Top Down Policy Designs Abuse, Grassroots Coalitions Are Needed
Medicare for All Sounds attractive. Health insurers are abusive, but replacing them is unlikely to improve Basic Health Access where most Americans most need care. The new insurance or government design has to understand these people and who serve them first, before any change in design.
Obamacare is clearly a best example of reforms that make matters worse. When you look at dollars and what they can do - dollars matter. That is why the only time period in US history with improvements in basic health access was the period 1965 to 1978 - the original Medicare and Medicaid designs. Only during these time period did the majority of the population most behind gain some improvements - because of more billions injected into their local health care, local economics, local jobs, and social determinants of health.
Since the 1980s the designers and their reforms and their innovations and their regulations have stolen and diverted more billions - away from these counties, their providers, and basic health access. Even 1965 to 1978, the design changes benefited those who already had concentrations of health care dollars and health care workforce. And their abuses resulted in the Era of Cost Cutting in the 1980s that still dominates health policy today.
Sadly the guilty with their abusive costs were not identified and addressed - and all of us in health care suffer as a result.
Someone Asked Me What I Buy Into
What I buy into is the fact that we need to have more than a majority of Americans focused together to accomplish change regarding any number of abusive designs.
Top down has failed us. AAFP, primary care associations, and foundations all focus on the top levels of government. AAFP leaders came down on me for complaining. But I still point out that they have a lack of effective action - as family physicians are still being abused the most by CMS and government and insurance designs.
- Why continue to work with an unresponsive patient. They are dead to you.
The government agents are not going to change. There is no impetus or pressure to change. AAFP and other attempts to deal with the top have failed.
Work with live Americans who are suffering, and need good advise with regard to who is abusing them and how they must change.
Be nice to CMS and others - but force them by popular thought and action to do what the should - provide more and better delivery team members to this half of the US population most behind by their designs.
So we need to go grassroots.
Family medicine could play a key role in helping to inform most Americans, the ones most behind in health care workforce, health access, and economics from health care. We are by far the most representative health care entity since we are near a majority found serving them 42 – 44% found locally for this 50%.
Grassroots Efforts Work
Our rural high school career fair seemed to be working well in East Tennessee, and then attendance dropped off. Those of us at the top did not understand this. But Linda Nwosu with her background in public health in Africa did understand - or at least wanted to find out. She was our coordinators and she decided to visit the schools - African American visitor in 98% plus east TN Appalachia. She found out that the rural students thought that it was for urban kids. She found out the right person to talk to at each school which could be the teacher or principle or vice principle or other.
With the grassroots given a voice, the Rural High School Career fair exploded.
The Minifellowship went over like a lead balloon when we wanted to preach. I listened to the Rural Medical Educators that we surveyed and so we retooled. We sought out those who had a rural medical education project and specifically designed meetings and curricula to meet those project needs.
Our Nebraska Community Connections program went great - once we figured out the mentors in each town or CHC so that we could get students into their mentorship - and learning and helping their community. As is common with government, they gave us and award and terminated us 2 years later as with other impressive grassroots programs (AMSA HPDP).
You can make government work, by making government work for people. You make government work by forcing it to listen to people.
Family Physicians Have A Huge Advantage and Always Have Had This
Our advantage is our distribution and our access.
Family Medicine Is American people-dependent
The situations that family physicians face are largely shaped by the way most Americans most behind are treated - and all of us are being treated badly.
The powers that be almost extinguished generalists in the 1950s. We were restored to a formal specialty by visionary FPGP docs working to that end throughout the 1960s – illustrating to Americans that they needed access to locally available basic everyday services.
People did not have local care and they needed a specialty that could adapt to a wide range of locations and patient and population needs. They got what they needed.
But family medicine stalled after 1980 in numbers, in respect, and more - and so have most Americans. Academic leadership is one reason. We grow distant from family physicians and our populations - while we drew closer to academics and government and other associations. And so we have chosen failure.
The chaos and confusion of the past decades has screened us family physicians from view.
We are not being effective. Neither is AAFP.
What could matter is Grassroots
A. SERPA – Southeast Rural Physician Alliance - This was a group of rural family docs that banded together to work with employers and local hospitals and workers come and benefits managers – the kind of local work required to exist and thrive. They did not complain about the big city abusers. They did something.
1. Getting bigger matters – clearly smaller, independent, less organized, with designers least aware of us and who least value us does not matter
2. Coalitions with employers matter
3. Demanding that government designers play fair matters
4. Learning all of the intricacies of finance matter
5. Sharing resources with each others practices and practice managers matters
6. Establishing yourself as a lasting presence in your communities matters
AAFP could help to disseminate that model and could focus foundations on supporting such a community based and regional model. Family physicians need an option to stay where they are and where they want to be – and they need to know that expending even more effort for such a model can work.
B. The works of Gerald Doeksen matter
Gerald is one who has spent a lifetime illustrating the local economic impact of rural family physicians, rural practices, rural hospitals, and local health care. This is captured in his creation at Rural Health Works https://ruralhealthworks.org/
If the 2621 counties lowest in workforce understood how health policy plays out to hurt them, they could demand better. But right now they just know something is wrong and abusive, and politicians use them for their own benefit – to their detriment.
Needless to say that few understand that billions of dollars matter – for more and better team members or when designs shape fewer and lesser
The designers fail to understand the massive abuse of most Americans and those who serve them by
1. Mandatory insurance – just track the billions more dollars stolen and not returned to most Americans most behind
2. Metrics, measurements, micromanagement – stolen from our practices and others like us and hospitals
To succeed we need to illustrate how the dollars are designed and how this hurts most Americans – especially in the few remaining basic services that exist locally
Many support ACA and its health insurance expansion and its quality focus
Intent can be good, but poor understanding led to abuse rather than needed support.
- Expansion of health insurance is not the same as expanding access to care, particularly in our nation where most Americans have ready access to half enough generalists and general specialists and the financial design rewards procedural, technical, most subspecialized, and least accessible services
- Expansions of the worst insurance plans for patients and for providers, often paying below the costs of delivering care, should never have been expected to improve health care
- The failure to shift payments where needed is massive.
- the 40.2% of Americans in 2621 counties lowest in health care workforce had only 40.6% of the uninsured. Compared to other parts of the nation, they had the same levels of uninsurance. Their problem is not lack of insurance. Their problem has been concentrations of Medicaid, Medicare, High Deductible, and worst private health insurance. The diagnosis was wrong so the treatment was wrong - for them.
No one examined ACA from the perspective of counties with lower levels of workforce - where insurance expansions of the worst public and private plans cannot help
1. Most of us if not all should point out how heinous this has been for most Americans and most of us in creating disparities.
2. Where are the Uwe Reinhardts who see thru the confusion and bring clarity with an economics focus?
3. Where are the family physicians who can bring greater understanding?
C. Rebuke Performance Based Payment Designs – Document that these have not improved outcomes and cannot
1. because outcomes are about the patients and populations, not the providers.
2. Do this while supporting social determinants and the need to invest in Americans – for better outcomes.
3. Point out how many billions have been stolen from most Americans and from their local providers – making their situation and outcomes worse.
AAFP must do something complex but necessary.
It should oppose performance based designs for all of the many reasons that we have pointed out. And we are the right ones to do this as we are the ones most punished and the patients that we serve are most punished. It will be hard to focus on A and B if we do not do C and allow the micromanagers to run over us more and more.
D. Insurance is currently present and well established and is out of control, and we have not even done our part to help change it.
We cannot do a Medicare for All or other replacement until our Grassroots campaign is successful in changing the values – and the designs. Medicare for All would be as great a distraction as ACA was – until that happens. Reshape what is valued such as basic services – then you can do major reforms that could matter.
What we can do is build awareness of abuse
1. We have never even focused a multistate and national effort to discipline insurance "payers" for all of their abuses.
2. Massive numbers of complaints coming in from patients and families and practices, that state insurance commissioners could not ignore, would force health insurance to change and to document each situation and what they did –
3. so that they could continue to sell their product in that state.
Did any of you read my blog on Why We Should Not Celebrate 10 years of ACA. In addition to the mandated insurance abuse, and the billions more stolen by micromanagement, this substantially raised the cost of health insurance. Not only that, but the plans expanded are meaningless to most Americans – not to mention being costly and least value based from their perspective and that of their communities.
If you want to understand most Americans and why they feel abused and perhaps why they vote poorly, see how the old and new health care designs punish them. Reflect on much the same in education design with lowest dollars going where most needed and with more billions a year stolen for metrics and measurements
Do you understand the 2621 counties most behind in health care and how they are being abused and why performance based designs hurt them, their practices, and their communities?
www.dhirubhai.net/pulse/... or
If we do not organize and tell them why and how they are abused, you can bet someone else will do so.
Bob Bowman
Basic Health Access
Primary care, generalists, and general specialists for half of the US population have been compromised and killed by policy designs progressively since the 1980s. The US populations growing fastest in numbers, demand, and complexity are abused by designs that result in declining access, declining workforce, declining health care dollars, and more of their scarce health care dollars stolen by performance based focus - costly and meaningless metrics, measurements, and micromanagements (that also disable and distract delivery team members, reducing their care and caring ability).
The COVID impacts are acute on chronic. The impacts only accelerate what the decades have made worse. Revenue has been flat and has been unable to keep up with usual costs of delivery not to mention innovation and regulation costs. 60,000 practices in 2621 counties lowest in health care workforce had 38 billion to invest in primary care delivery in 2008 for their 40% share of the US population. But the usual costs of delivering care have gone up at least a billion a year and their HITECH to MACRA to PCMH to value based adaptations have also resulted in a billion less a year. They have less than 30 billion to try to attempt basic health access where they once had 38 billion. Unlike rural areas which are stagnant in growth, these counties have been growing fastest in numbers, demand, and complexity for the past 5 decades tracked.
Primary care, mental health, women's health, basic surgical services, basic hospital services, basic ER services, OB units, cognitive, office, most prevalent, and most needed services have been specifically targeted and destroyed.
Most Americans have indications that they are being abused, but few understand that the designs of health care and education - have been specifically abusing them and those fewer who remain and serve them. So they believe what they are told by the primary abusers - with worse to come.
They need to know just how bad RVU, and DRG, and ACA, and other designs are for them and those who serve them. But you have to understand them and their demographics and their needs first. Try to understand the majority left behind - before proposing reforms or fixes on reforms.
Basic Health Access