The Deep Squeeze Financial Design Killing Health Access

As an academic family physician specializing in basic health access, I worked to resolve shortages and improve access to care. It was my privilege to work in some of the few remaining schools devoted to such efforts. Sadly this professor found that he was learning impaired - or perhaps I was indoctrinated by the process of medical education. The financial design was far too powerful to allow training design to address deficits.

What appeared to work in the 1965 to 1980 period of time, worked because of the financial design. Each year more dollars were pumped into basic services - especially where poor Americans and seniors were found. As it turns out, these are the areas with the most deficits. Initially the original Medicare and Medicaid designs helped, but they were changed into vehicles to concentrate dollars - not distribute care. The same designers continue to shape the designs into more for few and fewer for more - and basic health access suffers most by design.

My solo rural pr…

Stop the Insanity of Massive Overexpansions of Health Workforce

We should send a clear message to the "experts" and the media and associations and health professional training institutions: Please stop the insanity of doing the same thing over and over again expecting a different result. 

New innovative types of workforce have failed to resolve workforce deficits despite massive expansionsMore new types and more expansions have failed.More new types and more expansions are proposed.
It is the financial foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed.

It Is Not the Initials or the Expansion, It is the Financial Design

It is not about who is a better health professional or the type of training. Expansions are not the solution for any domination or perceived domination of health care.

Texas has another new medical school planned but a family physician dean will not be able to keep the promise of more doctors where needed.


Ignoring Evidence Basis in Health Policy Is Unhealthy

One year ago today we had all the evidence that we needed to move away from payment policies that punished practices and delivery team members with meaningless use and other abuse. A year ago today, a landmark comprehensive review indicated that outcomes were not improved by financial incentives. “In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clear evidence to suggest that they improve patient outcomes.” from

The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 1/10/17.  
Happy Anniversary to Aaron Mendelson, BA; Karli Kondo, PhD; Cheryl Damberg, PhD; Allison Low, BA; Makalapua MotĂșapuaka, BA; Michele Freeman, MPH; Maya O'Neil, PhD; Rose Relevo, MLIS, MS; Devan Kansagara, MD, MCR for a fine study - substantially ignored  Not even primary care associations have moved away from financial incentives. In fact AAFP…

Training Cannot Overcome Deficits By Financial Design

I loved my career in rural medical education. Only rural practice was better. As a rural medical educator I felt very comfortable with the fact that there were many ways to improve the preparation for rural practice. Over time I grew uncomfortable as I recognized more and more that training was not going to overcome workforce deficits.

The sad fact is that special training works for those associated with special training. Special training does not reduce the problem of inadequate access to care. The proof is in the concentrations of primary care where needed. These concentrations of primary care have remained the same - about half enough. Yes it is true that a special training program or school can have higher proportions serving in locations of need - but their success only results in displacement of others - FM for what was IM, and NP/PA for previous IM or FM. The specially trained replace the traditionally trained. This is a rearrangement of the deck chairs rather than an increase …

Micromanagement Steals Creativity and Many Billions of Dollars

Calculations reveal just how much micromanagement is costing primary care practices where they are most needed. The costs involve other specialties that are also basic, smaller, less organized, and most needed. With reflection, the epidemic of measurement has had even greater spread. Micromanagement costs and consequences devastate education in these same lowest concentration counties.

Primary Care in 2621 Lowest Workforce Concentration Counties 

The calculations reveal at least 8 billion dollars less remaining to invest in primary care in 2621 counties lowest in concentrations of primary care, health care workforce, and physicians. The same financial designs that impact primary care also impact nurse practitioners, physician assistants, and physicians. Women's health and basic surgical services are impacted.

Measurement focus in health care has attempted to improve costs and quality
But costs have been increased by digitalization, innovation, certification, and regulationQuality h…

Amazonian Concentrators Cannot Distribute Care Where Needed

Amazon, Berkshire Hathaway, and Chase grabbed headlines and many speculated on disrupting health care. In fact the headline alone sent health care stocks reeling. The power or concentrated dollars results in fear. To understand the power, follow the money.

Meet the New Boss, Same as the Old Boss

The money trail tells you what you need to know about the designs and designers. The money trail for this Big 3 indicates concentrations of more dollars into the hand of fewer. Experts in the concentration of dollars will likely do no better than those who have concentrated health care dollars and workforce over the past century.

But there will be those who cheer the Big 3 on. Many hope that they will bust through resistance to implement a new regime in health care.

But in health care as in economics, education, housing, and more there is not a new regime.

Meet the New Boss, Same as the Old Boss
Meet the Old Bosses Who Best Adapt and Change To Maintain Control

In health care the changes in the w…

Big Corporations Already Disrupt Health Care

Today as more big corporations capture national attention as they enter the fray to "fix" health care, you will see more promotions by a wide range of corporations. Many of them brand spanking new and financed by those who already profit most, including their health care investments. These consultants, corporations, and "experts" are complicating not only the work of those who deliver the care, but also their lives. Micromanagement of costs and of quality are still considered to be "good" even though the evidence base indicates no improvements in cost saving or in outcomes.
Micromanagment of health care steals the dollars needed to support those who deliver the care and also steals time from their relationships with patients, team members, and family members. The same is true with micromanagement and measurement focus in education. Together these dollar diversions of tens of billions result in better for the few in higher concentrations and worse for mo…