Demographics Distributions and Discriminations in Health Care

As we have more and more big data, the most basic and simple data makes more sense.  The problems that exist for most Americans are problems created by the designs for health, education, and other spending. The following is a review of the demographics, distributions, maldistributions, discriminations, and disparities by design.
Readers could gain some understanding of the frustrations of most Americans left behind, and why substantial Americans were willing to vote certain ways, and why those inside fail to understand those outside. There are also explanations regarding why expansions of the worst insurance plans (Medicaid, high deductible) did not work for lowest physician concentration counties as they did not have higher levels of uninsured. Also the Demographics Stack Against the Democrats.

Yes the health insurance expansion was poorly targeted as a solution for health access. The problem for these lowest physician concentration counties is that they have concentrations of lowest paying plans least supportive for local workforce. Workforce is the result of the past 30 years of health policies. Continuous and consistent deficits indicate consistent deficiencies in payment policies by design.

Higher Concentrations of Complexities

A figure indicating over 40% represents a higher concentration for these 2621 lowest physician concentration counties. This starts off with higher concentrations of poor to fair health status, diabetics, smokers, sedentaries, premature deaths, and other poor health behaviors. Does pay for performance begin to sound like a bad design for providers for these counties facing the least healthy patients with least local resources?

49.8% Number of Diabetics 2013 (also more obesity, smoking)
46.9% Payments for Social Security Disability 2010
45.1% Premature Deaths 2010
43.4% Social Security Benefit Payments 2010
42.2% SNAP Payments 2010 (should not be a surprise since most goes to those elderly, poor, or both)
42 - 45% of Medicare, Medicaid, Veterans, Elderly, Poor, Poor Children, Complex elderly, Homebound Elderly
41.0% Unemployed - not really much different than 40% despite changes in agriculture, mining, manufacturing...
Higher concentrations of the above indicate great potential consequences for Republican plans to cut Medicare, Medicaid, SNAP, and Social Security as these counties (essentially the Red Counties) are more dependent upon health, education, and social spending as there is less economic impact from other areas. Continued austerity focus at the state level with federal cuts as planned would be devastating for the counties that voted Republican.
40.7% Uninsured 2014 (so much for health insurance expansion as not that much different than the 40.2% of the population in lowest concentration counties)
40.2% Population in 2010
38.6% Population in 1990
36.6% Population in 1970
The lowest concentration counties are fastest growing in numbers, elderly, demand, and complexity. These are counties with no change to worse in health workforce. Generalists and general specialties are 75% of workforce and 90% of services and are being suppressed by designs of payment and training. Family medicine is 24% of physician workforce and is being eroded. General internal medicine was 13% of the workforce and is in full collapse. General specialties are in decline as few stop after their original residency training and do 1 or 2 fellowships that resulted in major increases in their salaries and support structures - along with worst distribution.
It is not hard to predict that maldistribution will be worsened, primary care and basic services will be more overwhelmed, and providers where needed will face the most burnout, productivity losses, turnover cost issues, and regulatory problems. These are a bad combination made worse.

The top concentration counties have half of the US population growth rate and some are shrinking but workforce is stable to increasing. Top concentration counties have 135 residents per 100,000 and lowest concentration counties average 115 active physicians per 100,000.
Fastest growing is also a problem for whoever the voters in these counties think is doing them wrong. 

Population Based Distributions of Workforce - Rare Except Family Practice
36.3% Active FM docs 2013 (FM grads decreasing from 95% FM to < 70% in the last decade with movements to ER, urgent, hospitalist due to payment design)
36.0% NP and PA in Family Practice Positions (only population based type, decreasing proportions due to departures for all other specialties)

Only family practice positions filled by MD, DO, NP, PA have population based distribution but all are falling to lower proportions by designs of payment and training. More specialties are being created with more finding their way to these specialties leaving family practice behind by design.

Education Deficits Are Not in Isolation

27.4% Bachelor and up Degrees 2000 - This is the one area blamed for election results as it fits stereotypes - about all some in top concentration media seem to understand. Even worse, simple education data is often used as a control in research studies. These fail to capture the many differences in many areas. Trying to compare rural to urban or male to female in quality is a problem because there are so many differences. Males and females are different in distribution and in many other areas - and in ways that would have explained the comparison.

Workforce Failures Continue By Payment Design

27.2% Gen Surgeons 2013 (falling fast by payment design)
26.9% Physician Assistants with NPI 2010 (flexible workforce follows payment)
25.8% Advanced Practice RN w NPI 2010 (flexible follows payment)
Payment is what prevents distribution and primary care solutions - not any number of proposed primary care solutions across past decades. 25,000 NP and PA were needed to replace lost resident workforce due to resident work hours limitations. Better payment works. Lesser payment fails. Better payment, better support, lesser complexity, and more amenities is a difficult combination to overcome.

25.5% Office Visit 99214 Medicare Payments 2015. Fewer office visits where needed are the result of insufficient workforce and this is confirmed with lowest payments for the same services. The numbers are bad and payments are worse - thanks to the transparency of Medicare data.

Less payment is seen in the lowest concentration states, regions, and counties and for office care and in rural areas and in counties without hospitals by payment design. Another discriminatory dimension was added via pay for performance.

Half of the Concentration
23.5% Mental Health Providers 2013 - 45% - 50% of mental health issues with less than 25% of MHP and less than 16% of psychiatrists - and again growing fastest in population, elderly, complexity, plus lowest local resources...

22.0% Physicians and Clinicians 2013
20.8% Active 2013 Physicians
20 - 24% Other General Surgical Specialties (ortho, uro, gyn, eye, ear) General surgical specialties were 24% of local workforce but are declining by payment design
20.2% Other Primary Care Not FM (takes 6 IM grads to get 1 for general IM and 12 would be required to get one where needed)
18.4% NonFM Docs 2013
12 - 17% Geriatric, Psych, Cardio, Nephro, Pain, Neuro, Derm, Rheum

Only 13% of geriatricians locate in lowest concentration counties where 45% of the elderly are found. The next time that you see geriatricians or geriatric ERs or geriatric solutions for the homebound elderly then you know that they are doing promotion and not solution. And if you see promotions of measurements of quality for the complex elderly, efforts that would add to costs and not actually help the complex elderly where most are found, you know that the designs are making matters worse by further meaningless distractions of overwhelmed local workforce.

14 - 17% Hospital Based Radio, Anesth, Path, Hospitalist)

6.6% Residents in Training 2013 Academic associated professionals are seriously maldistributed across faculty, researchers, medical students.

Does Academia Compromise Health Care for Most Americans?

Top Readmission penalties 1% and up when max was 2% were given to 14% of the hospitals that still remain in lowest concentration counties compared to 3% for urban and 9% of rural hospitals. 

Flaws in the Readmission Improvement Claims

MACRA also results in discrimination well known in pay for performance schemes - making matters worse for providers where care is needed and ultimately for patients who suffer via declines in social determinants.

Prevent MACRA to Do No Harm

Pipelines to Primary Care or Rural Practice or Underserved Practice Are Prevented By Designs Impacting Physicians Birth to Admissions to Training and Beyond

About 15% of US born physicians and only 10% of US physicians overall arise from lowest concentration counties - most urban, highest income, foreign born origins at 2 to 3 times more likely to become a US physician. Only about 25 - 30% are found in such counties. Trying to admit based on origins in the hope of better distribution is not worth the additional costs.      Birth Origins and Admissions Data

New Deficit Categories for Lowest Concentration Counties

Lowest concentrations counties have suffered the most closures of small hospitals over 700 since 1983 and closing at 1 - 2 per month again. The population in a county without a hospital is one of the fastest growing US populations and family medicine is particularly important for local workforce - but is prevented by design - mired at 3000 annual graduates since 1980.
Decline By Financial Design

Arguably lowest concentration county providers have the most increased costs of delivery per physician/clinician since 2010 and have had the most changes to make in practices. Many have chosen to merge or retire or change practices.

Also these counties have the greatest increases in recruitment and retention and locums costs. The cost continues to increase at 1.5 to 2 dollars more per person in the county per year. Annual increased costs are in the 400 million dollar range.

Turnover costs have increased past $300,000 per lost primary care physician.
These additional costs plus $40,000 to $60,000 more added in costs per primary care physician per year (more for Primary Care Medical Home) are devastating with stagnant revenue and lowest payments by design.

The changes support substantial losses of small practices and losses of local active physicians but it will take a few years for data to demonstrate this. Every important source of physician workforce is in slight to major decline.

Huge Disparities in Health Spending

These lowest concentration counties with 40% of the US only have 21% of physicians and about 13% of health spending. The figure of 3.3 trillion dollars can be used to estimate payments per person specific to the places where spending occurred. Based on physician distribution and payments by type of service, only about 3500 dollars per person spent in these counties compared to 29,000 dollars spent per person in the top physician concentration counties where 10% of the population resides. This is an 8 times difference matched also by differences in probability of admission about 6 - 8 times greater for those born in top vs lowest concentration counties. Subspecialists are also about 6 - 8 times more likely to be born in top concentration counties compared to lowest concentration. 
Only family medicine has equitable origins and distributions at about 1 per 100,000 per class year. All others have more exclusive origins and more exclusive distributions.  Exclusivity Index Table

Designs for health spending and education spending help to create disparities and access barriers.

Slash and burn for Medicare, Medicaid, Social Security, Disability, and SNAP would devastate these counties that have less other economic activity.

Essential for equity is an increase in payments for basic services and a decrease in costly regulation such that over the next 30 years these counties can shape reasonable levels of primary care, mental health, and basic specialty workforce.

The 2010 reforms did not help these counties that already had insurance, did not help the existing insurance to support local workforce, and did not take on cognitive vs procedural reforms needed such that MD DO NP and PA can be supported in the workforce that will meet increasing demand where that demand is most increasing.

Regions of the country are divided into top physician concentration counties with 10% of the population, Higher concentration counties with 20% of the population, a Middle 30% region, and a Bottom 40% lowest in concentrations of physicians, physician assistants, nurse practitioners, mental health providers, and a number of determinants of health.
Population % Top 10% Higher 20% Middle 30% Lowest 40%
Counties in Category 79 152 286 2621
Population Numbers 31.5 million 63 million 94 million 126 million
Active Physicians per 100,000 in 2013 Masterfile 468.9 305.0 222.5 114.6
Residents in Training per 100,000 as of 2013 154.39 58.75 29.90 6.43
Raw Economic Impact from Physicians per Person  $10,298.72  $6,704.83  $4,885.26  $2,487.15
Adjusted Economic Impact from Health Spending per Person  $14,043.71  $7,619.13  $4,441.14  $1,921.89
Raw Total Health Spending per Person  $21,655.14  $14,098.26  $10,272.23  $5,229.74
Adjusted Total Spending per Person  $29,460.32  $15,746.03  $8,804.23  $3,555.56
Index Comparison to Bottom 40% 8.3 times 4.4 times 2.5 times 1.0

Figures include 700,000 active physicians for 2013 from the AMA Masterfile, 2.2 million for the economic impact per physician from the AMA, adjusted using 3 million for top concentration physicians to 1.7 million for lowest concentration due to differences in payments and specialty types,  3.2 trillion used for total spending, adjusted for additional spending lines in top concentrations (21% to 29% of health spending).

Readmissions Better from ACA or Preexistingly Worse from DRG?

Does Academia Compromise Health Care for Most Americans?

Demographics Against the Democrats

Not Easy Being Swiss Cheesy in Health Info Tech

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.


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