Monday, February 20, 2017

Stop Saying That Access is Insurance

Foundation, association, and government leaders keep saying that access to care is about insurance. This "access is insurance" focus has wasted the 2010 reform effort for the purpose of restoring access. Access to care requires interactions between patients and health care team members. This requires the existence of local workforce to be available for any hope of access. Access is still lower or missing for most Americans because workforce is lower or missing where most Americans reside.
Leaders immersed in concentrations could assume that access is about insurance. Their web sites and reports promote insurance as the access solution. Where health care dollars and where health care workforce are most concentrated, it is entirely possible that expansions of Medicaid improved access where a few people were able to get insurance and also could engage health workforce and the necessary transportation. But this is only because these concentrations of workforce are supported by sources of revenue outside of Medicaid. 
Why Medicaid Fails for Access
There are many reasons for lack of access. Medicaid is avoided by providers because it commonly pays less than the cost of delivering care. Medicaid pays the least of all payers. It therefore contributes the least to care delivery or worse. Low payments are not the only access barrier arising from Medicaid. 
True access is limited as noted in GAO studies where half of the practices that said that they accepted Medicaid were found not to really accept Medicaid despite what they said. And there is also the problem of health insurance provider listings that do not match up to providers that take the insurance. 
Access is further limited where public transportation is missing as seen in the places lowest in concentrations of workforce. Once again this is the most common finding across lower concentration areas as public transportation is near universal across top concentration settings.
The gates that lead into the arena of health care delivery 
are fewest and most narrow where people most need care
with or without insurance. 
The concept that access is about insurance is full of too many holes to hold water. This is best seen where workforce is missing because of insurance and payment designs. Health care only exists where people have the ability to interact with members of a health care team.

Access Progress Involves More Support for Basic Access Workforce
Generalists, general specialties, and their associated health care team members are the initial and ongoing points of care for the delivery of basic health access. This is most important where care is most needed. Generalists and general specialties provide 90% of services in 2621 lowest physician concentration counties where 40% of Americans are behind by design. Lowest payments across 90% of services prevents access.
The US design subverts access. Primary care is only 6% of annual US health spending but provides 55% of the services nationwide. This increases past 70% of services where care is most needed - where other specialties melt away (see graphic at end of blog). Where care is most needed, primary care must do much more. Mental health services are 50% delivered by primary care, but the proportion is much higher for lower concentration counties. As noted in the graphic at the end, only family medicine distributes equitably. Other specialties have fewest docs per 100,000 people in lowest concentration settings.
Overwhelming By Design
In the places where generalists have lowest payments and least support (due to insurance payment), the most is demanded of them. It should not be a surprise that morale is falling and burnout is increasing just as turnover spirals past $300,000 in losses to each practice per lost primary care physician. 

The most specialized services are paid at the highest rates. This allows the most team members to be hired as well as the best team members. They all perform more specific duties that allows sharing of complexity. Highest concentration most specialized settings with least complex care help drain lowest concentration and basic services of workforce, team members, and more. Differentials drain care where needed by design in many ways. 
Most Americans need supported access, not drained access.
Access Workforce Processes More Complexity Despite Lesser Support
Old and new research, demographics, and distributions all support the high levels of complexity and the intensity demand facing generalists.
As social determinants and other factors go down, concentrations of workforce go down, concentrations of health spending go down, and concentrations of adverse conditions are encountered (diabetes, obesity, smoking, poor to fair health status). The providers are most stressed where lower income, indigenous, immigrant, displaced, and ignored peoples are concentrated. About 48% of preventable deaths are concentrated in 2621 counties with 40% of Americans. We spend dollars in so many ways other than addressing better outcomes. We spend dollars in so many ways other than addressing better outcomes.
  • Does it make sense that the new designs for payment send the least payments and the most penalties to lowest concentration providers?
Every increased demand upon generalists strains health access. There have been many increases in demand from many directions. Team members face complex new regulations. Every increased cost of delivery due to regulation strains the team members that deliver access.
Restoring Health Access for Most Americans Behind By Design
Changes must be made in the financial designs supporting generalists and general specialties that provide 90% of services in lowest concentration counties. This is the best route to sending substantially more dollars flowing to 2600 lowest physician concentration counties.

Since these are the counties that Republicans should most be willing to help, now is an ideal time to propose some real solutions for Red Counties. 
This financial solution is also specific to recovery of Basic Health Access, care where needed, rural health, and restoration of primary care and general surgical specialty workforce.

The Most Important Reasons for Payment Changes
  • Health Outcomes Improvement - Payment changes can change health and other outcomes. increasing dollars flowing to lowest concentration settings changes the jobs, economics, and social determinants - the real factors shaping outcomes in health and other areas. There are many reasons that just building up health access results in better outcomes. Outcomes are about people, relationships, situations, environments, local resources, local economics and social determinants - so much more than ratios of primary care. The counties, states, and nations doing better in many areas are the ones that invest in access. Access does not create "better." Thy myth of primary care increase as improving outcomes also needs to be dealt with. The dollar distributions are what matter to lowest concentration counties and health, education, and social spending are the best vehicles.
  • Health Access Improvement - Health access cannot be restored without decades of improved financial design. A minimum of 15 years would be required for significant changes. It takes hard work for steady improvement. There are no magic innovation wands to wave.
  • Training Intervention Success - Payment changes are required to actually allow training changes to result in needed workforce. No training intervention can work without support of the positions in rural or underserved locations or primary care/family practice, or lower concentration settings.
  • Changing Workforce to Address Demand - Workforce must be restored in anticipation of demographic changes. Decades of studies have indicated increases in the elderly with increases in demand and complexity of care. The greatest workforce needs have also been identified by HRSA. The demand and services are specific to increased generalists and general specialties.
Demographics of Lowest Physician Concentration Counties
  • All but a few counties in a small part of each state for the 40 states with lowest concentrations of physicians
  • 40% of the US population concentrated around lowest cost of housing/living
  • 75% of the rural population, 32% of the urban population
  • 43 - 45% of poor, elderly, homebound elderly, Dual Eligible, Age 65, Age 66
  • 44 - 48% of diabetics, smokers and those with obesity 
  • 42 - 44% of Social Security, Disability, and SNAP spending
Contrasts Between Top Concentration 
and Lowest Concentration Counties By Design

Top concentration 79 counties with 10% of the population have 450 active physicians per 100,000 as compared to115 active physicians per 100,000 in lowest concentration settings. This translates to at least $29000 per person spent in top concentrations vs $3500 per person in lowest concentration settings. 
There are more residents per 100,000 at 150 per 100,000 in top concentration settings compared to all active physicians in lowest concentration settings at 115 per 100,000. Only 6.5% of residency positions are found were 40% of Americans are left behind.
The national design results in greater concentrations 
of residents in training at 150 per 100,000 
where workforce is most concentrated 
than total active physicians at 115 per 100,000 
where workforce is least concentrated.  
Top concentration settings are stagnant to declining in population. These are the highest property value, highest cost of housing, highest cost of living locations. They drive out all but higher to highest income populations. Developers, government entities, and others all have designs upon the land where housing is low cost and deteriorating.
The lowest concentration settings have had 20 - 40% higher rates of population growth compared to the US average over the past 50 years - consistently the most rapidly growing populations with migrations of elderly, disabled, and lower income people playing a part (as they depart areas with more costly housing). This compares to top concentration settings with three times greater than average workforce levels and stagnant population.
More workforce in the form of more generalists and more general specialties are exactly what is needed in these lowest concentration places where population, elderly, complexity, and demand are increasing the most - where current payment design has failed to resolve access woes for decades with at least another two decades to go before changes could resolve access woes.
Workforce is too concentrated in a few places with few Americans resulting in few limitations in access and overutilization of services raising health care costs and not surprisingly the numerous attempts at cutting health care spending - cuts impacting lower concentration settings but not the top concentration providers most organized to prevent change and most diversified in revenue capture and generation. 
Workforce is missing in most places with most Americans resulting in significant limitations in access
Common sense, logic, demographics, and spending patters all indicate that access is much more than insurance To restore access, access must be the focus across financial, training, and other designs that support access. 

Access to care is about process. 
Access requires the ability to interact 
with health care team members. 
Access requires supports specific to Team Members. 

Designs that defeat access are designs that
  • decrease spending on generalists, 
  • decrease health spending in 2621 lowest concentration counties that already have the lowest spending by design (3 times less than average, 9 times less than top concentrations), 
  • penalize providers caring for those more complex that have lesser outcomes because of who they are (Readmissions, MACRA, Value Based), 
  • require more health care dollars received to be sent outside of lowest concentration counties for regulations or other costs of delivery (HITECH, ACA, MACRA and more)
Designs that defeat team member functions and result in too few team members in too few places are designs that defeat access to care.

Diabetes By Income Level in Massachusetts

Points to Consider
  1. Team members can provide access to people with or without insurance as long as the financial design supports the team members to deliver care in the places and times when they need care. In counties that have reasonable payments to support the workforce to deliver access, those insured and those not insured can get care.
  2. Insurance designs can change in a year or two, but access to care requires decades of sufficient financial design to support the positions and team members to improve access. Workforce is shaped over an entire generation of class years - about 30 - 35 class years for physicians or physician assistants and about 20 - 25 for nurse practitioners. This is determined by the length of the career.
  3. No training design

As a solo rural physician paid the least and paid even less with a 20% cut due to Reagan Care in 1983, I could still care for all who came to me in the community. Eventually higher costs of delivery and stagnant payments plus declines in the local economy took out my practice and left a community with just 2 physicians instead of 5. 

Worst health insurance plus worst economics plus cuts by state and federal government are difficult to overcome.

Essential Primary Care, Especially Family Practice

Family practice physicians remain 25 - 33 per 100,000 across the wide range of locations and populations while other specialties fade away with declining insurance, education, income, health literacy, facilities, and health care spending.

Saturday, February 18, 2017

Frying Pan to Fire for Red Counties

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

Out of the Frying Pan into the Fire Health care is only one of many frustrations for those who feel that the established designs are failing. It is likely that Lowest Concentration counties will remain most frustrated by lack of design change. Health care designs 2017 to 2021 are likely to make situations worse for Red Counties.

Red and Blue Lowest Concentration Are Similar - The Red Counties are bound together by many similar environments, situations, and determinants of health. They are lowest in physician concentrations due to health care design. Red Counties actually have more in common with minority dominant counties. A few dozen rural counties with largest proportions of minority populations - Native, Hispanic, Black - have lowest concentrations as well.

All are in the same sinking health care boat due to disparities are made worse by health spending and deficits of facilities and local workforce.

Did anyone really think that expansions of the two plans (Medicaid, High Deductible), the two plans worse for local health workforce, would actually help people in Red Counties with least access by decades of designs? See Four Horsemen of the Primary Care Apocalypse

Divisions between various peoples left behind 
are really good --- for those doing well 
in higher concentrations. 

Common ground is that these 2600 to 2700 counties are less organized. At the opposite end of socioeconomics, economics, and many more dimensions are those most organized and associated institutions, corporations, and foundations.

Those most organized who are closest to the government feeding trough have been able to design lines of revenue that favor those in concentrations.

Those least organized lose out in new designs and suffer the consequences of cuts that come with cost overruns because of the old and new designs most benefiting providers in higher concentrations.

The one constant across PPS, DRGs, hospital payments, physician payments, SGR, HITECH, ACA, MACRA, Readmissions Penalties, Pay for Performance, and Value Based is that higher concentrations do better and lower concentrations are left with more challenges to address with less payment, least workforce, and least local resources.

Strategies That Will Make Matters Worse for Red Counties

  • CHIP Termination - 47% of poor children are found in counties with 40% of the population. Children's Health Insurance cuts or termination will easily impact 50% of the population directly or indirectly. Loss of payments for child health care will take out workforce for everyone in lowest physician concentration counties. CHIP helps poor families to move up rather than being kicked back down by health care costs. Working poor are helped by CHIP. Why terminate what has long had bipartisan support? Start with CHIP to Return to Sanity
  • Medicare Eligibility Increased to Age 67 - About 43 - 45% of adults age 65 and 66 are in lowest concentration counties. This proportion could increase due to demographic changes and migration patterns. With Medicare design changes, workforce will be compromised not only for Age 65 and 66, but for places with concentrations of those age 65 and 66. Workforce is about support (concentrations) or lack of support (Red, lower concentration).
  • The planned 200 billion to be cut from Medicare and Medicaid (current 1 trillion spent by CMS) will not spare lower concentrations. The case can be made that the 20% cut will be spared from higher concentrations before, during, and after new regulations as they have dating back to the 1980s across all changes in policies.
  • Block Grant funding can also be reshaped to privatization or centralized and concentrated settings resulting in much less for lowest concentration counties. 
  • SNAP, Social Security, and Disability Cuts hit hardest in lower concentration counties where relatively more are impacted (43 - 45% for this 40% of the population) and where other economic contributors are least. Dollars lost are jobs, income, and local resource losses.
Demographics Will Force More To Move To Red Counties

There is no stopping the forces that drive people to Red and lowest concentration counties. See Demographics Against the Democrats. Developers and governments in higher concentrations want the land where poor people are found. They want to move lesser income populations away. They want to destroy housing where poor people are found. Those in top concentrations profit from higher concentrations as seen in property values.

Elderly, poor, Veteran, Disabled, fixed income, and lower income populations must depart the highest property value areas concentrated in concentrations and lowest concentration counties are their only real choices. These are counties that tend to have better climate. Mostly these counties have lower cost of housing and other living costs.

But after moving lowest cost, what is left? Ask yourself what happens when lowest concentration people have even more cut from income or higher cost of insurance or more family members to support. They have already cut budgets to the bone. There is no place else to go to save money.

Mapping Designs That Fail Red and Lower Concentration Counties

A major health care design flaw involves the types of physician specialties rewarded by the payment design. Red and lower concentration counties need generalists and general specialties - the ones that supply 90% of the services in these counties. Generalists and general specialties are paid least and abused the most under past decades of designs.

The following graphic categorizes active physicians as of the 2013 AMA Masterfile by specialty and by 4 types of counties from the top physician concentration counties with 10% of the population/32 million people to the lowest physician concentration counties with 40% of the population/128 million people but only 22% of workforce and less than 13% of health spending.

The actual disparities in workforce (residents, faculty, administration) and health spending (more lines of revenue, higher payments, more specialized care) are worse for a number of reasons reviewed at the close of the blog.

In this graphic, family medicine remains at 26 to 33 active family physicians per 100,000 across types of counties. Family medicine is listed as a blue line that is relatively flat. The ratio of concentrations of family physicians from top to lowest categories is 1.2.General practice is also flat at the bottom but is almost gone. FM is a great contrast with General Internal Medicine that was just 15 per 100,000 in lowest concentration and is over 70 per 100,000 in top concentrations with a 4.3 concentration ratio. Internal medicine has not been a good source of primary care or care where needed in quite some time. There are too many specialties that get much better support and the rapid rise to 40,000 internists taken from the generalist pool has collapsed general internal medicine. This recent rapid change would make the red line much lower and possible more slanted in favor of concentrations. Pediatrics in green also favors concentrations as does general orthopedics in purple

Some specialties are even more concentrated in top concentrations. Note the inflection toward the top 10% for internal medicine (not shown), pediatrics, psychiatry, ophthalmology, hematology-oncology, cardiology, and neurology - a movement away from 90% of the people of the United States. 

Payment Shapes Disparities

Physicians claim a small portion of health care spending but shape a substantial portion of such spending. Health care costs can be estimated by mapping physician distributions. The past 35 years of health payment designs have shaped substantial disparities. In the top concentration counties the design sends over $29,000 per person or 3 times the average and in the bottom concentration counties only $3500 per person is sent or 3 times less than average - a 9 times disparity.

Disparities in payment have resulted in disparities in the availability of physicians, nurse practitioners, and physician assistants. The disparities in payment help shape disparities in jobs, services, economic impact, social determinants, and outcomes in health and other areas.

Most consider workforce to be shaped by training. There is no common sense in this assertion. Regardless of training, the graduates can only seek positions that are funded. The financial design fails for Red and other lower concentration counties. No training can overcome payment designs that pay less for basic services, pay less where care is least concentrated, and pay less for the care of more complex populations.

As noted only family medicine has an equitable distribution with top concentration counties having 1.2 times the family physicians as lowest physician concentration counties. General surgery and general orthopedics have 2 - 3 times ratios toward greater concentration but both are declining in national workforce at 2 - 3 percentage points lost a year comparing the 2005 to the 2013 AMA Masterfile. General surgical specialties are second only to primary care with regard to workforce where needed.

Most Equitable Distributions of Specialties Are Fading By Design

Lowest Concentration County workforce:
  • Family medicine 23% - slight declines over time due to active FM dropping from 95% in FM positions to 70% and also declines in distribution such as 25% to 20% rural location. Most likely FM will remain 23% because of declines in the other specialties.
  • General internal medicine 13% - and collapsing from primary care and from needed locations. Preferences for better supported specialties, less complexity, and more concentrated practice locations defeats contributions where needed.
  • General pediatrics 7% - stable
About 46% of local workforce is primary care and another 23% is general surgical specialties. The workforce found in lowest concentration counties is older - another indication of poor recruitment of younger physicians. After training in general surgery, orthopedics, urology, ENT, and Ob-Gyn it is much better to continue training in one or two fellowships as the payment design rewards this substantially. Basic surgical services are paid least and most specialized are paid most. The recent decades have been least kind to lowest concentration counties as retirements are not being replaced as in other settings.

The newer graduates clearly do much better by avoiding primary care and by taking one or two fellowships. Few stay in their original specialty training. A big deal is made about the higher salaries that result from such training. The support for the specialty may be more important than the salaries. Salaries are easy to collect. Complexity has taken more time to assess. Support is even more difficult to assess. Clearly the most rapid rises in stress and burnout have been in the specialties that distribute the best - and this is likely due to financial designs that fail to support the care delivery

The most distortion is created by lowest payments 
that results in limitations
in numbers and abilities of team members and other supports.

The case can be made that broader scope results in greater complexity. This is now supported by studies that demonstrate greater complexity in primary care. The onerous documentation and regulation has made this worse.

Generalists Burned Out By Design

Declines in mental health and basic specialties thrust the burden upon remaining physicians - especially family physicians. Overall 47% of mental health is delivered by primary care and this has increased to 50%. The proportions of mental health care increase to higher levels where mental health most fails. This is thrust upon what remains.

  • About 36% of active family physicians are found in lowest concentration counties 
  • compared to 23.5% of mental health providers, 
  • 17% of psychiatrists, and 13% of geriatric or child psychiatrists. 
  • The 47% of poor children in lowest concentration counties stands testament to mental health demand with most limited access. 
Mismatch disparities abound. About 43% of the elderly and higher proportions of complex elderly are found in the lower concentration counties where only 13% of internal medicine geriatricians are found (45% of these are international graduates). Geriatrics is too complex to support given lowest cognitive payments and the failures are worse where payments are even less not to mention least local workforce, most complex patients, most Dual Eligible patients, most homebound elderly, least mobility and transporation, and more.

As seen in the chart, lower concentrations result in declines of ever other specialty eventually leaving family practice MD DO NP and PA as the remaining specialty. Broad scope is required for lowest concentration settings, but broad scope can be more complex and more overwhelming. Integration with the community has long been optional in urban settings, but integration with the community is often required where care is most needed.

Why Do Designers and Payers Delay and Deny the Primary Importance of Generalists and General Specialties that Are 90% of Local Services Where Needed

Supports are least where payments are least as seen in lowest concentration counties. Even when presented with Medicare data about this discrimination, there is resistance to reform.

Other specialties have 4 to 7 times higher concentrations where people, income, education, resources, and workforce are most concentrated. This is also where services are overused and high volume is most abused. In higher concentration settings, volume can be considered "bad." But sadly volume is considered bad where it is most lacking - and most needed. In lowest concentration settings volume is two things:
  1. Health access
  2. Survival because of inadequate financial design
Why should volume be considered universally evil when it is so good where care is needed - and so missing?

Why should designs force cognitive, office, and most needed delivery into survival mode?

There is little question that the designers have made it best for concentrated settings and worst where care is most needed.

The disparities in access, services, cash flow, jobs, and economics are significant. Disparities in payments shape disparities in workforce and team members that shape disparities in health care outcomes.

Some specialties are even more concentrated in top concentrations. Note the inflection toward the top 10% for internal medicine (not shown), pediatrics, psychiatry, ophthalmology, hematology-oncology, cardiology, and neurology - a movement away from 90% of the people of the United States.

Innovative Specialties Serve Highest Concentrations and Fail to Distribute

New types of Radiologists replace old. Pulmonary and Critical Care replaces Pulmonary Training. New Oncology replaces old. The one constant in replacing a specialty is that replacement specialties have even worse distribution as seen in pulmonary becoming pulmonary critical care or replacements for oncology or radiology.

Graduate Medical Education Disparity By Design

There is little evidence that the Graduate Medical Education design does much to address care where needed. Indeed only 6% of GME positions are found in 2621 lowest physician concentration counties with 40% of the population. Even if GME locations were changed, the physician concentrations would not change.

  1. No training intervention changes the specialties or locations or positions
  2. Only more support for a specialty or a location changes specialty position numbers or numbers in locations in need of positions

Even more important to understand is that payment design is so powerful that more GME positions in counties of need, more family physicians, more NP, more PA, or more physicians are incapable of addressing lowest concentration counties.

It is even worse when looking at specific needs in lowest physician concentration counties that have 43 - 46% of the elderly, the poor, poor children, obese, smokers, and preventable deaths.

The lowest concentration 40% have 48% of diabetics and only 12% of endocrinologists, 43% of the elderly and 13% of geriatric doctors, and the list goes on across cancers, trauma, fractures, and people with arthritis, kidney failure...

The payment designs that exist just do not allow enough spending to flow to lowest concentration counties where the Four Horsemen of the Primary Care Apocalypse are concentrated - the reason for least support. This is also why expansions of the least supportive plans fail for recovery of health care and access where needed.

See Six Degrees of Discrimination By Health Care Payment Design

Generations of Workforce Failure Require Generations of Much More Supportive Designs

The 1965 to 1978 boost in workforce where needed was temporary. Deficits existed before, during, and after. The last 40 years represent over a generation of physician workforce and two generations of nurse practitioner workforce shaped adversely for most Americans. This can only be changed by a completely different financial design with more for basic services (and less for others), and decreased costs of health care delivery - made much worse since 2010 due to regulation acceleration.

It will take a minimum of 20 years to shape a significant improvement in areas such as primary care, mental health, basic services, and care where most needed - starting a few years after the nation has permanently implemented true payment reform.

Red Counties, Lowest Concentration Counties, and Designs for Spending

The Red counties as seen in popular election maps plus the dozen or so Native American counties, the three dozen Black counties, and the dozen Hispanic border counties are represented by the lowest 40% in concentrations. The characteristics are much the same for 40 or 50% left behind in lowest concentrations when choosing a variety of variables.

Designs Shaping Disparities That Will Likely Be Worse than Projected

About $3500 in spending per person can be mapped to lowest physician concentration counties and $29000 per person can be mapped in top concentration counties where pockets of lowest access are seen even with the top concentrations of health care dollars. Top concentration county spending is three times greater than average compared to 3 times less than average for a 9 times disparity.This results in substantial disparities in health spending. The actual disparities are worse than indicated. This is because
  • Top concentration settings have the most lines of revenue including administrative and other costs not associated with physicians. Lowest concentration settings have fewer health care costs not associated with physicians. 
  • Leadership, association, lobbying, and related costs are clearly among the most concentrated. 
  • Insurance, health system, and practices are becoming more consolidated and demanding more dollars. This comes with compromise to small health.
  • Resident, faculty, and research costs are predominantly in top concentrations. Only 6% of residents are found in lower concentration settings and even fewer physician researchers. The residents in training are among the most concentrated at 135 per 100,000 in top concentration settings and lowest physician concentration counties have just 115 total active physicians per 100,000. 
  • We also know that residency location is one of the most powerful determinants of future practice location. Not surprisingly the states and counties with top concentrations of training have the top concentrations of active physicians.
  • Payment design shapes training design shapes training outcomes and places associated with most training most shape the payment designs

Internal Medicine Collapse - Worse in Lowest Concentration Counties

The collapse of internal medicine is the most dramatic primary care change as only 1100 per class year can be tracked to primary care - yielding only 30000 at a maximum. Recent changes since 2010 may result in this sooner rather than later aided by the massive increase in IM Hospitalists moving past 40,000. This will result in changes from 19000 in lowest concentration counties to less than 6000.

Health Care Dollars Forced to Be Spent Outside of Lowest Concentration Counties

The primary limitation is health spending design. Limitations of absolute dollars in payments going for primary care in these counties is bad enough. Dollars must be subtracted for costs of delivery. These force scarce dollars to be shipped outside of the county. Dollars shipped outside worsen disparities.

Designs shape lower productivity of team members to defeat revenue for practices most needed.

Designs Shape Turnover, Poor Morale, and Burnout

Since 2010 the levels of burnout and poor morale have increased dramatically. There is a sense of chaos, confusion, and lack of control. Small hospitals, small practices, and solo practices have closed up as there seems little point. There is no upside for a turnaround in the designs that shape stagnant payments with higher costs of delivery.

 face rapidly increasing numbers, elderly, and complexity with less resources and fewer dollars. The designs for health care are only one of the many designs shaping disparities. The remaining primary care MD DO NP and PA will be more overwhelmed than ever - not to mention collapses of general specialties as well.

This forces practices and hospitals to make cuts - and the personnel that deliver care are the ones most likely to be cut as they dominate budgets where care is most needed. Fewer personnel add to morale and burnout problems. 

But Wait, There Are More

Unlike some types of rural counties that are stagnant to shrinking, the lowest concentration counties are growing at 30 - 50% higher rates than the national average.
Also specific to lower concentration counties is one of the most rapidly increasing populations in the US - the population in a county without a hospital closure. The lowest concentration counties are increasing at 1.5 times the national population rate, the counties losing their last hospital have much higher levels of population compared to the first 600 hospital closures. The rate of hospital closure may be moving up from 1 per month to 2 per month. Because the other specialties are more hospital dependent, family medicine is even more important as seen in 30 - 35% of local workforce instead of 24% for 2621 lowest physician concentration counties.

The only specialties increasing in lowest concentration counties are hospital related (emergency medicine, hospitalist) - but the hospital closures negate these and they are increasing even faster in the higher concentration counties. In addition, studies indicate some value for academic hospitals regarding hospitalists with a half day of stay saved - but studies do not document benefits for other types of hospitals and studies have avoided small hospitals. The rapidly increasing costs of ER and hospitalist physicians have essentially been forced upon small health care by cultural changes benefiting the most concentrated.

Lower payments, declines in payments, increases in costs, higher demand in a number of dimensions are bad enough. ACA to MACRA has had greater adverse impacts upon small practices and small hospitals.

... but turnover costs are also increasing in a number of dimensions. Recruitment costs and retention costs are going up. The time for orientation and costs of certification and lost revenues are up. Workforce is moving from physician to NP/PA with twice the turnover rate,

The coming years bring the promise of cuts in Medicare and Medicaid that will once again impact lowest concentration counties more - no matter how they voted.

Lowest concentration counties have higher concentrations of people on benefits and dollars spent on benefits. Cuts in SNAP, Social Security, or increases in eligibility will magnify lowest concentration counties due to about 45% of those impacted in these counties with 40% of Americans. Veterans may be 50% found in these counties that attract more and more due to skyrocketing costs of housing in higher concentration settings, better climate, and lower costs of living. And yes, cuts in veterans benefits and centralization of VA care in concentrations is yet another reason for disparities by design.

Federal and state dollars are even more important since this 40% of the population only has 25% of the economic impact. Often the dollars from federal sources are siphoned off before making it to populations in lower concentration settings. 

More at Access to Care Is Not the Same as Insurance

Wednesday, February 15, 2017

Should Medical Associations Preach Evidence Basis?

Evidence basis gets much attention. Unfortunately there is much opinion and assumption that buries the evidence. The pathway to becoming a leader in an association is paved with areas believed to be important with or without evidence basis. Associations are prone to point out the need for evidence basis, but they may be the ones that should be improving evidence basis across leaders, staff, and media.

The popular media passed around is a great source for assumptions. Unfortunately works published in major journals need a great deal of improvement also.

AAFP has a number of areas for improvement regarding evidence basis

1. Maintenance of Certification is supported despite lack of evidence
2. Pay for Performance and derivatives are supported despite lack of outcome improvement in major reviews
3. Pay for Performance is supported despite the consistent evidence to lesser payment for those serving Americans left behind (where family physicians are 3 times more likely to be found)
4. AAFP should be exposing the lack of significant health outcomes improvements from a number of clinical interventions
5. AAFP should maintain a constant focus on the personal, community, social factors that are 60 - 70% of health outcomes. This also leads to a choice between outcomes improvements for most Americans or protection of the academic/clinical focus/status quo.

The above should be reflected in all media, leadership postings, and staff activities.

Opposing the Tyranny of Health Care Research

In addition AAFP should prioritize a return to evidence basis. There should be movement away from jump on the bandwagon acceptance of research methods and findings that were exposed as defective 100 years ago. Dr. Jha noted below has been consistent in such work.

"What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands that feed it." SAURABH JHA, MD (associate editor with The Health Care Blog)

More at The Tyranny of Health Care Research

Please No More So-Called Primary Care Solutions

As a consideration AAFP should also be critical regarding promotions of various training interventions. There has been some tacit understanding of "The Dean's Lie" regarding medical school leader claims of primary care result that are not really primary care, but AAFP has not remained critical in an evidence-based way.

There have long been claims of overall improvements across MD DO NP PA FM training in areas such as primary care, health access, rural practice, or care where needed. But all fail due to inadequate financial design.

Training interventions can only rearrange the initials and names but not change inadequate delivery capacity. How many decades of watching this happen across entire states should be tolerated before the top priority

As a cushion for the claim of inability to result in the necessary increased capacity, note
  1. The substantial increased cost of delivery via new regulations and certifications that can only make the financial design and capacity worse.
  2. 30 - 50% greater than average population growth in 2600 lowest physician concentration counties over the past 5 decades - not surprising given the inability of more Americans to pay for housing and other basics where workforce, property values, and cost of living are most concentrated
  3. 2600 lowest concentration counties with higher concentrations of elderly and complexity. 
  4. This is a massive increase in demand where 40% of Americans fall further behind by designs that fail for generalists and general specialties that are 90% of local services in these counties. 
  5. Compare this to 1100 zip codes with 10% of the population that have 45% of physicians and greater than 50% of health spending - leaving little for most Americans by designs that concentrate the most lines of revenue and the highest reimbursements in each line.
  6. Fewest remaining in primary care positions, particularly family practice positions across all sources, as the financial design rewards more new specialties with more added in each specialty

Keeping Perspective Is Challenging Because of Turbulent Health Care Design

Rapid chaotic change is what foundations and government and payers have promoted most in health care over the last decade. In the attempt to shake up health care and promote value, core values have been disrupted. Cost, quality, and access have not significantly improved. Costs have increased substantially. Outcomes have not improved. Access has not improved where most Americans need access. Even worse, people have been taught that access is about insurance - not much help when workforce is not available. In many ways what has been done via innovation has been distraction from actually addressing cost, quality, and access. 
Keeping Perspective During Turbulent Times was a recent post by Commonwealth. It is quite interesting that those who have engineered turbulent times would craft such a post. The following is a representation from the perspective of basic health access.

The Innovation Bandwagon Takes No Prisoners

There is no stopping this train as so many new players are excited about harvesting new dollars from health care. Each drives their own perspective and passes on their version of evidence basis, big data, and inflated claims. 

Innovation is the magic word, regardless of higher costs or other consequences. Those driving the innovation bandwagon appear to be oblivious to the changes. 

The team members that deliver the care have taken the most hits. This makes the side effects of declines in morale, declines in productivity, and increases in burnout most tragic.  Those most about the delivery of health care are impacted.

Why Disrupt Those Who Deliver the Care?

Relationships Are Important, But Are Inconvenient for Convenient Big Data
In particular the innovation efforts have disrupted important relationships. Behaviors, situations, environments, and local resources shape outcomes - but the data is collected for the purposes of billing and documentation. Numerous irrelevant study claims exist with more to come.

There is much talk about the problems of taking out ACA without a replacement.
There is much talk about team, but how can teams function best with divided loyalties and diminished support? How can health care function with fewer members with more duties and distractions?

Why Disrupt Those Who Deliver the Care Where Most Needed?

The new payments impact most needed providers directly and vulnerable populations indirectly as fewer dollars remain to circulate locally and impact the real determinants of health and other outcomes.What about the human subject experimentation called payment design with known consequences for providers caring for those most behind in so many dimensions that research consistently fails across the quality chasm?

Is it ethical to propose and promote treatments that delay real cures for access, cost, and quality? Treatments that delay cures for individual patients impact individuals. Treatments involving payment designs and regulations that force higher costs impact tens of millions.

Why Distract Those Who Deliver the Care Where Most Needed and Divert Funding?

Is health care better off with even more players seeking attention and more dollars or is this more distraction from those who have dedicated their lives to delivering care? 

If the health care pie is not growing, how can increased administrative and non-delivery costs do anything but shrink support for team members?

Case in Point - Primary Care

What does it take for optimal primary care?
  • Can primary care be micromanaged to full effect or 
  • Is optimal primary care about well supported team members kept in continuity with patients, practice, and community working over time
Which is the route to best accomplish higher primary care functions such as integration, coordination, and outreach?

My read is that the innovation bandwagon compromises primary care and especially care where needed in ways that increase discontinuity, make it difficult to practice, and make it even harder to do higher primary care functions.

Surely the literature is clear about the need for $105,000 more per primary care physician for Primary Care Medical Home and $40,000 more for MACRA not to mention tens of thousands more per year per physician to address the flood of chaotic changes for the past decade.

Volume Branded as Evil - Not Necessarily in Primary Care

The ragsheets decry volume in health care as waste or worse. But office primary care is different in many ways because it best represents access to care with 55% of US encounters.
  • Is higher volume in primary care evil or 
  • Is it called expanded access to care
The expansion in workforce can involve more team members supported, more productive team members, and team members in more places. These are all areas that cannot be addressed via expansions of low quality, inefficient, obstructive, low paying insurance coverage.

With Widespread Appreciation of Health Outcomes as Due to Patient, Local, Social, Community Factors then Why Clinical Interventions Known to Be Costly and Low Yield for Outcomes?

Why persist in the small change potential of clinical intervention, especially the costly digital subset?

Why not return the focus to populations in most need of changes in behaviors, environments, situations, nutrition, community resources, and social determinants - the real drivers of health, education, economic, and other outcomes?

Common Sense, SMART, Indicated, Evidence Based Solutions - Not Innovation Via Assumption

We know what we need to do. 

We need to facilitate investments in the people that invest in others - from the earliest ages.