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What You Will Not Hear in Workforce Reform Discussions

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Workforce discussions, conferences, grants, and articles are reliable in one key area - lack of discussion of the requirements for true reform. The workforce blinders will be on and the focus will be on training interventions - interventions that cannot work because of the financial design. There will not even be discussion of the real reason for maldistribution. The big players have wiped this off of the table either by intention or by lack of awareness. There are so many other better options - for them. They prefer expansions of insurance or expansions of graduates or special innovative payments or special innovative training. Most Americans need and entirely different training design, an entirely different payment design, and most likely both for recovery of their basic access to health.

If you understand what is proposed, who proposes the solution, and why - there can be clarity

If you understand how payment designs are crafted, those who benefit in top concentrations of workforce,…

Academic Medicine Scorecard on Social Responsibility

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The recent Beyond Flexner postings and social mission articles have revived interest in Academic Medicine's Season of Accountability and Social Responsibility by William T. Butler, M.D. Dr. Butler gave this address to AAMC in 1990 and expected a response - one that never came.

The following are predominantly Dr. Butler's words with an update regarding the lack of progress regarding his calls to action.


Public Concerns About the Overall Health Care System

Dr. Butler declared that academic medicine had entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. His recommendations are followed by comments regarding academic medicine addressing these concerns or not.
Public concerns have continued. There has been no progress in this area. The political arena has been a distraction, but the concerns continue. The same types of headlines listed not only are seen in the media headlines, but also …

Is an Academic Social Mission Possible Given Policy Designs?

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Periodically there are calls for Academic Medicine to be accountable for health care in areas such as health care workforce. This accountability includes the larger dimension of people with substantial limitations in their health care such as rural populations or underserved urban populations. The access situations are worsening across primary care, mental health, and general specialties - those who provide 90% of care for half of the population most in need of care. The lack of any significant improvement for decades indicates barriers not easily addressed. In fact it may well be that the top priorities for academic and largest systems are such that true reforms are prevented - reforms that would address the primary care, mental health, and basic services payments that are essential for distributions of services and broadening of health access.

A social mission or accountability would require academic and other health care leaders to stand up for higher payments for basic services, de…

Transforming Primary Care Requires Fuel and Efficient Design

The transformation of primary care requires payers and players. The payers have said no so the players are too few and are often overwhelmed where the players are most needed. Primary care needs fuel and a more efficient financial design, especially in the small and rural practices and those where care is most needed. The controversies continue to hold primary care hostage, especially primary care where needed where half of Americans will reside by 2040.
The primary care financial design begins with only $500,000 to $600,000 in revenue per primary care physician as the fuel to propel the activities of primary care physicians, clinicians, and teams for a year. Unfortunately the fuel supplied is lower where primary care is most needed and is higher where contracts gain annual escalation clauses for those largest, most organized, and in locations of least workforce need. 

Recent blogs have illustrated just how much fuel is stolen and how inefficient primary care delivery has become. True R…

Attempts to Address Overutilization Leave Most Americans Behind

Four decades of attempts to address overuse have not only failed to rein in overuse, the efforts have contributed to under-utilization and more Americans left behind by design.
Overuse has long been 2 to 4 times higher in highest physician concentration counties. Overuse supports too much workforce for few and results in too little for many. Overuse steals the workforce needed elsewhere and makes it appear that there are deficits of workforce with the need for more graduates - when the problem remains overutilization. Payment Design Plus Profit Motive Plus Political Power
Overutilization is largely the result of the payment design and profit motive and political power. The payment design results in too much paid for highly specialized services and too little for the basic services (primary care, mental health, basic specialties).  Profits are best supported by the march to ever more types of procedures and technologies that are paid the most because they are newest and most subspecialized…

True Reform is Needed to Get from Last to First for US Health Care

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Health care in the United States is notable for being the worst when comparing health care among wealthy nations. A Commonwealth article was published in NEJM highlighting four areas that need to improve. Interestingly an improvement in primary care finances would address all four areas, but this discussion was avoided. Fitz Mullan had another article promoting the social mission just published in JAMA. Once again addressing bankrupt primary care finances would contribute to the social mission. Lofty ideals are easy to discuss, but the hard work is missing when it comes to addressing access barriers, disparities, and most Americans falling farther behind. You cannot get from last to first by failing to address areas that must be reformed - areas that actually shape insufficient access, insufficient primary care, insufficient team member support, and disparities. 

Goals, Aims, and Missions must be replaced with specific actions.
True Reform Is the Beginning

The foundation, institutio…

Students and Residents in Family Medicine Want Equity

Students and residents should focus AAFP upon equity. Equity in payment would be a good start. Dollars are maldistributed in health care and this contributes to inequities in workforce, access and outcomes as disparities drive social and other determinants of health the wrong way.

AAFP wants to present the best case scenarios to students and residents, but there are major issues that must be addressed. Equity is indeed and important theme worthy of discussion

Equitable payments for primary care, mental health, and basic services should be most important for student or residents that truly hope to deliver these basics - especially in places with half of Americans where inequity and disparities dominate.  There should be no deception that most Americans are doing well. American health, education, and economic outcomes indicate that few do very well and most are left behind. Future family physicians deserve to know the big picture as family physicians are most likely to care for those le…