Frying Pan to Fire for Red Counties

Health care designs helped rebuild health access 1965 to 1978 via JohnsonCare. Many of the current Red Counties were blue back then but have since switched. Health care designs 1980 under ReaganCare slashed and burned health care in Red Counties as seen in hundreds of closures of small and rural practices and hospitals. Designs 1990 - 2010 have also failed for Red Counties. Health care designs under ObamaCare 2010 to 2017 were worse for Red Counties already getting the least and compromised the most.

Out of the Frying Pan into the Fire Health care is only one of many frustrations for those who feel that the established designs are failing. It is likely that Lowest Concentration counties will remain most frustrated by lack of design change. Health care designs 2017 to 2021 are likely to make situations worse for Red Counties.

Red and Blue Lowest Concentration Are Similar - The Red Counties are bound together by many similar environments, situations, and determinants of health. They are lowest in physician concentrations due to health care design. Red Counties actually have more in common with minority dominant counties. A few dozen rural counties with largest proportions of minority populations - Native, Hispanic, Black - have lowest concentrations as well.

All are in the same sinking health care boat due to disparities are made worse by health spending and deficits of facilities and local workforce.

Did anyone really think that expansions of the two plans (Medicaid, High Deductible), the two plans worse for local health workforce, would actually help people in Red Counties with least access by decades of designs? See Four Horsemen of the Primary Care Apocalypse

Divisions between various peoples left behind 
are really good --- for those doing well 
in higher concentrations. 

Common ground is that these 2600 to 2700 counties are less organized. At the opposite end of socioeconomics, economics, and many more dimensions are those most organized and associated institutions, corporations, and foundations.

Those most organized who are closest to the government feeding trough have been able to design lines of revenue that favor those in concentrations.

Those least organized lose out in new designs and suffer the consequences of cuts that come with cost overruns because of the old and new designs most benefiting providers in higher concentrations.

The one constant across PPS, DRGs, hospital payments, physician payments, SGR, HITECH, ACA, MACRA, Readmissions Penalties, Pay for Performance, and Value Based is that higher concentrations do better and lower concentrations are left with more challenges to address with less payment, least workforce, and least local resources.

For Example Readmissions Penalties Fail to Indicate Quality or Predict Outcomes
My studies indicated that hospitals in these counties had top readmission penalties at a rate of 14% as compared to rural hospitals at 9% with the average at 5% and urban hospitals at 3%. Readmissions penalties have always had correlations with lesser concentration settings that have more complex and less healthy patients.

Strategies That Will Make Matters Worse for Red Counties
  • CHIP Termination - 47% of poor children are found in counties with 40% of the population. Children's Health Insurance cuts or termination will easily impact 50% of the population directly or indirectly. Loss of payments for child health care will take out workforce for everyone in lowest physician concentration counties. CHIP helps poor families to move up rather than being kicked back down by health care costs. Working poor are helped by CHIP. Why terminate what has long had bipartisan support? Start with CHIP to Return to Sanity
  • Medicare Eligibility Increased to Age 67 - About 43 - 45% of adults age 65 and 66 are in lowest concentration counties. This proportion could increase due to demographic changes and migration patterns. With Medicare design changes, workforce will be compromised not only for Age 65 and 66, but for places with concentrations of those age 65 and 66. Workforce is about support (concentrations) or lack of support (Red, lower concentration).
  • The planned 200 billion to be cut from Medicare and Medicaid (current 1 trillion spent by CMS) will not spare lower concentrations. The case can be made that the 20% cut will be spared from higher concentrations before, during, and after new regulations as they have dating back to the 1980s across all changes in policies.
  • Block Grant funding can also be reshaped to privatization or centralized and concentrated settings resulting in much less for lowest concentration counties. 
  • SNAP, Social Security, and Disability Cuts hit hardest in lower concentration counties where relatively more are impacted (43 - 45% for this 40% of the population) and where other economic contributors are least. Dollars lost are jobs, income, and local resource losses.
Demographics Will Force More To Move To Red Counties

There is no stopping the forces that drive people to Red and lowest concentration counties. See Demographics Against the Democrats. Developers and governments in higher concentrations want the land where poor people are found. They want to move lesser income populations away. They want to destroy housing where poor people are found. Those in top concentrations profit from higher concentrations as seen in property values.

Elderly, poor, Veteran, Disabled, fixed income, and lower income populations must depart the highest property value areas concentrated in concentrations and lowest concentration counties are their only real choices. These are counties that tend to have better climate. Mostly these counties have lower cost of housing and other living costs.

But after moving lowest cost, what is left? Ask yourself what happens when lowest concentration people have even more cut from income or higher cost of insurance or more family members to support. They have already cut budgets to the bone. There is no place else to go to save money.

Mapping Designs That Fail Red and Lower Concentration Counties

A major health care design flaw involves the types of physician specialties rewarded by the payment design. Red and lower concentration counties need generalists and general specialties - the ones that supply 90% of the services in these counties. Generalists and general specialties are paid least and abused the most under past decades of designs.

The following graphic categorizes active physicians as of the 2013 AMA Masterfile by specialty and by 4 types of counties from the top physician concentration counties with 10% of the population/32 million people to the lowest physician concentration counties with 40% of the population/128 million people but only 22% of workforce and less than 13% of health spending.

The actual disparities in workforce (residents, faculty, administration) and health spending (more lines of revenue, higher payments, more specialized care) are worse for a number of reasons reviewed at the close of the blog.

In this graphic, family medicine remains at 26 to 33 active family physicians per 100,000 across types of counties. Family medicine is listed as a blue line that is relatively flat. The ratio of concentrations of family physicians from top to lowest categories is 1.2.General practice is also flat at the bottom but is almost gone. FM is a great contrast with General Internal Medicine that was just 15 per 100,000 in lowest concentration and is over 70 per 100,000 in top concentrations with a 4.3 concentration ratio. Internal medicine has not been a good source of primary care or care where needed in quite some time. There are too many specialties that get much better support and the rapid rise to 40,000 internists taken from the generalist pool has collapsed general internal medicine. This recent rapid change would make the red line much lower and possible more slanted in favor of concentrations. Pediatrics in green also favors concentrations as does general orthopedics in purple

Some specialties are even more concentrated in top concentrations. Note the inflection toward the top 10% for internal medicine (not shown), pediatrics, psychiatry, ophthalmology, hematology-oncology, cardiology, and neurology - a movement away from 90% of the people of the United States. 

Payment Shapes Disparities

Physicians claim a small portion of health care spending but shape a substantial portion of such spending. Health care costs can be estimated by mapping physician distributions. The past 35 years of health payment designs have shaped substantial disparities. In the top concentration counties the design sends over $29,000 per person or 3 times the average and in the bottom concentration counties only $3500 per person is sent or 3 times less than average - a 9 times disparity.

Disparities in payment have resulted in disparities in the availability of physicians, nurse practitioners, and physician assistants. The disparities in payment help shape disparities in jobs, services, economic impact, social determinants, and outcomes in health and other areas.

Most consider workforce to be shaped by training. There is no common sense in this assertion. Regardless of training, the graduates can only seek positions that are funded. The financial design fails for Red and other lower concentration counties. No training can overcome payment designs that pay less for basic services, pay less where care is least concentrated, and pay less for the care of more complex populations.

As noted only family medicine has an equitable distribution with top concentration counties having 1.2 times the family physicians as lowest physician concentration counties. General surgery and general orthopedics have 2 - 3 times ratios toward greater concentration but both are declining in national workforce at 2 - 3 percentage points lost a year comparing the 2005 to the 2013 AMA Masterfile. General surgical specialties are second only to primary care with regard to workforce where needed.

Most Equitable Distributions of Specialties Are Fading By Design

Lowest Concentration County workforce:
  • Family medicine 23% - slight declines over time due to active FM dropping from 95% in FM positions to 70% and also declines in distribution such as 25% to 20% rural location. Most likely FM will remain 23% because of declines in the other specialties.
  • General internal medicine 13% - and collapsing from primary care and from needed locations. Preferences for better supported specialties, less complexity, and more concentrated practice locations defeats contributions where needed.
  • General pediatrics 7% - stable
About 46% of local workforce is primary care and another 23% is general surgical specialties. The workforce found in lowest concentration counties is older - another indication of poor recruitment of younger physicians. After training in general surgery, orthopedics, urology, ENT, and Ob-Gyn it is much better to continue training in one or two fellowships as the payment design rewards this substantially. Basic surgical services are paid least and most specialized are paid most. The recent decades have been least kind to lowest concentration counties as retirements are not being replaced as in other settings.

The newer graduates clearly do much better by avoiding primary care and by taking one or two fellowships. Few stay in their original specialty training. A big deal is made about the higher salaries that result from such training. The support for the specialty may be more important than the salaries. Salaries are easy to collect. Complexity has taken more time to assess. Support is even more difficult to assess. Clearly the most rapid rises in stress and burnout have been in the specialties that distribute the best - and this is likely due to financial designs that fail to support the care delivery

The most distortion is created by lowest payments 
that results in limitations
in numbers and abilities of team members and other supports.

The case can be made that broader scope results in greater complexity. This is now supported by studies that demonstrate greater complexity in primary care. The onerous documentation and regulation has made this worse.

Generalists Burned Out By Design

Declines in mental health and basic specialties thrust the burden upon remaining physicians - especially family physicians. Overall 47% of mental health is delivered by primary care and this has increased to 50%. The proportions of mental health care increase to higher levels where mental health most fails. This is thrust upon what remains.

  • About 36% of active family physicians are found in lowest concentration counties 
  • compared to 23.5% of mental health providers, 
  • 17% of psychiatrists, and 13% of geriatric or child psychiatrists. 
  • The 47% of poor children in lowest concentration counties stands testament to mental health demand with most limited access. 
Mismatch disparities abound. About 43% of the elderly and higher proportions of complex elderly are found in the lower concentration counties where only 13% of internal medicine geriatricians are found (45% of these are international graduates). Geriatrics is too complex to support given lowest cognitive payments and the failures are worse where payments are even less not to mention least local workforce, most complex patients, most Dual Eligible patients, most homebound elderly, least mobility and transporation, and more.

As seen in the chart, lower concentrations result in declines of ever other specialty eventually leaving family practice MD DO NP and PA as the remaining specialty. Broad scope is required for lowest concentration settings, but broad scope can be more complex and more overwhelming. Integration with the community has long been optional in urban settings, but integration with the community is often required where care is most needed.

Why Do Designers and Payers Delay and Deny the Primary Importance of Generalists and General Specialties that Are 90% of Local Services Where Needed

Supports are least where payments are least as seen in lowest concentration counties. Even when presented with Medicare data about this discrimination, there is resistance to reform.

Other specialties have 4 to 7 times higher concentrations where people, income, education, resources, and workforce are most concentrated. This is also where services are overused and high volume is most abused. In higher concentration settings, volume can be considered "bad." But sadly volume is considered bad where it is most lacking - and most needed. In lowest concentration settings volume is two things:
  1. Health access
  2. Survival because of inadequate financial design
Why should volume be considered universally evil when it is so good where care is needed - and so missing?

Why should designs force cognitive, office, and most needed delivery into survival mode?

There is little question that the designers have made it best for concentrated settings and worst where care is most needed.

The disparities in access, services, cash flow, jobs, and economics are significant. Disparities in payments shape disparities in workforce and team members that shape disparities in health care outcomes.

Some specialties are even more concentrated in top concentrations. Note the inflection toward the top 10% for internal medicine (not shown), pediatrics, psychiatry, ophthalmology, hematology-oncology, cardiology, and neurology - a movement away from 90% of the people of the United States.

Innovative Specialties Serve Highest Concentrations and Fail to Distribute

New types of Radiologists replace old. Pulmonary and Critical Care replaces Pulmonary Training. New Oncology replaces old. The one constant in replacing a specialty is that replacement specialties have even worse distribution as seen in pulmonary becoming pulmonary critical care or replacements for oncology or radiology.

Graduate Medical Education Disparity By Design

There is little evidence that the Graduate Medical Education design does much to address care where needed. Indeed only 6% of GME positions are found in 2621 lowest physician concentration counties with 40% of the population. Even if GME locations were changed, the physician concentrations would not change.

  1. No training intervention changes the specialties or locations or positions
  2. Only more support for a specialty or a location changes specialty position numbers or numbers in locations in need of positions

Even more important to understand is that payment design is so powerful that more GME positions in counties of need, more family physicians, more NP, more PA, or more physicians are incapable of addressing lowest concentration counties.

It is even worse when looking at specific needs in lowest physician concentration counties that have 43 - 46% of the elderly, the poor, poor children, obese, smokers, and preventable deaths.

The lowest concentration 40% have 48% of diabetics and only 12% of endocrinologists, 43% of the elderly and 13% of geriatric doctors, and the list goes on across cancers, trauma, fractures, and people with arthritis, kidney failure...

The payment designs that exist just do not allow enough spending to flow to lowest concentration counties where the Four Horsemen of the Primary Care Apocalypse are concentrated - the reason for least support. This is also why expansions of the least supportive plans fail for recovery of health care and access where needed.

See Six Degrees of Discrimination By Health Care Payment Design

Generations of Workforce Failure Require Generations of Much More Supportive Designs

The 1965 to 1978 boost in workforce where needed was temporary. Deficits existed before, during, and after. The last 40 years represent over a generation of physician workforce and two generations of nurse practitioner workforce shaped adversely for most Americans. This can only be changed by a completely different financial design with more for basic services (and less for others), and decreased costs of health care delivery - made much worse since 2010 due to regulation acceleration.

It will take a minimum of 20 years to shape a significant improvement in areas such as primary care, mental health, basic services, and care where most needed - starting a few years after the nation has permanently implemented true payment reform.

Red Counties, Lowest Concentration Counties, and Designs for Spending

The Red counties as seen in popular election maps plus the dozen or so Native American counties, the three dozen Black counties, and the dozen Hispanic border counties are represented by the lowest 40% in concentrations. The characteristics are much the same for 40 or 50% left behind in lowest concentrations when choosing a variety of variables.

Designs Shaping Disparities That Will Likely Be Worse than Projected

About $3500 in spending per person can be mapped to lowest physician concentration counties and $29000 per person can be mapped in top concentration counties where pockets of lowest access are seen even with the top concentrations of health care dollars. Top concentration county spending is three times greater than average compared to 3 times less than average for a 9 times disparity.This results in substantial disparities in health spending. The actual disparities are worse than indicated. This is because
  • Top concentration settings have the most lines of revenue including administrative and other costs not associated with physicians. Lowest concentration settings have fewer health care costs not associated with physicians. 
  • Leadership, association, lobbying, and related costs are clearly among the most concentrated. 
  • Insurance, health system, and practices are becoming more consolidated and demanding more dollars. This comes with compromise to small health.
  • Resident, faculty, and research costs are predominantly in top concentrations. Only 6% of residents are found in lower concentration settings and even fewer physician researchers. The residents in training are among the most concentrated at 135 per 100,000 in top concentration settings and lowest physician concentration counties have just 115 total active physicians per 100,000. 
  • We also know that residency location is one of the most powerful determinants of future practice location. Not surprisingly the states and counties with top concentrations of training have the top concentrations of active physicians.
  • Payment design shapes training design shapes training outcomes and places associated with most training most shape the payment designs

Internal Medicine Collapse - Worse in Lowest Concentration Counties

The collapse of internal medicine is the most dramatic primary care change as only 1100 per class year can be tracked to primary care - yielding only 30000 at a maximum. Recent changes since 2010 may result in this sooner rather than later aided by the massive increase in IM Hospitalists moving past 40,000. This will result in changes from 19000 in lowest concentration counties to less than 6000.

Health Care Dollars Forced to Be Spent Outside of Lowest Concentration Counties

The primary limitation is health spending design. Limitations of absolute dollars in payments going for primary care in these counties is bad enough. Dollars must be subtracted for costs of delivery. These force scarce dollars to be shipped outside of the county. Dollars shipped outside worsen disparities.

Designs shape lower productivity of team members to defeat revenue for practices most needed.

Designs Shape Turnover, Poor Morale, and Burnout

Since 2010 the levels of burnout and poor morale have increased dramatically. There is a sense of chaos, confusion, and lack of control. Small hospitals, small practices, and solo practices have closed up as there seems little point. There is no upside for a turnaround in the designs that shape stagnant payments with higher costs of delivery.

 face rapidly increasing numbers, elderly, and complexity with less resources and fewer dollars. The designs for health care are only one of the many designs shaping disparities. The remaining primary care MD DO NP and PA will be more overwhelmed than ever - not to mention collapses of general specialties as well.

This forces practices and hospitals to make cuts - and the personnel that deliver care are the ones most likely to be cut as they dominate budgets where care is most needed. Fewer personnel add to morale and burnout problems. 

But Wait, There Are More

Unlike some types of rural counties that are stagnant to shrinking, the lowest concentration counties are growing at 30 - 50% higher rates than the national average.
Also specific to lower concentration counties is one of the most rapidly increasing populations in the US - the population in a county without a hospital closure. The lowest concentration counties are increasing at 1.5 times the national population rate, the counties losing their last hospital have much higher levels of population compared to the first 600 hospital closures. The rate of hospital closure may be moving up from 1 per month to 2 per month. Because the other specialties are more hospital dependent, family medicine is even more important as seen in 30 - 35% of local workforce instead of 24% for 2621 lowest physician concentration counties.

The only specialties increasing in lowest concentration counties are hospital related (emergency medicine, hospitalist) - but the hospital closures negate these and they are increasing even faster in the higher concentration counties. In addition, studies indicate some value for academic hospitals regarding hospitalists with a half day of stay saved - but studies do not document benefits for other types of hospitals and studies have avoided small hospitals. The rapidly increasing costs of ER and hospitalist physicians have essentially been forced upon small health care by cultural changes benefiting the most concentrated.

Lower payments, declines in payments, increases in costs, higher demand in a number of dimensions are bad enough. ACA to MACRA has had greater adverse impacts upon small practices and small hospitals.

... but turnover costs are also increasing in a number of dimensions. Recruitment costs and retention costs are going up. The time for orientation and costs of certification and lost revenues are up. Workforce is moving from physician to NP/PA with twice the turnover rate,

The coming years bring the promise of cuts in Medicare and Medicaid that will once again impact lowest concentration counties more - no matter how they voted.

Lowest concentration counties have higher concentrations of people on benefits and dollars spent on benefits. Cuts in SNAP, Social Security, or increases in eligibility will magnify lowest concentration counties due to about 45% of those impacted in these counties with 40% of Americans. Veterans may be 50% found in these counties that attract more and more due to skyrocketing costs of housing in higher concentration settings, better climate, and lower costs of living. And yes, cuts in veterans benefits and centralization of VA care in concentrations is yet another reason for disparities by design.

Federal and state dollars are even more important since this 40% of the population only has 25% of the economic impact. Often the dollars from federal sources are siphoned off before making it to populations in lower concentration settings. 

More at Access to Care Is Not the Same as Insurance


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