Go Path: Austerity Focus

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A popular video on social media lists 20 areas of improvement around the planet. It lists a 50% decrease in homeless veteran numbers. The rapid declines in Veteran homeless counts in metro areas are not necessarily a positive result. The media has a hard time understanding demographics and this makes it difficult when attempting to report on positive and negative areas.

Another popular poster notes that homeless veterans need attention before refugees. The fact of the matter is that many Americans are treated like refugees - as those who do well plan ways to do even better. Their designs continue to leave most Americans behind.

The relevant areas to consider for Veteran situations are not immigrants. The relevant areas are declines of veteran benefits, deteriorations involving lower income, disabled, fixed income, and less healthy populations of which Veterans are part. Most important is the consideration of available and affordable housing.

Factors Regarding Veteran Homeless Declines

It would be nice if all of these declines were about improved support for Veterans, but the fact is that Veteran benefits have been cut. Also, declines are explained by

Homeless counts are done in metro areas and may not reflect homelessness or housing in other parts of the nation
Natural deaths - WWII to Vietnam Veterans age 64 - 98 years
Deaths from Veteran System neglect - too little, too late
Suicide - 22 per day all ages
Forced migration from metro and higher concentration settings

Natural Deaths

The World War II veterans were 80% of the male population of the US for their age group. Few remain as illustrated. Korean veterans were 60% of the male population of the US and are about 8% of the Veterans.

Vietnam veterans are about age 64 to 74 - a longer time period and many are still around although their health care needs are increasing. Veterans that are younger are a smaller portion with somewhat less health care need.

Forced Migration

Places with concentrations have the lowest levels of

Light green counties lack available housing in high amenity areas and high concentration settings (people, income, education, professionals). Blue and green counties are lower concentration counties and have higher levels of available housing. Many populations with less are forced to depart higher concentration counties because housing is less available, making it more costly.

Migrations of Veterans, poor, working poor, lesser employed, elderly, disabled, and fixed income populations continue as they are forced to move to places with lower cost of housing and lower cost of living.

45 - 50% of living Veterans are concentrated in 2621 lowest physician concentration counties with 40% of Americans left behind in places with lowest concentrations of health dollars, health facilities, and health workforce.

Some places used to give bus tickets to dump unwanted people

from their metro areas. The modern way to do this is to dump them

via housing leaving them only the choice to be homeless or depart.

By taking out affordable and available housing, highest concentration settings can accomplish many desirable goals for them while sending people elsewhere. They do this by intention (greed), lack of awareness, and by neglect. Alarms are sounded daily about the lack of affordable or available housing in metro concentration areas and yet there is little response.

Veterans Are Treated Poorly As Are Similar Types of Americans

Veterans have high rates of disability, mental health, and chronic conditions. They also have lower income, fixed income, and are older. People with these characteristics are not treated well. Veterans are forced to move with all of these populations to lower concentration settings because they have few options for affordable or available housing in higher concentration settings.

Greed Drives Departures

High levels of available housing result in lower costs of homes and lower rental costs. It is best for those who own housing. It is worst for those who need housing, especially those that have less to spend on housing.

Greed is what drives homelessness, migration, and poor access to affordable housing, available housing, and available health care. Those who are greediest benefit the most with posters and postings that distract people from the real causes of most Americans behind by design.

Developers continue to convert low cost or public housing to high profit purposes. Government or government working with developers claim land by eminent domain for roads, facilities, health care, and other purposes. Government housing was often built poorly and fell apart - and the same mistake is being proposed again because as we would not want people too comfortable (Dr. Ben Carson, HUD). Suppression of government funding can make housing shortages worse and increase costs of housing. Homeless shelters on valuable land have been sold off. Even not for profits caring for the homeless caved for the greater good of others in need of food and services.

Where Is the Anger Regarding Mental Health Neglect?

Mental health is a key factor in homelessness. Low income, lack of income, and mental health go together. We spend half enough for mental health, half of mental health services are provide by primary care which is also underfunded by half. The spending on mental health goes to places far away from where most Americans in need of mental health are found. Another way that insurance companies or health care systems can lower costs and improve outcomes is to drive off mentally ill patients and populations.

Castaways By Design

The cast off Veterans join cast off elderly and cast off poor and cast off disabled and cast off mentally ill and cast off indebted people (medical, business, or finance failure) in being forced into limited choices as concentrated places continue to concentrate more dollars and leave more people behind.

Greed and Concentrations of Health Care Dollars Compromising Others By Design

Also greed in health care consumes twice the dollars it should leaving little support for those in most need or those in lower concentration settings - as reflected in decades of state, federal, and local budgets increasingly impaired by health care costs.

As more people are sent into debt, they cannot afford to live in higher concentration settings and are forced to migrate to lower concentration places. The most complex situations, environments, and conditions are in lower concentration settings and those forced to migrate there bring higher complexity and strain the local resources - which are also least by design.

Lower concentration counties are predominantly Red Counties noted below plus some blue border counties in Texas and Black Belt counties in the southeast and Native Reservation counties. All share lowest concentration populations and situations. Metro Blue Counties have highest cost of land, housing, and living. Migrations are forced by housing design.

More Cuts and Compromises

And cuts in support for Social Security, Disability, Veterans, and Food Stamps will hit these lowest concentration counties hardest because 42 - 45% of these dollars are sent to these counties with 40% of Americans. These are counties that lack economic contributions outside of health, education, and government spending. Frying Pan to Fire for Red Counties

As the United States continues to spend more on military and health care spending, there is little left. The least organized Americans suffer the most in their lower concentration settings. Budgets squeezed by military and health spending have less remaining for basic services - services most important for most Americans. Two Forces Shaping Declines in Health and Other Outcomes - Austerity Focus Plus Runaway Health Care Costs

Austerity Focus CMS Payment Design cognitive vs procedural errors of perspective Family Medicine health access health care design flaws Vulnerable Populations

The Primary Care Finances Fight Is THE Fight For Vulnerable Populations

Johnson matk at 01:11 0

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Family physicians are the most likely to encounter vulnerable populations. Addressing the needs of these populations requires more team members with better support. The team members are the ones most compromised in the past three decades of payments too low and cost of delivery too high made worse by rapid chaotic change.

Family medicine leaders have set up a series of meetings. The track record of these large gatherings is not stellar. The first of these meetings addressed access. The second of these meetings focused upon vulnerable populations. There is a third planned to address primary care workforce. The result will be more panels, reports, centers, and initiatives. But this will not address access, vulnerable populations, or primary care workforce.

When a single area is important to all of the core missions of family medicine associations, this should be the dominant if not the only focus.

Reports, Panels, Centers, and Grants are what CMS does when it cannot take care of health care delivery. Family medicine associations support more of the same.

"Continuing a long history of tackling disparities in patient care head on, Julie Wood, M.D., M.P.H., AAFP senior vice president of health of the public and science and interprofessional activities, announced the launch of the AAFP Center for Diversity and Health Equity, an initiative that will focus on addressing the social aspects of health care.
"The AAFP has developed its Center for Diversity and Health Equity to take a leadership role in addressing social determinants of health, nurturing diversity and promoting health equity through collaboration, policy development, advocacy and education," Wood told AAFP News."

Expanding access is a requirement for addressing vulnerable populations.

Vulnerable populations were once considered a small population. Austerity focus and the 21st century addition of 2 trillion more dollars to health care (past 3 trillion now) have conspired to compromise domestic discretionary spending and many if not most of the supports for vulnerable populations.

Austerity focus at the state and federal level and worsening health care costs both act to compromise health care, education, economic, and other outcomes.

Within health care, the changes also compromise the financial designs for primary care and basic services - the generalists and general specialties that are 90% of local services where care is most needed and where vulnerable populations are most likely to be found. The basic services, especially those delivered where most needed, are the ones that are provided by those least organized. Those most organized will continue to protect their interests. This will send an increasing burden to those who remain to deliver basic services - more patients, more added to vulnerable populations, more elderly, more with mental health needs, more with chronic illnesses, more complexity, less support, fewer team members, and more regulations. Vulnerable populations have no place to go other than to multiply. Family physicians are most prevalent where health access is in greatest need and this is where vulnerable populations are concentrated. Family medicine must fix the financial design for any real hope of addressing access, vulnerable populations, and primary care workforce.

The dominant US designs assure the rapid expansion of vulnerable populations to become the majority of Americans due to

Widening disparities in children in multiple outcomes shaping increased numbers of vulnerable populations.
Cascades of future impacts due to US children being last or next to last across child well being factors among developed nations.
Disparities in education and other spending at the state level with impacts upon health, education, and economic outcomes
Disparities in health spending 9 to 1 in favor of 79 top physician concentration counties as compared to lowest physician concentration counties
Lowest payments for primary care and basic services services that are 90% of the services where needed
Highest population growth (twice the average for decades), highest growth of the elderly, increasing complexity, and greatest increase in demand in 2621 lowest physician concentration counties - making populations more vulnerable (Red counties and a few dozen rural counties with a majority that are minorities and some of the worst disparities)
Forced migrations of vulnerable populations (fixed income, disabled, elderly, lower to middle income, Veterans) to lowest physician concentration counties where housing costs are lower and where climate is better for health conditions (43 to 48% of these populations are found in this 40% of the nation's population, The ranks swell to include 45 to 48% of diabetics, those with preventable deaths, smokers, and obese Americans.
The tripling of the elderly in the US by 2040
Rapid increases in minority populations
Closures of rural and small hospitals shaping populations in counties without a hospital and with subsequent declines in local workforce as one of the fastest growing populations in the nation due to more counties added and higher populations in the counties added
Cuts in payments to providers serving vulnerable populations from ReaganCare to ObamaCare.
Pay for performance (value based, readmission penalties, MACRA)) penalizing providers who serve vulnerable populations as outcomes are more likely to be lower because of the local, resource, patient, community, and other factors present

AAFP should save the dollars for the final forum on primary care workforce.

COGME III did enough 25 years ago.

The promises of CMS and primary care associations and various expert gatherings will not address vulnerable populations, health access, or primary care workforce. This requires more specific efforts. Every dollar that AAFP can generate should be focused upon what will actually address beleaguered primary care team members, vulnerable populations, and health access. There must be no rest from this labor until the payment designs are improved for primary care, for mental health, and for basic services. This critical change must occur where vulnerable populations are more likely to be found - where access and primary care workforce are most compromised.

It is time for True Primary Care Advocates to wake up to historical fact. The only time of progress in these heavily conferenced areas was

During the one period of time from 1965 to 1978
When more dollars were being injected into primary care and
When more dollars were being injected to support more team members where health access was most needed via
Expansions of Medicare and Medicaid spending,
Spending closely associated with vulnerable populations.
It also helped that this was a period of relatively less increase in cost of delivery
with increases in payment rates helping to cover the costs of inflation.

The Era of Cost Cutting Since 1980 With Rapidly Increasing Costs of Delivery

Since 1980 the payments have been stagnant and have at times have been cut. In addition, the cost of delivery has gone up due to regulation, turnover costs, higher than inflation costs of supplies and other practice essentials.

The largest practices and systems demand and get higher payments for the same services and even annual escalation clauses. The smallest practices and providers get take it or leave it least paying contracts from payers.

The largest practices and systems demand and get discounts from suppliers - leaving the rest to make up the difference.

The one sure thing since 1980 has been disparities worsened by numerous designs that shape health, education, economics, and children.

Clinging to Past Glory Is Misguided as Only Payment Has Mattered

Appearances have been deceiving. Numerous family medicine interventions looked good at the beginning but have not worked since. Family medicine and primary care associations and leaders still cling to the past. This time of great success when everything worked is the period of 1965 to 1978

The 1965 to 1978 policies are why so many "interventions" appeared to work

FM departments and student interest groups in every school,
Student resident conferences,
Primary care schools, and pipelines to primary care and rural practice.
FM reached 30% rural practice location rates by 1980 only to shrink below 20%. Only the hospital based (emergency, hospitalist) remains 26% rural because of better financial designs for hospital based FM grads.
All primary care sources have fallen away from primary care - as dictated by the financial design.
These all required steadily increasing injections of dollars to support the positions - the positions that once expanded primary care and care where needed. The financial designs fail for the positions and the team members to address health access, vulnerable populations, and primary care delivery capacity.

No training interventions can actually work because of failed payments. Decades of data support the same findings across the vast stretches of America where most Americans fail most in access - then and now. Tracking confirms little change other than names changing, or initials changing behind the name. Rather than patting people on the back for the success of their program or pipeline, it is important to examine what is actually happening nationwide, or across counties left behind, or regarding the practices that address vulnerable populations.

We still have 2621 lowest physician concentration counties that are persisting due to the same lowest paying, least supportive payment plans - compromised to lowest paying levels by those who take advantage in higher concentration settings and those who set payment policies based on their immersion in higher concentration settings.

A better financial design is the major requirement
for access and vulnerable populations and primary care workforce.
Why do family medicine leaders avoid what is critical
to all of the major family medicine missions?