Declines in Health Care Delivery Despite Increases in Health Spending
- Health care spending can be designed to go to those who deliver services or
- Health care spending can be diverted more to those who do administrative or support work or goods or services not related to delivery of health care.
- when the direct care spending is not increased
- when clinicians are pressured to do more with less while receiving less including declining support (with declining morale)
- when ownership is passing from clinicians to corporations with managers and administrators and CEOs and stockholders reaping the benefits
- when designs force consolidations and mergers into ever larger, more distant, less aware, and less personal health care corporations with little understanding of local health care needs
- when the zip code and county areas increasing most in health care demand have lower to lowest concentrations of clinicians as dictated by lowest local health care spending
- when more is spent on technology, software, health info tech
- when more time from clinicians and teams is spent on documentation and quality focus
Today's New York Times has an opinion piece about preauthorization of drugs indicating 20 hours required a week, mostly from staff. This is the ultimate nightmare for health care delivery as even clinicians and teams that deliver care - are limited by designs that sap their time, energy, and resources rather than specific focus upon care delivery. The rapidity of change makes it easy to find any number of examples of waste and inefficiency that detract from delivery of care
Not All Americans Suffer Equally Under Adverse Designs
Americans of advantage and those who serve them will continue to do well - powerful forces shape and protect their health care delivery. Even a tiny threat to their care ends up with headlines and promises of Congressional attention. The same is not true for most Americans behind in economic, education, and health care designs. The drug access situation illustrates this well. The worst situations are seen for patients without insurance followed by Medicaid patients then patients with low rent health insurance while advantaged Americans and their providers skip such barriers.
The deck is stacked
- By cost cutting
- By stagnant and lesser spending on primary care and basic services
- By greater population increases where care is needed
- By greater increases in the populations increasing the most in demand (elderly, Medicare, Medicaid)
- By greater complexity where care is needed
- By greater increases in complexity where care is needed (dementia, diabetes, smoking, obesity, lesser health status, fewer resources, less health literacy)
- By greater gaps in resources where care is needed
The current scenario is impossible for care where needed as in 2652 counties left behind with 40% of the population using geographic terms (lowest clinician concentration counties). Those left behind can be even more when considering barriers in other dimensions.
Slow steady worsening of support for basic care and for care where needed should not be surprising as attention is focused elsewhere.
Old and new designs defeat care where needed. Lower reimbursement across basic services for decades as well as innovative Pay for Performance designs are harm by design. Lesser spending by design results in inadequate workforce where most Americans are found. The economic impacts are multiple times less where most Americans are found while 1% of the land area with 12% of Americans and 45% of physicians enjoys multiple times more local health spending - by design. Harm to health care, harm to jobs, and harm to economic impact are all consequences of designs.
Smaller and rural practices and hospitals on the front lines of health access have been harmed by penalties - just because they care for more complex, less healthy patients lower on the social determinant scale. The same factors that shape lower concentrations of clinicians shape lesser health outcomes - and even less health spending under US Designs.
A review of Rural Workforce Prevented By Design indicates the consequences faced by rural areas but these same consequences are seen in primary care and in other basic services where needed.
Increased Spending Goes to...
Paradoxically increases have been seen in non-primary care areas, in areas where health care workforce has become more concentrated, and in certain states. Health systems desert inner city and lower income urban areas to move out to suburbs to serve patients with better income, better insurance, and best social determinants - resulting in best outcomes inherently and best pay under innovative payment designs. like concentrations of wealth and income, health care is defined by top concentrations and most left behind. Those "inside" or most associated with concentrations do well while those outside in 40,000 zip codes or 2600 counties do less well - by design.
Some states, some institutions, and some health systems are apparently quite good at redesigning more dollars their way or protecting themselves from cost cutting. Existing programs can be exploited and new programs can be created for their benefit. And these increased dollars are not necessarily going to those who deliver the care. This too is a result of design and designers.
This is why the workforce solution for health access recovery is instate workforce for 40 states behind, permanent primary care workforce most important for health access services and locations in need, and workforce where needed for 2600 - 2800 counties or 35,000 to 40,000 zip codes.
The rise of for profit influence upon health care was acknowledged decades ago and this juggernaut has rolled on for some time. Profit in a for-profit design is not plowed back into health care delivery. Profit is also diverted to whatever spending results in more profit. Greater for-profit focus leaves the less profitable behind.
In a stagnant US economy, health care has assumed a greater share with regard to a boosting of the economy. Many fear that spending cuts will result in declines in the US economy and to some degree this is true.
If the spending increases across recent decades had continued sufficient to satisfy both non-delivery revenue and delivery revenue, numerous pressures would be less. But of course the United States would have been severely damaged by 25% and even greater Gross Domestic Product consumed by the health sector. Clearly a nation spending the most upon health care with marginal results is spending far too much - especially with regard to non-delivery spending.
- to administrative costs
- to technology costs such as new drugs, new treatments, new procedures, new scanning devices, and health information technology
- to lowest volume and highest cost care providers, but not to highest volume delivery lowest cost providers such as primary care or basic service providers
- to more services where clinicians are concentrated - multiple times more services compared to the locations where care is needed
- to redundant care - patients passed from specialist to specialist rather than back to primary care
- to redundant care as in certain aspects of urgent or convenience or emergency care
- to utilities and to office space - worse because health care offices are stacked in the highest cost and high demand retail settings rather than in lower cost settings where people most need care
- to personnel that do not deliver care - non-delivery personnel
- Health info techs have increased rapidly and their salaries may be increasing at the fastest rates for an occupation. Many have reached the range of salary paid to clinicians. More techs needed at higher cost for many more sites and facilities is substantial increase in the cost of health care paid by the practices and facilities that deliver the care.
- Adoptions of electronic records or changes to different software have actually resulted in declines in revenue, declines in health care jobs, and declines in clinicians to deliver care in states such as Maine when largest systems make major changes. Tens of millions have been diverted from delivering care to something else.
- Health care design changes over recent decades have forced those who deliver care to hire increasing numbers of personnel to bill and to supervise the billing due to the complexity of services, codes, insurance plans, prices, regulations, mandates, certifications...
- Practices must hire more personnel to beg insurance companies for needed care - essential for insurance company cost savings but not for delivering care
- Insurance, health system, and other health care CEO salaries and benefits and bonuses skyrocket with more vice presidents and managers - the most distant from health care delivery.
- More personnel have been added to arrange care or manage care or manage costs. The personnel and other cost increases are often about the same level as what can be saved by "management." Often the savings accrue for insurance company and other payers (Congressional Budget Office study). Readmission penalty prevention in hospitals can be as costly as the penalty funding saved. It is difficult to improve outcomes when what needs to be improved is in the home or community rather than the hospital.
The real solutions for health care delivery are most likely to arise from those inside
of health care delivery rather than those outside of health care delivery
- The loss of 24,000 internists to become hospitalists with 30,000 primary care physicians lost overall in just the first decade of such workforce.
- Substantial time and effort by primary care nurses and clinics to address the needs of patients just discharged from the hospital and not always stabilized in their situations (especially the riskiest area of anticoagulation)
The Myths of Increased Primary Care Spending
The stagnant primary care workforce for decades stands testament to stagnant support for primary care delivery. Primary care spending may indeed go up somewhat, but not the primary care spending specific to delivery of primary care.
- 6 states with top concentrations,
- non-primary care careers
- practice settings with the highest spending
- 35 - 40 states
- primary care delivery
- care where most Americans.
- Requires more spending, but specific to states with lowest spending and fewest clinicians
- Requires more spending specific to the clinicians and teams who deliver primary care
- Requires more spending for 2600 counties for the support of clinicians to deliver primary care and basic services (general surgical services) - also the counties increasing most in primary care demand and demand for basic services because of higher concentrations of elderly, Medicare, Veterans, Medicaid, previous no insurance, and various underserved populations
- Requires decreased administrative costs, elimination of insurance and administrative brokers, decreased consultants - universal primary care
- Requires better support for lower turnover and better morale and better productivity
- Requires few or no changes (instead of rabid rapid changes)
- Requires permanent primary care position result from primary care training with no "primary care" support given to primary care schools or programs that are not 90% primary care in result for an entire career by whatever legislation and regulation necessary.
- by the political battles and their resulting cuts, consequences, and confusions - allowing even greater consequences due to the designs
- regarding the designs being facilitated by health care corporations with far too much influence tolerated and even facilitated
- about numerous bailouts where funding has been directed to corporations with most Americans failing to receive the benefits of "economic" stimulation or various special programs
- that more primary care graduates has failed for primary care delivery result
- that more spending does not necessarily result in more or better and may result in less and worse.
Accelerating Cycles of Primary Care Decline
To Follow the Money Is to Follow the Workforce and Vice Versa
Quote from Finding Forrester
Overcoming Barriers to Health Access Including ACA
Will Teaching CHC Sites Deliver on the Promise of Health Access?
How Bad Medicine is Sweeping The Country.
Preventing Rural Workforce By Design
Best of Basic Health Access