CMS Payment Design

Small Health Care Fights Back and Fights for US

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Same or better quality with lower cost is value. Those who endeavor to lower cost and improve quality as the route to “value” fail to understand the situations where value already exists. Rural health and small health has long been forced to lower spending. Being rural or small contributes to value in ways not entirely understood – but documented. 

Small ball with more singles and less home runs and costly players can be more efficient – Moneyball. Health care designers have been trying to hit national home runs while failing in local day to day health care delivery. Moneyball is selecting and supporting efficient and effective care – not second-guessing or forcing the players to be something that they are not.

Valuing Those of Value

It is not valuable to omit small health care from discussions of health care design. The abuses of small health are even worse. Designers often assume lower quality from those smaller because of lower volume or some other bias. Researchers expect to find against small health and are surprised to find better outcomes in small health care. The media are even quicker to trash small health – after all, it sells well and fits with bias and assumption. 

All fail to control for the challenges facing small health such as lesser payment, more challenging situations and environments, lower levels of workforce, less healthy behaviors, lesser local resources, and lesser payments in other areas such as education and social spending.

Alan Morgan correctly points out the value of small health as seen in rural health care. He points out the problems of those who fail to value small health or even include them in discussions. Not only is small health excluded, small health most represents local where solutions are actually found. A nation that creates more summits and summaries and reports and regulations and best practices, adds to complications.

Alan Morgan indicated in a commentary in Modern Healthcare

  • As we move forward, the data clearly demonstrate that despite an older, sicker, poorer patient population, rural hospitals have a strong track record of doing more with less and demonstrating high-quality outcomes.
Casalino showed the same better value with small practices regarding prevention of hospitalizations.

Unfortunately the designers and researchers fail to understand this. They assume that bigger or higher volume or unnaturally integrated drive better outcomes, failing to understand that smaller, lower volume, and naturally integrated has value. The designers and researchers fail to understand the internal pressures and motivations when team members provide care for neighbors, friends, family, or community members – just as they fail to understand that rewarding bigger, impersonal, distant, less interactive health care causes many of our health care problems.

Wrong Direction Designs and Spending
  • Crippling micromanagement regulation from above and far away that disables team members  is the wrong direction
  • The 3 trillion in US dollars spent for US health care each year that is spent predominantly for clinical intervention has been the wrong direction. 
  • Rapid chaotic change is the wrong direction as those who deliver the care must first of all deliver care and any changes that are truly focused on better health care should first of all support those who deliver the care
  • The health care dollars are spent in the wrong places with over 50% of the spending related to physicians going to 1100 zip codes in 1% of the land area with only 10% of the people. The 2621 counties lowest in physician concentrations receive less than 20% of spending despite 40% of the population – widening disparities.
  • Government and foundations continue to spend more dollars for the wrong reasons. The 300 million spent by Robert Wood Johson Foundation to align quality from above, failed to change population health or quality measures. More for no change is not value. Despite this HHS/CMS continues to send more for areas demonstrated to be less for more.
  • Clinical interventions or the smaller subset involving digital clinical interventions are indeed small factors in determinants of health.
Disconnecting Local from Consideration Has Long Been a Bad Idea for US

We need action, not best practices and regulations and academic models and software and grants/demonstrations and designers shaped by influences faraway. 

Health care has become passive and distant from care delivery 
– not local and active. 

The designers have avoided local too long. Their background, education, training, and life experiences institutions, corporations, government, and associations lead them away from local and active to designs passive and distant

Local people, local physicians, local facilities, and those who represent them have been left behind in designs and in support. 

The ACA focus on large practices and mergers has been successful, but has not helped for “value.” Even some of the ACA experts are beginning to see better value in small practices rather than large.   Where there are few practices in a county and mergers move across county lines or to regions, the local focus is quite left behind.
The solution is always local for health care or education 
as many discuss but few empower. 
The US needs collaborative efforts between physicians, clinicians, team members, patients, community leaders, and government. This must be focused upon local needs and local solutions with faraway and disconnected corporations, institutions, regulations, and associations staying out of the way.

There are no shortcuts to the people, group, local resource, and leader interactions to reshape outcomes.

Where Local Works and Where Failure Is About Local Focus Missing

  • Local works in rural health 
  • Local works in small health
  • Local works for tens of millions cared for by solo and small practices with 1 to 9 physicians
  • Veteran care fails to be local in application, orientation, and influence, and may fail most overall in efficiency, effectiveness, and where veterans need care most
  • Workforce and access fail most for 2621 lowest physician counties paid least where local care is stressed most
  • Addressing behaviors, situations, environments, and social determinants is local and is the best route to 60% of the influence upon health outcomes. 
  • Isolated clinical interventions might work for 10% of outcome influence and what small portion that works is what works locally. 
  • Digital interventions are a small portion of clinical intervention or attempted clinical intervention, and unfortunately distract local team members from care delivery. Distraction, lower productivity, and poor morale all impact local care most of all.

Commentary by Alan Morgan: For a model of efficiency, quality care, look at performance of rural hospitals

Wall Street Hears of Obamacare Large Practice Emphasis Mistake  

“What I know now, though, is that having every provider in health care “owned” by a single organization is more likely to be a barrier to better care. Over the past five years, published research, some of it well summarized on a Harvard Medical School site, has indicated that savings and quality improvement are generated much more often by independent primary-care doctors than by large hospital-centric health systems.”

Casalino indicates the value of small practices in preventable hospitalization.

Small Health Complexities and Demographics

Open Season Upon Small Health Care

Do Not Assume that All Small Practices Are Doing Well

Reference Links
  • Small health care (< 5 physicians in a practice) is 45% of primary care in America as noted in the recent Robert Graham Center one pager. 
  • The common assumption that bigger is better should not be accepted without question
  • Before readmission penalties, the adverse impacts upon Small Health and others with more complex patients were known
  • Small practices do better in preventable hospitalization
Preventing Rural Workforce By Design

Six Degrees of Discrimination By Health Care Payment Design

Value Failure By Those Who Promote Value

Does Anyone Understand that High Cost High Need Patients Drive Consumption?

Medicaid As Savior or Betrayer of Access

The MACRA Test – Can You Survive the P4P Discrimination?

Time Talent and Treasure to Measure Is Not Quality

The Mess that is MACRA – Kip Sullivan at The Health Care Blog

Scientists Fail at Science involving Physicians and Politics

Selling and Swelling a Bigger HITECH Bubble

Time to Burst the HITECH Bubble

Six Degrees of Discrimination By Health Care Payment Design

Assertions that Small Practices Can Prosper Are Not Helpful

Recovering General Surgery Is Impossible

Primary Care Must Rise from the Ashes of the Last 20 Years

Outcomes are Changed by Changing Patients, Not Physicians

Revisiting Basic Health Access in a Land of Smoke and Mirrors

Value Failure By Those Who Promote Value

Most Visited Early Blogs

Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care 

Finance-me-cratic Constants in the Bureaucratic Universe 

Meeting Primary Care Needs in the Last Half of the 21st Century

 Exploring the Health Consequences of Disease Focus


Basic Health Access: Does Primary Care Experience Matter?


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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