Go Fund Me and Basic Services for Most Americans

There are more indications of the punishment of health care costs upon our nation. A recent article in Forbes indicates that GoFundMe accounts are increasingly used to help with overwhelming costs. There are numerous indicators of worsening facing most Americans - the ones that health care designers fail to understand most.

Generally the article is a good review of the increasing costs as out of pocket expenses go up, employers and health insurers move to lesser coverage, and high deductible plans hit hard. Those who have lower income are often forced to go to lower cost high deductible plans - but of course the $10,000 that they have to pay is overwhelming.

The answer to this issue is we need to fix the healthcare system. There is enough spending at over 3 trillion. How the dollars are spent actually makes the situation worse. 

There are many solutions that can lower healthcare costs. The author lists some

• We spend 10% to 20% more in overhead than other countries. This equates to at least $300 billion per year in useless spending. Our billing system is a major culprit of these overhead costs. Implementation of a single billing system would fix this.
• Fee for service payment needs drastic overhaul. Payment should be based on how well care is delivered instead of how much care is delivered.
• Electronic medical records have killed efficiency. We need one electronic medical record built around patient care instead of billing.
• Primary care needs to be removed from insurance and provided directly without an insurance middleman adding to the cost. Insurance is meant to cover high cost and rare events. Primary care is not insurable. Primary care could be provided as a public service just with the money we save in overhead.

Almost - but not quite

The article does a good job with some recommendations involving overhead, middlemen, EHR, and primary care financing, but there are other considerations. People are forced to make other choices not in their best interest due to rising costs. 

The article indicates that payments should be made based on better outcomes, not volume. Sadly better outcomes are about the patient, not the practice. This is best seen in areas such as primary care.

Fee for service should not be considered a problem aseven insurance CEOs note that primary care does not break the bank. At 5% of spending, primary care has long been underfunded, too few, and overstressed with much worse in the last decade and worse to come. Separating primary care out as in primary care for all would be a good idea. There really are not good choices for primary care that have advantages over fee for service. 

This health care design leads to overuse of costly specialists and more use of hospital and other sources of care. Cardiovascular disease costs are an indicator of more costs and problems related to those without basic access who also have concentrations of diseases, situations, and environments resulting in poor health. Studies using health care data confirm maldistributions of cardiovascular hospitalizations. 

Beyond basic services, higher volume is far more expensive. The expensive services paid at highest levels are also concentrated in the best plans with the highest costs - for even higher costs.  Psychiatry services are four times more concentrated where workforce is concentrated. Psychiatrists are four times less likely to be found in lowest concentration counties with 40% of the population and over 45% of mental health problems. 

In contrast, the least paid basic practices are paid 15% less for office services where most Americans most need office care. This is called discrimination against the practices and the people in these communities who are poorly served with or without insurance due to the health care financial design

Most people need at least the basic generalists and general specialists to have any health care at all. Those with and without insurance have long suffered because the public and private plans support basic services least. It is a tragic everyday situation that health care designs are so focused on a few while most Americans and those who serve them suffer the most.

And since 90% of local services where most Americans most need care are generalist and general specialists, higher volume should be considered greater access to care. So most Americans have reduced care and this introduces numerous other problems.

The focus on reducing health care costs has actually resulted in decreases in access to basic services – especially where most needed.

The focus on improving quality has actually resulted in decreases in access to basic services as the practices most impacted are smallest and are most likely to be where most needed. In primary care, the various regulations and disruptions from HITECH to MACRA to Primary Care Medical Home have 30 – 80% greater costs per primary care physician in those smaller and where most needed. 

Larger practices have advantages in  revenue, in addressing rapid change, in addressing disruptive changes, and in keeping their costs of delivery lowest. The smalls are killed off by design as they face the most disruption – usual andhealth care designer constructed. These misguided attempts to change costs and to change outcomes not only do not work, they raise health care costs and create new health care players that lobby for more and more (software, insurance, pharmacy benefit plans, quality consultants, cost consultants...).

Value is often not what is presented. 

Larger practices demand higher payments and get them. More paid for the same services is not a good contributor to value. Small paid the least for the same services is higher value – except that so many cannot get the basics. Smaller practices absorbed into the collective of larger practices or systems get paid 30% more for the same services and for the same outcomes. This is the opposite of value but the designers have driven practices this direction. Most of the practices where needed are not going to be absorbed. They are ignored. The larger entities do not want them as they have patients that are more complex and have lesser outcomes because of the patients and their situations. This is another punishment by value based design.

Another adaptation that is important to understand for health care design is the influence of location such as location of housing. Numerous financial problems are being created by increasing medical costs and decreasing support for areas such as public housing. Also profits on housing are going way up and many cannot afford these prices. Shortages of housing are more common where people, health care workforce, and education are concentrated. The end result is changes in housing.

People have to change their housing because of medical and health related debts. They must live cheaper and housing plus better climate are a common choice. This unfortunately moves the most medically and financially vulnerable (and their families) to places with lowest concentrations of workforce, resources, and social determinants - essentially a move from Blue to Red Counties if you want a visual image. There are also about 60 rural Blue Counties that suffer most – the ones with concentrations of African American, Hispanic, and Native American populations.

This is very important because of future changes on the way. Remember that those in charge of the budget plan to cut 1 trillion from Medicaid and over 300 million from Medicare along with cuts in Social Security, Food Stamps, and other supports. 

Truly the designs favor those concentrated in money, power, and influence while most Americans fall further behind in health care design as in other designs. Only about 13% of health spending related to physicians goes to 2621 counties with 40% of the population and lowest concentrations of MD DO NP and PA workforce. This of course adds to job, income, and social determinant disparities.