Health reform debate understandably focuses on large system design. We should not omit attention to the “last mile” problem of physician payment theory. Achieving fundamental goals of integrative, patient-centered primary care depends on thoughtful financial support. This commentary describes the nature and importance of innovative primary care payment programs.

These are indeed dangerous times. In the name of “cost-effectiveness,” we cut back health benefits to the poor, who are more likely to be sick than the nonpoor. We miss our chance to heal. In the setting, we’re told, of “scarce resources,” we imperil the health care safety net. In the name of expedience, we miss our chance to be humane and compassionate.’Medicaid is again - still - the subject of reform discussions in Washington and in state capitals. The program (...) has been subject to varying, sometimes conflicting pressures since its inception. Its primary purpose has been serving the health care needs of the poor and disabled. It was structured, however, to appeal to private health care providers. In addition, its mix of state and federal funding and control was intended to draw in the states as partners. (shrink)

These are indeed dangerous times. In the name of “cost-effectiveness,” we cut back health benefits to the poor, who are more likely to be sick than the nonpoor. We miss our chance to heal. In the setting, we’re told, of “scarce resources,” we imperil the health care safety net. In the name of expedience, we miss our chance to be humane and compassionate.’Medicaid is again - still - the subject of reform discussions in Washington and in state capitals. The program (...) has been subject to varying, sometimes conflicting pressures since its inception. Its primary purpose has been serving the health care needs of the poor and disabled. It was structured, however, to appeal to private health care providers. In addition, its mix of state and federal funding and control was intended to draw in the states as partners. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs (...) requires thoughtful regulatory coordination between public and private health systems. (shrink)

The Affordable Care Act1 promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs (...) requires thoughtful regulatory coordination between public and private health systems. (shrink)

The Institute of Medicine has returned the problem of medical error to the top of the health-care agenda. Its report that 44,000 to 98,000 patients die each year as a result of medical errors in American hospitals has renewed scholarly interest in health system quality control. In To Err Is Human, the IOM provides a vivid picture of a health-care system riven with serious quality problems. It calls for systems-based error-reduction methods borrowed from other high-risk industries and forcefully argues against (...) the traditional tendency to assign accountability primarily to individual physicians. Most errors, the IOM argues, can be successfully addressed by engineering systemic fail-safe protections against the inevitable failings of human actors. (shrink)

The Institute of Medicine has returned the problem of medical error to the top of the health-care agenda. Its report that 44,000 to 98,000 patients die each year as a result of medical errors in American hospitals has renewed scholarly interest in health system quality control. In To Err Is Human, the IOM provides a vivid picture of a health-care system riven with serious quality problems. It calls for systems-based error-reduction methods borrowed from other high-risk industries and forcefully argues against (...) the traditional tendency to assign accountability primarily to individual physicians. Most errors, the IOM argues, can be successfully addressed by engineering systemic fail-safe protections against the inevitable failings of human actors. (shrink)