Social Determinant Focus Argues Against Value Based Designs
If you understand social determinants - you should understand that health care dollars shape jobs, income, economics, and other social determinant areas.
If you understand social determinants, you must oppose the health care dollar designs, especially the most meaningless, abusive, and low value designs.
Track the health care dollar changes
... to understand that health care designs and designers make social determinants worse for most Americans and will worsen outcomes.
Value based bandwagons are leading more Americans to decline in numerous outcomes.
- Track the dollars forced via mandated health insurance with tens of billions stolen from people most behind where most Americans have half enough generalists and general speicialists. See that out of each dollar stolen, only 10 cents on the dollar returns to the community via health care design. And some of that has to go outside by design. Track disparities to see worsening outcomes - better for few Americans and worse for most.
- Track the dollars forced for metric, measurement, and micromanagement focus stealing 1 billion more a year from primary care practices where most Americans most lack workforce. See this as what they are - dollars, jobs, cash flow, economics, social determinants stolen.
- Track the same meaningless metric, measurement, and micromanagement focus in education trying to force better outcomes involving children arising from decades of social determinant neglect
- Track these increases by tens of billions more each year that are taken from lower concentration places and populations and those who serve them to be paid to those in higher concentrations
Our health care designs are contributing to worsening outcomes - and they are not alone.
Our education designs also focused on micromanagement are also worsening the situations across education, schools, districts, teachers, and social determinants.
See the Measurement Focus for what it does - Causing Disparities and influencing worse outcomes and dividing our nation further
We should not tolerate abusive people - and that is where we are at this current time as a nation.
But we should see many of our health, education, housing, and economic policies as abusive to people and populations. These policies are in need of great change. To change people and outcomes, you must change these policies. But sadly, our nation has been going the opposite direction.
Social determinants have long been under attack.
See them for what they are - attacks on social security, disability, food stamps, veterans benefits, elderly programs - these are funds that are population distributed. About 42 to 45% of these funds go to 2621 counties lowest in health care workforce with 40% of the US populations.
Cuts to these dollars hurt most Americans most behind
See the lack of investment in child development and early education as these populations get less by property tax based education and because we tolerate political leaders that fail to support infants and youngest children and their parents at their earliest and most life influencing time period.
See the State Budget pictures
Rising health care dollars erode all of the investments in people - to pay for health care that does not change outcomes and increases in cost.
Do you see that health care is not value based - but claims to be as it makes outcomes worse and disables our nation's ability to invest in better outcomes?
And CMS is making the situation worse as are both parties and across state designs.
And this will be worse until there is better understanding of social determinants, most Americans most behind, and those fewer who remain and serve them.
The Primary Care Example
Primary care is being held accountable for areas almost completely outside of its control
1. Logical reasoning indicate the limited potential for life influence of primary care
2. Evidence based reviews document the failure of performance based incentives
3. Social determinant focus in payment is done by those with a poor understanding of social determinants as related to outcomes - and they are not alone
4. Micromanagement dollar tracking indicates design changes that worsen social determinants and disparities (not to mention disabling practices and team member duties).
It is not possible to cherry pick what you believe or do not believe. Be consistent.
If you believe that primary care shapes outcomes - then you must disregard social determinant, genetic, and other non-primary care influences.
If you believe in social determinants, then you should reject primary care as being able to shape outcomes. We may shape patient process, but not outcomes. Similarly our primary care practices have been forced to changes in process but this is not changing outcomes.
If you think that somehow primary care will be given increased funding at huge and prolonged investment levels required to help patients in social determinant areas, well there are bridges and swamps I can sell you.
Logically Primary Care Has Minimal to No Life Influence
The few short minutes of year of primary care patient contact are unable to change life influences compared to 350,000 minutes of life influences yearly while awake - and decades of previous life shaping experiences - and influences impacting individuals before birth. A decent understanding of social immobility in the US as well as social determinants is required for this awareness.
- Why would anyone think that the last days or months or years of life can change more than a lifetime of previous life influences?
New adjustments for social determinants will still be inaccurate measurements of areas that may or may not influence outcomes for that particular patient if we only knew how that relationship played out (dichotomous, continuous, threshold, parabolic, other). Hong demonstrated this in JAMA. Mostly the outcomes studies fail to include the number and complexity of social determinant variables and many have not even been attempted.
Evidence Based Reviews
Evidence based reviews demonstrate that performance based incentives work for process but do not significantly change outcomes (Annals of IM). Numerous scholars have pointed out how pay for performance discriminates against those who care for more challenging populations.
Social Determinant "Adjustments" Are Largely Unknown, They Are Vague, They Are Not Specific to Individual Patients
Which one of dozens if not hundreds? Which one is specific to the patient in front of me? How much adjustment? Will the additional revenue be taken up by patient needs - when our nation shorts people investments by hundreds of billions?
- Adding a new social determinant wrinkle is not a help at all.
Right now, the primary care practices that serve the populations with the best social determinants and plans and access to resources - have the best revenue and the fewest penalties and highest ratings. Those behind in all of these areas are being punished and in more than just penalties, 15% lower payments, and worst health insurance, public and private.
What we need is more support for the generalists and general specialists serving where most Americans most need care - not more punishment.
The Primary Care Vs Outcomes Dilemma
Not surprisingly in the US, primary care levels are associated with better outcomes - because about 100 social determinant and other variables also correlate with outcomes and with primary care levels.
The 2621 counties lowest in health care workforce and primary care represent concentrations of elderly, poor, disabled, Veterans, worst health plans, lowest social support resources, fewest general specialists, worst performing hospitals, obesity, smoking, diabetes, COPD, asthma, mental health issues, and more. See More Detail Here Regarding Flawed Research and Analysis
Stop thinking that primary care is going to change all of that.
Start focusing on these populations in most need of investment along with the generalists and general specialists that remain.
Half enough for half of the US population with half enough delivery team members is being made worse by HITECH to MACRA to PCMH for the 30% that can afford these - and costs 1 billion more each year reducing primary care dollars that can be invested in primary care delivery down below 30 billion (was over 38 billion a decade ago).
Usual costs of delivery are also up by 6 to 8 billion. These calculations do not include usual disruptions, penalties, security and update costs, lost productivity, or higher turnover cost.
Primary care for these counties demands 90 billion for higher functioning or patient centered or other designs that require more and better team members. But the designs shape fewer and lesser.
Stop this meaningless, costly, and disparity causing abuse.
We should not tolerate abusive people - and that is where we are at this current time as a nation.
But we should see many of our health, education, housing, and economic policies as abusive to people and populations. These policies are in need of great change. To change people and outcomes, you must change these policies. But sadly, our nation has been going the opposite direction.