Acute Abuse of Those Behind vs Chronic Abuse of Those Not Valued
It is a time when the long term abuses are exposed by acute events. There is likely to be some increase in awareness that there are underlying factors that contribute to outrage. Many who react violently in person or on paper or via social media are aware of the abuse, but they are less aware of the designs that so negatively impact them steadily and slowly over time. The health care design is a classic example of the abuse impacting most Americans and those few remaining providers that remain to serve them.
What Is Valued By Designers Is Rewarded in Designs
Rural, small, independent, basic, cognitive, most prevalent services have clearly been valued least by the designers, legislators, administrators, academic institutions, health associations, institutions, governments, and foundations. The 2621 counties lowest in health care workforce are not valued. Together with minorities, inner city, and those with Medicare, Medicaid, both, or some new plan failure – the US population made behind by design is much more than a majority.
What is valued is hospital, procedural, technical, fewest services, services least needed by most Americans, and services that help academic institutions and large systems do best. Insurance and government designers are less likely to mess around with those that are valued and are most powerful. In contrast those smaller, independent, basic, and cognitive are least valued - often are invisible to the designers along with the consequences of their designs. Mental health, public health, primary care, women's health, and basic surgical services are over 65% of services - but are least valued and are shrinking away under the onslaught of higher costs of delivery and stagnant revenue.
We kill off the most prevalent by abuse.
We kill off the generalists and general specialists that are 90% of locally available services for half of the American population. The financial design is the true cause of shortages that are predominantly about generalists and general specialists in places lowest in health care workforce because their local health care plans are the worst for the providers and the patients.
By not focusing attention on the true nature of the problem, we prevent the focus on the financial design - the design that continues to value them least.
We kill them (literally and figuratively) as we do not stand against the abuse. We choose to tolerate the lack of valuing those who do serve where needed. We choose not to help inform those not valued that they are being abused and that they deserve designs that shift dollars to serve them and local health care and local jobs and local economics and local outcome improvements.
The Era of Cost Cutting Rules and Punishes Those Least Valued
This Era of Health Policy has dominated payment since 1983 starting with PPS and DRGs. The designs have been changed to make it easier to cut costs
- regardless of these changes that increase the cost of health care
- regardless of the consequences to those who deliver care or the team members that we want to do care and caring – but cannot.
- regardless of the destruction of basic health access and all services and delivery team members that are least valued
Where care is most needed, it was never valued.
The US has always had deficits of workforce impacting large segments of the population. The 1965 to 1978 period has been the lone period of time where more billions a year were sent to local, basic, most prevalent, and most needed services. Unfortunately the original Medicare and Medicaid Designs were most abused by the larger systems and practices - resulting in massive health care cost increases.
The cost controls were not specific to those who profited most and grabbed the most. The cost controls hit all - including those most vulnerable.
For example in my rural practice, historically the practices were paid least in primary care, in Oklahoma, in rural areas of Oklahoma. The Reagan cost cutting presented me with an additional 15% cut in my payments because I was a new physician. These all indicate who is valued - or not.
Reforms in the 1980s, 1990s, 2010s, have not helped.
Reform Changes Make Situations Worse
Reforms represent opportunities for major changes. They have not worked out to help. They have been opportunities for the cost cutters to do even more cost cutting. This is why Medicare for All, even well intentioned, will not help. No reform can work until there is a change in what is valued.
If our nation valued what matters most, my rural practice in Oklahoma would have done well. Paid less in primary care, in OK, and in rural area 99 indicate what is valued or not valued. I was given additional cuts because I was a new physician and therefore most powerless and valued even less. Why would you start out someone as a new physician where most needed and give them a special cut?
The result is the same for direct abuse as it is for chronic abuse. If they came in and destroyed my office - it would clearly be abuse. But a destructive financial design has the same result.
The people of my town and many others are hurt by designs that close hospitals and practices where needed. The designers do not have dynamite. But they do have the infinite power of the financial design. They have long been blowing away care and caring where needed.
So I Turned to Health Leaders for Help with Changing the Design for Health Care
I turned to the AMA for help and became a Delegate in the House of Delegates - and found out that the AMA did not value Young Physicians, my practice, generalists, general specialists, or care where needed. It values procedural, technical, hospital, and subspecialized care and sends representation that reinforces what it values. The same is true for the AAMC. It values the financial well being of the academic institutions that it represents. It wants more funding for medical education and graduate medical education even if we are producing too many doctors. It opposes financial design changes that would take from the finances of its institutions to pay more for generalists, general specialists, and care where needed.
So we turn to those who say that they value health access and primary care and care where needed. Foundations and various primary care associations should help us - but do not. In fact they add to problems.
Do Gooder Foundations and Associations such as The Commonwealth Fund and AAFP Value Innovation and Marketing and Government Influence
- but they have failed to change what our nation's leaders value. You can work closely together on numerous projects to improve primary care, but not improve the financial design. This is because you have not changed what government or health insurance or political leaders most value.
So the financial designs get worse.
Even Worse, the Do Gooders Make the Designs Worse
Sadly the do-gooders add to the problem by supporting a worse financial design. It is bad enough to have lower payments, but the insult added is higher cost of delivery and lower productivity.
I can understand why AAFP wants a change - more organized practices (primary care medical home) and better payments - but they have made matters worse.
The move to Primary Care Medical Home is a costly move, particularly for family physicians that are (or were) 50% in small practices. Not surprisingly there has been low penetration rates. Even worse, primary care medical home has been integrated into the new CMS designs that still pay too little and complicate practice.
Primary care associations and health access foundations support value based care. They still cling to the hope for financial improvement. They still believe that practices can change outcomes in patients - outcomes that are predominantly influenced by patient factors. The designs do not address additional costs - usual or innovative or regulatory.
These new financial design flaws are the impact of the managed care to MACRA to PCMH to value based care bandwagons. Metrics, measurements, micromanagements, software, hardware, security, and maintenance have added 15% at least to the cost of delivering care. The financial designs have not changed to compensate for these losses, or for increases in the usual costs of running a practice.
The Families of Family Medicine Value Innovation that Has Not Improved Care or Caring in Family Practices.
Value based care and primary care medical homes add substantially to the cost of delivery care and can change some processes of care, but are limited in changing outcomes. They do disrupt primary care, care, caring, productivity, morale, and care where care is least valued and most abused.
If you tolerate or promote abuse - you are an abuser.
Politicians, government designers, insurance designers, associations, institutions, and do gooders all contribute to abusive designs. Why torture family physicians that are struggling to keep their practices going where most needed? Why? WHY? Why push them to the point that they realize that working one or two additional jobs to keep their practice going - is futile? Why force them to leave the practices, patients, and communities that they love - the ones that they have invested years or decades of life?
Abusive Innovation Worship Continues
Managed care, the Dartmouth Assumptions, the ACA, MACRA, and value based all track innovation worship with a micromanagement focus.
Do you hear any health care leaders standing up for care and caring - and against designs that cripple care and caring?
Any review of the CMS Innovation Center indicates that the predominant focus is cost cutting – no matter what other initials they promote. Those who become health care leaders are filtered through academic institutions, health associations, institutions, governments, and foundations along with their meetings and conferences to come up with the managed care groupthink and more ways to punish providers and cripple care and caring.
They value innovation, rearrangement, regulation, metrics, measurements, and micromanagements – that have destroyed what we do
1. Because primary care is 50% of services
2. Because family medicine is least valued. Our patients are not valued. The populations that we most serve are not valued.
Family physicians achieved population based distribution at about 30 per 100,000 across the major divisions of US populations by income, population density, and other categories.
Family physicians in office practice were 36% found in the 2621 counties lowest in health care workforce with 40% of Americans most behind by health care design. They were half of the primary care - primary care too low at about 40 - 60 per 100,000 or half enough for these populations.
This is because the populations in these counties have concentrations of the worse health insurance designs - Medicaid, Medicare, Dual Eligible, high deductible, Veteran, Native, lower income, and worst private insurance.
So What Can Be Done
People must insist on a change in what is valued. Movements are needed to help people understand how they are abused by designs. Local people need to understand how important local health care is to jobs, economics, and basic access at the local level – are required.
Why Not Work with CMS and Do Gooder Associations and Foundations?
Working with those who have been indoctrinated – has not worked and will not work. Their value system is kaput as are their designs.
AAFP is proud of all of the work done with CMS and constantly claims various successes in their work - but family physicians are losing continually by design changes.
Do Gooders need to work with the majority of the population abused and those who are abused that remain and serve them - if they ever hope to stop the abuse and restore basic health access.
The Glut of Workforce Exposed But Ignored from January 2019
Think Twice About a Medical Career
Seasons of Distortion Rather Than Accountability and Social Responsibility
Too Many and the Wrong Clinicians from 2014
Three Dimensions of Non-Primary Care vs Zero Growth in Primary Care July 30, 2011
The Glut of Health Workforce Exposed But Ignored January 2019