Tuesday, October 21, 2014

What Health Insurance Corporations Do

When given a chance to operate the entire payment package, what do Health Insurance Companies (HICs) do? For the past 8 years HICs have been given the freedom to operate Medicare Advantage - the high prestige seniors plan from CMS.
  1. HICs helped design the complex payment formulas for MA
  2. HICs found a way to upcode higher patient complexity for MA patients
  3. HICs shoveled in the profits using the design that they helped to shape their way
The Center for Public Integrity indicated, "For instance, audits of six plans found that health plans couldn’t justify payments from the government for 40 percent or more of their patients. The resulting overpayments were pegged at nearly $650 million for 2007 alone — just for those six plans."

When is it "gaming the system" and when is the line crossed to fraud?

The inconsistencies in HIC, GAO, and CMS efforts span the range of health care delivery. There is a pattern to the result. Some payment formulas benefit those with many billions while other payment designs penalize those with far less - like small health operations. One side helps those in need and the other side helps themselves.

Insurance companies in their role as payers have a great track record - deny and delay payment to those who do provide services. Turn about should be fair play. Why does CMS not deny or delay payments to insurance companies overpaid for Medicare Advantage plans? Given the magnitude of the problem, why has CMS not suspended, reduced, or otherwise reformed the program?

Physicians get blamed for upcoming in wave after wave of media blitz, yet insurance companies do mega-upcoding worth 70 billion more in Medicare Advantage dollars and few hear about it?

Medicare Advantage Seniors are urban and are often better off with a wide range of health, eye, dental, and other benefits. Contrast this with Medicaid patients that get the most restricted care packages and often have to beg to get care and appointments?

And where are the priorities of GAO - the government watchdog. It makes me mad when GAO targets rural hospitals for a measly 500 million in savings, due to what GAO brands as "overpayment." But GAO has failed for 7 years to audit insurance companies making 12 billion a year too much

Investigations by the Center for Public Integrity, CMS, and now GAO



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.

Monday, October 20, 2014

Bipartisan Senators Raise Rural Health Concerns

This headline is amazing in numerous dimensions - Bipartisan, 33 Senators together, showing concern for rural health!

But why have these 33 Senators not done more. More importantly, why have 70 Senators from 35 states not stood up for health care in their states - states left behind by the US health care design.

The health care design developed over recent decades clearly favors 6 states. 
What have Senators in 30 - 35 states been doing all of this time?


The Senate may well hold the key to addressing needed health care reform. The reform that is needed is not about insurance reform or penalizing more providers for meaningless reasons. The reform that is needed is to redirect spending from few states, providers, and locations to many states, providers, and locations - all who are in greater need of care. 

Like it or not, the design of the Senate favors numbers of states, even when the states have low levels of population. Senators could do more for their states.

Health care and training design works great for 250 counties, 3400 zip codes, and about 6 states using geographic coding. These are the states, counties, and zip codes with higher to highest concentrations of physicians and health care services (and health spending and jobs and economics). 

Half of the economic impact of medical education or 250 billion goes to a few dozen counties in 6 states, according to the AAMC. Because training is concentrated in these few counties and states, physicians tend to concentrate in the same locations. Health spending follows workforce and workforce shapes health spending. Both are impacted by the design of health care. 

So much for so few leaves much less for so many. The health care designs for payment and for training fail for 30 – 35 states. This still translates to 60 – 70 votes in the Senate. Senators representing these states need to work to gain more health spending for their states. The decades of toleration of lower health spending should be coming to an end. Redistribution of spending and redistribution of workforce and redistribution of training is required for numerous reasons - especially Americans in states, counties, and zip codes left far behind. 

The current health care designs result in the least training in these states and the fewest physicians and other clinicians in these states. These are states more dependent upon primary care and basic services – services marginalized in payment by decades of designs. 

Why would the great majority of Senators allow their states to fall further behind 
in jobs, economic impact, and health care?

If 60 – 70 Senators stood up for their states, the design could be changed - or perhaps not. Congress already acted over a decade ago to shift graduate medical education positions. The intention was to redistribute GME positions to states in need, to primary care positions, and to rural training locations. Unfortunately the training institutions managed to thwart the will of Congress with failures on all three counts (Chen et al).  Medical education institutions demonstrated that they were more powerful Congress in this matter. The also have managed to self fund thousands of fellowship positions. They have increased subsubspecialty fellowship positions by 11% a year for the past 10 years and subspecialty fellowship positions by 4% (Jolly, Academic Medicine). This is clearly winner take all by designs of training, revenue, workforce, etc. And in addition the institutions have been lobbying for over a decade to increase the billions given to them via Medicare.

Senators need to be able to say that workforce is growing in their states - all kinds of workforce, all kinds of training, all kinds of health care jobs, all kinds of economic impacts. 

Changes in Payment Design

What do 35 states, 2600 counties, and 40,000 zip codes need to improve health care, health care spending, economics from health care, and numerous other benefits?

These are locations that depend more upon basic services - basic primary care, mental health, general surgical services, services most common to small hospitals. More for more services is best for more Americans in more places in need of care. 

The 35 states need their 70 Senators to understand that our national designers have been steadily underfunding the basic services most important to their states - with devastating consequences to small practices and small hospitals. The formulas have been flawed for three decades with more to come. The squeals of the few doing well have been heard while the consequences across the land continue.

Senators Are the Key to Recovery of Small Health Care and Care Where Needed 

Why is there such poor representation for 40% of Americans that continue to have health system failure in 2600 counties. These 2600 counties have lower tolowest concentrations of clinicians and least local health spending - by national design!

Congress loves Veterans, but 50% of Veterans reside in 2600 counties behind by design. Rural health is important with 75% of rural Americans found in these 2600 counties, but this is only 45 million Americans. The 80 million urban Americans in these counties are also behind. When 120 million are left behind, it is bad enough. But these are the counties that are growing the fastest and growing fastest in demand for primary care and basic services. These are the counties losing workforce and hospitals, 

Improving care is important for those found in 2600 counties with 50% of Veterans, 70% of rural Americans, 33% of urban Americans, 45% of the elderly/Medicare, 45% of the poor/Medicaid and working poor. The designs for payment and for training leave them behind by design.

How Can Senators Jump on the Bandwagon that Matters for Their State?

Senators who care about health care can start by supporting basic services and access. Veterans clearly have had failures in access. Years of access failure have been made worse by coverups. 

Coverups remain the major problem preventing recovery of access for rural Americans, the elderly, the poor, and people in 2600 counties in need of care. Decades of designs continue to concentrate health care elsewhere, leaving them behind.

Access recovery is the first step toward health care of any kind and the most important step toward quality care. Without access, it is no care by design.


Access deaths are not easily determined – like hospital errors or other direct impacts. But tens of thousands of deaths should be considered important.


The designs continue to kill off more small practices (45% of primary care), more emergency rooms (domino effect for more), and more small hospitals.

How many revenue streams have been closing off? How many small health entities are being penalized where care is needed, let me count the ways...

Failure in General Surgical Workforce is a Case in Point

General surgical workforce (GS, Gen OBGYN, Uro, Ortho...) is declining by 2 to 3 percentage points each year - by national designs for training and poor payment for basic services. Comparisons of the AMA Masterfile active physicians 2005 to 2013 reveal this sad fact. Also the physicians in the counties in need of workforce are nearest to retirement - counties that have the most rapid increases in need for basic surgical services. Senators should be crying out for care for seniors and others rapidly increasing - if for nothing else other than their votes. Where is the primary care that Veterans, seniors, and others need? The answer is that it has been forced into stagnation by payment design and training design. 

Top Concentrations of Workforce and Health Spending Work for Few and Fail for Many

The health care designers are concentrated in a few institutions, associations, corporations, and government positions. The focus of the designers can be seen by who wins and who loses under the design. The design prospers those in 1100 zip codes in 1% of the land area with 12% of Americans and 45% of physicians and top concentrations of clinicians of all types and top health spending it will be all lines of revenue with the top reimbursement by a design that they shaped. SGR works well for physicians who are concentrated and fails for physicians who are distributed where needed – and their states, counties, zip codes, and neighbors. (Physician Distribution By Concentration)

Graduate training design is the last and most important training influence with regard to future practice location over a career. GME training is a 20 – 40 times multiplier of instate practice location using data on all active physicians in the AMA Masterfile.

GME design so concentrated in so few states and locations fails for 30 states, for 40,000 zip codes, and for most Americans. The failure involves care needs that could have been provided by residents and faculty during training. The failure continues throughout the decades of the careers of the physicians trained. The failure has continued despite the action of Congress to attempt GME reform.

Senators who truly care about having care could stand up with their 60 - 70 votes for their 30 - 35 states in need. They should stop giving way to the 6 - 10 states that get the lion's share of the benefits and still find ways to grab even more.

Senators Need More Pages of Substantive Change, Fewer Signature Pages

The document sent to CMS by the 33 Senators contains 3 pagesof signatures and part of 1 page of concerns expressed. I would have been happier with 3 pages filled with the problems with only one page for signatures...

The 30 – 35 states, 2600 counties, and 40,000 zip codes in need of better care also depend upon better distributions of other funding outside of health care. These are also places where populations benefit from the equitable distribution of Social Security spending, nutrition spending (Food Stamps), child development, unemployment, and basic education. Sequestration and other across the board cuts have been painful to locations already behind. Disproportionate share spending cuts were a direct blow. These are also counties that used to get billions for payment in lieu of taxes since they cannot tax federal lands to take care of their schools, law enforcement, and other basic needs. Critical Access Hospital spending has also been targeted. 

Over and over again the programs that are targeted for cuts are the programs most important to most Americans and Americans most in need of such funding. The cuts for many would help the few to do better at the cost of the many – in jobs, economics, health care, education, and more.

Regardless of the outcome of elections, Senators must be responsible for their state needs – and responsive to the populations that still remain behind by health and other designs.  

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.

Sunday, October 19, 2014

Improving Health Care Is Not Likely for 2600 Counties

Commonwealth indicated six areas where the US is behind compared to the United Kingdom.  Actually fixing health care requires fixing far more than health care or distributions of health care. The truth is that nations have better or worse health care due to distributions of income, economics, education, and other factors that shape health, health care, and health care outcomes.

It is often not possible to fix health care woes by health care focus.

For the United States to actually improve in health, the substantial populations of Americans that are behind would have to be addressed. What happens to 40% of Americans in 2600 counties with lowest concentrations of clinicians is paramount to recovery of health care. If the US does not address situations in 2600 counties, it will not improve American health care.

United States Health Spending Excesses

Direct attempts to cut health spending have typically resulted in across the board cuts in spending with small health care and rural health care most impacted – as well as 2600 counties in need of health care that are most dependent upon small health, primary care, and basic services. Lowest payment for these areas shapes decline by design.

Redistribution of excess spending has not progressed - those who spend so much have been too powerful and there are many advocacy groups that resist spending cuts for "their kind" of patients.

Unfortunately basic services have no advocates. Further cuts are likely and are likely to damage health, economics, and more in 2600 counties behind by design.

Delays in Access

In areas with higher concentrations of clinicians, utilization is multiple times higher. Patients with higher income, better paying health plans, and numerous health concerns dominate overuse. Meanwhile locations with lower concentrations of physicians have serious problems accessing care.

While Commonwealth states that access to specialists may be better in America, this is not the case in 2600 counties where specialists are few and where even fewer are found with each passing year.

The for-profit design of US care has guided too much workforce where clinicians are concentrated and less workforce where clinicians are needed.

Delays will worsen for a number of reasons. Populations are growing fastest in 2600 counties as are numbers of elderly and highest health care demand patients. More demand plus stagnant or declining supply means delays in access.

Patients Go Without Care Due to Cost

High deductible insurance is more likely where care is needed. Populations still in need of insurance or income or both are more likely to be found where care is needed. Costs of care can be higher where care is needed – where patients must transport farther with more disruptions to lives or jobs.

Too Many Emergency Room Visits

Fewer providers, hospital and ER closures, health literacy issues, deficits of primary care, lack of convenience/urgent/retail care all lead to more ER visits. Counties in most need of workforce share all these and more.

Preventable Death Rates Too High

The 2600 Counties have higher to highest preventable death rates. Once again this is about many factors such as poor access, deficits of primary care, risky occupations, more travel, poor roads, low health literacy, higher obesity, higher diabetes, and more. Simple changes in health care are not going to change the many factors that result in this problem. The 2600 counties also have higher rates of preventable hospitalization and higher readmission levels - shaped by these same situations and determinants. Penalty formulas cannot discriminate between poor care and care of poor people - thus penalties will make matters worse where care is needed. 

Higher Infant Death Rates

Infant mortality has long been understood as a measure of success or failure as a society. Societal issues, poverty, income divisions, psychosocial situations, housing, various environments, relationships, poor support, and situations facing the children who become mothers.

None of these areas can be fixed by a direct attempt to cut costs, graduate more clinicians, reform insurance, or regulate patients or providers.

A War on Poverty is the closest approach to improving these areas. The US has been heading in the opposite direction since 1980 in a number of areas, especially in health care.

Reversing decades of payment failure and health professional training failure will take much more and in many areas that impact health directly or indirectly.

Wednesday, October 1, 2014

October to December Disarray - Behavioral Health, Insurance, 2015 Redesign

Frontliners hang in there! It is indeed a tough time for 40% of Americans and those who attempt to care for them. Further deteriorations in access mean difficult times for primary care, emergency rooms, mental health facilities, and urgent cares. The end of this year brings new changes.

In the Arizona media there has been discussion about increasing behavioral health presentations to hospitals. I spared the link due to the usual excessive advertising. But after all, this is only the tip of the iceberg.

The Report from Arizona East Valley ERs and Urgent Cares

Mental health issues are being multiplied at the current time. Even though there is the potential for more care, the factors driving increases in mental health problems are up, access appears up (insurance) but is in decline (workforce changes), and there is even less ability to "fix" the problems. 
  • The country appears in an unsettling disarray with enemies foreign and domestic, 
  • The US has designed worsening economics where most people live - the cumulative impacts of state and federal cuts impacting much of the nation's population (economics, jobs, well being)
  • 90% of Americans are not benefiting from increases in wealth
  • Jobs have little change of advancement
  • Situations for children and their children are not improving
  • Family members are less able to support those with financial or mental health problems. They have depleted finances and increased exhaustion.
  • The usual political tear down has become even nastier close to voting time
  • Social media doom and gloom
  • New and expanded wars
  • A new TV season with major violence a theme
  • Declining public confidence in politicians, courts, police, sports - especially NFL issues, 
  • Those bringing their kids to the ERs and urgent cares for alleged abuses are up (wonder where they got the idea to bring kids in spanked with belts leaving bruises?), 
  • Doctors offices are shedding the more complex patients (not saying no but saying later, which means no), others are not signing up patients, cherry picking - a natural result of cuts in revenue and delays/denials plus increased costs of care
  • Breakdowns of primary care specific to small health care - 45% of primary care, increasing realization that some changes are required (concierge, direct primary care, employed work)
  • Changes of insurance with more restrictions on care
  • Disrupted continuity 
  • Family deterioration (Maricopa County adds to grandparents as parents category of families)
  • Overwhelmed mental health resources
  • Epidemics of STDs and not enough public health
  • People being refused care at various sites (just because you say you are primary care or urgent care doesn't mean you actually accept patients and take care)
  • Feelings of people controlling the political process with little say in the matter - more revelations about financial corruption, difficulty trusting public officials, and 
  • In the next week even more disorder due to hydrocodone going to schedule II with the least preparation of patients and providers for such changes.
It is hard to clear behavioral health as it just recycles and spreads without being addressed. This results in multiple visits to places who are unable to address behavioral health, and more side effects.
  • Plus high deductible insurance helps convince people to avoid the ER to go to urgent care (that can turn them down until they find someone who will care for them or has to care for them, worsening their situation). 
  • And continued strep, nasty viral sore throat, persistent fever virus, increasing drug dependency visits, continued epidemic norovirus, intriguing viral rashes, large area reactions from mosquito bites and/or cellulitis, and 
  • the beginning of the ebola scares… (The media will have a field day). Soon a number of patients with major fever will want ebola testing, especially after the ebola patient in Dallas was sent home for a few days.
  • Then a coming attraction is flu
Most of the above are specific to ER and urgent care. Primary care is dealing with insurance changes, cuts from insurance plans, changes in fees and coding, the usual delays, no increases in payment by federal design, threats of cuts, higher costs of delivery, increasing dissatisfaction from ever higher expectations, and patients ever more confused and forced into more changes.

For emphasis - There are three times as many urgent cares in the east valley in the past 2 years plus increases in retail care. Despite this, they all appear to have stable to increasing volume. More urgent cares and high tech designs are on the way.


Wednesday, September 24, 2014

About GME - Insider Trading Is More than Just Wall Street

Insiders dominate the designs of health spending and the designs of health professional training. Not surprisingly these insiders shape workforce, services, and spending to just a few states and a few locations.

Resident training is even more stacked against care where needed. The determination of practice location is about origin influences, training influences, and specialty choice. Origins, training, and specialty influences are moving away from states in need, away from primary care, and away from care where needed locally.

Top Concentration States - Physician and GME - About 6 states receive 50% of the economic impact of US medical education which is 500 billion a year according to AAMC. Actually insider stacking is even more prevalent as only a few dozen counties receive this impact. Origin and training location facilitate concentrations of clinicians in a few states and in a few locations.

Top Concentration Zip Codes or Super Centers - About 55 - 60% of residents are trained in Super Center zip codes with 200 or more physicians or 1100 zip codes in 1% of the land area with only about 12% of pop, 45% of the physicians, and well over 50% of health spending - This may be the only practice location shaping experience of allopathic private graduates, graduates of exclusive/research/MCAT schools, and international graduates - which is why these cohorts have lowest distribution       Physician Distribution By Concentration

Major Centers are the sites of training for about 25% - 30% of residents. They are trained in zip codes with 75 - 199 physicians (Major Centers) in about 2.5% of the land area - this is a midrange between Super Centers and Outside

Together about 72% of physicians are found in about 3.5% of the land area in 3400 zip codes inside of super center and major center concentrations - leaving only about one-quarter of physicians remaining for care outside of concentrations. The highest concentrations of 82% of graduates inside of concentrations are seen in allo private, most exclusive US school grads, and international graduate cohorts. The best distribution at 50% inside and outside is seen in medical schools with 20 - 35% FM choice. This is also the result of family medicine choice as well as origins and training more normal with regard to state and location.

Experiential Place or Past Life Influences Help Explain Concentration and Distribution

Exclusive in origin and training and specialty results in concentration with poor distribution. More normal distributes.

Normal Origin and Training Facilitates More Normal in Distribution

Sadly less than 15% of residents are trained in 40,000 zip codes outside of concentrations of physicians. Outside zip codes have 68% of the population including higher proportions of the elderly as well as all who are increasing in population and in care demand. With declines in physician concentrations the health spending goes down, the complexity goes up, and the non-family practice workforce melts away.

The Family Medicine Multiplier

Family medicine is a three times multiplier of "outside" zip code practice location controlling for origin and training influences. FM multiplies needed result across medical schools and across types of locations outside of concentrations of physicians. All other specialties result in further concentration where physicians are already concentrated.

Generic expansions of graduates without FM predominating are only going to facilitate more concentration - especially with 11% annual increases in subsubspecialty fellowships and 4% annual increases in subspecialty fellowships (Jolly, Acad Med, 2001 - 2011) 

Expansions outside of FM allow more opportunities to escape FM or primary care. This is the opposite of the 1990s when massive declines in choice of hospital based residencies took FM over 3600 annual grads for a brief time. Specific is indicated - not generic.


Until there is an end to aberrant payment design and...
Until there is an end to all out assault upon core specialty result from training, there will not be care where most Americans need care. 

Insiders Dominate Inside with Highest Specialization, Academization, Centralization, and Concentration. 

More normal core specialties dominate care outside of concentrations - FM, primary care IM, primary care PD, general surgical specialties. All are stagnant or in decline by designs for training and payment. 

Designs for inside, shaped by insiders, fail for most Americans, fail for primary care where needed, and fail for most family physicians who are outside.

Nurse practitioners and physician assistants are also concentrated in the same zip codes and counties as physicians and physician specialists. Only the family practice result from NP or PA distributes above NP or PA averages - or reaches the 2 to 3 times multiplier of FM. This FP result continues to decline with each passing class year and year after graduation for NP and PA down to 25% and below.

Once you know how payment design fails for primary care and for distribution for all types of clinicians, you can understand how generic expansions continue to facilitate even more non-primary care and even greater concentrations of clinicians.

Insider trading and focus is found beyond Wall Street.

As Commonwealth recently speculated, the designs for health care may indeed shape America in ways not best for most Americans.

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.