Declines in Health Care Delivery Despite Increases in Health Spending

It would seem that an increase in health care spending would result in more health care delivery. This would be "incorrect assumption for $800 (billion), Alex" for the Jeopardy fans. Jeopardy is a correct consideration as tens of millions of Americans are at risk under the current health care designs.

Increases in health spending do not always translate to more health care delivery. Spending increases do not tend to go to the teams and clinicians that deliver care. Health care spending can be designed to go two different ways.
  1. Health care spending can be designed to go to those who deliver services or 
  2. 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. 
The evidence from primary care workforce and from workforce where needed indicates that health care spending is not being increased for those who deliver services. The failures in primary care delivery indicate too little spending and spending diverted to non-delivery expenses. 

Robert Kocher in the Harvard Business Review indicated some of the downsides of increased spending growth. This includes decreasing productivity and various increased costs. Kocher discusses the current situation that requires limitations upon health care spending but somehow must make up the increased health care demand by increases in productivity and decreases in salaries and personnel costs. This is an impossible scenario for tens of millions of patients in need of care and those that attempt to provide care for them.

Optimal health care delivery for the United States and especially for the 30 - 40% in most need of care is about increases in spending with spending specific to clinicians/teams who deliver care. This spending must be specific to the support they need to deliver care. More care requires increases in the numbers of clinicians and teams that actually provide more care where care is needed.

It is just not possible to satisfy increased health care demand when motive (cost cutting), opportunity (poor awareness), and means (designs) all lead to reductions - in some cases substantial reductions
  1. when the direct care spending is not increased
  2. when clinicians are pressured to do more with less while receiving less including declining support (with declining morale)
  3. when ownership is passing from clinicians to corporations with managers and administrators and CEOs and stockholders reaping the benefits
  4. 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
  5. 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
  6. when more is spent on technology, software, health info tech
  7. 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
  1. By cost cutting
  2. By stagnant and lesser spending on primary care and basic services
  3. By greater population increases where care is needed
  4. By greater increases in the populations increasing the most in demand (elderly, Medicare, Medicaid)
  5. By greater complexity where care is needed
  6. By greater increases in complexity where care is needed (dementia, diabetes, smoking, obesity, lesser health status, fewer resources, less health literacy)
  7. By greater gaps in resources where care is needed
The last decades have been a slow, steady squeeze play for the delivery of care where needed 

set up by cost cutting with high health care cost sectors escaping the cuts.

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.

Only those unaware could think that the current designs of cost cutting would work to meet greater health demand. Magical thinking is a requirement when designers far away from health access think that their designs address health access. 

What has happened and is likely to continue is a continued decline in care delivery in the usual areas outside of the awareness of those who must respond to the political and other pressures. Those inside with regard to designs are outside of services delivery. They are somewhat familiar with care nearby where clinicians are most concentrated. They are "inside" with regard to concentrations of clinicians where corporations and institutions and foundations hold sway. Their awareness of most Americans outside is lacking, especially regarding primary care and basic health access services.

Slow steady worsening of support for basic care and for care where needed should not be surprising as attention is focused elsewhere.

Declines By Designs

Primary care, basic services, and services where needed have been and will be primary examples of stagnant or declining health care delivery in the face of increasing health care spending. In some ways the rapid increases in health spending have forced cuts in spending - cuts that bludgeon health care delivery. Across multiple changes, designers have rarely attempted the surgical cuts to remove "the fat" will avoiding damage to essential care. 

Across the board cuts have been made without regard to the consequences. 
These include harm by design - violations of "do no harm" in health care.

It is quite incredible that few seem to grasp the deadly consequences of lower pay and more penalties that reduce substantial portions of American populations to greater probability of death or disability as well as shorter life span. Blaming people for the adverse impacts of health care design is just a part of blaming most Americans for their difficult situations.

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. 

When your only health policy tool is a cost cutting hammer, 
you can pound away health services that need to be expanded.

Cost cutting designs have been present for decades since DRGs and prospective payment. innovation focus dominates recent policy designs but almost every innovative design for payment or grant receipt requires substantial cost cutting as the heart of the design. Innovation Centers have become cost cutting centers. Even foundations supposedly devoted to health access end up promoting innovations, including innovations that can damage health access.

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. 

Profiteering Focus and Redesign

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.

What has transpired is not surprising. The administrative arm gained more and more control. Clinician were relegated to a lesser role. Choices had to be made and the administrative decision favored non-delivery costs. The marginalization of those who deliver care has steadily set in motion for decades. As clinicians diminish due to less support, more regulation, and lesser control - another cycle is set in motion.

Why Not Cut Out the Middle Men?

Efforts to cut out the "middle men" have been suppressed and in fact, brokers (insurance corporations) have taken over payment areas of Medicare, Medicaid, drug arrangements, etc. Recent studies have indicated the failure to add value by this arrangement. Connecticut even once took Medicaid away from insurers for the same reasons. However, resistance seems to be futile as 

The American design rolls on for more spent for less care 
with even less care where care is needed.

Corporations and institutions are faring well. Technology costs, drug costs, insurance costs, training costs, and consultant costs work well for few and poorly for many. The 2003 Part D Medicare debacle (a worst moment of Congress) is a primary example of drug costs that were supposed to be reduced. Instead Congress actually passed a law preventing drug cost savings by preventing government from negotiating costs with drug companies. Basically best paid drug company lobbyists as well as future lobbyists and consultants (who were in Congress or working as aides at the time) - voted more of the treasury to drug companies. Changes in health design insured that these dollars were more centralized and were funneled to drug companies and certain drug plans for health corporations. Corporations have helped to design Medicare Advantage their way as well as other legislation and regulation.

In the United States, more ways have been found to spend health care dollars, other than directly on those who provide care and care where most needed.

Increased spending goes
  • 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
Non-delivery personnel and their costs are increasing rapidly across health care 
  • 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

Runaway cost increases have been seen across non-primary care areas. Because primary care spending remains inadequate, primary care workforce remains as inadequate as primary care delivery. Patients are being diverted to higher cost areas such as emergency care, subspecialty care, urgent care, and convenience care. This forces higher health care costs as patients grow desperate for access. 

Optimal access is also not likely from those who provide basic care without adequate support. Overwhelmed providers are not going to be able to increase volume to move more millions toward access. Overproduction of MD, DO, NP, and PA clinicians will not help matters. Overproduction shifts even more control away from clinicians of all types - and into the hands of those who design or administrate rather than deliver.

Design changes force declines in health care delivery 

These changes are often slow and subtle but accumulate over time. For example the change to Diagnosis Related Groups in the 1980s eventually resulted in Hospitalist workforce about a decade ago. The early impact was more patients discharged earlier. This forced families and primary care offices to expend more effort "free" while higher resourced hospitals managed to benefit from lesser cost and more admissions and more revenue. The consequences to primary care have included
  1. 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. 
  2. 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)

More work for no more pay plus substantial losses of primary care workforce is not the direction to increase health access and primary care delivery. 

The teaching hospital redesign for resident work hours limitations is also a misguided design change. This resulted in another 30,000 chunk of clinicians being lost as these NP and PA graduates were hired by teaching hospitals to fill this workforce gap. The resident work hours limitation did not improve care in studies. This should have been expected from those that have common sense and realize that hospital outcomes are most often about patient situations and limitations existing before and after hospitalization rather than shaped by a few minutes of various interactions during a hospitalization. But the losses of clinician workforce

Less workforce from residents and primary care trained graduates 
is a major reason for declines in health care delivery 
in primary care and in care where needed. 

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. 

More spending for primary care training should result in more primary care delivery. But this is also a myth as primary care training funds go 70% to non-primary care workforce result.

There is also the myth of more primary care delivery due to loan repayment and numerous hundreds of millions spent for recruitment, retention, and locums temp workforce costs. These costs are increasing at rates far greater than inflation. Alaskan primary care where needed is forced to come up with 2 dollars more per person in the state each year (over 1 million dollars more each year) because of failure for primary care delivery result. The same failures are found in 30 or more states. By my estimate, some 300 - 600 million more dollars a year are being spent not to deliver more primary care, but due to recruitment and retention and locums costs just to have some primary care. This estimate does not include state and federal brokers, administrators, and others to run such programming - more administrative costs for no primary care delivery result. 

Because primary care design fails for primary care delivery result, more such spending is required. Instead of more and more spent for no increase in  delivery, this type of spending should go to permanent primary training that results in permanent primary care workforce. 

Winners attracting clinician graduates
  • 6 states with top concentrations, 
  • non-primary care careers
  • practice settings with the highest spending

Losers losing out 
  • 35 - 40 states
  • primary care delivery
  • care where most Americans.

Recovering Primary Care Delivery and Basic Health Access
  • 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. 

It is not possible to recover primary care with emphasis upon indiscriminate cost cutting, preservation of highest spending in 1% of the land area, higher administrative and other non-delivery related costs, and more primary care practices having to spend more in non-delivery budget areas.

Americans must pay attention to the lessons being taught 
  • 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

Recent Works

Perverse Health Payment Dividing US

How To Resolve Health Access for 40 States Behind By Design

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

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

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.


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