Basic Health Access

Just in from Annals of Family Medicine (Miller, Rubenstein, Howard, Crabtree) Shifting Implementation Science Theory to Empower Primary Care Practices Hope for primary care, generalists, rural health, and care where needed requires a very different perspective after decades of failed designs. Not surprisingly this will need to come from inside of these practices and places. Not surprisingly policies and practices dictated from outside have been not only a poor fit - but have been abusive to the populations most in need of care and the practices that serve them. There is hope from the primary care research community. The perspective must be inside of practice looking out - instead of outsiders forcing changes. Qualitative research explores and discovers and reflects as Ben, Will, and others taught me along with the various rural family physicians interviewed and researched in the 1990s in Nebraska. The current focus on quantitative research has demonstrated little to ...

The Value Based Movement lacks Value. It is important to understand how AAFP, Commonwealth, and others have arrived at their misguided focus about what is value.You will hear the various promotions constantly in journals, policy papers, and in the media. The following are more critical evaluations via Jha, Soumerai, Sullivan, CBO, Annals of IM, and others with my comments, critique, and assumptions regarding the real influences on outcomes. I still have hope for associations and foundations, but they need new leadership and a return to missions such as health access – real health access.Their staff need to be re-educated regarding the true value of family physicians and others serving in teams on the front lines despite that greater challenges of the value-based focus. Value, P4P, Performance Based Evidence Is Lacking Annals of IM 1/17 in a comprehensive review did not indicate value for performance based incentives. Only process was improved.   It is hard to stop a...

All three primary care home demonstrations have failed as noted by Kip Sullivan in a recent thehealthcareblog. Kip Sullivan is a voice of reason in an insane policy period. This is only one of many appropriately critical pieces that make sense. In another sad twist of fate, a major reason for the failure was the promotion by medical associations - including family medicine. Even more important in reading his works, is the discrimination specific to those smaller, where needed, caring for the most complex, and most ignored. Family Medicine has long had the best track record for all of these areas. Sullivan and Soumerai have noted that these innovations and regulations have taken on a life of their own.   Pay for performance: a dangerous health policy fad that won't die Others such as Casalino who have noted the value of small practices in some areas such as preventing admissions, have at least implicated that the policies are clearly running over those smaller, independe...

Primary care services have decreased in number steadily, year after year. Payments for primary care services overall have been stagnant as with other basic services taken for granted. Population, demand for care, and complexity are all increasing in ways that should have resulted in much more primary care for anyone who cares about primary care - but there is steadily less primary care. The financial design is broken by stagnant revenue and accelerating costs of delivery. The digital revolution has actually caused regression of primary care via worsening burnout, productivity, and meaningless complexity. The costs of delivering primary care have been increased across multiple dimensions by those who think that they are improving care when actually they are killing small health, primary care, generalists, general specialties, and basic access to care. This little death steadily, slowly over time is also specific to primary care physicians who appropriately describe it as trauma si...