How many failures in how many ways should be tolerated?
Insurance Expansion - The failure of insurance expansion for the purpose of access to care has been exposed. Denial will not help Medicaid, Medicare, and new plan patients to actually get the care that they need - poor payment long ago prevented the workforce that they needed and in the places of most need.
Accountable Care Organizations - This attempt can be considered a failure as half of ACOs have fallen with more to come. It is likely that a real effort in this area would cost far more, but the costs have already been substantial.Why would you think that you can create competition when you main direction is to aggregate more into bigger plans, systems, practices, etc.?
Primary Care Medical Home - PCMH has become a fantasy land of promotions and numerous claims - unrealized. Foundations and primary care associations jumped upon this bandwagon hard. But they apparently lost their objectivity or the fact that half of their members cannot afford the costs and other consequences. Even worse are the lack of cost savings or quality improvements.
- The Kaiser Family Foundation (KFF) offered this summary of the results of the three PCMH demos: “Among the office-based multi-payer models (MAPCP and CPC) and the FQHC/APCP model, little to no savings have been generated after accounting for the outgoing Medicare expenditures in care management fees”
- Costs of delivery for the privilege of being called PCMH have accelerated to over $100,000 per primary care physician per year. PCMH is complicated by ongoing costs plus the new costs being added on a yearly basis to all practices. Quality metrics and MACRA will add $40,000 more per physician per year this year. These additional costs are making practice difficult for primary care physicians and team members. Studies also indicate the need to understand the culture of the practice to improve structure and function. An external part time advisor/consultant appears to be little help as noted.
Quality Metrics - Quality metric efforts turned into marathons and quagmires. Meaningful Use efforts to hold practices accountable have been meaningless and menial but this did not stop implementation or expansion. Those delivering care have suffered all across development, implementation, and consequence. Instead of learning from their errors, the CMS Innovation Experts are doubling down with MACRA - 954 pages of more torture that experts have difficulty with.
The EHR Community built by the 30 billion from HITECH may have one of the best takes on this as well as the lack of understanding of family medicine associations regarding the serious threat of MOTHRA err MACRA: Massachusetts General Hospital's and Harvard Medical School's John Goodson, MD, foresees troubles ahead for small physician practices in particular JG: There's an implication in there that everyone needs to be aggregated — I call this the attack of the aggregators. You really do worry about the little guy practices and how they are going to perceive this. I don't think it's gotten to them yet. And if you look at what's coming out of the professional societies, particularly family medicine, it's not quite clear that they see the alarm quite yet, but I promise you they will. (no indication at all)
The Board Chairman of AAFP asked CMS whether there would be a chance to delay the rapid implementation of MACRA. After all, the CMS leaders had just pledged in front of 300 family physician leaders to listen and to attempt to decrease the burdensome regulation. But there was no listening, reflection, or attempt to change. There was a mention of a tight time line and so it is still damn the torpedoes and full speed ahead. The recent rounds of hospital, primary care, and rural health meetings by CMS officials apparently only helped CMS to learn the language to express while continuing what they planned to do.
Why would we want more "progress" when the previous progress attempts were failures?
Why would we want acceleration of chaotic change?
Why would we want to bundle services, creating more winners and losers? The example of DRGs is plain that it takes decades to realize all of the consequences and yet we accelerate into more bundling?
Why would we want to force much needed front line primary care, mental health, and basic service practices to shell out more tens of thousands each year per clinician for each new innovative wrinkle, regulation, or certification when these practices are already at or below margin?
Is there no understanding that cash diverted to everything else other than paying for more team members is what prevents integration, coordination, outreach, and innovation one on one between team member and patient - real innovation that matters most?
Why is it hard to understand that access to care requires more team members in more places supported by more funding for cognitive, office, and basic services - the ones paid least by decades of designs made worse by forced higher cost of delivery?
Why would any practice, hospital, or system want more Medicaid patients or more lowest paying plan patients when those with the most such patients are declining by design. The impact spans the largest systems to the smallest practices resulting in changes from positive (survival) to negative margins. An 80 million decline resulted from too many California Medicaid patients served by Dignity Health - the difference between a positive and negative margin.
Designs that fail from smallest to largest and for most Medicare and Medicaid patients
need serious restructuring - not more rapid innovation.
The three most important areas of health care are cost, quality, and access. In the haste to cut costs and to force quality, access gets blown away by design after design.
And more bad news for CMS regarding basic functions such as keeping names and billing straight - CMS is Lambasted for failure to Control Fraud and Abuse.
A number of legitimate health care providers would indicate abuse by bounty hunters hired by CMS and paid based on how much can be recovered - for more abuse potential.
Primary care can be recovered and should be recovered,
but cannot be recovered when moving the wrong directions
