If You Support Value Based Payment, You Support the Adverse Consequences

Primary care has been providing over 50% of health care encounters each year for decades. There has been little interruption of the primary care to patient relationship during that time. That time is over. In recent decades the design for primary care has been turned over to micromanagement focus in two areas - costs and outcomes. These changes have resulted in consequences to primary care delivery that few consider. The changes have even greater impact where primary care delivery capacity is weakest.

If you have a perspective involving consumer focus, health equity focus, cost saving focus, social determinant focus, Basic Health Access focus, and team member satisfaction focus you should consider that the new designs compromise these areas.

Before you read on

• Think logically, try to escape the many promotions of progress via innovative designs
• Consider that primary care is a service - a basic access to health venue. The value is in the service - availability, continuity, contact, interaction, consultation, support, and higher functions such as integration, coordination, and outreach (if well supported for this).
• Consider that primary care team members need support, not complications. It is difficult enough to adjust to the increasing complexity of the American population without having to address complexity as worsened by the new designs. Team members need to be valued, not disrupted. Designers should pay attention to their lives rather than ignoring them. This is especially true where half of Americans have half enough primary care team members.
• Consider that outcomes are not about a few minutes in a doctor's office out of 350,000 life influencing minutes awake each year and after decades of life shaping influences. (Consider that many if not most studies demonstrating differences in outcomes are really comparing two populations that have different outcomes)
• Consider that innovations are costly to primary care practices and are disabling to primary care team member functions and lives. The focus is not longer on the patient or delivering care. The focus is on micromanagement.
• Consider that innovations that disable primary care, can worsen health care costs two ways - the costs of the innovations and the additional costs due to inadequate primary care that has been disabled by design. The costs of administration and management have contributed substantially to health care costs - and act to compromise what remains to deliver the care. Few appear to remember that increased costs divert health care budgets - which are mostly about personnel. When dollars are increased in non-personnel areas, this leaves fewer for the support of team members.
• Understand that studies document the new design disruptions of time with patients, time with team members, and time with family - making the personal and professional lives of team members worse. This likely contributes to burnout, lower productivity, increased turnover, increased costs/losses due to turnover, and primary care failure.
• Consider that primary care is not trying to profit from more services for more revenue. This is particularly true for primary care where most needed where practices have the lowest collection rates and 15% lower payments for office services (Medicare 2011 data). Do you really think that physicians choose primary care and practices in places paid least - to make a huge salary? Primary care where needed is a contrast from highly specialized care where procedures and tests generate much more revenue - and this is where workforce has been increasing fastest for decades.
• Consider that the managed care groupthink, Dartmouth, ACA, and value-based assumptions based on overutilization - are really bad for places, practices, and populations that have the most difficulties with underutilization, insufficient basic workforce, and disabling designs.
• Consider that primary care is just trying to survive. Substantial proportions of primary care physicians have a second job to support their practices and families - and this proportion has increased astronomically in the past decade. Why not listen to these physicians as they agonize over the changes as well as the very difficult decision to leave primary care or leave primary care where needed? The same is true for NP and PA in family practice positions - as their proportions in family practice fall to new lower levels each passing year due to the primary care financial design and massive overproduction of graduates.
• Don't believe that nurse practitioners and physician assistants are immune to the financial design. Indeed, they have always had higher primary care turnover rates. Studies have long demonstrated steady departures from primary care for those that enter. Fix the financial design for more to enter and remain in primary care for all sources. Consider that all physician, nurse practitioner, and physician assistant sources of primary care fail to enter primary care and stay in primary care at higher and higher levels - as seen in recent decades of class years of MD DO NP and PA.
• Consider that the financial design worsening, has helped to shape the least experienced primary care workforce in the history of the United States in conjunction with massive overproduction of new graduates.

Primary Care Value Is About the Service - Not the Outcome

The reality is that basic health care is a service. The value is the service. Consumers want the service. But the fact of the matter is that most Americans have difficulty accessing the service as they live where the national design only supplies have enough generalists and general specialists. Making the design worse devalues primary care and access. Without access improvements, more costly consequences will worsen.

Advocates Arise to Awareness of Design Consequences

• If you have a consumerist focus - Consumerist focus would require twice as much primary care where needed so that consumers could actually have care. AAFP has recently collaborated with a consumer focus group - but continues to promote value based designs that sadly impact family physicians and their practices most of all.
• If you have a health equity focus this translates to support of financial designs that would support twice as much primary care where needed (not 25% where 40% of the population is found). The current design supports hospital and subspecialty care most - resulting in little remaining for basic generalist and general specialty services that are 90% of local services where most Americans most need care. It is hard not to see that the cost overruns outside of primary care where needed - act directly and indirectly to compromise this Basic Health Access.
• Cost saving focus would also free up primary care to be primary care. Primary care delivery capacity, team members, and workforce all need to be increased where most Americans most lack care. Access to care improvements can reduce more costly emergency room and hospital visits which the current design shapes.
• Satisfaction of team member focus translates to a design that does not burden team members, often meaninglessly. Team members are also compromised in their numbers and support when budget dollars are diverted elsewhere. Once again the various Triple Aim or Quadruple Aim areas - are compromised when examined under greater scrutiny. The foundation of health care is people interacting with people. America needs a return to foundational values. Consider Team Member Empowerment - the Opposite of the Current Design
• Social determinant focus demands health care dollars better distributed to primary care where needed. This would require health care dollars to be shifted away from large systems and practices and more specialized care - to practices, patients, and places lowest in health care spending. Only about 13% of health spending attributable to physician services goes to 40% of the nation in lowest workforce concentration counties. This focus on equity and social determinant impacts via True Reform would support jobs, economics, and cash flow where they are least - and would eventually shape better outcomes where needed. This is of course not supported by those who design health care and who most benefit from the health care design. The new designs worsen social determinant factors due to stagnant revenue, more penalties, and higher costs of delivery. Worst of all is a reverse Robin Hood effect. Billions more each year is diverted from these practices and counties in most need to go to corporations, consultants, and CEOs that do not deliver care and are located where dollars, workforce, and economics are concentrated.
• Social determinant focus is another new bandwagon to consider. Those who promote well and benefit from promotions, are promoting social determinant interventions for primary care. They assume that a last minute intervention in housing, transportation, or social resources will reshape outcomes. For a few patients, it might. Sadly there is a vast American population that suffers deficits. Yes, you can predict these with higher probability of cost and quality problems. But no, you cannot predict the individuals that will have these problems. This remains the folly of micromanagement. Also, by taking billions away from health care to pay for social determinant interventions - this defeats health care delivery - especially primary care. The social determinant solution requires a societal investment in people and those who interact with people in need - as early as possible and beyond.
• It is a great folly to think that health care or social determinant interventions in the last hours, days, weeks, months, or years of life will do much. But apparently we find ways to continue to try to do so - and find more ways to increase costs without increasing outcomes while compromising Basic Health Access by design.

If you have a Basic Health Access focus

There is nothing good to report in decades of policy. Only 1965 to 1978 has the US acted in ways to substantially increase the dollars going to counties in most need of basic health workforce. The dollars, team members, practices, and small hospitals were expanded to facilitate Basic Health Access during this time period. Many other interventions get credit for the 1960s and 1970s improvements (CHC, NHSC, special training, family medicine, others), but the fact of the matter is the CMS controls the dollars that go where needed - and shapes the shortages by their design. There is nothing that HRSA can do with million dollar grants that CMS cannot undo with a trillion dollar design and even more influence via private insurers.

Enter the Era of Cost Cutting - from the 1980s and beyond 2019

More dollars where dollars, access, and workforce are most needed is good, but the there were excesses far outside primary care where needed (such as larger systems) during this time period. This resulted in cost cutting focus in the 1980s. This Era of Cost Cutting has dominated health care and even innovation.

Tragically, those who consume the most health care dollars have found the most ways to bypass cost cutting (new services, new technology, new tests, new workforce, coding rearrangement, more lines of revenue, highest reimbursements in each line). But Basic Health Access where most needed continues to suffer with fewest lines of revenue (basic, office, cognitive) and lowest reimbursement, and rapid increases in costs of delivery - and disruptions of team members.

Which Perspective Wins Is What Shapes Health Care Design

Academic leaders, researchers, and managed care proponents have a different view. They have retained a Captain of the Ship attitude. In other words, they still think that physicians, practices, and hospitals shape outcomes. They do not. So much is shaped before and after encounters by so many personal, social, and other factors that clinical interventions are quite limited in shaping encounters. Others have a blame the physician attitude. This feeds in to the belief in micromanagement. Few understand how limited physicians are given their patient situations, employment, and patient factors.

Consultants, corporations, and CEOs have created publications, magazines, journals, conferences, and positions of power and influence that support micromanagements of cost and quality. This has been a strong and powerful bandwagon. CMS has gone along with this and so has Congress.

It is hard to find someone critical of this movement. Look closely.

Since the bailout of 2008 those closest to the feeding trough have been looking for ways to make more money. Health care in America is Big Big Business. They have been very successful and helping to shape legislation, programming, and opinions favorable to them. American businesses suffering due to poor revenue - have turned to health care as a source of revenue. They are very good at extracting more revenue. The purpose of the bailout was to inject dollars into the economy rapidly. HITECH did not do this and has added to the drain on the economy that is US health care.

Back to Basic Health Access

When you examine these changing designs from the perspective of most Americans most behind by design, few have considered the consequences. The opinions of those who design and who most influence policy were recently reviewed. What they support does not indicate awareness of health care where most Americans most need care.

What We Need to Do

Try to support the team members. Designs should not make their numbers fewer, their turnover higher, and their productivity lower. Consider the consequences - preferably before some new policy experimentation is enacted.

Try not to discriminate against care where needed where people already lack sufficient team members and where outcomes are shaped by almost everything else - other than health care.

Support True Reform - more dollars for the basic services most important where workforce, dollars, and outcomes are lowest. Support fewer dollars for the more specialized workforce.

ROLAIDS for True Health Reform

Health Care Interventions Are Incredibly Limited in Outcomes

There is little or no impact of services upon outcomes. This should also be obvious where the financial designs most prevent numbers of team members to share the load or deliver higher functions such as integration, coordination, and outreach.

Discrimination By Design

Practices penalized more for not having certified EHR - tend to be smaller and where most needed and are least paid. They do not need this discrimination or the others that result in Six Degrees of Discrimination By Design.

Even worse, value based payments work for those with patients that inherently have the best outcomes, and VB punishes those who care for populations with inherently lesser outcomes - who are usually found in places with half enough basic workforce and less local support resources.

So if you support performance based incentives, you support discrimination and programs that worsen disparities of access, cash flow, and jobs.

Support Team Member Function, Not Dysfunction

Primary care is about office interactions - and these have been compromised by design. Studies demonstrate destruction of time with patients, team members, and our families.

So if you support disruptive innovation - you are helping to disrupt what is most important in our personal and professional lives.

It does not matter what the design is - as long as it supports the team members that deliver the care, and enough team members for care of the half the population with currently half enough team members.

A focus on making problems better is a good idea but most Americans have bad going to worse by design.