Burying More Americans By Health Design

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Each new day brings more promotions of health care influence by ACA or CMS or various institutions or foundations supportive of innovation focus. Despite numerous claims of patient centered focus, there is more movement away from the support of the people to address people and patient factors.  
A phone survey (goodness) is promoted in the New York Times with claims that Obamacare Appears to Be Making People Healthier. Even the worst of study designs about changes with the least potential to change health manages to find publication and promotion. Meanwhile most Americans await meaningful change because of health care design.
DRG to ACA for Better or for Worse?
A better case can be made for past decades of DRG to ACA designs making people less healthy. When designs slash the team members to address people factors and slash the cash needed to address social determinants to really influence health, lesser health is far more likely for more Americans. 
Burying People Influences Can Bury More People
The policies of 2010 to the present have continue to bury more Americans by burying the top influences on health outcomes – the 60 – 70% of influence due to people factors. Mountains of studies and their promotions tend to bury the fact that we fail to invest in better environments and situations. The people factors are clearly the most influential for better health. Payment design marginalizing cognitive services for decades has defeated any move toward more team members to invest in people. Behavior change is people helping people to change behaviors via mental health and in primary care (50% of mental health care). 
Driving People Influences Away By Design
Decades of poor support via Medicare and Medicaid have resulted in deficits of workforce 
  • at the worst time in history and in the worst places 

Cognitive and basic services dominate health care delivery in the places where care is most needed. These are the places most increasing in population, elderly, and complexity. Failures in payments for 60% of the workforce to deliver care in these places is a major reason why insurance coverage expansions have no influence.

If you are in places with health care workforce because of the design and gain insurance, you might gain access. If your are in places without health care workforce because of past decades of design, insurance access is not going to address your barriers to care.

Where Americans are concentrated by lowest cost of housing, there are more people who are older, more complex, and less healthy. These are the places where providers are fewest and are most penalized by ACA and CMS designs. Multiple factors influence health and health outcomes and the span from advantaged to disadvantaged layers out the outcomes in ways that clinical interventions are powerless to address.
Shifting Influences to Lesser Outcomes

ACA took away Disproportionate Share and other special payments to address the needs of providers left behind by CMS designs. Even worse ACA and CMS designs now cut more payment where resources are lowest and patients are increasing fastest in numbers, complexity, and demand. 
Payment Failure Results in Training Failure Results in Disparities 

Payment failure has shaped a generation of training failure despite expansions to more sources of workforce and massive expansions of graduates since 1980. Payment design insures that deficits of primary care and mental health and basic surgical services will remain. 
Designs that concentrate 50% of physicians in 1% of the land area with 10% of the population insure lesser access and additional deficits from half of Americans behind by design.
Place and Population Based Decline By Design
The demographic changes reinforce the payment failure. The payment designs discriminate against 2621 counties with 40% of Americans that receive lowest payments from Medicare and Medicaid, shaping lowest concentrations of health workforce and reinforcing lesser determinants of health – a much more likely influence on true long term health outcomes.
Marginalizing People Who Could Promote Better Patient Factors
People interacting with people can have great influence. Designs should support the team members to facilitate changes in behavior, situations, and other patient factors. Health care design has been discussed as an inverted pyramid with far too much invested in areas with little influence while the foundational areas are marginalized.
The huge expenditures for academic/hospital/subspecialty/technical/largest system/corporation influences have continued. They defend themselves best from cost cutting. Rapid change also favors those who can adapt. Chaotic change most favors those best supported by previous designs who are most organized and can take advantage of changes.
DRGs ushered in the Era of Cost Cutting. Across the nation some simplistic calculations have allowed slash and burn to proliferate across Medicare, Medicaid, insurance, hospital, practice, prescription, and other areas. Studies are crafted to demonstrate simplistic cost savings, but the studies fail to consider impacts upon other health care or additional costs outside of health care. For example closures of mental health facilities are considered cost savers, until the entire cost to law enforcement, people not mentally ill, and other health care areas are considered. 
Those most organize defend from cuts while cuts proceed in the people that could impact people factor change. 
Administrative Excess Diverts Health Spending Away from People and Care Focus
More cost from managed care or managed cost was a start. New layers of more cost for less influence were ushered in by To Err is Human.  This has reinforced administrative excess for even less investment in the team members to deliver the care. True health reform was prevented in 2010 because these distractions were reinforced rather than replaced.
The dollars have followed administrative, hospital, subspecialty, technology focus while avoiding investments in people, behaviors, situations, and determinants. We continue to allow claims of clinical influence – even with the most minor of clinical interventions such as EHR and insurance coverage.
True reforms such as increased payments for cognitive services or investing in people to address people factors are avoided. Even worse the attempts at quality divert funding away from dollars spent on local care delivery, especially where care is most needed. Dollars are ever more concentrated along with the health impacts that follow. 
From DRG to ACA we have failed to invest in people and thus fail to improve health.

Note also the recent lawsuit settled by CMS that indicated too little was paid using underestimates of the numbers and overestimates of those who had some payment.

Recent Posts and References 

A Few Hundred Million More is 8 Billion Less for Primary Care

More Geriatricians Will Not Solve the Geriatric Care Crisis

Rallying One Hundred for Health Access Not MACRA

The Ultimate Government Health Care Paradox – Government must facilitate better EHRs and better health access, not prevent them.

Prevent MACRA to Do No Harm
Poor Payment Dictates Poor Training Outcomes in Primary Care
No Positive Spin for the Innovator Tailspin – more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access – claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

The Federal Cause of Shortage Areas and Access Barriers – The Federal Design for payment shapes the breadth, depth, and locations of shortage areas due to lowest payments for Medicaid and Medicare and other plan designs that pay least 

Primary care can be recovered and should be recovered, 

but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.

The blogs represent the opinion of the blogger alone.

Basic Health Access Web   Basic Health Access Blog   World of Rural Medical Education

Copyright 2016

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