Health Care Designers Shrink Workforce Where Population is Growing Fastest

It could be considered a major problem in a few decades when the health care has been decimated by designs that close hospitals and practices where most Americans most lack care. The fact of the matter is that the US design has always compromised basic health access for large portions of its population.

In the graphic you can clearly see the faster growth of the US population in the county categories middle and lowest in concentrations of physicians.

• The slowest population growth is in counties with top or higher concentrations of physicians. This 30% of the population is favored with the most lines of revenue, the highest reimbursements in each revenue line, and the most concentrations of health care dollars with the resulting jobs, cash flow, other social determinants, and more.
• The middle to lowest concentration counties have had the fastest growth decade after decade. This is also where hundreds of hospitals have been designed away along with thousands of practices. These tend to be smaller to middle sized and least organized.

The financial design is the major problem closing hospitals and practices.

Primary care that still remains in 2621 counties lowest in health care workforce faces the tyranny of

• 45% of complexity for this
• 40% of the population that has half enough generalists (46 per 100,000, 45% from family medicine) and half enough general specialists with just 
• 25% of primary care and women's health and 23.5% of mental health providers supported by
• 20% or less of spending for each of these 3 workforce cohorts

And the financial design has been made steadily worse by micromanagement based designs - Minus 2% of revenue lost from these practices each year due to additional micromanagement regulations, innovations, and digitalizations.

The higher concentration counties also benefit from ever higher costs of micromanagement as these dollars are taken from middle and lower concentration practices to go to consultants, corporations, and CEOs that do not deliver health care.

I only used a 30% penetration into these practices to calculate the annual increases in costs based on Health Affairs publications indicating what it costs for HITECH to MACRA to PCMH to Value based. These major changes have subtracted about 1 billion lost per year from the 60,000 primary care practices that were present in 2013 in the AMA Masterfile (not as many now).

The 20% share of annual primary care spending above translates to about 38 billion in 2008. but what remains to invest in primary care is less than 30 billion due to stagnant revenue and 1 billion more a year forced out of their hands.

When you are paid 15% less by Medicare and have concentrations of Dual, High Deductible, poor, near poor, Medicaid, and other worst private health insurance - you have the worst finances by design.

The Financial Designs Shape Deficits of Workforce

The county and other populations that have concentrations of the worst public and private health insurance plans are the ones that have deficits of workforce. The same populations had lower income levels and had deficits of workforce before Medicare and Medicaid. But since the 1980s the health care designs have made the situation worse.

• Health insurance expansions of the worst plans, the ones that pay less than cost of delivery, do not help. See how Obamacare fails in this and other ways. Why Most Americans Should Not Celebrate 10 Years of Obamacare
• The population in these lowest concentration counties has also had to ante up more for health insurance which only returns 10 cents on the dollar back to local health care providers. About 90 cents on the dollar goes to big health care, big insurance, and providers in higher concentration counties. This should be seen as a disparity. Meanwhile those in higher concentration settings benefit with mandatory health insurance expansions. They have the workforce and health insurance corporations and consultants and CEOs that all benefit most.

And the Designers Still Want More from Lower Concentration County Health Care Providers

It continues to bother me that the designers want more and more from practices and hospitals that have the fewest lines of revenue and the lowest levels of reimbursement in each line. Over and over you hear about higher functioning primary care and patient-centered primary care.

How do you integrate, coordinate, and outreach in the practices with worst finances and in counties with the lowest levels of primary care, women's health, mental health, and social supports to integrate or coordinate?

The very financial design shapes fewer and lesser team members - the opposite from higher functioning or patient centered primary care?

Who will point this out to CMS, The Commonwealth Foundation, various primary care organizations, and others who push for integration, coordination, higher functioning, and patient centered designs.

The volume to value mantra - is absolutely and totally wrong

Consider that a focus on volume from primary care practices where most needed could well be about survival. The financial design is so bad that volume is the only adjustment left. Until there is a better financial design the usual annual cost increases and the micromanagement related cost increases will force even worse in the future.

Don't Forget About the Usual Disruptions - Another Area Neglected by the Designers

The designers continue to value procedural, technical, subspecialized, and hospital services while marginalizing basics. They reward providers in higher concentrations and this has supported more and more workforce while most Americans fall further behind - by design.

The bigger win and the smaller lose in health care design.

Mold illustrated how the Usual Disruptions from changes in key personnel, ownership, location, billing, EHR hit the small and medium sized practices hardest (and likely the FM docs that remain most of all)

• No one has been successful in communicating the Usual Disruptions to those who set up billing. Disruptions and constant changes in policies are more costly to smaller practices - the ones where most needed.
• The changes from CMS and Congress continue to favor those largest while taking out smaller practices and hospitals - by design.

How difficult is it to communicate that policies to push cost cutting as the cure for overutilization - work out very poorly for populations and providers that suffer from barriers to care that limit overutilization and sufficient utilization?

Why do the designers ignore 2 to 4 times utilization rates in higher concentration counties and cut their costs rather than taking bites out of smaller practices paid the least and challenged the most?

If you cannot cut costs where they are excessive, why cut costs where workforce is already at lowest levels?

• Is it hard to see that cost cutting fails for those largest and most powerful - but hurts those smaller and most needed who are paid less and must pay the most per primary care physician for each new change?

Family Medicine Leaders Talk Up Big Support for Family Physicians

But did they count the family physicians who have shed their practices and have lost their communities and their way of life? Has this been presented to the media or to those who shape designs?

These practices where most needed best represent what family medicine is about - primary care, basic health access where most needed, broad scope, high intensity, complex primary care, and more. And they are dying - and AAFP must understand this.

If you cut the heart out of your membership, you lose your soul also.

Put another way, some action is required when a patient loses blood slowly and steadily and progressively and faster than they can replace it.

The vital organs all suffer - what remains of health care, health access, jobs related to health care, health care leadership in these communities - IS DRYING UP and DYING.

Do Not Forget the Major Disparities Caused By Design

In rural situations, the population has been stagnant and changes in local health care and economics do tend to send some of the population packing - especially younger people.

But the situation in the 2621 Counties Lowest in Health Care Workforce is somewhat different. It is important to understand two things

1. People in lower concentration counties have nowhere to escape as the economics and situations worsen. They are often there because the cost of living is low, housing cost is low, and housing is available.
2. More people move to these counties because the cost of living is low, housing cost is low, and housing is available - as the more to most concentrated counties increase in property values and have less available housing - the migration will increase

Rural populations are stagnant to shrinking - but these lower concentration county populations are not - and the impact of the financial design is readily apparent.

See how the US continues to worsen the situations for most Americans.

The US most concentrates workforce, health care dollars, and access in the counties with the slowest rates of growth. The population in top concentrations would be stagnant or shrinking without metro Texas Hispanic population growth. It is actually shinking in these top concentration counties in many top concentration states.

Notice the faster to fastest growth in the middle and lower concentration counties with 30% and 40% of the US population. The US is growing where workforce is not being grown - by design. Does it bother you for most Americans to do less well while few Americans do better and better? If not, you missed the advocacy component inherent in family physicians.

The lowest concentration counties stagnant in workforce with closing hospitals and practices as shaped by the financial design have 3 times the growth rate of the top concentration counties. They also have the oldest workforce due to lack of replacement.

Primary Care is Flatlined for MD DO NP and PA. The reason is that primary care spending is flatlined. Non-primary care spending and workforce continue to increase. And this is specific to the counties with higher concentrations of health care workforce already.

More for fewer, and less for most at ever higher cost and without significant changes in outcomes. This is a major theme of the US Health Care Design.

No training can address these deficits

... as the financial design continues to defeat the existing workforce while shaping fewer and lesser delivery team members, higher turnover and burnout and lower productivity.

Studies fail to understand the importance of organization for health care in these counties - because the designers and researchers do not understand or value these people or those who serve them. More and more millions of people are being forced to transport from these counties across 1 or 2 counties to get basic care - while many decide not to go get care or screening at all.

Rural associations do not represent these counties as there are large rural systems that can have more impact.

Rural does not represent the 32% of the urban population in these lower concentration coutnies.

How long until you understand that this population in lowest concentration counties will become 50% of the US pop by 2060? Does it matter that they will have even lower levels of workforce and few remaining hospitals?

Who Will Advocate for Lower Concentration Counties?

It is their hospitals that have closed - rural, smaller, less organized, lowest paid - over 800. They continue to close at 1 to 2 closed per month.

This should be a top priority. We have had some interesting times in the past few years. Whether our voting patterns get better or worse, has to do with how we address basic needs - such as health care. There is unrest in these counties because they have figured out that they are falling behind - and they are listening to those who desire to manipulate them while not helping them.

How will these counties vote in the future as they become more of the US population left behind?

Do you not see major reasons to help them understand their major sources of economics - health care, education, social supports, government jobs, better small businesses, ...

See How Social Media and Politicians Hurt These Counties

Some hurt them with misguided designs. Others convince them that social supports are evil - even though about 42 - 44% of food stamp, disability, social security dollars go to this 40%. Since their other economics are limited, these social supports are magnified in importance for local jobs, food availability, social determinants, and more. The impact of these cuts would be devastating. They must know how important it is to them.

Do not think that the bailouts will get to them, because they are still not valued or understood. They are far from the feeding trough and so many at this trough crowd them out almost completely.

Primary Care Is Also Least Valued, especially Where Most Needed and Most Important

Do you not see this about primary care as well? We have always been too far from the trough. This is why we get most abused - by designs.

We must accomplish important changes in awareness and in health policy, education, economic, and other designs that punish them most.