Government Compromise of Trauma Response

In the wake of another gun tragedy there have been many calls for change. Trauma experts have asked for better trauma response preparedness. The advocates for change are taking advantage of this narrow window of opportunity, 

but their calls for changes will not do much. 

How can I be so sure? First of all, calls for greater preparedness for disasters or traumas have been made for decades. The calls have been made by those logical in their thinking as well as those passionate after disasters. But most importantly, there is no design to support change. The funding designs, training designs, and locations of health care would need to be changed in the opposite ways of the last 30 years.

It only takes common sense to understand that responses have become more limited with ER closures, mergers, and movements. The personnel to respond to disaster are fewer and are less linked to ERs than ever. The on call systems that backed up emergency rooms and disaster responses have long been marginalized. Surgical centers allow many surgeons to avoid hospital and ER environments. Trauma Centers are quite costly and often depend upon state decisions regarding Medicaid payment as well as federal support through special funding such as graduate medical education. Some of this federal funding to compensate for low federal health care payment (disproportionate share) has been taken away by recent "reforms." A critical review of the last six years of reforms reveal failure after failure - failure in new insurance plans, failures in coverage, failures due to confusing rapid change, failures with designs that cannot possibly discern quality or cut costs. The failures with most specific import to access are about payment failures. Medicaid expansion fails even in states that expand Medicaid because of payment too low. 

Where concentrations of Medicare and Medicaid populations and other federal patients are found, you will find deficits of front line health access due to payments too low. 

From 1965 to 1980 the M & M design injected funding where there was no funding and increased fees for services regularly. Since 1980 the M & M design has paid relatively less for basic services and pays less for care where needed. The same basic services are paid less and practices and hospitals where needed do no have the more expensive services or more exclusive insurance payments or more exclusive businesses to bail out their lack of support. The impact is greatest upon those smaller and less organized and less able to demand discounts from suppliers or the required higher payments from insurance and government payers.

Rebuilding Response and Responders - a Matter of Funding

For any health care delivery where care is needed, it takes blood, toil, sweat, and tears. Mostly it takes lifeblood. Lifeblood in health care delivery is money. Governments only want to pay less for health care. This is a problem as disaster response requires spending enough to be ready for a disaster or trauma victim or victims. 

For any rebuilding of trauma response, it will take funding. This funding change will need to be led from the top. It is government designers at the federal (CMS) and state levels that will need to send funding to the facilities that must stand ready 24/7/365.

Designing Access for Trauma Patients Means Matching Up Facility Distributions to People Distributions

Payments most for those biggest and most centralized has resulted in emergency response that is limited by design. The responders are concentrated away from those in need of response. Across urban and rural America this has been going on. Once again, hospital systems compete for the local closest to the advantaged and as far away from the disadvantaged as possible - and lowest paying Medicaid, Medicare, Metallic, and other plans.

For decades CMS has caused massive closures of small hospitals. This is a function of payment too little for the cost of deliver plus the increased cost of burdensome regulation. Add to this the rapid change - difficult for the largest and impossible for the smallest. 

To address response to trauma and disaster, designers must stop closing small and rural hospitals and ERs by payment designs that pay too little for Medicaid and Medicare services. 

Leapfrogging to Survive in American Healthcare

Compromises of emergency rooms are guided by bottom lines as hospitals follow the dollars and avoid lower paying populations - the populations that tend to live in areas at higher risk for gun deaths, motor vehicle accidents, industrial, recreational, and other traumas. 

Over the decades you can see what transpires. In Waco in the 1980s, Providence was closest to care where needed and soon decided to move past Hillcrest to the advantaged side of town. Within a few years the entire environments of both hospitals changed. Hillcrest almost failed due to payments and leapfrogged in location, which resurrected the hospital via different location, structure, and function - and more distance from care where needed. 

Hospitals in Omaha have leapfrogged farther away from East Omaha where payments are lower due to patient mix. When primary care is also taken down, there are more consequences. Loss of primary care means loss of a buffer against higher cost patients with lower paying plans. The loss of primary care is a 1 - 2 punch on facilities where care is needed. Academic and other hospitals have long learned to manipulate the system to find ways to get federal shortage facilities to buffer their hospitals. This is why you can find them in close proximity to such high concentrations of workforce, usually rationalizing the high numbers of Medicaid patients without access. Note how lack of payment in Medicaid causes the barriers and creates the opportunity to manipulate the current design. The biggest also help protect the shortage programs in their area. Of course this still results in a doughnut of shortage around their concentrations of workforce.

But overall the hospitals have been forced to move away from central city areas - leaving them more vulnerable to disaster and trauma. The trauma and disaster potential arising from central city highway, industrial, sporting event, recreation, and entertainment concentrations are not considered.

Designs that shape responders are not consistent with need for response.

Domino Decline By Design in ERs

Failed Primary Care and Overwhelmed Emergency Care Shapes Profit Opportunity

The sad fact is that failures in primary care, mental health, and basic services have compromised basic access to care. Emergency rooms were overwhelmed. Entreprenuers have responded to the opportunity with convenience care siphoning off the higher paying patients. Stand alone emergency centers, urgent cares, and retail clinics have stolen ER volume and have taken less complex care away from emergency rooms. These new designs target the advantaged with better paying plans. The overall design results in the more complex and lower paying patients for emergency rooms. 

If want to see another rapid change in your hospital, watch as your ER converts to a Level I trauma center. This is an incredibly complex change as you must be ready for major changes in operations, waiting room environment, personnel cost, and equipment utilization. You can also expect impacts as certain patients decide not to go to the ER or to this ER.

Freestanding ERs and Urgent Cares and even Surgicenters could take up some of the trauma and disaster response - except they are located where retail business is concentrated - away from trauma, disaster, and needed care where lower paying patients are found.

Supplies and Supplier Readiness 

Orlando ran short of critical supplies. This is not surprising as various respiratory or GI epidemics have overwhelmed even basic supplies such as IV fluid. The new cost cutting designs with supplies provided time on target have no leeway for sudden demand. Hospitals with thin margins have cut deals with suppliers to provide a minimum of supplies. Learning from Walmart and others, some facilities do not even own the supplies until they are used even.This does reduce waste and allows a reduction from 20,000 different items to 11,000 but there is no disaster preparedness. 

CMS designs pay even less where access is most needed which is generally where such patients are concentrated. Cost cutting does not allow for key medical supplies to be stockpiled for even a flu epidemic much less for a local disaster. 

As the risk for disasters increases, our transportation deficits are magnified. 

And in the case of transportation disruptions, resupply can be difficult or impossible. Power failures, floods, hurricanes, tornadoes, earthquakes, transportation strikes, construction events, civil disturbances, or high demand for services can cut off most of the people from access to the facilities needed.

In epidemics and disasters, the media can cause more problems.

Ever since the CNN started highlighting various epidemics, the public has been encouraged to crowd into overcrowded facilities - thus exposing the worried well to those who are spreading the epidemic. The push to bring the latest information adds to crowds and crowding in disasters. How many times have you wondered by someone didn't act to help someone instead of filming their trauma?

Poor Payment Design Kills off General Surgical Specialists

Payment designs have been killing off general surgical specialists. More have continued to do one or more fellowships to specialize for better jobs and for better support. General types of specialists are the professionals most important in the 2161 lowest physician concentration counties with 40% of the US population, especially for response to trauma. General surgical workforce used to be 25% of the physicians in these counties but fewer graduates entering the workforce after initial surgical training plus retirements result in a rapidly aging surgical population. The oldest and nearest to retirement depart as forced by age and by national policy direction. As small hospitals are closed, the workforce linked to hospital and general specialty care also fades - as does access to care.

Nationally in the AMA Masterfile 2013 compared to 2005, the various general surgical types (general surgeons, orthopedists, ENT, eye, ob-gyn, urology) were all decreasing by 2 to 3 percentage points a year. New regulations with greater physician frustration, ER closures, surgical department closures, Surgicenter competition, and small hospital closures are making this workforce deficit much worse. 

Sympathy and Empathy Are Distractions from Symphony

The calls for trauma access reform are well-intentioned, but a very different health care design is required to actually have a health care delivery system that can respond to trauma. Battlefield Lessons To Advance National Trauma Care     Up to 1 in 5 trauma victims may die unnecessarily

Articles address a piece of the problem and are usually written from the point of someone who is promoting their side as a solution, but true solutions required a much more comprehensive awareness.

We have numerous innovative people, advocates, groups, disciplines, programs, or institutions that are willing to benefit from their claims of being a solution. They are doing more harm than good.

When designs or articles or programs are not specific to focus on the team members to deliver the who what when where how and why of needed care, they actually move the nation away from solutions. This is not a training or workforce problem. It is first of all a payment problem. No training design or special grant program or other intervention can work if the payment does not support the intended changes. 

Design Failure is Compounded By Failure in Implementation - Deficits of Engineer Thinking

We do not have the leaders that function like engineers to put together the teams to deliver the care, and the supplies, and the workforce, and the training, and the funding, and the administration... to support the facilities in the locations needed. We just have enough of a health care design to allow manipulation to result in care for a few at high cost while leaving behind most Americans.

Bloated Administration

What is also apparent is that the administration generally has become excessive and unresponsive, in ways that preventing action from the local to the national level. Review How to Destroy a Great ER or How to Destroy Care Nationally with the same framework as used in how to destroy an ER.

Designs focused first upon cutting funds and forcing quality have failed to cut funds or improve quality although they compromise front line basic access to care and front line trauma response. The evidence based reviews of MACRA confirm the failures as well as the serious consequences forced upon those who attempt to deliver care where needed.      Prevent MACRA to Do No Harm

Recent Posts and References  

Talk About Unpaid Stressed and Abused For Decades - a journalist wakes to health care abuses, but then there is primary care. 
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure

Population Health from Above or Below  - population health must not be another new crop to harvest for consultants, associations, and institutions. In must remain about the health of the population, not the wallets of those already doing best.
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric

Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions


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