Tuesday, January 24, 2017

TeleOutreach or TeleProfiteering

The 2010s have been a time of great claims of value from numerous innovations. While it seems that much is being done to help to improve health access, there has actually been very little change. The new proposals can actually undermine health outcomes and undermine the local workforce that is most important for access to care. Resistance to Telehealth may be futile, but there will be consequences that we need to understand.




When High Tech and High Touch Go Wrong

Telehealth has much surface appeal. High tech with the appearance of high touch has appeal. It seems so simple. After all in the photos or descriptions it appears that all you have to do is just link up and someone magically appears to address your needs.

For the purposes of discussion we can leave behind the discussions of laws, licensures, privacy requirements, payment uncertainties, certifications, and also controversies regarding the quality of telehealth.

There are a number of reasons why telehealth is not all that it seems.

Overutilization and Higher Costs Via TeleProfiteering


Retail clinics have demonstrated that convenience is costly. With televisits there will be a wallet biopsy up front and care only for those who pay up front despite claims of access improvement. 

Repeat customer focus could lead to medication overuses. Those who want their antibiotics day 1 of a bad cold are going to go to telehealth services that provide this.

Ecology of Medical Care says out of 1000 people about 800 have some health concern or symptom each month, 327 think about seeking care, and 217 visit an office (half in primary care). Those who think about profit all waking hours know that they can exploit about 30 more visits from each of three categories - those who have symptoms, those who think about a visit, and those who visit an office. 

The potential is to have as many visits from telehealth as seen in primary care. At $50 - 100 dollars a televisit for hundreds of millions in additional visits a year one can see the attraction to those who devote their lives to profit.

This appears consistent with the rest of the US design for highest cost and lowest yield health care. 

It is also consistent with Fire, Ready, Aim as implementation comes first, then adjustments, and finally studies to document benefits and consequences.
 

TeleOutreach Can Complement Local Care 

Sometimes those who institute telemedicine have a greater understanding of local needs and patient needs and family needs.

Project Echo in New Mexico represents telemedicine linked to local care for the purpose of local care support. Project Echo supports local health care professions who present their patients to University specialists - giving the optimal savings of time and costs while providing teachable moments to boost the capabilities of local nurses, clinicians, and physicians. This allows services to exist locally in areas involving general specialties and some subspecialty care. Project Echo has even been expanded to train local health care teams - helping to keep them locally to deliver and expanded range of services. 

Training of health professional students via Project Echo has the potential to revolutionize training and make it specific to local care. There is great potential in keeping training local and avoiding centralized training.


Specific uses of telehealth have been demonstrated to be powerful for teaching and for specialty services outreach (Project Echo).

Telehealth can save costs and improve access in conjunction with home care for complex homebound (usually Dual Eligible) but the constructions of beneficial telehealth are entirely different compared to convenience telehealth which is more appropriately termed TeleProfiteering.
 
Determinants of Health Falling Down By Design

Telehealth can ships dollars away from places that need dollars to places with higher concentrations of dollars, workforce, and services. Jobs, economics, and social determinants of health represent the investments in people and communities that are the key to improved health outcomes. More fertile US soil is required for improved health and health care interventions.  Dollars not sent due to lower payments represent discrimination. Dollars shipped out of town translate to fewer dollars circulating in a town.

Improved health outcomes require changes in local social determinants, local environments, local resources, local jobs, local income, local organization for care, and local behaviors.

Telehealth is a clinical intervention and as such can only provide a small less than 15% influence upon health outcomes. This is likely to be high cost relative to benefit not much different from other clinical interventions.

Telehealth Represents A Policy or Design Change

The changes result in winners and losers. No change works well for all. Telehealth concentrates dollars into the hands of those investing in telehealth. Clearly there will be many smaller players and eventually only a few bigger players. The winners are likely to be the same corporate profit conglomerates who see new opportunities for profits.

Potential TeleProfiteering Abuses

Telehealth (or retail care or urgent care) can be abused or overused as with retail clinics that increase convenience and increase costs. It can take the easiest patients/conditions and can leave the most complex for local providers.  

And HIT, EHR, digital, and telehealth can be outsourced outside of the United States. Shipping jobs outside of the US is a really bad idea to improve social determinants where needed.

Telemedicine is an example of high tech that promises much but can fail to measure up from the local perspective.

Telehealth Cannot Solve Deficits of Workforce

The problem of access is still the problem of insufficient workforce across primary care, mental health, and basic services. There is still a requirement for workforce. Trained team members are still needed to interact with patients in need of care.

Telemedicine only changes the location of the workforce. Not surprisingly the telemedicine design results in more workforce where workforce is concentrated and less workforce where workforce is lacking.

We still have overall deficits of primary care and mental health workforce because of decades of payment too low. Telehealth cannot solve deficits by design and could make them worse.

Telehealth is not a specific workforce solution. It is a different venue.

But of course this will not prevent the promotions of telehealth as a solution for workforce.

TeleOutreach is a solution that builds and supports local workforce. TeleProfiteering does not.

Designs that fail for local remain a problem for local

Who Benefits from Telemedicine?

Telemedicine benefits those who supply the equipment, software, and connections. The media, particularly the digital promotion media profit from Telemedicine considerations. Not surprisingly promotions of telemedicine proceed from similar sources. 

Large systems and academic institutions can benefit from telemedicine. This can be set up to benefit local needs or help concentrate dollars where dollars are already concentrated.



Of all the forms of inequality, injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 



Recent Blogs 

The Tyranny of Health Care Research

Why Prevent Doctors and Nurses from Teaching and Nourishing?

Office Visits Do Not Break the Bank But Insurers Can

Necessary Rather than Disruptive Transformations

Ending the Disruption of Pay for Performance and Payment Plans that Lack Evidence Basis and Discriminate

Best of Basic Health Access Blogs

Do Family Medicine Leaders Deserve the Trust of the Students Choosing FM?

Family Medicine Leaders Must Move Access Forward Not Backward

Readmissions Better from ACA or Preexistingly Worse from DRG?

Does Academia Compromise Health Care for Most Americans?

Demographics Distributions and Discriminations in Health Care

Demographics Against the Democrats

Not Easy Being Swiss Cheesy in Health Info Tech

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 


Friday, January 20, 2017

The Tyranny of Health Care Research


What is must important for health care leaders, designers, and researchers to understand is their limitations. Leaders have chosen the designs and research that they like without understanding the limitations and defects of the research. My vote for what has most set the US behind in health care goes to the tyranny of the aggregate. 

Once again, Dr. Saurabh Jha comes to the rescue by nailing this tyranny the best.

"What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands that feed it."  SAURABH JHA, MD (associate editor with The Health Care Blog)

This is likely the most valid critique of quality studies using regressions - the ones that have resulted in hundreds of billions spent on medical error, insurance expansions, and whatever variables are loaded by the researchers for little actual gain in health care.

Drug researchers use the same types of studies to gain approval even if there is marginal benefit at major cost of the drug. When this was pointed out to me regarding widened approvals for statin drugs, I did not yet understand just how this worked. But clearly those who understand and manipulate aggregates their way can save research costs and gain approvals for drug distribution - even with the lack of longer term studies or any real indication of relevant benefit.

It is important to understand that there are many researchers named Jha. This is something that confused me. Saurabh Jha MD has done very fine critiques of ACOs, hospital studies, and the tyranny of the aggregate noted here. Another Jha was the senior author of the male to female physician comparison study - enjoying its short time in the sun while taking advantage of lazy generalizations via the tyranny of the aggregate.  This is pointed out by Dr. Saurabh Jha.

The comparison of male to female physicians has other issues such as differences in distribution, volume, types of locations, types of patients seen. If would take 200 hospital admissions to only female internists to save your life one time. Also the study never considered excluding physician types known to be quite different in key areas such as communication skills. Previous problems with apples to oranges studies have already been reviewed. Different subjects require different studies and do not deserve being placed  together for comparison.

I have performed tens of thousands of regressions if not hundreds of thousands in various studies of health care workforce, county level studies, and other areas. Playing with regressions can be come an addiction. It is quite wonderful, until you begin to understand the limitations of the variables and your findings. Even worse, you can see how the studies can be manipulated intentionally or not. You may even forget why you did the studies or even the question that you asked. Now we know not only why some studies are difficult to replicate, but how.

If you thought physicians were hard to change, think how hard it is to change the beliefs of innovators, health researchers, digitalization worshippers, and others who have seen the works without the limitations.

The Tyranny of Health Care Research 1995 to 2020

Inconsistent is the best description of what is presented as research in areas such as quality, cost, and access. It is important to understand the assumptions of regression studies and other approaches. Perhaps it is important to highlight the impact of such works under categories such as
  • Health Insurance Expansion and Intervention - expansions of insurance did not impact important areas such as primary care, mental health, and basic services which have remained stagnant or are in decline. The lowest physician concentration counties with concentrations of lowest paying insurance plans still remain behind.
  • Medical Error Studies and Interventions - studies have claimed dramatic numbers such as 100,000 to 200,000 deaths a year in US health care that supposedly could be avoided. But 20 years of interventions have not demonstrated significant progress at great cost.
  • Pay for Performance Studies and Interventions - Pay for Performance has been another assumption that has failed to significantly change outcomes in small to large scale studies. Even worse, the pay for performance, MIPS, MACRA, value-based, and Readmission Penalty designs discriminate against providers that care for more challenging populations with lesser resources, greater complexity, and more difficult situations/environments.
There are just a few that fight against the Tyranny:
  • Competent Researchers
  • Those who deliver care and understand the compromises
Competent Researchers are outnumbered and outgunned. Popular research gains the attention of journals and the media. The research demonstrates that the limitations are far too few and studies are taken out of context and beyond limitations. Even worse, health policy interventions in areas such as payment have been implemented nationwide before reasonable study and critique.

Those who deliver care have long sensed the problems involving assumptions, rapid chaotic change, and compromise of patient care. But often their concerns are minimized or worse. Often they have been called incompetent or resistant to change. It is the duty of all who provide care to be diligent regarding patient care. Their compromise is a compromise to all of health care.

Research Dividing the Nation

Research that fails to understand most Americans left behind and what impacts their health, education, economic, and societal outcomes is research that helps to facilitate national divisions.

At one time research was focused upon disparities between populations. This led to important changes decades ago.

Recent research has been more dominated by what is popular. Research with value for advertising revenues and social media appears to be preferred and has a fast track to publication - even if pages of limitations and necessary explanations are missing.

Forgive me for going with the dramatic and the popular, but these various blogs and articles are easy targets.

Everyone with large databases is able to demonstrate what looks like large differences in populations voting for Trump. The differences have been linked to numerous social determinants, health outcomes, and other demographic differences.
  • The first problem with these studies is that actual voting is inferred. 
  • Also most people did not vote. Voting is one of the least representative characteristics as not everyone can vote. 
  • Those that do vote are a select group and can be different from the people in the places where they vote. 
  • Americans can also vote differently than predicted as is well known now. Researchers, policists, and the media were off in their estimates, possibly because they understand most people left behind the least.
  • Research often looks at averages and fails to examine distributions of voting. Inclusion as a red county or blue county may involve only a small margin of difference. This can lead to the need to manipulate the changes to magnify the difference - such as changes in voting last election to this one as seen in some of the research. 
  • The fact that people did change from last to this election is lost in the stereotyping that goes on across the choice of research, the capture of data, the analysis, the selections that lead to acceptance and publication and promotion by the media. 
  • Red county or blue has varied over elections for many reasons. 
The difference for most counties was small. Some studies apparently needed to use their own take on the variable to use such as magnitude of change in voting from past to the current election to show differences. This is an obvious demonstration that the candidate makes a difference, or what is perceived about that candidate that makes people vote for or against them. This, of course, is usually not presented in the research and is too complex for media or social media reduced to a few words or a small politically charged poster or posting.

More Tyranny of the Aggregate

Rural people as a whole do have lesser social determinants, but there are wide variations. Picturing Trump voters as less educated, or more likely to be dependent is not helpful.

Few consider that painting rural people or minorities or others in a bad light helps to divide the nation and may result in voting behaviors guided by emotion rather than other considerations.

Understanding the Oppression of Agendas

Does it matter now to understand where Obamacare came from? Does it matter than the managed care and Dartmouth researcher assumptions became the law of the land - assumptions based on a small portion of the population? Does it matter than most Americans and their needs were not considered along with small practices, small hospitals, and care where needed? Does it matter than most Americans are not desired by ACOs, insurance plans, practices, and hospitals because they are associated with adverse outcomes because of who they are and their behaviors, situations, environments, and deficits of local resources and workforce?

Guidelines for Researchers Desiring to Get Published

  • If you want to get published, choose an area of study involving quality measurement, male vs female, or divisive politics - the more the merrier.
  • Be sure to develop databases with hundreds if not thousands of variables. Choose the variables most favorable to your cause.
  • If you want to show no difference, choose the same or similar populations for care (NP vs MD, Resident work hours limitations studies before and after). You can also focus on a distracting area such as handoffs implying problems. Since you are the researcher you can find your way to a study that gets published even though it may be a distraction from the population and local resource factors that are much more likely to shape outcomes.
  • If you want to show a difference, compare populations who are different or providers who are different with different populations served (Primary Care Medical Home, Urban vs Rural Hospitals, Pay for Performance). Including states that perform well and are advanced in information prowess such as Washington State makes independent nurse practitioners look good in Medicare, since half of the combined populations of the 7 states for comparison were from Washington State.  
  • Avoid areas such as health access or real solutions to health care problems. The solutions are a poor fit with current beliefs and assumptions and are usually too complex to grasp. In addition, the evidence against is mostly common sense and global and macro as compared to micro biomedical or micro policy research studies that are simplistic and work for comparisons involving one independent variable which is often not really independent.

Male vs Female Internist Studies Compare Apples to Oranges

Few would contest the statement that males and females are different. Somehow it is hard to see that a comparison of males to females is problematic. When there are differences between the two types of subjects being compared, it is difficult to compare them or there will be compromise or there will be flaws in the comparison
  • We should question the differences when there are differences between males and females such as origins, ages, years in practice, training, practice location characteristics, practices of different type, and practices in different regions of the nation. Without complete inclusion of controls for all of these areas, then females will look different but not necessarily because of gender. 
  • Males are found in places that have less healthy hospitals with lesser payments and poorer outcomes. The study did not account for lower ratios of internist to patient which was implied as indicated by higher volumes assigned to male internists. Hospitalists with high patient ratios lose the ability to discharge faster and other adverse outcomes are likely. When there are differences in the populations receiving care, it is very difficult to provide controls as these are also apples to oranges different. 
  • Pay is different for many reasons not involving gender. Such studies are popular because of advocacy groups, beliefs, and assumptions. The differences make if difficult or impossible to tell what is gender and what is not.
  • We should question the differences based on females - female physicians more likely to be in settings with greater support from more lines of revenue and higher payments.
  • We should question based on the higher volume of male physicians compared to females.
  • We should question based on the consistent differences. When a wide range of outcomes all have consistent differences between males and female rather than some better for one outcome and at least a few better for the other this implies consistent differences such as is seen in distribution.
  • We should question based on the communication skill differences of certain internal medicine males such as those born in other nations - known to have higher discipline rates.
Males are more likely to be found in places with lower concentrations of workforce, health resources, social determinants, and local support along with patients who are older, less healthy, and smoke, binge drink, eat more, exercise less, and have poor to fair health at higher levels not to mention higher levels of preventable deaths.

Readmission Improvements - Shaped by DRGs or ACA?

Then of course there is the problem of DRGs and their cost cutting focus. This results in a change in the priorities to lesser cost. Lower costs are best addressed by sending patients home quicker and by cuts in personnel. Nurses suffer the most under such cuts. DRGs was a knife at their throat and a major motivation to much activity and advocacy. More importantly the combinations of dumping out patients faster and marginalization of the safety and education contributions of nursing should have some impact - and there is such evidence as provided by  The readmission rate improvement claims are another problem as readmissions were likely increased by DRGs which left some room for the recent decrease. Whatever happened to the usual caution when interpreting changes in outcomes - known to go slowly when millions of people are involved. The readmission rate is seriously flawed as a measure of hospital "quality." One size of 30 days does not fit all diseases, diagnoses, DRGs, patients, patient populations, places, and care settings. This is seen with highest penalties where expected at 14% for lowest physician concentration counties (red counties) with 9% for rural and three times less at 3% for urban.

Managed Care to Dartmouth to ACA/MACRA Distortions

It is bad enough to have research that lacks evidence basis. It is worse when this is applied to important areas such as payment policy. The lack of ability of CMS to understand people and local factors is why MedPAC and RAND have had differences with CMS. The fact that these differences surfaced at all is unusual. But there are major issues such as the CMS estimates of expanded health care coverage twice as high as CBO.

That Readmission and MACRA make matters worse where care is most needed should not be a surprise as this has been going on for decades of designs.

Rural vs Urban Hospitals

Assumptions that bigger is better and higher volume is higher quality have also ignored apples to oranges differences. The male to female study fits in the waste bin with rural vs urban hospital quality under the category of apples to oranges flaws since there are differences in locations, populations, local workforce, hospital personnel, local resources, local situations, local behaviors, and lesser payments.

The Future of Health Care Improvement Is About People Improvement Before, During, and After the Limited Impacts of Clinical Interventions

Some day we might just see through such studies when we do finally understand that 60 - 70% of outcomes in areas such as health and education are about the people and their behaviors, environments, situations and how they interact with the community over decades before the event, admission, test or other outcome is measured. And in the case of readmissions, almost as bad as MACRA in inability to discern "quality," the various people and local interactions after discharge come into play.

Then we can understand that To Err is Human has been a great diversion from the real determinants of health outcomes just as spending 1 and then 2 more trillion on health care has also been higher cost for little change in outcome - the opposite of value based.

Even worse we can look at data from Blue States and Red States and begin to see how the massive increases in health care costs are worsening investments in people and their communities - and worsening health, education, economic, and social outcomes.  The most blue counties receive health spending at 29000 per person while the red counties only receive about 3500 per person.

But the journals and the media are too busy polarizing and paralyzing the country and making it easier for the misguided to make matters worse by slashing and burning spending that matters such as Social Security, disability, Veteran benefits, Medicare age 65 and 66, and insurance for poor children - all slightly more concentrated where outcomes are least and where most Americans are found - left behind by numerous designs.

Then there might be some understanding regarding those who would vote against the candidate most closely associated with the establishment that has done little for them for decades as disparities widen for most Americans.

And those perceiving correctly that they are left behind by prominent areas such as health care and have had little attention in other areas might just vote differently in the next election as they did previously - except for the venom being released by social media and other media outlets and fueled by numerous journal articles that are as much about stereotyping as the material found in the media. Isn't it great to write articles that gain you praise from academics and the media and various advocates as the material adds to the advertising and marketing revenues while leading the nation to greater divisions and impaired healing. 

Recent Blogs 

Why Prevent Doctors and Nurses from Teaching and Nourishing?

Office Visits Do Not Break the Bank But Insurers Can

Necessary Rather than Disruptive Transformations

Ending the Disruption of Pay for Performance and Payment Plans that Lack Evidence Basis and Discriminate

Best of Basic Health Access Blogs

Do Family Medicine Leaders Deserve the Trust of the Students Choosing FM?

Family Medicine Leaders Must Move Access Forward Not Backward

Readmissions Better from ACA or Preexistingly Worse from DRG?

Does Academia Compromise Health Care for Most Americans?

Demographics Distributions and Discriminations in Health Care

Demographics Against the Democrats

Not Easy Being Swiss Cheesy in Health Info Tech

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 


Thursday, January 19, 2017

Why Prevent Doctors and Nurses from Teaching and Nourishing?

Some basic questions need to be asked and answered by those in charge of the designs. Words have histories that can help us see just how much change has occurred - from the earliest origins of the words "doctor" and "nurse" until today.

One of the most important questions is...

Why have health care designs taken doctors and nurses out of their original designs?

The Word "Doctor" from the British Medical Journal 2011

The origin of the word 'doctor' is to teach. One of the main roles of a medical doctor is to teach the patient about their health and illness. Doctors are effective teachers given sufficient time. Patients and family members are the main agents of positive changes in health at a population level. http://www.bmj.com/rapid-response/2011/11/01/origin-word-doctor-teach

It's all there. Sufficient support and the need to impact patients and families that are the main agents of positive change.

Unfortunately doctors have moved (and have been moved) "beyond teaching" to areas that have minimal overall health impact. Even worse, the high cost of health care defeats efforts at the person, family, and community level. The high cost of defense and health care are what defeat our nation in its most important outcomes.

When I hear someone talk about leaving doctors to do the more exclusive care needs, it is clear that those words are spoken by those that have a very different understanding regarding the primary functions of physicians, nurses, and health care.

Doctors were not alone in this change. From the 1980s to the present, the Era of Cost Cutting has dominated health care design. The designers of health care essentially have shaped the workforce and the consequences by payment designs.  Payment too little in areas such as primary care, mental health, and basic services has clearly compromised
  • time with patients, 
  • teaching, and 
  • support of team members to teach and interact with the community
Designers out of touch with the primary functions of workforce have not helped, and doctors have not stopped them.

Nurses have some defense as they have less time at the help designing health policy, but they have also been forced away from their priority areas.

The Word "Nurse" from Nurse Manifest in 2012

The first instance in English of nurse occurred in the early thirteenth century as the Anglo-Norman nurice, derived from the fifth-century post-Classical Latin nutrice, a wet-nurse (hired to provide an infant with breast milk when the infant’s mother would not or could not do so), although by the time it entered the Middle English lexicon, it had already absorbed the figurative sense of any female caretaker of children (Oxford English Dictionary 2010). Etymologically it is related to our modern word nourish, to feed.
Already by the late fourteenth century nurse had also taken on the figurative sense of any thing or any place that nurtures or fosters a quality or condition, and by the early fifteenth century, any person who takes care of, looks after, educates or advises someone. https://nursemanifest.com/2012/04/24/some-history-on-the-origin-of-the-word-nurse/

As has been previously discussed, the Diagnosis Related Group Prospective Payment change was a dagger pointed not only at nurses, but at their primary teaching, caring, and nourishing roles. Too few nurses and patients discharged too soon has left little opportunity for teaching or learning. Not surprising has been the higher level of readmissions and other adverse events far too frequent via health care payment design.

The designers either intentionally figure out how to micromanage and marginalize, or they focus elsewhere and covertly accomplish the same compromise.

Compromises of Teaching and Learning

Of course our designs hardly give teachers time to teach so perhaps the real problem is about our nation and its approaches to teaching and learning. This impacts children from the earliest ages leaving most behind. Earliest impacts also damage the exclusive in areas that they least understand - and impact our nation in designs for health, education, economics, and politics.

The real crisis in education is an Open Letter from a Teacher to the incoming Secretary of Education. This gives just a glimpse with regard to measurement, test focus, and other impediments in teaching and learning by design.

The Lessons of Exclusive Origins, Exclusive Designers, and Exclusive Designs

Today in Upshot in the New York Times the level of eliteness in the elite colleges was illustrated in graphics. The graphics reveal that the top 1% supplies more students than the bottom 60%.

Most of the time, this is used to illustrate lack of diversity. But few seem to see the most major problem - the lack of awareness. Those born, raised, educated, and trained exclusively have very little chance to understand the real world or most people quite different from them.

Two movies come to mind. In Overboard, Goldie Hawn was given the chance to understand what it was like in poor working class situations after a life of luxury. From her personal servant played by Roddy McDowell - "But you madam, have had the... rare privilege of escaping your bonds for just a spell. ... How you choose to use that information is entirely up to you."

In Father Goose, Cary Grant's character was a history teacher that gave up on the exclusive children that failed to learn from history and were repeating the same mistakes - as seen in World War II. 

Cary Grant dropped out into the South Pacific to major in scrounging and alcohol. He has been forced to become a coast watcher to identify Japanese plane and ship movements. Leslie Caron plays a school mistress in charge of children. They have been stuck on an island together and she has been bitten by a snake – or rather a stick that looked like a snake. They both think that she is dying and they are being totally transparent, with the help of the alcohol used to kill her pain. She is referred to as Goody Two Shoes and Cary Grant is the Filthy Beast.

Goody Two Shoes/LC - What was she like


Filthy Beast/CG - She who



LC - The lady that drove you to … drink

CG - That was no lady

LC - That was your wife – (cackles)

CG - No, No, There was no wife



LC - From what are you running away from, hmm?

CG - Oh I’m not running away

LC - There must have been some…some…

CG - There was, it was a necktie.



LC - A what?

CG - A necktie. I was late for class one morning. I forgot my tie and they wouldn’t let me in.

LC - How long ago was that?

CG - About eight years ago (1933)

LC - Weren’t you a little old to be going to school?

CG - Oh, I wasn’t going (looks around to see if the children are listening)

Ahem… I was teaching. I was a professor of history. (shrinks down)

LC - And what about the necktie.

CG - This is no time to talk about me.

LC - Why not?



CG - (Sighs) Why not?- Well, see, I thought they would be more interested in what was inside of a man’s head than what was around his neck. Then, I noticed that they all wore ties. They all looked alike. They all behaved alike. They all talked alike. They were all going the same way, no matter which way they said they were going. So what was the use of teaching them history, or anything? They weren’t learning by it. They were still creating the same world (or old) problems. So I packed, got on a boat, and got away from them.

Now Look what they got me doing



LC - (Giggles uncontrollably) You - a schoolteacher.

(Sits up, gasps) Oh dear (she collapses and seems dead, he pulls up cover over her head, takes a belt)



Watch Father Goose from 1964 for the revival, marriage, and escape. This movie took the Oscar for Best Screenplay and those winning credited Cary Grant for winning a number of Oscars - for everyone else.

Recent actors deserve some credit for indicating that movies are just movies, but there are lessons to be learned from history.

We can also learn from the roles that they have played. I have been thinking about Robin Williams much lately and the roles in Good Will Hunting, Awakenings, Good Morning Vietnam, and others. In Dead Poets he was teaching the students to explore and reflect and consider. Those most exclusive appear to need different awareness and understanding. 

We need to get away from creating the same world problems and learn from our mistakes. The quality gurus understood the need for the outside perspective. Since this perspective involves well over half of the nation's population, leaders in health, education, economics, and politics better learn to listen.


Recent Blogs 

Why Prevent Doctors and Nurses from Teaching and Nourishing?

Office Visits Do Not Break the Bank But Insurers Can

Necessary Rather than Disruptive Transformations

Ending the Disruption of Pay for Performance and Payment Plans that Lack Evidence Basis and Discriminate

Best of Basic Health Access Blogs

Do Family Medicine Leaders Deserve the Trust of the Students Choosing FM?

Family Medicine Leaders Must Move Access Forward Not Backward

Readmissions Better from ACA or Preexistingly Worse from DRG?

Does Academia Compromise Health Care for Most Americans?

Demographics Distributions and Discriminations in Health Care

Demographics Against the Democrats

Not Easy Being Swiss Cheesy in Health Info Tech

The 25th Anniversary of the COGME Third Report and No Change By Design

Why Is Value So Hard to Recognize in Health Care and why does family medicine not value family physicians and the high value places where they practice

The Four Horsemen of the Primary Care Apocalypse - Medicaid, High Deductible, Veteran, and Medicare Plans shape failure by payment design

Plea to Academic Leaders - Please No More So Called Primary Care Solutions - No Training Intervention or Practice Rearrangement Can Work without Payment Reform

What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 


Sunday, January 15, 2017

Office Visits Do Not Break the Bank But Insurers Can

Small health care has managed to survive despite impairment by financial design. The Big Squeeze has long been in play. There too many ways for Big to Win and Small to lose. Innovation worship and inconsequential reforms gain headlines while few look critically at health care designs. The consistent finding is that health care entities less organized, smaller, and most distant lose. Those largest, most organized, and shaping the designs win. This is the American health care way.

Of all the forms of inequality,  
injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr. 



New Ways for Big to Win and Small to Lose
If you are small compared to Big Health, and face higher costs of delivery due to supplier inequities, and get paid less where you practice by government and insurers, and get paid even less because you dare to care for people in most need of care...

You Are Caught in the Big Squeeze
More Observations

There is little or no competition in places where 30 - 50% of Americans are found - the most complex and underserved Americans.

Note the decades long move to fewer insurers. This leaves remaining insurers with greater market share - and more power to determine who lives, who dies, and who they buy out for best profits. Insurers such as United or Blue Cross that are stuck with the wrong populations or locations - just dump out of the market. This also leaves fewer insurers that can pay less and demand more in premium.

One of the only ways to increase office payments where primary care is most needed is to be bought out by a hospital or large practice - if you can find one that wants your practice.

Unfortunately if you sell out to big, you sell out your community as those bigger and distant have entirely different priorities rather than addressing local patients, situations, and resources.

The Small Fish in a Big Pond loses. The Big Fish in a Small Pond wins. 

Health care works for those most concentrated. It is not a surprise that so many different corporations and entrepreneurs want to get a slice of the health care pie. If you understand the rules, you can play to win - big. If you get into health care to care for people in need of care, well this can be a challenge in more ways that you can assess.

There are many confirmations of the discrimination that goes on. You can categorize this by size of provider, by type of location (rural, lower concentration, underserved), level of organization, or other categories but it always ends up the same. If you are smaller, less organized, distant, and have the most complex populations - the government, insurance, and academic designers have been driving you out of small practices and small hospitals for decades of designs.
  • Lower payments for generalist and general specialty services
  • Lower payments in states most behind in workforce
  • Lower payments in counties most behind in workforce (with few or no hospitals)
  • Lower payments for small practices
  • Lower payments where insurers are bigger
  • Lower payments via Pay for Performance for small, underserved, rural, or most complex care
The biggest and most advantaged for private insurance payments can expect 90 - 100 dollars for basic office services while Medicare pay is less than $60 in some states and locations with Medicaid even less. 

Medicaid – well we can just hope that there is some payment in the future from Medicaid but it has always been a loss leader.



As a Reminder, This Quote from Jim Purcell was directed by him to fellow CEOs, physicians, and execs in health systems and insurance:



Unfortunately those doing well have found that Cherry Picking works and this can work very well by
  • avoiding mental health patients or high mental health populations
  • avoiding primary care practices with more complex patients 

This works for the larger practices and systems that can change locations to avoid such patients.

This works for health insurance corporations.

But this does not work for most Americans behind by more designs than can be tracked.



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Office Visits Do Not Break the Bank But Insurers Can

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