Our Health Care Designers Cannot Solve the Health Care Problems That They Make Worse

Health care design failure summary

1. Failure to cut costs, mainly because they have failed to rein in those doing best.
2. Failure to improve quality. This was inevitable since outcomes are about populations, not plans or providers.
3. They have shaped the least experienced front line basic health access workforce in our history across ER, primary care, retail, urgent, women's health, mental health
4. They tolerate serious errors in quality studies that support more micromanagement when social determinants, situations, environments, and other non-clinical factors are most important. The misuses of statistics and the obsessive measurement disorder will only get worse.
5. The folly of expanding the worst quality health insurance plans has continued and cannot address the main insurance problem, worst quality health plans unique to the United States and causing health access deficits and health inequities.
6. The designers prevent access by design as they shape the lowest levels of workforce where there are concentrations of elderly, poor, disabled, and worst employers with concentrations of the worst quality public plus private plans.
7. The financial design is so bad that there is total failure of any training intervention or design that can address half enough basic health access workforce for half of the US Population (or the least experienced workforce)

Government and Insurance Solutions have failed for decades

And you can make the case that the situation is worsening over time, as we age, as we have a major or chronic illness, as we have a family member with same, and as we are forced to move from higher cost of living areas of the nation. This forces us to move to places lowest in workforce and supports.

The designs work less and less for most of US. So I ask that you examine health care in a different way, and include advice from those who have delivered care and done the research about workforce, policy, and failures by design.

How can they ask more and more despite less and less of us in basic health access made worse with less and less support? How can you ever have sufficient primary care for all Americans when half remain mired at half enough?

CMS prevents the seven vital conditions that it recommends.

Why can we in practice see so much better than designers about true solutions?

The designers are quantitative in focus and they exhibit the worst of the flaws of qualitatives. They lack the mulitimethod, qualitative, and contextual awarenesses needed. See Miller and Crabtree about the Inside Out perspective.

See How Mold contributed the most from the 117 million spent on quality improvement in primary care by outlining the Usual Disruptions of small and medium size practices - not even considered in the financial design or as a cause of burnout, turnover, and primary care decline.

Give us that deliver the care a chance to explain because we have served where most needed. Listen to those of us who have studied the misguided attempts and assess the failures from our unique perspective - the bottom up. We often see that the solutions that will work are not going to be top down.

If those at the top never grasp most Americans or their team members, they can only cause harm by design.

Everything that we have been taught about solutions - is wrong.

More new types of graduates have failed, despite massive overexpansions. Micromanagement has failed to save on costs and clearly our outcomes are worsening.

You can begin to see the problems and solutions if you move away a focus on cost cutting or quality micromanagement. Move away for a time from minority or rural focus? Then you can begin to see the Majority of Americans left behind with worst to come.

Seek the reasons for health care design failures for 40 years, particularly for most Americans always most behind. Examples are many and involve far more than small segments of the population.

To begin to address the many US Health care problems, try to see from the perspective of 40 - 50% of Americans most behind and why the worst failures are specific to them and their health care needs.

My journey led me to Physician Concentration coding. The many limitations of rural urban coding were made evident as there is less relevance to health care dollars and workforce distributions. Also rural is small, stagnant, and 20 million are doing fairly well in or around larger hospitals or systems - that benefit from most lines of revenue and highest payments like the urban big health entities.

Coding by concentrations of physicians can demonstrate the deficits, plus you can layer in county data on workforce, outcomes, resources, health insurance, and more.

For example you can see the flaws in the assumption that greater levels of primary care cause better outcomes. In the graphic primary care is 133 per 100,000 in top concentration counties and across the lowest concentration counties with inherently the worst outcomes - the level is about 50 or half enough. You can pick dozens of variables and say that any one of them is associated with lower outcomes.

There are plenty. Across social determinants, environments, employers, plans, chronic illnesses, behaviors, and numerous outcomes, these counties are behind in many ways.

When you examine from the bottom up and ignore top down dogma, Then you can see that

• 45% of patient and population and practice complexity is packed into
• 40% of the population growing fastest in numbers demand and complexity in 2621 counties lowest in health care workforce with only
• 25% of the primary care, womens health, mental health, and basic surgical workforces supported by
• less than 20% of spending in each due to
• 15% lower payments from CMS (30% less for their hospitals) plus worst social determinants and patient finances from the worst employers with their worst benefits and worst quality health plans concentrated in these counties (packed with duals, high deductibles, worst insurance payments and abuses, worse in 30 states). See how the US design can only shape failure where we have concentrations of elderly, poor, disabled, and worst employers in the weakest and worst states.

Now perhaps you can understand the closures of 500 of their hospitals and many times more practices (do not celebrate the 40TH anniversary of DRG, blame it for the carnage created to these communities and for the deaths of patients dumped too soon with certain diagnoses)

See the financial design forces that have always shaped half enough basic health access workforce with worse to come plus fewer and lesser delivery team members plus numerous poor quality adaptations to survive financially (more volume, part time jobs, side gigs in practices).

See the obstacles that prevent integration, coordination, outreach, patient centered care. The workforce does not exist for any of these and the social supports are lowest.

Understand the horror of the impacts as the designs most impair the one on one innovations with each patient that are the heart of health care delivery and the only innovations that matter. Can you see how micromanagement, technology, and other areas distract and divert from what is most important? If not, discuss this with people that you know who deliver the care - or stop designing or writing about your solutions.

Leadership in Health Care Locally

If what I indicated above is true, then why have you not heard about it. First, you need to understand from the perspective of those delivering the care. Then you need to see the designs as very successful in driving off those who could fight against these designs and changes. Those who are most aware are being driven off. The closures of hundreds of hospitals and many more practices drive off what remains of locally focused health care leadership across hospital administrators, physicians, NP, PA, and all delivery team members and social workers.

They are no longer there to inform, to protest, to suggest changes that would work for them.

And we are not talking just a few who are minority or rural. Slowly, steadily, we have designed failure for over 40 years.

WE ARE TALKING ABOUT THE PROGRESSIVE EXTINCTION OF BASIC HEALTH ACCESS FOR HALF OF THE NATION.

AND

WE ARE TALKING ABOUT THE POPULATIONS GROWING FASTEST AND FALLING FASTEST IN OUTCOMES - BY DESIGN

See stagnant top and higher concentration counties - the places where the most lines of revenue and top payments and RBRVS and DRG support ever higher workforce concentrations for few while most suffer.

See the fastest growing US population, the urban population quadrupling from 40 million to 160 million and every bit as behind as the rural population (stagnant).

And perhaps the urban portions of the 2621 counties are worse as seen in this readmissions graphic from Year 2 with 1 to 2% withheld as the top penalty - multiple times higher for these counties.

Can you see how almost everything that CMS touches is harmed by design?

You will see many graphics about the cost of US health care going up as outcomes like life expectancy flatten or decline. But consider that most Americans, if ranked as a separate nation, would rank 40th or worse - behind developed nations and some others as well. You can never improve outcomes without improving the half of the American population most behind and being made worse by health, education, economic, and other designs.

Local Health Care Leadership Is Being Killed and Compromised So We Need More from National Advocacy Groups Who Say That They Support Access to Care and Health Equity - But Total Failure from Them

The foundations and associations that have access missions could address this, but some are wedded to the innovation micromanagement bandwagon and have even elected Presidents with careers in same (The Commonwealth). Commonly these entities push health insurance expansions which unfortunately are about the worst quality health insurance plans. They fail to see the real insurance problem as lack of value in insurance and poor quality health insurance plans. These are concentrated where the poor, elderly, disabled, and worst employers are concentrated.

Primary Care Associations and Those Who Say That They Are Primary Care or Are Solutions for Primary Care are collaborating with the designers perhaps in the hope of better finances. But they ignore the past, present, and future clear and present danger of 40 years of policies, practices, innovations, digitalizations, reorganizations, certifications, distractions, disruptions, forced multitasking, and more.

It took 40 years for protections vs physician abusers and it took 50 years for Human Subject Research Protections. It may well take 50 years to understand CMStrogenic - or the harms done by health policies. The CMStrogenic harms are most easily seen to those least valued

See the failure of primary care by design. Revisit the Standard Primary Care Year measuring tool to see the falling primary care retention and ever fewer primary care years per graduate across all sources.

Can we call internal medicine, nurse practitioners, and physician assistants good sources of primary care as they have fallen below 4 years per career per graduate and are on the way to less than 2 each?

Massive overexpansions and the compromised primary care finances and environment will continue to collapse what remains of primary care.

Micromanagement Focus Is a Deadly Distraction

The evidence is strong against Type 1 Micromanagement Cost Cutting and against Type 2 Micromanagement Quality Improvement DOING MUCH OF ANYTHING POSITIVE, but this is worse as these futile and punitive attempts have proceeded with a total disregard of most Americans most behind and their health care.

There can be no change from further decline by design as long as designers arise from the same institutions and flow through the same associations, foundations, corporations, and government positions as well as reading the same distorted articles in the same journals.

They must continue their destructive assumptions and "reforms" because this is all that they have been taught and all that they pursue - and this has made their careers and fuels numerous sources of income for those doing quite well with micromanagement, with ever greater expansions of worst quality health insurance, with ever worse overexpansions of RN NP PA DO and MD.

There is little evidence of inside out thinking from the grassroots health care delivery perspective of team members. There is maximal evidence of designs from above, far away, with little consideration of the consequences.

They do not understand US Americans. They do not understand our health care and our delivery teams and our practices and hospitals. They focus on quantity and superficial quality measures that are about differences in the populations - with outcomes that can only be improved by improving the half of the population most behind - which they are worsening in outcomes with their designs.

Don't you see that the assumption of overutilization is exactly wrong for most Americans most behind that suffer from underutilization and inappropriate utilization.

Don't you see that cost cutting focus is not ethical and kills the most where we have the most vulnerable populations

Don't you see that where our populations are least literate in multiple dimensions, they need the one on one personal care from more and better delivery team members - which is very specifically denied by design.

Don't you see that the better financial designs such as negotiated highest Medicare Advantage payments - are responsible for massive improvements in cost and in quality due to moving Americans with no or lowest access to superior access - which is not about value based focus! (ChenMed, others). If you invest in more and better delivery team members and cut administrative costs and profits to the minimum, you can accomplish much for most Americans most behind. But our designs do the opposite and have for 40 years.

Look at geriatrics. 45% of this population is found in the 2621 counties most behind and geriatrics is complex and worst paid requiring the most delivery team members and the most one on one interactions, but these counties only have 15% of geriatricians so this burden goes to remaining primary care. The same is true for inadequate mental health with 15% of psychiatrists and 23.5% of mental health providers overall for this 40% with 45% of mental health need - and the absolute worst quality health plans, worst for mental health.

Why let CMS Behavioral leaders prescribe cures from on high when they and past CMS leaders have prevented each and every solution that they promote?

Why let the CMS Innovation Center exist after 47 failures in 52 tries costing billions - and the one most obvious failure involved a massive investment in primary care which is one of the most important investments for any future of primary care, more and better delivery team members, and eventually better outcomes. And speaking of this area, former CMS Director Verma said that their failure could have been success if these practices were put into double sided risk. Why would practices serving the populations most abused in plan quality and plan payments that inherently have the worst outcomes - benefit from any more risk beyond the already apparent certainty of decline and demise by design?