More Confirmation of Small Health Value and Small Health Neglect

No small part of America is impacted by designs and information sources that disadvantage small hospitals and small practices. In turn, this continues to disadvantage and damage the people that depend upon small health care.

Over six months ago this first small health review indicated substantial problems. More evidence has been added regarding the value of small health and further neglect of same.

Studies have indicated improved outcomes for small practices and a new one from BMJ demonstrates the same for low volume hospitals. 

The chief actuary for CMS has indicated that increases in the cost of delivering care are too much compared to stagnant payment. Remember that primary care and small practices are paid less and have more difficulty making all of the regulation adjustments.

The Paucity of Awareness Continues

Paucity used to be a favorite AAMC word. Sadly it is our health leaders that often have deficits of awareness. The impact of lack of awareness continues to damage and destroy.

At a recent panel discussion to discuss the great benefits of ACA:

"We need to be sure that the delivery system provides enough capacity in primary care, especially in rural and targeted urban areas," said Slavitt (acting administrator for CMS).  

This appears to be good awareness, unfortunately CMS has done much to destroy capacity in primary care, specifically to the rural and targeted urban areas of need. 

Learned panelists continue to make the mistake that access is about insurance - when access is really about available and accessible workforce. Payment too low for decades has shaped poor access, and payment too low continues by design along with higher cost of delivery.

Small Practices 

  • Are perceived as impacting relatively few, but small practices of 5 or fewer physicians include 45% of primary care in America - essential for 40 - 50% of Americans in basic health needs. This is about 25% of encounters.
  • Are most commonly basic health need areas include mental health, basic surgical services, primary care, and dental health. If an area is in decline, it is generally associated with small health.
  • Receive few lines of revenue, have few basic services, are often paid less for the same service as compared to larger or outpatient settings
  • Can have higher costs of supplies and other costs of delivering care
  • Can have the highest special cost increases such as recruitment, retention, and locums costs because of shortages of various health personnel at small practice sites - shortages due to designs of payment and training
  • Are hurt by rapid change - rapidly increasing costs of regulation, certification, software, revisions
  • Have higher complexities of patients and often deal with gaps in local social and health resources plus other factors that shape lesser outcomes rather than providers
  • Can receive more penalties for care outcomes - outcomes that they often do not shape. This makes situations worse where care is needed
  • In the media and in the literature are often painted in a negative way and small health themes include rural, small, lower in volume, and generalist vs specialist controversies 
  • Articles in the media/literature often ignore small practice differences in many areas that shape outcomes such as patient populations and resources, assets and barriers - poor awareness contributes to misunderstanding 
  • Small health is an easy target for political and health designers bent on cost cutting. Small health is small, distant, poorly organized, and  attacked from so many directions such that defense is difficult
  • Small health can lose out on federal funding because bigger entities are more organized. Sometimes funding (CHC funding) must be protected for the use of small or rural practices to keep from further inequitable distribution.

Small Hospitals

  • Include emergent or acute hospital services for 40% of the US population including nearly all rural hospitals and many single county urban hospitals
  • Have few lines of revenue, paid less, may have higher costs, not able to demand discounts from suppliers
  • Can suffer from higher costs in the same supplies needed for health care deliver and other costs can be higher including recruitment, retention, locums
  • Have rapidly increasing costs of regulation, certification, software, software revision
  • Are more dependent upon low pay (Medicare, Medicaid, lesser insurance, high deductible), and no pay (indigent)
  • Face declines in revenue due to declines in disproportionate share funding, limitations in Medicaid expansion, economic and other declines in the counties specific to small hospitals
  • Are in counties where population growth is higher 
  • Are in counties where complex populations are increasing faster (elderly), are higher in complexity, tend to have lesser outcomes
  • Are in counties with populations likely to result in readmission penalties for the hospital, based on care of patients oldest, poorest, least in health literacy, and with higher smoking, obesity, sedentary rates, attitudes and behaviors not conducive to best health outcomes   
  • Face media and academic articles predominantly negative, usually from authors not familiar with small health, and often compared to Big Hospitals with multiple more streams of revenue, higher reimbursements, different patient populations, different personnel, different relationships, and other differences - differences that should prevent publication or require as much explanation as the length of the article itself
  • Are an easy target for political or health care cuts
Is there any purpose for trashing small health other than closing small health?

Such attempts at closure are misguided, because small health is all that exists for much of America - suffering under Big Health design.

Small health is not the reason for cost overruns, and in many ways represents higher value with same outcomes for less cost and fewer visits. 

Health Professional Training Design Contributes to Inequities

Health professional training is concentrated in a few states where big health dominates and the focus is highly specialized career for MD, DO, NP, and PA. The design of health professional training is the opposite from the requirements of a small health workforce - a workforce that requires training distributed equitably among states (not stacked in 6), emphasis on primary care and basic specialists that remain in core specialties, and training in small health locations.

The Triple Aim of Health Access is
  • Instate in states of need, 
  • permanent to primary care for a career, and 
  • training influences specific to small health locations 
This is what is required for recovery of basic health access and primary care. 

Rural and urban locations in need of clinicians are Small Health Care in America 
  • Areas in need of services, jobs, economics; 
  • Areas with lesser social determinants involving income, jobs, economics; populations subject to previous exploitation, outside land ownership, public lands that yield no tax revenues; 
  • Populations distant, different, less organized, and with less political clout; 
  • Locations disadvantaged by a number of government designs involving spending, making recovery even more difficult

Populations More Likely to Be Served By Small Health America

  • Small health is more likely for those in need of lower costs of living and lower costs of health care
  • Elderly, Medicare, Medicaid, Veterans, working poor, and less educated populations as well as others on fixed income or subject to lower income are about 43 - 50% found in areas of Small Health dominance where 40% of the Nation's Population can be found in 2621 counties with lowest concentrations of clinicians
  • Population growth in lowest concentration counties still remains 1% per year where Small Health is found- twice the rest of the nation. The rate of population growth in the 2621 lowest concentration counties has been three times greater as compared to the 79 counties with top physician concentrations each decade over the past three decades - a key reason for health care costs too high is health provided where costs in the US are highest - and are least accessible.
  • The populations increasing the most such as the elderly are also increasing most in demand for primary care and basic services. These services are supplied by the workforce facing the greatest challenges, especially where care is needed.
  • Increasing demand is specific to small health.
  • Stagnant/decreasing workforce production is specific to workforce needed by small health care
Rapid growth in demand for multiple reasons and failure to provide the specialties needed or the payment support needed - is failure by design.

  • Small health location for a patient is the result of previous small health location or movement to a small health locations because of inability to live where Big Health dominates.

    Big health care is associated with big cost of living, higher property values, better financed schools or private schools, higher levels of college educated and professionals, and services that are more specialized across the gamut from health to home repair. Movement toward small health location is inevitable when lives reach a point where income no longer increases.

Big Health Physician Origins Are Increasing with Declines in Smaller Origins

Based on birth origins of the most recent decades of physicians, children raised "big" immersed in highest concentrations are 2 to 8 times more likely to become physicians and as physicians they are least likely to choose small practices or careers such as family medicine, primary care, or core specialties - specialties that are most needed by small health care. . 

About 23 - 27% of US born physicians were born in 79 top concentration counties where 12% of the population was found (2 to 1 ratio) as compared to lowest concentration origins that are 1 to 2 or about 19% arising from 38% of the population.

Big Concentration children have been even more likely to gain higher education and medical school admission in the past decade - and also can bypass US schools for Caribbean and international medical schools. Big Concentration children from other nations not surprisingly also concentrate where care is already concentrated

International medical school graduates from other countries are 82% found in 3400 zip codes with 75 or more physicians, leaving 18% for 40,000 zip codes where 68% of the US population is found - including even higher proportions of those needing more care (elderly, veterans). Only the most elite children from the most elite schools (allopathic private, top 20 MCAT schools, top research schools) reach 82% concentrated in higher concentrations. Only the schools with normal distributions of origins and schools with top family medicine proportions of graduates reach population based distribution or about 40% found where the 40% of the population in need is found.

Exclusive concentrated origins are further complicated by Big Health designs for training - a design that shapes physicians to locate in just a few states and among higher concentrations of physicians. This is rewarded by payment design that pays more for the services most commonly seen in Big Health ventures. Primary care and basic services are least important for Big Health and are most important for Small Health.

Population Based Spending Is More Important (State or Federal Government) 

Basic health, basic education, child development, basic nutrition, and other basics are more important for the places associated with Small Health.
  • Small health sites are associated with populations more dependent upon population based spending - spending distributed according to the population.
  • Many sources of spending, especially health spending, are concentrated in few locations
  • Child development, basic early education, basic nutrition, basic services and primary care, basic social services, and small health are more likely to be population based
Small health is more dependent upon retention of local market share - as more people go outside of local for shopping, primary care, or hospital care the local market share decreases. As people transport outside for health, they also shop outside. Since few are thinking about those small and in need, it is more important for small health and other small entities to work toward their own benefit.The Center for Rural Health Works is consistently working to help local small health to become better.

The Good, the Bad, and the Ugly involving National Designs for Dollar Distributions (millions) and Population Distributions (millions)


The basics often have population based distribution with regard to lowest concentration populations as demonstrated by ratios of population or spending relative to the 40% found in 2621 lowest concentration counties. With more specialized services or care comes greater concentration as is best seen in the 79 counties with 10% of the population and highest concentrations of physicians.

Numerous past, present, and potential future political plans include cuts 
in population based spending and other distributions. 

Counties with higher concentrations have advantages in health spending, more lines of revenue, more and highly specialized services as well as top jobs and education, Government spending of all types is centralized in such counties. Government cutbacks from the 1980s to the present typically involve jobs and services in outlying counties with lower to lowest concentrations. Setbacks in the economy may lag in impact for a short time, but small areas take more time to recover after setbacks.

Insurance coverage works well for higher concentrations, but less well for lower and lowest concentrations. Even with insurance reforms, small health locations still have barriers to care and barriers to the spending needed to expand care.

Lower and lowest concentration county populations also tend to have lesser insurance and high deductible plans. Poor competition between insurance companies translates to lesser value - higher cost of premium and less benefit. Populations already behind pay more of their income for health insurance coverage and get less value for their investment. A nation that has 30% waste of health care spending makes matters even worse for those already behind that have to spend relatively more.

General surgery as demonstrated in the table is the best distributed of the physician specialties (compared to 0.9 ratio for family medicine), but general surgery is still poorly distributed, is shrinking nationwide, and is shrinking even faster at 2 - 3 percentage points a year where care is most needed. Other general surgical specialties are shrinking at 2% per year where care is needed.

Two to three times as many graduates are needed to get 1 to distribute to 2621 counties with lowest concentrations. A design that requires too many specialists is insanity for care where needed result. Other specialties beyond family medicine and general surgery are generally 0.35 to 0.55 distributed in a population based fashion when it comes to lowest concentration counties. Nurse practitioners and physician assistants that are active clinicians are 0.62 distributed where most needed. Producing more of any specialty other than permanent family practice increases concentrations of MD, DO, NP, and PA clinicians.

Health spending that is population based is needed to support the broadest generalists and general specialties for small health. In fact, without more spending, there is no solution for small health as there will not be more workforce and more services where demand is increasing most.

Health spending designs
  • Concentrate spending where the most specialized are found
  • Concentrate MD, DO, NP, and PA where clinicians are concentrated
  • Pay less for primary care and basic services and care where needed
  • Convert MD, DO, NP, and PA to non-primary care specialties with losses of basic specialties and core specialties
  • Facilitate 11% growth of physician sub subspecialty positions and 4% growth of subspecialty fellowships for incredibly rapid growth of most specialized physicians at the cost of core specialties, basic services, and primary care (Jolly, Academic Medicine)
Big Health payment and training designs make it difficult to find and support the workforce needed for small health and in small health locations.


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."

Open Season Upon Small Health Care

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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