Micromanagement Is Suspect for Value and May Worsen Outcomes

The following list was brainstormed in response to questions about these studies. Since 2005 claims have been made about digitalization and innovation as having great potential for savings of costs and improvements of quality. Clearly there have been no major impacts. The experts have little awareness of the situations involving most Americans and their designs from above are a poor fit if not dangerous for those most challenged in basic health access.

• Methods are bad used in so called quality studies. Not uncommon is basic errors such as comparing apples to oranges. (rural vs urban, male vs female physicians)
• Variations between two compared populations are often marginal compared to variations within the populations being compared.
• Approaches involve attempts to demonstrate what is demonstrated, Funding bias Negative studies not published. Nice review of data science flaws
• Incomplete data, particularly involving nearly all components of the patient social determinants, life influences, barriers to care, and more. See how a studies indicating that a comprehensive intervention helped, was flawed and had to be retracted. With the proper methods and controls that intervention appeared to worsen outcomes. COPD hospital based intervention retraction 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. https://jamanetwork.com/journals/jama/article-abstract/2752467
• Arbitrary measures, that also change, and may not reflect quality
• CMS has had numerous definitions of medical homes and other entities, adding to the confusion. The Medical Home Demonstration failed times 3 as reviewed by Kip Sullivan.
• There can be Discrimination against providers caring for populations with inherently lesser outcomes
• It is difficult to attempt to adjust outcomes for populations behind so that penalties are not unfairly assessed. Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings  Clemens S. Hong, MD, MPH; https://jamanetwork.com/journals/jama/fullarticle/186551
• Proxy values for income or education inserted based on patient zip code which are 80% incorrect, as Jha points out in tyranny of the mean. Rarely do data sets include data specific to the patient and encompassing all of the many dimensions and life experiences that influence outcomes long before events or outcomes.
• The Annals of IM Evidence based review for performance based incentives indicated some impact on process with failure to significantly improve outcomes
• Even with minor significant studies, there is limitation of relevance
• Value Based Care – no progress since 1997 https://thehealthcareblog.com/blog/2020/10/12/value-based-care-no-progress-since-1997/
• Numerous works of Kip Sullivan https://thehealthcareblog.com/blog/tag/kip-sullivan/
• CMS Innovation Center success only 5 of 32 (Verma) - billions for 27 failed innovation attempts
• Costs of micromanagement are often underestimated - particularly the addition time, effort, lost productivity, disruption to the team members that deliver the care
• The assumption of overutilization as a major problem requiring cost cutting and value based designs - is a huge problem where 40 - 50% of the US population has half enough generalists, general specialists, social supports and inherently lesser outcomes.
• The Dartmouth Assumptions have many flaws and this influence moved into ACA and beyond. Assumptions based on small atypical parts of the population may not work out for most Americans quite different in many ways.
• Underutilization and poor utilization choices can be forced by design as seen in the 2621 counties lowest in health care workforce.
• Maldistribution of health care workforce has been worsened by the financial design, by the additional costs of micromanagement on practices where most needed, by the consequences of worst private insurance expanded, by concentrations of the worst health insurance public and private plans Why Most Americans Should Not Celebrate 10 years of Obamacare. They are not getting good insurance and their local finances and health care are being designed away. Again you must understand from the perspective of most Americans most behind - and not listen to micromanagers and their assumptions from above. https://www.dhirubhai.net/pulse/why-most-americans-should-celebrate-10-years-obamacare-robert-bowman/

You can even make the case that the health care design actually worsens health outcomes

1. By failing to distribute dollars and social determinants

2. By forcing more of the fewer dollars that get to the practices and hospitals where needed - to be sent to higher concentration settings

Yep, the attempts to micromanage for better is likely to make outcomes worse.

More details on the above with request.

The New England Journal Posting by the current CMS Innovation Center director highlights numerous problems with past, present, and future innovation projects. I took his bullet points and illustrated why we should terminate innovation focused on micromanagement due to inaccuracies, gaming, poor risk adjustment, and mostly due to poor understanding of the situations of most of the US population and what remains of their health care.

Terminate Innovation and the CMS Innovation Center - The fourth director of the CMS Center for Innovation posted an article in the New England Journal highlighting the focus of the center. Quotes follow with my comments below each point made. Why continue with such failures?

"The Center will ultimately be successful only if it is able to launch and scale models that either decrease cost or improve quality."

My response - Since the Center is 5 for 52 projects that have been successful, one consideration is that health care costs and outcomes are about the population and not some innovative intervention.

https://www.dhirubhai.net/pulse/terminate-innovation-focus-cms-center-robert-bowman/