Showing posts from March, 2018

The Deep Squeeze Financial Design Killing Health Access

As an academic family physician specializing in basic health access, I worked to resolve shortages and improve access to care. It was my privilege to work in some of the few remaining schools devoted to such efforts. Sadly this professor found that he was learning impaired - or perhaps I was indoctrinated by the process of medical education. The financial design was far too powerful to allow training design to address deficits.

What appeared to work in the 1965 to 1980 period of time, worked because of the financial design. Each year more dollars were pumped into basic services - especially where poor Americans and seniors were found. As it turns out, these are the areas with the most deficits. Initially the original Medicare and Medicaid designs helped, but they were changed into vehicles to concentrate dollars - not distribute care. The same designers continue to shape the designs into more for few and fewer for more - and basic health access suffers most by design.

My solo rural pr…

Stop the Insanity of Massive Overexpansions of Health Workforce

We should send a clear message to the "experts" and the media and associations and health professional training institutions: Please stop the insanity of doing the same thing over and over again expecting a different result. 

New innovative types of workforce have failed to resolve workforce deficits despite massive expansionsMore new types and more expansions have failed.More new types and more expansions are proposed.
It is the financial foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed.

It Is Not the Initials or the Expansion, It is the Financial Design

It is not about who is a better health professional or the type of training. Expansions are not the solution for any domination or perceived domination of health care.

Texas has another new medical school planned but a family physician dean will not be able to keep the promise of more doctors where needed.


Ignoring Evidence Basis in Health Policy Is Unhealthy

One year ago today we had all the evidence that we needed to move away from payment policies that punished practices and delivery team members with meaningless use and other abuse. A year ago today, a landmark comprehensive review indicated that outcomes were not improved by financial incentives. “In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clear evidence to suggest that they improve patient outcomes.” from

The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 1/10/17.  
Happy Anniversary to Aaron Mendelson, BA; Karli Kondo, PhD; Cheryl Damberg, PhD; Allison Low, BA; Makalapua MotĂșapuaka, BA; Michele Freeman, MPH; Maya O'Neil, PhD; Rose Relevo, MLIS, MS; Devan Kansagara, MD, MCR for a fine study - substantially ignored  Not even primary care associations have moved away from financial incentives. In fact AAFP…

Training Cannot Overcome Deficits By Financial Design

I loved my career in rural medical education. Only rural practice was better. As a rural medical educator I felt very comfortable with the fact that there were many ways to improve the preparation for rural practice. Over time I grew uncomfortable as I recognized more and more that training was not going to overcome workforce deficits.

The sad fact is that special training works for those associated with special training. Special training does not reduce the problem of inadequate access to care. The proof is in the concentrations of primary care where needed. These concentrations of primary care have remained the same - about half enough. Yes it is true that a special training program or school can have higher proportions serving in locations of need - but their success only results in displacement of others - FM for what was IM, and NP/PA for previous IM or FM. The specially trained replace the traditionally trained. This is a rearrangement of the deck chairs rather than an increase …