Value Based Designs Fail and Discriminate

There is little doubt that outcomes are shaped predominantly by non-clinical factors. The health care designers

1. Continue to resist the evidence basis including the Annals of Internal Medicine evidence based review of pay for performance
2. Continue despite the 5 for 54 record indicating massive failure for the CMS innovation center
3. Continue despite the failure of a comprehensive 100 million dollar RWJ foundation demonstration
4. Continue despite worsening US outcomes as most of our population falls further behind in health care and other determinants.

The CMS Director plans more innovation, more micromanagement, and more financial risk arising from new value based models of care.

This would result in lower payments or penalties for the practices that care for patients that have lower outcomes. This of course ignores the fact that 40 - 50% of Americans inherently have lesser outcomes and live in places with half enough generalists, general specialists, and social supports.

How can practices treated the worst by health care design - go at risk? They are already marginal to losing money, by design. How could they go at risk to lose more when lower outcomes are likely because of the populations that they serve?

Exposing the Micromanagement Catastrophe

Since 2005 the promises have been and policies developed based on assumptions, yet micromanagements of cost and of quality have continued to fail. Meaningless use is abusive to finances and to the forgotten team members that deliver the care.

And there are clearly ways that the micromanagement bandwagon can worsen outcomes by stealing more billions each year from the practices, hospitals, and populations most behind in outcomes, health care dollars, and health access. Simple economics 101 is all that is required.

Oh how we miss Uwe Reinhardt.

And you will not listen to Sullivan, Soumerai, and some consultants who point out the failures from ACO to medical homes to MACRA to value based.

COVID spread and intensity confirms the worst outcomes where Americans are lowest

... in social determinants, employers, jobs, situations, conditions, environments, and other non-clinical factors. These all conspire to contribute inherently to the lowest outcomes where these factors are concentrated. https://www.dhirubhai.net/pulse/covid-confirms-americans-most-behind-key-areas-health-robert-bowman/

Since the regression equations are loaded for co-morbidity, race, and ethnicity, this is what they show, but better studies reveal some of the likely reasons that are patient and population based involving determinants of health. When you begin to understand how populations behind have lower levels of education, health literacy, worst employers, and more - you can begin to see design failures that would indicate termination of performance based designs - not new expansions.

Tragically this can be seen in the 2621 counties lowest in health care workforce where health care spending, health care workforce, and health access are most compromised by design.

This 40% of the population includes 75% of the rural population and 32% of the urban population. This population is older, sicker, and poorer with higher levels of premature death and lower maternal and infant mortality and lesser longevity. Concentrations of mental health, diabetes, obesity, smoking, COPD, and asthma are notable.

You are not going to change the outcomes lower in these counties and populations for many decades - with some new health policy innovation. The designers do not understand health care in these counties, but they must to be able to grasp these concepts to be able to improve outcomes. How will a few minutes of contact with a health care team member over a year's time help change outcomes, realistically?

Primary Care Compromised By Design

There were about 60,000 primary care physicians in these counties lowest in health care workforce. These practices tend to be smaller and are most disrupted by the usual changes and ever higher costs of running a practice - and HITECH to ACA to MACRA to value based has made this much worse. These practices face

• 45% of the primary care need arising from this
• 40% of the population with only
• 25% of the primary care workforce supported by just
• 20% of primary care spending.

Discrimination is the correct term when

1. The Medicare design sends them 15% to 30% less for their practice and hospital services.

2. The Medicaid design pays less than the cost of delivering care in most states

3. The states refuse to address poor payment and poor treatment by the worst insurance plans concentrated in these counties

4. Performance based or value based designs penalize them for the "crime" of caring for populations that inherently have lesser outcomes

Each year the bandwagon from HITECH to value based has diverted about a billion more dollars a year from the primary care practices most in need of these dollars (calculated at 30% penetration, likely all that many practices could afford). The diversions of these dollars also transfer billions from populations with the least to places with the most - another source of disparities and potentially worse outcomes. Another likely impact is workforce departure from primary care or from these counties - as shaped by discriminatory designs. There is little doubt that these practices have been forced toward fewer and lesser health care delivery team members - the opposite direction from higher functioning, patient centered, and sane primary care practice.

Concentrations of the Worst Health Insurance Plans Shape Access Barriers

This financial design and the shortage of workforce has long been shaped by the concentrations of the worst public and private health insurance plans in these counties. This is dictated by the federal design, by state designs, by the worst employers in these counties, and by the worst health insurance corporations (for patients and for providers). Note also that many billions more go out due to expansions of health insurance - only returning about 10 cents on the dollar because of the deficits of workforce, practices, and facilities. This is another way that designers have worsened disparities by transferring many more billions from those with the least to those with the most.

If health care or political leaders really want to help these counties

1. They must learn about these counties and their populations and situations

2. They must stop basing health policy on assumptions and must do the proper studies on any new policy with full evaluation regarding the impact on these counties

3. More health care dollars must go to these counties and this will need to be in primary care, mental health, women's health, and basic surgical services which are 90% of local services.

4. More dollars must be paid for basic hospital services

5. Micromanagement should be terminated as harmful by design to those most vulnerable

6. Health insurance expansions should be examined for harmful impacts rather than assuming only benefits. Health insurance design should be seen as a reason for deficits of workforce rather than seen as a solution for health access woes.

7. The assumptions that training more graduates or special training schools or programs must stop. Only financial improvements specific to generalists, general specialists, and populations short of workforce can fix deficits. All four main sources of health professionals have been expanding annual graduates at rates 6 to 12 times the annual population growth rate for decades. This clearly indicates that training has long been incapable of addressing deficits.

This movement is consistent with health equity and improvements in the social determinants in these counties as well as improvements in Basic Health access.

This will need to be done

1. Even over the protests of Managed Care Groupthink and their numerous unproven assumptions

2. Even over the protests of the highly profitable micromanagement industrial complex

3. Even over the protests of academic and largest systems who oppose this true payment reform that will cost them their top procedural, technical, subspecialized dollars.

4. Even over the protests of NP PA DO and MD leaders who clearly want to continue expansion even with the massive glut of workforce being created. It is most useful for them to continue to claim to be the solution for health workforce deficits - which are clearly about the financial design and not training.

Worth Review

Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect.26https://jamanetwork.com/journals/jama/fullarticle/2770410

Value Based Care – no progress since 1997 https://thehealthcareblog.com/blog/2020/10/12/value-based-care-no-progress-since-1997/

Data Science Has Become About Lending False Credibility To Decisions We've Already Made

Kalev Leetaru Contributor AI & Big Data

https://www.forbes.com/sites/kalevleetaru/2019/03/24/data-science-has-become-about-lending-false-credibility-to-decisions-weve-already-made/amp/

Social and other determinants shape health and education outcomes and the 2621 counties lowest in health care workforce have the worst determinants to go with inherently worst outcomes. This exposes micromanagement, particularly value based designs, as discriminatory. These designs punish the providers who are already tasked with taking care of some of the most complex populations in places with the least health care and social resources. https://www.dhirubhai.net/pulse/aheader-few-go-behinder-most-get-robert-bowman/

To actually improve the delivery of primary care, you need to focus on the support of those who deliver the care. The focus on micromanagement of cost and quality has hurt, not helped. https://www.dhirubhai.net/pulse/health-care-designs-do-support-patient-centered-value-robert-bowman/?

Understand the rise of administrative costs and the decline of health access and outcomes where most Americans most need care. https://www.dhirubhai.net/pulse/stop-designers-from-making-health-care-delivery-worse-robert-bowman/?

Changes in health policy have consistently failed to reduce health care costs or significantly improve health outcomes – and sadly have been compromising Basic Health Access by design.

https://www.dhirubhai.net/pulse/valuing-basic-health-access-over-value-based-designs-robert-bowman/