Basic Health Access

One of the biggest problems in health care is a focus on "my area" rather than considering the overall impact. An intervention in payment or an intervention in training may appear to look good - until you consider the overall impact. For decades various medical educators have pushed rural training or training in Community Health Centers or experiences with minority populations. Few consider that such innovations have not worked to address deficits in workforce for one reason - the limitations in the dollars that go into primary care spending. No matter what you do to try to influence students or residents or clinicians to choose positions in front line health access practices, the current dollar distribution comes up short compared to patient demand, particularly where care is needed. No practice can expand team member positions or extend to do outreach or other functions, without more payment for cognitive office codes in areas such as primary care, mental health, geriatri...

Critical attention is needed to address claims of "value" for any number of recent health innovations. Enough is enough. It is about time to turn from distraction to needed action. Rapid Change Is Costly and Distracting In this health policy period of incredibly rapid change, it should be apparent that change comes with high cost and often accomplishes nothing at all. Half of ACOs have fallen by the wayside. Meaningful Use is being left behind. Medicaid expansion was held hostage and even with expansion it still fails for primary care and mental health due to payments too low. Medical homes have finally gained the close examination required of such a costly endeavor at $105,000 per primary care physician more in cost of delivery per year. Physicians now spend hundreds more hours a years on EHRs leaving less time for patient care and for generating revenue to support care delivery. A narrow focus upon "quality" can be very costly - especially when...

Policy changes have all good intentions, but they have good and bad results. The value is not about innovation. The value is about implementation. Denial and distraction only work temporarily to hide poor implementation. At the very start of ACA there have been massive promotions and massive protests - but both sets of claims were quite uninformed and politically motivated. In many ways, CMS seems to move rapidly to new innovations perhaps to cover up problems with the past innovations. Sadly the claims of benefit continue in the face of known adverse consequences. In Think Progress the headline screams that Obamacare helps the sickest to gain insurance. This author is taking some liberty with his reporting (like so many others). A more detailed examination reviews those sickest, the role of insurance access, true access barriers, and what is going on where care is compromised by design. Who Are the Sickest in America? The sickest in the United States are the oldest people wi...

There is a Queen song that will have greater and greater play in future years,"Another one bites the dust." This should be in your head now as sung by Freddie Mercury as we all chime in. Another one bites the dues will continue to apply to Physical infrastructure decline such as water pipes, roads, bridges, public buildings Human infrastructure declines in teachers, nurses, public servants, primary care, public/mental health If you want, you can replay the song with images of bridges falling down or Flint Michigan replayed a thousand times across the nation. There will be more infrastructure failures this year and next year... We are just seeing the poorer areas and situations where public investment has fallen behind the most. We will also only see the dramatic and not the usual as these are far from media or public attention. We have not chosen to pay attention yet, but we will have our chance as these failures impact more people and in more ways. Innovation as Procr...

Amy Bassano, incoming deputy director of the CMS Innovation Center, said, “We feel good that hospitals are ready to start (bundling payments) on April 1.” Those of us in health care delivery would all feel a lot better in health care if CMS knew that hospitals are ready - but CMS doesn't know what or who is ready and they have not known so for some time. This is more evidence that we need more health care engineers in health care and fewer innovators, researchers, and entrepreneurs at the controls. Why do we feel bad when CMS says they are feeling good about something? Unlike other innovations sent our way in rapid order, there is some potential to estimate the impact for this new innovation in payment. Diagnosis Related Groups bundled hospital payments by diagnosis. What were the results? There was some impact on cost control. There were big winner hospitals, winners, loser hospitals, and lost hospitals. The bigger ones won and those smaller lost with closures of hundreds...

Simple failure is common and involves the failure to perform an action or duty. Massive failure is failing to accomplish what can be done while attempting to do what cannot be done. This is further complicated by distraction from real solutions. If you massively increase the cost of what is done without addressing what is wrong - well...   The United States has accomplished substantial failure in health care workforce via primary care payment design. Innovations and reforms in payment have been designed around improving quality. Not surprisingly these have failed and for good reason. Health outcomes are mostly shaped by people, situations, determinants, and other factors not possible to address by health care design (clinical means). Efforts to force higher quality have been quite costly in ways that steal primary care delivery capacity in multiple ways. Payment design has shown the ability to change workforce composition. Primary care has been built up in the 1970s and du...