Open Season on Small Health By Big Media

Numerous articles by Big Media, by Big Health experts, and by researchers immersed in Big Health Care
are misleading Americans about small health care.

Articles commonly include poor assumptions, glaring research errors (comparing apples to oranges), and poor controls. Research in recent decades has also been significant but the changes are so small as to not be relevant. 

The New York Times and other Big Media outlets have an eye out to capture the quaint "best of times" for those smaller, but their attempts to expose the worst of times can fail to hit the mark. It is really hard to write about someone or something quite different because your own perspective gets in the way. This is true for journalists and also for medical journals.

A JAMA articles that indicated lower quality for rural hospitals started off by violating a most basic research error of attempting to compare apples to oranges. The study lumped numerous types of hospitals in numerous types of locations together including hospitals with different services, patients, personnel, and patient selection. A most important difference is different funding. It is difficulty enough to do such studies. Rural hospitals can be compared to each other with some difficulty.

Medical journals have struggled with studies that have attempted to explain quality differences. Unlike the typical drug studies with large numbers and double blinded design, quality studies require substantial data collection in more dimensions. Often any differences in the findings are about differences in the populations receiving care. 

There are also other limitations not commonly discussed. One problem with distribution of scanning technology is that the corporations can be unwilling to sell to small health operations that are somewhat distant. The cost of maintaining such technology can be prohibitive and techs can already be in short supply.

Big Media Coverage Bias

Media coverage is often minimal or lacking when large is demonstrated to be a disadvantage.

Sixteen state attorney generals from states of various colors have agreed that larger hospitals and employed physicians represent higher health care costs for a state.

A few recent articles have indicated some advantages of smaller practices. Imagine that, small practices of 5 or less physicians with a lower rate of preventable hospitalization and even lower rates of hospitalization with 2 or less physician practice size.

Large may mean quite distant from populations in need of care when dimensions other than distance are considered. Large can mean more impersonal.

Where Is the Coverage of Big Health Squeezing Small Health?

Big Health can demand discounts from various suppliers that then turn to smaller health operations to make up the difference. Discounts for a few can mean price hikes for many. Where is the coverage illustrating the disadvantages to those small when Big Health squeezes suppliers.

Big Health can pay employees more and select employees with more skills and experience. Small Health must turn to rookies or those less experienced. Small Health must pay recruitment bonuses, retention pay, and locum tenens, plus losing ground with turnover of personnel. Primary care has an entire pecking order with underserved practices often having rookies. More experienced and better personnel can move on to primary care practices with better support. Eventually such personnel can find jobs with hospitals and sub specialists again following better pay and support by national payment design. Across dimensions from small to large, there are differences in personnel, scope, specialization, resources, and other areas typically shaped by payment design.

Small also translates to little ability to address serious and growing problems regarding delays or denials of health insurance coverage by insurance or government actions. Appeals are easier for Big Health. Big Health can have entire divisions of personnel jamming the official channels with their appeals. Small Health may not be able to afford the time or effort to even make a protest. Waiting for two years for an appeal may be possible for Big Health Care, but such a delay is far too long for Small Health cash flows. In the smallest or solo practices, the physician can take time to make an appeal, but this cuts into time for generating revenue or family time.

Forcing Big Health Costs On Small Health Care

Few articles talk about the disadvantages of small health care forced to be bigger or forced to spend too much to deliver care - by national regulations. There is some growing awareness of the substantial disadvantage of health information technology, electronic software, Meaningful Use, conversion to ICD-10, and other changes in rapid succession past, present, and future. Small hospitals and practices may have difficulty surviving. In fact, the intent of much of the recent Big Health directed innovation and reorganization is to force smaller to be combined with bigger - a situation that has not worked out well for local health care needs in the past or present and not likely in the future either.

An example would be Big Health taking over smaller mainly for the Big Revenue benefits - referrals for specialists and hospitalizations. It takes a minimal effort by a big system to accomplish this and it is all too easy to neglect investments in local health access and basic services - lowest paid by national design. Big Revenue attracts the attention and becomes the focus and the basic needs of those smaller fall behind. The recent march on Washington by a small town mayor over the larger system takeover of a local hospital and the broken promises along the way is only one of many situations facing small health care. 

                     Small and rural hospital closures appear to be accelerating. 

Sheer large size has often forced Big Health to do more with information, personnel, management, administration, higher paid CEOs, more vice presidents, integration, teamwork, and other areas. It is frustrating for small organizations to be forced to change to such procedures and practices when there is less reason to do so and where integration, teamwork, and continuity already exist. 

Hospitalists and the Hospitalist Design has worked for Big Health, but this design may not work out for Small Health. Of course small health has been forced to go along for even higher cost of delivery while facing serious revenue issues. 

The pressure to close the small and force care in larger facilities has become enormous. Of course small may not necessarily mean lower quality. Care outcomes often have nothing to do with rural, small, large, urban, insurance, type of provider, or other common pop culture followings.

Anatomy of an Article Assuming Small Health Problems

A recent New York Times article indicated that small military hospitals were a problem.  In time, the Big Health perspective can be seen in the assumptions that are exposed.


Are These Facilities Really Too Small?

Of course the article defined "Small Health" by New York City standards – 30 or fewer inpatients a day. Perceptions can be distorted when you are used to 5 to 10 times the national concentration of physicians and there are no facilities around without many times more inpatients seen. 

As noted previously, across the nation thousands of hospitals fit these “too small” criteria. These hospitals have segments that have high and low performance measures.

Is There a Reason for Military Hospitals To Be Small?

The article fails to mention the specific needs of the military or advantages of embedded primary care, mental health, physical therapy, and local hospital care – essential for a most efficient and productive military. In the military, many things can go wrong very fast and very distant from Big Health. Big Health also is forgetting that small hospital closures are killing people in need of emergent care.


Small design is also essential for breaking down the barriers to care – a common problem for soldiers who may tend to avoid health care for mental or physical needs. 

Did the Article Consider the Population Served?

The strengths and limitations of those who become our soldiers are not mentioned. Soldiers tend to come from less advantaged backgrounds. Advantaged populations are the ones with better outcomes, but they have not been volunteering as much for military service.

Some of the smallest units have been and will be on the front lines – 
surely not all small military operations are problematic 
or have we forgotten the great advances of MASH units?

Why Focus on Small Military? Why Not Other Problem Areas?

Numerous stories could have been shaped involving military health care – chronic problems with TriCare, poor quality in some of the largest military hospitals, or closures of many military health facilities. These would be old news however. The article also fails to mention closures of a number of smaller military facilities, but this would undercut the points made in the article.

Was There a Good Point of the Article?
 

The article did mention military cost cutting as a reason for adverse effects. A real story useful to the nation could have been an article about the worst impacts of cost cutting upon facilities that are most distant, smaller, and poorly supported with least cash flow. One could also ask the question whether the military can address its health care needs and accomplish what it wants to do.


Writing Your Own Article for the Gut Punch

Americans need to understand how research and media articles are misleading. Articles that generate controversy are more likely to get published. Articles about poor quality are really hot right now. Grants about this area are also being funded. The problem is that it is really difficult to demonstrate poor quality - unless you have a study that compares advantaged to disadvantaged populations where you can demonstrate a difference. 

There are a number of reasons why small hospitals or small practices do better or worse – and the reasons are often not about being small.

Step 1 – Anecdotal Story

Readers need to be captured quickly so it is important to find a tragic anecdotal story of a person that has somehow been impacted by small health care. A picture of such a person who is a child or minority can help. "Patients done wrong" plays well in the national media.

Often those interviewed are unaware with regard to how their interview will be used, or taken out of context. I became a poster child for doctors done wrong in rural practice in 1987. If you can find a picture of an old facility, this can add to the assumption. I learned the hard way about the media and how "doctors done wrong" plays well for physician media.

Also a Medical Economics editor wanted to make rural hospitals look bad, ghostwrote an article, and when I rejected the article he posted the bad examples out of context anyway. 

In qualitative research it is considered a measure of validity when you share the research article with your subjects. Interestingly few take this step - hmmm

The bandwagon is ripe for heaping blame upon physicians also. Find the error in this statement: We pay doctors when they provide lots of health care…  This one has numerous errors. Two-thirds of doctors are employed by corporations and institutions so the correct statement is that we pay corporations when they provide lots of health care. Arnold Relman was right to fight business and profiteering influences as long as he could. But it is sadder that doctors get too much credit and too much blame - along with rapidly declining respect. With such declines, the cost and complexity of care will increase.

Step 2 – Find an Expert

Next you need support for your assumption about small practices. You can find some one in academics who has castigated small practices to add a colorful quote. Big Health and Harvard experts go together for this NY Times article.

Step 3 – Provider Statements to Fit

If you ask questions the right way, you can get the answers that you want. If you cannot find this directly, a general statement without any detail or documentation will do nicely.

Step 4 – Take Advantage of Popular Beliefs with Half Truths

Sentences combining half truths are quite believable, until sentences are carefully examined.

The main sentence of the article deserves specific detailed attention. “Many of the hospitals run by the armed forces are so small and the trickle of patients so thin that doctors and nurses say their ability to properly treat serious illnesses is compromised.” Talk about being vague and general...

Many of the hospitals are so small - Readers should now understand that most of the remaining US hospitals are small across many US divisions. Small may or may not be relevant.

Trickle of patients is so thin - just because you are small does not mean a trickle of patients. Also if the patients tend to have the same conditions, common in military personnel, then there is often experienced with the type of care in most demand. 

Doctors and nurses say their ability to treat serious illnesses is compromised – It has been difficult to find doctors or nurses that admit care compromise, especially in the military. Serious illnesses in the military as in other settings are generally not treated by small facilities.



I learned this the hard way when testifying in Federal District Court about the Reagan payment design of 1983 that paid 20% less to new physicians for the services that they provided. The federal lawyer asked me how this resulted in compromise to my patients. In other words doctor, how are you committing malpractice due to lower pay? Now we know that patients do suffer, but this is more about lower concentrations, more gaps, less resources, and worsening situations - by state and federal and corporation designs.

Small hospitals and practices are not necessarily worse or better. Good research and good journalism should capture important areas such as small is different than large.

Those intent on comparisons where comparisons should not be made and finding differences where there are not differences - are most likely to mislead.


Recent Works

Open Season On Small Health Care

Costs and Consequences for Hospitalist Growth

Health Access Failure from the Start

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

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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