The Lack of Quality in Health Care Quality Improvement
You see a constant barrage of papers, reports, promotions, and advertisements regarding the value of performance based measurement.
I can assure you this is a house of cards based on assumptions. The studies are flawed across design, funding, methods, analysis, conclusions, and lack of limitations.
The Overview - Failure in Cost Cutting
The lack of progress in cost cutting for decades speaks to the failure of micromanagement and points to those largest and most powerful as the ones winning while most Americans lose - including us. (They also say they are for more primary care funding but their most powerful lobbies act against any cuts in their procedural, technical, subspecialized payments for no actual change - hypocrisy over and over)
The Overview - Worsening Outcomes, Not Improving
The lack of progress in outcomes improvements for decades speaks to the failure of micromanagement, innovation, technology, rearrangement, and regulation. The worsening of the American population, particularly the half most behind, testifies to worsening disparities and declines in social and other drivers of health outcomes.?
And we know too well that micromanagement is costly, it shifts our practice budgets away from the support of those who deliver the care, and it is quite meaningless. It acts to deteriorate the doctor patient relationship in many direct and indirect ways.?
Cutting thru the hype can be difficult. I have been collecting material for the past decade that you might find useful.
Obsessive Measurement Disorder
Sullivan's work often at The Health Care Blog is worth a review. His works are summaried here?https://thehealthcareblog.com/blog/tag/kip-sullivan/
You will not see a better description of the micromanagement madness than the link below site via Sullivan and Muller. Sullivan has worked in health care as a lawyer and Muller?
"Muller, a professor of history at the Catholic University of America in Washington, DC, makes it clear at the outset that measurement itself is not the problem. Measurement is helpful in developing hypotheses for further investigation, and it is essential in improving anything that is complex or requires discipline. The object of Muller’s criticism is the rampant use of crude measures of efficiency (cost and quality) to dish out rewards and punishment – bonuses and financial penalties, promotion or demotion, or greater or less market share. Measurement can be crude because it fails to adjust scores for factors outside the subject’s control, and because it measures only actions that are relatively easy to measure and ignores valuable but less visible behaviors (such as creative thinking and mentoring). The use of inaccurate measurement is not just a waste of money; it invites undesirable behavior in both the measurers and the “measurees.” The measurers receive misleading information and therefore make less effective decisions (for example, “body count” totals tell them the war in Viet Nam is going well), and the subjects of measurement game the measurements (teachers “teach to the test” and surgeons refuse to perform surgery on sicker patients who would have benefited from surgery).
What puzzles Muller, and what motivated him to write this book, is why faith in the inappropriate use of measurement persists in the face of overwhelming evidence that it doesn’t work and has toxic consequences to boot. This mulish persistence in promoting measurement that doesn’t work and often causes harm (including driving good teachers and doctors out of their professions) justifies Muller’s harsh characterization of measurement mavens with phrases like “obsession,” “fixation,” and “cult.” “[A]lthough there is a large body of scholarship in the fields of psychology and economics that call into question the premises and effectiveness of pay for measured performance, that literature seems to have done little to halt the spread of metric fixation,” he writes. “That is why I wrote this book.” (p. 13)"
If you are for or against 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.
Basic Research and Analysis Flaws - Lazy Generalizations That Distort and Distract
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)
Quality studies at least require some controls for population differences. But they commonly use mean values of the zip code (maybe) of the patient. This value is 80% wrong given a normal distribution (if normal). The COVID studies with better controls indicate that this results in regressions that give too much explanation by race, ethnicity, and co-morbidities since the factors more important are not entered in the equation. As an editor I rejected these studies and in a few cases allowed them with major work on limitations from the authors.?
LAZY GENERALIZATIONS MUST STOP. GOOD RESEARCH DEMANDS SUPERIOR EFFORT AND CONVENIENCE DATA IS LAZY DATA THAT INVITES LAZY ANALYSIS AND PRESENTS THE OPPORTUNITY FOR MAJOR BIAS TO BE INSERTED
What Can Go Wrong and Does Go Wrong - The Failures of the Best Journals and Editors
Reflect on this series of publications about a clinical intervention to improve COPD outcomes. This?COPD intensive intervention that was retracted 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.
The first publication of this intervention indicated 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 approaches. 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. - Convenience data, lazy generalizations, and assumptions are destroying academic rigor.
Because the authors find what they want and get publication, they rarely consider looking back or probing for errors - which are many.?
Even worse, the editors tolerate grossly insufficient limitations sections, leading statements in the introduction, and bias in the conclusions. This is how we have the nightmare of micromanagement continuing and worsening what we do.
Data Science Has Become About Lending False Credibility To Decisions We've Already Made
The applications of this are many - in micromanagement, in workforce studies, in primary care. I quote this author regularly because so clearly the massive data collections are so abused.
?Kalev Leetaru ?Contributor?AI & Big Data
As an Aside for the Primary Care Passionate
We clearly have latched on to primary care level increases as "causative" for improved outcomes - This is not so.
It is quite easy and lazy for us to promote primary care increases as causing improved cost or quality outcomes. Correlation is not causation.?
Please understand that you can only change outcomes if you value populations and population changes. It takes a massive generation to generation effort to change outcomes. No significant course correction can be done in a few minutes a year in a primary care office and there should be no expectation of such changes after a lifetime of influences, often many shaping negative outcomes.
Other nations that value children and outcomes and support - have much better outcomes and they also value primary care. Correlation is not causation. The US is last or near last across Child Well Being measures. The low outcomes as a nation and the disparities with much lower outcomes where populations are most behind confirm the matrices of relationships all pointing to lesser outcomes, situations, conditions, workforce levels, access, and more.
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.
Resident work hours studies, rural vs urban hospital studies, high vs low volume hospital studies (apples to oranges, poor controls, different funding, different workforce, different populations), NP vs MD care (no different when populations are similar) female vs male hospitalists (diff pops), old vs young hospitalists and many more have major flaws - apples to oranges, poor controls, and more.?
In other words, they trash rural, small, basic, generalists, MDs, older docs, male docs and more with flawed studies.?
Witness the recent releases on antibiotic prescribing. They find that 40% is done by 10% with family physicians prominent in "overprescribing". They did not control for many key areas (family practice, care of the elderly, region, health literacy of population). They have no data from the chart other than a prescription. They found what they wanted to find and justify more funding for more such research so that they can do better. Yes, we overprescribe. We know it and work on it. But they over regulate and do not recognize it and think that they are helping when they are hurting us. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2789484
The micromanagement madness is made worse for populations that are most behind.
Veronica Mallett, M.D., the president and CEO of Meharry Medical College Ventures in Nashville, said that one problem is that the current benchmarking in value-based payment programs isn't designed with equity in mind. “It's based on the assumption that historic spending and utilization can always be lowered while maintaining or increasing quality. I would submit that in marginalized and vulnerable populations, that is often not the case. In fact, in order to achieve the desired outcome, more spending more services are often needed, especially initially,” she said. “Those services would include things that are often not covered, like community health workers, remote patient monitoring, social workers, oral and digital health.?
The horror of the To Err is Human, managed care groupthink, Dartmouth Assumptions, ACA, MACRA to value based is found in the assumptions. What goes on in the small portion of Americans doing well is not relevant to most Americans behind by design. The assumption of overutilization is deadly and damaging where most Americans have half enough generalists and general specialists and have had little change in these ratios since the 1980s. Too much or too little is also about lack of health literacy, which is concentrated in the populations most behind.
Micromanagement Costs More for Practices and Hospitals Not the Largest
Many studies demonstrate higher cost per physician for each of the new added costs such as seen in digitalization, HITECH, ACA, MACRA, Primary Care Medical Home, and more.?
Largest already have much of this in place because they are larger. The changes favor the largest over those even slightly smaller
1. Micromanagement costs relatively more
2. Payments are higher for those largest by their negotiation
3. Discounts of supplies and services are given to those largest
4. Big insurance has been shown to abuse those smaller
5. Payments are less where workforce levels are lower where practices are smaller and are more needed - especially family practice
?
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The Massive Failure of Innovation at the CMS Innovation Center
If you try new projects as a development director of a business and you go 5 for 52 spending billions of dollars - you would be fired and your division would be terminated. But the CMS Innovation Center is such a case. Here is their graphic
Their focus has primarily been cost cutting and it has not focused on better team members or practices. And outcomes are beyond the usual innovation.
And with their failure they indicate that one problem is that the practices "have no skin in the game" - they want us, already lowest financed by their designs and most abused by their innovation, to go at risk even more.
A worst failure was in the high up front investments in primary care. Well, they forgot that primary care is underfunded so what did they expect.
Medical Home Use and Abuse
Many good practices have medical home points covered well, with or without certification. The goal should be more and better delivery team members - not more costs that can result in fewer and lesser.
Sullivan posts about the failure of CMS Medical Homes x 3??https://thehealthcareblog.com/blog/2018/06/07/the-verdict-is-in-all-three-of-cmss-medical-home-demonstrations-have-failed/
New studies confirm the failure of 3 approaches to do much different.
Once again, if the populations remain the same, the outcomes remain the same.
Now there is some good indication that moving the populations with the worst access to good access can work for cost, quality, and other improvements. (ChenMed, hospice, CalPers retirement, telehealth to the bedbound, disabled) But this is not about value based or capitation as ChenMed states over and over. It is about infinite improvements in access (little or no to best) and a much better financial design which funds more and better delivery team members and much better access.?
Family Medicine and Primary Care Leaders Must Stop Grasping at Straws
Desperate for more revenue, many have embraced new models or innovations. This has to end. Since the 1980s these "reforms" have introduced flaws and have avoided the major changes in reimbursement needed especially where half of the American population has only half enough primary care - where lesser and fewer delivery team members are set by design.
We cannot embrace innovation, regulation, micromanagement, managed care group think, or value basis
1. Because they are flawed and based on assumptions that have failed to demonstrate improvement as promised (holding them accountable as designers should be the same standard as in physicians or in human subject researchers - vulnerable populations protected, beneficent intent rather than simply cost cutting, informed consent, rigorous approaches)
2. Because they harm our practices, particularly the most vulnerable and most needed
3. Because they hurt vulnerable populations
4. Because they promise better payments but fail to result in what we must have
We must have a better financial design - such as a doubling of primary care revenue from 38 billion in 2008 to 90 billion to move half enough toward sufficient. This translates to
1. Increased revenue specific to cognitive, office, basic, most prevalent, most needed services - and freedom from any and all cost cutting measures until the nation's abused populations and primary care practices achieve parity.
2. Revenue increased regularly and sufficiently to cover the usual cost of delivery increase,?
3. Revenue increased to cover any and all added costs from micromanagement or other demands of the payers or regulators
4. Revenue increased to cover the Usual Disruptions as outlined by Mold - changes in key personnel, EHR, billing, ownership, location, and local environmental changes that impact finances
5. Revenue increased to cover higher turnover settings where the costs and losses are about $300,000 per primary care physician with a turnover each 3 years for $100,000 per FTE per year.
We cannot tolerate blatant discrimination
...with lesser pay in 30 worst states who are also lowest in workforce levels, in primary care, in underserved areas, in 2621 counties lowest in health care workforce. See this in Medicare payments in 2011 which were designed to expose physicians soaking Medicare - but analysis indicates that Americans most behind are abused along with their family physicians whe are more and more important as our national designs shape lower and lower levels of workforce and more complex patients.?
Why Do Health Care Leaders and Designers and Payers Fail - Miserably
They do not understand the populations most behind or their care or the factors that result in lesser outcomes. They do not understand the populations most behind or their care or the factors that result in lesser outcomes. They do not understand the populations most behind or their care or the factors that result in lesser outcomes.
Crabtree and others point out the need for the inside out perspective. Outsiders cannot design or?lead well. Shifting Implementation Science Theory to Empower Primary Care Practices by William L. Miller, Ellen B. Rubinstein, Jenna Howard and Benjamin F. Crabtree in The Annals of Family Medicine May 2019, 17 (3) 250-256; DOI: https://doi.org/10.1370/afm.2353
"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.
This is the reference to Mold about Usual Disruptions. Out of 117 million dollars spent on quality improvement and the entire supplement to Annals of FM on this area, this is the study that I find to be the most useful. Instead of quality improvement, metric, measurement, and flawed outcomes approaches - Mold tried to find out why practices could not do quality improvement. He also exposed flaws in the financial design and reasons to increase funding for small and medium size practices.
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 by James W. Mold, Margaret Walsh, Ann F. Chou and Juell B. Homco in The Annals of Family Medicine April 2018, 16 (Suppl 1) S52-S57; DOI: https://doi.org/10.1370/afm.2201
Casalino also is a clinician researcher and I follow his relevant comments.?
He also expected to find that smaller practices performed less well. He was wrong and managed to get this published somehow.?
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.
It seems that someone who has been inside has a better read on what is a problem and what is most important for any progress.?
Additional Links
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
?Value Based Care – no progress since 1997?https://thehealthcareblog.com/blog/2020/10/12/value-based-care-no-progress-since-1997/
?Transform the financial design, the training, and the population to improve access, cost, and quality for most Americans most behind https://www.dhirubhai.net/pulse/true-solutions-health-care-most-americans-behind-robert-bowman/ ?
Expansions of four main sources of health professionals at 6 to 10 times the annual population growth rate confirms that the financial design is the cause for shortages of workforce and a massive glut of health professionals is being created. Yes, the leaders who claim that their kind is a solution for health workforce are not correct. https://www.dhirubhai.net/pulse/real-crisis-facing-health-professionals-too-many-far-fast-bowman/ ?
Expansions of the worst Medicaid, Medicare, high deductible, and private plans cannot help basic health access deficits for most Americans as these have caused the deficits. These Americans never lacked for health insurance more than others, they have always had the worst plans. https://www.dhirubhai.net/pulse/myth-insurance-coverage-expansion-solution-basic-health-robert-bowman/
Physicians and human subject researchers must follow evidence basis, avoid harm, and protect vulnerable populations. Health care designers do not. https://www.dhirubhai.net/pulse/ahrq-foundations-who-support-research-must-stop-harm-health-bowman/