Basic Health Access

There are certain people who pay attention to salaries and benefits as shaping physician specialty choice. There is a correlation, but correlation is not causation. I look at these are great distractions. What's behind the salaries and benefits is more important. And what drives this from upstream is even more important. The real force, the major influence, is the financial design - revenue, cost of delivery, complexity. Behind this is powerful vs powerless. There are more than salary and benefit factors at work in career choice. And beyond the areas obvious to medical students and residents, are the upstream forces. This should be quite obvious in health care where the largest and most organized have the greatest influence regarding the payment design. They design themselves the most lines of revenue, including lines of revenue such as graduate medical education, research, patents, corporate ventures,  and foundation support that others do not rece...

When you pay so much more for health care costs as seen in Massachusetts - you deplete child development, early education, mental health public health, higher education, environmental changes, housing, nutrition, and public security. The US is among the worst toward the right. A few people benefit from the health care design. A few locations benefit from health care spending - particularly in just a few zip codes in the state of Massachusetts. State budgets are also depleted by prison spending. Federal budgets are depleted by military cost increases and prison costs - also about twice the level of spending as compared to other nations, just like runaway health care costs. In many ways too much for too little result in health, in prison, and in military spending results in greater divisions, worsening disparities, and declining outcomes. These increasing costs deplete the human infrastructure investments needed and the physical infrastructure investments needed - w...

The recent Beyond Flexner postings and social mission articles have revived interest in Academic Medicine's Season of Accountability and Social Responsibility  by William T. Butler, M.D. Dr. Butler gave this address to AAMC in 1990 and expected a response - one that never came. The following are predominantly Dr. Butler's words with an update regarding the lack of progress regarding his calls to action. Public Concerns About the Overall Health Care System Dr. Butler declared that academic medicine had entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. His recommendations are followed by comments regarding academic medicine addressing these concerns or not. Public concerns have continued. There has been no progress in this area. The political arena has been a distraction, but the concerns continue. The same types of headlines listed not only are seen in the media headl...

Periodically there are calls for Academic Medicine to be accountable for health care in areas such as health care workforce. This accountability includes the larger dimension of people with substantial limitations in their health care such as rural populations or underserved urban populations. The access situations are worsening across primary care, mental health, and general specialties - those who provide 90% of care for half of the population most in need of care. The lack of any significant improvement for decades indicates barriers not easily addressed. In fact it may well be that the top priorities for academic and largest systems are such that true reforms are prevented -  reforms that would address the primary care, mental health, and basic services payments that are essential for distributions of services and broadening of health access. A social mission or accountability would require academic and other health care leaders to stand up for higher payments for basic se...

In family medicine we most need change agents and least need those who remain stagnant and unable to change the course of health access, of primary care, and of health outcomes for most Americans. We fail in training and in family medicine workforce because we fail in selection and preparation in ways that training cannot address. The STFM blog highlighted the quality improvement potential of family medicine residents. There is so much more potential for those that begin efforts much earlier and work throughout their lives as change agents. The Social Beginning Is the Beginning of Change Agents Potential medical students and others preparing for health and education careers should spend age 14 to 30 years working in their communities improving health, education, and local resources in their communities. These important interactive life experiences should be the most important determinants for selection as nurses, public health officers, or family physicians. Selectio...

Data is often collected, processed, and promoted for dramatic impact. Dialing for dollars is very lucrative when it comes to health care. The controversies dominate our attention  as health care eats its way through our budgets, our employer budgets, our state budgets, and the federal budget. Physician salary data is a popular attraction. This data is often used to claim that physicians seek careers associated with higher salaries. The payment design shapes much more than physician salaries and in turn shapes those in our nation that win and those that lose - by national design. Data from Medscape The payment design has long favored procedural-technical services over office-based/cognitive/basic services. The highest paid physicians perform procedures that are paid at highest rates. Other highest paid physicians are those that perform higher volumes of higher paid procedures. These highest rates have been determined by academic, hospital, and physician association representat...

Family medicine leaders still cling to traditional academic medicine. Many of the major family medicine efforts arise from family medicine departments and from medical school based family medicine programs. Soon family medicine will have a 50th anniversary. Should family medicine tolerate another 50 years of stagnation?    Constant Strain in the Academic Family   The relationship between academic institutions and family medicine has always been strained - when academia was getting started, when formal family medicine training was started, and continuing to the present.   Family practice general practice predates modern academia in the United States. The dominant physician 100 years ago were connected to local populations across origin, training, and practice. The academic designers consistently built up what became formal academic training. The consequences of such training were seen in just a few decades. Flexner conceded that the distribution of phys...