Abusing Most Americans By Health Care Designs

So many solutions are proposed to address shortages of workforce. Usually those solutions not only do not work, they make the situation worse for most Americans already most behind. Attempts to save costs or improve outcomes also result in increases in the cost of delivering care. Flat revenue and increasing costs of delivery specifically compromise delivery team member numbers and functions where most Americans already have half enough generalists and general specialists. Only a major increase in the dollars going to generalist and general specialty practices where most Americans have half enough can address deficits of workforce, access, and health care dollars. Until the designers and leaders understand how they are causing harm, more harm should be expected.

Also outcomes for patients and for populations are shaped by decades of previous life experiences. These drivers are very complex and interrelated and the major influences are consistently negative where most Americans are behind. Even worse, researchers do not have data on these drivers. All that they have is a zip code that may represent the location of the person for a recent short period of time.

• And the use of the mean income for that zip code is 80% of the time wrong. This is a reason that race, ethnicity, gender and co-morbidities are emphasized as shaping worse outcomes - because important specific data is missing from collection and analysis.

Trying to force primary care or hospitals to shape better outcomes is particularly harmful as they are trying to work too late with far too little investment already.

Plus the patients return to the same environments, conditions, relationships, and other outcome shaping forces after the encounter. Please review the graphic to see just a few of the concentrations of challenges facing health care where most needed along with the pittance of support given.

Designers have failed to help workforce or access. Designers have increased the costs and burdens of delivering care without supplying the resources to address the needs of most Americans. Designers are causing financial and team member harm to practices, hospitals, and populations most behind.

Remember that physicians and researchers are held accountable for harm done and must show beneficent intent and protection of vulnerable populations, but health care designers have no such restrictions and have been causing harm with design changes since the 1980s . The harm is most specific to most Americans most behind and most vulnerable who are suffering from the worst designs already.

Payments Are Lower for the Same Services

Primary care is paid lowest by 15% in the 2621 counties lowest in health care workforce using Medicare 2011 data. CMS data collected and published to embarrass physicians is actually a major embarrassment to them. They hurt health access for most Americans directly by their designs and indirectly as their payments shape private insurance design.

The worst Medicaid, Medicare, and private plans are concentrated in these counties following concentrations of the elderly, the disabled, the poor, and the most abused by the worst employers. This has been tolerated by about 30 states that have long failed to address inequities and basic health access.

Understand the 45 40 25 20 Rule - 45% of complexity in this 40% of the population with about 25% of the primary care supported by less than 20% of primary care spending.

This 40% of the population lowest in health care workforce only has 25% of the primary care workforce but the payment reductions result in less than 20% of primary care spending for these counties. This is a very specific indicator of fewer and lesser delivery team members "supported" by the financial design. The same 45 40 25 and less than 20 rule is true for mental health, women's health, and basic surgical. Generalists and general specialists supply 90% of locally available services in these counties - generally across a 2 or 3 county area.

In 2008 this translated to only 38 billion dollars to invest in primary care delivery or about 20 % of national primary care spending. Stagnant revenue and potentially some declines in distributions to these counties have been seen since 2008. Inflation raises the usual costs of delivery and remains uncompensated, rising at 1 to 2% of revenue each year. If you increase the costs of delivery by 3 or 4% a year and keep revenue stable or worse - you kill basic health access by design.

If designs destroy payments, raise costs of delivery, and lower productivity they worsen access. Primary care is 50 - 60% about the personnel. More in a primary care budget for non-personnel areas lessens personnel. Stagnant revenue makes this worse. Greater burdens defeat productivity and revenue and increase burnout and turnover. How can you move to higher functioning primary care or person centered primary care with designs that result in fewer and lesser delivery team members?

The Destructive Power of Managed Care Groupthink

Back roomers have been sitting around proposing solutions for health care costs and health care quality since the 1980s. In some ways the excesses of the early Medicare and Medicaid spending forced cost cutting discussions and designs. One result was managed care and the first HMOs. The costs have continue to climb. And the quality improvement changes have been grossly unsuccessful.

Even the most recent efforts as seen in the Medicare Innovation Center have been only 5 for 52 in positive outcomes changes and only 3 were replicable . In other words we have had nearly 40 years of design changes that have failed to rein in costs or improve outcomes significantly. The same 40 years has massively increased health care costs specific to places with concentrations of workforce while doing little if anything for the providers and populations that remain most behind.

Micromanagement, digitalization, innovation, and reorganization as sources of increased delivery costs are also not addressed and increase by at least 1% based on costs per primary care physician.

This calculation does not include higher turnover costs which can be 10 - 15% of revenue due to losses each 3 years and $300,000 in costs and losses. Productivity losses are evident thanks to micromanagement. Also not addressed in the payment design are the usual disruptions outlined by Mold with higher costs of delivery, lower productivity, and other consequences with changes in key personnel, EHR, billing, ownership, or location - and the researched list was not exhaustive (Mold, Usual Disruptions, Annals of FM ) This was the only study relevant to primary care workforce and practices among the 117 million spend on QI by AHQR - a grand distraction of major primary care researchers away from relevance and important contributions.

I estimate that the primary care practices have less than 30 billion to invest in primary care delivery now, down from 38 billion in 2010 for these 2621 counties. More to do and higher complexity with less support is a financial design for worsening access, worsening productivity, increasing burnout, and further compromises of the populations most impacted.

Medium and smaller size practices are hurt the most across these old and new cost factors, they are abused the most by insurance "payers" and suppliers. They are concentrated in these 2621 counties lowest in health care workforce.

• The bigger systems, hospitals, and practices demand and get better payments and supply costs - which results in small and medium making up the difference.

These counties have half enough generalists and general specialists as dictated by the financial design. This includes 75% of the rural population or 40 million truly behind. It includes 32% of the urban population or 90 million in 2010 that are similarly behind - and they are the fastest growing US population.

In contrast the counties with top and higher concentrations are growing least, only half the US average for population growth. Unfortunately these counties get the lion's share of health care spending, workforce, and access by design, leaving most Americans behind and getting worse.

Decades if fastest growth for middle and lower concentration counties with stagnant to declining workforce, spending, and access highlights worsening inequities. It also contributes to the understanding as to why training more graduates or new types or special training cannot address workforce and access gaps.

More for fewer and less for most is the rule in health care design.

Primary care spending and workforce have been flat for some time with the massive expansions of MD DO NP and PA almost entirely buying more non-primary care workforce and resulting in ever higher health care costs.

The work of the Graham Center and my works confirm flat spending and flat workforce. This is clearly indicated in research involving DO and PA graduates with little gain in primary care entry despite doublings of annual graduates. In US MD the horror story is clear with declines in primary care career contribution result despite increases in annual graduates now at 4% more a year. Hospitalist workforce has passed primary care contributions for internal medicine, consuming 50,000. IM primary care is headed to lower than 30,000 - down from 150,000 in the 1980s.

In NP there are slight gains in primary care numbers but ever lower proportions as NP and PA add new specialties and add more to each new specialty at the cost of primary care and family practice result.

Distribution is About Family Practice - but so is the worst abuse by design

By the way, only the NP PA DO and MD graduates in family practice positions can claim population based distribution or 36% found in this 40% of the US population. This is a 3 to 1 multiplier compared to other sources.

See how the payment design most compromises family practice where it is most needed.

Internal medicine graduates no longer make viable contributions as so few do primary care and the distribution is among the worst of all specialties. International grads are also among the worst.

Studies document only 15 to 25% of PA and NP in primary care from AAPA studies, surveys, Oregon Nursing Center studies , and U of Washington studies.

Note that AAPA data had 54% of physician assistants in family practice in 1984, nothing since but down down down.

The Financial and Training Designs Result in the Worst

NP in primary care are the least experienced. This is due to massive overexpansions of graduates dumping 40,000 a year into the 350,000 workforce plus lowest activity (60% vs 80%) plus lowest volume plus experienced primary care NP departing and taking their experience out of the pool.

Higher turnover, churn, and departures from family practice hurt care where most lacking already. Only the family practice component found in practice matters for most Americans most behind, but they cannot stay due to the financial design.

Family Medicine Leaders Are Misguided Also as are Primary Care Coalitions

You cannot even increase family medicine graduates to boost workforce as the calculations of primary care contributions indicate that it would take 1.8 recent graduates to equal the same primary care delivery over a career as compared to a 1975 FM graduate.

It absolutely requires a financial design change of at least 30% more for primary care in these counties to allow any training design to work.

Of course it is impossible to convince AAFP of this. They have failed to reshape the financial design that most abuses family practice. Their membership, power, influence, research, student and resident efforts, and more all fail because of financial design failure.

Cautions About My Primary Care Delivery Estimates Over a Career

My estimates are based on the type of graduate and their date of entry into the workforce. The estimate is a product of 4 factors - their primary care retention, years in their career, activity in practice, and a volume adjuster.

Assessments of primary care graduates by type of graduate reveal the truth now and then.

And a warning - my estimates of primary care retention have been too rosy.

This means that the actual delivery capacity of a type of graduate over a career are likely to be less to much less, depending upon how rapidly they have left primary care. The declines have actually been faster than predicted as so many more MD DO NP and PA have left over time. There is little doubt that the financial design has worsened the situation and the environment of primary care.

These 2621 counties most behind are older, sicker, and poorer - and the designs of health care, education, economics, and housing make this steadily worse. They have always been behind in education, in mortality and death rates, in income, in workforce, in health access, in health care dollars, and more.

Health Care Designs Must Not Cause Harm

1. ACA insurance expansion was most abusive stealing 90 cents on the dollar and returning only 10 cents to local providers.
2. Also ACA expansions of Medicaid plans paying less than the cost of delivery are no help to struggling practices and hospitals. Imagine what Community Health Centers could do if the Medicaid plans impacting half of their patients paid 110% of the cost of delivering care instead of only 70 - 80%.
3. ACA also resulted in costly micromanagement also stealing scarce dollars from practices and communities in the highest need.
4. DRGs have killed hundreds of hospitals since 1983 with 1 a month still dying by DRG PPS design - paying 30% less. Many have justified such closures by noting the lesser outcomes of such hospitals - which are predominantly about the populations that they serve and not the hospital! Such is the distortion of the research community regarding outcomes.

Marginalized research worsens the situation again and again.

Once again the marginalized payments for basic, smaller, and most needed plays out in discrimination.

A Requirement of Leadership or a Designation as a True Expert in Health Care Is Demonstration of Awareness Regarding the Populations that they Lead or Impact

There is little indication that the designers and health care leaders and academics understand these counties or have any desire to address their basic needs. They say that they support primary care, but indicate that not if this would result in carve outs from the procedural, technical, subspecialized care that pads their profits (AAMC).

So cost cutting focus has hurt those most needed while those larger and more mobile can avoid the cuts and shift for best profits to the patients, populations, and services most rewarded.

It is hard to design any worse for these counties. The practices and hospitals in these counties are stuck with populations inherently the worst in outcomes (very bad for performance based or value based payments), in employers, in benefits, in paychecks, in workforce, in social supports, and in complexity. These providers are increasingly held responsible for what they are powerless to reshape.

See how readmissions penalties played out poorly for their hospitals in year 2 with 1 to 2% withheld

• 3% of urban hospitals max penalty
• 5% overall average
• 9% of rural hospitals with the max withheld
• 14% of the remaining hospitals in 2621 counties lowest in health care workforce with inherently worse outcomes to go with half enough generalists and social supports (plus worst environments, etc.)

HITECH to ACA to MACRA to Primary care medical home to value based has been a nightmare with the same mistakes, traumas, and abuses repeated over and over.

Even worse, many in these counties fail to understand the important economic contributors to their local economy or how they are abused in health care design, education, economics, trade, housing (directly or indirectly) or social supports.

Disability, social security, and food stamps make 42 to 44% contributions to these counties with 40% of the pop but are constantly under attack.

Substantial education is needed so that they cause themselves less harm and demand reasonable treatment by health and other leaders. For those who want to shape higher concentration, victory is found when they convince most Americans most behind, that what actually helps them is wrong or evil or causes laziness or is wasteful. And they are winning.

The Housing Design impacts are important to understand. There is a consequence to the continued financial pressures that have resulted in increases in the costs of housing where workforce and economics are concentrated. The housing design forces millions to move to lower concentration counties as the costs of living and housing continue to go up in counties higher in concentration.

This may be a primary reason for fastest growth. There is higher internal growth. There is an inability of those most behind to go to more costly counties higher in concentrations. There are more Americans forced to depart costly higher concentration counties that have increasing deficits of housing - and they must go to counties lower in cost and in concentrations of workforce.

Decade after decade the US population continues to grow fastest in population numbers, demand, and complexity in the counties where health care workforce is being most compromised.

How did we stray so far - see Data Science Has Become About Lending False Credibility To Decisions We've Already Made

Kalev Leetaru ?Contributor?AI & Big Data

https://www.forbes.com/sites/kalevleetaru/2019/03/24/data-science-has-become-about-lending-false-credibility-to-decisions-weve-already-made/amp/

New types of health professionals, more schools and programs, and bigger class sizes have not fixed health access deficits and cannot, because of the financial design. They can create a massive glut of workforce, however. https://www.dhirubhai.net/pulse/your-favorite-new-medical-school-fix-deficits-workforce-robert-bowman/

More about the 2621 counties most behind at https://www.dhirubhai.net/pulse/count-down-2621-counties-most-behind-understand-why-health-bowman/

Most Americans can be seen as behind across health, education, economic, and other designs. When small minorities (rural, race, ethnic) are promoted as behind, this can distract from the majority most behind with worse to come. https://www.dhirubhai.net/pulse/your-minority-too-small-my-majority-us-robert-bowman/

Exclusive medical students, exclusive medical schools, exclusive training, and exclusive health policy leaders/designers, and exclusive remedies are what act together to kill basic health access. https://www.dhirubhai.net/pulse/medical-student-admissions-family-medicine-choice-robert-bowman/

It is a great idea to have a personal physician. It is interesting that the National Academies has brought this up. But these learned scientists still have a lot to learn - especially about their academic and administrative colleagues that most influence health care design.

The United States has never had a financial design that would support a primary care physician for every person. It has never come close. It has only had progress toward this goal from 1965 to 1978. Since the 1980s each passing year or fad or bandwagon has moved the US away from this personal primary care physician goal. https://www.dhirubhai.net/pulse/what-prevents-americans-from-having-personal-primary-care-bowman/

Terminate Innovation and the CMS Innovation Center - The fourth director of the CMS Center for Innovation posted an article in the New England Journal highlighting the focus of the center. Quotes follow with my comments below each point made. Why continue with such failures? "The Center will ultimately be successful only if it is able to launch and scale models that either decrease cost or improve quality." My response - Since the Center is 5 for 52 projects that have been successful, one consideration is that health care costs and outcomes are about the population and not some innovative intervention. https://www.dhirubhai.net/pulse/terminate-innovation-focus-cms-center-robert-bowman/