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 ...

Every day there are articles, blogs, and speeches proposing a fix for primary care. The latest to cross my desk comes from Health Affairs. Another value based plan is proposed to address the needs of patients with dementia. We can agree that individuals with dementia do have complex health care needs and their caregivers are often overwhelmed. We can agree that primary care is the most appropriate care venue for such patients. But I would argue that primary care is currently not capable of the challenge. Before additional proposals are considered such as those involving innovation, digitalization, reorganization, regulation, integration, coordination, or outreach  – the financial design must be addressed. How Does Innovation Hurt Where Practices, Towns, Health Facilities and Resources are Small Innovation Is a Distraction from Real Primary Care Solutions Innovation Focus Forced on Team Members Contributes to Overload Innovation Is More Likely Where Primary Care...

We should send a clear message to the "experts" and the media and associations and health professional training institutions: Please stop the insanity of doing the same thing over and over again expecting a different result.  New innovative types of workforce have failed to resolve workforce deficits despite massive expansions More new types and more expansions have failed. More new types and more expansions are proposed. It is the financial foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed. It Is Not the Initials or the Expansion, It is the Financial Design It is not about who is a better health professional or the type of training. Expansions are not the solution for any domination or perceived domination of health care. Texas has another new medical school planned but a family physician dean will not be able to keep the promise of more doctors where nee...

One year ago today we had all the evidence that we needed to move away from payment policies that punished practices and delivery team members with meaningless use and other abuse. A year ago today, a landmark comprehensive review indicated that outcomes were not improved by financial incentives.   “In summary, we found low-strength, contradictory evidence that P4P programs could improve processes of care, but we found no clear evidence to suggest that they improve patient outcomes.” from The Effects of Pay-for-Performance Programs on Health,Health Care Use, and Processes of Care: A Systematic Review, Annals of Internal Medicine 1/10/17.     Happy Anniversary to Aaron Mendelson, BA; Karli Kondo, PhD; Cheryl Damberg, PhD; Allison Low, BA; Makalapua Motúapuaka, BA; Michele Freeman, MPH; Maya O'Neil, PhD; Rose Relevo, MLIS, MS; Devan Kansagara, MD, MCR for a fine study - substantially ignored    Not even primary care associations have mov...

While promoting the new well-being efforts at AAFP, the promotional material indicates what AAFP must address to result in improvements in well being for family physicians. "To function at your best in an ineffective system" would first of all require AAFP to lead the nation to address the ineffective system. Top on the AAFP list should be all resources focused upon the grossly insufficient investment in primary care. Also high on the list should be efforts to address insufficient investments in people, families, and communities for best health outcome results. Attending a conference may not work out for well-being as those who attend will return to an ineffective system.  The following critique is directed at the latest AAFP efforts to address family physician well being by web sites, live chats, and well being conferences. I learned during my time as an AMA Delegate that association activities were often turned into parties for those most associated with the ...

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...

The transformation of primary care requires payers and players. The payers have said no so the players are too few and are often overwhelmed where the players are most needed. Primary care needs fuel and a more efficient financial design, especially in the small and rural practices and those where care is most needed. The controversies continue to hold primary care hostage, especially primary care where needed where half of Americans will reside by 2040. The primary care financial design begins with only $500,000 to $600,000 in revenue per primary care physician as the fuel to propel the activities of primary care physicians, clinicians, and teams for a year. Unfortunately the fuel supplied is lower where primary care is most needed and is higher where contracts gain annual escalation clauses for those largest, most organized, and in locations of least workforce need.  Recent blogs have illustrated just how much fuel is stolen and how inefficient primary care delivery ...

Students and residents should focus AAFP upon equity. Equity in payment would be a good start. Dollars are maldistributed in health care and this contributes to inequities in workforce, access and outcomes as disparities drive social and other determinants of health the wrong way. AAFP wants to present the best case scenarios to students and residents, but there are major issues that must be addressed. Equity is indeed and important theme worthy of discussion Equitable payments for primary care, mental health, and basic services should be most important for student or residents that truly hope to deliver these basics - especially in places with half of Americans where inequity and disparities dominate.  There should be no deception that most Americans are doing well. American health, education, and economic outcomes indicate that few do very well and most are left behind. Future family physicians deserve to know the big picture as family physicians are most likely to care for t...