Articles by "Lowest Physician Concentration County"
Showing posts with label Lowest Physician Concentration County. Show all posts

at 0
health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..
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

 
Continue reading

at 0
health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..
Annual graduates continue to increase at rates must faster than population growth or growth of the elderly, yet more sources all expanded have failed to address shortages. Where did the graduates go? Not surprisingly they follow the dollar directions shaped by health policy. GME training produces the wrong physicians for the wrong specialties and the wrong places.
Residency expansions could increase the physician workforce but will not address shortages of workforce, poor retention of graduates where needed, health outcomes improvements, or access to care for Medicaid and Medicare populations falling most behind. Residency expansions will worsen health care costs and will further marginalize physicians in their contracts with employers. New medical schools, residency programs, or nurse practitioner/physician assistant programs should not be promoted as a solution for health access woes. Only substantially more dollars to support more team members in lowest concentration settings will address health access deficits.

Graduate Expansions Fail for Relief of Shortages
  • Residency expansions cannot address shortages. Too few dollars go to the places to allow adequate team members. Only payment changes can address shortages.
  • Residency expansions cannot address poor retention and higher turnover where payments are least, support is least, and complexity is highest. Only payment changes can address these areas. 
  • Residency training continues to produce the wrong specialties for the wrong places. The payment design prevents MD DO NP and PA from remaining within primary care careers and prevents residency graduates from staying within general specialties as taking a fellowship or two results in a great deal more support with less complexity and more team members to share the load.
  • Uses of Medicare and Medicaid dollars for training are not specific to the needs of Medicare and Medicaid patients most left behind. The designs prevent graduates from going to places where such patients are concentrated and prevent the specialties that they most need.
Health Care Cost Acceleration
Expansions of residency positions are promoted by those who most benefit from such expansions. Fewer graduates can help to prevent runaway health care costs.  Nurse practitioners and physician assistants have long been promoted as excellent contributions for primary care, but do as well or better in subspecialty teams. More patients can be seen in more settings and the physicians can focus on the highest revenue areas.
Accelerations of health care costs are a primary mechanism resulting in across the board cuts - cuts that hurt the lowest margin practices. The lowest margins are seen in generalist and general specialty workforce.

Overproduction  
Too many MD DO NP and PA graduates are being produced. The growth far outstrips population growth and growth of the elderly. The result has been employer dominated workforce. This tips the balance greatly toward employers, particularly in areas with the least payment support. Various sources are played against one another and this prevents understanding of the damage done by too many graduates.

Inequities Contribute to Disparities and Poor Outcomes
Residency funding is distributed most inequitably, adding to disparities directly in dollar distributions with further contributions in the products produced. Only 6.5% of residency positions are found in lowest physician concentration counties with 40% of Americans and 43 - 47% of the elderly, poor, and others most left behind.

Residency training design is a great fit for the highest physician concentration places. These include 6 states, 100 counties, and 1100 zip codes that already have top concentrations of physicians. 
Residency is the dominant factor in practice location. About half of residency positions and 45% of physicians are found in 1% of the land area in 1100 zip codes that have the most lines of revenue and the highest reimbursements in each line. These are crafted by payment designs that leaders in top concentrations have largely shaped and protected.

Research has long established that physicians will crowd in to higher concentration places rather than to distribute to places of need.
Too Many Graduates Already

By the end of 1980 the US had 20000 physicians entering the workforce with 1500 for PA and 1500 for NP. Now 30,000 physicians enter the workforce with 20,000 for NP and 9000 for PA. In only a few years there will be more NP and PA than physicians. Each year brings a few thousand more NP graduates with no sign of slowing. New medical schools are being added and new PA programs as well.
The US will never resolve shortages by producing more graduates. Massive expansions have long failed as demonstrated with a 12 times increase in nurse practitioners since 1980 along with a 6 times increase in PA and two doublings of DO graduates plus 25% from international sources plus a 30% increase in MD graduates.



These increases have resulted in little or no increase in primary care and a massive increase in non-primary care workforce. 
Health care institutions, corporations, and businesses prefer to generate more revenue from services, tests, procedures, and evaluations that are paid at much higher rates. It is even better if this has lower overhead. Primary care and basic services are high in overhead and low in revenue. Businesses invest where profit is most likely and payment designs have take away the profit in primary care for decades.

Expansions Fail for Primary Care, Mental Health, and General Surgical Specialties

Despite recent expansions, the collapse of internal medicine primary care, family medicine down to 70% primary care result, and pediatrics down below 40% have resulted in less physician primary care. Each year the US gets less primary care result despite more graduates.

The last doublings of physician assistant and osteopathic graduates resulted in no net gain in primary care workforce. The entire expansion was devoted to non-primary care.




The last few decades of workforce expansion have entirely been in non-primary care highly specialized workforce areas in places with higher concentrations of workforce - where we already overutilize and have costs too high. Too Many and the Wrong Clinicians. The dollars expended follow the workforce to more spent for procedural, technical, hospital, and highly subspecialized leaving less for primary care and basic services.
Primary care spending and spending where people need care has remained stagnant for decades by design. NP and PA also add more specialties and more are added to each new specialty - leaving family practice positions behind - the predominant primary care form for NP PA and DO. 
Even family medicine is no longer immune to payment paucity with over 90% active in FM dropping to less than 70% in the last 15 class years. Family medicine may soon break the 50% mark with less than a majority remaining active and in primary care over their careers. This could begin in the next few class years due to insufficient primary care support, costly complications, and rapid increases in complexity. Burnout is at record high levels due to payment design. 

Primary care turnover costs are estimated to be over $300,000 per lost primary care physician or about twice the cost of loss of NP and PA clinicians, but clinicians turn over at twice the rate of primary care physicians. Worsening morale, productivity, burnout, and turnover result in negative margins.

Flexible workforce follows funding. Once primary care training physicians had no other options, but now they have many hospital, urgent, emergent, and specialty options. NP and PA graduates once had few options, but this is no longer the case. As with physicians, they have more support and more team members and more specialized roles with less complexity and higher salaries - all set up by payment design.

The Evidence All Points to Payment Failure

The evidence points to shortages as the result of payment design. Only the academic community clings to workforce as being shaped by training. Without the dollars injected into the services provided by basic specialties, there can be no resolution of shortages.
The nation needs generalists, mental health, and general surgical specialties now and for decades to come due to aging changes. This is even more important where most Americans are found with lowest concentrations of workforce as there are few other types of specialties. 

These basic services are lowest paid services and remain so by design. The MD DO NP and PA expansions do not reflect any movement toward addressing these workforce areas because of payment design. The failure of massive expansions should have long ago pointed to payment failure.

Payment Failure Fails Most Where Workforce is Most Needed.

Demand increases are greatest in 2621 lowest physician concentration counties that are growing the fastest
  • In population (30% faster for decades)
  • In elderly
  • In chronic diseases
  • In complexity
The Role of Affordable Housing

Americans in higher concentrations are being displaced by city, county, developer, and government designs. Land is most valuable in higher concentration settings. Converting areas of lowest value (affordable housing, older housing, public housing) to highest value is quite profitable. Many participate in these schemes. Articles indicate the worsening shortages of affordable housing across metro areas of the nation.

Destruction of affordable housing in higher concentration settings forces Americans who are older, less healthy, disabled, Veterans, Medicare, Medicaid, and Dual Eligible to go to lowest concentration counties - counties with the least resources and workforce. They bring their worst paying, least locally supportive insurance plans with them. These plans now exclude local providers, often pay less than cost of delivery, and require numerous hoops to jump through to address patient and payer needs. Those who do not want to take care of them include state, federal, and insurance payers. Providers caring for them get penalized by payment design because they care for them.

Concentrations of Patients with Lowest Paying Plans Shape Shortages of Workforce

The lowest concentration counties are shortest in workforce with 40% of the population and less than 13% of health spending. Only 22 - 26% of physicians, clinicians, internists, pediatricians, and general surgical specialties are found in this 40% segment.

In these counties about 46% of local workforce is primary care and 25% are found in general surgical specialties. Practices in these counties tend to have the oldest physicians - also an indication of lack of replacement. These counties have been hit hardest by recent designs that have compromised small practices - particularly the MD DO NP and PA that remain in family practice despite the design.
The specialties important for lowest concentration counties are in decline or are disappearing. In the following graphic the ratio of concentration is noted, followed by active physicians per 100,000, the proportion of the local workforce provided by the specialty, and expected changes.
Family medicine distributes most equitably at 1.18. Psychiatrists are 7 times more likely to be found in the 79 top physician concentration counties as compared to the 2621 lowest physician concentration counties. Family medicine remains at 26 to 32 active family physicians per 100,000 across the US and various divisions. In the very lowest concentration counties, only family practice is found. In top concentrations FM is only 3 - 5% of local workforce. Where policies are most shaped, family medicine is a small fraction. Where health access is most important, family medicine most matters. Family practice NP and PA have similar distribution, but only when staying in family practice positions. 


Only the general specialties provide much care in lowest concentration counties 
and only when they stay general and do not go on for one or more fellowships. 
Note that residents are 150 per 100,000 in the 79 top concentration counties - a level much higher than 115 active physicians per 100,000 from all specialties as found in the 2621 lowest physician concentration counties. It is a great advantage to design a new line of revenue specific to higher concentration settings.
General specialties are in decline and some are collapsing. In recent years, new specialties have replaced old as seen in pulmonary, oncology, and radiology. The new forms of oncology and pulmonary critical care and radiology do not distribute well at all and are replacing the older more general types. This is a reflection of differences in training and lack of distribution of those younger. 

Hospital closures are predominantly in these lowest concentration counties and the closures force the departure of 20 - 30% of local workforce. Care of challenging populations with lesser health results in more penalties - a known consequence of Pay for Performance. 

The loss of a hospital also forces delays in the care of urgent and emergent care needs such as involving trauma, falls, sepsis, acute vascular events, respiratory failure, asthma, allergic reactions, dehydration, burns, and other conditions.There are more ways for children, infants, new mothers, pregnant women, toddlers, teens, and older Americans to die - by design.
Demographics, Distributions, and Discriminations All Around

Poor Fit All Around

Resident training depends upon medical school selections. Medical schools select the wrong origins for these careers and locations. Medical schools train wrong for these careers and locations. An initial residency is just a stepping stone past these careers and locations. Payment design prevents these careers and locations. 

Just one fellowship that greatly benefits the teaching hospital allows the residency graduate to bypass what is needed to a place with better support, more team members, and less complexity along with higher salary and opportunities for income beyond salary.

The dollars flowing to these lower concentration places are too few to support the workforce - regardless of any training intervention. NO Training Intervention can help until payments are increased for generalist and general specialty services. Only then can more be hired and better supported along with the team members to address the massive and growing shortages.

Movement from 6% of health spending to 12% for primary care is required with nearly all of the additional dollars going to lower concentration counties - and without requirements for additional tasks that distract team members from restoring access.
Additional Funding Is Not Needed for Residency Positions
The last decades of residency expansion have been funded teaching hospitals and the VA.
Once again the most lines of revenue and the top reimbursement in each line goes to teaching hospitals. They have demonstrated the ability to create and sustain residency positions.

Teaching CHCs - Close But No Cigar for care where needed
What is Stunning About Primary Care Is No Change By Design


Continue reading

at 0
health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..
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.

 
 
Continue reading

at 0
health is wealth, fitness is beauty, dieting is inspiration, weight loss is recreational learn how to..
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.
The MACRA Test: Can You Survive the P4P Discrimination? Will you even have the resources to survive?

The Primary Care Finances Fight Is THE FIGHT For Vulnerable Populations

Time to Burst the HITECH Bubble - ever higher health care costs, especially non-delivery costs, for no improvement in outcomes is the opposite of value based.

Get Beyond Salaries to Understand Failed Payment Policy Design - the impacts span across the team members, productivity, morale, revenue generation, team member retention, and more.   

The Experts Find New Ways Not to Focus Attention on Fixing Primary Care Finances

The Academic Family Medicine Mismatch - Will family medicine tolerate another 50 years of stagnation or will it focus attention upon the payment that powers primary care, family physicians, team members, the patients of family physicians, family medicine training, and all that family medicine associations want to accomplish?

Punishing Primary Care with Medical Homes - How can higher cost of delivery help those paid least with the lowest margins or the team members marginalized most by payment design with even less remaining for team members after the higher costs of Medical Homes? Costly innovations and rearrangements should give way to support of the team members that deliver the care - not everything else.

Worsening Costs Quality and Necessary Access with Telehealth - another example of mechanisms that defeat primary care - more cost for little gain in outcomes, dollars sucked out of communities most in need of dollars, and undermining of local primary care as the easy care is lost, leaving more complex care behind.
Continue reading
Subscribe to: Posts (Atom)