Amazonian Concentrators Cannot Distribute Care Where Needed


Amazon, Berkshire Hathaway, and Chase grabbed headlines and many speculated on disrupting health care. In fact the headline alone sent health care stocks reeling. The power or concentrated dollars results in fear. To understand the power, follow the money.

Meet the New Boss, Same as the Old Boss

The money trail tells you what you need to know about the designs and designers. The money trail for this Big 3 indicates concentrations of more dollars into the hand of fewer. Experts in the concentration of dollars will likely do no better than those who have concentrated health care dollars and workforce over the past century.

But there will be those who cheer the Big 3 on. Many hope that they will bust through resistance to implement a new regime in health care.

But in health care as in economics, education, housing, and more there is not a new regime.

Meet the New Boss, Same as the Old Boss

Meet the Old Bosses Who Best Adapt and Change To Maintain Control

In health care the changes in the workforce reveals the dollars that have been flowing to those most organized, most concentrated, most procedural, most technical, and most subspecialized. The History of Medical Education from Welch to the present tells this. When you carefully plan each step with your own best interest kept highest, you will find a way to stay on top. Biomedical prowess has been developed. After the first decades of substantial contribution, the newer developments resulted in less gain at much higher cost. Medicare and Medicaid were perceived as government invasion by Big Medicine. But it only took a few years until the designers cultivated Medicare and Medicaid to concentrate dollars. Not surprisingly the 1980s resulted in cost cutting, but those largest protected themselves and those smallest took the worst of the cuts.
  • For example when I started solo rural practice in 1983 I was paid least for primary care services and paid least in Oklahoma and paid least in Area 99 of Oklahoma and was awarded a 15% cut from the Reagan administration as a new physician. DRGs took down hundreds of small hospitals while the larger and largest hospitals did well and even captured new lines of revenue such as GME. The Medicare and Medicaid designs were changed to concentrate dollars - away from distribution where poor and elderly populations were concentrated. 
  • Managed care was a threat, until the powers declared a truce and combined forces with policies that favor academic, administrative, and micromanagement of costs. Not surprisingly they have the major influence over the research, the information distribution, the media, and public belief - which is why the crabgrass of Pay for Performance still spreads despite lack of evidence basis for good and clear evidence for harm. 
  • The academic influence is seen in the micromanagement of quality - also costly, favoring the few, and hurting most Americans and those who try to serve them in lower concentration settings. There is little doubt that precision medicine will be the most costly for the fewest with care delivered in the fewest locations.
                     Surviving Pessimists and Optimists to Deliver Care

Most Lines of Revenue and Most Payments in Each Line - By Design

The 2013 data from the AMA Masterfile combined with census data reveals the concentrations of workforce, lines of revenue, and health care dollars. About 1100 zip codes in 1% of the land area concentrate 45% ofphysicians and over 50% of health spending in places with 10% of thepopulation. 

The Association of American Medical Colleges likes to boast of economic impact arising from medical education - but using their data it is obvious that this impact involves few. Six states have half of the economic impact. This concentration is specific to few counties and a few dozen zip codes. Designs that concentrate favor few over many.

Even primary care is concentrated at over 130 per 100,000 in these top concentration settings with less than 50 per 100,000 where most Americans are found.

There is another little secret. Even those living near top concentrations have great challenges just accessing basic care. A new category of shortage area had to be created - Medicaid population without access due to providers not accepting Medicaid. Designs that create shortage areas amid top concentrations result in diversions of dollars where most needed where workforce, access, and dollars are needed most.

The Tsunami of Runaway Health Care Costs

Wave builds on wave after wave with regard to runaway health care costs. The waves of runaway health care costs have been specific to higher concentrations - biomedical, administrative, micromanagement of cost, and micromanagement of quality. Academic joins biomedical joins CEO/profit focus joins cost cutting joins corporations focused on consultants and info tech - distracting most who deliver care from care while taking away their support for care and caring.

Lowest concentration counties, zip codes, and basic office/hospital services fall behind while highest paid, subspecialized, procedural, technical, and other most concentrated services are protected.

The largest can change their service mix, health plans, payments, location, size, and information. The smallest are stuck with locations, populations, worst health plans, lowest payments, and the consequences of deteriorating national finances and families as well as aging and more complex populations

Leadership Develops the Same Leaders Who Make the Same Associations and Mistakes

Those who lead our nation to higher concentrations circulate through academic, association, institution, corporation, and foundation dogma. If you experience this first hand when you are still more objective - such as entering from rural practice - you will see that there is a grooming process that progresses some and moves others out.

Grooming/culling is also a reason why it is possible for concentration goals to outweigh the evidence basis
1. Against highest cost for little increase in outcomes
2. Against micromanagement of cost - with cost increases the same as saved (CBO)
3. Against micromanagement of quality - also with an evidence base demonstrating no significant increase in outcomes with cost and other consequences

Sadly associations and foundations promoting a mission of health access


  1. Consider insurance access the same as access to care - it is not  Does commonwealth support health access?             Critique of Commonwealth Ensuring Equity
  2. Consider micromanagement of costs and quality to be successful and desirable - they have not demonstrated their value or the value of value based approaches. And their is the problem of discrimination and widening of disparities    Information Technology Cannot Deliver Health Care

The experts apparently do not even understand that each of the digitalization, certification, regulation, and innovation changes cost 50 - 100% more for those smaller as compared to those larger. This is one of many ways that designers have widened disparities in access, workforce, health care dollars, and social determinants.


The theme remains Inspiration Cannot Fix Health Care. It Takes Perspiration - a Return to Designs that Support the Team Members Who Deliver Care.




This is something ignored for too many decades. Delivery of care and caring requires a top priority focus upon those who deliver the care.

The most important theme for improvement of outcomes - It is about the patient, the population, the social and other determinants.

Most Americans need designs that are specific to their needs - not designs forced on them worsening health care and caring.

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