Basic Health Access

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...

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...

Health Affairs has another of a long line of interesting articles that point out the potential of nurse practitioners and other interventions regarding primary care, but with stunning failure to document the primary care situation and what is needed to address recovery of basic health access.  In this stunning Health Affairs article - the usual promotions of nurse practitioners are noted. The article fails to note the limitations such as fewest active, fewest years in NP careers, highest turnover, lack of specificity of primary care training for primary care outcome result, steady departures from primary care - shaped by NP training design and made worse by payments too low for NP and for primary care. How Long Do We Tolerate Lack of Primary Care Delivery Capacity Increase Despite  Four new sources of primary care with more proposed Huge expansions of new sources Countless training interventions Countless billions for primary care training th...

The latest headlines spout 250 million saved for Oregon in the movement to Primary Care Medical Home. Claims of savings often fail to consider the additional costs of an intervention or the supplemental government or foundation funding required. Based on $105,000 additional cost per primary care physician per year the following table demonstrates $250 million to 1 billion dollars more in cost for primary care medical home across Oregon. It is important to consider not just the savings, but also the higher costs of new models. Specifics are not given but the impact of the primary care medical home can be estimated across the number of clinics that could participate and the doctors per clinic over a 2 or 3 year period. The number of doctors may be small compared to actual. The high and low levels are shown along with a possible average cost. If studies involved less than 2 years they should not have gained print. The limitations in new studies with new measurements as measured an...

Thomas Paine MD has illustrated how to destroy clinical care in an emergency room setting. I used his subtopics to illustrate how CMS and others are doing much the same to clinical care in the area of primary care in the United States. 1. Ignore and undervalue clinical experience.       While attention is being paid to value-based, MIPS, and MACRA payments - there is not much change to lowly paid cognitive, office, and basic services. This may also be why experience is least rewarded in primary care as the youngest to oldest salary gap is smallest. In contrast, newer orthopedist are paid most similar to oldest. The payment design rewards the most subspecialized - where the most income can be generated. CMS physician payment design rewards longer training and more technology but ignores factors such as experience, continuity, and retention in a needed career - factors important in primary care and mental health delivery. Where the patients are...