Fight Design Discrimination to Restore Basic Health Access - and Our Nation
I seem to be beating this drum more and more – but it is important to focus on practice finances, the ones that shape and maintain shortages and access barriers
There are 3 very important reasons to fund basic services to a greater degree where they are most needed. We should fight for this even if the dollars must be taken from highly specialized care to be budget neutral. We have to fight for the basics and for those most in need, even if those doing well by the current designs fight back and oppose us.
Why?
1. BECAUSE THOSE PRACTICING WHERE MOST AMERICANS MOST NEED CARE NEED THE SUPPORT – and our nation fails them, and they deserve not to face discrimination by design
2. BECAUSE MOST AMERICANS MOST BEHIND MOST NEED THE SUPPORT– and our nation fails them, and they deserve not to face discrimination by design
3. BECAUSE OUR NATION CANNOT IMPROVE HEALTH, EDUCATION, ECONOMIC, AND SOCIETAL OUTCOMES – because the designers are making choices and shaping designs that make disparities and outcomes worse.
It is hard to problem-solve in basic health access or basic education – if you have designs and designers and media that distract and delay the recognition of the contributing factors. If your conferences and business meetings and association meetings all focus on areas that are not solutions – there will be no progress toward a solution.
So please follow with me what I have spent the last decades of study to understand. There is one period of our time that we invested where most needed, and all other times since.
Start with 1965 and the original Medicare and Medicaid designs
These original designs acted to inject billions more into rural areas and into 2621 counties lowest in health care workforce - because these places have concentrations of elderly and poor in these counties.
See the impact not only on these populations, but also on the others in the county not poor or elderly who benefited from more and better practices and hospitals and ERs and delivery team members.
This one period of time was perhaps the only time in US history where these populations actually received more support with an increase in access.
This was a very important time for family medicine
Family medicine leaders fought to gain recognition during this time period and did so. Family medicine experienced its one time massive expansion from zero to 3000 annual graduates – during this one favorable health policy period of time. Family physicians benefited and in fact could choose primary care and distribute – because of these dollar distributions increasing 1965 to 1978. These distributions were more limited beginning in the 1980s.
The Downfall of Basic Health Access - 1980s to the present
The managed care and micromanagement focus on cost cutting began in the 1980s, predominantly because those larger and more powerful worked to change the Medicare and Medicaid designs to benefit themselves more and more.
Right now there are proposals to improve primary care spending. The powers that be want CMS to fund these, but not if it comes out of their highly specialized care.
The battle goes on and on and most Americans continue to lose - by design
Runaway Costs Resulted in the Health Policy Era of Cost Cutting
Too much for too few in too few practices and hospitals resulted in the Era of Cost Cutting that has dominated since that time.
This in turn gave rise to micromanagement focus.
Micromanagements of cost and quality were intended to help, but they cause harm.
This is most evident in the practices and places where underutilization and underpayment are worse. These are places where the practices are paid less and are smaller and more punished by policy changes. These are populations that have fixed long term shortages and access barriers - by health policy design.
Now see the situation 1980s to the present, and worse in the past decade. Follow along as we see why the plans to do help people and do better via ACA/Obamacare, have actually made the situations worse.
See how the focus on value based is discriminatory.
Payments too low with cost of delivery too high and increasing have been the reasons for shortages and access barriers. The financial evidence has been seen for decades across rural areas and across 2621 counties lowest in health care workforce.
Medicaid payments too low also hit Community Health Centers hardest because they have some of the highest proportions of Medicaid patients. Native health care is also most limited by Medicaid design and by health care dollars ($2000 per person vs $11000) that are 5 times lower than the US average.
If you have been on Medicaid or have a family member with Medicaid – you probably understand the inherent discrimination being made worse.
An article in Modern Healthcare notes that Medicaid Rolls are up – not because of unemployment and lost insurance, but because the Medicaid state interventions to dump patients from Medicaid have been interrupted. Yep, they dump people regularly and force them to do mountains of paperwork to justify being on Medicaid.
All of the worst health plans in the nation are concentrated in the lowest concentration counties and shape the deficits and shortage barriers.
The 2621 lowest health care concentration counties continue to face high levels of discrimination and destruction by design. Who are they?
These 2621 counties had 75% of the rural population or 40 million plus 32% of the urban population or 90 million for overall 40% of the US population or 130 million in 2010
This is a most important geographic marker. Unlike rural populations that are stagnant to declining, this population is rapidly growing and will likely reach 50% of the population in the 2050s due to more rapid growth.
What Drives Population Growth in Counties Lowest in Health Care Workforce?
Consider that higher costs of living and housing in counties higher in concentrations of health care workforce and people will continue to drive migration to these counties. Note the impacts of higher eviction rates, aging, worsening health, and worsening finances due to junk health care insurance coverage will drive even more to move from higher to lower concentration counties – that had consistently had the fastest growth for decade after decade.
A Listing of the Results of Dysfunctional Designs
This 40% of the pop in 2010 had just 25% of the primary care workforce (AMA Masterfile, Area Resource File), 25% of office services (Medicare 2011 data), and 20% of primary care spending (estimated from lowest payments, worst public and private insurance, and lowest collections). Some primary care practices are outpatient and associated with hospitals and get a facility fee – but not so much for these practices that are often where there is not a hospital.
What makes me angry is discrimination.
It angers me that so many leaders and experts propose so much – that cannot work and will not work where most Americans most need care.
Awareness is a curse. When you see practices and populations with great limitations by design, it upsets me to see solutions that are just not possible for these practices or make situations worse for them and their local populations.
Nearly every day the arm chair quarterback experts far away in more than just distance
…promote costly and burdensome changes to health care delivery according to their assumptions and managed care groupthink. They never have to scientifically justify their fire ready aim health or insurance policies – they just perpetrate and penetrate the core of primary care – the personal and professional lives of the delivery team members.
Primary care is about people serving people. You punish primary care budgets, you punish the people who deliver the care.
There are no penalties for unethical behavior as with physicians or human subject researchers – and they can harm tens of millions. No one even discusses holding health care designers accountable for their designs – or insurance companies.
But in family practices we are held accountable for
- higher functioning primary care,
- coordination with mental health or women’s health,
- integration,
- innovation,
- outreach
- more costly technology, and
- more burdensome and costly regulation focused on meaningless and confusing and inaccurate metrics and measurements.
Great ideas all – we would all do it in a heartbeat but…
Note that the various primary care improvements above are nearly impossible in these places with half enough generalists and general specialists and delivery team members. These are practices with team members shaped to fewer and lesser and being cut due to finances.
And it is difficult to facilitate social support in places with half enough social support resources in places where local economics are also in decline.
But wait til you see matters worsen
... with cuts to Veterans Benefits, Food Stamps, elderly programs, and Social Security – because these populations are all concentrated in lower concentration counties. These are all jobs, dollar circulations, economics, social determinants, stores, and better situations for friends, family, and neighbors. Cuts in these areas hurt and hurt and hurt.
Our designers fail to understand the hurt and harm that they cause.
These practices where most needed are hit hardest with penalties due to lack of EHR or due to lower outcomes because of the population that they serve – which the payers also do not value – despite their misguided promotions of discriminatory value based and financial incentive based designs. Yep, you heard it.
And because family physicians are 36% distributed to this 40% of the population, it is by far the most important to these counties, and the most discriminated against.
Over and over again family medicine is most associated with the people in most need – because all other specialties concentrate in concentrations of people, dollars, and health care whereas family physicians remain about 26 to 30 per 100,000 in distribution – despite the discriminatory designs.
And that distribution where most Americans most need care is value not appreciated and not rewarded – in fact it is most penalized.
Equate value based designs with discrimination, disparities, and worse
– because they penalize the practices, providers, populations most behind. Eventually on trial they can claim that they were trying to help – but trying to help when not understanding the consequences – can cause harm and is causing harm.
Notice that it is not possible to promote social determinants of health and other non-clinical determinants as important and shaping outcomes – while also promoting value based financial incentives. You cannot have both. Clearly practices are not the important factor. Populations shape outcomes.
So now you can see some of the discriminations and disruptions and real world financial issues caused by the designers and their discriminatory designs
Summarizing the Situations in these 2621 counties
1. Their generalist and general specialty finances are predominantly office dependent and they are paid 15% lower by design (Medicare 2011)
2. There are concentrations of Medicare, Medicaid, Duals, high deductible, and worst private health insurance – making the finances worse and the burdens higher
3. They are concentrations of patients that are low in health literacy (older, lower education levels, access deprived), low in health insurance literacy, and low in trust of government, insurance, and health care
4. They have the lowest bandwidth
5. They have the lowest collection rates because of the local populations that they serve (you might also see why they need to see more volume – because of the financial design and the need to survive – despite the design – they are also tired of having second jobs to prop up their failing practices)
6. They have the least ability to pay for digitalization and regulation and are more likely to get hit with the 4% penalty for not having the grand and grandiose Medicare certified EHRs which milk them for all possible dollars
7. They have lower outcomes because of the populations that they serve which inherently have lesser outcomes resulting in lesser finances and round and round
8. Their local hospital is also least able to support them or local care or local outreach because they are paid 30% less and are 2 to 3 times more likely to take a readmissions penalty at the highest level (Which should not be surprising given the population that they serve with inherently lesser outcomes and more chronic diseases to go with lower concentrations of generalists, general specialists, and social support resources)
Their challenge is to address what is likely 43 to 45% of primary care need adjusted for the complexity of this older, sicker, poorer population. So 45% of need arising from 40% with only 25% of workforce and 20% of primary care revenue reduced by about 2 – 3% a year stolen for innovation and regulation.
So they have fewer and lesser team members, least ability to do higher functioning or patient centered primary care, with least ability to integrate, coordinate, outreach, digitalize, innovate, legislate, or function
- - by financial design.
It is easy to see the discrimination hitting the rural counties that are predominantly African American, Hispanic, or Native. They are lowest workforce concentration counties.
But do you see this 32% of the urban population as facing discrimination that are also lowest workforce concentration counties – a predominantly white population.
Do you see them as being manipulated and abused by state, federal, and insurance designs?
Now reflect on concierge care, or direct primary care, or Medicare Advantage – and how little these mean to most Americans most behind
Do you see how mandated health insurance has made matters worse? Just connect the dots – or dollars that is.
Many billions stolen from these populations to pay for the worst private health insurance that fails to financially secure them and fails to support their local practices and hospitals. And perhaps 90 cents on these insurance dollars goes out of the county and only 10 cents on the dollar returns.
Do you see the disparity caused by people who think that insurance expansions are helping – even though the health insurance is meaningless to these populations, practices, and providers most behind?
Do you see the disparities caused by the managed care groupthink bandwagon from HITECH to ACA to MACRA to PCMH to Value Based
– all implemented with great and glowing promises of cost savings and outcomes improvements since 2005 – and failing miserably to improve outcomes (because they are about populations, not providers) and failing miserably to save costs – which they have increased.
60,000 primary care physicians in 2621 counties lowest in health care workforce in 2008 had 38 billion as their 20% share of primary care revenue to deliver 25% of services
- Minus 1 billion a year for the digitalization, regulation, innovation pathway from HITECH to ACA to MACRA to PCMH to Value Based at only 30% implemented (all they could afford)
- Leaves less than 30 billion to invest in primary care delivery where they once had 38 billion
Not counting higher usual costs of deliver from inflation
Not counting the higher cost of disruptive changes such as changes in key personnel, EHR, ownership, location, billing which hurt small and medium size practices most (Mold, Annals FM)
Not counting the other disruptive changes not considered such as changes in the local economy, illnesses in team member families, insurance shenanigans
Focus on the financial design
Focus on telling the truth of training
Focus on exposing the lies of training
Family practice is a solution – but requires a much better financial design to do the necessary access facilitation and to keep family practice MD DO NP and PA in family practice, in primary care, and where most needed.
Family medicine is a solution – but it is limited by the proportion that remain active and in primary care – which is fading by financial design as all sources fall to lower and lower proportions and retention in primary care continues to decline.
NP and PA in family practice have similar distribution – but this is lost when they leave FP positions. Yes, the NP leaders are not telling the truth. They lie like the US MD Deans lie about primary care contributions of their medical students which fail to enter primary care at higher and higher levels.
NP leaders claim high numbers and half in primary care, but only 45% train in family practice and fewer remain. Any decent studies show this. Advance for NP and PA surveys have shown this. And a new one does.
The study by the Oregon Center for Nursing examined state licensing renewal forms that nurse practitioners fill out every two years. The center’s analysis found that just 745 of the more than 3,000 known practicing nurse practitioners provided primary care services in 2018, the most recent year state data were available.
You can reach Elon Glucklich at [email protected].
Note that the actual levels are much lower – at 15 to 20% of the graduates who could practice age 34 to 65. This is because HRSA studies have consistently shown RN and NP are only 60% active. This Oregon study selects out those who are active and licensed. Yes, the NP numbers in primary care are increasing – because of massive expansions. But the non-primary care is expanding at a much faster rate – and the primary care NPs are leaving.
NP PA DO and MD are a solution for primary care – if and only if the financial design is fixed.
Bob Bowman