Basic Health Access

By permission from Shane A Avery, MD    August 29, 2018 12:47 PM as posted in AAFP News I am a rural, solo, self-employed family physician who is practicing with his wife, an NP; in one of the poorest counties in Indiana. I was one of the physicians who reported the first cases of HIV during the historic outbreak in 2015. I lobbied at the state level for a needle exchange program when our governor and state health department said it should not be done. It is quite sobering to have the heads of the HIV division of the CDC sitting in your hospital boardroom. I had fought the opioid epidemic before it was recognized, when JCAHO was telling us to monitor pain as the 6th vital sign. I watched a rural community flounder under an epidemic of death, disease, and disability brought on by opioids with the blessing of the healthcare and pharmaceutic industry. But I am a family physician. I kept seeing patients in the office, providing complex care coordination. I did home...

Health care in the United States is notable for being the worst when comparing health care among wealthy nations. A Commonwealth article was published in NEJM highlighting four areas that need to improve. Interestingly an improvement in primary care finances would address all four areas, but this discussion was avoided. Fitz Mullan had another article promoting the social mission just published in JAMA. Once again addressing bankrupt primary care finances would contribute to the social mission. Lofty ideals are easy to discuss, but the hard work is missing when it comes to addressing access barriers, disparities, and most Americans falling farther behind. You cannot get from last to first by failing to address areas that must be reformed - areas that actually shape insufficient access, insufficient primary care, insufficient team member support, and disparities.  Goals, Aims, and Missions must be replaced with specific actions. True Reform Is the Beginning The foundati...

Discussions of state or federal budgets draw much attention, but it is the American people who make America work, fill in the gaps, and accomplish far more than the dollars expended.  Ideally the designs for dollars, people, and services all align for best result. A divided nation will accomplish far less, and this will often result in a widening gap impacting most people.  M Scott Peck wrote a book on "community" and noted that you knew community existed when it happened. Happening worth having is togetherness. We are not together. Our inefficiency rocks the core of our nation, what we hope to accomplish, and how we can accomplish it. Infrastructure is a popular word. Embedded in infrastructure is the ability to facilitate more efficient and effective function. There are multiple types of infrastructure in a nation. America is made up of physical infrastructure, spiritual infrastructure, and human infrastructure. Rarely have these all aligned except for major wars and...

Context matters in health care. This is because outcomes are about the patient, community resources, social determinants, environments, situations, behaviors,  housing, and other personal and community factors. Outcomes are predominantly not about clinical interventions. This is a very difficult to understand but most important concept. Clinical interventions are small change regarding health outcomes. The context for this blog response is a recent Commonwealth Review of PCMH. There were changes in a few outcomes, but overall there was little change. "PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care visits, emergency department visits, inpatient visits, and four quality measures." The article claims that context matters, and may explain the lack of outcomes for primary care medical home.  High Cost for Little Change Via PCMH - the Opposite of Value Primary care medical home costs run about $8...