The Impact of Maldistribution of Awareness

Health designs in the United States work for few people in a few locations at high cost. This health design spends so much on administrative and highly specialized services that basic services and basic health access are insufficient for most Americans. A major reason for decades of failure is the maldistribution of health information.

The scientific process begins with awareness of the problem. Those who design health care are raised and trained and constantly immersed in top concentrations far away from most Americans - and far away from the awareness needed to lead the nation in health access, basic services, primary care, and care where needed. 

Medical Group Management Association statements have consistently acknowledged the information arising from the largest and most organized practices. When very little arises from the smallest and least organized, awareness is maldistributed.

Where funding is missing, facilities and practices and workforce are missing. This also results in insufficient access and encounters. The recent insurance expansion can accomplish little without the accessible workforce to do services. Expansions also fail with fees too low and the need to entirely retrain many if not most Americans - who have been trained that access is not around, payment is missing, and usual care is emergent or worse.

The following graphic from Where Americans Get Health Care indicates the ecology of health care. Where most Americans are aware of changes in their health, there is little awareness and little data. Where few receive care there is the most data and the most awareness. These most organized entities also dominate health care design while those least organized and most distant are left out in payment, in workforce outcomes, in health outcomes, in economic benefit, and in growing disparities.

The smallest practices are the most basic, are 45% of primary care (Graham Center), are the least organized, and are falling behind the most under ACA as with previous designs. Despite the challenges, studies indicate advantages for small practices although the new designs are clearly trying to eliminate them. Where practices are smaller there are some advantages to more personal for clinicians, teams, staff, community, and individuals. Again this awareness is common knowledge for rural physicians and the family physicians that most often remain long term locally, but awareness is lacking for those designing payment and penalties.

Health information technology gurus are having a fit when there is any delay to Meaningful Use - which has been implemented as Fire, Ready, Aim. This not quite ready for prime time "advance" and those promoting MU do not have the awareness of clinicians, especially those in the smaller practices and those most threatened.

Even worse, the next ten years will be essentially no pay increase. Meaningful Use change is costly, requires adjustment, and can decrease productivity and revenue. About 10,000 family physicians are within 3 years of retirement and about 36% are providing primary care in 2621 counties lower to lowest in physician workforce concentrations. It is very likely that those not aware will continue to drive more away from needed practices or any practice - by their designs shaped by poor awareness.

From 1950 - 1980 the United States attempted to focus on a health care design that was specific to delivering health care including the wide range of age, income level, and geographic locations. Since 1980 the direction has been more for fewer in fewer locations with ever higher concentrations of workforce. Since 1983 the health care design has had the top priority of cost cutting without attention to preserving the basic services or primary care which have fallen into decline. Lack of awareness killed off 400 rural hospitals in the 1980s and early 1990s and lack of awareness has returned such that another 300 will soon be gone. 

Awareness can improve care and lack of awareness can kill tens of thousands due to declines in basic access.

Variation in the Ecology of Health Care

Revisiting Physician Distribution by Concentration Coding

Ecology of Health Care for a Disadvantaged Population - Native Americans

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

Open Season Upon Small Health Care

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

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


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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