Value Based Designs Can Never Reduce Disparities For Most Americans Most Behind

Another Health Affairs posting pushes value based care and tries to claim that value based care can reduce disparities. Such claims are distressing enough, but immediately come the comments that agree with this focus. I obviously do not agree.

In fact, the managed care to micromanagement road leading to value based care has actually worsened existing disparities.

I answer from the perspective of most Americans most behind in health care workforce, health care dollars, and health access - the ones that you should pay the most attention since the disparities and outcomes are worst for them - as is the healthcare design.

If you examine for disparities with an economic dollar flow focus, you can see the designs that are increasing disparities exactly where health care designs already shape the most disparities. When you have physician databases and area resource file data with county breakdowns and county ranking data you can begin to see the lack of value in so called value based designs.

More for Those Most Concentrated Is Disparity By Design

The healthcare design favors procedural, technical, subspecialized, and hospital. The places with concentrations of health care workforce have 80% - 90% of this most specialized workforce with their highest paid services by designs that they support and promote.

These places of highest concentrations enjoy the most lines of revenue and the highest reimbursement in each. They have even been able to create their own lines of revenue from research, GME, foundations, and health care corporate entities.

They are extremely successful and powerful. Databases of physicians mapped to zip code locations indicates about 1% of the land area with 10% of the population in 1100 zip codes (academic and largest systems) are places that claim 45% of physicians. This translates to more than a majority of health care spending attributable to physicians and likely even more when considering other costs and cash transfers.

Micromanagement has merged with digitalization to create new industries. New layers of consultants, CEOs, and corporations feed at the health care trough and contribute to greater concentrations. Precision medicine and other new technologies will continue to do much the same.

The places with about 30% of Americans doing best have 2 to 4 times greater utilization in these highly specialized areas. The designs overserve these populations. Cost cutting should have focused on this overspending but it has failed rein in the most powerful who benefit the most.

For decades the massive expansions of physicians, nurse practitioners, and physician assistants have facilitated more profits and ever higher health care costs for the nation - another source of major disparities. This has resulted in the Era of Cost Cutting dominant since the 1980s. Clearly this effort has been ineffective for cost cutting as health care costs and non-primary care workforce have continued to mushroom.

But the micromanagement focus has been most deadly for most Americans and for their health care where underutilization and access are worse.

Two America's Exist as we should understand quite clearly after the past few years, but we seem not to do so in health care. If we continue to make the situations worse for those most behind, we should expect worse. Health care designs are making the situations worse, particularly in the last 12 years. The value based band wagon contributes to worse.

The practices and hospitals that serve most Americans who are most behind rely on lowest paid basic cognitive, office, most needed, most prevalent and least valued services - valued even less by the 15 - 30% lower payments for the same services. Federal, state, and insurance designs cause disparities where 90% of local services are basic, generalist, and general specialty services.

Where are the equity advocates? Where do they stand with regard to these inequitable designs?

I don't see massive support for health equity or a multitude of health disparity advocates fighting for this cognitive vs procedural design change or a leveling of the payment structure to equitable payments.

At best there are deans and association leaders who say yes to an increase in primary care revenue or in revenue where most needed - but not if it cuts my precious overpaid multiple lines of revenue. They actually profit by having chronic shortages. These justify their statements that we can fix shortages by more training - but they cannot because deficits are about the financial design, not training.

But the authors of this article are focused on value based designs as the savior of health care as with so many others. So why not apply the same math to see if their claims of disparity reductions by value based micromanagement hold up where most Americans most need a better design for health care.

Start by tracking the dollars stolen to pay for the relentless micromanagement focus. Examine the impact of these dollars lost on the remaining 55,000 or so primary care physicians and their practices in 2621 counties lowest in health care workforce. Note that there were 60,000 in 2013. There are also about 100 fewer hospitals now as their hospitals are closed at 1 or 2 per month, and have been hit hardest since 1983 when PPS and DRGs began the major cost cutting micromanagement campaigns.

If you want a geographic map, picture two different lowest concentration populations - the Red Counties in the 2016 election plus the border Hispanic, Black Belt, and Native Reservation counties or the rural counties bluest of the Blue. These two are essentially the 2621 counties lowest in health care workforce. They have been lowest for decades with more to come.

40% of the population with 25% of the primary care workforce supported by 20% of primary care spending is not equitable

Before the HITECH to ACA to MACRA to PCMH to value based bandwagon rolled over their health care and caring these practices had 40% of the population to care for with just 25% of the primary care workforce supported by only 20% of primary care spending. A similar situation exists in women's health and mental health.

These practices have chronically been paid less by 15% and even lower due to the worst employers in these counties. The worst employers pass on the worst paychecks and benefits including health insurance.

• Note that they did not lack for employment or for insurance more than other higher concentration places, they just have the worst employers and insurance.

These practices also get paid less and collect less because of the populations they serve and because of the plans that abuse them and their patients - as tolerated by the states. They also now get penalized more because of their finances (not able to do certified EHR) and because they care for populations with inherently lesser outcomes.

It gets worse as demands and complexities are increased by population changes and micromanagement demands.

These counties have been increasing fastest in population numbers, demand, and complexity decade after decade as their workforce, practices, and hospitals are eroded away. By 2060 they should become 50% of the US population but by then it will be far too late to help them to address deficits that continue to be made worse year after year.

The delivery team members face more duties and since there are fewer of them they have to multitask even more. Studies demonstrate the impact upon their personal and professional lives, but the worst impact is likely in the practices and hospitals in these counties.

The micromanagements have never really considered most Americans most behind or those who serve them. And their designs are consistent in their abuse.

Micromanagement does not add up for most Americans most behind or those who remain to serve them. It subtracts and causes disparities to worsen.

These 2621 counties had an estimated 38 billion to spend on primary care in 2008 based on the above. They are now down to less than 30 billion to invest in primary care deliver. This is the result after 1 billion more a year has been stolen by the additional costs of HITECH to ACA to MACRA to PCMH to value based.

• These are calculations using Health Affairs articles that indicated the cost of making the changes per physician.
• Also I only estimated a 30% penetration of these regulations and innovations based on the articles and the poor finances of the practices.

Mold also indicated the greater challenges of quality improvement for smaller and medium size practices from the usual disruptions such as changes in EHR, billing, key personnel, ownership, and location - and his was not an exhaustive list of disruptions - as most physicians who have practiced in these areas can tell you.

• But then, why consult the people or practices most behind to see what works and what does not in terms of reimbursement design?
• Why consider those farthest away from you in geographic distance, social determinants, health literacy, and access to care?

Turnover hits hard, likely at a cost or loss of $100,000 per fte of primary care physician per year or about 15% of revenue generated. This is based on about $300,000 per loss and a loss each 3 years.

• Turnover is not helped by micromanagement, worsening finances, lower productivity, more to do, and less to do the work.

The micromanagement and managed care bandwagons are primary examples of disparity by design. The impacts are worst upon the practices and hospitals most needed where populations are most behind.

Micromanagement means more for those with concentrations and includes dollar transfers to the most concentrated places. This leaves less for those in most need of dollars, jobs, economics, social determinants, and outcomes.

These practices where most needed tend to be smaller and independent and suffer more due to any change, but the metric, measurement, and micromanagement changes have been deadly to them and to local health access - another disparity result.

Finances going down from low and stagnant revenue with major increases in the cost of delivering care also force closures and compromises.

The likely fewer result is fewer and lesser delivery team members. Notice that this is a change in the opposite direction from the requirements of higher functioning and patient centered care, but these are already a challenge given half enough primary care, women's health, mental health, and social support. You have to have such entities covered to hope to integrate and coordinate for best impact.

Micromanagement in education is also a design source of widening disparities - more taken away leaving less where needed. Value based applied to education is just as deadly. Property tax based education results in disparities in a different way. Does this make you feel good about focusing on value? This also results in lower budgets with even less remaining to spend on those who teach. Obviously the education in these populations is less valued and the consequences of micromanagement make this worse.

Consider that outcomes are really about population differences and you will see how much more meaningless the value based equation really is.

Social and other non-clinical determinants of health expose value based and performance based designs for what they really are.

The designers have proposed that overburdened primary care practices with fewer and lesser employees can do more to change outcomes that are set in stone by decades of previous life experiences - including the constant barrage of being thought to be of less value.

Attempting to make up for the errors of value based design by integrating social determinants - is a new horror story. Stop the madness. Humans are far too complex as are their various health care influences dating back to birth and beyond.

• https://www.dhirubhai.net/pulse/social-determinant-focus-argues-against-value-based-designs-bowman/
• https://www.dhirubhai.net/pulse/covid-confirms-americans-most-behind-key-areas-health-robert-bowman/

But to really worsen disparities - try out the cash flow changes from mandatory health insurance

Most would agree that the mandated health insurance packages are not the best. But few consider how bad they really are for counties lowest in health care workforce where 97% of the counties without a hospital are found.

These low value health insurance plans redirect 90 cents of each health insurance dollar from lower concentration places and people to go to higher concentration places, people, health care, and corporations.

Why Most Americans Should Not Celebrate 10 years of ACA/Obamacare -

Higher concentration entities are doing even better while lower concentration settings are doing worse.

Lowest health care workforce counties receive a return of only 10 cents on the dollar. The places most behind in dollars, jobs, job quality, health insurance quality, social determinants, cash flow, and outcomes have even fewer dollars that remain locally to spend on basic needs or local health care.

If you care about disparities, you must stop the design changes that make them worse for most Americans who are already most behind by design.

If you only consider what is happening to the 30% of the population in top concentrations - the source of most of the data, research, studies, publications, and more - you will miss what is going on involving half of the nation in most need of health, education, economic, and societal outcome improvements.

When you think about data, don't forget the missing data from the half of the nation that lacks access, workforce, and therefore data.

After the last 4 years, you might consider why most Americans question their designs and governments. Perhaps we should resolve to try to narrow disparities by turning away from designs that make them worse.

As quoted in Philipp Frank's book "Einstein: His Life and Times," This was Einstein’s response. “It is not so very important for a person to learn facts. For that he does not really need a college. He can learn them from books. The value of an education in a liberal arts college is not the learning of many facts, but the training of the mind to think something that cannot be learned from textbooks.”

We should get more value from our most educated populations, especially if we ever hope to have a less divided nation, and a less easily divided nation.