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



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



- 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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