The Horror of Health Care Design for Most Americans

These are interview questions that I have inputted so that you can see just how bad the health care design is for most Americans. And you can expect even worse in the future

Question: Dr. Bowman you claim that training does not work to resolve deficits of workforce and shortages. What you say does not make sense and does not fit with what we hear from physician and nurse practitioner leaders?

Response: After rural practice I dedicated my life to resolving deficits of workforce in rural and in underserved areas. I lead national and international efforts in this area for decades. It was a privilege to be a part of one of the best rural pipelines – in Nebraska at UNMC. I was teaching, delivering, and researching basic health access. I had access to major databases not accessible outside of academic circles. Nebraska also started up one of the best workforce tracking systems. I also kept my own databases and mapped the workforce. The research indicated fabulous success for the rural pipeline in Nebraska that began in the teen years and impacted at all levels of admission, medical school, and FM residency. UNMC students with FM choice were about 12 to 16 times more likely to be found practicing in one of 70 counties of greatest need in Nebraska (14 without doctors chronically due to low population) and 9 with average to higher concentrations of primary care. So we should celebrate, right? Wrong! The concentrations of health care workforce did not change over decades of time. All we were doing was rearranging the deck chairs on the Titanic. The financial design did not allow an increase.

Question: What do you mean by the financial design?

The financial design for an area such as primary care is quite limited. About 50% of services are supported by just 5% of health spending. The Medicare, Medicaid, and private plans make this worse by paying even less in the states and counties lowest in health care workforce. Using 2008 as an example, about 2621 counties lowest in health care workforce have half enough primary care. Since they have older, poorer, and more complex populations they have 45% of complexity in this 40% of the population. They only have 25% of the primary care workforce. Correcting for worse plans and for lower payments by 15% or more, they only have 20% of primary care spending for this 40% of the population. And it gets worse.

Question: Why is it getting worse?

Each year the pressures to cut costs keep the level of spending stagnant in areas such as generalist and general specialty services. Lowest payments already reflect how little these are valued and there is no way that they are going to get improvements as the payers have kept these payments low since the 1980s. And the usual office and other costs of delivering care continue to go up, usually at rates higher than inflation and certainly higher than any payment raises. The final blow has been the increased costs of micromanagement – digitalization, innovation, regulation, and value based care. Not only do these add costs, these additional costs are not accompanied by increases in payments. They also require more delivery team time and effort, which cuts into productivity and revenue generation. This also contributes to burnout and turnover – which is also worse where the financial design is worse. The added cost of turnover also defeats practices where most needed.

Question: So what is the solution?

Answer: As with most basic services in health, education, and other areas, the solution is that the basics must be valued – and not taken for granted. The teachers, nurses, primary care team members, public servants, social workers, and other front line serving professionals must be supported.

Universally they need more and better team members. Their financial designs defeat them with fewer and lesser delivery team members. Micromanagement in health care and in education also diverts school and practice and hospital budgets from supporting those who deliver the care, to pay for micromanagement – benefitting those far away that do not deliver the care.

The financial design absolutely prevents resolution of shortages by any type or training or increases in graduates or special pipelines.

The financial design prevents higher functioning primary care as it results in fewer and lesser delivery team members – not more and better. How can you do outreach, integration, and coordination if you locally lack the primary care, mental health, women’s health, and social support areas with half enough or less?

The financial design prevents person center primary care, or hiring a patient consultant, or hiring a scribe to ease burdens on physicians or others.

Question: But what about Obamacare?

Obamacare made the situation worse, not better. The designers have long desired to manipulate health care and have made assumptions that they feel will help.

• Obamacare assumed that their problem was lack of health insurance.

This was not true in these 2621 counties with 40.2% of the population. They had about 40 – 41% of the uninsured – no different than the rest of the nation before Obamacare. They also have about the same level of unemployment. They do not lack for insurance or employment. They have concentrations of the worst health insurance plans and concentrations of the worst employers with their worst paychecks, benefits, and private health insurance. Obamacare did not increase basic payments and expanded the worst plans that often pay less than the cost of delivering care. In Community Health Centers the biggest problem is Medicaid that pays less than cost of delivery. Expanding health access via CHCs most requires a boost in Medicaid – about half of their patients.

• Obamacare assumed that outcomes can be improved by micromanagement.

Now you know that the financial design is too weak for practices where most needed and has been made worse. Also outcomes are mostly about people factors – conditions, behaviors, situations, environments – the social drivers or determinants of health care.

Value based designs punish health care providers where most needed as their populations are inherently lower in outcomes as shaped by years or decades of previous life influences.

How will we ever help to resolve deficits of workforce with policies that fail to address the financial design and make it worse? Hospitals and practices paid 15 – 30% less are more compromised with each passing year.

Question: This is all pretty gloomy. Is that all the bad news?

Answer: Unfortunately, no. The 2621 counties lowest in health care workforce with the worst financial designs and the most compromises – are growing fastest. This 40% of the nation has long been growing fastest in population numbers, demand for care, and care complexity. The counties higher to highest in health care workforce are slowest growing or are stagnant in growth. They cost too much and have housing shortages that also act to drive more people to move to counties lower in concentrations of workforce.

You can also see how insurance expansion steals 90 cents on the dollar out of these populations most behind and only returns 10 cents on the dollar – maybe. This is because they lack practices, workforce, hospitals, and facilities. Sometimes the plans do not even accept local providers.

You can also see how micromanagement and health insurance “advances” can cause worsening of outcomes. With more dollars stolen, less remain. This is a negative influence on social determinants and a likely contributor to worsening access and outcomes.  Each year our designers for health care and for education set up designs that support health and education less where most needed while extracting more billions for the costs of micromanagement – that is powerless to change outcomes.

This creates worsening disparities as seen in more for fewer in higher concentrations leaving less for most Americans most behind – by design.