Domino Decline By Design

Studies now demonstrate the domino decline effect in a number of types of facilities, urban and rural. This has long been going on for decades. Perhaps the rapidity of the change makes it difficult to deny.
  • Kaiser News illustrated the domino effect for emergency room closures.
  • Small and rural hospital studies have illustrated this problem.
  • Urban facilities in higher poverty settings fall prey to decline or demise, setting nearby facilities on the same pathway.

There is worsening care as patients associated with greater complexity and lower resources and lesser social determinants begin to access the next existing line
1. of emergency rooms
2. of hospitals
3. of clinics

National designs relegating substantial populations and their providers to lower levels of reimbursement help to shape declines and closures - the foundation of the domino effect. Even academic centers with multiple lines of reimbursement are impacted by the domino effect.

As "patients begin to access care in "good facilities," these facilities can "go bad." The change in clientele also tends to drive off "the good patients" (those with better social determinants and insurance), worsening care outcomes and revenues.

The United States design dictates that facilities must move to have the best outcomes as their better performing populations move - but facilities cannot easily move. The facilities less flexible or too far down the path to financial compromise can have situations worsen or even be the next to fall from domino effect.

Higher dependence upon advertising, rankings, and ratings may also favor those with best finances while those caring for patients where needed are less able to play the marketing game.

Rural hospital closures and emergency room closures, both rural and urban, indicate the same domino effect.

Systems can also cherry pick "the good" facilities with "the good" patients or mergers or acquisitions. No system wants to save facilities where needed - there is no profit in such a choice. Choices for acquisition are based on the same principles that shape retail centers - concentrations of income, wealth, traffic, and profit to be had.

Hospital closures also result in departures of clinicians (MD, DO, NP, and PA) and better paying jobs as hospital jobs and services are lost. This results in lower concentrations of clinicians and declining local health access along with lesser health spending and lesser economic impact - shaping further declines in the process.

If you watch over decades, you see the leapfrog contribution to the domino effect. Time after time ERs and hospitals close older facilities in less desirable locations to leapfrog one another to be in a better position for better patients with less complexity and greater revenue result. Some "underserved areas" on the outskirts of a metro area are favored by developers and become the retail centers and health facilities compete or conspire for the increased profits to be obtained.

Penalties due to Readmission and Pay for Performance help to send even less spending and income and economic impact where needed while those doing well due to better location and the most profitable populations avoid penalties or lesser reimbursement.

Sometimes you become the front lines due to closures of other facilities. Sometimes you become the front line by a change in services.

Adoption of a Level 1 trauma designation may seem like a good idea for a hospital or ER, but soon the waiting area and ER takes on a different environment - one less suitable for "the good patients."

Academic centers holding on to aging facilities surrounded by complex and lower income populations with Level 1 trauma designations face great challenges. As states have manipulated Medicaid and forced academic centers to ante up dollars to match with federal dollars, serious consequences have resulted as seen in eastern Omaha to UNMC and Creighton. As care fails, providers move on and patients follow to the next available facilities - next in line for decline. 

The solutions are better pay for primary care and basic services, better pay for small and rural facilities, and design changes that result in less compromise of care where needed. 

Improvements in Basic Health Access can limit or reduce the domino effect 
  1. Instate workforce and payment for 40 states behind
  2. Primary care made permanent and support for primary care clinicians and teams
  3. Workforce and payment for locations in need of care where most Americans are found and need primary care and basic services and facilities

Further concentrations of workforce and spending in 6 states, in highly specialized care, and in 1% of the land area with top concentrations of workforce will accelerated domino decline by design.

Accelerating Cycles of Primary Care Decline

Recent Works

Declines in Health Care Delivery Despite Increases in Health Spending

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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