Congress has voted, now we begin the hard work of making reform real

The US is moving closer to joining the ranks of all the other developed nations in the world.  While each has its own set of challenges and flaws, all of them manage to cover 100% of their citizens with health care and most do it better and cheaper than us.

Real health care reform requires three moving parts:

1. Get everyone on the bus:  Congress has moved us closer to the ranks of first world nations that cover all their citizens (and almost all of them at lower cost and with better results).
2. Redesign the system to support robust primary care: high performing health systems are based on effective primary care.  We need to move away from our 'clean it up after it's broken' mentality.
3. Reform payment to support effective primary care: it is possible to achieve huge outcome improvements, huge increase in satisfaction, increase the supply of primary care AND lower total costs when we support effective primary care.

Doing all of the above is going to take political guts 'cause the savings all come at someone's expense (in this case the avoidance of unnecessary hospitalization and procedures). 

Effective primary care requires implementation of technologies that better support our patients and our work, it requires getting off the hamster wheel and spending more time with patients, it works better when we can coordinate the work of a multi-disciplinary team on behalf of struggling patients. Doing all of this costs about twice the going rate of primary care but the good news is that - even when accounting for the full funding of effective primary care - the net effect is a 20-30% reduction in the total cost of care.

The primary care folks I know are ready.  They can invest as soon as they see that the real work is funded - not pennies promised for huge reporting burdens (e.g. typical PCMH initiatives) but full funding for the real work of primary care.

The practices fastest out of the gate are the ones that have figured out how to fund the work of primary care.  In some regions of the country a practice can do this by radically dropping overhead, in other parts of the country it is still impossible to survive unless the practice finds additional sources of revenue to fund the work.  In these ever-enlarging 'dead zones' for primary care, the survivors are funding the work by joining the ever growing ranks of cash based practice.

When the middleman adds nothing but pain, complexity & cost, it is time to explore other options.