Fighting for Small Health Means Fighting Washington and Those Who Misuse the Media

More articles indicate more closures of small hospitals. These articles have been appearing for over 30 years. Washington designers have implement a lethal combination of cost cutting to shrink revenue plus ever higher cost of delivery as shaped by regulation. The margins are low to negative and hope for the future of many hospitals is vanishing. All it takes is lost hope to die.



Small practices face much the same decline by design as seen in small hospitals - and for the same reasons. It is hard to tell who to blame – Republicans, Democrats, the media that profits from controversy, or the designers that are so out of touch with basic health care needs for most Americans.

The one thing that unifies all who are against small health care is the lack of awareness regarding the situations facing more and more Americans - soon to be half of Americans behind by design.

It was quite interesting to see the HRSA impression regarding these closures. In many ways, HRSA was blaming the patients and their situations. This is particularly telling since the job of HRSA is basically to make up for the deficits that CMS and its designers have in large part shaped for decades. Even with expansions of health care coverage, there has been no reform of the dollar distribution designs that concentrate the dollars into the hands of those largest, most specialized, and most organized. 

This is seen in 1% of the land area in 1100 zip codes with 45% of physicians and over 50% of health spending in places with just 10% of the population. A few states, 79 counties, and 1100 zip codes manage to keep their top concentrations by designs that they largely shape, while most Americans fall further behind. MD DO NP PA and RN are all concentrated in concentrations with family practice, primary care, mental health, rural health, small health, women's health, general surgical, basic, office, and cognitive services all in decline. 

Those proposing more graduates from MD DO NP PA and RN training often claim that they are attempting to address shortages - but they are preparing, admitting, and training the wrong students plus training in the wrong settings plus failing to produce the right career mix needed to address shortages. Such is the power of the financial design to prevent any and all interventions - even with the best training attempts that I was privileged to be a part of as a rural medical educator, was able to study as an editor, or explored in my research.

What will it take to make Washington aware of the chronic problems
that arise from their designs? 

Will they even listen to those outside of concentrations?


American Health Care Claims to Be Moving to Value Based But Has Been Going the Opposite Direction for Decades

As more trillions go for more subspecialized services and more administrative costs, it is quite obvious that American health care is spending more and more for little or no gain in outcomes - by design. The dollar distributions alone shape disparities for many with advantages for few. 

At the opposite end of the concentration spectrum where 90% of local services are lowest paid generalist and general specialty services, more and more is required without increases in the support to do more. 

Small health is actually higher value - same or similar outcomes paid much less. This is a back door route to higher value, but higher value nonetheless. The front door shaped by designers insures that low value and worsening value are the rule rather than the exception.

Dollars prevented from lower concentration counties and dollars forced to be sent away from lower concentration counties practices represent declining health outcomes. Only 40 billion for primary care in 2621 lowest physician concentration counties has been made worse by 6 - 8 billion subtracted for innovation and regulation. This impacts the dollars, jobs, and social determinants that do actually shape outcomes.

More trillions added to 3 trillion health care dollars will only decrease what can be invested in people, local, social,  and community determinants of health as seen across federal, state, local, employer, and personal budgets. 

Higher cost for little or no change in outcomes and runaway spending patterns that worsen outcomes by design represents the opposite of Value Based. Why is it so hard to recognize value in health care?

Triple Threat Kills Health and Health Care Delivery

If you have spent time in the highest and lowest concentrations, the failures are most obvious. It only takes a small measure of common sense to figure out that Triple Threat is compromising care and caring for most Americans - and has been for decades. Care delivery is the heart of health care and designs that compromise those who deliver the care are designs that defeat health care. 

The Triple Threat is killing health and health care delivery:
  1. Decreased revenue for those smaller, less organized, distant, and delivering basic services (with increases for those largest, most organized, most concentrated, and most subspecialized)
  2. Increased costs of delivery forcing more providers where needed to send more dollars away from local care, local jobs, and local determinants of health to pay for more consultants, more grant applications, more costly specialized services, more software, and more regulatory defenses
  3. Increased complexity of care delivery including meaningless and costly changes as well as requirements to address the increasing complexity of Americans and their communities as they age and require more care and caring.
It has long been a grave mistake to think that only inner city or rural populations suffer by design. Already 40% of Americans (with and without insurance coverage) suffer in 2621 lowest physician concentration counties along with other tens of millions left behind in regions of zip codes also lowest in health care workforce, health care dollars, and health care design influence. Deficits of workforce surround highest concentration zip codes in a halo effect. In 30 states there are 1 - 3 areas in one part of a state with highest concentrations while the rest of the state is relegated to lowest workforce concentrations - places where small practices and small hospitals are closed and compromised.



Revenue Too Low
  • Basic hospital and practice services have long been paid at rates far too low. 
  • The worst paying and least supporting public and private plans are concentrated where basic services are most important - but follow the same national design that is unsuitable for most Americans.
  • These lowest payment rates have been set up by those who are immersed in concentrations and concentration concepts. Procedural, technical, subspecialized areas are rewarded with cognitive, office, and basic compromised by design. 
  • For the past one hundred years the designers have been able to use their location, situation, and high level of organization to best design dollars their way. They demonstrate almost daily that they are lacking in reality testing with regard to the situations facing providers where most Americans live and breathe. 
  • These policies have long had discriminatory impact on smaller hospitals, practices, and communities most depending upon the basics. Meanwhile more health care lines of revenue, more health care facilities, more health care workforce, and more health care dollars are ever more concentrated to benefit fewer Americans directly and indirectly. The largest also demand and get automatic increases in payments from payers while the smallest get delays, denials, and take it or leave it contracts.
  • Payments for the same services are 15 - 25% lower where care is most needed and where most Americans need improvements in basic care.
  • Financial incentives not only fail to demonstrate needed outcome improvements, they actually penalize the small providers, rural providers, lowest workforce concentration county providers, and providers for the underserved. This also is documented in the Pay for Performance literature - but momentum has been increasing rather than decreasing. Ending the Disruption of Pay for Performance Is Unlikely for Designers.
  • Even worse, the primary care associations and the foundations that claim to support health access have jumped on the same bandwagon. Divisions have developed between the leaders and the members of such associations. Foundations have selected digitalization leadership to lead health access efforts - neutralizing progress in health access.
  • Revenue is shifted lower also due to lower productivity arising from impairments in the ability of team members to deliver care, the time required for digitalization

The academic, corporate, government, and other designers love to gain press coverage regarding their small and inconsequential efforts to address disparities or the needs of the poor. They love to climb on the newest bandwagons such as the latest population based claims. They have no standing regarding any positive societal gains as their designs help to result in the very situations, conditions, shortages, and environments that they claim to be addressing. The increasing proportions of Americans left behind over the decades indicate just how hypocritical their words actually are.



Costs of Delivery Moving Basic Care to Small or Negative Margins

Any true power of transformation requires the power of investment in the people to drive transformation. Transforming primary care requires fuel - fuel denied by design.


Claims of Triple Aim ring hollow where cuts in costs worsen care where underutilization is the problem and where higher costs of micromanagement compromise or close small practices and small hospitals. This makes it difficult to meet patient needs. The end result is more compromise of Basic Health Access. 

Costs of innovation, digitalization, certification, and regulation have increased faster for those smaller. It is important not to allow claims of outcomes improvement or dollars saved when these policies have helped to compromise care and caring where most Americans most need care. Studies only need to cherry pick the better outcomes of the slightly more advantaged to demonstrate the small amount of difference seen in various studies and reports. Care rated lower because of providers caring for those in most need of care and then used to penalize those providers is unconscionable - but has become the law of the land and the dominant policy of payers.

It is hard to fathom how the original designs of Medicare and Medicaid have so changed. And as is well known, the private payers follow the designs shaped in Washington. Why not, they serve the private payers well.

Meaningless Complexity Forced on Practices
Combines with Unavoidable Complexity

Complexity is ignored by the designers as they continue to make rapid disruptive changes. The designers forget that disruptive changes in health care most disrupt the care and caring. 

The demands have most increased in settings with fewer employees where multitasking is the rule. The biggest can best adjust to the changes in the designs and can manipulate the changes best. The smallest cannot match this effort. The biggest answer that resistance is futile - the smallest will be gobbled up. The smallest know all too well that their populations and practices are unique and their needs are lost by large systems just as Washington designers lose track of their needs.  

Multiple changes make it more difficult to address the complexity of patient, practice, hospital care, family, and community demands where such complexities are higher and the resources are lowest - by national, state, local, and employer design.


Attacks on Small Health Can Result from Intention and from Neglect
Flawed studies have long been used to promote the demise of smaller and lower volume settings. There is a consistent bias that smaller is lower in quality. The major flaw is that those smaller are taking care of different patients and different challenges with less funding and less local support. Nevertheless the designers have received a distorted picture of small health. In many ways changes have been made "to improve health" in smaller settings. Unfortunately this micromanagement has often resulted in worse, not better situations.

Those smaller and less organized most critical for access have been under policy attack since the 1980s. Lack of awareness of the needs of most Americans most behind has worsened this attack since 2010. Summary of Small Health Complexities

Contributions to Decline By Design
These all contribute to ever higher proportions of Americans left behind in places where smaller in size is what is most important to people and patient care. Disruptions, rapid changes, meaningless uses, and barking down numerous wrong trails only delay the necessary responses to Triple Threat.


In almost every case, those bigger and trying to increase their share of the US health care dollar are hurting most people in the US and those who provide care for them. And they are hurting all Americans by the continued compromise of those who actually deliver care as well as compromise of investments in people, communities, local resources, better housing, better nutrition, and better children - the real determinants of health outcomes - or lack thereof.

Every primary care association and rural association and underserved association must fight against this quality/micromanagement bandwagon rather than going
along. The evidence basis is on there side and those supporting the bandwagon should be returned to evidence basis and the necessary prerequisites to lead in health care - a basic awareness of the needs of most Americans left behind by design.

We should be angry - and we should be fighting for real reforms. 


We should fight for basic services paid more and less basic paid less, primary care paid more and non-primary care paid less (also more for mental health, basic surgical services), and more payments for services in locations lowest in concentrations of workforce and less for places with top concentrations of health care dollars.



Left With No Other Solution Other than Obligation

And if there are no changes in the financial design, there will be no changes in workforce as seen in the last generation or 30 class years of graduates. 

It will take 2800 counties most behind to organize and take over the training of their health care professionals to make their training and career contributions specific to lowest concentration counties. 

The sad fact is that the primary care rates of turnover have become so high and the costs of such turnover continue to increase far past $300,000 that it would be less costly and most reliable to begin training at age 14 - 20 using local only students working with local health providers to facilitate community projects while preparing for careers in health access - with training and obligation entirely specific to their needs. 

The preparation and training of teachers, nurses, generalists, and general specialties should be entirely different in ways that those immersed in concentrations of concentrations can never do.

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."

Outcomes involving cost and quality are really about the populations. Clinical or digital clinical interventions are costly and inappropriate for the purpose of changing health outcomes for most Americans. This theme is repeated over and over but designers continue to push their agenda - against the evidence basis.

Small Practices 

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