Insanity and Discrimination in Payment Design Maintain Shortages of Workforce

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.