Stop Insurance Coverage Preoccupations to Start Basic Health Access Improvements - the sad story of The Commonwealth Foundation

Dear Commonwealth please stop the focus on a coverage gap when half of the US population has locally available half enough primary care, mental health, women's health and basic surgical workforce. The biggest boost to health care where most needed is about better health insurance - not more.

The worst public and private health insurance plans are concentrated in 2621 counties lowest in health care workforce.

Medicare plans pay 15% less and Medicaid is worse. How can practices benefit with Medicaid paying only 70 - 80% of the cost of delivering care to its patients as seen in CHCs? The worst private insurance arises from the worst or weakest employers with their worst paychecks, benefits, and health insurance plans. Lower income levels also force worst health insurance plans. Mandated insurance is even worse with 90 cents on the dollar leaving these counties and only 10 centers returning.

The Commonwealth focus on micromanagement

makes this worse as these practices with little margin are forced into negative margins by HITECH to ACA to MACRA to value based.

These counties, their population, and what remains of their providers are not valued

- so health insurance coverage focus is a distraction from better access. If you do not understand how your policies and promotions fail to improve access, you should not have better access as a mission. And Medicare for All and other reforms will make the situations worse as long as there is not better value placed on most Americans most behind, and their health care.

If you want to help,

fight the academic and largest system focus on preventing true reform such as a shift of 100 billion dollars away from their overpaid concentrations of health care dollars to be sent to what remains of primary care where deficits exist. They say that they support primary care, but they state that this should not come out of their non-primary care excesses.

• Those who design health care that works for most Americans most behind, will find that they will be fighting against their colleagues and friends who have a focus on concentration dollars, workforce, and profits. Future health care leaders arise from the same institutions, associations, corporations, and foundations - that are quite the opposite in background and awareness and design focus when compared to most Americans most behind - thus the failure to address their needs.

If you want higher functioning primary care,

please understand that this can only happen with more and better delivery team members. Understand that these counties have 45% of patient complexity in this 40% of the population while health care designs limit them to 25% of the primary care workforce supported by just 20% of primary care spending.

If you want burnout reduction, decreased turnover, higher productivity, and innovation improved with each primary care patient - then support a reversal of this discriminatory financial design.

If you do not want changes in access or process or improved distributions health care dollars - go on supporting meaningless micromanagement and meaningless coverage expansion.

A decade of Previous Blog Postings and Letters Directed to Commonwealth without response, usually with postings on their web site or social media sites. The writings have not changed - and neither has Basic Health Access for most Americans most behind.

Critique of Commonwealth Fund Report on Ensuring Equity October 08, 2011

A Critique of?Ensuring Equity????A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations

The COMMONWEALTH COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM????October 2011

A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access, to have primary care or health access someone must be there to deliver the care.

?This foundation sponsored report attempts to focus attention upon bringing equity to health care. This is a most important area,?but the report fails to mention primary care workforce other than the following:

• Additional efforts may be required to develop the workforce pipeline, such as an expansion of medical education debt relief for primary care providers, specialists, dentists, and others practicing in health centers, safety-net hospitals, and medically underserved areas. P12 also repeated on p39?
• Additionally, efforts may be needed to increase the number of physicians and allied health professionals available to deliver such care. P14 also?repeated on p41?
• Expanding the workforce and engaging the private sector’s providers to serve vulnerable populations is critically important as people gain health insurance under the Affordable Care Act. P24

Schools and students may need debt relief, BUT PEOPLE NEED HEALTH ACCESS. And this requires workforce. And this requires that the workforce be in position. With only 25% of workforce found in 30,000 zip codes with 200 million Americans (65%), serious design flaws exist.

Like Health Affairs issues devoted to?Disparities (October 2011)?and to Primary Care (May 2010) as well as other government and foundation reports, the reports fail to indicate how the nation can get to health equity. To actually innovate, reorganize, reform, or change health access, first and foremost there must be

• Primary Care Workforce?and a specific type of workforce:?Family Practice Workforce

This one back in 2014 highlighted the Commonwealth selection of a micromanagement guru to lead this health access mission foundation.

Not surprisingly health access has not improved. https://basichealthaccess.blogspot.com/2014/08/information-technology-cannot-heal.html

• Listed in the above was by Dr. Blumenthal - Of Leaders and Geeks noting the rise to power of those with health info tech prowess. "Today's and tomorrow’s successful leaders do not need to be technologists, but they do have to own technology policy and problems in a way few do right now. And they have to incorporate into their inner circles of advisers individuals capable of bridging the historical divide between technology experts and leaders. The alternative could be a future full of healthcare.gov launches, or worse, a continuing failure to take full advantage of the power of information to optimize health system performance."
• Seven years later we still see the failed launches and an entire aberrant micromanagement culture has taken over health care - with increasing costs and worsening outcomes.

Another open letter to Commonwealth asking the direct question "Does Commonwealth support basic health access?" https://basichealthaccess.blogspot.com/2017/08/does-commonwealth-support-health-access.html

Transforming Primary Care Requires Fuel -?The transformation of primary care requires payers and players. The payers have said no so the players are too few and are often overwhelmed where the players are most needed. Primary care needs fuel and a more efficient financial design, especially in the small and rural practices and those where care is most needed. The controversies continue to hold primary care hostage, especially primary care where needed where half of Americans will reside by 2040.?

Real Health Care Solutions, Not Value Focus

November 25, 2018

The Value Based Movement lacks Value. It is important to understand how AAFP, Commonwealth, and others have arrived at their misguided focus about what is value.You will hear the various promotions constantly in journals, policy papers, and in the media. The following are more critical evaluations via Jha, Soumerai, Sullivan, CBO, Annals of IM, and others with my comments, critique, and assumptions regarding the real influences on outcomes.

Improving Health Care Is Not Likely for 2600 Counties - Basic Health Access Actually Has No Advocacy Group, Particularly with Regard to the 32% of the urban population (90 million) in lowest concentration counties.

October 19, 2014

Commonwealth indicated six areas where the US is behind compared to the United Kingdom.?Actually fixing health care requires fixing far more than health care or distributions of health care. The truth is that nations have better or worse health care due to distributions of income, economics, education, and other factors that shape health, health care, and health care outcomes.

It is often not possible to fix health care woes by health care focus.

For the United States to actually improve in health, the substantial populations of Americans that are behind would have to be addressed. What happens to 40% of Americans in 2600 counties with lowest concentrations of clinicians is paramount to recovery of health care. If the US does not address situations in 2600 counties, it will not improve American health care.

United States Health Spending Excesses

Direct attempts to cut health spending have typically resulted in across the board cuts in spending with small health care and rural health care most impacted – as well as 2600 counties in need of health care that are most dependent upon small health, primary care, and basic services. Lowest payment for these areas shapes decline by design.

Redistribution of excess spending has not progressed - those who spend so much have been too powerful and there are many advocacy groups that resist spending cuts for "their kind" of patients.

Unfortunately basic services have no advocates. Further cuts are likely and are likely to damage health, economics, and more in 2600 counties behind by design.

Commonwealth Highlighted in 2014 That All Health Care Was Local - but seems to fail to understand this other than highlighting a few examples while ignoring half enough basic workforce for half of the nation's population.

Will Small Health Make the News Long Enough to Matter?

September 12, 2014

It is about time that Small Health Care received some attention as the small hospitals and small practices, but will this continue. Off and on over past decades, primary care has received much attention, but the attention has not resulted in changes in payment policy. In fact the increased cost of delivering care has made matters worse.?

Small Health Care is at least half made up of primary care and much of the remaining local care is basic services - services lowest paid by design. Small health does not have multiple lines of revenue with the top reimbursement in each line as seen in large health care.?

It is an impressive run of articles with some content regarding small health care, often negative but a few positive

The AMA says changes are needed in health information technology - but our nation plunges on with far less efficient HIT. The software still takes far too much time and effort.

CMS moves on recklessly with Meaningful Use regulations in 2015?even though experts in HIT?and those representing rural health care (National Rural Health Association) have encouraged more caution.

AAFP experts also agree that the Meaningful Use regulations are ridiculously complex.

9/11/14?Commonwealth - All Health Care Is Local

9/10/14 Headlines -?Small Hospital Closures Accelerate, Finances Weaker for Stand Alones

9/9/14 Commonwealth?Do Health Care Costs Fuel Economic Inequality in the United States?

9/8/14?Regarding the flaws in Pay for Performance

Small practices do better in preventable hospitalization

Changes have not come

• Primary care pay remains low and especially low compared to non-primary care specialized services
• Disproportionate share funding is going away and across the board cuts have continued to reduce revenue.
• Graduate medical education has not been reformed despite legislation and nearly a decade to observe the legislation going for naught.
• Continued funding for Medicaid to remain at higher rates of pay has not passed.?
• The government has not eased up on penalties that more commonly go to sites where small health is found.
• The state governments have not reformed Medicaid criteria, eligibility, payment barriers, or low pay.

Can rural and small practice urban sites rally together to get more than just discussion?

Will federal facilities and funding supports contribute to care or undermine what remains of private small health care?

What will turn clinicians around to primary care and small health care when payment so obviously rewards specialized care and sites with concentrations of clinicians?