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.
- More than just complex disease - Studies document that diabetic patients report that primary care physicians care for much more than diabetes.
- Higher Concentrations of Complexity - It is important to understand that diabetic patients are not evenly distributed. About 48% of diabetics are found in the 40% of the US population in 2621 lowest physician concentration counties.
- Lower Concentrations of Access Supported in the US - The United States is near last in generalists among developed nations (23 or 26)
- Even Lower Concentrations Where Needed - The US falls way down the rankings when it comes to the least served 40% of the population.
- Diabetes incidence is related to income level. Diabetes levels are three times higher for the lowest 40 - 50% of Americans as compared to the top quartile. See graphic below on diabetes by income and also see how the US spends so much on the wrong priorities.
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 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 interactwith 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)
Diabetes By Income Level in Massachusetts
Points to Consider
- 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.
- 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.
- 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.