8.20.2011- The Big Fish Will Once Again Escape |
The Big Fish Will Once Again Escape - We Will Net the Small Ones Cri Posted by: "Robert Bowman" This e-mail address is being protected from spambots. You need JavaScript enabled to view it on the Spirit of 1848 Sat Aug 20, and 2011 11:07 am (PDT)
Summary - across the board cuts penalize those delivering older long established health services and those in most need of basic services and populations most associated with basic services - the US design with ever more newly created services and tests and technologies rewards the newer needed by fewest and penalizes the basic bread and butter. With across the board cuts, the penalties are greater on those basic long established services. Also increasing costs of health care delivery in the face of stagnant reimbursement or cuts in reimbursement - is a guarantee of further destruction of basic services and basic health access. This is facilitated in every way by the bigger and biggest fish, that can direct the most resources to preventing change or to preserving their highest proportional health spending. Even worse, since we direct little attention to basic services with maximal attention elsewhere, we will not even understand just how much worse matters will be for most Americans. Witness focus on innovation in primary care without any real attention to increasing primary care workforce or delivery capacity.
The elderly, poor, near poor, lower income, middle income, lower population density, and middle population density populations have long had limitations in health services access, health spending per capita in their locations of residence, economic impact from health care, and jobs arising from health care. This is because our designs favor locations and populations associated with combinations of concentration and the most expensive services needed by the fewest. Spending designs have resulted in massive doublings of non-primary care workforce each 15 years, those most likely to concentrate in top concentrations already. New lines of revenue are created with more services and techologies and tests inside of top concentrations. Those outside of concentrations depend mostly upon the basics - the only services available locally. Broadest scope generalists are consistent in sending health spending, economic impact, jobs, and health services to most Americans left behind. Broadest scope generalists have increased less than primary care, which is still stagnated at the 1980 design level. Limitations for 30 years have been specific to those most needed for basic care - by designs that favored services to fewest Americans in fewest health areas delivered in fewest locations.
Specific cuts have long been needed in the services for the fewest Americans that have very specific illnesses and costly illnesses or are at or near the point of death - and we know that many if not most of these expenditures are without much benefit and can cause harm.
But all it takes is to trot out some death squad rhetoric so that the current design is maintained. Or else people can be easily convinced that government control or government designs are at fault. Or if this is not enough some funding can be directed to the advocacy groups involved so that they can gain dramatic attention - so that the most expensive services can continue.
Since the newest services are typically the most expensive and are the least likely to have competition and have not faced across the board cuts, the design favors new services - even services with little benefit and great cost. Rational thought over the past 100 years has addressed substantial issues related to improvement of health for the least cost. Now we have innovations that cost much and do little, but we keep going,
In any case we get more funding shifted to fewer for less benefit - and we appear incapable of rational thought (short of Oregon). We do not even study these areas. Only pediatric cancer has anything near complete data collection - likely because we realized early on that we were often torturing children - an intolerable thought for children or any age. Other areas with incomplete data collection involve services already fewest, a huge problem in understanding benefit to risk and cost factors.
Benefit to risk, to cost, is always important and rarely discussed or evaluated rationally. Even worse, those doing the studies are delivering the services and often have little objective review.
So we have these across the board cuts
We have all of these incredibly potent lobbies for so much for so little
And we have half of the nation left behind already along with primary care and public health.
And we are destroying primary care workforce with formulas that fail to keep primary care revenue above the cost of delivering primary care
- making patients more likely to access more expensive and most expensive care or to be less productive at their jobs - making workforce less likely to enter primary care or to remain in primary care after entry
And our primary care workforce will have to cut nurses, staff, techs, and professionals back
- driving more primary care workforce away - decreasing the amount of primary care delivery - making primary care delivery less effective (less experienced workforce, timing of care is wrong, overwhelmed even more)
Insurance companies will follow suit and smaller practices and primary care will take the hits while the bigger dogs will negotiate better deals
- further declines in health access, less local decision-making and more care influenced by those distant and less aware
We have already had this for decades and matters are likely to get worse. I see it already happening in our clinics.
Increasing costs of health care already force cutbacks in primary care personnel (and school systems, and public servants)
- resulting in less health care delivery and other basic services
And the current Medicare coverage is already so bad that those that can work past 65 just to get better coverage
- not good for those needing a job.
And we have nurses that have come out of retirement to take jobs because of their spouses lack of a job or health care coverage or decent health care coverage
- suppressing basic nursing workforce entry and retention
Our designs past, present future will continue to allow the big fish to get away and net the small ones critical to most needed care.
Bob Bowman www.basichealthaccess.org
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