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Showing posts from May, 2016

How to Destroy Clinical Care Nationally

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Thomas Paine MD has illustrated how to destroy clinical care in an emergency room setting. I used his subtopics to illustrate how CMS and others are doing much the same to clinical care in the area of primary care in the United States.
1. Ignore and undervalue clinical experience. While attention is being paid to value-based, MIPS, and MACRA payments - there is not much change to lowly paid cognitive, office, and basic services. This may also be why experience is least rewarded in primary care as the youngest to oldest salary gap is smallest. In contrast, newer orthopedist are paid most similar to oldest. The payment design rewards the most subspecialized - where the most income can be generated.

CMS physician payment design rewards longer training and more technology but ignores factors such as experience, continuity, and retention in a needed career - factors important in primary care and mental health delivery. Where the patients are most complex, the clinical experiences prior to…

Senator Who Do You Think You Are Fooling

The minute the Senate calls your name, in this case about the alleged lack of family physician response to the opioid crisis. This is the response of a family physician

We family physicians invite you Senator, to visit us in our practices.

We ask you to explain to us how we will be able to address growing opioid and other addictions, mental health deficits, expanding geriatric demands for care plus screening for hepatitis, depression, suicide, nutrition, health literacy, resources, medication access, and other complex areas that we must integrate and coordinate.

We would like you, Senator, to reflect upon the impact of deteriorations in situations, income, jobs, education, housing, and other determinants of health and health outcomes. 

We ask how we can do more with less since we are already paid least and CMS will pay us even less because we care for these more complex patients. Also we will be having to pay more for HIT, EHR, MU, MIPS, MACRA, PCMH - efforts that will wor…

Are New Departments of FM Necessary?

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A story out of Boston (or New York, or...) brings attention to a long term dream of academic family medicine - having a family medicine department in every medical school. Not surprisingly the latest article or blog is soon promoted and passed around by FM associations. For decades the Family Medicine journal has listed family medicine results once a year and has categorized by department - keeping this focus alive. The question remains...

Are new departments helpful for family medicine or not? 



Payment Design = Workforce, Regardless of Training

Can departments of family medicine boost family medicine? Apparently not since the most rapid increase in family medicine residency growth from 1970 to 1980 was the period of fewest family medicine departments. What really fueled the rapid growth of family medicine was substantially more payment going to increase primary care. Since family medicine is the most dependent upon primary care payment (cognitive, office, basic services), family medicin…

No Positive Spin for the Innovator Tailspin

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In health care delivery, reflective practice is considered a best practice. There is apparently no reflection at CMS or across the innovation whirlwind. Instead of learning or pausing to reflect, there is only acceleration of the chaos we call American health care. 


How many failures in how many ways should be tolerated?

Insurance Expansion - The failure of insurance expansion for the purpose of access to care has been exposed. Denial will not help Medicaid, Medicare, and new plan patients to actually get the care that they need - poor payment long ago prevented the workforce that they needed and in the places of most need.

Accountable Care Organizations - This attempt can be considered a failure as half of ACOs have fallen with more to come. It is likely that a real effort in this area would cost far more, but the costs have already been substantial.Why would you think that you can create competition when you main direction is to aggregate more into bigger plans, systems, practices, et…

Population Health from Above or Below

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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…