Monthly Archives: febbraio 2014

Value-Based Health Care Is Inevitable and That’s Good @Medici_Manager @pash22 @leadmedit

by Toby Cosgrove  http://bit.ly/17GkMG7

Vaccines. Anesthesia. Penicillin. Bypass surgery. Decoding the human genome. Unquestionably, all are life-saving medical breakthroughs. But one breakthrough that will change the face of medicine is being slowed by criticism, misunderstanding, and a reluctance to do things differently.

That breakthrough is value-based care, the goal of which is to lower health care costs and improve quality and outcomes. It will eventually affect every patient across the United States. Not everyone, however, is onboard yet, because part of the value-based equation is that hospitals will be paid less to deliver better care. That’s quite a challenge, but one that Cleveland Clinic is embracing as an opportunity to do better. Others must, too.

How the Health Care World Will Change

We all know that U.S. health care is too expensive, too inefficient, and the quality is too varied. The goal of value-based care is to fix that.

A major component of the Affordable Care Act is to change the way hospitals are paid, moving away from a reimbursement model that rewards procedures to one that rewards quality and outcomes. No longer will health care be about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. Instead, it will be about costs and patient outcomes: quicker recoveries, fewer readmissions, lower infection rates, and fewer medical errors, to name a few. In other words, it will be about value. And that is good.

Whether providers like it or not, health care is evolving from a proficiency-based art to a data-driven science, from freelance physicians to hospital-employed physicians, from one-size-fits-all community hospitals to vast hospital networks organized around centers of excellence. Each step in this process leads to another.

When hospitals employ physicians on an annual salary as we do at Cleveland Clinic, a doctor is paid the same no matter how many patients he sees, how many procedures he performs, or how many tests he orders. One-year contracts hold our doctors accountable, with yearly performance reviews that include each doctor’s quality metrics, clinical outcomes, and research. And having all your doctors on the same team makes it easier to coordinate patient care among different groups of specialists.

As more independent physicians begin to be hired by hospitals, the opportunity for large group practices and hospital consolidation grows. As consolidation expands, data and transparency become increasingly important, as a way to ensure that caregivers across the system are providing comparable care.

All of this, of course, leads back to quality, which requires an effort to achieve standardization, reduce variation, and eliminate unpleasant surprises. It’s analyzing processes, measuring outcomes, and changing practices until you get it right.

To remain viable in today’s rapidly evolving environment, health care systems must reduce costs while continuing to improve quality and outcomes.

The Cleveland Clinic’s Journey

In the October issue of Harvard Business ReviewMichael Porter and Tom Lee cite six components of high-value care-delivery systems: integrated practice units; cost and outcomes measurement; bundled payments; integrated care delivery across facilities; expanded services across geography; and an information technology platform to enable those processes.

As they note, Cleveland Clinic is one of two medical centers worldwide that has implemented all six, beginning with integrated practice units, which we call “institutes.” A patient-focused institute combines medical and surgical departments for specific diseases or body systems. All of our institutes are required to publish outcomes and measure costs. With bundled payments, we combine all the services provided before, during, and after a complex procedure like joint replacement, into a single charge. We have integrated care through shared protocols and the electronic medical record at all of our 75 care-delivery sites. And our expansion across Northeast Ohio into Florida, Nevada, and overseas allows broad geographic access to our services.

What makes Cleveland Clinic different stretches back to our founding 92 years ago as a physician-led group practice that runs a hospital – not a hospital that employs doctors. This distinction is important. Decisions from the CEO on down are made by physicians based on what is best for the patient.

Mining Data

As a leader in the electronic medical records, we have a wealth of data that can tell us what’s working and what’s not. For instance, we were able to comb through data of heart-surgery patients to find that those who received blood transfusions during surgery had higher complication rates and lower long-term survival rates. This finding – mined from our own data – changed the way we do things; we now have strict guidelines in place to limit transfusions.

We’ve made similar strides in many other clinical areas, using data to drive quality. By collecting data on provider performance and making that data transparent, central-line infections have decreased by more than 40%, while urinary-tract infections have dropped 50%.

Data can help identify variations in clinical practice, utilization rates, and performance against internal and external benchmarks, leading to improved quality and a sustained change in culture. Last year, we established a values-based care team, which seeks to eliminate unnecessary practice variation by developing evidence-based care paths across diseases and to improve comprehensive care coordination so that patients move seamlessly through the system, reducing unnecessary hospitalizations and ER visits.

Lowering Costs Without Compromising Quality

American health care is on an unsustainable path. Health care spending topped $2 trillion in 2011. The Centers for Medicare and Medicaid Services predicts that without major change, it will account for more than 20% of GDP by 2021, up from 5.2% percent in 1960. What that means is that if we continue on our current path, $1 in every $5 spent in the U.S. economy will go toward health care.

We can choose a different path, though. At Cleveland Clinic, we’ve been engaged in an ongoing effort to trim costs across the entire system. Through a concerted focus on our supply chain, we use rigorous value-based purchasing protocols, market intelligence, and business analytics to examine every purchase from the standpoint of value, utility, and outcomes. Over the past two years, this has resulted in cost savings of more than $150 million.

Our electronic medical records are also programmed with a “hard stop” function to reduce unnecessary duplicate tests. This led to a 13% reduction in blood-gas determinations, generated $10,000 in monthly savings for laboratory tests, and resulted in savings of $117,000 in just the first month for genetic testing.

A key part of the cost solution is to educate all caregivers, including doctors, about what items cost. Earlier this year, we created a Cost Repositioning Task Force to work with all caregivers across the entire Cleveland Clinic system to assess everything we do and everything we spend. Now, as part of the purchasing process, dozens of doctors gather to discuss the merits of certain products: Which ones provide the best outcomes for patients? How many are needed? How much does it cost?

Traditionally, knowing the cost of a stitch or a catheter or a bone screw — or any of the thousands of other supplies used during surgeries — hasn’t been part of doctors’ medical consciousness. To remedy that, we’ve taped price lists to supply cabinets in some ORs. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.”

As health care reform kicks into high gear, providers are facing a difficult challenge: being paid less to produce better outcomes. We must view this as an opportunity, not a burden. After all, the providers who make the transition early will be rewarded with more satisfied patients, lower expenses, and pride in a job well done.

Follow the Leading Health Care Innovation insight center on Twitter @HBRhealth. E-mail us athealtheditors@hbr.org, and sign up to receive updates here.

6 strategies hospitals should steal from the airline industry @Medici_Manager @pash22

by Jonathan H. Burroughs  http://bit.ly/15CSWz6

The Institute of Medicine, in its landmark report “Better Care at Lower Cost,” concludes at least $750 billion of the total national healthcare budget of $2.7 trillion represents waste as a result of poor IT infrastructure, supplier- rather than patient-centered reimbursement, lack of quality and transparency, and inefficient operations and flow.

Wasteful operations may include: delays, over-processing, redundant work, poor inventory management, inefficient transport, unnecessary motion, over-production (push instead of pull), and defects that cause harm and re-work.

The airline industry has worked on these problems for decades and although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements we can learn from to give us a jump-start on mastering and taming a difficult but necessary component of operational design that will lead to improved outcomes at lower costs.

1: Air traffic control is managed as a system, not a place

Flow through the airport affects and directly result from flow outside the airport, and air traffic control does not make any distinction. We often treat emergency department or intensive care unit flow as an isolated problem whereas every aspect of an individual’s care from inpatient, to post-acute, to ambulatory has a direct impact on the other. As it turns out, what happens to an individual outside of a hospital has a greater effect on length of stay and flow than what happens inside. Thus, we will never master hospital flow until we master the flow of the entire system.

2: Airport operations function 24/7

Airports function 24/7 and so should healthcare systems. Flow should be managed around the clock and utilization managers should be replaced with flow coordinators who hand off their oversight continuously based on time of day and setting of care. For instance, when a plane takes off, airport air traffic control transfers responsibility to regional air traffic control, and oversight of the flight is continually monitored from control station to control station until the flight terminates at another airport.

Similarly, a flow coordinator should orchestrate a patient’s non-emergent arrival, the admission process, the inpatient care, the discharge planning process and then transfer responsibility for the patient to an outpatient flow coordinator to ensure appropriate follow up and continued optimal care. Ideally, the term “discharge” should be replaced with “care transition” so we stop thinking of moving from one environment to another as a beginning or end.

3: All departures are scheduled in advance

The three most common bottle-neck areas in a healthcare organization are the emergency department, the intensive care unit, and the surgical areas (pre- and post-operative). The vast majority of delays in these expensive settings involve the discharge planning process as patients in these areas often have no place available to go, thus backing up operations throughout, delaying treatment for others waiting to come in, reducing patient/staff satisfaction and increasing costs. Ironically, most discharges are predictable to within one hundredth of a day based upon risk and severity-adjusted length-of-stay data bases (e.g., Premier) for each diagnosis-related group.

Therefore, most discharges should be scheduled at least 24 hours to 48 hours in advance (ideally when the patient arrives) with arrangements made for nursing home or ventilator beds, physician appointments, home health on the day of admission in anticipation for discharge. Many healthcare organizations are purchasing or contracting with nursing homes, home health services, psychiatric facilities and physician practices to gain greater control and ease of scheduling by extending the chain of its operations into the outpatient setting.

4: All arrivals are scheduled in advance

One healthcare myth is that emergent arrivals are unexpected. As it turns out, if emergent ED, surgical, or ICU admissions are tracked over time, the vast majority are predictable. For instance, most emergency department admissions arrive between 3 p.m. and 11 p.m. with the fewest arrivals between 4 a.m. and 9 a.m. There will be rare disasters, which require special resources through a disaster planning process; however, these can be managed and illustrate the difference between random (uncontrollable) and non-random (controllable) variation in flow.

Truly random variation can and should be managed by policy whereas non-random variation should be eliminated by standardizing flow to accommodate predictable admissions in a predictable way through optimum staffing, resource allocation (including beds) and standardized admission processes.

5: Flight schedules are smoothed throughout the day and week

An airport only can handle its capacity of arrivals and departures at any point in time and so it manages the schedule to ensure a consistent schedule of flights throughout the week and time of day. Emergency departments, surgical facilities, and intensive care units can be similarly managed so that non-emergent patients who arrive at the ED can be transferred to lower acuity areas during peak hours, elective surgical schedules can be scheduled evenly throughout the week to avoid demand surges, and ICU admissions can be coordinated based upon regional transfer agreements in compliance with EMTALA to ensure appropriate stabilization and safety.

The system needs to be viewed holistically so all of the units and outpatient facilities coordinate flow in a synchronized and synergistic way to accommodate flow throughout the system and not within a unit alone.

6: Delayed flights are taken off of main runways and taxiways

When air traffic control delays a flight, the delayed flight does not block other flights but is directed to another area to await further instruction and movement. Delayed discharges, transfers and admissions should not sit in beds blocking patient flow but should be immediately moved to a comfortable and appropriately supervised holding area where they can be safely managed and not delay the timely diagnosis and treatment of non-stabilized patients.

Most patients waiting for beds are stable and should no longer receive top priority or undermine the overall efficiency and effectiveness of the system. Similar holding areas can be utilized for admissions, transfer, and discharges if beds are interchangeable and staff is cross trained to handle a broad range of diagnoses and conditions.

Conclusion:

Although air traffic flow is simpler and easier to manage than healthcare, the industry can offer many lessons that will enable us to treat patient flow systemically as a 24/7, inpatient/outpatient, continuous operation that requires continuous management and oversight to standardize processes, exploit bottle-necks, manage random variation and eliminate non-random variation. By doing so, we can reduce costs, improve quality/safety/service and successfully compete globally for high quality-low costs services.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.

Le implicazioni pubbliche della vecchiaia

Girolamo Sirchia

L’aumento dei soggetti anziani nella nostra società mette in allarme i nostri economisti, che parlano di una bomba a tempo per la spesa sociale. Essi infatti calcolano il cosiddetto “rapporto di dipendenza anziani” (old age dependency ratio) che è dato dal rapporto:

n° di pensionati
_______________________________

n° di soggetti di età tra 16 e 64 anni

che oggi si aggira sul 30%, ma che è destinato ad aumentare nei prossimi decenni. Ciò significa che per ogni pensionato ci sono solo due persone che producono e questa situazione è destinata a peggiorare. Tuttavia questo indicatore non è attendibile, in quanto nella situazione reale non basta considerare solo l’età assoluta, ma devono essere considerati gli anni di vita residui (cioè l’aspettativa di vita), che è molto cresciuta negli scorsi decenni e ha consentito agli anziani molti anni di vita attiva in salute. Meglio quindi considerare la dipendenza come rapporto tra:

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Il Buonismo

Girolamo Sirchia

Nel 1906, Vilfredo Pareto nel suo Manuale di Economia Politica (Università Bocconi Ed., Milano, 2006, par. 85) cosi scriveva:

“(…) in Francia, ove più progredisce la democrazia, sono accaduti notevoli mutamenti nella seconda metà del secolo XIX. …. Si possono notare i seguenti mutamenti nei sentimenti morali: 1) un aumento generale della pietà morbosa, a cui si dà il nome di “umanitarismo”; 2) e specialmente un sentimento di pietà e anche di benevolenza pei malfattori, mentre cresce l’indifferenza pei mali del galantuomo offeso da quei malfattori; 3) un aumento notevole di indulgenza e di approvazione per il mal costume femminile”.

E così prosegue (Par. 86):

“ I sentimenti di biasimo per i malfattori, specialmente per i ladri, sono certamente molto affievoliti; ed oggi sono ritenuti buoni giudici coloro che con poca scienza e nessuna coscienza, cupidi solo di malsana popolarità, proteggono i malfattori e sono rigidi ed aspri solo…

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Nurses under pressure: do risk assessment tools help prevent pressure ulcers?

Evidently Cochrane

Tools to help assess a patient’s risk of developing a pressure ulcer have been in use for half a century, but do they actually result in fewer pressure ulcers, or do they take up nurses’ time which could be better spent with the patient? An updated Cochrane review gives us the current state of the evidence.

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Renewing the dialogue between the medical and nursing professions @kevinmd @Medici_Manager

  http://bit.ly/1eRzDVZ

A recent post observed that the “highly charged scope-of-practice” fight between the medical and nursing professions has resulted in social media hate speech – too often, from physicians directed at other physicians. “Like bees to nectar, a post on the topic is sure to draw dozens of anonymous, hate-filled comments” write the authors.  They propose the following “principles for civil discourse” which I believe should apply more broadly to all social media commentary, not just on the physician versus nurses conflict:

“Anecdotes are fine, but avoid drawing generalizations from one story. (‘We had that dumb NP once. She didn’t know where the gallbladder is located. So NPs must all be dumb.’)

Identify the underlying emotion of a comment that irks you, and name it when you respond. (‘Doctor Strangelove, it sounds like you’re frustrated that NPs have fewer hours of training and are asking for the same salary as MDs. Here’s my take: ….’)

Name-calling is out. Polite, respectful comments are more likely to be taken seriously, and to stimulate a productive conversation. ( ‘SJ, I appreciate hearing your viewpoint. Here is WHY I disagree with you.’)

Own your comments. Instead of making broad generalizations, make it clear that you are offering your opinion. (Rather than saying, ‘NPs simply should not be practicing without some sort of physician supervision,’ say ‘I don’t think NPs should practice without any physician supervision.’)

Consider phrasing your comment in the form of a question. (‘I’m troubled by the thought of NPs working in a rural area with no access to collaborating physicians. Does anyone have experience with that?’)

Go for the win-win. (‘The demographics, economics and politics of health care reform suggest there’s enough pie for all of us in the primary care world. We are all undervalued and overworked. By uniting in cause and working with each other, both groups stand to gain in terms of creativity, relationships, and (dare we say) income.’)

Find the best alternative to a negotiated agreement (known as “BATNA” — taken from the classic tome, Getting to Yes). (‘NPs are here to stay, with increasing autonomy across more and more states. Let’s find a way to work together — whether you’re a doctor or NP, our end goals are the same.’)”

If such principles were broadly accepted by all of us involved in social media commentary, they would result in a much better informed, respectful and constructive discussion than name-calling and personal attacks. Civil discourse, though, by itself won’t be enough to end the uncivil war between the nursing and medical professions.  What’s needed is a way to get to the “win-win” point where the legitimate interests and concerns of both professions are recognized and addressed.

Recently, the Annals of Internal Medicine, ACP’s flagship peer reviewed journal, published a paper titled, “Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper” which I believe could become the basis of such a win-win outcome. (Full disclosure: I am the principal author of this paper, along with my co-author and colleague Ryan Crowley, which was written by us on behalf of ACP’s Health and Public Policy Committee and Board of Regents).

Our goal in developing the paper was to constructively address the legitimate concerns of both professions as a step toward renewed dialogue between them.  Nurses have legitimate concerns about being held back by restrictions on their licenses and physician supervision arrangements that limit their ability to provide care to patients, that is within nursings’ skills and competencies.  Physicians have legitimate concerns that their unique and more extensive years of medical training are being devalued by the calls to substitute independently practicing advanced practice nurses for primary care physicians.  Both professions assert that their views are based on what is best for patients.

Our paper asserts that professionalism is the answer to resolving such differences. “Professionalism” we wrote “requires that all clinicians — physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals — consistently act in the best interests of patients, whether providing care directly or as part of a multidisciplinary team. Therefore, multidisciplinary clinical care teams must organize the respective responsibilities of the team members guided by what is in the best interests of the patients while considering each team member’s training and competencies.”

The goal, then, must be to assign, “specific clinical and coordination responsibilities for a patient’s care within a collaborative and multidisciplinary clinical care team should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time to personally deliver particular aspects of care and maintain overall responsibility to ensure that the patient’s clinical needs and preferences are met. If two team members are both competent to provide high-quality services to the patient, matters of expedience, including cost and administrative efficiency, may contribute to division of that work.”   While we affirm the importance of, “patients having access to a personal physician who is trained in the care of the ‘whole person’ and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home” we also state that, “Dynamic teams must have the flexibility to determine the roles and responsibilities expected of them based on shared goals and needs of the patient.”

“Although physicians have extensive education, skills, and training that make them uniquely qualified to exercise advanced clinical responsibilities within teams…well-functioning teams will assign responsibilities to advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals for specific dimensions of care commensurate with their training and skills to most effectively serve the needs of the patient.”  We observe that, “especially in physician shortage areas, it may be infeasible for patients to have ‘an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care” and that, “in such cases, collaboration, consultation, and communication between the primary care clinician or clinicians who are available on site and other out-of-area team members who may have additional and distinct training and skills needed to meet the patient’s health care needs, are imperative.”

On the debate over each profession’s role in solving the primary care workforce shortage, our answer is, “a cooperative approach including physicians, advanced practice registered nurses, other registered nurses, physician assistants, clinical pharmacists, and other health care professionals in collaborative team models will be needed to address physician shortages.”

And on the most divisive issue — state regulation of nursing scope of practice — we state that, “Clinicians within a clinical care team should be permitted to practice to the full extent of their training, skills, and experience and within the limitations of their professional licenses as determined by state licensure and demonstrated competencies. All clinicians should consult with or make a referral to other clinicians in disciplines with more advanced, specific, or specialized training and skills when a patient’s clinical needs would benefit from such consultation and referral.”  We assert that,  “Licensure should ensure a level of consistency (minimum standards) in the credentialing of clinicians who provide health care services” and called on state legislatures and licensing authorities, “to conduct an evidence-based review of their licensure laws” and “consider how current or proposed changes in licensure law align with the documented training, skills, and competencies of each team member within his or her own disciplines and across disciplines and how they hinder or support the development of high-functioning teams.”

Now, I know that the paper will not please everyone in the medical and nursing professions, but we hope that it can be the starting point of a renewed dialogue between the professions.  We end the paper by noting that, “ACP offers these definitions, principles, and examples to encourage positive dialogue among all of the health care professions involved in patient care—in the hope of advancing team based care models that are organized for the benefit and best interests of patients. ACP also hopes to inform policymakers to ensure that regulatory and payment polices are aligned with, rather than creating barriers to, dynamic team-based care models. ACP encourages discussion of dynamic clinical care teams that puts patients first.”

Let’s get this dialogue started — with civility, of course.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

La storia del tuo Ospedale alla prova della “seconda curva”: Integrazione e Trasformazione

Questo rapporto presenta e racconta di programmi di assistenza integrata di successo , nonché  forme di integrazione di altro tipo, ideati i primi e progettati i secondi per aiutare gli ospedali a costruire sistemi di cura basati sul valore (value-based).

La storia degli ospedali all'imbocco della seconda curva: valore e trasformazione

La storia degli ospedali all’imbocco della seconda curva: valore e trasformazione

In ultima analisi l’assistenza sanitaria ha superato la “prima curva”, (dove gli ospedali operano in un contesto basato sul volume) e sta imboccando la “seconda curva” (dove si devono costruire sistemi di cura basati sul valore e su modelli di centrati sulla popolazione medicine). I medici e gli altri dirigenti ospedalieri devono sviluppare strategie efficaci per imboccare al meglio questa seconda curva, migliorando così la qualità delle cure e la salute della popolazione, riducendo i costi. Questo report dell’American Hospital Association delinea esempi di strategie di successo  da seguire, evidenzia capacità manageriali da padroneggiare e pone 10 domande strategiche…

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We are spending billions to train the wrong kind of doctors @kevinmd @Medici_Manager @WRicciardi @pash22

  http://bit.ly/1991PRY

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization’s ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients.

Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization’s limited resources.

Additional funding required? How about $9.5 billion? That’s the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America’s physician workforce needs.

If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

new study in Academic Medicine by health services researchers at George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all.

Notably, they conclusively disproved “The Dean’s Lie“ that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That’s the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center’s free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.