Basic Health Access

It is clear from the recent Supplement to Annals of Family Medicine that some of the best and brightest primary care researchers have been focused on a specific area. They may not have much choice as primary care research is poorly supported. They have millions of reasons to do "quality improvement" research - 117 million ARHQ dollars. But is this a good choice? AHRQ continues to follow the Bandwagon of quality micromanagement - disappointing for an evidence-based entity because of the evidence basis mounting up against quality improvement efforts set in motion with To Err is Human and accelerated by the Dartmouth Assumptions, ACA, MACRA, CMS, and various associations. Even when primary care association members are hurt, the Bandwagon rolls on and over them. Particularly distressing are the various for-profit entities cashing in on quality improvement claims - often claiming to do it all or improve costs, quality, and more. What is most clear is the tran...

What is must important for health care leaders, designers, and researchers to understand is their limitations. Leaders have chosen the designs and research that they like without understanding the limitations and defects of the research. My vote for what has most set the US behind in health care goes to the tyranny of the aggregate.  Once again, Dr. Saurabh Jha comes to the rescue by nailing this tyranny the best. "What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands that feed it."   SAURABH JHA, MD (associate editor with The Health Care Blog) This is likely the mos...

JAMA has granted access to government officials for another publication. This time the author was President Obama. One portion of his publication stuck out. "We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since." Ideas should easily be recognized as not proven.  During an era where legislators are not willing to invest more dollars, there is a good probability of loser and a smaller probability of winner.   With government focused on cost cutting as a top priority since 1983, remaining dollars for meaningful use are more limited. With a for-profit health care design, winners are magnified and losers are further left behind. With strong lobbying by the largest and most organized corporations and associations, the probability of being a loser increases.   As we marginalize the local and the individual, those more organized and largest gain even more.  Ideas shoul...

For decades we have had stagnation in important areas such as health access and in quality. Meanwhile, costs have skyrocketed. The opposite of value has become the norm for health care in the United States.    A worst case scenario in health care would be More funds to those already with the most and more payment to those with the simplest and briefest tasks of care - the traditional US payment design Less funds to those providing care for those most need of care because of least funding plus higher cost of delivery resulting in even less that can be done Cuts in resources making social determinants, jobs, and situations worse. Vague measures of performance and vague definitions of interventions making it easy to claim benefit and hard to actually improve (ACO, PCMH, value-based payment) or easy to exaggerate  ( NC Primary Care Medical Home, Milliman ) such that advocates and consultants can continue to expand while primary care contracts Rapid change without...

Achieving Value in Primary Care is an article worth reviewing in the current Annals of FM. It is a theoretical article with substantial review of the existing literature. Unlike many of the popular reports supportive of innovation, this one takes a realistic look. Headings include: Primary Care Medical Home Recognition May Not be a Valid Indicator of Model Adoption The Existing PCMH Model May Not Result in Substantial Improvement in Outcomes Cost Impact of PCMH is Difficult to Demonstrate Demonstrating Value - The 2 initiatives showing the most substantial impact on quality and on cost or utilization—the Vermont Blueprint for Health and the Comprehensive Primary Care Initiative (CPCI)—provide substantial resource support for PCMH transformation and care delivery. Value Could Be Considered Health, Healing, Cure, Precondition Support, Experience of Care Divided by Cost - internals to patient not externals Take Homes from Recent Articles About Primary Care and Quality Qual...