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Showing posts from March, 2017

Punishing Primary Care with Medical Homes

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Context matters in health care. This is because outcomes are about the patient, community resources, social determinants, environments, situations, behaviors,  housing, and other personal and community factors. Outcomes are predominantly not about clinical interventions. This is a very difficult to understand but most important concept. Clinical interventions are small change regarding health outcomes.

The context for this blog response is a recent Commonwealth Review of PCMH. There were changes in a few outcomes, but overall there was little change. "PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care visits, emergency department visits, inpatient visits, and four quality measures." The article claims that context matters, and may explain the lack of outcomes for primary care medical home. 



High Cost for Little Change Via PCMH - the Opposite of Value

Primary care medical home costs run about $80,000 to …

The Least Healthy Counties Across the United States

Journalists and researchers find common ground in dramatic presentations that illustrate the extremes of those doing best or those doing worst. What works to gain publication or to reap advertising revenue does not help in understanding disparities - especially those shaped by the health care design. Choosing the worst county is a poor choice because these counties are so few and so atypical. Rural counties are also atypical as the counties have lowest concentrations of people, but not necessarily other demographics. A measure more consistent in health representation can be helpful in understanding disparities in outcomes. Categorizations that compare counties by concentrations of physicians illustrate important concepts regarding health workforce, outcomes, insurance, and demographics.  Few Ahead and Many Behind There are only about 5 - 10 counties in most states - that have higher to highest concentrations of  physicians and health spending, education spending, economic impact, income, …

The Academic Family Medicine Mismatch

Family medicine leaders still cling to traditional academic medicine. Many of the major family medicine efforts arise from family medicine departments and from medical school based family medicine programs. Soon family medicine will have a 50th anniversary. Should family medicine tolerate another 50 years of stagnation?  Constant Strain in the Academic Family The relationship between academic institutions and family medicine has always been strained - when academia was getting started, when formal family medicine training was started, and continuing to the present. Family practice general practice predates modern academia in the United States. The dominant physician 100 years ago were connected to local populations across origin, training, and practice. The academic designers consistently built up what became formal academic training. The consequences of such training were seen in just a few decades. Flexner conceded that the distribution of physicians was impaired by the new model, but…

Two Forces Shaping Declines in Outcomes in Health Education and More

Cries of victory may ring out today after the apparent defeat of the misguided Republican Replacement Plan, but the sand people will be back and in greater deception. The designs over past decades will continue to be shaped by those with their own agendas - agendas that are a poor fit with the needs of most Americans or true improvements in health outcomes.

The first realization that must be made is that the designers will be back with plans that work for them, but not for most Americans.

The second realization is that good intentions taken to excess have consequences as seen in austerity focus and in runaway health care costs.

Austerity FocusRunaway Health CostsCuts or prevents or diverts investments in areas that shape local determinants of outcomesIncrease so rapidly that federal and state dollars are diverted to health care and away from the determinants of outcomesThe Determinants of Health, Education, Economic and Other Outcomes include housing, nutrition, senior reso…

Mastering Well Being for Residents Physicians and Patients Takes Time

During this time of "value" focus, we have apparently replaced the temporary focus upon reflective practice. Recent patient care experiences confirm the value of reflection as there are so many dimensions of learning available, especially compared to the few via biomedical focus. Well being is about restorative time. Across residency training and primary care practice, there is an assault on this time and the value of such efforts. A major theme for practice or for patients or for those in training is the value of rest and reflection time.

The most important learning requires rest and reflection - and these require time. Well-being is compromised when rest, reflection, and sleep are compromised.

Too often it is easier to just work toward the end of the day. It is easier to speak too soon, listen too little, or jump to treatment as seen in too much medication. It is harder to insure best communication or to go the extra mile to impact the care experience of a child or a new …

Match Hype Hinders Health Access Solutions

In this time of avoiding the Truth, perhaps primary care training will be exposed to the truth as well. Each year the annual residency match generates numerous promotions of various types of programs as being primary care solutions. Sources low yield for primary care are not good sources for care where needed. The Match may indicate more medical students who begin training in primary care, but few will enter primary care and even fewer will stay in primary care.

Claims of nurse practitioner and physician assistant solutions for primary care are just as spurious. Those entering primary care and remaining in primary care continue to fall to lower levels. 

This year the claims of international graduates as solutions for underserved areas are prominent. About 50 - 90% of the services provided where the underserved need care are provided by primary care. International graduates fail as good sources of care where needed due to

20% loss to home or other nations45% choosing lowest primary care y…