Designers Make Disparities Worse for Most Americans Across Health and Education Designs

We can we truly make American outcomes better by addressing disparities, but first we must raise awareness regarding the designs that make most Americans worse. Then we need to stop the harm done by designers. Finally we must invest in the Americans most behind generation after generation to steadily move the nation toward better health, education, economic, and societal outcomes.

There was a Great Depression, but our designers are shaping a Greater Depression that will last for generation after generation until it is addressed. Those doing well will ignore it and this includes the designers. Those doing less well will suffer more. They will also be told of many reasons why they suffer more by those who focus on profit, power, politics, or promotions that work best for them.

The designers are blind to the daily lives of most Americans most behind.

The health care designers examine data that is distorted. It is often based on billing for health care services. This data is missing for those who cannot access health care. Existing data is distorted as it arises mostly from Americans who have the least access barriers who tend to overutilize by 2 to 4 times the national average. Practice data is captured from the largest practices and systems - another source of biased data.

The managed care assumptions have often been based upon Medicare patients and a distorted sample of Medicare patients. DRGs were tested barely a year in the atypical state of New Jersey before implementation - a horror story that still continues for populations most behind and most different. Obamacare was considered an advance involving insurance expansion and micromanagement focus. But for the populations and practices most behind it has worsened disparities. You only need to track the dollars redirected in mandated insurance and micromanagement focus to see this.

• One thing that you can count on is that the designs favor those largest and most powerful where health care dollars and workforce are most concentrated. But this is not the case for most Americans most behind with half enough generalists and general specialists where practices and hospitals are being closed and compromised - by design.

Designers Distant in Many Dimensions

The insurance, association, government, and policy designers generally do not deliver health care. The few that do deliver health care that contribute to designs are not providing basic services in the places where most Americans most need care in lowest health care workforce counties far away from the designers.

At some point we need health care designers that understand much more about most Americans most behind, so that they can do no more harm by health care design.

Their focus on data, metrics, measurements, micromanagement, and meaningless health insurance expansions is not helping.

Until they have some awareness, they will continue to make disparities worse for most Americans already most behind.

Costs of Housing and Costs of Housing Shape Local Populations

Personal situations shape access to care. And personal finances shape where you can live. This may result in a place of residence that has limited Basic Health Access.

Many view rural populations or minority populations as most behind. Few consider that most Americans are most behind. The lessons of Occupy Economics were strong then and are much stronger now. The forces concentrated more dollars into the hands of a few individuals and a small portion of the population are much worse.

I consider the focus on rural or on minority as a distraction from the important consideration of the United States population as the Minority Left Behind.

Housing designs shape migration patterns and what America will be like decades in the future. To understand the future of health care for most Americans, you must understand the impacts of the designs for housing, economic, and health care.

Where people live or are forced to live is a concept that helps to understand how health care designs act to worsen disparities.

Americans behind the most must live in places with lower cost of housing and lower cost of living. They must move away from places with costs too high and places that lack affordable housing. Sadly the housing design is shaping more and more Americans away from counties higher in concentrations of workforce and social resources to move to counties lowest in these and other areas.

These lower concentration populations are being joined by millions of other Americans who are forced to migrate to these counties of lower concentration.

The trends are quite clear as seen in the header main graphic regarding population growth by county concentrations of health care workforce.

• For this graphic I stacked US counties from highest to lowest concentrations of workforce using census data and the AMA Masterfile. I arbitrarily set up the 10% of the population, 20%, 30%, and 40% categories as I wanted a lower concentration and middle concentration comparison.
• The top 10% of the population in 79 counties had 470 physicians per 100,000 with 305 in the higher 20% in 152 counties and 222 in middle concentration counties leaving 130 million people in lowest concentration counties with 115 physicians per 100,000.
• About 90 million people in these lowest concentration counties are urban representing 32% of the urban population. About 40 million are rural or about 75% of the rural population. For a map visual representation, think of Red Counties and minority predominant rural counties (Southeast African American, Border Hispanic, Native American reservations) as the lowest concentration counties. You might consider that minority population and Red County populations have suffered by health, education, and economic designs.

Also the counties with lowest concentrations of health care workforce have higher concentrations of older, sicker, and disabled populations indicating higher complexity and higher demand for health care as well as inherently lesser outcomes.

• These are populations to avoid if your hospital or system or ACO or health insurance corporation wants to profit overall, especially from Shared Savings or Value Based design.
• Those who take over these practices and hospitals want the referrals, but not the responsibility for providing lowest paid basic health access.

The US Population has grown fastest in numbers, demand, and complexity in these lowest concentration counties.

This is seen in the 40% of the population in 2621 counties lowest in workforce in census data dating back for at least 5 decades. About 30% of the population in counties in the middle range of health workforce concentrations has a higher pattern of population growth at the same high level as lowest one decade and actually higher in one of the decades.

Note in the graphic that counties highest in health care workforce concentration have had lower population growth and the top concentration counties have had some decline. In fact, there would be more decline except for Hispanic population growth in Texas counties higher to highest in health care workforce concentrations. Few understand that Asian populations are over 50% located in counties highest in concentrations of people with 33% for Hispanic populations, 22% for African American, 17% for Whites, and 12% for Native Americans. This was based on the counties with highest concentrations of people (not workforce) with the top quintile or 20% of the most densely packed American population.

• With lower concentration counties stagnant in health care workforce and with primary care stagnant in workforce decade after decade, the last decades of workforce growth is easy to see. The workforce continues to grow fastest in non-primary care areas and in counties higher in concentrations already. Same or less for places with most Americans and much greater increases where there are fewest is a cause of disparities.
• About 1% of the land area in 1100 zip codes with 10% of the population has 45% of physicians and receives over 50% of health spending. Only a few dozen zip codes in six states receive 50% of graduate medical education dollars.
• The 2621 counties lowest in health care workforce receive only about 13% of the economic impact attributable to local physician workforce using the AMA Masterfile and AMA estimates of economic impact. The 65,000 primary care physicians in these counties represent 25% of the primary care workforce for this 40% of the population but only receive about 20% of the primary care spending because of lower payments and worst local insurance plans concentrated in these counties. And the newer designs involving micromanagement have stolen about a billion a year more. They had about 38 billion in 2008 but now have less than 30 billion to invest in primary care delivery each year.

As you will consistently see, the health care design is a poor match for most Americans most behind and is a best fit with those who design health care in higher concentration settings.

Health care design has always has been a poor fit and the new designs make it worse. Only 1965 to 1978 with the new Medicare and Medicaid dollars did substantially more billions flow to the providers in counties lowest in concentrations. But those in the largest systems and practices in higher concentration counties abused these designs. This shaped the 1980s Era of Cost Cutting that still plays on today.

You can track the cash flow changes as health care dollars are steadily taken away from lower concentration populations and providers to be concentrated in higher concentration settings.

Designs That Shape Increasing Disparities

• There have been basic payment design discriminations in many dimensions with lesser payments where most needed, lowest paid generalists and general specialists most important where most needed, worst paying health insurance plans concentrated where most needed, and multiple lines of revenue funded at the highest levels for higher concentrations (research, teaching, graduate medical education, health corporations, foundations, institutions, academics, hospitals, subspecialty, procedural) with only 1 to 3 lines basic revenue lines present and funded at lowest levels for lower concentration counties. An example is only 6% of GME or residency positions found in 2621 counties lowest in health care workforce with 40% of the population and most of the academic lines follow much the same.
• Value based designs and other performance based designs discriminate. They pay less and penalize more where providers serve populations that inherently have lesser outcomes, lesser social supports, more chronic conditions, and the worst environments, situations, and conditions. Readmissions data indicates highest penalties for 14% of hospitals in lowest concentration counties, 9% of rural hospitals, 5% overall, and 3% of urban hospitals. Star Ratings are identified as having huge errors. MACRA also has serious flaws. Indeed, performance based incentives fail for outcomes effects. They can be shown somewhat to impact process.
• Since they have lesser levels of primary care and workforce, it appears that the higher levels of primary care are related to better outcomes. This is a spurious association - a correlation is not causation. Outcomes are clearly about the populations and not about the providers. Recovery of outcomes for most Americans requires far more than just primary care moved above half enough.
• Americans falling behind in health and income have three choices as they get older or poorer or both (and often because the health insurance design does not protect them from financial ruin). They can become homeless or they can move in with family or friends or they can relocate to a county lower in cost of living with affordable and available housing.
• Lower levels of education follow lower income and lower property values making education funding more difficult as well.
• Older, sicker, poorer, and less educated populations tend toward lower health literacy, worse behaviors, worse mental health, and lesser outcomes. This makes the care more complex along with lower levels of social supports locally. This is another case where designs of least value are considered by designers to be most valuable.
• Metric, measurement, consultant, software, update, digitalization, innovation, regulation costs divert scarce health and education dollars from lower concentration settings to higher. This also steals jobs, economics, and cash flow from places and populations most in need. This micromanagement focus also has personal and professional life impacts upon those who deliver care or teach.
• Studies in Health Affairs and other journals have indicated that the costs of implementing micromanagement are relatively higher (as in per primary care physician) in these settings that tend to have smaller facilities, practices, and schools and less support personnel to task with micromanagement. More duties arising from regulation and innovation are dumped on fewer team members - another cause of burnout. This is another case where designs of least value are considered by designers to be most valuable. This again is meaningless use abuse.
• Mold has also demonstrated greater disruptions to small and medium size practices with changes in key personnel, EHR, billing, ownership, and location. There are many more disruptions that have greater impact with smaller practice size.
• Also these practices are less likely to have a facility fee to compensate for low primary care payments - another discrimination.
• Health care insurance expansion designs have moved many billions from lower to higher concentration settings. These plans expanded often pay less than the cost of delivering local care and fail to protect local people from financial ruin. They also result in higher debt situations for local providers. This is another case where designs of least value are considered by designers to be most valuable.
• You might at this point begin to see why innovative designs that promote innovation, coordination, and other higher functions might not work for counties with insufficient workforce, supports, resources, and funding.
• Primary Care Medical Homes or patient centered or higher functioning primary care all require more and better team members and are defeated by financial designs that dictate fewer and lesser delivery team members as more is paid to consultants and others that do not deliver care.

If you do not consider the situations facing most Americans most behind, you will never see the design discrimination.

• Categorizing counties into lowest concentrations is a window to examine discrimination involving designs that shape dollars and complicate local health care delivery.

Health Care Workforce Follows Health Care Dollar Designs, Deficits of Dollars Shape Deficits of Workforce and Basic Health Access

• Designs shape and maintain deficits of workforce in the locations and populations with concentrations of the worst public and private health insurance plans. This can be seen where there are concentrations of older, poorer, disabled, chronically ill, less educated, and most abused populations who are valued the least and supported the least by the worse insurance designs.
• Deficits of health care workforce are predominantly about generalists and general specialists paid lower for their basic, office, cognitive, most prevalent, and most needed services. About 90% of the locally available services for 40 - 50% of Americans most behind are generalist and general specialty services. These populations and their basic practices have historically been punished most by health care designs, especially where their concentrations are lower. The new designs make their situations worse.
• Primary care and basic services can work as a loss leader for larger practices and systems as this can capture and funnel patients in for higher paid procedures or more specialized care. Small practices and hospitals do not have a loss leader advantage. They are entirely dependent upon lowest paid basic services.
• Higher volume in small practices and hospitals is considered important for survival as a compensation for lower payments. Some compromise in the number and quality of team members is also shaped by the financial design. Both of these contribute to lower levels of Basic Health Access. The Volume to Value crowd continues to see volume as evil. Volume in basic services is closely related to access to care. With national levels of primary care services falling prior to COVID year after year, there clearly has been little value placed on the volume that shapes Basic Health Access. This is another case where designers fail to understand the important areas where volume is important - particularly where volume and access are far too low - by design.
• Designers could also learn that it is hard to implement practice changes considered progressive with regressive funding and obstructive designs combined with serious issues dealing with usual disruptions that hit small and medium sized practices hardest. The designers do not base revenue and payment designs on many areas most relevant to the practices and hospitals in lowest health care workforce concentration counties.
• Deficits of health care workforce cannot be addressed by training interventions such as more graduates, additional types of graduates, special training, or pipelines to primary care or rural practice. These have all failed in numerous attempts over recent decades. A special program or school can look good individually with a higher proportion of graduates in a target area of deficit or higher odds ratios of such a location, but the target state, county, type of county, or population will still have a deficit until the financial design is addressed. Until then there will be half enough workforce, half enough team members, complexity too high, turnover too high, lower productivity, and insufficient delivery capacity across Basic Health Access
• Social determinant focus as implemented by health care will not work to change outcomes. It will be too little, too late, and high cost - as with health care design itself. Health care impacts few people. Health care is out of position as it is concentrated in higher concentration settings - far from the people in lower concentration settings. Social determinants and other non-clinical factors impact outcomes over years, decades, or generations of life shaping influences. There is no last minute cure or save. The numbers of disparities, their degree, and their resistance to change are too great. You cannot intervene effectively in the last months or years of life. Interventions must be early and often across development, education, parenting, and more. We do not even support the basic human infrastructure to impact children and families - teachers, public servants, day care, public health, primary care, social workers, child developers. We also fail to support the physical infrastructure that impacts the daily lives and health of most Americans most behind - clean water and conduits, broadband, sewer, roads, bridges, etc.

The population is growing faster to fastest where health care workforce is lower to lowest in concentrations - and the health care designs assure even worse to come. Training more graduates is not a solution and contributes to a number of consequences to health care and the MD DO NP and PA workforce forced to deal with a glut of workforce times 4 sources.

It is an unprecedented time in America. In recent decades most Americans have fallen fast and far. A Great Depression has been made specific to this half of the population while a smaller portion is experiencing the Roaring 20s.

It is a time of difficult decisions as with the 1930s politicians. FDR was given a choice of saving either the Great Plains land or the Great Plains people. There was not enough to do both, but he said both. Designs that killed the land were curtailed. Science was applied to agricultural practice. The programs that supported the people were created and still exist, although they are threatened.

Clearly the nation has a vast need for small armies of young people to restore the physical and human infrastructures of our nation. We must restore child development, early education, local public health, local primary care, and outreach into homes. The 1960s brought about the War on Poverty and focused on supports for the elderly - looking far into the future that is now. Sadly these programs have continually been compromised and have often been cut. This has left us even less prepared to address the increases in aging population, demand, and complexity. And the situations are worse where those older and more complex are concentrated.

Contrast the Great Depression with the current crisis.

The recovery funding is going to corporations that are doing well while the people doing poorly get little. This is short term thinking on the part of the politicians and the businesses - who would do much better with a better American people.

• Run the money changers out of the temple
• Keep those most powerful and closest to the politicians away from the treasury
• There is only one recovery in America and this recovery requires a focus on the American population. This is also what shapes great institutions, corporations, and decisions.

Stop the Innovation Worship

We cannot fix America with innovative new designs. It takes hard work and long term investments to change populations to be able to change health, education, economic, and societal outcomes.

Those who sell snake oil remedies need to be told no thank you. Those who promote a solution that fits them and not most Americans need to be redirected to solutions that fit most Americans most behind.

The people in counties lowest in concentrations deserve to be told

...about the discriminations that hurt them most in health care and in education - arising from both parties as well as state and federal government. They need to know that cuts in Food Stamps, Veterans Benefits, Meals on Wheels, disability, and Social Security hurt them most. Lowest concentration counties are 40% of the population but have 42 - 50% of the dollars arising from these programs. These dollars pay for nutrition, local jobs, local services, and local social determinants. These dollars support better outcomes and better communities.

It is a horrible distortion to convince people in the counties most behind - that these support programs are wrong for the nation

...when they are mostly right for them and their neighbors and children. These funds represent better local stores and groceries and services and jobs and benefits. Funding that goes away will worsen food deserts and other deserts, just as it has worsened Basic Health Access deserts.