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Draining the Primary Care Medical Home Swamp

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All three primary care home demonstrations have failed as noted by Kip Sullivan in a recent thehealthcareblog. Kip Sullivan is a voice of reason in an insane policy period. This is only one of many appropriately critical pieces that make sense.

In another sad twist of fate, a major reason for the failure was the promotion by medical associations - including family medicine. Even more important in reading his works, is the discrimination specific to those smaller, where needed, caring for the most complex, and most ignored. Family Medicine has long had the best track record for all of these areas.

Sullivan and Soumerai have noted that these innovations and regulations have taken on a life of their own.  Pay for performance: a dangerous health policy fad that won't die

Others such as Casalino who have noted the value of small practices in some areas such as preventing admissions, have at least implicated that the policies are clearly running over those smaller, independent, rural, …

Another One Bites the Dust - Micromanagement Fails Again

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Another micromanagement has demonstrated costs of micromanagement as much as what might be saved. This is of course what CBO indicated a decade ago about such interventions. This time the CMS Comprehensive Primary Care Initiative failed to demonstrate much - in the practices that survive in the US. 
"The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures."


Higher costs without changes in outcomes - this is not value-based. Once again it appears that the personnel used up in micromanagements of costs and of quality could have better been used to address care delivery.


Oregon PCMH Saved 240 million but spent over 250 million
Words like comprehensive and continuity mean little in primary ca…

Innovation Is the Problem Not the Solution for Worsening Health

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Innovation is good. Innovation worship is not good. Innovation application without scientific testing or clinical trials is unethical regarding clinical interventions and should be just as prohibited with regard to health policy. Clinical trials can harm hundreds or thousands. Innovative policies can harm millions.

It takes a reasonable understanding of health care, health care outcomes, social determinants, and the investments that most improve social determinants to understand the consequences arising from the innovative nightmares past, present, and future.

If you review the information sources with a critical eye, you too may find that the innovative policy designs have been disruptive to care, have hurt health care where health care is most needed, have reduced access to care, and have resulted in distortions in the literature. Indeed what is accepted and published in journals seriously lacks consideration of alternative hypothesis, lacks inclusion of many pages of limitations…

Dividing Rather than Supporting Better Health Outcomes

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There are many ways to avoid improving US health outcomes and the United States seems to be best at avoiding.

The Past Contributions To Poor Outcomes

If you understand what was good about the US economy and reductions of disparities 1940s - 1960s, then you can understand what has been bad for health outcomes. Increased spending in a few areas results in decreased spending more specific to the determinants of health outcomes. The areas contributing to declines in outcomes include the contributions of
runaway health care costs, runaway defense spending, runaway prison spending, spending on the debt at high interest rates, maldistributions of health and education by their spending designs that worsen disparities, the consequences of Republican slash and burn (now by both parties Reps and Dems), the consequences of costly Democratic regulation (now by Reps and Dems in health care), autonomous divisions and agencies that can perform in a manner the opposite with regard to improving social d…

Why Salaries Are Downstream and Powerful vs Powerless is Upstream

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There are certain people who pay attention to salaries and benefits as shaping physician specialty choice. There is a correlation, but correlation is not causation. I look at these are great distractions. What's behind the salaries and benefits is more important. And what drives this from upstream is even more important.
The real force, the major influence, is the financial design - revenue, cost of delivery, complexity. Behind this is powerful vs powerless.

There are more than salary and benefit factors at work in career choice. And beyond the areas obvious to medical students and residents, are the upstream forces. This should be quite obvious in health care where the largest and most organized have the greatest influence regarding the payment design. They design themselves the most lines of revenue, including lines of revenue such as graduate medical education, research, patents, corporate ventures,  and foundation support that others do not receive. They can use their size an…

CMS Fails Rural Health in Access, Support, and Innovative Design

CMS has a long track record of failure with regard to rural health and actually the failure is specific to twice the population in 2621 lowest physician concentration counties. The CMS failures are specific to the emphasis areas indicated by current CMS leadership: Improving access to care for Americans living in rural settings;Supporting the unique economics of providing health care in rural America; andEnsuring that the health care innovation agenda fits rural health care markets. CMS has been a total failure in these areas except 1965 to 1978. CMS made matters worse since 2010 by exceeding the will of Congress and crafting regulations specifically hurting small providers essential for rural populations and the half of American most dependent upon small health care. CMS continued to implement designs beyond the recommendations of Congress and of RAND - the consultant used to assess the impact of the regulations. 
Three key areas defeat small health, rural health, primary care, access t…