More Reasons for Lesser Performance for Small Health

America is aging. With increases in age, Americans become more dependent and have more care needs in areas such as health, activities of daily living, finances, and more. Aging in America is not equitably distributed. States like Alaska and many of the locations associated with small health care have more rapid rates of aging growth and oldest American growth. Once again increasing demand for health and other services is occurring in locations that have lowest resources and fewest clinicians.

Unprecedented changes are being seen across America - particularly where small health care is dominant. Only a few years after penalties have been proposed and implemented for Pay for Performance or for Readmissions penalties, the landscape has changed. Economic declines, cuts in state and federal spending, failure to produce the specific clinicians needed, higher cost of delivery, and increasing patient complexities have proceeded and have even accelerated in some locations.

Why Do Payment Designs Persist in Penalizing Small Health Care Providers?

The situations are quite different from a few years ago and even worse is on the way.  Just when you think you have Summarized Small Health Complexities, new studies come out to contribute even more to our understanding of complexities - and the folly of attempting to link quality issues to lower payment. A new study highlights the rapid rise of care needs in seniors as reported in Healthjournalism.org from Millbank Quarterly.

Overall, researchers found:
  • Out of the 18 million older adults with some late-life disability, 19.6 percent had difficulty and 28.7 percent received help from another person with self-care, mobility or household activities.
  • Another 11.5 million adjusted for their limitations through assistive devices or reducing activity frequency.
  • About 20 percent of those under age 85 and more than 75 percent of those age 90 or older received some type of additional help
  • Women and widows made up a disproportionate share of those needing assistance, which is not unusual since women tend to outlive men. African-Americans and Hispanics were overrepresented in self-care and mobility assistance categories.
  • Those in the lowest-income quartile had significantly higher needs across all levels of assistance, especially those requiring help with three or more ADLs or IADLs.
  • Family caregivers continue to provide most of the assistance to older adults, particularly for those in lower income brackets.
  • Fifteen percent of older adults reported adverse consequences related to unmet needs in the month before the analysis.  Minorities, widows, or never-married, and those with the lowest income reported the greatest number of adverse consequences.
  • For those living at home or supportive care environments, 32 percent reported at least one adverse consequence in the previous month.
See New Millbank Report Highlights Seniors Unmet Care Needs

And our nation's politicians want to continue to cut needed areas of support?

There is nothing about this report that would indicate anything other than declines in local health outcomes where these scenarios are most likely to be found. We know from national payment distributions of nutrition funding, disability funding, Social Security, Medicare, and Medicaid that small health is where these populations are concentrated.

From what we understand about small health or the 2621 counties with lesser concentrations of clinicians, there are more elderly and they are more likely to be older and less healthy in a number of dimensions. Health literacy correlates with education level and age.

Slow steady worsening of rural hospital outcomes regarding Medicare patients (JAMA study) may actually reflect the slow steady worsening of patients and their situations as guided by aging and deterioration of local resources.
  • It is difficult to see how penalties and even lower revenue from Medicare or Medicaid or insurance would do anything other than worsen care and care outcomes.
  • It is difficult to see how forced closure of remaining small hospitals or small practices would do anything other than worsen local workforce, local revenue, and local social determinants of health 
Social determinants help shape health care outcomes and those with various deficits lack the resiliency to recover. Their communities are in the same shape. Social Determinants and Health Disparities

What happens in rural America has is often a prelude to what will happen in the rest of America. Adverse consequences and challenges often proceed from the smallest health care sites and smallest concentrations of workforce to somewhat larger and eventually even the largest:
  • Rapid aging
  • Increases in populations in need of care and resources
  • Poorly targeted programs
  • Programs that are targets for cost cutting
Rural hospitals  that escaped the closures of the 1980s due to overzealous cost cutting designers were given improved funding during the 1990s but in the last decade, increasing costs of delivery plus deteriorating conditions for local populations are once again difficult to address.

Current and even accelerated declines seen in rural and smaller hospitals may already represent what happens to health care redesigned by health designers who fail to understand the people, their situations, their health care, or their health outcomes.

Continue on to Open Season on Small Health By Big Media

Reference Links

Recent Works

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Too Many and the Wrong Clinicians for graphic - Additional consequences result from designs not specific to primary care or care where needed.   

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

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



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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