How Bad Health Design is Sweeping the Nation

Health care articles commonly indicate that health care has been taken out of the hands of physicians and others who provide care.

Not just the red states in this Bad Medicine map are suffering by design.  All states have been seeing red since 1983 (not just the 35 on the map). During the 1980s the cost cutting approach was established as the predominant modus operandi in US health policy. Most of the people in WA, OR, CA, NV, NM, CO, WY, IL, ME, MA, NY, NJ, NH, VT, and MD also suffer from the national and state cost cutting as seen in the states colored red. Bad Health Care Has Been Sweeping the Nation, not just Bad Medicine (see link below). My recent article Preventing Rural Workforce By Design reviews the many ways that our designs compromise health care where needed - and in more than just rural locations.

When did health care design and domestic policy get refocused on more for less for less result for the nation?

When did we depart designs for health care focused upon delivering health care, or focused upon delivery of education, or delivery of services to people in need of help? When did our designs defeat the ability of our servants to serve?

More for fewer has indeed been the defining trait dividing the nation into advantaged and disadvantaged across economics, business, politics, education, health, and other sectors.

It is indeed a tragedy that health care is becoming a major reason
for further divisions in the United States.

Multiple times greater health spending goes to 1% of the land area with top concentrations of physicians, clinicians, and health care services. Multiple times less health spending goes to 40,000 zip codes with 68% of Americans. Half of the economic impact of medical education (500 billion annually) goes to just 6 states and to just a few counties and a few dozen zip codes in these states. And we continue consolidations, mergers, closures of rural and smaller hospitals and practices, and produce the wrong workforce by design.

Instate, Primary Care, Where Needed = Health Access By Design

We need primary care that remains permanent to primary care. Primary care fails because our designs result in less than 30% yield for primary care from primary care training sources. Our designs for residency training fail for most states lower or lowest in physicians. Training more in a few states with top concentrations insures a continuation of this design. Even our reforms have failed to move training to primary care, to rural training, to counties in need of workforce, and to states in need of workforce (Chen, also analysis of Teaching CHCs)

And in a decade or two we shall finally realize that divisions shape health, education, and economic outcomes and vice versa. Meanwhile the task of repentance (going the opposite direction from failure) becomes more difficult.

It was the Reagan administration that shifted health care design in the 1980s. This ended the short period 1965 to 1978 when health care designs actually focused on delivering health care - especially health care delivery for Americans left behind by health care design. The period of 1965 to 1978 was restorative to primary care and to care for poor and elderly populations. (See graphic indicating the only real increase in primary care production

Other than a small bump of change in the 1990s, primary care production has flatlined in the face of a 39% increase in the population. We are still cruising upon designs set in place by 1980, designs unable to keep up after 33 class years. Even worse we are already experiencing the 2010 to 2040 doubling of the elderly and an even more rapid increase in demand for primary care and basic services. But we fail for primary care.

In our desperation we are grabbing at anything as a primary care solution and we are making matters worse.  We seem to be focusing upon everything other than direct support of the clinicians and teams delivering care where needing and adding to their support and their workforce.

Our core specialties most important for basic services where needed are also a failure by design as general surgical services lead the way in decline.

We act as if generic expansions of MD, DO, NP, and PA will work. Expansions fail because those produced are not the specialties required. We need permanent broadest generalists and core specialties that remain in their core specialty. This is about 70% of the workforce found where 40% of Americans need care. The demand is rising faster from the 65% of Americans outside of concentrations of workforce.

Our designs for training and payment fail most Americans and will continue to fail as populations in need of care increase faster than workforce and payment designs.

What Happens When Designs Are Specific to Delivery, not Cost Cutting?

Once upon a time we did have designs refocused upon delivery. After 1950s and 1960s, it was clear that America was neglecting the elderly, the poor, areas with concentrations of elderly and poor, and family practice. Rural areas and smaller urban settings benefited from the 1970s policies that focused upon spending where needed, workforce where needed, and support of health care providers and facilities where needed. The only lasting expansion of family medicine occurred 1970 to 1980 (re-creation to 3000 annual graduates) with family medicine suppressed since this time, a time with the other five sources falling steadily away from primary care retention.

What Happened in the 1980s to Reverse Health Access?

DRGs and Prospective Payment came into being and the payment was so low that hundreds of rural hospitals were taken down. After building up health care, local rural workforce, hospital services, and local economics for a brief time, this support where needed was lost.

DRGs and lower payment designs still kill rural hospitals and further cost cutting has taken out 20 more rural hospitals in the past 18 months. There are no eyes and ears in the field to guide which hospitals are lost, making the losses worse for areas in need of rural facilities and the greater levels of workforce around such facilities. The population increases in counties without a hospital are rapid with population growth and last hospital in the county closures adding more counties and counties with greater levels of population. My estimate is that zero hospital counties will increase from 25 million to over 40 million in the next 20 - 25 years. In these counties there will be lesser income, lesser concentrations of clinicians (MD, DO, NP, PA), and lesser social determinants and economic impact - in other words lesser health, lesser health status, and lesser health outcomes by design.

To make matters worse, more stresses are placed on care where needed. Top readmission penalties of 1 to 2% of all Medicare funds taken away for 2014 can be found in 9% of rural hospitals compared to 3% of urban hospitals. Taking care of people in need of care can be even more hazardous to your finances and survival as a provider.

Inequity in Payment By Design

Physician payment design rewards longer training and more specialized services. The 1980s design clearly supplied too little health spending with a rapid fall in primary care career entry. The “reform” SGR designs were temporarily better but still reward fewer and more expensive services. As the costs of delivery increased faster than reimbursement for services, primary care has had no choice other than to decline. Stagnant payment can be made worse, and has. In the last decade the even higher cost of delivery has compromised primary care teams and clinicians further, even while claims are made of improvements.

It is the revenue design inequity that is ruining primary care
as a workforce and as a career for MD, DO, NP, and PA graduates.

Flexible sources such as internal medicine, nurse practitioners, and physician assistants are most vulnerable and have mostly moved away due to flexible design and poor primary care support. 

We are entering a new permutation of cost cutting focus. Value based and Pay for Performance implies some increase in pay, but actually time after time these designs result only in penalty with little benefit. And also the way to better performance is to care for advantaged patients while avoiding those disadvantaged. We already know that value based and pay for performance designs for payment are designs that compromise revenue for providers serving where needed (Hong, others, county based studies, Pay for Performance Pounds Poverty Providers)

Veterans, rural populations, and most Americans need services to exist where they reside. Paying a fee for services rendered in primary care is reliable for getting the services performed. Paying for Performance and other designs actually shrink volume and health access – by design. They also result in more administration and management costs and fewer involved in health care delivery.

Now as the Veterans Administration "Pay for Performance" Bonus debacle extends from primary care to health access to disability payments – we truly see how bonuses work against the services needed. Bonuses can indeed be obtained when services and access are worsening. These bonuses are not going to the clinicians and obtaining bonuses is often not about clinician work. The bonuses often go to others for being more efficient - often due to the compromise of care. Will Congress bail out the VA debacle after failure to send enough money and failure of administration? Will Congress bail out 40% of Americans for their lack of access by design?

What About Fraud in the Era of Designer Dominance
As Compared to Provider Directed Care?

Administrative and management types committing fraud or worse just move to another similar or better job. Often the practices or facilities that are abused choose not to pursue charges. One reason is that they could be charged with massive penalties – because of fraud and billing abuses on a large scale. Even the penalty design works in favor of rewarding the guilty and punishing those who provide care. Accountability fails. Even at the corporate level, corporations are willing to invest in areas that profit while leaving individual patients behind. Corporate care or institutional care is quite different than clinician care.

The situation is different when physicians and clinicians cross the line. They can lose their jobs, licenses, and livelihood. Accountability remains.

Management is getting paid more and more and those who deliver services 
are getting more stress, less support, and more blame. 

One can easily guess how much worse we are with clinicians diminished and administrators in charge.

As we send more dollars for Primary Care Medical Homes, management of services or patients, Community Health Center sites, consultants, recruitment bonuses, Health Info Tech, retention bonuses, loan repayment, and those who manage such programs – are we really just adding to bureaucracy without adding to support for the team members and clinicians that deliver the care?

The VA debacle and others indicate failure by design.

In summary 
  • Numerous innovations indicate less volume, cost cutting, and poor support for delivery of services where needed.
  • Numerous innovations indicate that care quality differences, when they exist, are about the care of advantaged as compared to disadvantaged populations.
  • Innovation often results in compromise rather than focusing on delivery of health care and those who deliver health care.
  • Specific training designs and specific payment for services delivered where needed - this is what is required of a health care design.

True recovery of health access – and the United States – is about recovery of most Americans by designs for health, education, child well being, and early education.

Designers that sweep the bad news under the rug are not helping most of the nation with their designs. 

How Bad Medicine is Sweeping The Country.
Preventing Rural Workforce By Design
JAMA by Hong on Pay for Performance Inequities

Best of Basic Health Access

Robert C. Bowman, M.D. 

World of Rural Medical Education at


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