Mr Health Care Designer Tear Down This Wall - Stop Killing Basic Health Access

Some walls are being torn down while others are made worse. There is a wall that prevents most Americans from ready access to basic services. It is a financial wall that favors health care for fewer Americans and compromises care for most. This Wall has a financial design so powerful that no technological weapon can penetrate it. No training design can send graduates to serve on the other side of the wall as behind the wall the finances do not exist to support them. Even massive over expansions of trainees cannot penetrate.

I experienced this financial wall challenge directly in 1983 as the Reagan administration acted to cut costs. It was bad enough to practice where the worst health plans were concentrated but I was also paid lowest for being in primary care, and for being in Oklahoma, and for being in Area 99 of Oklahoma, and minus 15% due to cost cutting action by the Reagan Administration. These actions in the 1980s did not spare my rural practice or others where there were deficits of workforce. And the DRG change in design killed off hundreds of small and rural hospitals, compromised most of the rest, and shifted workforce and basic health access away from most Americans. Studies have marginalized the impacts of these losses, but there are areas that have not been assessed

• Losses of general specialists such as women's health and basic surgical can be traced to killing off the hospitals and hospital finances where most Americans are most behind.
• Killing off local hospitals and practices kills off the local health care leadership
• Job and economic losses are often considered limited, but the impact is multiplied as health care is such a large portion of the local economy. Indeed education, health care, social supports, and government jobs are a huge contributor to local economics where most Americans are found.

Do the Designers Not Understand that 2621 Counties Are Lowest in Health Care Workforce as the Direct Result of their Health Care Designs - always have been, always will be until a major design change

Once again this 45% of patient and population complexity in 40% of the population most behind has only 25% of the primary care workforce supported by 20% of primary care spending - and big powerful health care will not even allow 50 billion in chump change to them to go to raise generalists from half enough to sufficient. Who wants to work for the lowest salaries and worst benefits in practices with fewer and lesser delivery team members serving where the complexity of diseases and conditions is highest and workforce and social supports are lowest?

I continue to assert that there is nothing better than working in complex primary care when you are well supported. ChenMed and other designs that have better finances attest to this and just won an award for being an outstanding employer.

But a bankrupt financial design can only punish those who care the most where it is most needed.

What part of health care discrimination by design do you not understand, Mr. Health Care Designer?

• Do you understand how you are closing and compromising practices and hospitals where most Americans most need care - for decades of policy decisions?
• What is hard to understand about basic health access compromise with deficits of generalists, general specialists, and basic hospital services where most Americans are most abused by health care design?

What set me off this time is an Article in JAMA

that explores different variables used to calculate just how behind a certain population is. Although it did illustrate how different populations are quite different, the conclusions were the same - more research and policies along this line. Why is this a problem?

1. These researchers and micromanagers want to figure out how to pay based on outcomes. It keeps their jobs as researchers in areas that are poorly supported otherwise. Do you think that they would get funded if they found that micromanagement did not work or was too complex or too costly? No way they get funded or published unless they find in favor of micromanagement.
2. These researchers still assume that outcomes can be reshaped by some clinical intervention. Despite dozens if not hundreds of attempts to change outcomes, they continue this vain attempt.
3. This line of research could well shape formulas that will determine payment which may be helpful to some but is almost certain to punish others - including those who already have worst finances by health care design. Hong in JAMA articles long ago demonstrated 1) Pay for Performance punished CHCs and was likely to punish others serving populations behind 2) They could not figure out how to adjust for disparities. Note that CMS has refused to make adjustments as they clearly delineated that some would prosper too much from being paid more for those considered more complex while others would lose out. But what about the vast deficits of workforce shaped by payment design with half of the population having ready access to half of generalists and general specialists.
4. Attempts to see the trees results in more failure to see the forest. They are putting out a house fire while climate change and raging fires insure worse to come. Health care is a design like education and economics that leads to unrest and worse. We need local, state, and national designs that support all Americans - especially in areas such as child development, early education, public health, and basic health access.

There are only two reasons for such treatment of half of the population most behind.

1. The health care designers do not understand health care essential for most Americans

2. The health care designers do not care about most Americans

They may say they care enough to shape better outcomes - but note that they cannot shape other outcomes via health care micromanagement. In fact their assertion that they can change outcome distracts necessary reforms that would change the American population. Their micromanagement has been demonstrated over and over to result in higher costs of delivery, disabled and distracted and burned out delivery team members, and worse.

Innovation in health care cannot descend from Above.

Innovation in health care must be restricted to what happens between patient and physician. The delivery team members need to be supported, not measured, or rewarded, or punished. They need more and better delivery team members but the micromanagement focused designs reshape budgets in ways that marginalize the personnel area - resulting in fewer and lesser. And this Bandwagon rolls on and over delivery team members - especially those where most needed where

1. the financial design is worse
2. the population is more complex - and growing fastest
3. the health care workforce is most compromised already
4. and the providers where outcomes are inherently the worst - would be punished even more

The designers see themselves as single-handedly fixing health care, or education, or economics. They fail to see that better health, education and economic outcomes are also about transforming the population.

Health Insurance Transformation Has Massively Delayed True Reforms

- see previous article

• Medicaid is bad for most Americans most behind and what remains of their health care after closures and compromises shaped by health care design.
• Medicare plans are bad with payments 15% less and the worst plans where most Americans are most behind.
• High deductibles are concentrated where people have less income - making the situation worse for them and for what remains of their local care.
• The Americans most behind have the worst employers shaping worst income, benefits, and private health insurance.

And micromanagement from HITECH to value based has substantially worsened the cost of delivery for what remains of their care while not improving revenue and in many cases acting to worsen revenue.

Not only does this design fail to save on costs and fail to improve on quality - it actually worsens quality via worsening of social determinants, non-clinical drivers of health outcomes, and worsening access.

Remember that these 2621 counties lowest in health care workforce with the worst determinants, complexities, and financial challenges are growing fastest as their health care is designed away (rapid increases in blue for lowest workforce concentration and in red for middle concentration counties) due to local growth within these counties and more millions forced to move there for lower costs of living and housing and available housing. Changes in higher concentration counties will likely increase this growth pattern.

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