Basic Health Access

The debates over health care have continued to draw the attention of the entire nation. It is a time of difficulty understanding the truth or the consequences. Even those who promote reform may not understand the truth or the consequences impacting most Americans that most lack access. This is how the "experts" can point to 153 studies that indicate improvements when most Americans are falling further behind by design. Most apparent should be that access is not improved by insurance expansion where access to local workforce is the dominant reason for access barriers. Who would think that expansions of plans with neutral or negative margins would help increase primary care, mental health, and basic services - services that are 90% of local services where most Americans most lack care. Slash and burn involving insurance or Medicaid is not likely to help, but neither are costly regulations. Designs resulting in the worst of both are designs that impact basic care fo...

Over a decade ago as a faculty member at Nebraska I was working on a birth origin project. I was mapping the physician birth origins in the AMA Masterfile data on 900,000 physicians. Some were easy to map by city and state to a county location or zip code of birth. Others were more difficult as their towns of origin no longer existed.  Two physicians were listed as born in 1942 at Rivers, Arizona. My search for the town of Rivers came up empty. This was not unusual, but  I dug deeper into the past.  The trail led to Gila River and finally to a visit to the place where these two physicians were born and where dozens of others spent time in the 1940s. Birth Origin Project Summary Generally those with exclusive, most urban, or foreign birth have a much greater chance at becoming a US physician. Rural origin, lower income county birth, birth in a county without a medical school, and birth in the US all decrease probability of becoming a physician. Ethnicity i...

Triple Threat is what creates, maintains, and worsens burnout - and the essence of what we are in primary care. Threat 1. Insufficient revenue Threat 2. Accelerating cost of delivery Threat 3. Complexity increasing in multiple patient, practice, and community dimensions Complexity is inherent in the life of a primary care physician.  Complex primary care delivered with sufficient revenue and support to cover the costs and complexities of delivery is highly satisfying. A bad financial design made worse is what erodes margin as well as time - time with patients, team members, colleagues, and family as well as personal time. Value based designs tear at the fabric of who we are.  We know that outcomes are beyond the ability of our practices. This is actually supported by the literature in major reviews of pay for performance. Even worse, these schemes discriminate against those caring for the most complex with the least resources - with lesser pay and added comple...

New initiatives by medical associations can help patch up wounded members, but are not solutions for the systemic dysfunction impacting tens of thousands of members. AAFP gains high marks for wonderful resource materials and this will likely be the same to address burnout, but their efforts to address burnout will not prevent burnout. To prevent burnout, AAFP must go upstream. Triple Threat is the cause of burnout. Burnout is due to the Triple Threat challenges of 1. insufficient revenue, 2. increasing cost of delivery, and 3. worsening complexity. Stress is not the problem.  Stress is inherent in the life of a medical student, resident, and family physician. We were taught about ratios of stress over support. Stress must be balanced by support in patients, in physicians, and in team members. Too little in dollars,  in other support,  in numbers of team members,  in numbers of physicians and clinicians, and  in satisfaction with r...

As Michael Munger MD takes over as AAFP president he indicates "One of my real concerns is around payment reform. And it's a multilevel concern. Will we really see meaningful payment reform?" Your responses at the AAFP site indicate that you are asking the right questions... But under your leadership will AAFP work effectively and successfully to combat the Triple Threat - Revenue too little,  Accelerating costs of delivery (including the shift to value based), and  Complexity increasing in multiple practice, patient, community, and other dimensions? Who will help AAFP to see through innovation, digitalization, certification, and regulation as adding to costs of delivery and worsening Triple Threat? How many more dozens of articles are needed to be added to the evidence basis that indicates that performance incentives fail to change health outcomes. Even worse, they discriminate against the patients and populations that best fit the description of those cared for ...