Wednesday, November 26, 2014

Distribution Failures Behind By Many Designs

The 3138 US Counties can be coded by physicians, by types of physicians such as active family physicians seen here, by population and by other demographics, including those age 65 that are increasing rapidly and even more in health care demand.

As previously noted, the locations with top concentrations of physicians have lowest proportions of family physicians and primary care. 

Numerous forces interact to shape higher proportions of family physicians where care is most needed and where higher proportions of elderly are found. These are counties most behind in education, employment, and poverty in addition to health spending, health facilities, and health care workforce.




Slowest population growth is seen in counties most concentrated in health workforce. Highest cost of living and health care may shape most Americans elsewhere, especially the elderly and those on fixed or lower incomes. 

Designs for health, education, and economics fail where needed. Population based distributions are more important where care is needed but are falling behind due to sequestration, cuts in Social Security, cuts in SNAP (nutrition), cuts in child development, cuts in early education, cuts in primary care and basic services, readmission penalties, pay for performance, and other impairments specific to small facilities, small practices, and care where needed. 

As more funds are diverted outside of the county for consultants or software or technology in education and health care, less remains to deliver care. 

High costs of recruiting teachers, clinicians, and others plus high costs of retaining them make it even more difficult.

Simplistic changes in small areas will not resolve health access and other problems.

Designs must be specific to the counties and populations in need.


William T Butler, MD, in his Academic Medicine's Season of Accountability and Social Responsibility

Recent Blogs


Still Failure After All These Years

Acting Upon Discrimination in Health Spending

Understanding Common Errors in Quality Studies

Real Reasons for Rotten Outcomes

Too Many and Still the Wrong Clinicians

The Government Control Card Still Plays Well

Rotten Apples, Rotten Support, or Rotten Media?

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

Friday, November 14, 2014

Still Failure After All These Years

The following is a 2004 prediction specific to the year 2014 made by US Health Experts as captured by US News and World Report:

In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.

Ten Years After

By assumtion and belief backed by the creation of programs and expenditures, the US has actually helped to distract spending toward administrative costs and away from direct spending on those who deliver care - failing to meet increasing needs for workforce and services.

Experts failed to understand the limitations of various designs. Care management, even using the most promising designs, did not result in appreciable savings. The cost of doing the management often ate up any savings as investigated by the Congressional Budget Office.

In many ways the US has not improved since the 1970s - the year Still Crazy After All These Years was recorded by Paul Simon.

Insanity is attempting the same thing over and over expecting a different result.

I'd Love to Change the World

It seems that designers still don't know what to do. Of course one thing is different from the Ten Years After Song. We did not tax the rich and feed the poor although in some ways the rich did disappear since a few dozen individuals own so much of the world.

We lost the hard work and investment of 1965 to 1975 - investment that was specific to care delivery with money spent most directly upon the clinicians and teams to deliver the care. It seems easier to do something else other than to invest in the teams and clinicians that actually deliver the care. An alternative explanation is that other entities, facing a more stagnant US economy, decided to find their way into the health care pie.

And predictions by 2025 contain the same as for this year, even though we have made little progress. For example primary care workforce is not improving because spending specific to primary care is not improving and cost of delivery for primary care is increasing in ways that prevent the increases in team members and clinicians to deliver the care.

Reducing deficits of workforce is unlikely as the 2600 counties with lower to lowest concentrations of clinicians are growing the fastest in population, and are growing the fastest in the populations increasing most in care demand.We are also failing to produce the types of workforce specific to the needs of these 2600 counties (broadest generalists and general types of specialties).

Magical thinking must be replaced by nuts and bolts common sense for any real progress in health care. It takes people to deliver care to people. Technology can aid this delivery, but it can also get in the way. This is the great lesson of the past decade and recent decades also.

If you really want a blast from the past, check out this 1991 review of US health care by the Chairman of the AAMC of the time - William T Butler, MD, in his Academic Medicine's Season of Accountability and Social Responsibility. Butler reviewed these headlines of 23 years ago:

Newsweek: The Revolution in Medicine
Fortune: Taking on Public Enemy No.1
Business & Health: Physician, Cut Thy Costs
Nation’s Business: Curbing Costs of Health
The New York Times: Demands to Fix US Health Care Reach a Crescendo
The Houston Post: Church Leaders Decry Nation’s Health Care
US News and World Report: Doctor’s Dilemma: Treat or Let Die?
Business Week: Driving Down the Costs of an Aging America
Time: Scandal in the Laboratories
Newsweek: The Big Business of Medicine
The New York Times: Medical Technology Race Adds Billions to the Nation’s Bills
The Washington Post: Medical Care: How Much Health Care Can We Afford?
Newsweek: State of Emergency
Newsweek: Not Enough for All – Oregon Experiments with Rationing
The New York Times: Why Emergency Rooms are on the Critical List
Corpus Christi Caller: Doctors in Short Supply – Rural, Poor Areas Rely on State Incentives
American Medical News: Healing the Homeless
Newsweek: Can You Afford to Get Sick?

Butler's reforms are still ignored and his model medical education examples are still successful today but have not been widely replicated. Concentrating workforce as usual remains the design for health spending and health professional training.

Links

CBO Working Paper 2012-01 Lessons from Medicare's Demonstration Projects on Disease Management and Care Coordination

William T Butler, MD, in his Academic Medicine's Season of Accountability and Social Responsibility

Recent Blogs

Acting Upon Discrimination in Health Spending

Understanding Common Errors in Quality Studies

Real Reasons for Rotten Outcomes

Too Many and Still the Wrong Clinicians

The Government Control Card Still Plays Well

Rotten Apples, Rotten Support, or Rotten Media?

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


Tuesday, November 11, 2014

Acting Upon Discrimination in Health Spending

Spending Designs Discriminate

Designs for spending send less to counties in most need of care that have populations with multiple dimensions of "left behind." This can be tracked by measuring distributions of Medicare dollars or by measuring workforce distributions. Counties with lower to lowest concentrations of workforce not only have fewer services, they have higher proportions of primary care and basic services. In other words they have less of the services and providers that generate the most revenue under US design. Thirty or more states, 2600 counties, and 40,000 zip codes geographically map discrimination. Discrimination can also be mapped by economics, race, ethnicity, age, income, education, and other measures.

Decades of inaction indicate continued Discrimination by Design.

American health spending, like workforce, is concentrated in 6 states, 250 counties, and 1100 zip codes. Spending design favors those doing well across a wide range of social determinant dimensions. Workforce and training are similarly concentrated - influencing distributions of workforce and health spending.

Training Designs Discriminate

Designs for workforce production send fewer graduates to states and to counties in need of care and fewer to family practice positions (for MD, DO, NP, and PA grads). Family practice positions filled represent the multiple times greater multiplier of care where needed because family practice positions are the only ones distributed equitably. All other types of positions concentrate where clinicians are concentrated.

Only graduate results maximal for distribution can resolve deficits of services where needed. Population based distribution is seen in family medicine with 36% of family physicians in 2600 counties where 40% of Americans reside along with even higher proportions of nearly every population in greater need. The declines in the other major primary care contributor, internists, places even greater importance upon family practice position outcomes. Declines in MD, DO, NP, and PA family practice position result is discrimination against care where needed by training design. Designs must be specific to permanent family practice outcomes - the optimal health access recovery result.

Innovative Payment Designs Discriminate

Designs for pay for performance, value based, and readmissions penalties punish the same providers in the same locations - and the same populations that reside there.

Innovative Highly Technical Care May Not Benefit Those in Need of Care

To obtain maximal benefit from cancer chemotherapy, major surgery, or conditions requiring long term recovery, substantial support is required from family, insurance, employers, or others. The evidence is gathering that highly technical care designs fail for those in most need of care.

Clearly higher spending upon technologies such as Health Information Technology, results in less that can be spent upon clinicians and team members to deliver the care. This is not the only problem. As practices and states must spend more upon primary care locums or recruitment/retention incentives for needed primary care, even less remains to pay the clinicians and team members that delivery care.

CMS and Insurance Payers Support Discrimination

CMS has had critique, but much of this critique has apparently been dismissed as critique by those against Obamacare. When they have responded to charges of discrimination by individuals, experts, and studies, they have stated that to modify their formulas would not be fair. They have basically justified the destructive declines in health care delivery and health care workforce where needed.

Insurance policies that require smaller providers to beg for prescription approval, goods, consultations, admissions, and other services substantially raise the cost of delivery. Denials and delays in payments hurt smaller providers most. Many never even raise a protest as they have far too much service responsibility to allow distraction - already overwhelmed due to too much demand and too little supply of workforce. When small or needed practices spend more on personnel that address administrative needs, this leaves less for the support of clinicians and team members that deliver care.

With regard to Medicare Advantage, the insurance companies were obviously allowed too much ability to design their reimbursement - and used the design to harvest 70 billion more in the past 6 or 7 years. After complaining about over coding by health providers, it is the insurance companies using their mastery of health information that has provided one of the best examples of over coding and overcharging government. 12 billion a year dedicated to specific family practice workforce production would have contributed to primary care recovery and recovery where needed. When more is spent for those doing well, most left behind fall further behind by design.

Failure of Designers

Designers (pride? arrogance? defensive? unaware?) given the opportunity to demonstrate their designs have been focused on their own designs. The decisions made when given a change to reform, was to compromise on real reforms such as universal insurance or single payer. The designers may have been more focused on their own innovations or upon innovation for the sake of innovation. They may have underestimated the magnitude of the problem of America's failed health design. Clearly they have failed for decades to be aware of the chaos that they have promoted - chaos due to rapid change.

Designers from a few states, zip codes, and counties 
may not be able to grasp the situations facing those outside of their perspectives.

The last few years have resulted in substantial attention paid to health care. It was a great opportunity to showcase the best designs and the best leaders doing well in this important component. High expectations were a contrast with the major failure that is US health care. Decades have been required to get to the current situation. It will take decades of payment change and training change to shape real improvements where care is needed.

The magnification of health care tended to exaggerate the failures of health leaders and designers. This was a key reason that political victory was handed to those who are committed to even less support of populations in need of support across Social Security, child well being, nutrition, and basic health services - essentially any spending that is distributed in a population based pattern.

Consequences to Expect

The logical and expected result will be even less workforce, even less spending, and even lower outcomes for 40% of the nation in 2600 counties and even more with limited access despite residing in counties with too much workforce.

The result where care is most needed will be declines in health spending, declines in workforce, and declines in other spending. This will shape the social determinants of health adversely as well as failing for cost savings, failing for access, and failing for quality.

Show Me the Studies

Lessons for the future when reading studies claiming successful interventions - Accept less, assume less, question more! Think about advantage vs disadvantage in patient, provider, setting, and other dimensions.

When you see studies or interventions that claim improvements in multiple key areas, close examination is required.

It is very difficult to improve quality by spending less where care is already limited by lack of spending,  lack of workforce, and more complex patients

It is very difficult to reorganize care with Primary Care Medical Homes or consultants when the problem is lack of sufficient revenue, insufficient workforce, high turnover of personnel, higher cost of delivery getting rapidly higher, and high complexity of patient population.

It is impossible for the practices most needed - to function well with the numerous dimensions involved in delivering care with rapid changes in each dimension.

When you see such studies and differences are seen in cost - look for studies with populations that had too much spending already. Look for lost access or cherry picking.

When you see improvements in quality, look for differences in the populations studied.

When you see no difference for an intervention, consider this the norm. In a study with good controls involving the same patients or populations, the results should be the same. The setting, situation, and relationships of the patient shapes outcomes with provider or type of provider limited in impact.

The 2600 counties lower to lowest in clinician concentrations are paid the least per capita, are growing the fastest in population, have higher proportions of populations that are growing most in demand for services, and have the most social determinant challenges in the most dimensions. Why would improvements be likely at all?

Like designs for economics and for education, 
health care design assures even less for more and more for less.

Numerous studies have been done for decades and even more can be done. The time for action is long overdue.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. 
Martin Luther King, Jr.

Inequality in Medical Education - A Tribute to Martin Luther King, Jr.


Recent Blogs

Understanding Common Errors in Quality Studies

Real Reasons for Rotten Outcomes

Too Many and Still the Wrong Clinicians

The Government Control Card Still Plays Well

Rotten Apples, Rotten Support, or Rotten Media?

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

Friday, November 7, 2014

The Government Control Card Still Plays Well

The Politifact Lie of the Year in 2010 was awarded to the term "Government Takeover." Government Takeover or Government Control in various forms emerged from Republicans, health insurance association consultants, and certain media outlets. A brief attempt at naming the new health design as "public option" lost out. The spin doctors succeeded beyond their wildest dreams. The first Democratic agenda moved on the defensive and in many ways never recovered.

The best interventions are the simple ones. The Government Control card played well from start to end. It will be interesting to see if Republicans are going to be perceived as in control and if Democrats can return the favor. This is, of course, a reason why America is difficult to govern.

The Government Control card has indeed been played by both sides dating back many political campaigns. The latest and most successful example paved the way for a simplistic and powerful campaign 2010 to 2014 with the results as we have seen. Successful political candidates profited by "We really do not want to disclose what we are for, but we are against government control, Democrats, government programs/spending, Obama, and Obamacare." Linking any and all together worked well. No one really listened to much of anything else apparently.

In the last few years, health care moved from backstage to center stage. This made the simple strategy even more effective.

Democrats had more than enough time to catch on. There were also any number of attack points that could have moved the debate in a different direction. But Democrats were divided from each other, from Democratic leaders, and from Democratic concepts.

The Democrats needed a major push to "take down" or appear to take down Wall Street, Banking, and other "perceived abusers". Going on the attack is preferable and is easier than defense, as Democrats found out. More and more defensive is a prelude to failure.

The Democrats were not willing to take on health insurance companies, Wall Street, or Banking. No one was adept enough to appear to take on these or others who have damaged America and Americans.   No Democrat could explain why Americans were being deprived a better piece of the pie, but the Republicans had many explanations. If you do not tell people how their lives will be improved, they will vote for someone else (or allow others to take control).

Multiple Democratic failures in health policies and in health appointments made matters worse. Americans began to feel more experimented upon with rapid change, more chaos, and less stability.

Many of the Democratic attempts had good intentions. Good intentions may or may not work out. Unfortunately they can also take quite some time. Many of the concepts that result in a more equitable nation are difficult to communicate well, and Democrats have failed most of all in communication.

Belief in Government Control plus belief in the inevitability of Wealthy Control plus voter suppression was a powerful combination.

Health care where needed faces similar challenges. Long slow steady improvements in economics, health, and education are difficult to sustain - but offer the best hope for a narrowing of divisions and overall progress as a nation.


Politifact Lie of the Year 2010 - Government Takeover

Rotten Apples, Rotten Support, or Rotten Media?

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

Rotten Apples, Rotten Support, or Rotten Media?

America's teachers reached the cover of Time Magazine recently, but not in a favorable light. The response of teachers is recorded:
  • America’s teachers are not rotten apples, as Time’s cover suggests, that need to be smashed by Silicon Valley millionaires with no experience in education…. Yes, there is a real problem facing America’s teaching profession, but it has nothing to do with tenure. The problem is in recruiting, retaining, and supporting our teachers, especially at the hardest to staff schools. Randi Weingarten American Federation of Teachers

The blame game has been most popular, but Rotten Apple branding is often a distraction from the real situations and relationships crippling education, the teacher-student relationship, and the learning of the child. 

The same basic defensive statement can be made regarding any number of basic serving professionals that are under fire, facing declining support, increasing responsibility, increasing complexity, more regulation, and declining appreciation:
  • America’s primary care clinicians are not rotten apples, and their essential services cannot be provided by hardware, software, integration, reorganization, or innovative payment change. The problem is in recruiting, retaining, and supporting our primary care clinicians, especially in the counties with lowest concentrations of clinicians where most Americans await care.
  • America’s nurses are not rotten apples. The problem is in recruiting, retaining, and supporting our nurses.
  • Continue with Public Health, Public Servants, Mental Health, and all on the front lines.

Outcomes in health, education, economics, and other societal components are about cumulative impacts beginning with child well-being and early education. The numerous life events that demonstrate support for a person, or lack thereof, help to shape individual and societal outcomes.

The real rotten apple goes to those who fail, as a nation, to provide the best possible first 8 years of life for a better child, student, employee, patient, and citizen – essential components of a better nation.

You cannot fix primary primary care providers and delivery, teaching and teachers, or nurses and nursing without fixing the student or patient and the various situations and relationships involved.

Note also that research studies about "quality" also fail to include sufficient controls for the numerous barriers facing 30 - 50% of Americans in education, health, and other societal outcomes. This results in too much blame placed on teachers, nurses, doctors, and others on the front lines - especially where they are most needed where there is least support and where patients, students, and citizens have been most left behind by national design.

In other words, when you see a difference in an innovation or reorganization, this is usually because a higher status better situation population was compared to another population just enough lower to matter statistically. Not surprisingly the aberrant methods used to measure, evaluate, and pay end up reducing support and revenue where care or education is most needed (Pay for Performance, Readmission Penalties, Teacher Pay Schemes)

It is interesting that nurses have unionized with the teachers union, and hospitalists have also turned to unionization when they felt that they were being marginalized along with their patients. 36 Local Doctors Decide to Unionize  More coalitions of front line infrastructure along with half of Americans left behind are a requirement for any real progress in a nation.

Links

This Cover Was a Sucker Punch to All Teachers

36 Local Doctors Decide to Unionize

Other Works

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair