Numerous articles have appeared in recent years with the common theme of "small health care is poor quality." These usually come from authors, researchers, and experts with Big Health origins, BH training, BH financial support, or all of the above. It is important to remember that over the past decades, small health origins have all but been eliminated, small health training has remained a tiny fraction of training, and small health financial support is multiple times less by payment designs. Not surprisingly there are misunderstandings when Big Health or Big Media writes about Small Health. Examples of poor assumptions are reviewed.

It is difficult for Big Health to comprehend those different in one or more dimensions.

Americans have been led to believe that their health care is the best in the world. Big Health care in big systems and big institutions can do quite miraculous things - but for only a small portion of Americans for a small portion of their time on earth and only in a small portion of locations. This is the achievement of Big Health care. Geographically one representation is 1% of the land area or 1100 zip codes with 45% of physicians and over 50% of health spending in places where only 12% of Americans are found. AAMC studies indicate 50% of the economic impact of medical education specific to just 6 states - and actually in only a few counties and a few dozen zip codes.

A design that concentrates health activities in a few states and in a few locations leaves most Americans behind in multiple dimensions - local services, health access, local jobs, economic impact, social organization, education, professionals, best insurance, best local resource support, and more.

No one has a choice regarding there origins, and origins shape Big Health or Small Health concepts.

Small Health - Because That Is What Is There

Small health care dominates areas where 40 - 60% of Americans are found. Small health dominates where Americans need care, need clinicians, etc.

Small health care (< 5 physicians in a practice) is 45% of primary care in America as noted in the recent Robert Graham Center one pager.
Small and rural and single county hospitals are important for 40% of the nation's population in 2621 counties with lowest concentrations.
The 2621 counties with lowest concentrations of physicians have 838 or 84% of the one hospital counties and 1509 counties without hospitals or 98% of those without.

The method used for selection of lowest concentration counties stacks the counties lowest in physician concentrations until 40% of the US population was reached - counties less than 200 physicians per 100,000. Also these are the 2621 counties that remain after smoothing or the removal of counties adjacent to higher concentrations of clinicians. In other words, the ability to transport readily to an adjacent county with higher concentrations removed the county from the lower concentration county category. Deficits in these counties are more likely to require crossing at least one county and possibly more to get care. In many states there are only 4 - 9 higher concentration counties in one or two geographic locations in a state with 10 - 15 times as many counties spread across the state with lowest concentrations.

This following table indicates County Concentrations of Physicians Divided into

79 Most Concentrated Counties with 10% of the pop averaging 478 physicians per 100,000
152 More Concentrated Counties with 20% of the pop averaging 311 physicians/100,000
286 Less Concentrated Counties with 30% of the pop at 229 physicians per 100,000
2621 Least Concentrated Counties with 40% of the pop averaging 116 physicians/100,000

The Population may be 10%, 20%, 30%, and 40% but the resource distributions demonstrate a different pattern - a higher concentration pattern

Data from the US census, the Area Resource File, and the AMA Masterfile indicates that small health sites contain more people and fewest physicians, fewest residents, fewest faculty...

Any specialty other than family practice fails for distribution for all clinician sources - MD, DO, NP, and PA. The NP and PA in family practice positions are not shown in the table, but have the same population based distribution as family physicians. Unfortunately the family practice result is shrinking as more specialties are added and more are added to each new specialty. Only the family practice position filled by MD, DO, NP, and PA approaches ratios of 1.0 or population based distribution. The highly specialized specialties best for Big Health are being added - specialties with even poorer distribution and less suitability for Small Health.

Small Health Solutions Are Avoided

(or Big Health Designs Prevent Small Health workforce)

This is why the optimal training should be specific to family practice permanent over an entire career with training in the states in need and in the locations in need. The NP and PA training designs fail to be specific to care where needed because they fail for permanent family practice under their current flexible design. Medical education design fails in health access because the design prevents family medicine choice - the only permanent primary care and permanent population based outcome.

Comparisons of the distribution of population, physicians, residents in training, and various types of clinicians are helpful in understanding the flaws in the American health care design. Top concentrations are seen in residency training funds and research funds. The major influence upon practice location is residency training location. Failure in residency location is across the three major dimensions important for health access:

Concentrations of residency positions in 6 - 10 states - a design failing 30 states with lower concentrations of physicians and lower concentrations of residents
Concentrations of residency training in places with the ultimate concentrations of physicians for maximal influence upon future concentration in such counties or nearby
Failure of residency training to result in primary care or in the general specialties that provide basic services (general surgery, general ob-gyn, general orthopedics). Where care is needed, family medicine is 25%, adding other primary care reaches 50%, and adding general specialties reaches 70% of the physician workforce in the 2621 counties. It is not possible to supply this 70% from only about 20 - 25% of physicians entering the workforce under current designs for training and payment.

Graduate medical education design prevents instate, primary care, and where needed. Chen and Phillips demonstrated the failure of reform legislation to address these three areas. My recent article also indicates the prevention of rural workforce and also prevention of primary care and care where needed. Preventing Rural Workforce By Design

Big Health Care Versus Small As Seen in Ratios or Multipliers

Biggest Health Care is typically jammed into a few zip codes in the top 79 most concentrated counties that have higher ratios of physicians and clinicians - usually ratios of 2 to 3 times greater than population. The least physician concentrated counties have deficits as indicated by ratios less than 1 or far less than 1. Nurse practitioners, physician assistants, and physicians are all 2 times more likely to be found in these locations or 20% as compared to the population of 10%. Generic expansions are best for expanding workforce in non-primary care and in higher concentration locations. Small health care result requires very specific designs for training and payment.
Small Health Care is found in less and least concentrated counties where 70% of Americans are found. Access problems are magnified where concentrations are least and resources are also least in these locations, making care more complex.

The challenges of small health care are great. Populations have higher complexity, fewer resources, fewer clinicians, fewer community supports, lower income, lower health literacy levels, and other barriers to care. Delays before pursuing care are far too common. These 2621 counties are growing faster in population (twice as fast as the most concentrated counties) and are growing fastest in demand for services.

Small and rural counties, small health care, the elderly, Veterans, poor, Medicare, Medicaid, less advantaged populations, and family physicians are more likely to be found where clinicians are needed.

Big Health Gets Big Pay and Small Health Gets Small Pay

Big health care captures the funding and the workforce under the current designs shaped by Big Health. Big health is also capable of deflecting the cost cutting or other policy changes by utilizing their superior revenue plus higher levels of organization plus control over the design changes.

Pay for Small Health services is less by national design. Lesser pay also is a function of relatively more Medicare and Medicaid patients as well as lowest pay for patients with these coverages - pay so low that it can be insufficient to pay for the cost of doing the service.

Designers immersed in Big Health have been very creative in the way they design payment. The designs favor payment based on longer training rather than more experience or greater continuity. Designs favor more resource utilization rather than less, more specialization rather than broad scope, and hospital payment based on flawed wage indexes

Designs pay more for hospital outpatient care and less to physician practices - for the same service! Small health practices get paid 15% less for the same service as compared to practices in top concentration counties.

Our nation designs payment so that expansions of services can be made

where concentrations of clinicians are greatest

while cutbacks in services and personnel have to be made where care is most needed.

Small health gets the small share of the resources. Instead of accountability designed by Small Health and specific to Small Health outcomes, Small Health suffers under accountability forced according to Big Health design. Big Tech, most useful to Big Health, is forced on Small Health, that has insufficient payment to be able to afford BigTech.

More paid by Small Health to Big Corporations in highly concentrated centralized locations represents funding diverted outside of the communities where Small Health is found - communities in most need of cash flow. Big Drug aided by mail order and Part D Medicare has also diverted funding outside of Small Health.

Big Health and Small Health are quite different in many areas other than size. Big Health and Small Health have unique needs, assets, and liabilities. But one size is supposed to fit all and so Big Health wins.

Small health has advantages in a number of areas that could be considered higher quality but Small Health does not pick the measures to assess and reward quality - areas where Big Health would do poorly. Small practices do better in preventable hospitalization. As noted in a recent study

“The common assumption that bigger is better should not be accepted without question, at least in practices of 19 or fewer physicians,” the authors conclude. The authors also question the practice of insurers typically paying lower rates to physicians in smaller practices, which typically have no negotiating leverage. Such an approach may well be shortsighted, they say, since the lower preventable admission rates achieved by small practices compared with large groups can mean lower overall costs for patient care.

but our national designers must understand that there are many other characteristics of small practices and the populations that they serve that contribute to care outcomes - not just size.

New Population Based Study in Annals of Family Medicine demonstrates 3 times greater disparity in hospitalization for those lowest in income compared to those highest. "In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care–sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor."

Pounding Small Providers Again and Again By Payment Innovation

Payment penalties based on "quality" will make matters worse. About 90% of the 2014 readmission penalties at highest levels (1 to 2% of Medicare funds withheld) went to the remaining 838 hospitals in these 2621 lowest physician concentration counties. About 10% of these hospitals received the top penalties and 9% of rural hospitals received top penalties. This is 3 times the level of 3% or less for hospitals in urban or more concentrated settings.

Once again policies crafted under the influence of Big Health are a reason for intended or unintended disadvantages for Small Health. In smaller settings, patient and family and community influences exert more influence and the patient conditions seen are more linked to situation and setting. Where practices are overwhelmed by rapid change or higher complexity or insufficient resources, outcomes may be impacted.

Before readmission penalties, the adverse impacts upon Small Health and others with more complex patients were known and after readmission penalties, these adverse impacts have been confirmed. CMS has ignored experts and expert testimony and research in this area.

Readmission penalties have always been tenuous with regard to their correlation with "quality." Readmission penalties are also shaped by "out of hospital influences," patient mix, patient selection, and comorbidities. This was known before the implementation of such penalties and has been published again and again, but this practice continues. Many hospitals have turned to community resources to aid readmission rates. Some programs such as those involving A T Still University students working with community resources have been outstandingly successful with low cost. Punishing hospitals in communities where resources are missing seems highly discriminatory.

Even though there are higher rates of top penalties involving Small Health, many hospitals do well and this can be due to advantages in the populations that they serve in Small Health or in Big Health. In fact, one of the ways that Big Health stays Big is that it can move its hospital and other locations to take care of advantaged populations - moving to newly developing highest income suburbs.

Small Health is often where there are consistent disadvantages and challenges in many dimensions. It is not a surprise to see discrimination by such penalty designs as readmissions, pay for performance, or value based. The penalties will make matters even worse.

Areas with lesser health spending are not going to improve with even less spending by design and lesser spending by design will shape the entire population further behind.

Talking About Value Based

If you want to discuss value, many if not most of the Small Health settings with less to least health spending come up with the same outcomes as found in Big Health. Value is same or better with less health spending as many in rural health research have attempted to demonstrate without much attention paid.

A payment design set up by Small Health would send more spending to such locations - rewarding Small Health for small costs and good outcomes. This was also suggested by the researchers that found that small practices do better in preventable hospitalization

The reality is that Big and Small both suffer when the main determinant of national health policy is cost cutting. Health spending should be an investment in care delivery. Instead many in Small Health are held hostage - caught between the need to care for patients and increasing costs of delivering care and declining payment.

Regardless of outcomes or value, more is cut with even more cuts coming where providers are smaller and less organized. This may well be the national political design - a continuation of the past 31 years of policy.

Addressing Disparities and Inequities By Design

Building awareness of inequity by design is the first step toward equity.

Policies that continue to put small health care at a disadvantage will adversely impact people in most need of health care directly and also indirectly through economic impacts. The 2621 least concentrated counties have 40% of the population but still receive only about 20% of the Medicare spending of 2011 sent to physicians (recent data release).

Our designers may eventually begin to understand social determinants and distributions of funding and workforce as factors that shape health, education, and other outcomes. But most of us should not hold our breath as this could take some time.

United States Big Health attitude is often contagious and spreads to other nations.

Outcomes in patients with heart failure treated in hospitals with varying admission rates: population-based cohort study This Canadian study also should not have been published. The authors divided patients into high, medium, and low volume emergency room settings. This one choice alone is enough to invalidate the study. A dichotomous choice of high and low would not have reached significance. Even comparing the highest to the lowest was a barely significant. Relevance is also small. As noted previously, the types of patients, the types of physicians, the locations, the research subject selection, and the patient selection factors are always a problem for such studies. One paragraph of limitations is far too little to even begin to address the limitations in this study.

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.

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

How To Resolve Health Access for 40 States Behind By Design

Preventing Rural Workforce By Design

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

Information Technology Cannot Heal - Time to Get Out of the Way of Healing and Those Who Can Help Remove Barriers to Healing

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...

Overcoming Barriers to Health Access Including Portions of ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access?

How Bad Medicine is Sweeping The Country.

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Blogs indicate that primary care can be recovered and should be recovered.

Robert C. Bowman, M.D. Robert.Bowman@DignityHealth.org

Basic Health Access Web Basic Health Access Blog World of Rural Medical Education

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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Open Season Upon Small Health Care