Thursday, April 23, 2015

More Confirmation of Small Health Value and Small Health Neglect

No small part of America is impacted by designs and information sources that disadvantage small hospitals and small practices. In turn, this continues to disadvantage and damage the people that depend upon small health care.

Over six months ago this first small health review indicated substantial problems. More evidence has been added regarding the value of small health and further neglect of same.

Studies have indicated improved outcomes for small practices and a new one from BMJ demonstrates the same for low volume hospitals. 

The chief actuary for CMS has indicated that increases in the cost of delivering care are too much compared to stagnant payment. Remember that primary care and small practices are paid less and have more difficulty making all of the regulation adjustments.

The Paucity of Awareness Continues

Paucity used to be a favorite AAMC word. Sadly it is our health leaders that often have deficits of awareness. The impact of lack of awareness continues to damage and destroy.

At a recent panel discussion to discuss the great benefits of ACA:

"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt (acting administrator for CMS).  

This appears to be good awareness, unfortunately CMS has done much to destroy capacity in primary care, specifically to the rural and targeted urban areas of need. 

Learned panelists continue to make the mistake that access is about insurance - when access is really about available and accessible workforce. Payment too low for decades has shaped poor access, and payment too low continues by design along with higher cost of delivery.

Small Practices 

  • Are perceived as impacting relatively few, but small practices of 5 or fewer physicians include 45% of primary care in America - essential for 40 - 50% of Americans in basic health needs. This is about 25% of encounters.
  • Are most commonly basic health need areas include mental health, basic surgical services, primary care, and dental health. If an area is in decline, it is generally associated with small health.
  • Receive few lines of revenue, have few basic services, are often paid less for the same service as compared to larger or outpatient settings
  • Can have higher costs of supplies and other costs of delivering care
  • Can have the highest special cost increases such as recruitment, retention, and locums costs because of shortages of various health personnel at small practice sites - shortages due to designs of payment and training
  • Are hurt by rapid change - rapidly increasing costs of regulation, certification, software, revisions
  • Have higher complexities of patients and often deal with gaps in local social and health resources plus other factors that shape lesser outcomes rather than providers
  • Can receive more penalties for care outcomes - outcomes that they often do not shape. This makes situations worse where care is needed
  • In the media and in the literature are often painted in a negative way and small health themes include rural, small, lower in volume, and generalist vs specialist controversies 
  • Articles in the media/literature often ignore small practice differences in many areas that shape outcomes such as patient populations and resources, assets and barriers - poor awareness contributes to misunderstanding 
  • Small health is an easy target for political and health designers bent on cost cutting. Small health is small, distant, poorly organized, and  attacked from so many directions such that defense is difficult
  • Small health can lose out on federal funding because bigger entities are more organized. Sometimes funding (CHC funding) must be protected for the use of small or rural practices to keep from further inequitable distribution.

Small Hospitals

  • Include emergent or acute hospital services for 40% of the US population including nearly all rural hospitals and many single county urban hospitals
  • Have few lines of revenue, paid less, may have higher costs, not able to demand discounts from suppliers
  • Can suffer from higher costs in the same supplies needed for health care deliver and other costs can be higher including recruitment, retention, locums
  • Have rapidly increasing costs of regulation, certification, software, software revision
  • Are more dependent upon low pay (Medicare, Medicaid, lesser insurance, high deductible), and no pay (indigent)
  • Face declines in revenue due to declines in disproportionate share funding, limitations in Medicaid expansion, economic and other declines in the counties specific to small hospitals
  • Are in counties where population growth is higher 
  • Are in counties where complex populations are increasing faster (elderly), are higher in complexity, tend to have lesser outcomes
  • Are in counties with populations likely to result in readmission penalties for the hospital, based on care of patients oldest, poorest, least in health literacy, and with higher smoking, obesity, sedentary rates, attitudes and behaviors not conducive to best health outcomes   
  • Face media and academic articles predominantly negative, usually from authors not familiar with small health, and often compared to Big Hospitals with multiple more streams of revenue, higher reimbursements, different patient populations, different personnel, different relationships, and other differences - differences that should prevent publication or require as much explanation as the length of the article itself
  • Are an easy target for political or health care cuts
Is there any purpose for trashing small health other than closing small health?

Such attempts at closure are misguided, because small health is all that exists for much of America - suffering under Big Health design.

Small health is not the reason for cost overruns, and in many ways represents higher value with same outcomes for less cost and fewer visits. 

Health Professional Training Design Contributes to Inequities

Health professional training is concentrated in a few states where big health dominates and the focus is highly specialized career for MD, DO, NP, and PA. The design of health professional training is the opposite from the requirements of a small health workforce - a workforce that requires training distributed equitably among states (not stacked in 6), emphasis on primary care and basic specialists that remain in core specialties, and training in small health locations.

The Triple Aim of Health Access is
  • Instate in states of need, 
  • permanent to primary care for a career, and 
  • training influences specific to small health locations 
This is what is required for recovery of basic health access and primary care. 

Rural and urban locations in need of clinicians are Small Health Care in America 
  • Areas in need of services, jobs, economics; 
  • Areas with lesser social determinants involving income, jobs, economics; populations subject to previous exploitation, outside land ownership, public lands that yield no tax revenues; 
  • Populations distant, different, less organized, and with less political clout; 
  • Locations disadvantaged by a number of government designs involving spending, making recovery even more difficult

Populations More Likely to Be Served By Small Health America

  • Small health is more likely for those in need of lower costs of living and lower costs of health care
  • Elderly, Medicare, Medicaid, Veterans, working poor, and less educated populations as well as others on fixed income or subject to lower income are about 43 - 50% found in areas of Small Health dominance where 40% of the Nation's Population can be found in 2621 counties with lowest concentrations of clinicians
  • Population growth in lowest concentration counties still remains 1% per year where Small Health is found- twice the rest of the nation. The rate of population growth in the 2621 lowest concentration counties has been three times greater as compared to the 79 counties with top physician concentrations each decade over the past three decades - a key reason for health care costs too high is health provided where costs in the US are highest - and are least accessible.
  • The populations increasing the most such as the elderly are also increasing most in demand for primary care and basic services. These services are supplied by the workforce facing the greatest challenges, especially where care is needed.
  • Increasing demand is specific to small health.
  • Stagnant/decreasing workforce production is specific to workforce needed by small health care
Rapid growth in demand for multiple reasons and failure to provide the specialties needed or the payment support needed - is failure by design.

  • Small health location for a patient is the result of previous small health location or movement to a small health locations because of inability to live where Big Health dominates.

    Big health care is associated with big cost of living, higher property values, better financed schools or private schools, higher levels of college educated and professionals, and services that are more specialized across the gamut from health to home repair. Movement toward small health location is inevitable when lives reach a point where income no longer increases.

Big Health Physician Origins Are Increasing with Declines in Smaller Origins

Based on birth origins of the most recent decades of physicians, children raised "big" immersed in highest concentrations are 2 to 8 times more likely to become physicians and as physicians they are least likely to choose small practices or careers such as family medicine, primary care, or core specialties - specialties that are most needed by small health care. . 

About 23 - 27% of US born physicians were born in 79 top concentration counties where 12% of the population was found (2 to 1 ratio) as compared to lowest concentration origins that are 1 to 2 or about 19% arising from 38% of the population.

Big Concentration children have been even more likely to gain higher education and medical school admission in the past decade - and also can bypass US schools for Caribbean and international medical schools. Big Concentration children from other nations not surprisingly also concentrate where care is already concentrated

International medical school graduates from other countries are 82% found in 3400 zip codes with 75 or more physicians, leaving 18% for 40,000 zip codes where 68% of the US population is found - including even higher proportions of those needing more care (elderly, veterans). Only the most elite children from the most elite schools (allopathic private, top 20 MCAT schools, top research schools) reach 82% concentrated in higher concentrations. Only the schools with normal distributions of origins and schools with top family medicine proportions of graduates reach population based distribution or about 40% found where the 40% of the population in need is found.

Exclusive concentrated origins are further complicated by Big Health designs for training - a design that shapes physicians to locate in just a few states and among higher concentrations of physicians. This is rewarded by payment design that pays more for the services most commonly seen in Big Health ventures. Primary care and basic services are least important for Big Health and are most important for Small Health.

Population Based Spending Is More Important (State or Federal Government) 

Basic health, basic education, child development, basic nutrition, and other basics are more important for the places associated with Small Health.
  • Small health sites are associated with populations more dependent upon population based spending - spending distributed according to the population.
  • Many sources of spending, especially health spending, are concentrated in few locations
  • Child development, basic early education, basic nutrition, basic services and primary care, basic social services, and small health are more likely to be population based
Small health is more dependent upon retention of local market share - as more people go outside of local for shopping, primary care, or hospital care the local market share decreases. As people transport outside for health, they also shop outside. Since few are thinking about those small and in need, it is more important for small health and other small entities to work toward their own benefit.The Center for Rural Health Works is consistently working to help local small health to become better.

The Good, the Bad, and the Ugly involving National Designs for Dollar Distributions (millions) and Population Distributions (millions)

The basics often have population based distribution with regard to lowest concentration populations as demonstrated by ratios of population or spending relative to the 40% found in 2621 lowest concentration counties. With more specialized services or care comes greater concentration as is best seen in the 79 counties with 10% of the population and highest concentrations of physicians.

Numerous past, present, and potential future political plans include cuts 
in population based spending and other distributions. 

Counties with higher concentrations have advantages in health spending, more lines of revenue, more and highly specialized services as well as top jobs and education, Government spending of all types is centralized in such counties. Government cutbacks from the 1980s to the present typically involve jobs and services in outlying counties with lower to lowest concentrations. Setbacks in the economy may lag in impact for a short time, but small areas take more time to recover after setbacks.

Insurance coverage works well for higher concentrations, but less well for lower and lowest concentrations. Even with insurance reforms, small health locations still have barriers to care and barriers to the spending needed to expand care.

Lower and lowest concentration county populations also tend to have lesser insurance and high deductible plans. Poor competition between insurance companies translates to lesser value - higher cost of premium and less benefit. Populations already behind pay more of their income for health insurance coverage and get less value for their investment. A nation that has 30% waste of health care spending makes matters even worse for those already behind that have to spend relatively more.

General surgery as demonstrated in the table is the best distributed of the physician specialties (compared to 0.9 ratio for family medicine), but general surgery is still poorly distributed, is shrinking nationwide, and is shrinking even faster at 2 - 3 percentage points a year where care is most needed. Other general surgical specialties are shrinking at 2% per year where care is needed.

Two to three times as many graduates are needed to get 1 to distribute to 2621 counties with lowest concentrations. A design that requires too many specialists is insanity for care where needed result. Other specialties beyond family medicine and general surgery are generally 0.35 to 0.55 distributed in a population based fashion when it comes to lowest concentration counties. Nurse practitioners and physician assistants that are active clinicians are 0.62 distributed where most needed. Producing more of any specialty other than permanent family practice increases concentrations of MD, DO, NP, and PA clinicians.

Health spending that is population based is needed to support the broadest generalists and general specialties for small health. In fact, without more spending, there is no solution for small health as there will not be more workforce and more services where demand is increasing most.

Health spending designs
  • Concentrate spending where the most specialized are found
  • Concentrate MD, DO, NP, and PA where clinicians are concentrated
  • Pay less for primary care and basic services and care where needed
  • Convert MD, DO, NP, and PA to non-primary care specialties with losses of basic specialties and core specialties
  • Facilitate 11% growth of physician sub subspecialty positions and 4% growth of subspecialty fellowships for incredibly rapid growth of most specialized physicians at the cost of core specialties, basic services, and primary care (Jolly, Academic Medicine)
Big Health payment and training designs make it difficult to find and support the workforce needed for small health and in small health locations.

New Population Based Study in Annals of Family Medicine demonstrates 3 times greater disparity in hospitalization for those lowest in income compared to those highest. "In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care–sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor."

Open Season Upon Small Health Care

Continue on to Open Season on Small Health By Big Media

Reference Links

Recent Works

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

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

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

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, April 20, 2015

Heroes for a Few or For Tens of Millions

We no longer tolerate discrimination in research design. We still tolerate discrimination in the designs of payment and training.

Almost any day in the New York Times there is some death of someone's hero. A recent health care death stimulated some comment. A cardiologist who was one of few to expose the Tuskegee syphilis experiment died recently. For the past 65 years it has been a struggle to expose and address discrimination against vulnerable populations and other abuses of human subject research experimentation. Hundreds and sometimes thousands have died in each episode. Actually we are still only aware of the tip of the iceberg as prisoners, nursing students, medical students, people in other nations, and many others were subjected to abuses.

It can be difficult to find critique in health care where my way or the highway is far too common. Critique is too often missing when it comes to damage or death to vulnerable populations. Health systems fail, states fail, and federal designs fail with regard to the services, workforce, and support needed.

While we have improved in some areas involving small numbers in horrendous ways, we fail in being critical about the following...

Pay for performance and readmission penalties and a long line of payment designs continue to pay less where pay is already least and often is most complex.

Lesser pay (stagnant pay plus cuts) continues while regulation requires higher cost of delivery. This has long been a formula for disaster for small practices, small hospitals, primary care, and geriatrics due to higher complexity. Outside sources of funding to prop up these areas are drying up.

The design of GME fails to address inequities. About 55% of training in found in 1% of the land area with 10% of the US people. About 50% of medical education economic impact concentrates in a few dozen zip codes in just six states. Workforce remains concentrated in a few locations due to GME design as graduates tend to locate nearby or in locations similar to training. GME failure continues for primary care, basic services, mental health, and care for the elderly although some of the failure is shared payment failure. Payment failure can also be associated with academics.

COGME recommends specialties that GME cannot produce. More in general surgical specialties cannot result in more in general specialties because too few (and getting fewer) remain after graduation from first residency. More in internal medicine fails totally for primary care or for geriatrics. More in pediatrics has resulted in no increase in primary care pediatrics. Geriatric training fails to actually distribute geriatricians to the locations where the elderly in need of care are concentrated.

The current GME expansions of fellowship positions continue at 4% annually for subspecialty and 11% for subsubspecialty each year and this has continued for over a decade (Jolly AAMC) and likely over 15 years. Despite this continued expansion, institutions and associations scream for more Medicare money.

Teaching Community Health Centers are also too dilute by design with only a small portion with training specific to specialty (FM) and county of need and state of need.

The 4th Year of GME for FM is a worst possible result for vulnerable populations at the current time. This would require a change to fewer FM GME positions per class year shrinking FM production and FM workforce 12 - 20%.

New medical schools often promise greater primary care but their choice of sponsors, students, curricula, location, and other factors say otherwise. Any school not committed to 100% family medicine result will not achieve the optimal primary care and distribution required for a true health access focus. No medical school can control graduates driven away from primary care by primary care payment design (expansions of older schools fail too). An entire FM school beginning in locations of need in local high schools and continuing through 6 years of obligation also serving where needed is most specific to health access and most resistant to failure due to payment and training designs.

NP and PA are considered to be solutions for primary care but this also is not possible due to insufficient primary care payment and lack of support. Only the NP and PA family practice position result can address care where needed but this is the result that continues to shrink due to payment design plus the great flexibility of NP and PA training. Only the family practice result from MD, DO, NP, and PA is population based and equitable in distribution. The designs for all health professionals are too flexible and are not specific to the one outcome most important for health access.

Resident work hours restrictions seemed to be a good idea but have resulted in higher costs to run teaching hospitals with no gain in quality. There have been deteriorations in the training of residents such that longer training and even higher cost may be needed. There was also the national loss of 30,000 NP and PA plus hospitalists hired to fill this gap left by the the residency work hours restrictions. This has resulted in diversions away from primary care and an even greater concentration of NP, PA, and physician workforce.

Family medicine training continues in the wrong places with the wrong faculty and curricula to address the needs of family physicians, especially in the future. Being somewhat better about training location is not the same as optimal. There is also the GME failure to understand that primary care training is mostly about the decade after graduation because graduates have the specific context needed to learn best - the specific team, patient, community, and local relationships for optimal learning in the multiple dimensions required for health access.

Millions of dollars have been expended via FM Marketing focus from Keystone to Primary Care is Primary. This most important capital has not been focused upon top priority areas such as higher pay or more family physicians or a training design specific to 100% family medicine. Marketing is not needed for most family physicians who do not suffer from lack of marketing. Most family physicians are in locations where marketing is no help. These family physicians need student and resident support, colleagues, replacements, better payments, and a respite from constant change so that they can remain on the front lines.

Accelerating the exit of front line physicians is another serious consequence of the current chaos due to rapid change - the result of current designers and their innovative designs.

These represent discrimination 
as the consequences continue to impact tens of millions 
in health, economics, social determinants, and more. 

Also we remain distracted from real solutions, making matters worse.

It took 50 years to develop human research subject protections such as those for vulnerable populations. We cannot even get populations abused by current payment designs to be aware of how they are being abused such that they can organize and address the abuse.

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

And those who think that they are representing equality and equity, yet are not, are seriously contributing to the substantial and growing problems.

Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

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...

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

Saturday, April 18, 2015

A Bridge Too Far to Cross the Quality Chasm

Pursuit of quality is an ultimate good thing in health care, right? But what if the current pursuit of quality decreases the financial viability of the practices and hospitals that are on the front lines of health access? Where care is threatened, populations are more complex

Should Providers Be Held Accountable For Situations Beyond Their Control:
  • Health Literacy Barriers
  • Selection Bias Due to Geographic Location, Transportation, Age...
  • High Acuity from Presenting Too Late for Care
  • Community Resource Deficits (lack of local, state, federal investment)
  • Lesser Social Determinants
  • Numerous Dimensions of Patient Complexities Across Situations and Relationships
Accountability continues to creep up on cost cutting as a top CMS priority. CMS needs to pay attention to research findings as summarized by the government - important research demonstrating the ways that patient outcomes are limited by patient factors. 

The following comes from the Agency for Healthcare Research and Quality AHRQ - the research arm of HHS. This is titled,  “Why Should Practices Implement Health Literacy Universal Precautions?”
  • "Experts recommend assuming that everyone may have difficulty understanding and creating an environment where all patients can thrive. Only 12 percent of U.S. adults have the health literacy skills needed to manage the demands of our complex health care system, and even these individuals' ability to absorb and use health information can be compromised by stress or illness. Like with blood safety, universal precautions should be taken to address health literacy because we can't know which patients are challenged by health care information and tasks at any given time."
To repeat: 
"...Because we can't know which patients are challenged 
by health care information and tasks at any given time." 

Only 12% of adults (adults not elderly) who are health literate enough is just the tip of the iceberg. We know that older and oldest adults are less health literate. We know that they are concentrated together where social determinants and patient situations are more challenging, where health literacy is less, and where more barriers to care exist. 

Concentrations of the Complicated

There is not a level playing field when it comes to the most complex and complicated populations. Those that inherently because of who they are and because of their past decades of life influences have the lowest outcomes are concentrated together.

In the new wave of innovation, this translates to even lower pay for those geographically associated with complex populations or the providers that remain to be chosen by such populations or those selected out by insurance or other payers. Movements toward narrow networks and other fragmentations can make matters worse. In each case, the divisions shape the advantaged and best paid and best covered one direction and those less to least in the other along with their providers.

Policies, pay, regulations, training, access issues, and complexities all align to shape

A Bridge Too Far to Cross the Quality Chasm 

For decades the designers have been creating an access chasm. This Access Chasm has not been addressed and may be worsened by efforts to Cross the Quality Chasm - particularly when cost cutting is an even higher priority compared to quality.

The very foundation of the Bridge to Cross the Access Chasm is being eroded by efforts to Cross the Quality Chasm. There is also an increasing awareness that unless patients and their situations are changed, the Quality Chasm will not be crossed.

It has not helped that the innovators innovate based on their awareness of populations that have care, while the United States still has tens of millions with low or no access and little or no health information. Where we know the most involves the most specialized conditions and facilities while we know the least about populations, basic conditions, and resources where care is needed.

 When access is worsened:
States and counties short of workforce combine low pay, rapidly increasing costs of delivery, higher complexity of patient, and least support. Forty per cent of the US Population is found in 2621 counties lower to lowest in physician concentrations along with lowest health spending, health workforce, and health access:
  • Medicare and Medicaid populations are higher proportions along with those with low insurance coverage (such as high deductible). This is a reason for insufficient pay and insufficient providers. The decades of insufficient payment design have acted to help create health care problems.
  • Obesity, smoking, poor activity, fair to poor health, premature death, and other characteristics associated with poor health outcomes are more common (data from U of Wisconsin County Rankings).
  • Lesser political and social organization
  • Lesser resources for health care
Studies of readmission penalties and pay for performance document the problems created for providers where care is needed – where patients are more complex, less health literate, and have more diseases, conditions, and situations that limit care outcomes. Instead of reflective consideration of the consequences, there is acceleration of change.

A Bridge Too Far to Cross the Quality Chasm

Apparently CMS cannot see the problems it is creating by its implementations of "accountability focus" far beyond the ability to be accountable. Lack of awareness remains a problem for government, foundation, and association leaders. Paying less to providers who care for patients in most need of care represents a substantial problem. Failure of care where needed would seem to be the opposite of any true design for health reform.

Elderly populations are among the least health literate, receive the most care, need explanations the most, and yet have primary care supported at lowest levels. Numerous factors coincide in ways that make payment for performance impossible. 

CMS designs are holding practices and hospitals responsible 
for areas that are difficult or impossible to address.

Applications To Workforce and To Quality
With reasonable awareness, one can understand how rural hospitals, primary care workforce, and geriatric workforce are threatened.

High Complexity + Low Pay + High Delivery Cost + Low Resources = Failure By Design
Restricted to the most complex and time consuming patients with multiple overlapping health and other problems plus low pay by design translates to little or no expansion of workforce. 
  • Geriatrics remains tied dependently upon other institutions or training. Without the contributions of those associated with training (pharmacy, faculty, teaching hospitals) Not surprisingly the distributions of geriatricians fail for the purpose of geriatric care. Where elderly are concentrated, they are more complex and have less support. This is the domain of family medicine, the only specialty that has population based distribution to serve all of the various populations more complex and lower paid.
Family medicine has also had little or no expansion due to high complexity, lower pay, and a distribution pattern quite the opposite from the choices of medical students born, raised, and trained in top concentration settings. Family medicine delivers substantial care for the elderly and poor as well as others limited in finances, education, and local resources. 

Family medicine is the physician specialty most associated with care where needed – at 2 to 4 times other specialties. The graduates of state medical schools in Kansas and in Nebraska that choose family medicine are 16 to 22 times more likely to be found in a county with lowest concentrations of physicians in Kansas or in Nebraska. 

Family medicine has long managed higher volume despite a mix of the most complex populations with the least resources. This has been an expectation turned reality for general practice long before family medicine. This is a formula for practice viability for frontline health access across private practices, rural health clinics, FQHCs, and community health centers. It is also a reason why family physicians are the top choice of these front line access sites. 

The new focus on "higher quality" may not accomplish higher quality for many reasons, but the attempts can limit volume and health access and payment and support and more.

Interestingly there are studies that demonstrate that small practices are associated with improved quality with regard to preventable admissions. This was not specific to family medicine, but family medicine is most specific to small practices. Decades of working with the same people in the same practice with the same team and community may have advantages.

Family physicians have developed expertise in working with people. This is not necessarily about training because family physicians stay in their practices long term. With 3000 - 4500 encounters a year specific to health care team, patient, family, and community resources - substantial learning is possible most relevant to care including care of the most complex. 

Why would anyone think that they could determine or define quality 
far away and separated from where quality needs to occur?

Many aspects of the innovative designs are in the opposite direction from the needs of people in need of care and especially those who deliver care to them.

What nation would design the most obstacles for the small practices, the small hospitals, and the family medicine specialty at the heart of care where needed – rural, small urban, underserved, lowest clinician concentration counties – however you want to define need for 20% to 40% of the United States population.

One reflection to consider: How is it that the United States has consistently developed designs for the past 50 years that pay more for the care of advantaged populations and that pay less for care where needed?

The method of payment may be changing, but this one truth of payment continues.

In the only developed nation without universal coverage, it appears that the inevitable result is persistent divisions created by health care design.

Coming Soon: Is It Possible to Measure Quality When People Just Want Basic Care?
  • Does volume cause a problem when more patients can be seen when and where they want to be seen?
  • Does quality matter when taking more time to input more information can inhibit the when and where of care? 
  • Does the recent designer preoccupation with innovation really matter when it comes to sore throat, cough, skin conditions, red eye, ear pain, urinary complaints, basic care for chronic disease, and numerous aches, pains, or injuries?
One Caution About Health Literacy

It is entirely possible to attempt to assess health literacy and create a barrier to care. This is a sensitive area and cookie cutter approaches can backfire. When you ask patients about sensitive areas, care is needed and experience with care. As with all that we do, it is important to adapt to patient and situation. Those experienced in primary care must apply this every day. Those not experienced or aware can design more barriers in ways that they do not understand.

Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

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...

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, April 17, 2015

The History of Good Deal Bad Deal Payment Designs

The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent.

Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially for primary care and all physicians paid on the lower end of the payment scale.
  • Good Deal Start Bad Deal End Number 1  was the original Medicare and Medicaid falling behind in about a decade
  • Good Deal Start Bad Deal End Number 2 - 1990s "reforms" - falling behind in about 5 years
  • Good Deal Start Bad Deal End Number 3 - MACRA - few if any years ahead (but better than a 21% cut?)
The AMA actually rented out the auditorium where Kennedy announced what would become Medicare and Medicaid to lodge its protest. Fifty years ago there were at least some leaders raising concerns regarding what would happen. Now with Medicare and Medicaid so much of the payment design, matters are worse.
  • By the 1980s, primary care payment was insufficient to the cost (rampant inflation, liability cost, lower pay going up lower), primary care choice was going down fast, and primary care retention dropped.
The 1990s reforms did initially adjust primary care pay higher, but set it lower than non-primary care. Managed care threats scared more students into primary care. Primary care choice rose and internal medicine grads returned from 44% to 54% in office primary care - for a short time.
  • By the late 1990s, internal medicine office primary care retention was dropping 3 to 4 percentage points a year down to below 20% where it has stayed. 
  • Family medicine had a few years over 3000 annual graduates before dipping back below 3000, the level that it has remained essentially since 1980. The lack of family medicine expansion is an overall measure of payment design failure and failure of payment where care is needed - since 1980. 
  • The internal medicine retention in office primary care also tracks the same failure as does physician assistant primary care. The doubling of PA annual graduates (100% more from 1998 to 2008) resulted in over 200% increase in entry into non-primary care with just a small (and disappearing) 30% gain in entry to primary care. 
  • More specialties are added with more added to each new specialty for NP and PA - by payment design. Over 30,000 were added to teaching hospitals due to better pay and also resident work hours restrictions (higher cost, no increase in quality, bad value change).
The 2015 MACRA deal, is another bad deal that fails to acknowledge the cost of health care delivery rising much faster than inflation.
  • The fact that the CMS Actuary actually states this is quite interesting. Someone doing his job and away from political gain!
Steadily Shorter Time Periods Before Payment Failure

For primary care/basic services paid by Medicare and Medicaid since 1965, the period of time before any design has resulted in insolvency has been shrinking (10 years to 5 years to 1 year).

Payment Failure is Most Evident Where Workforce Fails - By Design

Sadly most Americans and the small practice and small hospital providers that they need the most are falling steadily behind by design.

Insurance reform fails when payment design fails, and payment design that costs providers even more and can pay small providers even less - fails to an even greater degree and where most needed - by design.
Buck Up Leaders

When our physician leaders fail to acknowledge these failures, they fail at leadership. They have failed with bad assessments of payment and bad assessments of workforce due to bad assessments of payment plus bad assumptions. It may be tough to inform political leaders and the public, but that is the job of physician leaders.

In the past few years it has become more difficult to critique health care delivery design. Political polarization has made this worse. It is possible to be highly critical of ACA and be appropriate. Complicating the problem is research failure. As Science pointed out, few studies of health care delivery are randomized. This allows too many assumptions, too many consequences, and implementation of new policy too fast and too dangerous while claiming success.

One main failure of ACA has been financial instability in the design:
  • Cost of delivery increased too high
  • Decreases in productivity due to ACA and rapid change
  • Distractions from care delivery due to ACA and rapid change
  • Confusion of public and providers due to ACA and rapid change
  • Revenue increasing less than inflation and far less than cost of delivery
Delays and mistakes by CMS and Congress have also caused problems - holding up payment.

Who cares how payment occurs if it supports health care delivery, avoids needless distractions, and supports care delivery where care is needed? Why change if you really do not know the consequences and you do know that change and rapid change are harmful?

Payment Design Failure Due to Failure to Support Care Delivery

Frankly since 1980 the new payment designs have abandoned all resemblance to payment for the support of health care delivery. The payment designs have been based upon cost cutting. The carnage has been seen in small hospital closures and small practice deficits with more and more territory and higher proportions of the population found where concentrations of clinicians are lowest. About 40% of Americans reside in 2621 counties lower to lowest in concentrations of  clinicians where 41 - 45% of older Americans, poor Americans, Medicare and Medicaid populations, diabetics, smokers, and those with poor to fair health are found. These populations:
  • Are being left behind by design and 
  • Their providers are paid less by design and 
  • They will be paid less by new design including penalties
Bonuses and Penalties, Quality or Not, Are About Populations not Providers

It is ludicrous to think that payment can be adjusted for the incredible complexity range of the American population - particularly those elderly or poor. Hong in JAMA demonstrated the discrimination of pay for performance.

For decades, the payment designs have continued to pay more where care is concentrated and less where care is needed. Another decade of this design will continue.
  • More lines of revenue and higher pay rates continue where care is concentrated
  • Fewest lines of revenue, few codes, and lowest pay rates continue where clinicians are least concentrated
  • Bonuses are only for those caring for the advantaged or Medicare Advantaged.
  • Penalties are for those taking care of populations behind by design.
Primary Care Investment Pays and Saves

The evidence builds for investment in primary care as a solution for better quality of primary care, better organization, and same cost of delivery. There can be no resolution of primary care without 20 - 30% more in payment support. Michigan recently had a demonstration project that fit these criteria with enough payment to cover increased costs of delivery and this resulted in overall savings of 1% regarding overall costs.
  • If you can pay primary care more to deliver better primary care and hold costs the same over years of time and not require a change to a more complicated and confusing payment design - why delay implementation?
Primary care delivery capacity is a function of primary care revenue minus the cost of delivery minus distractions from productivity.

Five Periods of Primary Care Payment Consequences           Individual Graphics

Internal medicine once contributed 65% of graduates into primary care. This resulted in internal medicine as the most important source with steadily over 3000 per class year added - for over 110,000 at one point. Sadly the consistent level of over 3000 in primary care per class year has become 1400 for primary care a year under the past decades of payment design.

Numerous distractions continue. Hospitalist workforce has claimed over 37,000 internal medicine graduates. Subspecialty fellowship positions increase by 4% per year and subsubspecialty fellowships by 11% a year (AAMC, Jolly). And our leaders still claim internal medicine as primary care training? And our researchers claim that internal medicine will contribute 90,000 for primary care. Try a maximum level of 40,000 for active office primary care by 2030 which is about all that 1400 per class year for 30 class years can provide.

Frozen family medicine, frozen pediatrics, and declining internal medicine translate to gaps in care and care where needed. Massive expansions of NP and PA have barely kept up with the declining internal medicine because fewer and fewer enter and remain in primary care. Expansions fail for primary care because of payment design. Failure in payment design also means more cost of delivery in areas such as primary care where needed. Locums costs, recruitment and retention bonuses, payment to brokers and headhunters, advertising costs, and administrative costs increase at federal, state, and local levels.

As usual, the graduates fail for locations of need - also due to poor support. Even worse,
populations are increasing fastest (twice as fast) where care is needed and where family medicine is most in demand. NP and PA are leaving family practice and primary care for better support and pay in non-primary care areas.

Marketing Has Become the Focus; Failure to Understand the Market Continues

The market interpretation is quite obvious. Pay is insufficient for primary care and for care where needed. The data is extensive and dates back for decades of class years.

Frustrated leaders appear to have turned to marketing. Marketing is needed where physicians try to crowd into locations with too many physicians. This is of course driven by payment design and better paying patients that also are easier to care for.

Marketing is not needed where care is needed. What is needed where people need care is higher payment, better support, lower cost of delivery, permanent family practice and permanent general surgical specialties (surgery, orthopedics, ob-gyn) - all falling further behind by payment and training design.

Primary care leaders, true to primary care, must have one major focus - pay for primary care consistently above the rising cost of care delivery.

Primary care leaders were able to take the debacle of the 1950s and 1960s and recover some level of primary care by 1980. The failures have been steady for primary care and for health access since that time.

Oops We Did It Again in Payment Design

Lack of awareness continues to add consequences by design.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

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...

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

Wednesday, April 15, 2015

Oops We Did It Again for Too Little Payment By Design

The one major problem that has faced primary care for the past three decades has been cost of delivery rising faster than payment. Each "fix" has not really been a fix as steadily fewer enter and remain in primary care from all six sources. 

MACRA is the new design and CMS has already projected the impact for decades. Here is what the Chief CMS Actuary says in his April 9, 2015 report:

"While H.R.2 avoids the significant short-range physician payment issues resulting from the current SGR system approach, it nevertheless raises important long-range concerns that would  almost certainly need to be addressed by future legislation. In particular, additional updates totaling  $500 million per year and a 5 percent annual bonus are scheduled to expire in 2025, resulting in a payment reduction for most physicians. In addition, this bill specifies the physician payment update amounts for all years in the future, and these amounts do not vary based on underlying economic conditions, nor are they expected to keep pace with the average rate of physician cost increases. The specified rate updates would be inadequate in years when levels of inflation are higher or when the cumulative effect of price updates not keeping up with physician costs becomes too large. We anticipate that physician payment rates under H.R.2 would be lower than scheduled under the current SGR formula by 2048 and would continue to worsen thereafter.  Absent a change in the method or level of update by subsequent legislation, we expect access to Medicare-participating physicians to become a significant issue in the long term under H.R. 2."  

Temporary Fixes
  • The initial Medicare and Medicaid design initially was a great boost to primary care and care where needed. In a few years the design proved insufficient to keep up with staggering inflation, malpractice, personnel, and other costs in the 1980s. 
  • The RBRVS fix in the 1990s was also short lived. 
  • SGR left all physicians hanging under the Sword of Damocles - so much so that anything seemed tolerable. 
  • The MACRA gets away from SGR, but whether it is a fix is questionable.
  • Note that the actual payment process has yet to be determined and this could be powerful in who survives and who thrives, but much will happen in the next ten years and MACRA does not have the flexibility.
MACRA Appears To Be Just What the Doctor Ordered

That is for those doing well in the largest and most organized practices that have the most advantaged patients.

For the smallest practices where care is most needed, MACRA will pay less.

Discrimination By Design

Readmission penalties and Pay for Performance cannot help but pay less where care is more complex and most needed. The same social determinants, situations, and conditions that have shaped shortages of clinicians and access barriers also shape lesser outcomes. Lesser pay will add insult to injury. 

It is most likely that MACRA will join Medicare Advantage as paying more for the care of populations that have advantages. Populations in need of care are left behind by MACRA and populations in smaller and less organized settings cannot access the favored payment plan - Medicare Advantage. The new designs do not work well for small hospitals, small practices, and care where needed. Lack of awareness continues to add consequences by design.

Accelerating Recruitment and Retention Costs

Where care is needed, there are more storm clouds. Even if patchwork programs survive, primary care delivery faces more problems. Insufficient payment is a primary reason for the rapidly rising cost of recruitment and retention bonuses, locums payments, broker fees, consultant costs, and other special programs.

A major consequence of insufficient payment is greater turnover of the teams and clinicians to deliver the care. The costs of turnover now include learning new software and other applications. There is little encouraging about the most important determinants of primary care at the current time.

SGR has been defeated. Congress did get a payment plan through. But more than two miracles are needed to recover primary care delivery capacity.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

Open Season Upon Small Health Care

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...

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.