Wedding Kurat

Policy and Design Seeds of Health Improvement Fail on Barren US Soil - Any number of interventions can work in a nation that invests in children, and improved environments, situations, and social determinants. In nations failing in support, health interventions can be expensive and can fail to work. Medicaid as Savior or Betrayer of Access - Higher payments from Medicaid can increase access for patients with or without insurance. Medicaid expansion with current payments too low cannot support Medicaid patients, local providers where care is needed, or patients with insurance either. Selling and Swelling a Bigger HITECH Bubble - C herry pi cking has become essential for those who provide or insure health care. Choose the easiest route will capture more dollars with less cost of delivery - and this will earn more bonuses and assure no penalties. Changes since 2010 will reward those already doing well and will penalize those already behind. Cherry picking has apparently moved to top impor...

An article by Andrew Weil indicates how "The Biomedical Model is Failing Us." Despite lofty claims, the drugs promoted have not done much for mental health. Not surprisingly the biomedical model may have failed most when applied to mental health where so much is about behaviors, relationships, and other people factors. Weil points out, "In 1977, the journal Science published a provocative article titled “The Need for a New Medical Model: A Challenge for Biomedicine.” I consider it a landmark in medical philosophy and the intellectual foundation of today’s integrative medicine. The author, George L. Engel, M.D., was a professor of psychiatry at the University of Rochester (New York) School of Medicine. Determined to overcome the limiting influence of Cartesian dualism, which assigns mind and body to separate realms, Engel envisioned medical students of the future learning that health and illness result from an interaction of biological, psychological, social, an...

Quality measurement focus has resulted in higher cost, distractions from care, and lower productivity. Articles proposing more quality measure emphasis may be popular but will not move homebound seniors toward the care that they need. An understanding of the situations facing homebound seniors is required.   Based on higher levels of disabled payments, Social Security payments, Medicare patients, Medicaid patients, seniors, obesity, smoking, and sedentary lifestyle at least 45% of homebound seniors are found in 2621 lowest physician concentration counties.   It helps to have access to care and workforce to provide care and local resources and many other areas addressed before more quality measures.   Homebound seniors where care is needed face Lack of mobility - condition, housing Lack of transportation - due to family situations and lesser public transportation Lack of insurance competition Insurers who avoid them due to cost and complexity Providers who avoid them due t...

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 that yields less and less...

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 and analy...