Health Care Designs and Designers Compromise Most Americans

As we examine compromises, intolerance, and abuses including those of political and economic leaders - don't forget about the healthcare designs and designers that have long contributed to discrimination.

Organized health care resists necessary reforms

1. Cognitive/office/basic services paid more vs procedural/subspecialty reimbursement paid less
2. Improved revenues where workforce is lowest in concentrations - where revenue is lesser by insurance and government designs.

Do Gooder Micromanagers Think that They Can Improve Outcomes

1. But they add to costs of delivery and burdens while decreasing productivity and increasing turnover
2. But they cannot improve outcomes that are set in stone by the condition of the patient or population without much chance of primary care changing outcomes in a few minutes a year compared to a lifetime of previous experiences shaping so many outcomes factors
3. But they do not understand those delivering the care or the negative impacts of their micromanagement
4. But they do not understand that most Americans suffer from underutilization because of limited workforce, supports, and access.

How Did We Get This Way

Red Counties and rural minority counties suffer as the lowest workforce concentration counties because they were not valued. They have long been sold out by their politicians and by the business leaders that dominate health care. They have not been valued or supported. Even worse their anger has been captured and focused by those that do not value them or their health care, education, economics, and more.

Medicaid Was Born in Compromises

Many have long forgotten that Medicaid was a compromised design. Medicare and Medicaid separately did not have enough political clout to get passed separately. They were combined to get passage. Another compromise was made by the designers to allow Medicaid to be designed at the state level. States demanded and received the "flexibility" to not support poor people or disabled people (or the providers who served them) as they saw fit.

The same states have also opposed ACA/Obamacare expansions.

The same states also tolerate the worst private insurance although this also partly stems from the worst employers that have the worst finances.

These states have the lowest levels of health care workforce and the worst health, education, and other outcomes.

The compromises were specific to most Americans most behind and those fewer who remain to serve them.

The deficits of health care workforce in 2621 counties lowest in health care workforce with 40% of the population are the result of the designs (or lack thereof) of the worst states, worst health insurance plans, and worst employers.

There are half enough generalists and general specialists (about 25% of primary care, mental health, women's health, basic surgical) and about 15% of various cancer, heart, geriatric with even lower proportions of the more subspecialized workforce. Designs shape the deficits and the deficits and access barriers.

These all increase and worsen with advancing age or chronic illness.

MD DO NP and PA are all concentrated by the health care design in concentrations and away from most Americans and those in most need of health care.

About 1% of the land area involving 1100 zip codes with just 10% of the US population has 45% of the workforce and well over 50% of health spending. This is what happens when you have the most lines of revenue and the highest reimbursements in each line where health care is most concentrated - and most powerful. This power lobby prevents health care dollars from being cut from their concentrations even to bolster lowest health spending impacting health care workforce for half of the nation - far behind by design.

Health care designs were compromised from the start and have been abused by the largest and most powerful entities for some time.

They Are More Like Guidelines - Says the Famous Pirate

Guidelines were developed to prevent Medicaid abuses by the states that wanted to retain the ability to abuse in 1965 - but the guidelines were ignored and taken down only a few years later.

But the 1965 to 1978 Medicare and Medicaid contributions stand out as the only period with increases in health care workforce for these 2621 counties most behind. This revealed the secret to resolving deficits and access barriers - the financial design with increasing revenues as compared to the cost of delivery. Since this time the opposite has been closing and compromising Basic Health Access where most lacking.

Enter the Era of Cost Cutting

The 1965 - 1978 Medicare and Medicaid designs were manipulated by the largest and most powerful resulting in major increases in Medicare and Medicaid costs. They had the workforce and the subspecialty and hospital and other services. They added more lines of revenue and the highest reimbursements. The hammer came down and missed them because they are the largest and most powerful - but those least valued where hit even harder.

As a reaction to the massive cost overruns going to the health care providers doing best in top concentrations, the Era of Cost Cutting began - a new era of micromanagement that has not only failed to rein in costs, it has added even more cost and costly layers of bureaucracy.

When the 1983 Reagan prospective payment and diagnosis related group cost cutting began, small health care began to fail and the failures were specific to the Americans most behind and still least valued.

Guidelines Again Were No Protection for Patients or for Nurses

There were also guidelines intended to prevent the obvious responses of hospitals such as

1. dumping patients faster/too soon or to prevent hospitals from
2. short staffing in RN and other personnel

The guidelines did not stop such practices. The compromises of nurses accelerated in the 1980s and extended to more and more delivery team members including physicians in the basic specialties in the last 15 years and beyond.

Government plus profit focus is the reason for decline by design

The designs have resulted in the closures of over 800 small lowest paid hospitals and the closures and compromises of primary care long seen. The impacts continue to be most specific to the 2621 counties lowest in health care workforce - essentially Red Counties and Red States (who were previously Democrat but changed to Republican). There is another smaller component of lowest concentration counties - the rural counties that are predominantly Native American, African American, and border Hispanic.

Yes, the US has long discriminated against most Americans via health care design - and the same is true for education designs.

See how the design prevents any possible intervention from training to address deficits of workforce and access barriers.

The US has 45% of patient and population complexity (age, chronic illness concentrations) in these 2621 counties with 40% of the population. This has long overwhelmed the 25% of the primary care workforce in these counties (by design) that are supported by only 20% of primary care spending.

How Health Insurance Reforms Have Hurt and Not Helped

Lower levels of spending are shaped by the worst insurance plans concentrated in these counties (Medicaid, Medicare, Dual, high deductible, private) and 15% lower payments for services to go with the worst collection rates. This is also why expansions of the worst plans via ACA/Obamacare has not helped and indeed has hurt these counties by stealing many more billions for health care plans that only return 10 cents on a dollar to providers in these counties. The problem was never lack of health care insurance as this 40% of the population had about 40% of the uninsured.

• The problem was always about the worst employers, worst insurance, and worst health plans hurting these counties the most. Do gooder foundations have helped to focus reforms on areas that cannot help the 2621 counties and may make their situations worse. They still equate health insurance with health access - a very bad mistake.

Academic Institutions, Nurse Practitioner Associations, AAFP, and others Make the Situation Worse By Their Claims that Training More Graduates or Special Training Can Fix Deficits - They cannot.

The US can never, never, ever fix deficits of health care workforce by any training intervention. You cannot fix the financial design by creating more sources such as family physicians, nurse practitioners, and physician assistants. We have not resolved deficits by expanding nurse practitioners from 10,000 annual graduates past 40,000 since the 1990s and still increasing at 6% a year or a rate 10 times the annual population growth - 10 times! PA and DO have been expanding at 8 times for over 40 years but each increase in annual graduate contribution to primary care has been negated by a lower proportion in primary care. US MD since 2003 is up 3 to 4% more each year (and the primary care result is actually going down as so few enter and stay in primary care.

Designers That Claim That More Graduates Can Fix Deficits Are Preventing the True Financial Reforms That Are Required to Fix Deficits

It is not ethical to treat a patient with a medication that will not address their disease when there are existing treatments that will fix the disease.

Even More Family Physicians Will Not Work without a Financial Design Change

Only the positions filled by family practice MD DO NP and PA have population based distribution or 36% found in this 40% of the population lowest in health care and other concentrations.

But all of these family practice sources are being driven away by the financial design. They are departing primary care for better financial designs in urgent, emergent, hospitalist, and other careers.

• Family medicine is not a solution
• Nurse practitioners are not a solution
• The financial design is the solution

Clearly the deficits are caused by the health care design, by the compromises made, and by the lack of state discipline toward health insurance.

The states that have long compromised Medicaid, DRGs, Obamacare, and health insurance continue to compromise most Americans most behind. The health care designers that understand most Americans least - are making this worse.

Another way to interpret this is that most Americans are least valued and are least understood. Even worse the bandwagon toward value based care has valued them least of all.

Yes, providers paid according to outcomes will be consistently paid less and penalized more when they have practices in these counties where the populations have inherently the worst outcomes, the most chronic illness, the worst environments and conditions, and the least social supports.

But then again the researchers will continue to find reasons to justify this micromanagement bandwagon that actually results in more billions for the consultants, CEOs, and corporations doing best while resulting in less health care and fewer jobs and lower social determinants for most Americans already most behind - while shaping worse outcomes via these mechanisms.

And by the way the consistent fastest growth pattern decade after decade in these counties will assure that this 40% in 2010 becomes 50% by 2060 - a majority left behind. Housing inequities may result in even faster growth. As Americans grow older and poorer (wealthiest doing better) and sicker they get even poorer by design and this forces them to move to counties lowest in health care workforce (or forces them to stay in these counties). Housing is too costly and is lacking in availability in the Blue concentration counties. Those moving will be leaving places with concentrations of workforce and overutilization to go to places with half enough generalists, general specialists, and social supports.

Happy 2021 and beyond, but not for most Americans most behind with worse to come.

Additional Information and References

Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect.26

https://jamanetwork.com/journals/jama/fullarticle/2770410

It's the microenvironment of the primary care delivery team members that is distorted by micromanagement. This helps to cripple and kill primary care where most needed - and too many Americans. https://www.dhirubhai.net/pulse/microenvironments-damaged-micromanagement-defeat-basic-robert-bowman/?

When considering most Americans most behind, the graphic above paints America as rosy. The truth is rankings far below the scale and behind 40 - 50 other nations for this half of the population. https://www.dhirubhai.net/pulse/worst-outcomes-us-even-worse-most-americans-behind-robert-bowman/

There is only one way to prevent primary care from total failure by design. The financial design must be changed, progressively and substantially. The past years and decades have shaped deterioration by design. https://www.dhirubhai.net/pulse/only-future-primary-care-2020-beyond-robert-bowman/

For over a decade the designers of American health care have been fiddling around. They believe that micromanagement can improve US health care. They have not improved costs or outcomes - as these have both worsened. But they still cling to the assumption that the right combination of technology and micromanagement can turn cost and quality around. But they are making the financial design worse where most Americans most lack basic health care services. 

https://www.dhirubhai.net/pulse/nero-fiddles-thousands-practices-burn-robert-bowman/

Value Most Americans most behind and those who serve them. Do not value the value based designs that most abuse those most behind.

https://www.dhirubhai.net/pulse/value-populations-those-who-serve-them-based-designs-robert-bowman/

If you examine for disparities with an economic dollar flow focus, you can see the designs that are increasing disparities exactly where health care designs already shape the most disparities. When you have physician databases and area resource file data with county breakdowns and county ranking data you can begin to see the lack of value in so called value based designs. https://www.dhirubhai.net/pulse/value-based-designs-can-never-reduce-disparities-most-robert-bowman/

Frying Pan to Fire for Red Counties from February 18, 2017

Health care designs helped rebuild health access 1965 to 1978 via JohnsonCare. Many of the current Red Counties were blue back then but have since switched. Health care designs 1980 under ReaganCare slashed and burned health care in Red Counties as seen in hundreds of closures of small and rural practices and hospitals. Designs 1990 - 2010 have also failed for Red Counties. Health care designs under ObamaCare 2010 to 2017 were worse for Red Counties already getting the least and compromised the most. https://basichealthaccess.blogspot.com/2017/02/frying-pan-to-fire-for-red-counties.html

About 40% of the American population is behind with the lowest concentrations of health care workforce, the worst outcomes, the worst access to care, and the lowest levels of economic contributions from health care. Micromanagement focus has worsened each of the above from HITECH to ACA to MACRA to PCMH to value based. https://www.dhirubhai.net/pulse/micromanagement-abuses-most-americans-design-robert-bowman/?