their health care needs do not exist, because the designers do not understand the limitations of the data. This helps to shape assumptions that result in worse designs. DRG designers did not anticipate hundreds of rural hospital closures via their reform/cost cutting/micromanagement/bundling hospital payment design and they did little about it even with hundreds of hospital closures and compromises of local practices and access.
An example is the focus on overutilization and cost cutting, developed in the 1980s and impacting the 1990s with increasing consequences since. Where the major problem is underutilization and lack of access - a focus on cost cutting and overutilization can be destructive to basic health access. This is clearly the impact of meaningless and mindless micromanagement.
Truth in Outcome Improvements
Americans deserve better outcomes. New self-pronounced heroes claim that they are a solution. Daily new promotions tout their interventions as improving outcomes. But they fail.
When they are subjected to critical review, mostly what they do is compare two different populations with different outcomes.
There are basically two ways to take a population and actually improve outcomes over time. Outcomes can only be improved consistently
- with improvements in access or
- with long term generation to generation investments in people, especially children and all who serve them.
The US is so behind in basic access and in investments in people that it will take both for any hope of improving outcomes.
Access and Outcomes Are Defeated Across All Important Budgets
There are fixed dollars to invest. As one area of a budget increases, there are declines in other areas. Sadly health, military, prison, and debt spending are increasing so fast that our investments in people are declining rapidly - and thus our outcomes are worsening.
Maternal, infant, longevity, premature death, education, other health, and economic outcomes fail because of decades of neglect. And health care practices are held accountable for failing to improve outcomes which are inherently worse by design. This is best seen in the counties lowest in social determinants, access, workforce, health care dollars, education dollars, and outcomes - a contrast with a small portion of the nation doing best in the world.
The US is land that promotes, sustains, and worsens disparities by design. But worse is that it does not understand even the most basic area of access.
Devaluing Access and Access Delivery Team Members
Clearly the micromanagements have resulted in a worsening financial design and a worse environment for delivery team members.
Basic Health Access is not valued in the US - thus the underinvestments in generalists and general specialists. This is particularly seen in counties and places with 40 - 50% of Americans that have half enough generalists and general specialists. These practices are paid 15% less (Medicare 2011) and are found where the worst public and private insurance plans are concentrated. The high deductible, low pay, and no pay patients are also concentrated there - further impairing access.
Insurance Designs Fail Access Worse
The access barriers are even worse because of insurance designs. The proportion of the US with access barriers is much higher because of valueless health insurance with insufficient networks, lists of practices that are in error, practices that do not take the patient health insurance due to abuses, and more.
Discrimination By Access Design
A nation that does not value Basic Health Access discriminates by design - punishing half of Americans left behind and the 25% - 30% of the workforce that attempts to serve them with half enough team members and a steadily worsening financial design. Similarly the hospitals in these counties are being closed. Generalists, general specialists, hospitals, nursing homes, pharmacies, and other needed health services are being closed and compromised by design.
Lower payments, increased costs of metrics and measurements, declines in team member productivity, and distractions from care impact care where needed most.
Performance incentive designs have already been documented as discriminating against practices and hospitals that care for populations that inherently have lesser outcomes.
But we tolerate discrimination, increased disparities, and worse.
Rural or Official Shortage Area Focus Distract from the Magnitude of Access Woes
The worst case scenario is access failing most where most Americans are found - where population growth, health care demand, and complexity of care are all increasing most. But that is exactly what is going on.
For many years there has been a focus on rural locations. There are many definitions based on population density. But this often does not have much to do with health care design. Health care density is needed to be able to consider areas such as access deficits. Concentrations of MD DO NP PA primary care women's health and basic surgical workforce has a density, or lack there of. This overlaps with rural, but rural is not specific to access barriers.
Sadly many designers see a small impact on official shortage areas or rural locations. The federal shortage area designations have failed reform multiple times and do not reflect the magnitude of basic health access woes. Rural is too small, declining in the proportion of the US population, and 25% of the rural population is doing very well.
In contrast the 40% of the US in lowest health care workforce counties involve a much larger proportion, are growing toward 50% by 2050, and are increasing most in numbers, demand, and complexity. But their workforce is not - by financial design.
The False Valuation of Value Based Design
One would think that that the financial design cause would be obvious, but our designers are still off seeking "value." Since they do not value the basics of access and the basics of social resource investments over decades (not at point of care) they will never improve costs or quality. In fact, what they do is exactly what you would expect as consultants, corporations, and CEOs seek more health care dollars. And the literature, academics, associations, researchers, and journalists not only let them do this - they facilitate their efforts.
Until it is understood that the true value is access, our nation will continue to refuse to invest in the team members that deliver basic care, shortages will remain, access barriers will worsen, and social determinant factors will result in more disparities via the designs for health and education focused on metrics rather than those who teach or treat people.
Access Matters to Outcomes
Studies fail to be consistent in improving costs and quality via various interventions in health plan or practice design or incentives or reorganizations - but studies are consistent in regarding the improvements to outcomes involving access.
These access improvements have result in improvements in costs, quality, or both. Sadly the articles about these improvements make claims of improved outcome due to a new technology such as telehealth or a new reorganization of primary care such as primary care medical home.
Improvements in access involve up front funding of primary care (Michigan BCBS), but the articles claimed benefits for primary care medical home. PCMH is expensive and quite limited. Investments in primary care involving more and better team members can deliver on the promise of outcomes improvement. Designs that impair finances and limit team members - can worsen higher functions.
Investments in primary care, telehealth, hospice, and homebound elderly can make a difference.
If access was valued, the articles would be written about access improvements, but those who design and promote health care make claims about the new technology or reorganization rather than valuing the access improvement.
Many desire higher functioning team members (more and better) so that they can facilitate integration, coordination, outreach, opioids, mental health, social resources, and more. The fact of the matter is that these basic health access practices are not valued and thus cannot hire more and better team members. They certainly cannot move to higher functions. Also with half enough team members and half enough local social resources, the question can be asked
Is it even possible to move to higher function without a nation that values access, delivery team members, and social resources?
The answer for most Americans is that it is not possible. Even worse, these are the practices most needed facing the most complex and paid even less and penalized more and forced to pay relatively higher costs because of micromanagement of costs and micromanagement of quality.
#valuebasedcare #valuebasedhealthcare #paymentreform #directprimarycare #advancedprimarycare