Basic Health Access

The list of distractions from True Reform are impressive. For decades True Reform has been specifically avoided as primary care worsens within practices and from outside. The demise is most specifically about the financial design. Unless there is a focus on True Reform, there is little hope for Basic Health Access. This may not make as much sense to those outside of family medicine. Family physicians not familiar with AAFP may also be clueless. If you think that you can fix primary care with more technology, more rearrangements, more types of health professional graduates, or more expansions of training - think again. None of these have any hope of working without financial design changes - major changes. The following are various concepts that dominate the discussions at AAFP and primary care meetings and media releases of associations and foundations and institutions. Members, staff, media releases, programs, and personnel have been reviewed.  There is little about...

Searching on CMS and rural health is revealing. There are regular headlines with regard to reports and proposals and programs. The themes of innovation and quality grab the attention. But there has been a continued lack of progress where it matters most - in Rural Health Care and the Ability to Care In the last decade even worse has been the case. The next decade seems to have the potential for devastation to rural health. CMS says rural health needs major improvements in quality,  but CMS leads the nation to pay too little resulting in half enough generalists and general specialists – those who provide 90% of rural services in the places with limitations of quality, outcomes, workforce, and access. Quality and outcomes are actually about the situations, conditions, relationships, and environments as well as income, housing, jobs, education, and other social determinants. CMS contributes to lesser social determinants by designs that send 15% less to rural p...

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...

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 increas...

Those shaping health care have long deserted the top priority focus upon health care delivery. Their efforts from above make it much harder for those delivering care down below. Those delivering care are forced to bail out health care delivery - working harder and harder to keep US health care delivery afloat despite greater challenges from above and from outside of the boat. They are too busy and are too poorly organized to address those largest, most organized, and most distant from health care delivery who continue to shape designs that fit those at the top best while leaving the rest behind.   The designers have created more lines of revenue for health care in highest concentrations (training, schools, foundations, research related corporations, management groups). The designers send the highest payments in each line of revenue to highest concentration settings. The designers are selected by a process that involves highest concentration and most exclusive origins, schools...

For decades the designers have ignored the consequences of their designs as hundreds of small hospitals, small practices, and practices where needed have fallen prey to revenue too low, costs of delivery accelerating as complexity overwhelms health access. More counties are added and millions more a year are added to those with low or no access - by design. Triple Threat translates to little or no treatment for most Americans. Vampires suck the life blood of health access while zombies design costly and cumbersome innovations. Image from sfreporter.com Fight Zombie Thinking - Stop the Insanity The evidence basis is quite clear. Clinical interventions and especially digital clinical interventions are costly and can only address process - not outcomes (Annals of IM Comprehensive Review, more) Less Datapalooza and more Team Member Support - Team Members cannot celebrate their contributions because digitizers are celebrating. Health Access Care Still Fai...