Talk About Unpaid Stressed and Abused For Decades

When a journalist wakes up the the real world, there are great opportunities. But can the journalist manage to capture the perspectives needed to truly understand the reality of health care delivery?

I enjoy the variety of information that I allow to access me. Sometimes there is amusement. At other times I see the best of humanity or try to turn off the worst. In the health care area, I am usually frustrated with what rises to the surface, particularly from health care journalists.

A few years back I tried to do more work in this area. I found that there was not much interest from the perspectives that I embrace - local care, health access, care where needed, and preparing health professionals for these areas. I thought that the experiences of 30 years of teaching, researching, and delivering health access would be valuable - since the nation has long been drifting away from health access, local, care where needed.

It took years for the decades of habits and experiences to peel back before I could see more clearly. Those attempting to pass on the information that we seek, do not have decades of experiences or much reflective thought.

Vox has been informative and a new piece describe the challenges of those attempting to care for a troubling and persistent condition. This is not new as the New York Time has had a number of provocative pieces including some where the journalist let passion get beyond journalistic sense.

This author sees herself and others as unpaid, stressed, and abused. I do hope that she resolves her problems.  I hope that she can learn beyond her situation to see the situations facing many if not most Americans now or in the near future.

I see much of primary care, mental health, and basic service delivery as much the same. It will even get worse because of the numerous journalists that help foundations, institutions, and government promote their solutions - solutions that are not a fit with the reality facing most Americans.

Underpaid Stressed and Abused Primary Care

There are many questions that arise in this area. Decade after decade we have allowed basic health access to deteriorate - primarily due to lowest payment for primary care, mental health, and basic services. These are the services provided by generalists and general specialists - the ones going away by payment design. So much more paid for technical, procedural, and highly specialized care is a major reason for cost of health care increase. Someone with a somewhat different perspective could tell us whether the payment design or the rapidly increasing administrative costs killed off more care delivery. I suspect administrative costs have increased the most with payment distortions to highly specialized care a major reason. Not surprisingly this has resulted in compromise for primary care, generalists, mental health, geriatrics, and other basic services destroyed by little or no increase in payment, inflation of usual costs, and new added costs of delivery.

Despite this obvious reason for health access failure, more and more innovators, organizers, advocates, deans, program directors, and associations claim to be a primary care solution. Even worse, government grants and foundation dollars go to support their innovations, consultants, and corporations.

As soon as these blogs, social media pieces, or journal articles are published and as soon as government promotes some new innovation - the band wagon process rolls on and in a direction away from the reality of care delivery where needed.

The One Specific Solution to Health Access Is More Funding

The only effort specific to health access recovery, more funding, is the one that is avoided as "everything else" is attempted. What is worse is that these efforts distract from the real solution and diffuse the organization needed to make the solution a reality - a solution demonstrated 1965 to 1980 and a few years in the 1990s and denied since that time by payment policy. Not surprisingly these have been the only gains in graduates most specific to primary care, geriatric care, health access, care where needed, rural health, and population based care - family physicians. FM rose from restored to 3000 annual graduates 1969 to 1980 and has had little change since other than a few years in the 1990s when 3300 - 3500 graduated from FM residencies.

Why Don't Associations Specific to Primary Care Support More Funding?

Even family medicine does not get it. FM associations and leaders and media pieces promote meetings, conferences, training, retraining, departments of FM, residencies in every state, and the marketing known as Primary Care Medical Home even when these matter little to most family physicians.

What matters most to most members is more support for what they do, more team members, more colleagues, more replacements, and more support for their patients - denied by the reality of payment design. (same reflection for teachers and students)

Can a health journalist experiencing health care for a first time aid in progress toward a solution? Can we get some perspective here?
  • At some point age 15 - 35, some sort of chronic condition will strike many of this age. Instead of the usual episodic illness and rapid recovery, much more care will be needed. 
  • This is usually quite frustrating due to the visits required, the uncertainty, and the logistics. 
  • Also there is the realization that a person is not immune to chronic health problems and sometimes there is the beginning of the understanding that death is inevitable, as are numerous limitations.

The example of a health journalist "experiencing" health care delivery gives numerous lessons for those willing to reflect

Why do we tolerate the care delivery that we have, or don't have? (perhaps her point)

How much worse is it to have Medicaid, or Medicare, or Veteran care, or live hours from needed care? And why do we only pay attention to Veterans (some) when Medicare, Medicaid, rural people, minorities, and other tens of millions have been putting up with many times this for decades?

Would she have written hundreds of previous health care articles the same way if she had her new realization long ago?

What would she do differently if she had the training and practice experience of a physician?

How different would her writing be, if only...

One of the problems of our current time is a serious level of misinformation arising from blogs, social media, and often from major journals.

What If (my personal reflections from career experiences)

What if she had the 60,000+ patient care experiences of a family physician?

What if she had 400 encounters with Medicare patients and patients with Medicare and Medicaid in their homes last summer - low cost of housing homes in low cost of living locations because this is all that they afford - with health care deficits that make matters worse even with insurance coverage?

Will a journalist see beyond self to tens of millions of others who have even fewer options lasting back decades in time and decades of life? 

The Treasure Trove of Reflective Rural Practice

How would her perspective change if she saw the best of rural practice for 2 years and then the most difficult times as friends, families, patients, neighbors, businesses, and more fell apart with declines in agriculture, state cuts in education and social services, centralization of state services away from your town, and decreases in payments for local health care? Would she understand the deficits of designs that allowed school districts with great taxable property to steal the teachers and resources that they need from schools without low taxable land? Would she try to save the local daily rural newspaper, one of the last existing? How would she feel with the demise of a practice and then hospital and local Walmart and more?  Would she feel that she wasted countless hours of work organizing local care, writing legislators and Congress, working with the chamber of commerce and local clubs and the ministerial alliance and social services locally, and sacrificing thousands attempting to find a way to keep practices, communities, and care afloat?

These lessons and more were learned but took time to set in. And it is even more frustrating that we think that we can address primary care and mental health - doing everything other than sending funding specific to the team members who actually deliver the care.

Why would we think that those without front line experiences (journalists, health policy researchers, consultants, experts, Congressional or legislative staff) could comprehend what has been going on?

The above experiences over the last decades, and especially the most recent years, have been my experiences.

The personal experiences of a family physician can be important to the reality and the context of care. Sadly until many highly specialized physicians have the experience of care, they never have the chance to learn where care matters most. But sometimes the awareness of care can be overwhelming - a real reason for burnout levels high in primary care physicians.

The experiences of other family physicians can be informative...

What if she had been forced from her primary care practice by payments too low and cost of delivery made too high for the 50% of family physicians in small and solo practice? Imagine what if feels like to see meaningless regulations making matters worse and forcing unpleasant decisions to cut personnel or spend substantially more despite making less, with the risk of being paid even less.

How do FM docs feel when the association that is supposed to represent them embraces each new innovation - primary care medical home, value based, MACRA with all of these adding $40,000 to $100,000 per year per primary care physician to a practice that already is an neutral or negative margin?

Imagine the final blow when you come to the reality that you can no longer sustain the life you love or the patients you love - patients that have care demands that are less and less likely to be met. Others work outside jobs to sustain their practices. The journalist has experienced a few hours of frustration. Imagine the frustration of a life spent in service, often poorly supported, with great demand and sacrifice required, and clearly not valued by those who design payment and distribute the ability to survive elsewhere and to thrive for a privileged few.

I hope that all of you get past the barriers to care - and find your way to realization of the care delivery conditions in this nation, or lack thereof.
When you see the health information, see past the information to the reality.

We will remain victims of our perspectives,
unless we reflect and allow reality to change US.

Primary care can be recovered and should be recovered, but cannot be recovered when moving the wrong directions

Recent Posts and References  

The Consequences of Innovation Procrastination - Delays in indicated care result in harm to patients. Distractions due to innovation result in harm to millions who need care delivery, not rearrangements, confusion, reorganization, and rapid change.

The Massive Failure that is Primary Care Payment 
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
Health Care Who Is it Good For? Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation
Safety Net Must Sunset and Front Line Health Access Should Rise

Experimental Innovation or Basic Infrastructure? Wouldn't it be nice if we actually funded infrastructure and basics instead of trying to substitute innovation or other distractions? 

For Better or For Worse in Quality - More for fewer and less for more - thus continues the new innovative designs - same as the old designs

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.


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