Go Path: Discrimination By Design

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CMS Payment Design cognitive vs procedural Discrimination By Design errors of perspective MACRA Pay for Performance Subspecialization

Attempts to Address Overutilization Leave Most Americans Behind

Johnson matk at 00:54 0

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Four decades of attempts to address overuse have not only failed to rein in overuse, the efforts have contributed to under-utilization and more Americans left behind by design.

Overuse has long been 2 to 4 times higher in highest physician concentration counties. Overuse supports too much workforce for few and results in too little for many. Overuse steals the workforce needed elsewhere and makes it appear that there are deficits of workforce with the need for more graduates - when the problem remains overutilization.

Payment Design Plus Profit Motive Plus Political Power

Overutilization is largely the result of the payment design and profit motive and political power. The payment design results in too much paid for highly specialized services and too little for the basic services (primary care, mental health, basic specialties).

Profits are best supported by the march to ever more types of procedures and technologies that are paid the most because they are newest and most subspecialized. The profits by those most organize pave the way for political power - power that prevents true reforms such as more for cognitive, office, and basic services as well as services where most needed for those smallest and least organized.

Too much for too little result, too much profit over the basics, and too much power vs too little - these are what drive the US health care design the wrong way.

Payment Design Diverts Workforce

Nurse practitioners and physician assistants have followed the higher payments to new specialties with more added in each specialty. The dollar distributions shaped by payment policy would not allow more primary care physicians, clinicians, or team members.

The effects of payment upon the physician workforce are obvious - and this pattern is being repeated in the rapid changes seen in NP and PA workforce. For decades NP and PA were promoted as solutions for primary care, care where needed, and efficient care.

It is obvious that there is no solution for care where needed as the deficits remain despite massive expansions.
Primary care similarly remains stagnant by design.
The NP and PA "efficiency" advantages claimed in primary care did not work out in lowest paid primary care paid even lower.

NP and PA advantages have best been seen in non-primary care. As the specialty and subspecialty barriers all fell away, the NP and PA advantages shaped new career options. The NP and PA graduates helped highly specialized practices

to capture more market share,
to handle the basics with NP and PA graduates
to shift highest paying procedures and services to subspecialty physicians for maximal revenue generations,
to allow care delivery in multiple sites (office, different hospital sites), and increase utilization of existing testing equipment and personnel.

This has allowed largest systems and practices to cut expensive subspecialty physician costs to the minimum while maximizing services, testing, and billing.

Expansions Facilitate Increases in Workforce, Services, and Overutilization

Massive expansions of PA from 1500 to 9000 annual graduates a year and NP 1500 to 20,000 a year since 1980 have substantially contributed to increasing utilization, higher costs, and overuse.

Recent doublings of NP, PA, and DO graduates have not contributed to more primary care as expansions are negated by fewer remaining in primary care. MD primary care results are shrinking despite expansion - as fewer remain in primary care. There is no other choice. The numbers of positions are limited by the revenue - minus the other costs of delivery and more limited by delivery costs that have been increasing.

Blocked from primary care by the annual revenue limitation of 160 - 180 billion for primary care or 6% of spending (minus expenses), NP and PA and DO and Caribbean and MD expansions have fueled the massive increases in non-primary care workforce.

The workforce design compliments the increased utilization of highest cost services and penalizes basic services. Expansions of graduates cannot improve access as the basic services are all prevented from expansion by payment design.

Suppressing the Basics Accentuates the Highly Specialized

Even worse, the deficits of primary care and access facilitate greater utilizations of higher cost services - emergency care, specialty care, subspecialty care, urgent care, and convenience care.

More graduates translates to more workforce and more highly specialized workforce - leaving the basics far behind.

Ever Higher Health Care Costs Are Unopposed

Runaway health care costs have followed

From rapid ever purer expansions of non-primary care workforce
Plus rapid expansions of administrative costs
Plus digitalization costs
Plus micromanagement costs

The increases in administrative and non-delivery costs have been significant. These include more personnel in administration and management, managed care efforts, managed cost interventions, and managements of high risk patients which have added about the same costs as would have been saved by management efforts (The CBO was right).

The consequences of spreadsheet cost cutting have been significant. Physicians have often told the cost cutters of the consequences, but they are long past listening. The cuts look good on paper but translate poorly to the real world where complex interactions between individuals, groups, and society are difficult to capture. The CBO was right, the White House and Steven Brill Were Wrong by Kip Sullivan.

Additional and substantial tens of billions a year have been added by HITECH to ACA to MACRA to value based. The Pay for Performance additions are some of the worst, adding higher cost of delivery for no significant change in outcomes (Annals of IM review) while discriminating against those who provide care to more complex patients with inherently lesser outcomes as noted in increasing numbers of studies past 15 already. Pay for Performance has delayed needed reform - especially cognitive vs procedural.

The obvious result of so much more for little or no gain in outcomes has been failure in value. The US has obviously been moving the opposite direction from value. This is another reason why attempts at value basis are misguided at best.

Consequences of Cost Cutting (Caused by Overutilization and Costs Too High)

Overutilization has been bad, but innovation and regulation and certification efforts have made the situation worse. Cost cutting has been a very non-specific tool with a four decade history. The collateral damage has been greatest

in primary care with 55% of services delivered
in basic services care where needed where margins are thinnest
in small practices where cost of delivery increases are most

Those largest, most organized, and most powerful are in the best position

to prevent adverse legislation
to reshape regulation is desired ways
to influence implementation

Those doing best are the largest and most organized in places where workforce is most concentrated.

Good business decisions require that essential areas not be cut and may even need to be given increases because they are essential - but this has not happened. Even worse the basics have continued to fall relative to those highest paid and overutilizing - dragging more team members, clinicians, and physicians this direction.

Those smallest, least organized, and most basic have steadily been left behind as overutilization, overregulation, overadministration, and overcertification have continued while costs have worsened, outcomes have worsened, value has worsened, and access has worsened - with the worst impacts on increasing proportions of Americans - your choice of 30 to 50% and increasing.

Closures and compromises of small practices and small hospitals continue where care is most needed, where populations are growing fastest, where fewest health care dollars go already, and where more dollars are required to be shipped to higher concentration settings - by each new permutation of the health care design.

Only those immersed in higher concentrations could fail to see the situations, conditions, environments, and compromises.

Research Immersed in Concentrations Results in Policies Rewarding Concentrations

The research base has long been immersed in the places and practices and systems that are largest and that most overutilize. The latest designers from managed care to Dartmouth to the present have continued to base their assumptions on this top 20% most concentrated. The research has long ignored those who fail to access services. The data is also distorted when the populations involved have difficulty accessing care in places where insufficient workforce and other access barriers exist - where underutilization is a major problem.

The research differences promoted widely have largely been the result of comparisons of different populations - not the various clinical interventions that have gained press.

cognitive vs procedural Core Access Principles Determinants of Health Discrimination By Design Equity in Payment Higher Cost of Delivery True Reform in Payment

True Reform is Needed to Get from Last to First for US Health Care

Johnson matk at 10:18 0

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Health care in the United States is notable for being the worst when comparing health care among wealthy nations. A Commonwealth article was published in NEJM highlighting four areas that need to improve. Interestingly an improvement in primary care finances would address all four areas, but this discussion was avoided. Fitz Mullan had another article promoting the social mission just published in JAMA. Once again addressing bankrupt primary care finances would contribute to the social mission. Lofty ideals are easy to discuss, but the hard work is missing when it comes to addressing access barriers, disparities, and most Americans falling farther behind. You cannot get from last to first by failing to address areas that must be reformed - areas that actually shape insufficient access, insufficient primary care, insufficient team member support, and disparities.

Goals, Aims, and Missions must be replaced with specific actions.

True Reform Is the Beginning

The foundation, institution, association, government-associated authors can begin to address four areas and the social mission by a true reform focus - equity in payments for basic services compared to most specialized and compared across the nation.

The authors fail to indicate the one most important area for improving primary care, mental health, and basic access services -

more payment for cognitive, office, basic services.

This must be the top priority even if less goes for procedural, technical, subspecialized. This is the only way to balance generalist MD DO NP and PA vs non-generalists.

Primary care is the best distributed of all workforce and therefore is the best route to distributing health care dollars.

About 70% of local services where needed in 2621 counties lowest in physician concentrations are primary care services.
Lowest paid basic services are 90% of local services.
Only 6% of spending goes for primary care which involves 55% of services and also covers 50% of mental health services.
Where hospitals are missing, are threatened, or have closed - primary care is even more important.
Distributions of dollars also help to distribute improved outcomes as outcomes improvements require dollar improvements in areas such as education, economic development, housing, local resources, and other areas. Designs that concentrate create disparities. Designs that distribute can help address disparities.

Procedural, technical, subspecialized services are rewarded the most and are most concentrated where physicians are most concentrated. These are also the places where the institutions, largest systems, corporations, foundations, and associations are most powerful and are most willing to oppose this top priority reform. Primary care and basic services are a small proportion of local services and workforce where there is immersion in highest concentrations. The academic/research/workforce consultant/payment policy gurus are not going to support true reform.

Will academic, foundation, association leaders identified with social mission, access barriers, primary care, and disparity reduction stand up - perhaps at the risk of their jobs and reputations?

Authors that move in the most powerful circles have to stand up and promote this true reform even if other academic, association, foundation, institution colleagues oppose this reform.

Other nations have better balance involving higher levels of generalists. Higher concentration counties in the US rank well among other nations. Half of the US population ranks far below all developed nations in generalist to population ratios.

Despite the wondrous and expansive rhetoric regarding training interventions as a solution for generalist deficits, it has long been clear that generalist MD DO NP and PA workforce has been prevented by payment design. Few enter and even fewer remain - by financial design. The primary care design also results in a less experienced primary care workforce that may not perform as expected. Higher functions such as integration, coordination, outreach, and community partnerships are more likely with better designs that result in better retention and improved continuity.

No MD DO NP PA school or program or special training design can address gaps in primary care, mental health, and basic surgical services until this true primary care payment reform is addressed.

Once again this is about the limitations in primary care with revenue too low overall and specifically in places where half of the US population most needs care.

The US Health Care Design Is Specific to High Cost and Low Yield Outcomes

The runaway health care costs have been fueled by overutilization of highest cost services. These are services typically provided in higher to highest physician concentration counties. These services offer the least improvements in outcomes for the highest costs.

Expansions of subspecialty, administrative, and micromanagement costs continue to drive lowest yield for highest cost. These changes over the decades have acted to increase disparities.

Disparities are widened by overspending where services are concentrated and by underutilization involving most Americans.

Expansions of MD DO NP and PA workforce have been successful in one area - increasing non-primary care workforce. The expansions of the NP and PA programs have been ideal for a more efficient financial design - for non-primary care practices. Replacing as many most costly subspecialist physicians as possible is essential to lowering costs of delivery - of non-primary care services. This also boosts profit margins for higher to highest concentration providers.

True Reform Needs a Solid Financial Design

A universal coverage for primary care with 20% higher payments would be a start. Universal coverage for primary care is more palatable and more affordable. It is already a best value at 55% of services for 6% of spending.
Universal coverage for primary care with a 20% boost would be a 25 or 30% improvement for places with lower collections and greater challenges in billing, delays, and denials of payment. There would also be benefits in terms of less turnover and productivity losses.
A universal payment scale paying the same for office codes across the nation would bring equity to primary care payments for another 20% boost for those paid lowest - where services are most impaired by the current design.

The recommendations above would likely provide 45% more revenue for primary care where primary care is lacking - especially in lowest concentration counties. This redistribution of dollars would be a best match to the counties and practices most in need of workforce. Efforts specific to It also avoids the very costly and compromising issues of the current overproductions of MD DO NP and PA graduates.

Best Timing for True Reform

The time to do this was 2010 to allow at least 30 years to be able to address the populations most left behind that are increasing from 40% to 50% of the population by 2040. Sadly the US has not been moving from 40 to 60 billion to expand access as the insurance expanded pays too little and requires too much innovation, regulation, and certification cost. Economic improvements have also avoided these counties resulting in further deficits where turnover costs are highest and are increasing most.

Basic health access deficits bad and worsening are about patients with lowest paying insurance plans concentrated where deficits of workforce are greatest, where costs of delivery are increasing fastest, and where complexity is increasing most in multiple dimensions.

A reasonable understanding of the social and other non-clinical determinants of health that dominate in shaping health, education, and other outcomes...

...leads to the conclusion that billions taken away from lowest concentration counties by each of HITECH, digitalization, MACRA, and Primary Care Medical Home results not only in a decline in access but also a decline in health outcomes - as the non-clinical determinants are worsened. Education has a similar discriminatory design and a similar loss of billions from these counties by measurement focus. Measurement focus is ridiculous when these are counties that need to retain dollars to retain workforce and improve outcomes.

The designers underestimate the disparities caused by the health payment policies including worse outcomes due to dollars 3 times greater spent in 79 top physician concentration counties with over $30,000 spent per capita and 3 times less or less than $3000 per capita spent in lowest physician concentration counties that should have 50% of Americans by 2040.

Further Decline By Design Impacting More Americans

Demographic and other changes insure worse to come. This is because of housing collapse, closures of small hospitals, and meaningless costly micromanagement and other non-delivery costs accelerated. Housing collapse drive more financially and medically vulnerable populations to lowest concentration counties, closures of small hospitals add 10 - 12 counties a year to the ranks of lowest concentration counties, and micromanagement steals billions more each year from areas such as primary care that only get a minimal 35 - 40 billion for primary care.

This is officially half enough in raw numbers of dollars required and only one-third enough given the higher concentrations of poor, elderly, fixed income, disabled, veteran, poor child, diabetic, obese, smoking, and mentally ill populations in these counties.

You can add the latest research indicating concentrations of populations with lower health care literacy, nonadherence, high risk, and high cost.

Runaway health care costs are fueled by overutilization in higher concentration counties, highest payments for the highly specialized services that do the least for health outcomes, decades of increasing administrative costs, decades of increased profits distributed to a few Americans. Runaway health care, military, and prison costs together with austerity focus compromise the personal, state, federal, employer, and local investments needed to change outcomes. Better investments in people, local resources, environments, and situations is required for better outcomes. This was noted but was not emphasized.

Much of the recent confusion, distraction, and inefficiency added is about the insertion of micromanagement into health care design - a bandwagon assumption that cannot improve outcomes as noted in evidence based reviews.

If you stand for access then you must stand up for true payment reform. If we cannot get foundations with a mission for access to support access improvements specific to the needs of most Americans, we will not make progress in access, costs, or outcomes.

AAFP CMS Payment Design cognitive vs procedural Discrimination By Design health care design flaws innovation dysfunction insufficient cognitive payment

Students and Residents in Family Medicine Want Equity

Johnson matk at 00:52 0

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Students and residents should focus AAFP upon equity. Equity in payment would be a good start. Dollars are maldistributed in health care and this contributes to inequities in workforce, access and outcomes as disparities drive social and other determinants of health the wrong way.

AAFP wants to present the best case scenarios to students and residents, but there are major issues that must be addressed. Equity is indeed and important theme worthy of discussion

Equitable payments for primary care, mental health, and basic services should be most important for student or residents that truly hope to deliver these basics - especially in places with half of Americans where inequity and disparities dominate. There should be no deception that most Americans are doing well. American health, education, and economic outcomes indicate that few do very well and most are left behind. Future family physicians deserve to know the big picture as family physicians are most likely to care for those left behind in multiple dimensions.

Inequities Cognitive Vs Procedural

Basics including cognitive and office services should be paid more and procedural, technical, subspecialized should be paid less to obtain equity in workforce and equity in distribution of workforce

Inequities Higher Vs Lower Concentration Counties

The designers have created for themselves multiple lines of revenue and the highest reimbursement goes to those in highest concentrations of workforce. Inequity is over 50% of health care spending going to 1% of the land area in 1100 zip codes with just 10% of the population but 45% of physicians. So much for so few in few locations makes equity impossible. Since outcomes are minimal at high cost, value is low across US health care.

Attempts to address inequities in payment are vigorously resisted by the academic, association, institution, foundation, corporation designers.

Equity Translates To...

Equity would translate to equitable access, equitable distribution of workforce, and equitable payments. Equity in payment is required so that training interventions can result in equitable distributions of workforce.

Even if students or residents want to provide primary care or care where needed - the designs make this most difficult. Too few positions are supported.

Equity in Access

Access is impaired by 2 to 3 times less local workforce for 40% of Americans in 2621 lowest physician concentration counties - counties that receive less than 13% of health spending and only have 22% of primary care workforce. The only equitably distributed workforce is family medicine with 36% of family physicians to match up best to this 40% of the nation. All other specialties concentrate in counties with higher to highest concentrations of physicians - leaving most Americans behind along with higher concentrations of elderly, Veterans, disabled, and others most complex and least served.

The 2621 lowest physician concentrations have lowest concentrations of MD DO NP and PA workforce because the counties have concentrations of people with the worst paying plans. They also have concentrations of people with lesser social determinants in places with least economic impact.

These 2621 counties only get about 40 billion in primary care revenue each year. Payments are 15% lower for the same services. This translates to 6.6 billion less in payment. Equitable payment would go a long way to support primary care teams and higher functions - denied by design. Collections issues result in 5 - 10% less for 2 to 4 billion less.

HITECH to MACRA has diverted 8 to 10 billion that can no longer be used to support care delivery. In fact it never gets a chance to circulate locally as it comes in and goes out before it can help address jobs, economics, or social determinants. The design concentrates health care dollars in higher concentrations and results in less equity for lower concentration counties.

Payment inequities make matters worse. Payments are lower for primary care and are 20% lower for the same services in these lowest physician concentration counties. HITECH to MACRA has resulted in over $100,000 per primary care physician in uncompensated cost of delivery increases. Payments lower, costs of delivery higher, and complexity of patients greater is the opposite of equity.

Widening Inequities By Design - Does Family Medicine Care?

These 2621 lowest physician concentration counties are growing faster in population and in numbers of counties:

Inequities in payments for basic services continue to result in small and rural hospital closures which decrease local workforce
Specialties other than family medicine exit counties without hospitals to add more counties to the 2621 lowest concentration counties.
Small practices are more common in lowest concentration counties and small practices are also being compromised by payments too low, costs of delivery too high, and complexity increasing
Affordable housing is vanishing in higher concentration counties and most in these counties are paying too much already. The housing crisis picks off the most vulnerable in physical, mental health, and financial need. Many have no choice other than to move to lowest workforce concentration counties lowest in resources but often with better cost of housing, better cost of living, and better climate.

Inequities Made Worse By Design After Design

A few Americans benefit from financial designs that put more wealth into the hands of fewer leaving most Americans behind.

About 74% of top college positions go to children of top income quartile parents with only 3% arising from the bottom quartile and less than 13% from the bottom half in income.

Health care dollar distributions shape similar inequities. By 2040 half of the US population will reside in 2800 - 2900 lowest physician concentration counties because of hospital inequities, inequities in education funding, and inequities in housing that drive the most vulnerable in physical, mental, and financial capabilities to reside in lowest concentration counties with least resources, worst social determinants, and greatest patient complexities.

The top 79 physician concentration counties with 10% of the population receive over $30,000 per person in health spending while the 2621 lowest physician concentration counties receive $3000 per person in spending - ten times less. Highly specialized services added, more new and expensive drugs, precision medicine, increased administrative costs, more practice consultants, more software, and more health info tech all divert dollars from lowest to higher concentration counties.

Six states have top concentrations of physicians and residency training. Thirty states have lower to lowest concentrations of physicians and residency training. The 2621 lowest physician concentration counties with 40% of Americans only have 6% of residency training. Because these counties have too little spending, there is no chance that any training intervention can actually reduce inequities in distribution of workforce. The nurse practitioner and physician assistant maldistributions plus expansions actually worsen health spending disparities.

The leadership of AAFP often shapes the information going to students and residents, but students and residents should do their own exploration and analysis. They should pay close attention:

to their future
to more equitable future for them and for their patients,
to a more equitable future for half of Americans left behind by design.

Should students focus on small proportions of the population or should they consider half of the US population a worthy cause to address?

Perhaps students and residents can help the Families of Family Medicine to understand that they need to reconsider innovation, regulation, and certification that make care more complex, add to costs of delivery, decrease productivity, and add to inequities in payments, workforce, and access - by design.

Family Medicine Must Move Beyond the 1960s Design to Address the 2040s

Business Models Large Vs Small Primary Care Practices

The GME Lie Distracts from Payment Reform

Veterans Not the Only Ones Driven Out of Housing and Out of Town

Focus on Change Agents to Change the Culture to Healthier

Why Are More Federal Dollars for Graduate Medical Education Still Not Able to Produce the Workforce Needed for Most Americans Now and Especially Not in the Future?

Insanity and Discrimination in Payment Design Help to Maintain Shortages of Workforce and Access Barriers

ACA CMS Payment Design cognitive vs procedural Complex Elderly Discrimination By Design innovation dysfunction Primary Care Solutions Small Health Care

Business Models Large Vs Small Primary Care Practices

Johnson matk at 19:22 0

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Triple Aim, innovation, regulation, certification, cost cutting, and other changes have widened the gap between small primary care practices and large practices for the past 37 years. The treatment of small practices and those that they serve will some day be recognized as discrimination by design.

Revenue and Collections

The financial design for primary care has been an issue since the 1980s. Stagnant payments, increasing costs of delivery, and increasing complexity represent the Triple Threat to primary care. This threat is most prevalent in the smaller practices.

15% higher payment are common in large vs small practices for the same office codes (Medicare Data 2011). This translates to about $65,000 less payment per primary care doctor. This is shaped by a number of different factors such as being small or rural, not being associated with a hospital, being in the wrong state, and being less organized.
Large systems and practices often have 5% annual escalation clauses. Small practices have take it or leave it contracts that are burdensome to the practices and their patients.
Larger means the ability to strategize, to shift resources for best profit, to choose and adapt location, patient population, and health plan contracts for maximal revenue, maximal outcomes, least cost of delivery, and most local resources. This has not been so for smaller and less organized practices where revenue has been stagnant and practices are fixed in place, population, and location.
About 10% is lost to collections in large primary practices vs 15 - 20% for small. A 5 percentage point differential translates to $50,000 per doc per year.
Delays and denials can be more challenging for small practices and for the insurance plans more likely in small practices

Higher Costs of Delivery Via Innovation, Regulation, Certification

Rapid changes are more difficult for small practices with fewer and less specialized personnel. In the last decade a number of regulation, innovation, and certification changes have been thrust upon primary care. In general, the adverse impacts are more likely for small practices. Sometimes these changes have been implemented even when knowing these adverse impacts.

$32,500 for HITECH per doc (MGMA)
$30,000 at least for additional digitalization, HIT and similar costs
$40,000 for MACRA per doc (Health Affairs)
$43,000 for Primary Care Medical Home (PCMH) for large practices - $60,000 to $105,000 in other estimates (Annals FM) - likely higher cost for smaller practices

The costs of the above may be greater for small practices although some small practices are spared (by MACRA) or are choosing not to spend the dollars. CMS has already published the expected problems for smaller practices via MACRA.

Productivity losses occur due to the above but these have been poorly studied. Additional time for documentation has been studied and extra hours a day per physician for documentation, messages, and internal reviews add up. Burnout, higher turnover, and morale problems have increased due to all of these above.

The bottom line has been shave so much that personnel have not been added to address these areas. More burden is placed on fewer taking more time and effort for little in the way of apparent gain.

Value based and other forms of Pay for Performance have already been reviewed for adverse impacts. Smaller practices tend to have patients that are inherently less healthy which will result in lesser payment.

Another assumption of the micromanagers is that larger providers are better. Actually larger practices have different and better finances, advantages in team members, and patients with inherently better plans and outcomes.

There is an assumption that larger practices and systems will absorb smaller practices for their own good. Why would an insurance plans, systems, or practices absorb practices where patients are more complex and have lesser outcomes and fewer resources. Many that do have better finances in mind, not the care of the patients in the small practices. Small practices are focused locally and actually had better outcomes in studies by Casalino. These better outcomes for practices smaller than 10 physicians and especially for 1 and 2 person practices were a surprise to researchers - who were looking for worse.

Why blast small practices away, and local focus, and community orientation for dubious benefits, if any? Much of what is published has dubious value despite the focus on "value based."

Even worse is the discrimination inherent in innovative "accountable" payment designs. Underserved practices such as seen in Community Health Centers have had direct studies demonstrating the discrimination inherent in Pay for Performance (Hong, JAMA). Pay for Performance Fails to Deliver

Higher Costs of Personnel Turnover

Buchbinder indicated $225,000 cost for primary care physician turnover years ago. A reasonable update of the costs of recruitment, retention, locums, lost productivity, orientation costs, and adapting to the practice and patients and team members would be $300,000 for the turnover cost of a lost primary care physician. This translates to $100,000 per primary care doctor per year with turnover about each 3 years.

Smaller practices face over $100,000 per primary care turnover per year with less than 3 year averages and higher costs of recruitment, retention, advertising, orientation, lost revenue, lost productivity, and other adaptation costs
Larger practices may face little in the way of turnover costs as recruitment and retention incentives, advertising, and gaps can be filled by minor adjustments of existing personnel and physicians.

Small practices that run short on workforce end up losing patients to other practices because they cannot schedule new patients or return established patients to care. This represents a future problem with revenue and more difficulties balancing personnel to revenue. A poor financial design worsens this common scenario. If revenues decrease it can be hard to replace a physician assistant, nurse practitioner, or a physician. Large practices can make up gaps by shifts among remaining workforce.

A sudden decline of 2 physicians, physician assistants, or nurse practitioners in a small practice requires substantial management to restore revenue and stabilize existing and future workforce.

Recent studies in Annals of FM regarding rural practice indicate that higher turnover is seen around metro areas and in places lowest in concentrations of physicians. These are where small practices are more prevalent. Larger practices are often sought by new graduates or by those departing small practices.

Twice the turnover and half the revenue generation limit nurse practitioner and physician assistant contributions. Scope of practice and complexity of patient care can be challenging for new graduates. Expansions of NP to 20,000 annual graduats and PA to 9000 acts with the poor financial design to set up a revolving door situation resulting in limitations in new area such as primary care experience.
Many of the short and long term effects of the current financial design have not been considered or studied.
The value of a long term primary care physician retained for 10 - 15 or more years is recognized, but again studies have failed to consider the positive contributions while the negative assumptions continue to be published and promoted.

Higher Costs in Non-Personnel Areas of Primary Care

Supplies, equipment, and insurance costs are discounted for large practices and practices in large systems. Some largest can even negotiate to result in no waste as the suppliers are responsible for the supplies. Only the supplies used are charged to the practice. Size dictates negotiating power for higher payments and lower costs as document in studies of insurance, systems, and practices. The costs for non-personnel areas run about $40,000 to $50,000 per primary care physician. Savings from size were estimated at $10,000 per primary care physician. Very efficient large practices can save substantially in discounts and less waste. Smallest practices end up paying for these discounts as suppliers recoup their losses.

Physical Plant Costs

Cost of office space, utilities, maintenance, and property taxes are higher for large practices. Best locations with best patients and best insurance plans are costly. However this increased cost is offset by better payments, depreciation, investment, and contributions. Small practices often receive support from hospital or community although support is limited by federal laws and poor finances inherent in small hospitals and small or lower income communities.

Additional Limitations for Small Practices

Small practices are often located where patients are more complex and have more chronic diseases and fewer resources. Medicare, Medicaid, disabled, poor, fixed income, and vulnerable populations are often more concentrated in small practice settings. Poor payment, poor support, and poor design make greater complexity of practice, patient, and community even more difficult.

CMS Payment Design Determinants of Health Discrimination By Design Lowest Physician Concentration County MACRA Pay for Performance Red Counties Scope of Practice Vulnerable Populations

Soon No Specialties Left to Limit Family Medicine Scope

Johnson matk at 23:57 0

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Recent meetings of family physicians brought up the age old question of expanded scope. Some raised concerns about threats to this scope. As is the usual, what is most important is the context. Where half of Americans are found, there is not a reason to be concerned about scope.

Only in highest concentration settings are family physicians limited - since all specialties other than family medicine concentrate in higher concentration settings.

The competition is less and less of a problem regarding broad scope for family physicians in lowest physician concentration counties. Few of the other specialties remain and many are in decline.

This places more burdens upon the remaining family practice workforce. This comes at a bad time as the practices require more time for documentation and there is less time for expanded scope such as hospital and procedural activities.

As discussed previously in recent blogs, the payment designs continue to be the major limitations for all of the above workforce types. Generalist and general specialty services are 90% of the services in these lowest concentration counties. The overall payment design pays less for the basics and the basic services are paid less in these counties. This is a poor design where care is more complex and resources are more limited.

Notably the attacks on scope have proceeded from insurance and payer designs.

Liability premium costs put the brakes on many procedures - and a key route to better revenue generation in practices sent the least revenue by payment designs. This forced full scope obstetrics beyond many family physicians, unless they predominantly did such work to support the liability premiums. Hospitals are closing and obstetrical services are closing in these 2621 lowest concentration counties also a consequence of payer designs failing for the basic hospital services of these smaller facilities.
Government and insurance payers have also dumped assistant surgery - once a key expansion of scope and another revenue generator.

Countdown Workforce in Lowest Concentrations

FP positions filled by MD DO NP and PA distribute best at 36% to match up to this 40%. FM is 24% of local workforce where needed and reaches 38% when counties do not have a hospital or in the states such as Nebraska and Kansas.
General internal medicine was 13% of local workforce where needed but is collapsing to 30,000 or below. The 4 times greater multiplier for top concentration settings will substantially reduce this contribution to 5% or below.
Contrary to many studies indicating the need for geriatricians, they fail for distribution where the elderly and most complex elderly are found. Only 13% of geriatricians are found in this 40% of the population where 45% of the elderly are found. Geriatrics fails for financial design reasons - basic services paid too low and complexity too high. Inkind contributions from academic centers, nursing homes, rehab centers, and large hospitals insure that geriatrics remains concentrated along with the physician origins most closely associated with higher concentration settings.
Pediatric workforce is only 6% and stable but pediatric physicians are stacked toward concentrations along with every other specialty other than family medicine. Gender changes, origin changes, and payment changes will further limit distribution.
Mental health fails for lowest concentration counties where this 40% of the population easily has 45% of mental health problems. Only 23% of mental health providers overall and 17% of psychiatrists are found in these counties.
Shrinkage of public health has long complicated care in lowest concentration counties and has also expanded scope.
General surgeons were 27% with general orthopedics at 24% and general obstetrics gynecology at 22%. These and other general surgical specialties have been shrinking at 2 - 4 percentage points a year from 2005 to 2013 in the AMA Masterfile. There has been no sign of stopping. This should not be a surprise since these are the lowest paid services. These are also some of the oldest physicians - an indication that training of these basic surgical types is incapable of addressing care where most Americans are found and are increasing most in elderly, demand, and complexity.

All physician types who could act to reduce family practice scope are concentrating and contracting. This should result in lower physician concentrations overall and higher proportions of family medicine in the lowest concentration county physician workforce.

In addition to challenges of scope, the challenges from patients are also significant - and are substantially increased in these places with lowest resources and workforce.

US Population	40%
SNAP/Food Stamp Spending	42%
Poor Americans	43%
Elderly Americans	43%
Obese Americans	43%
Social Security Spending	43%
Smoking Americans	45%
Preventable Deaths	46%
US Veterans	46 - 48%
Poor Children	47%
Social Security Disability $	47%
Diabetic Americans	50%

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 (30% faster than US average), in elderly, in demand, and in complexity - only the finances remain stagnant, miring these counties at 115 physicians per 100,000 and likely less.

Combinations such as Dual Eligible patients, homebound elderly, poor children, those with more mental health days, and those with poor to fair health status are more likely to be seen in these settings. The permutations that add to complexity are endless but the support has been limited by past, present, and future designs.

Housing and other lower cost of living factors shape patients with lowest paying plans into lowest physician concentration counties. Those stuck cannot leave and those driven out of higher concentration counties (financial reasons, lack of affordable housing) accumulate. The health payment plan failures shape the workforce failures.

Family physicians increase in proportion as local determinants of health decrease. The payments also decrease for the same office codes. The new Pay for Performance designs place additional limitations with higher costs and more penalties because of the populations in lowest concentration counties. The discrimination has been documented, but the bandwagon of Pay for Performance Rolls On.

The major battle remains the financial design that rewards non-basic services and penalizes those who most serve where needed, their patients, the communities in need of services, and basic health access in the United States.

But the new health care law, if enacted, will make matters worse. The impact will be substantial upon Red Counties already hurt by cuts in the supports noted above, with more to come.

The Few Least Healthy Counties or 2621 Lowest Physician Concentration Counties

From March 25, 2017 - Cries of victory may ring out today after the apparent defeat of the misguided Republican Replacement Plan, but the sand people will be back and in greater deception. The designs over past decades will continue to be shaped by those with their own agendas - agendas that are a poor fit with the needs of most Americans or true improvements in health outcomes.

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 and since 2010 have also failed for Red Counties.

CMS Payment Design Cost Cutting Focus Discrimination By Design errors of perspective health care design flaws health care spending insufficient cognitive payment Lowest Physician Concentration County

Insanity and Discrimination in Payment Design Maintain Shortages of Workforce

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Insanity is trying training interventions that cannot work to address deficits of workforce, because of payment design. Discrimination is paying less for care where populations most need care. Gross discrimination is a new payment design that pays less and penalizes more.

The proper assessment of Basic Health Access for the last few decades is stagnation by design.

For decades, workforce reports have pointed to payment changes as the real solution.

The COGME Report of 25 years ago has long been enough, but there has been little progress in payment or in workforce where needed. The discriminations in payment have been maintained and have been worsened by recent design changes.

Transparency in Medicare Payments Go Both Ways
Revealing the Discrimination By Design

CMS has put forward a number of costly database collections and has made them public. One release involved payment data on physicians. Perhaps they wished to embarrass certain physicians paid so much or the problems of high volumes of services. This data can also be used to show just how much the designs discriminate against the Americans most left behind, the care they most need, and the providers that still manage to survive the payment design.

But those who most depend upon volume are cognitive, office based, primary care, mental health, and basic services - all lowest paid. They have had all of their procedures and other non-office based codes taken from them. They depend upon office codes. These codes represent 90% of local services in lowest physician concentration settings - rural and urban. The physician workforce in these areas is shrinking - by payment design.

Generalists and general surgical services are 90% of the services in the lowest physician concentration counties and are shrinking at 2 - 3 percentage points with each passing class year (AMA Masterfile 2005 compared to 2013). Fewer remain in primary care to enter after training and fewer remain in the years after graduation. MD DO NP and PA sink to new lower proportions active in primary care year after year. The family practice shrinkage is the most important as family practice positions filled are the only specialty with population based distribution. All others are concentrated where workforce, income levels, people, facilities, and many other factors are concentrated.

And the lowest physician concentration counties continue to increase fastest in numbers, elderly, complexity, and demand. The fact that they need generalists and general specialties most is also ignored by the designers. In fact, the overall changes in demographics demand increased support of generalists and general specialties - prevented by payment design.

The Medicare data reveals just how discriminatory payment design has been for decades - the decades that have shaped more Americans falling further behind.

A county database was used to categorize Medicare payments according to the Number of Hospitals in County ranging from Zero to 9 and Above. Categories include Routine Established Patient Visit 99213 and More Extensive Visit 99214 and % of Medicare 2011 Payment and % of Medicare Enrollees

Number of Hospitals in County	Routine Established Patient Visit 99213	More Extensive Visit 99214	% of Medicare 2011 Payment	% of Medicare Enrollees
0	$42.31	$63.25	2.1%	11.5%
1	$43.67	$65.20	15.6%	22.6%
2	$44.37	$66.38	13.5%	14.1%
3	$45.36	$67.89	10.5%	9.6%
5	$46.79	$69.96	29.9%	23.9%
9+	$49.19	$73.07	28.3%	18.4%
	$43.42	$64.94	100.0%	100.0%

The payments are lower across counties by hospital number, by physician concentration categories, by population density, and by county income levels. Across the social determinant and health determinant categories, the payments make matters worse.

Numerous levels of health care payment discrimination exist to compound the disparities that already exist. The design sends even less where workforce is most needed.

Primary care represents 55% of the 1 billion annual visits yet only receives about 6 - 8% of health care dollars.
Lowest payments for mental health and basic services assure that primary care has little help, greater burden, and more complexity where it is dominant.
Office visits are a greater proportion of the Medicare dollars that go to counties with fewer hospitals and lesser workforce.
Family medicine is 38% of the physician workforce in counties without a hospital compared to 14% for those with 1 or 2 hospitals
Counties without a hospital or with only 1 hospital receive proportionately less in payments also due to prevalance of basic payments but also face the most complex populations with the least local resources and local workforce.
Highest payments go to procedural, technical, subspecialized services
The most lines of revenue and the highest reimbursement in each line is received in top concentration settings. Lowest physician concentration settings have few or one line of revenue and lowest payments.
These designs are shaped by those in top concentration settings with little if any consideration for primary care, mental health, basic services, and health care workforce in the places where most Americans most need care and are increasing the most. The impact of disparities of payments upon health outcomes is inevitable due to the differences in the dollars, jobs, services, and supports.

Medicare 2011 Major Services from CMS Data Release

Number of Hospitals	Number of Counties	Medicare 2011 Physician Payment Billions	Medicare Enrollees 2013 in Millions	% of Medicare 2011 Payment	% of Medicare Enrollees	Index Payment to Medicare Enrollee	Index Medicaid to Pop
0	1555	1.621	6.587	2.1%	11.5%	0.186	1.377
1	997	11.89	12.987	15.6%	22.6%	0.692	1.169
2	295	10.29	8.082	13.5%	14.1%	0.963	1.122
3	110	8.003	5.523	10.5%	9.6%	1.096	1.046
4 to 9	142	22.695	13.744	29.9%	23.9%	1.249	0.914
10 up	39	21.520	10.578	28.3%	18.4%	1.539	0.751
	3138	76.023	57.501	100.0%	100.0%	1.000	1.000

Indexing By Hospital Number in a County

Number of Hospitals	0	1	2	3	4 to 9	10 up
Millions of People in 2010	25.7	59.7	38.7	28.4	80.7	75.6
% of Population 2010	8.3%	19.3%	12.5%	9.2%	26.1%	24.5%
Medicare 2011 Payment Index	0.256	0.809	1.081	1.146	1.142	1.155
Active 2013 Physician Index	0.354	0.747	0.890	1.116	1.189	1.230
Active FM 2013 Index	1.032	1.022	1.161	1.155	0.973	0.861
Physician Assistants NPI 2010	0.579	0.870	1.052	1.224	1.088	1.041
Advanced Practice Registered Nurses with NPI 2010	0.530	0.850	1.059	1.232	1.194	0.954
Nurse Practitioner w NPI 2010	0.594	0.862	1.007	1.188	1.176	0.984
Certified Registered Nurse Anesthetists with NPI 2010	0.390	0.828	1.224	1.419	1.231	0.825

Six Degrees of Discrimination By Health Care Payment Design

Numerous factors combine for lowest payments such as being in a smaller practice, a rural practice, in a lower paying state, in a lower paid region of the state and not associated with a hospital. You can also say that the practices in the states with the most state budget challenges are paid least. They have also had greater levels of supplementation for decades - but this has not been directed to primary care, mental health, or basic services.

It is not surprising that few enter and remain in least supported primary care with migrations away from primary care and where needed. The payment design is incapable of resolving deficits of workforce and access barriers. Expansions of Medicaid and high deductible plans cannot solve the problem as Medicaid pays less than cost of delivery and high deductible plans fail for primary care support. Veterans also are more concentrated where workforce is missing and the Veteran payment design fails for the support of local workforce where needed. Medicare and other insurance payers get away with paying even less.

Important Facts About Payment Discrimination

The family medicine specialty most associated with payment discrimination has not expanded for 35 years of payment designs. It has remained at 3000 annual graduates since the class of 1980. Stagnant payments with increasing costs of delivery continue to defeat distribution and care where needed.
FM has declined from 95% of active FM grads in family practice positions down to less than 70% as opportunities for better payment and better support are seen in emergency care, hospitalist, urgent care, and other settings. Other primary care sources have declined to just 15 - 30% active and found in primary care positions for those age 30 - 65.
The design just got worse with pay for performance

which is not evidence based for health outcomes improvement because outcomes are about the population characteristics and local resources, or lack thereof.
which has been demonstrated to discriminate against providers who care for the most complex with the least local resources and workforce (see below and references in these blogs).

Primary care associations continue to promote more studies of workforce and shortages, but have failed to make progress regarding reports indicating real solutions 25 years ago. COGME Third at the 25th Anniversary
Family medicine associations promote MACRA - a payment design frankly discriminatory against family physician members who provide a higher share of the care where physician concentrations are lowest and patient complexities are highest and local resources are most lacking.
A major value of Family Medicine is that active family physicians maintain a concentration about 26 to 32 per 100,000 across all of the population distributions listed, including the zero hospital counties averaging 96 active physicians per 100,000. Internal medicine primary care is fully collapsing under the design. Both pediatric and internal medicine concentrations are least where deficits in workforce are the most.

The challenges are great. Rural, primary care, and family medicine associations have failed to bring needed payment reforms - for decades. The less organized, smallest, and most distant face the greatest discrimination by design.The practices least organized:

Have no voice to defend themselves from CMS, Congress, federal policy designers, state legislatures, state Medicaid designers, and the academic and health care leaders that continue to shape designs that add to discrimination and take away needed support for team members. An entirely opposite design in nearly every dimension is required to reverse discrimination and resolve disparities in health spending, health services, and health workforce
Receive the least support despite having the least workforce.
Receive the most penalties under pay for performance schemes because of the populations that they care for - the population with the greatest disparities already.
Depend upon volume - and volume has been painted as evil by the research and health care community even though Office Visits Do Not Break the Bank But Insurers Can - Volume where services are most lacking is called access to care.

Even worse, the Tyranny of Health Care research fails to capture the issues regarding high volume vs lower volume, rural vs urban, gender of physician, type of clinician. Popular topics get published and critical works fail to survive the bandwagons of innovation and those new to big data without understanding the many ways such studies go wrong. This is especially true when the patient populations being compared are different (rural to urban, higher vs lower volume, physician gender and origin). There is a defacto assumption that small health care should be limited and payment designs insure that this is made so. It has been Open Season upon Small Health Care for some time.

These Small Health Complexities are just a few of the issues and factors that researchers and designers fail to consider that result in discrimination by design.

Ending the Discrimination of Pay for Performance - Hospitals and physicians are paid less and penalized more by pay for performance.

Pay for Performance Delays Needed Payment Reforms that should direct funding to support the team members that deliver the care, especially where the care is most complex and the local resources are least.