Population Health from Above or Below

The innovation gurus have declared population health to be a key factor in health outcomes. As usual there are those who plan to help others while helping themselves. Can Big Data approaches make a difference? Are there other approaches? Do we trust consultants and corporations from afar to help diagnose and treat community wide health problems? Is there another approach that does not involve distant, different, and shipping scarce dollars elsewhere?


Those who truly want to improve the health of populations might want to consider approaches local in focus, lower in cost, and of no benefit to anyone outside of the community not to mention decades of previous development. 

Community Oriented Primary Care and Asset Based Management are approaches that have been around for over 50 years. The history of COPC is quite revealing as Sidney Kark tried to go to South Africa to address trauma - but found what was needed was sanitation and public health. Such problems are common when those far away attempt to address local care needs without really understanding the people or the who what when where and how of engaging people for change.

Advantages of local population determined approaches include 
  • Engagement specific to local priorities and preferences 
  • Full utilization of local resources plus needs assessments for the development of more
  • Local organization of health care efforts rather than disintegration as in current health care
  • Specific data development and utilization for specific local application (not shotgun approaches of too much collected with little used and even less relevant)
  • Development of interventions specific to desire to change
  • Skipping decades of mistakes, local resources, local desire to change, and other specifics that big data from above cannot hope to address. 
Local approaches are not one size fits all as in top down approaches. The proper approach is one size developed by one community fits one community.
One former proponent of primary care medical home eventually saw the light as there was little that a distant and different part time consultant and coach could do. What really matters is often the culture, the organization, the understanding - all local.
Local also might avoid the major folly of the US health care design - more layers of administration and management added in ways that accomplish less for ever higher cost.

Why not try the opposite of top down or more local dollars shipped elsewhere for nebulous reasons.


Family medicine represents the worst and best. Many family physicians have participated in local approaches and some teach these approaches. But the family medicine leadership fully embraces the latest innovations including those that are a poor fit for most family physicians. FM leaders like to talk about leading change, but do not embrace the local led change that family medicine has to offer. FM like many others are still waiting for solutions from above rather than facilitating local care. It is maddening for FM to ignore the decades of experiences of local family physicians while jumping for the latest innovation.


FM leaders want to promote primary care in Health is Primary. Many hours from many people go to promotional pieces. There is much ado but no focus on the way to do what is promoted. For example point 4 of 6 points in Health Is Primary is "Integrate public and mental health into the Patient Centered Medical Home (PCMH) and add care managers, health coaches and population health professionals to the primary care team." Of course there is nothing in any of the six major points about increasing payment so that family practices can do any of this, particularly the solo and small group half of family medicine going away by payment design and made worse with higher cost of delivery.

This is another one of those Americans can always be counted upon to do the right thing areas (Churchill quote) and more will be tried expensively and ineffectively until Americans do the right thing or exhaust the US treasury sending money to corporations to try everything else.

Primary care can be recovered and should be recovered,
but cannot be recovered when moving the wrong directions

Comments

Post a Comment

Popular posts from this blog

Another Fine CMS You Have Gotten Us Into

Perhaps we are indeed back to the time of Another Fine Mess (Laurel and Hardy). In a mad rush to implement innovation and to save all possible costs, CMS is creating complications for people that it is most responsible to protect. As PBS and Ken Burns celebrate the legacy of The Roosevelts, it is tragic to see what has become of over a century of effort involving Social Security, Medicare, Medicaid, and health care equity. The United States has one of the most complex health designs and clearly the various designers often know not what they are doing to others. More cartoons and comedians would find this a ripe area for material if not for the suffering involved. Health and Human Services has a huge role across Social Security and US health care. CMS or the Centers for Medicare and Medicaid Services has a dominant role to play in the design of health care in the United States.  CMS can be progressive or regressive. Interestingly CMS has chosen to appear to be progressive and in
Read more

The Essential True Reform Restores Primary Care and Much More

The list of distractions from True Reform are impressive. For decades True Reform has been specifically avoided as primary care worsens within practices and from outside. The demise is most specifically about the financial design. Unless there is a focus on True Reform, there is little hope for Basic Health Access. This may not make as much sense to those outside of family medicine. Family physicians not familiar with AAFP may also be clueless. If you think that you can fix primary care with more technology, more rearrangements, more types of health professional graduates, or more expansions of training - think again. None of these have any hope of working without financial design changes - major changes. The following are various concepts that dominate the discussions at AAFP and primary care meetings and media releases of associations and foundations and institutions. Members, staff, media releases, programs, and personnel have been reviewed.  There is little about Tru
Read more

Why not inside out empowerment rather than outside in abuse?

Just in from Annals of Family Medicine (Miller, Rubenstein, Howard, Crabtree) Shifting Implementation Science Theory to Empower Primary Care Practices Hope for primary care, generalists, rural health, and care where needed requires a very different perspective after decades of failed designs. Not surprisingly this will need to come from inside of these practices and places. Not surprisingly policies and practices dictated from outside have been not only a poor fit - but have been abusive to the populations most in need of care and the practices that serve them. There is hope from the primary care research community. The perspective must be inside of practice looking out - instead of outsiders forcing changes. Qualitative research explores and discovers and reflects as Ben, Will, and others taught me along with the various rural family physicians interviewed and researched in the 1990s in Nebraska. The current focus on quantitative research has demonstrated little to
Read more