Showing posts from 2015

Medicare and Medicaid at 50 and Beyond

When did M and M design change from support for health access to against health access and why?

Government and Foundations are currently celebrating the accomplishments of Medicare at Age 50 - but which Medicare? Claims of improving the cost of care are merely cover-ups of cost cutting designs - cuts that shrink care. The consistency of Medicare and Medicaid design is best seen from 1980 to 2020 - and not the initial years. The initial years were focused upon rebuilding the US health care system with emphasis on restoring access to populations left behind for decades before (and decades since 1980). As it turns out this was also a good idea for rural health and for care across zip codes and counties with higher concentrations of poor and elderly and increased support for health care where health care was less - by design or lack thereof.

What we have seen in recent years is a continuation of the process begun in the 1980s. Cost cutting, accelerated cost of delivery, increa…

More Confirmation of Small Health Value and Small Health Neglect

No small part of America is impacted by designs and information sources that disadvantage small hospitals and small practices. In turn, this continues to disadvantage and damage the people that depend upon small health care.Over six months ago this first small health review indicated substantial problems. More evidence has been added regarding the value of small health and further neglect of same. Studies have indicated improved outcomes for small practices and a new one from BMJ demonstrates the same for low volume hospitals. The chief actuary for CMS has indicated that increases in the cost of delivering care are too much compared to stagnant payment. Remember that primary care and small practices are paid less and have more difficulty making all of the regulation adjustments.The Paucity of Awareness Continues Paucity used to be a favorite AAMC word. Sadly it is our health leaders that often have deficits of awareness. The impact of lack of awareness continues to damage an…

Heroes for a Few or For Tens of Millions

We no longer tolerate discrimination in research design. We still tolerate discrimination in the designs of payment and training.

Almost any day in the New York Times there is some death of someone's hero. A recent health care death stimulated some comment. A cardiologist who was one of few to expose the Tuskegee syphilis experiment died recently. For the past 65 years it has been a struggle to expose and address discrimination against vulnerable populations and other abuses of human subject research experimentation. Hundreds and sometimes thousands have died in each episode. Actually we are still only aware of the tip of the iceberg as prisoners, nursing students, medical students, people in other nations, and many others were subjected to abuses.

It can be difficult to find critique in health care where my way or the highway is far too common. Critique is too often missing when it comes to damage or death to vulnerable populations. Health systems fail, states fail, and federal de…

A Bridge Too Far to Cross the Quality Chasm

Pursuit of quality is an ultimate good thing in health care, right? But what if the current pursuit of quality decreases the financial viability of the practices and hospitals that are on the front lines of health access? Where care is threatened, populations are more complex
Should Providers Be Held Accountable For Situations Beyond Their Control: Health Literacy BarriersSelection Bias Due to Geographic Location, Transportation, Age...High Acuity from Presenting Too Late for CareCommunity Resource Deficits (lack of local, state, federal investment)Lesser Social Determinants Numerous Dimensions of Patient Complexities Across Situations and Relationships Accountability continues to creep up on cost cutting as a top CMS priority. CMS needs to pay attention to research findings as summarized by the government - important research demonstrating the ways that patient outcomes are limited by patient factors. 
The following comes from the Agency for Healthcare Research and Quality AHRQ - …

The History of Good Deal Bad Deal Payment Designs

The various leaders of medical associations are lining up to defend the latest "Good Deal" as the reality of a not so good trade is apparent.

Our designers and our leaders understand history so poorly that they are doomed to repeat it over and over, especially for primary care and all physicians paid on the lower end of the payment scale.
Good Deal Start Bad Deal End Number 1  was the original Medicare and Medicaid falling behind in about a decadeGood Deal Start Bad Deal End Number 2 - 1990s "reforms" - falling behind in about 5 yearsGood Deal Start Bad Deal End Number 3 - MACRA - few if any years ahead (but better than a 21% cut?) The AMA actually rented out the auditorium where Kennedy announced what would become Medicare and Medicaid to lodge its protest. Fifty years ago there were at least some leaders raising concerns regarding what would happen. Now with Medicare and Medicaid so much of the payment design, matters are worse.
By the 1980s, primary care payment w…