The Key to Understanding Value Based Care Designers is Understanding What They Fail to Value

Value based care claims to improve quality, patient safety, patient experience, and costs of care. The primary failure of US health care designers is not about what they value. Their failure is about what they fail to value including what matters most - the one on one innovation between each patient and delivery team member.

The primary failures of value based and micromanagement focused schemes are the failures

1. to value those who deliver the care. (CMS, other payers, states)

2. to value the care environments across basic health access practice and hospital care

3. to value the one on one interactions that are the heart of health care delivery - the only innovation that matters. Designs that shape fewer and lesser and less experienced delivery team members cause great harm in many dimensions

4. to value most Americans most behind and falling further behind via their health care designs

5. to value basic hospital and office services

6. to value proper testing of models with proper controls for population differences before implementing designs based on assumption (research, academic, micromanagement promoters, managed care to Dartmouth assumptions to Orsag to ACA and beyond) (see Do No Harm by Health Care Design)

Please note the major failures of Micromanagement

• Type 1 Micromanagement Cost Cutting has failed to rein in exploding health care costs
• Type 2 Micromanagement Quality Improvement has failed to improve quality. These so called innovations have always been based on assumption with Fire Ready Aim imprecision. Despite numerous regular failures to change outcomes positively as seen in the CMS Innovation Center 5 for 52 performance, the micromanagement bandwagon manages to promote itself to greater and greater prominence. Facing increasing critique, this micromanagement snake in the grass adapts such as the recent social determinant focus.

It Is Important to Understand the Way that Micromanagement Captures the Attention and Support of Those Who Must Fight It's Lack of Value and other Deceptions and Assumptions

• Is the social determinant community so happy to have some attention that they fail to see the obvious conflicts? Numerous overlapping matricies of relationships are involved, this is not just housing or food or a few areas.
• This acceptance of value based change despite so many consequences is also seen in the primary care leadership. In their decades of frustrating failure, they can seize upon anything that appears to be some attention with the hope of eventually some improvement in the financial design. This bottom line continues to get worse. The primary care leadership still embraces changes even though these have not actually improved their 250 billion flat lined funding - which is annually reduced in effectiveness by more billions of costs and distractions via micromanagement.

If you understand social determinants and non-clinical factors as predominantly shaping outcomes., how can you embrace any value based or micromanagement focused design?

• The non-clinical dominant influences are incompatible with designs that force practice delivery team members to attempt to change outcomes - which they predominantly cannot change.
• Decades of previous life influences are far more powerful than a few minutes a year of patient contact in the compromised health care environments of today.

For 40 years, the delivery team members have not been valued and the impacts of Type 1 Micromanagement Cost Cutting have been failure to cut costs and serious harms done to the personal and professional lives of delivery team members.

Examples include DRGs targeting Registered Nurses directly and indirectly in many ways such as personnel budget changes plus adding more for them to do in less time.

• Guidelines were developed to prevent low staffing ratios, dumping patients too fast, and other abuses - and the guidelines have all been violated constantly.

The environments of primary care, mental health, women's health, and basic surgical have all been so compromised as to be unrecognizable to those of us experiencing what they used to be and how they improved 1965 to 1980 only to free fall for 40 years (unless you are in the top 30% regarding best quality health care insurance and best local proximity to well supported care).

Not surprisingly those setting up the designs live in a different world and cannot see the carnage that they create and worsen.

A few important studies have captured this failure to understand from the inside out (Miller Crabtree , Mold and Usual Disruptions , Lack of Value in Value Based Designs , 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

Their biggest Designer failures are not seeing the future that is so bleak for

1. Most Americans as they age, get sicker, family members get sicker, or they lose income or best employers

2. fastest growing populations such as 90 million urban Americans in the 2621 counties lowest in health care workforce as their remaining health care is designed away

3. places with concentrations of elderly, poor, disabled, and worst employers that will never have resolution of basic health access woes due to the worst quality health insurance plans concentrated in their area (the focus on expansion of the worst quality health insurance has been one of the worst failures of ACA and beyond)

Did you even consider that states not expanding Medicaid have been behind in income, finances, and numerous social determinant and outcome factors and will stay behind despite ACA or expansions or numerous health care design innovations?

Why do top journals in health policy publish these studies with so many obvious flaws?

Did you consider that new waivers to allow Medicaid dollars to go for housing or food will make the situation worse for those delivering their care? If you understand the Medicaid plans as worst quality (paying less than cost of delivery, abusive to patients and providers, shaping deficits)you can begin to see the problems.

1. Medicaid shorts practice and hospitals most, particularly those that have higher proportions of Medicaid patients

2. Medicaid payments to new and increasing sources dry up funds and divert them away from paying for more and better delivery team members - an essential for any patient centered or higher functioning care

3. Medicaid paying for housing or food allows other entities not to pay for housing or food

4. Medicaid paying for housing or food requires increased tasks and multitasking from overwhelmed primary care delivery team members.

See from the inside of practices. Force designers to stop ill advised changes. Blow the tires off of the micromanagement bandwagon.

• To Improve Practice Environments
• To address burnout, turnover, and worse
• Because health care funding should most support health care delivery. This is by far the top purpose of health care funding.

Forty Years of Worsening Health Care Design is Forty Years too Long. Forty Years of Concentrating Workforce and Health Care Dollars and Services via most lines of revenue and highest payments in each line must come to an end.

Balance Most Be Achieved and To Get There, the Reasons Must Be Identified and Nullified

Closures and compromises are the result of DRG, RBRVS, lower payments across plans including Medicare (in 2011 data), lower payments in their state and also in their region and also lower if they are small or medium sized. The only thing missing is the 15% less for new physicians that I had to face entering solo rural family practice in 1983 (thanks to Reagancare)

Ask Yourself the Most Important Questions. What must you value as a top priority to design health care that is equitable and supports most Americans most behind and the most important innovation of all - the one on one innovation worked out between delivery team members and patients?

More and better delivery team members should be the top focus to improve access to care. to improve health care process and environments, to improve the true innovation that matters, and to reverse burnout (and worse), turnover frequency, turnover costs, declining productivity, and further worsening financial designs.

And perhaps least studied and most important in the future, is the failure to value experience as a health care professional or team member

This experience needs to be seen with the context of experience

1. Within their specialty area

2. Within their practice

3. Within their community

For example the massive expansions of NP and PA result in higher proportions of their workforce with no or little practice experience such as 14% of NP with less than 1 year of experience and likely 50% with 3 years or less experience in high turnover least supported basic health access areas such as primary care, retail, urgent, and emergent.

Massive expansions of annual graduates (7% more a year NP and PA), only 60% active (NP), shortest careers (NP), least volume (NP), and worst turnover (NP, PA, and maybe physicians now) shape least experience. Also micromanagement focus not only marginalize important care experiences, they can distract from care and caring focus.

It's Not What You See in Health Care Design, It's What You Don't See that Matters

So many end of year summaries. So many predictions.

But for most Americans, you will only see worse, especially as they get older, sicker, poorer (worse employers or illness in family)

So it is important for problem solving for most Americans to see what is not being seen.

You will not see:

• Fewer tasks for delivery team members, especially in primary care
• More ability to focus one on one with each patient across hospital and practice and nursing and primary care...
• More revenue for practices and hospitals serving the half of the nation most behind - despite and because of 40 years of CMS designs
• You will not see apologies to most Americans for the abuse over 40 year
• You will not see Value Based focus placed on their care, that values most Americans, their delivery team members, and their basic health access
• You will not see integration and coordination facilitated specific to their care by supporting more and better delivery team members
• You will only see cuts and compromises specific to most Americans most behind and their basic health access

CMS prevents-seven-vital-conditions-it recommends https://www.dhirubhai.net/pulse/cms-prevents-seven-vital-conditions-recommends-robert-bowman/

Why You Should Read Clayton and Also Muller to understand Statistical Deceptions and Micromanagement focus for the past 100 years. This is essential for those who hope to see the damage being done to most Americans via health care, education, and other designs.

• The first book is “SOMETHING IS WRONG WITH THE PRACTICE OF STATISTICS IN SCIENCE” by Clayton.
• This when combined with Obsessive Measurement Disorder brings it all home. https://thehealthcareblog.com/blog/2019/02/13/obsessive-measurement-disorder-etiology-of-an-epidemic/

Understand that No Training Design or Intervention, Even with Massive Expansions of Graduates, Can Fix Deficits of Workforce and Access Facing Most Americans.