Micromanagement in Health Care Has Failed, Try Returning to Care and Caring

Research has long indicated patient safety and quality improvement problems in the United States. The solutions proposed have usually focused on technology, software, and accountability. Lack of progress in quality improvement over recent decades via these approaches suggests that patient outcomes are shaped predominantly by other factors, especially those involving patient and patient environments. What can be done by delivery team members is still poorly understood. Also neglected is research to understand practice environments, especially the toxic environments that appear to be driving so many away. Research to support micromanagement has had its chance and must give way to studies that can make a difference.

Belief in micromanagement started from far above and far removed from health care delivery. It too quickly resulted in a focus on quantitative studies.

• Quantitative designs are not the best choice when concepts need exploration. This is particularly true with regard to clinical interventions as delivery team members and practice environments are important. Qualitative or mixed methods are better for explorations.
• The quantitative research has also not been quality research. Controls for the non-delivery factors have been missing. If studies cannot explain away the alternative hypothesis, they are not valid. The alternative hypothesis that outcomes differences are about differences in populations being compared, has become dominant. Studies not addressing this need pages of explanations or should rarely be published.
• Data collections for quality research should be intentional. Convenience data has issues. Proxy variables for income or for education are commonly used. This gives rise to the fallacious thinking that zip codes shape outcomes despite widespread variations in the individuals in the zip codes across dozens of variables. Zip code proxy data is not specific to the patient and can be wrong 70 - 85% of the time, depending on zip code Bell Shaped Curves.
• Promotions of people and products continue based on these studies despite their limitations.
• So far the studies have been unsuitable for the advance of high-quality research required to shape policy or program interventions that would make a real difference. The ability to explain away the alternative hypothesis appears to be most difficult in health care research where so many variables involving multiple matrices of relationships exist involving patients, plans, access, community factors, team members, behaviors, and situations. Population differences can shape outcomes differences and in some cases the findings in favor of an intervention had to be completely reversed (COPD intervention) https://www.dhirubhai.net/pulse/lack-quality-health-care-improvement-robert-bowman/?
• Interventions can be costly in a number of ways. The direct costs involve technology and measurement, team member burden is another cost, budgets diverted from personnel and team member support is a third consequence. Cost factors are often not fully assessed. When studies are marginally significant, the consequences can overcome the benefit. Significant may not be relevant or practical.
• There is also a common sense argument. How can a primary care delivery team member in just a few minutes significantly change outcomes that have been impacted by years or decades of previous life shaping experiences?
• Many of the proposed technologies have limitations when it comes to real world applications. There are substantial deficits in health and other literacies in the American population. These tend to be concentrated together presenting challenges for certain providers.
• What about key areas important in day to day interactions such as relationships, loneliness, life events? https://www.dhirubhai.net/pulse/outcomes-harvard-80-year-robert-bowman-rsg9c/?trackingId=3w2ys2r4RJilnYuo9ClNeg%3D%3D

The consequences of the managed care bandwagon have been significant.

• Entire industries have been built on the shifting sand of marginal interventions. They have powerful marketing and lobbying. It could take some time to disengage CMS, Congress, institutions, corporations, journals, and lobbyists so that some exploration can be done. New generations have been trained by those focused on micromanagement. A return to objectivity will be difficult.
• A worldwide review of DRG demonstrated 18 studies that attempted to look at inefficiency and all 18 found this regarding Diagnosis Related Groups. How can this help with cost cutting or team member recruitment and retention? Where are the US studies that summarize the many consequences of Diagnosis Related Groups or the nations that have curtailed or terminated this design?
• There are major deficits with regard to understanding practice environments and the team members to deliver the care. Occasionally a quantitative study will reach publication.
• Designers and their assumptions of overutilization with their volume to value focus seem to be poorly aware of the serious problems where deficits of access shape underutilization and inappropriate utilization, where lower payments, penalties, and more costs of delivery from micromanagement can worsen access.

There are other reasons to emphasize detailed studies of team members and practice environments.

• A major reason is the current hemorrhage of health professionals from health care.
• Micromanagement is linked to significant issues regarding burnout.
• There are multiple consequences of cost cutting, profit diversions, measurement obsession, frustrating data collections, gaming of measures, and team members held accountable for areas beyond their reach.
• Small and medium size practices and hospitals have suffered significant setbacks with accounts payable increased and accounts receivable decreased. They also suffer more from usual disruptions such as changes in key personnel, billing, EHR, location, and ownership.

A careful review of health plans finds them to be deficient.

Public plans often pay less than cost of delivery. This puts the burden upon patients who are often limited in finances. The last resort is better paying health insurance, but this requires better employers. Unfortunately vast regions with deficits of health care can find it difficult to recruit and retain better employers. This tends to keep health care stagnant even in places growing in population numbers, demand, and complexity.

Basic Health Access Has Been Failure By Financial Design

Studies do indicate that current financial designs fail for basic services. This presents a challenge to practices that have a mission for access, care, and caring. Designs favoring better finances include direct primary care, capitated care, and concierge care (Miller, Crabtree, Annals FM). Increases in revenue, decreases in costs of delivery, and bypassing low paying plans and their requirements are more and more important.

RBRVS Causing Harm by Design

Patterns of burnout indicate a Red Zone approximated by intent to leave practice and intent to cut hours. The basic specialties including generalists and general specialists shift into the Red Zone. These are the specialties most abused by lower payments via Resource Based Relative Value Scale and even lower payments due to more distributed location and due to small to medium size of practice.

RBRVS never considered key areas that harm practice financial designs such as higher turnover costs, higher costs of each micromanagement, and usual disruptions.

These have cumulatively pile up and are difficult to overcome. These all impact the number of team members that can be supported and their quality and training levels.

Indeed there are half enough of each basic health access specialty in the 2621 counties lowest in health care workforce where 40% of the nation still awaits progress since 1980.

Finances shape environments, which is often hidden when the focus is on physician salary or physician training.

Increasingly toxic environments are suggested by shortening of health professional careers, losses of experienced team members, chronic deficits of workforce across vast regions impacted by insufficient funding, and diversions of budgets away from the support of the team members to deliver the care.

There would appear to be consequences from the movement to the least experienced workforce perhaps in our history, but studies are lacking in this area.

• Continuity has been reinforced as important in better outcomes and may be a reason for better outcomes in smaller practices, but studies fail to capture important details about continuity or reasons for the failures of small and medium size practices leaving as much as half of the US population with basic health access deficits.
• Research that has focused on concepts and assumptions and technology and micromanagement without good understanding of the personal and professional lives of the team members would appear to be a reason for increasingly toxic practice environments. We are ill prepared for the cumulative losses of care, caring, and continuity.
• Toxic environment focus in research can help to understand the inevitable result of abusive health policies and the impacts of employers shaving personnel costs due to profit focus, investment focus, or attempted survival. Poor support of delivery team members is a common denominator for toxicity, but how the numerous complexities of patients, caregivers, practices, and team members are addressed can make this worse.

When designs shape fewer team members to share the complexity, the march to toxicity has begun. The environment shapes higher turnover with loss of experienced team members. The move to fewer team members (lower ratios) and lesser team members is now complete.

All areas and specialties of health care have complexity. The folly of Resource Based Relative Value Scale is that it favors teams involved in procedural technical subspecialized areas and it discriminates against teams doing basic services.

Increasing patient loads or specialties with patient surge volume can accelerate toxicity as in ER environments. Financial designs that focus on cost cutting can result in lower levels of funding. Diagnosis Related Groups was such a cost cutting design. DRG illustrates acceleration of toxicity given more to do of higher complexity despite fewer team members and lesser team members. Small and medium size hospitals had greater decline by design from DRG cost cutting. Hundreds of hospitals died with most of the rest compromised. Those pushed into survival mode are approaching the end stage.

Diagnosis Related Groups also specifically targeted nursing with decline by design - for 41 years and still going.

Payment by diagnosis resulted in pressure to depart patients in shorter time periods. A fixed payment with increasing costs of delivery over time shapes budget challenges. The pressure to cut personnel becomes overwhelming and nurses are the big contribution to personnel costs. Few understand that DRG was terminated in Hong Kong over a decade ago after a short 3 year run with major concerns about what was happening to nursing and other personnel where the patients were more complex.

Basic health access declines in the United States have been the result of insufficient finances for office, basic, cognitive, primary care, mental health, women's health, and basic surgical services.

Geriatrics never had a chance with high complexity. Internal medicine residency graduates once were 150,000 strong in primary care with 5000 per class year entering and staying. Financial designs shaped much better environments for those doing fellowships. Those entering primary care faced entirely different situations.

Designs that shape fewer and lesser delivery team members given too much to do have been fmade worse with increased complexity and fewer to share the load

• DRG, profit, and nursing
• RBRVS, lower payments, and basic health access
• Small and medium size practices

Multipliers or accelerators of decline include profit or investment focus, leaving less to invest in team members

Multipliers can include survival focus where the financial designs put practices or hospitals in harms way - usually where the public plans are worst or the private plans are bad, and always when the public and private plans are worst as seen in 2621 counties forever lowest in health care workforce due to concentrations of the elderly, poor, disabled, and worst employers (as health care, education, and government jobs with their better plans are being designed away)