Centralization is One of Four Horsemen Harming Most Americans Most Behind

This was stimulated by Eric Bricker MD that illustrate the beginning of the Centralization Bandwagon. Ellwood, Jackson Hole, Managed care, Fisher, Dartmouth Assumptions, Orszag, ACO, ACA from above and far away, have consistently been bad for most Americans most behind. This can only happen when the designers have absolute faith in their designs and they do not ask for or receive feedback specific to the consequences of their designs

Academization, centralization, digitalization, and innovation worship have been the four horsemen of the health care apocalypse for most Americans most behind.

• Academic is about distancing. Academic MD DO NP and PA have made claims to be a solution for workforce. This is not true when it comes to most Americans most behind because their deficits of workforce are about finances, not training interventions.
• Centralization is illustrated by Eric and Kip Sullivan.

Kip Sullivan continues the middle and later part of the apocalyptic trail with his letters to President Obama, attempting to inform him and the nation about misguided policies that continue to this day.

More learned from Kip about so many design failures and so much centralization of dollars and resources and services at https://thehealthcareblog.com/blog/tag/kip-sullivan/

or at https://muckrack.com/kip-sullivan/articles

• Digitalization to artificial intelligence still promises improved costs and quality that have yet to materialize (other than consequences to those delivering the care and - yep, most Americans most behind.
• Innovation failure is illustrated by 5 for 52 for the CMS Center for Innovation given billions to discover that cost and quality focus still fails just like in past decades.

The deadly consequences have been

1. Health care workforce and other team members shaped fewer and lesser by design
2. Hospital nurses shaped fewer and lesser for hospitals in survival mode due to worst health plans
3. Hospital nurses in hospitals focused on profit mode shaped fewer and lesser due to marginalizing personnel and the largest component in personnel - a massive 1 2 punch by survival mode and profit mode that can only force departures of experienced nurses with replacements by those with low or no experience.
4. Worsening of care situations for most with chronic illnesses who are concentrated where health care delivery is most compromised - lung, heart, diabetes, mental issues, disabled
5. Numerous impairments of caregivers across the nation, particularly those serving most Americans most behind
6. Steady losses of basic health access primary care, mental health, geriatrics, basic surgical

Designs for decades continue that are exactly wrong for most Americans most behind in political, economic, and power circles - those least valued by design. Big and powerful health care helps to shape designs and does not care about the consequences to others. They are embedded in decision making from research to policy. There are no allies to support most Americans most behind

Exactly wrong for them are Overutilization focus, Quality Metric focus, and Expansions of Worst Quality Health Insurance

Overutilization with cost cutting focus

• plays out worst for those farthest from the feeding trough/least valued
• those smaller, basics (primary care, mental health, etc), most Americans most behind

Quality outcome focus

• Also exactly wrong for most Americans most behind that inherently have worst outcomes and drivers of outcomes thus their lower payments are made worse by performance/value-based designs. Assumes that all practices and hospitals have the power to significantly change outcomes that many feel are entrenched and difficult to change after decades (Medicare) of life influences and low literacy levels in multiple areas or after generations of poverty (Medicaid).

The findings that cost and quality outcomes are difficult to improve

...speaks to the power of social and non-delivery drivers which were not considered from Jackson Hole to ACA - the span of centralization, academization, digitalization, regulation, and innovation. Where most Americans are most behind in workforce and drivers of outcomes, quality focus with payment linked to so called quality measures is costly, burdensome, ineffective, and discriminatory. The costs and consequences are worst for practices smaller and with the worst financial designs.

3. Health insurance expansions of the worst public and private plans has also been exactly wrong where vast regions suffer from worst paying public and private plans due to concentrations of the elderly, poor, disabled, and weakest employers. The solution of insurance expansion as seen in ACA was the wrong policy for most Americans most behind who suffer from Medicare and Medicaid plans that have been paying providers below costs of delivery almost as soon as HCFA and punitive designs took over.

The only time of improvement in future primary care years per class year and health care for 2621 counties most behind, was 1965 to 1980. Since this time and via managed and micromanaged takeovers of health policy, primary care, mental health, women's health, basic surgical, and geriatrics have been designed away.

Rural and urban areas in the 2621 counties lowest in health care workforce have had the most closures of hundreds of hospitals and countless practices due to worst paying public and private health insurance plans. These are made worse by one size attempts to fit all policies such as Diagnosis Related Groups and micromanagement that hurt smaller hospitals and practices. Researchers have contributed to the demise by providing some justification for closures due to "poor quality" which were poor quality studies with poor controls that unfairly blamed rural or smaller hospitals and practices for poor outcomes not considering populations packed with poor drivers of outcomes, poor supports, and lowest levels of workforce and access

Worse and Worse

A. those with fewest lines of revenue and office service dependence - lowest payments as set by RBRVS RVUB, for 40% of Americans are most behind in workforce and access in 2621 counties

B. Medicare 2011 reveals 15% lower payments because of poor auditing by CMS and unchecked insurance abuses

C. for the vast regions with worst employers getting worse that have employer based plans as weak or weaker than Medicare and paying less than cost of delivery permanently defeating health care in the 2621 counties lowest in health care workforce as well as other settings - and made worse by cost cutting, delays and denials of payments, narrow networks, and costly micromanagement to attempt to improve quality

No Hope for Most Americans Most Behind by Design

The counties most behind are increasing faster in population numbers, demand for care, and complexity as their health care is designed away. The combined blue line rural and urban for 2621 counties illustrates this 40% moving to 50% by the 2060s. Then it will be a true majority permanently left behind and not dependent upon numerous pockets of discrimination arising in counties with concentrations of workforce. This usually involves barriers to Medicaid patients and others with lowest paying plans.

The 2016 Red Counties and the Blue Rural Minority Counties are the ones most behind. Or you can map out VA facilities that are centralized and veterans that are over 50% in the 2621 counties most behind. Rural is a poor choice for advocacy. Some rural populations are doing very well and the same is true for rural located hospitals and systems that are larger. The 2621 counties are consistently behind and their insurance and financial design is the main reason.

There is no escape from the 2621 counties most behind since the financial design must change. This requires the population to change as numerous better employers must suddenly locate in these counties to be able to power progress where most needed. Sadly deficits of health care locally are sufficient to defeat recruitment of better employers as well as retention of same.