Count Down 2621 Counties Most Behind to Understand Why Health Policies Fail or Make It Worse

This will describe the type of coding that I have used to illustrate the health care designs that relegate most Americans to the least access, least workforce, and least economic impact from health care. Coding using geographic divisions has long been important in understanding maldistribution, but our health care designs have not been progressed by such coding. Often the coding illustrates differences involving a small minority of the US population. This has long been problematic since half of the US population is behind to very behind by design.

I have great respect for those who have coded our nation into rural vs metro and other categorizations. But as great as this contribution was, it was limited to a small portion of the population. Why focus on a minority behind when a majority of the US population is behind to far behind and is being made worse by further designs?

Physician Distribution By Concentration

I took a different approach and presented this initially in San Antonio. Initially I looked at zip code practice locations and found that 10% of the population had 45% of physicians while 60% of the population had only about 20%. Zip codes are problematic as they represent small areas without much travel required to cross 4 or 5 zip codes.

I turned to county level and 150 physicians per 100,000 as a cutoff. This helped to see a few counties in a small part of many states with the concentrations and most of the population outside to far outside.

I continues to focus on concentrations of physicians and health care workforce because this reflects maldistributions of health care dollars. These are designed in specific ways. Sadly those who most influence the designs are shaping the most lines of revenue and the highest reimbursements their way - Medicare, Medicaid, private insurance, and other. I find that most Americans find less benefit in health care - by design.

I used two versions of the AMA Masterfile (2005, 2013) and Area Resource Files to map workforce to counties. These also include other variables. I added more from county databases. I wanted to see how the populations varied across workforce concentration categories.

I divided the active physician numbers by the county population to get concentration values.

• This is a contrast with rural that is based on population density and has less consistent relationships to health care dollars or workforce. Rural populations are not pure for deficits, especially around the medium or largest systems that are little different than the metro bigs.

I stacked the counties of the US from top to bottom in concentrations.

The Occupy Movement Focus was 1% doing fabulous and most left behind in the financial design. You will also see this in health, education, and other designs.

I used the Occupy ideas to do a Top 10% highest concentration counties which were 79 counties, the highest 20% involved 152 counties, the middle concentration counties were 286, at the lowest were the 2621 counties lowest in health care workforce - verified for physicians, nurse practitioners, and physician assistants that were active.

In the following graphic you can see not only the categories and population, but also the rapid population growth in lower and middle concentration counties with slower growth in higher and top concentration counties.

See how the 79 top concentration counties are growing very little with only about 30 million who benefit directly or indirectly. Population growth was about 1% a year or 10% in a decade during this time. Top and higher concentration counties have lowest growth levels while middle and lowest concentration counties are growing fastest.

The problem with rural methods of coding are exposed and rural advocacy is limited

Only 75% of the rural population is found in counties lowest in concentrations - only 40 million. The others are doing better to best as we know around largest rural systems. Note surprisingly their economics are awesome too because of their health care - but around them there is not so good due to the vacuum and their abuses - well documented in BCBS vs Marshfield antitrust activities - what a lesson that was.

Advocacy Is Lacking for a Population that Is Largely in a Situation of Unrest

About 32% of the urban population or 90 million is behind by design. This is an unrecognized population without an advocacy group.

Rural would do well to adapt and adopt, because of the power of representing 40% of the nation. Even more important is that this 40% is growing fastest and should reach 50% by 2060.

Why More Rapid Growth - Internal Growth Plus Migration to These Counties

The studies on housing and cost of living illustrate why more millions depart counties highest in costs and concentrations and social supports to go to counties lowest. Housing is increasingly unaffordable and unavailable in these higher concentration counties. The cost of living forces many to depart. As Americans age they get poorer and less healthy, and poorer because they are sicker under the US health care design. This also concentrates those with health limitations in counties lower in concentrations as they cannot leave to higher concentrations - as those like them are being moved to join them in lowest concentration counties.

See graphic to recognize how the population is stagnant to slowest growing where workforce and health care dollars continue to be increased along with health care jobs, economics, and outcomes. In lowest and middle concentration counties the growth of the population is greater in numbers, demand, and complexity as their health care is closed or compromised.

Let Us Examine the Rural vs Urban Coding as compared to Lowest Concentration Coding

I did a brief study on readmissions in year 2 looking at the highest penalties with 1 to 2% withheld.

• 3% of urban hospitals
• 5% overall
• 9% of rural hospitals with top penalty
• 14% of the hospitals remaining in 2621 counties lowest in workforce.

As far behind as rural populations are, they are limited by the 25% of the rural population that is doing well. Meanwhile the providers in counties lowest in concentrations of health care workforce are constantly facing increasing numbers, demand, and complexity as their finances are being designed away - talk about a formula for burnout, turnover, lower productivity, and worse. Indeed they face about $300,000 in losses and costs for each lost primary care physician and turnover each 3 years for $100,000 per FTE per year - about 15% of revenue. This is an uncompensated cost of delivery increase. Also the Usual Disruptions noted in smaller and middle size practices apply to these practices - losses of key personnel and changes in billing, EHR, location, and ownership. Mold did not have a comprehensive listing which would also include changes in employer or employer health plans, changes in local economics, and other setbacks. Rapid change, stagnant to declining revenue, fewer and lesser personnel, and changes due to innovation and regulation are killing off basic health access where most needed.

A county rankings review plus dozens of variables that I have collected by county for decades reveals the county proportions of the following as 98% of these counties have no hospital. Comments are added so that you understand just how bad the health care designs are and how we should expect worse.

97.9% No Hospital in County - (Counties without a hospital represent some of the fastest growing US populations given in-migration, internal growth, and more counties being added with larger populations. Hospital closures have generally proceeded from the smallest counties to those larger in population. As fast as growth is in the 2621 counties lowest in health care workforce, the growth is even faster in populations without a local hospital in the county.

97.4% Low Education County 2004 - Populations that are older and less educated have lower health literacy levels. This is another reason that performance based or value based designs are so bad for the providers in these counties. In fact, the social determinants or social drivers that we know most shape outcomes are all lower. This is why value based designs are not only crippling to their finances, they are most likely to punish the practices already paid least and facing the most with the least support. Value Based Care – no progress since 1997?https://thehealthcareblog.com/blog/2020/10/12/value-based-care-no-progress-since-1997/ A recent randomized study calls into question the basic benefits of managed care. The CMS Medical Home Studies failed to demonstrate success in changes in outcomes. The graphed lines demonstrate the almost complete overlap of intervention vs no intervention. The CMS Innovation Center is 5 for 52 in success and only 3 are replicable, and the changes are minimal.

• I can only ask you to consider population differences as shaping outcomes - NOT some intervention in a plan or practice or technology. The American people need transformation and the other efforts not specific to changes in literacy, behavior, and other non-clinical factors - are distracting and meaningless.

84.1% One Hospital Counties in these 2621 counties

• Sadly about 1 to 2 closures a month continue and some of these will take out the last hospital in the county. There is still no planning to modify the adverse impacts on access, jobs, and economics.

75.0% Rural population of US - but not those doing well. Rural is not pure for low outcomes. The 2621 counties are more specific to population differences that shape lesser outcomes.

50.0% Veterans estimate - This reflects Veterans arising from these counties and also preferring to return or forced to go to these counties due to their situations, conditions, and financial limitations.

49.8% Number Diabetics 2013 (obesity, smoking, COPD also at this level

46.9% Disabled Work Benefit Pay $ Dec2010

45.1% Total premature deaths, also mental illness indicators

43.4% SocSecBenefitPayment $ Dec2010

43.4% NumberChildreninPoverty2013

42.2% SNAP payments 2010

Food Stamps, Disability, Social Security

See how cuts in these social supports would be devastating

1. due to concentrations in these counties and
2. due to less economic activity in these counties. These social supports are much more important as a proportion of local economic impact. Indeed health care, education, social supports, and government jobs are very important - and all are being compromised or threatened.

• Interventions that Could Make a Difference Include Rural Health Matters Initiated by Gerald Doeksen. Rural Health Matters helps local communities understand the importance of health care and other contributors to local economics. RHM needs a major expansion to all of these counties so that they will learn to fight these cuts and losses of government jobs and education battles. They may be less likely to fall prey to political predators.

41.6% Persons in Poverty2009

41.0% Number of Unemployed 2013

40.7% Number of Uninsured 2014 - similar in 2010

See how these counties have not been down in employment or insurance compared to others - they have had the worst public and private health insurance plans shaping deficits along with the worst employers with their worst paychecks, benefits, and private health insurance plans.

40.2% pop 2010

36.3% of Active FM docs in 2013 found in this 40% population Family practice MD DO NP and PA is the only population based distribution but all 4 are departing family practice employment - because of the financial design

Primary care levels change dramatically led by internal medicine and pediatric concentrations within existing concentrations of workforce.

• Point to ponder - Pediatric initiated the primary care medical home which I consider to be little more than a marketing tool best used where there is much competition - as is the case for IM and PD primary care. FM which is dominated by higher concentration academic and larger practices also bought in, but the primary care medical home has been too costly and has low penetration where most Americans most lack care.

Family practice physicians (and NP and PA in FP positions) distribute equitably in population based fashion - but ONLY when they remain in family practice POSITIONS. Training in FM or FNP no longer matters as few stay in these positions. This is dictated by the financial design.

32.0% Urban population of US - An unrecognized population abused by a number of designs and without an advocacy group

27.4% Bachelors Graduate Degree Professional School in 2000 (also lesser high school educated) - Less educated is a problem and also the designs for health care and education also limit the numbers in these counties - and those who could help these populations understand what is going on.

27.2% General Surgery 2013 Active

26.9% Physician Assistants with NPI 2010

25.8% Advanced Practice RN w NPI 2010

25.5% Office Code 99214 - The 43% with Medicare in these counties is compared to 25.5% of Medicare office services in these counties - confirming about 25% of the primary care workforce. This is remarkable considering only 20% of primary care spending and is another indicator of overstress. It is not surprising that many of these practices have greater volume. The value based bandwagon people say that volume should be turned to value - but volume in these practices is called financial survival because of the financial design. Volume is also access to care

• Value based proponents should go jump - as far as these counties are considered

24.0% Orthopedics - Orthopedics has been better distributed in some ways to meet the demand - but the aging of the population, the increased injuries, the disabilities, and the growth of all of these will create much more demand. Fewer finishing orthopedics go into practice. More and more do fellowships. Indeed this allows them to make as much or more in salary as compared to older orthopedic doctors.

The financial design helps shape declines in general surgery and women's health and other surgical basics of about 1 to 3% lost a year and the greatest losses are in these counties most behind with oldest general specialists. Older is a measure of lack of replacement by younger.

23.5% Mental Health Providers 2013

22.5% Non-FP Position PA - based on the greater fp position for PA, this is what remains. PA has not really done much as so many more go to places and careers with much better financial designs.

22.2% Obstetrics-Gynecology

Generalists and general specialists are underfunded and remain at 23 - 26% - by financial design. Since 85 - 90% of locally available services are basic services, the failure to reform payments for basics (by stealing chump change from the bigs) is what prevents distributions of health care dollars, health care workforce, and health care access. This causes increasing inequities and disparities and likely outcomes declines.

Academics, deans, and associations who want to support health equity yet their associations will not tolerate even small redirections of funding from them to go to support basic health access. Why they are not called out for their statements of support of health equity is a mystery to me.

22.1% Emergency Medicine - Emergency Medicine also concentrates in concentrations. FM has been doing more in ER in these counties to fill this gap. Indeed about 19% of active office based family physicians are found in rural areas with 16% of the population. This compares to 24% of hospital based family physicians in rural areas due to emergency and hospitalist positions filled by FM trained residents. This is the statement of Shane Avery as his part time ER doc job was needed to keep him and his practice solvent - and eventually he took a full time ER job. His discussions with Indiana and national health leaders at CMS did not change the abuses.

My brief time in the AMA and my House of Delegates position helped me to understand that the AMA and government were shaping problems as I was driven out of rural practice in lowest paid primary care in a lowest paid state and in Area 99 rural with lowest payments and paid 15% less via Reagan cost cutting in 1983 - 1985 before taken out (another joke federal district court story here if you want).

20.2% Pediatrics - Pediatrics has also been departing primary care and converting to less active plus having lesser distribution.

19.8% Internal Medicine - IM has not been a good source for primary care since the 1980s when the creation and rapid growth of GME dollars and IM fellowships reshaped internal medicine trained workforce. IM is a poor solution as it is most concentrated and least distributed and also departs rapidly - for even less experience. This is a complete change from the pre-1980s contributions. The 150,000 plus workforce is moving to less than 30,000 as less than 1000 can be tracked per class year in IM (30 times 1000 is 30,000 minus activity losses).

Internal Med international grads are even worse for people in most need of workforce

This is because so many leave the nation (30 - 40%) with fewer doing obligations (more loopholes). IM is the best choice for those who want to leave the US as it best translates to other nations. Those who do obligations in the US also tend to leave primary care and leave places where most needed. This is easily seen in physician databases using cross sections rather than the usual biased medical literature studies. These biased studies often are used to justify more GME positions. They bias the studies by capturing those who stay in the US who also remain active (and have data). They can shape higher distribution by are still in obligations. There are 2 or 3 states that benefit with special programs, but often this works because the practices are near to metro areas and allow commuting. Sadly GAO and other studies document some abuses and misuses of International Graduates - which also explains poor distribution.

The Standard Primary Care Year is a Measuring Tool Specific to Contributions in Primary Care. It is the product of years in a career, primary care retention, and practice activity plus a volume adjuster (lower for NP and PA). Activity, years in a career, and practice activity remain relatively constant and are specific to the type of workforce. Lower levels in NP shape lowest contributions per graduate. The important thing to understand is that the primary care years realized have been falling for all sources due to fewer remaining in primary care. In rapidly expanding workforce with a stagnant primary care financial design, more graduates with fixed finances results in more non-primary care result - for even less primary care delivery per graduate.

Internal medicine has not been a good source of primary care for decades of class years. PA and NP have always been limited. FM and PD residency graduates are more limited in recent years. In pediatrics there have been increases in the numbers of graduates but these have been negated by a lower proportion remaining in pediatrics. In FM there was a rapid expansion to 3000 annual graduates 1970 to 1980 with ideal distribution facilitated by billions more added to the places specific to FM by the new Medicare and Medicaid dollars. Since 1980 the policies have been guided by cost cutting rather than support of those delivering the care. FM has lagged back with some declines in the 1980s and no more than 1% annual growth since 1980 overall, about as fast as population growth.

The deficits in primary care and in care where most needed - are predominantly about the financial design

NP and PA have also followed the financial design with more graduates going to non-primary care to more added specialties - and concentrating more in concentrations of health care dollars and health care workforce. The financial design shapes better salaries and benefits and delivery team members in higher concentration settings.

Birth Origins Studies

19.0% Physician Born in County - as with rural origins, birth in one of these lower concentration counties cuts the probability of becoming a physician in half. In the lower pop density or lower income counties, this odds are 5 to 1 against. Contrast with top concentration populations that are 5 to 8 in favor of becoming a US MD Physician - and these are populations that can access DO and international and Caribbean training as well for even better admission for them and relatively less for those most behind.

Highest income, most educated, urban origin parents and origins in a county with a medical school all boost the probability of admission (and better standardized test scores since these advantaged children set the standard). Those different and more normal do not test as well or access the same top colleges.

In my studies of African American, rural, and lower concentration populations the females are twice as likely as males to gain entry - often at levels not far from parity.

This is consistent with decades of studies of males who are basically declining rapidly across lower and middle income origins across the races (so much for diversity, baby you have come a long way,

Where are the male focused programs to reverse 100 years of male decline in college and higher education. I am sorry, it seems we still need a boost for females despite steady and progressive declines in 30 - 40% of the US population.

14.8% Psychiatry (child and geriatric at 11% levels)

14.6% Hematology Oncology - yep cancer care takes a 1 to 3 county or more travel across screening, diagnosis evaluation, and treatment.

14.4% Internal Medicine Geriatrics - Geriatrics is heavily promoted but is irrelevant for these counties with 40% of the population and 45% of the elderly. The financial design kills geriatrics everywhere and where people are more complex and the payments are worse and there are few providers to bail you out (academic, long term, short term) - no distribution.

13.0% Estimate of US Health Spending - suspect it less than 10% but 13% is all I can calculate based on physician economic activity. Yes it is true that these counties have the fewest lines of revenue and fewer facilities but this is no excuse for paying less for the same services and failing to support practices when they have additional costs. Note that supplies and services can be purchased by the bigs at a discount. Who do you think makes up for the lack of revenue that results? Not surprisingly those smaller get to pay more to support those who supply goods and services. And the increasing usual costs of deliver go up and up and kill more care where most needed.

• Remember that 1% of the land area in 1100 zip codes has 45% of the physicians in this 10% of the population - leaving less for most Americans. Those largest and most powerful have the most lines of revenue and highest levels of reimbursement which they primarily shape for themselves.

6.6% of Resident Training Positions in these 2621 counties in 2013 - GME is totally out of position. Studies and reports have documented that GME is not evidence based for distribution or for primary care result. Indeed half of medical education is confined to 6 states that have top concentrations of physicians - and is further limited to relatively few counties and zip codes in these states. Physicians in faculty, administration, subspecialties, hospitals, and other activities are stacked in counties with top concentrations. Where needed there are office and hospital based contributions and retired physicians and little else.

I pushed rural medical education as a solution for decades. I was wrong.

My rural practice lessons should have taught me that. Half enough primary care and general specialists is about the financial design. https://www.dhirubhai.net/pulse/rural-training-more-graduates-gme-cannot-fix-deficits-robert-bowman/

The financial design is so bad that no training can contribute to the resolution of deficits in

1. Lowest paid generalists and general specialists

2. Lowest paid practices with concentrations of the worst patient finances and worst insurance corporation payments (read abuses)

Yes you can show higher proportions of graduates where needed - that fade with time and beyond the length of nearly all studies. You can show odds ratio improvements as well. But what you cannot demonstrate is increases in the concentrations of health care workforce where they are lowest - and where there are not changes in employers, health plans, or other financial areas that shape or resolve deficits.

Special training, rural training, CHC training, and pipelines are all rearrangements of the deck chairs. The special graduates just displace those who would otherwise fill the positions.

Mapping clearly indicates persistent deficits in Appalachia and across lower concentration counties - except for growing suburbs or interstate related changes.

There are also other problems. Teaching CHC Could Be Targeted Specifically to help with the underserved workforce,

There are at least factors to address if you want a GME or other training program to boost distribution. According to the literature should be

1. Family Medicine choice

2. Location in states of need such as 30 states of greatest need

3. Training location in 2621 counties of greatest need

Only 10 - 15% of Teaching CHCs fit all 3 criteria. As usual these are set up locally by those organized to grab dollars - not according to a distribution plan. Teaching CHCs include other specialties and location in states and counties with highest concentrations.

Also in CHCs the financial design prevents resolving deficits and keeps them with fewer and lesser delivery team personnel as in lower concentration counties. For example in CHCs the major impediments are Medicaid payments only 70 - 80% of the cost of delivering care to Medicaid patients as NACHC demonstrates. In lower concentration counties there are

1. The worst of the Medicaid plans for providers and for patients (dating back to 1965)
2. The worst of the Medicare plans
3. The worst employers with their worst health insurance plans
4. The patients with lower income levels forced into high deductible and other most limited plans for them and for their local health care.

To fix the discrimination you address the financial design. Anything else is a rearrangement of the deck chairs. Usually the interventions are padding someone else's pocket while distracting from needed attention and intervention.

Check out FQHCs. You need a designation as a shortage area. In higher concentration counties this is difficult, but they have a bypass. You can get a designation for limited health access for Medicaid populations. The real solution for this problem is Medicaid that pays 100 - 110% of costs of delivery - not a special designation because of the sad Medicaid financial design.

Why would our nation have Medicaid and Medicare plans that compromised health care with insufficient support?

Why would foundations and associations think that major expansions of these worst plans - would help resolve deficits when they fail to pay their way? https://www.dhirubhai.net/pulse/stop-insurance-coverage-preoccupations-start-basic-health-bowman/ If they do not get their act together and focus on Basic Health Access rather than insurance or micromanagement - there will never be improvements in access.

ACA Obamacare Has Been a Nightmare for these Counties

Micromanagement is just one way that ACA hurt these counties. The insurance payment transfers with 90 cents on the dollar leaving and only 10 cents returning - is another reason that ACA causes more disparities. Disabling the local practices is another. The small increase from lowest Medicaid payments to slightly better Medicare level payments was temporary and did not address Medicare payments 15% less or the lack of outpatient facility fees given to hospital outpatient services. Again you must understand from the perspectives of most Americans most behind and their practices - and not listen to micromanagers and their assumptions from outside and from far above.?https://www.dhirubhai.net/pulse/why-most-americans-should-celebrate-10-years-obamacare-robert-bowman/

Lesson on benefit from ACA/Obamacare - you have to be big health, big insurance, or a county with higher concentrations of workforce to benefit from the ACA reforms, or any "reform" since 1983. My translation - the health care designers do not value these people or what remains of their health care.

Valuable Research Specific to these Practices is Lacking

Some are helpful such as Shifting Implementation Science Theory to Empower Primary Care Practices by William L. Miller, Ellen B. Rubinstein, Jenna Howard and Benjamin F. Crabtree in The Annals of Family Medicine May 2019, 17 (3) 250-256; DOI: https://doi.org/10.1370/afm.2353 https://www.annfammed.org/content/17/3/250.full.pdf+html

If would seem that Medicare for All would be a good idea.

But it cannot work at the current time with the current designers and their poor understanding and misguided approaches. Almost certainly they will continue to pay less and punish more the practices most behind.

1. Costly changes and rapid changes - any changes are more difficult for these practices
2. Compromise in implementation - they usually cost more per physician due to smaller size plus more stress on their fewer and lesser delivery team members
3. Continued maldistributions of dollars

All of the above worsen the situations for practices and hospitals where most Americans most lack care.

Solution Summary

1. Major efforts are required to educate and inform the majority of Americans most behind regarding the major economic contributors to their communities - health, education, social supports, government jobs, and specific areas. They must know that they deserve better health care and education financial designs. They need to protect their government jobs. They should fight for more social supports as they are aging faster and in ways that require more support, more caregivers, more access - all denied by design.
2. 90 million people or 32% of the urban population must have an advocacy group. NRHA is best positioned to represent them but only if it completely changes its name and its focus. It would also need to move away from the large rural system support that is key for them as this involves counties with higher concentrations. Without this change there will be more unrest in this population left behind for good reason as the health, education, economic, and other designs make their situation worse. They are also growing fastest without any planning that will lead to any improvements in their health care situation.
3. Foundations and associations such as The Commonwealth Foundation and AAFP that claim to be health access focused must dump micromanagement and insurance expansion focus. Resolving health access problems requires them to focus on more and better team members serving the majority of Americans most behind with half enough. The focus must be on this support so that innovation can be with each patient - and not forced from above and outside. Starting with why ACA was so wrong for lowest workforce concentration counties would be a help. Understanding how micromanagement increases the costs of delivery in ways that compromise delivery team numbers and functions is required. If you do not understand basic health access for most Americans most behind, then you should not say that you have access to care as a major mission. You certainly should not associate insurance coverage with access to care. Value based or performance based bandwagons have rolled on and over these lower concentration counties. Their states tolerate these abuses (Medicaid, lower support for local education, property tax based education, failure to discipline health care insurance corporations).
4. Micromanagement in health and in education steals the dollars from these hospitals, practices, schools, and districts most in need of these dollars - and sends these dollars to those with concentrations - corporations, consultants, and CEOs in concentrations).
5. More research must occur within practices at the grassroots level. We need less from outside by those who have no clue about basic health access where most needed. More such as Mold did on Usual Disruptions or from Miller and Crabtree on inside out or from Casalino who was surprised at the higher performance level of small practices, particularly the smallest. No journal should publish an article when there is clear evidence that the funding body (CMS) has censorship ability such that a researcher is not free to find that value based designs compromise practices. Sadly this has happened. Research involving data must be understood as commonly flawed. This is what happens when the researcher, data, funding, study design, analysis, and conclusions are all directed toward what is expected to be found.
6. Health care designers must be held accountable much the same as physicians or human subject researchers. There must be an absolute focus on evidence basis - not assumption or speculation or belief as in micromanagement and managed care interventions. There must be a focus on beneficent intent - not cost cutting. Protection of vulnerable populations should be a top consideration. Current designs abuse tens of millions or far more than any physician or human subject researcher could ever abuse.
7. Cognitive, office, basic, most prevalent, and most needed services such as primary care, mental health, women's health, and basic surgical need a major boost in revenue with most of the increase where paid 15% less in lower concentration counties. This must come from those doing the best where care is far too costly and overutilized most. The current design fails with 45% of complexity for this 40% of the population defeated by 25% of the primary care workforce supported by just 20% of primary care spending - minus additional costs of delivery each year including micromanagement costs from HITECH to Value Based.
8. Performance based designs must go away. The evidence indicates little progress on the road to value basis and much trauma and disruption. Outcomes are about transforming populations - not practices. The more health care emphasis the higher the costs and the less that remains to invest in people - required for transformation.
9. If there is no change in the financial design, the 2621 counties lowest in health care workforce must organize to address their own needs. They should develop training that arises from local origins, that selects trainees based on their performance doing community health, education, and development projects as well as their ability to communicate, work in teams, and work as a change agent. Transformation ability is preferred. Those selected will train locally and practice locally for at least 8 years. Since all of their years are local, this is not likely to be as much of a problem. Keeping care local can also keep the health care dollars locally, helping to build up economics to double from health care in the key areas for them. Direct contracting will be required.
10. Health care professions students and residents must be properly informed about the coming situation with a major glut of health care workforce - the result of massive expansions of NP PA DO and MD for decades of class years. Unfortunately what will need to happen is regulation of the academics in these nursing, physician, and physician assistant areas to prevent even more abuse. Never should expansions continue with annual graduates increasing at 6 to 10 times the population growth level or 3 to 5 times faster than any demand increase. This is a nightmare with too many graduates in 4 sources, more new types of workforce on the way, fewer and larger and more powerful health care employers, and already major declines in independence and autonomy with more to come. These massive overexpansions have not resolved deficits and clearly indicate that training is unable to fix deficits under the current financial design. See Graphic Below
11. Academics will also need to be held accountable for contributing to the least experienced primary care workforce in recent history due to massive expansions, expansions of those with fewer years in a career and lesser activity levels, and fewer remaining in key areas such as the financial design. This takes those experienced in primary care out of the primary care pool. The public will need some protection. There is also a need for research to highlight the adverse impacts and ways to address this. Not only do the expansions continue, they have continued despite faculty shortages, shortages of training resources and patients, and during COVID which impairs training and experience further. See graphic at end

Optimal primary care has trained specifically for primary care, intends to remain in primary care to optimize learning during early practice, that stays a career in primary care, that has a low level of inactivity in practice, and has few changes of practice. A steady state physician primary care workforce has about 3% new graduates with similar losses out of the existing primary care workforce pool. NP with shorter careers need to replace 4% a year. Massive expansions create a bubble that will burst. NP has 40,000 entering that have no NP experience compared to the 350,000 in NP. About 40% have 5 or years less and this will be even less experience in high turnover primary care due to least support by the financial design. This is shaping fewer and lesser delivery team members inadequate to address high levels of complexity getting worse. As has been the case, the situation will be worse where the financial design is worse and where the complexity is highest.

Why should Americans tolerate worsening - by design?

Cancer and Geriatric Care Designs Fail for Most Americans

Try to start with understanding distributions:

• 45% of the complexity/need/adjusted demand/age related care requirements of the US population can be found in
• 40% of the population in 2621 counties lowest in health care workforce with
• About 25% or half enough generalists and general specialists (1 to 2 against) and
• 12 to 18% (1 to 3 against ratio) of geriatrics, oncology, psychiatry, and even less of more specialized workforce.
• 15% lower is about the norm for payments for office and basic services to the practices in these counties along with 30% lower payments to the hospitals in these counties for the same service

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 - the one time major boost in dollars injected in the counties most behind. 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/

Claims of Outcomes Improvements By So-called Value Based Designs Are Likely About Improved Access to Care

There are many claims of improved outcomes via value based care. Actual documentation is sparse. When there are claims of improved outcomes, it is important to see if the actual factor improving outcomes was improved access to care. This article was stimulated by Chen-Med - a very popular source of postings on LinkedIn. https://www.dhirubhai.net/pulse/claims-outcomes-improvements-so-called-value-based-designs-bowman/?

Value Based Payment Problems Are Deadly to Basic Health Access

Designs that increased the costs of delivery while not increasing revenue defeat health access. Designs that cannot improve health outcomes need to be terminated, not replicated. https://www.dhirubhai.net/pulse/value-based-payment-problems-deadly-basic-health-access-robert-bowman/

Micromanagement Fails Most Americans at the Micro and Macro Levels Their designs have consequences and complications. If you think about it you can even predict who would suffer the most - the ones already valued least, understood the least, and most abused already.

The following is a summary of the failure of micromanagement involving 2621 counties lowest in health care workforce that are already supported the least by design just as they are abused the most by the new designs. https://www.dhirubhai.net/pulse/micromanagement-fails-most-americans-micro-macro-levels-robert-bowman/

Everything that You Know is Wrong About So-Called Primary Care Solutions?There are many who claim that their graduates are primary care solutions. They are wrong. The only solution for primary care deficits is a better financial design. We must get to the truth before we can actually address primary care deficits and basic health access deficits specific to most Americans most behind. https://www.dhirubhai.net/pulse/everything-you-know-wrong-primary-care-workforce-solutions-bowman/

Our recovery as a nation must be generation to generation and this greatest battle for civilization can only be one when each new generation has a greater and greater proportion of its children growing up in thrival mode rather than in survival mode. – RCB You cannot regulate or micromanage health care or education to improve outcomes. You must improve the population. https://www.dhirubhai.net/pulse/only-true-solutions-health-education-outcomes-robert-bowman/