GLG News by Robert Forster

Implications: As a clinician leader for some time, it is overtly obvious that comprehensive genetic testing will be fraught with misinterpretation and will lead to consumer confusion and potentially wrong life behavior. Genetic testing has been available for 2-3 decades on a very limited basis and for specific fetal diseases yet physicians wholly inadequately trained are referring patients to nursing geneticists with a 85% incorrect diagnosis or treatment recommendations for patients.  This wholesale look into the future will bring chaos and fright to many patients.

Analysis: I disagree with Mr. J. Goldstein on this one from a point of personal experience and knowledge of our medical academic training.  We have for 3 decades used genetic surrogates, e.g. Fasting glucose, lipids, BSP, etc for genetic abnormalities.  In addition less than 10 specific diseases with specific genes could be identified especially targeted for the gestational period.  Academic studies have repeatedly shown that physicians of all types are wholly under trained to interpret these simple and few tests and referrals to medical geneticists are incorrectly referred today at least 80-85% of the time--a fact.

Broad sweeping genetic "analysis" of healthy individuals is going to be poorly interpreted, poorly executed on, and financially abused--"modern day fortune teller."

Consumers (since Americans are technology junkies) may demand it, but unless there is a specific indication, this broad analysis of genetic makeup of individuals is dangerous and can be financially abused.

Implications: Although administrative and nursing/allied medical staff can and will respond to the Quality challenges, physicians (forgive my stereotyping) must be approached more comprehensively to elicit medical behavioral change based on evidenced based medicine or process improvement.  They will slow the process if not attended to their resistance factors for change.  Hospitals and medical groups alike need to understand comprehensively physician resistance for change and accordingly design appropriate interventions for the good of the American People.

Analysis: In the hospital setting particularly, administrators and nurses are responsive to change and embrace it typically .  Execution is usually not an issue--the right process change to improve Quality although is crucial.

However, I am biased re: behavioral change from physicians having led and watched them over 40 years in the medical field.  For whatever reasons, possibly selection criteria to medical school, length of education, social stature, history, etc., physicians have many hurdles to make before each and every one will make behavioral change even if given evidence based medicine--just look at the C-section rate and out patient fetal monitoring to see how they resist Quality care.  Some of the other barriers may be the following:
  1.  Change financially hurts them (and thus their family)
  2.  That is not what I learned at medical school or residency
  3.  That is not what I have observed empirically
  4.  This is coming from bureaucrats
  5.  I already practice the best Quality of medicine (arrogance)
  And much more.
Each of these need to be attended to when asking the highly trained professional to accept change that does not originate from themselves.

Implications: There are many reasons why the commercialization of human genome "information" will be ABSOLUTE CHAOS AND COST.  The three most prominent are the following:   1. Physician education is almost devoid of practical genomic teachings except for Diabetes and lipid disorders.   2.  Fully 85% of genetic referrals now are inappropriate with "simple" genetics.  Human genomic knowledge is quantums greater   3.  The American people will embrace this new gizmology (technology) especially when forecasting the future and invest highly ripe for greed and opportunism.

Analysis: The human genome project will advance science no doubt considerably but without governmental controls and human nature will also bring chaos to American understanding and unnecessary cost where it could be better spent for the masses of common diseases. 

Physicians are poorly trained in practical genetics and legitimate medical literature reveals that a full 85% of physician referrals to geneticists are inaccurate and have done harm to the patients inadvertently.  This is currently.  In no way do we have enough well trained geneticists to council about obtuse findings on broad screening of the human genome.  Now who is going to do this? 

Americans are enraptured with gizmos (technology) and will embrace this quickly and costly to find a vendor who will service their curiosity.  There will be massive investment and greed and misinformation driving this and TV and other mass media will promote mistruths.

Our culture to live better and longer (to an ultimate life span of 110yrs) needs to emulate low technology countries with good health (estimated to be 35-40) superior to USA at 50% of the cost. 

I am not anti-science in any way--but the delivery system of meaningful data from the human genome (with rare exceptions) will be decades behind for practical, common sense use.

Implications: If I may, Mr. Goldstein suggests that education to providers re: cost/benefit or value will drive drug selection.  I disagree in that there are may barriers to provider (most physicians) behavior and their selection of drugs.  To mention a few are as follows:  1. My anecdotal experience 2. My eductation (in past). 3. Do I believe in this? 4. Is this aligned with my best interests 5. Never the first to try something new and never the last.  And so on.  If education was the dominent driver, then propranolol and a thiazide diruretic would be the first choice of anti-hypertensives based on evidence based population studies.  Yet drugs 10-20 fold more expensive are often used as first line. Adherence would increase volume and if free market dynamics are alive would decrease costs/unit.  Total cost may rise and I agree with that. Price controls have never worked--let them die.

Analysis: Education to prescribers has never been the dominent driver of use or Pharma would not be spending twice as much for advertisizing to consumers than physicians and twice as much as research (knowing the drug).  The power of the consumer culture predominates choice of drugs particularly in the last 20 years and consumers are VERY influencial in that decision making.  Physicians have a multitude of barriers to prescribing beharioral change but are most influenced by consumer input-not education.  Tort issues (as perceived by physicians) also have a role despite its non evidence based foundations.

Our culture is Technologically driven and new drugs are technology.  That is why direct to consumer advertisizing has occured with now great limitation on education going to the prescriber.  The diffusion of technology is cultural and must be approached through a long term population education program emphasizing the harm created when technology is diffused too quickly or inappropriately to marginal cases.

The issue of adherence will be with us for ever.  We need a gene for it.  However, if a drug was taken as prescribed and a patient received maximum benefit, additional drugs would likely not be added to enhance the desireable effect.  Thus, the total cost of drugs is really unknown and pure speculation.  No doubt improved adherence would improve outcomes in a specific medical issue.

Let's inform Americans of new medical  technology dangers and benefits, use tried and true therapies where they work the best, not be influenced directly or indirectly by pharma or DTC advertising, and allow the market to set the prices.

Implications: From the rather strick interpretration of Peter Stark's antitrust principles complied with mostly in the 1980's we have entered an era where rampent greed and highly sophisticated antitrust relationships exists in nearly of all hospitals especially with their own "dedicated" (read as owned)  multispecialty group or with the traditional hospital based groups or high earners for the hospitals such as orthopedists, cardiologists, pathologists, anesthesiologists and imagining specialities (radiology for the most part).  Allowing (if the report is correct) the most compensated specialists in Medicine to bill for procedures performed in the hospital setting (technical component) would raise eyebrows of Mr. Stark and the DOJ and FTC (whichever appropriate).  These veiled relationships have contributed greatly to the rate of inflationary growth of medical care and is a powerful source opposed to the use of evidence based medicine to guide indications for high priced diagnostic procedures.

Analysis: Lack of prosecution of obvious antitrust relationships within providers of all segments has led to Medical inflation in that the "greed factor" for self referral and lowered threshold of indications for diagnostic proceedures are reduced when one has a vested financial interest in the diagnostic facility/program.  Not only does affordability of medical care suffer, so does it put a financial strain on those physicians who are under paid for time/cost of eductation  and responsibility for the Medical Home (Pediatricians, Family Physicians, General Internists).
And lastly. it continues to depreciate the words "medical professional" and moves medicine further towards a transactional "business" where the patient does not in fact come first before the financial benefits of the provider. 
Consolidation of the segments  of Providers (mostly hospitals, to a much lesser extent physicians) and Payers has all but elimitated free market principles/dynamics from our health care "system."

Implications: Illegal and unethical bribes to orthopedists have gone on since time immemorial and have been visible throughout the medical and device profession and business.  Yet little (despite Peter Robert Stark's attempt) to separate this added incentive from the most highly paid specialists in medicine, it has continue unabated.  Yes, it has morphed as the law has, but it continues as long as the orthopedist influences revenue generation within the walls of the hospitla. Yes, other specialties also have the same conflict of interest, but the lack of man power and political willingness to prosecute this few in the medical profession has "sanctioned" its spread.

Analysis: The willingness to pursue flagrant conflicts of interest for money do occur rarely but is and will remain the tip of this abuse in our health care system.  Inadequate resources and lack of political will to prosecute physicians has led to more creative relationships and additional ones within the walls of hosptials to enhance income for both the physician and the hospital to the unnecessary cost of health care for Americans.

Unless it becomes a priority of the American people, little impact in this area is likely despite its growing presence.

Implications: Fred is both right and wrong by history.  Ranking of physician performance is akin to work (or payment) for performance.  Since I was around at the beginning of this movement and watching its development, it is clear that work efficiency particularly will high acuity patients is very difficult to measure and our metics are immature to say the least.  Misrepresentation of performance will be rejected and health care savings will return to a contracting strategy (known to work).

Analysis: Ranking physicians except at 3 standard deviations from quality and cost is neigh impossible given poor definition of metrics used, their complexity, and finally their subjective interpretation.  Health care EMR is as only as good as what is put into the data base--guess what--physicians will control this and they will control their own destiny by what they enter.  EBM and finite protocols and their adherence is not a part of this process as it is with Retail Based Clinics so use of anecdotal medicine by physicians will continue with much variance and will be justified by what is entered into their EMR. 

Yes it may prevent some duplication of services and yes help communications with specialists (although PCP are specialists) and facilities, labs, etc--but this is all chipping around the edges of cost and is not yet an effective tool for performance evaluation .  It will frustrate providers and their patients who will hear of it as they did of HMOs and ultimately die by acclimation.

Implications: While cost per capita is the highest in the world, why is our quality substandard?--Health care status is not solely based on healthcare and rejection of accountability of American people remains prevelant. More money is NOT the answer to what ails us in health care.

Analysis:  I appreciate Mr. Manheims more eloquent explanation of why the unit cost in America is twice our nearest Westernized country yet rates #40 in quality (did not explain).  I believe until the model of competition changes from pain by consumers, our system will remain misdirected and overpriced.  I concur that use of benefit design is the best cost control mechanism today given the mental mind set of Americans--who seem oblivious to all the scientific work by major universities showing major flaws and no accountability with the quality of care given to Americans.  Oversight of quality is regarded as an intrusion between physician and patient yet most respectable MCOs have physicians asking via evidence based medicine reasonable questions--"will this service change your course of therapy or help the outcome of the patient." 

Our American's understanding of our health status is linked almost solely with our health care delivery system--this is far from reality.  One can have the best bar none health care system yet poor population health.  I would suggest instead of pouring more money into an over technologically oriented and abused system by stakeholders to issues of behavioral patterns, genetics, environmental exposures, and even social status/environment.  I suspect Americans suffer from too much inappropriate health care and not enough assessment and focus on their own behavior, e.g. smoking, obesity, and inactivity.  Our inner city issues require a very multi-focus approach.  Until this happens, cost control will be leveraged by benefit elimination by payers by necessity.

Implications: I disagree with Dr. Horvitz's assertions regarding rising cost of health care being the government and health plans.  These costs are but a drop of water compared to the actual unit cost of services and the # of services being delivered to Americans.  Health plan + governmental costs are in the 15% of the total spend. The mirror is a good place to begin for physicians if they wish to mitigate our national trajedy--Twice the cost per capita (wage adjusted) and somewhere about 35th. on population quality by all metrics commonly used. The second place to look is at the American culture and its expectations of our "health care system"--nothing but the perceived best for me--"spare the cost" even though it may have no medical evidence basis.

Analysis: It is true that health plans, hospitals (in most environments), and Pharma have been profit taking during the past 5 years under a favorable business climate by overestimating medical costs during a negative dip in the underwriting cycle.  This has happened since the 1940's repeatedly.  These cycles have no or little impact on the overall medical cost trend.  They do inhibit both hospital and payer consolidation for a time which is good for the consumer (no reason to merge when coffers are full and mergers occur to consolidate for cost leveraging=bad for the consumer).

The stepping back culturally from HMO's/economic model where all stakeholders are more aligned than not, the absence of national tort reform for many states, Pharma dominence and hospital consolidation,  and mostly the wide and very rapid diffusion of high cost technology to all segments of our population has led to our unsustainable medical model based on unit cost.  Other Westernized countries do not seem to be afflicted by this malady and it all starts with consumer expectation to be tested and physician's willingness (thus the mirror) to give them what they want regardless of medical appropriateness.

Our system since the late 1980's has never been more fractionated, narcissistic, self serving, and greatly consolidated for the purpose of leveraging Average Joe American.  The physician with his pen has been a willing participant perhaps unknowingly to play this game of optimizing profit and not quality for Americans.

A system without health plans has shown not to work in the 1940's since physicians seemed to over value their services with employers who could not afford their charges.  A single payer especially if supported or regulated by the federal government would surely fail given our history and expectations of Americans.  New models with cooperation and alignment of use of national resources (as was started with the true California HMO) will have to come forth to "save" this system which we have knowingly built and allowed many intermediators to assert themselves while the healers shun any facet of accountability or transparency especially around quality comparison.

Physicians should be the last to embrace the past--how foolish.  They are intelligent and leaders as a group (sterotypic but mostly correct)  and should work to not point fingers but find the real root causes and lead and not just defend.

Implications: The current RBRVS pre-payment system to hospitals currently rewards hospitals for those patients who suffer a hospital induced infection, injury, or other illness that elevates their acuity and ultimately payment from Medicare.  Only a payment for services system that pays for excellence and a lowering of the rate of harmful nosocomial events can focus money and expert attention to these issues. The new Medicare policy is an attempt at this change but lacks the recognition that adverse events will always occur at some lower level and will never reach zero.

Analysis: Hospitals in general are THE EXPERTS at clinical coding under the RBRVS system and will do well financially  no matter what tinkering of the system is taken to improve on the current rates of nosocomial infections and injuries.  Knowing that the incidence can never reach zero, the policy should reward those that have a documented improvement program and are showing statistics below the 2007 median.  Conversely, those above the 2007 median should have financial penalities levied.

Year over year improvement could be demonstrated by keeping the 2007 stats as baseline as the median continues to fall--assuming this is instituted. 

Behavior that is rewarded is likely to be demonstrated.  Current Medicare policy increases payments when one of these tragedies occurs and thus fixing the root cause gathers few supporters under today's Medicare payment system.  Levies would be removed when rates of incidence fall to or below the  2007 benchmark.

What ideal rate or benchmark is yet unknown.  However we have much room for improvement.

Implications: Retail clinics are health care centers of limited low risk services staffed most commonly by masters in primary care level nationally certificated Nurse Practioners who have provided primary care to millions of Americans for 40 years without issues of Quality by all evidence based studies. This is serving the uninsured who have difficulty finding a "medical home" and those Americans who wish a more accessable, convenient, lower cost per per episode  ) for minor low risk issues well within the training, education, and experience of licensed health care professionals.  This is only a "turf issue" and where money may flow cloaked in the cloths of "Quality."  Dr. Nosrati should study the model before commenting on Quality.

Analysis: Care by Advance Registered Nurse Practioners for primary care is not new or revolutionary.  Nurse practioner care centers sponsored by the federal government initially for the under served have been a tremendous success and all federal and academic Quality and Outcomes of care studies have shown equivalency with traditional primary care.  High quality of these Primary care or adult/pediatric certificated healers is unquestioned by evidence based studies.

Sarah Kershaw's article in the NY Times says cost is near equal to primary care--that is not true.  It is true that the transparent per episode of care is near a visit payment level for primary care, but billings above their professional bill cause the entire episode to be in nearly all geographical environments double the cost for a traditional primary care physician.

However, this model complements the primary care dilemma we have in America by not competing with the full scope of practice of nurse practioners that is regulated, but by seeing patients for single episodes when patient's (if they have one and 30% of the insured do not) primary care physicians are not available--after 5pm and weekends.  Continuity of care is maintained by copies of the care episode made available to the primary care physician.

In the days of HSA's and HRA's and any high deductible health plans, these clinics offer a more convenient, lower cost quality venue than an Emergency room which is 10X-15X's more costly--This will not set well with consumers with their primary care for minor illnesses and a understandable lack of their primary care physician availability (studies show Primary care physicians work nearly 60 hours per week already).

The reality is, we could double the number of dwindling primary care physicians we have now and not meet the needs and expectations of consumers for minor medical issues in a low cost, convenient, in their neighborhood venue.  This greatly simplifies the complexity that is often surrounded by taking time off from work or managing children while seeking minor care evaluation.

All health care providers can and will make mistakes.  Yes it will happen in this model setting no doubt.  If this model truly serves the best interests of American consumers, it will survive such expected incidents as has traditional medicine.

Affordable (especially for the uninsured), convenient, high quality, accessible care is enhanced to all Americans with this model--embrace it and integrate it proactively to complement the critical shortage of primary care physicians (that is predicted to only get worse).  Having primary care physicians manage higher acuity and complex patients to their level of education and experience only makes rational sense. 

Consumers must be our first priority and let us not act reflexively out of "turf issues."

Implications: The requirements of "market forces" or better free market enterprize as defined by Adam Smith has long been obliterated from American Health care. In the absence the of the  free market and daily attack on the Golden rule. one cannot rely on increased demand ultimately dictating more supply. American health care with its stakeholder consolidation, asymmetry of information re: value, and governmental intervention will always "sit on the side lines of free enterprize" and will not achieve a fair priced, efficient, quality system for all Americans. It is likely that Specialty Societies and Hospitals will be the subverting dark forces for a healthy Primary care segment of providers to meet the growing needs of Americans.  Consumer culture unknowingly aids and abets our chaotic, self-serving, inefficient, mediocre provision of health care. 

Analysis: The supply and demand principal seen in free enterprize systems has not and is not apparent in the American Health care system.  The phenomenon that has been present for decades is Supply creates Demand.  More doctors, more services rendered to a fixed population is the rule.  Why?  Because fundamental elements of a free enterprize system exposed in World of Nations by Adam Smith are missing in our "transaction of business."

There is almost a secrecy regarding our "system" as it is today to the populations we serve.  Health care stakeholders have done a very poor job of informing the populace on its basic structure, how it is entered, how the money flows, what is its evidence based value and many more secrets.  Thus the purchaser has an asymmetry of information from that of the seller (providers, hospital administrators, Pharma, etc) and thus value cannot be assessed.  This is a fundamental flaw for free enterprize to work--fair price for known services delivered.

Additionally "Trade Unions" exist in some segments and not others.  Smith felt that consolidation of providers in any segment inflated cost without appreciable value creation.  Our physician Specialty societies have been very successful in maintaining their preeminence in the RBRVS Medicare payment schedule that is shadowed by nearly every health plan in the commercial market.  Hospital consolidation to the chagrin of Peter Robert Starke has occurred to such a great level that unit price has tremendously increased for hospital services without a measurable improvement in value (efficiency, quality or any value measured). Our government allowed obvious antitrust violations with open eyes and hands stretched out to lobbyists.  These two sets of stakeholders are entrenched as is the AMA and its narrow perspective of health care to ensure free enterprize does not happen.  Thus Americans will not benefit from Demand creating a supply since they control most of the dollars spent in our "system."

Our "Father of Economics" also felt that there is an implied requirement of the Golden Rule in all transactions--in my opinion while  observing our system for 40 years is that this rule is the exception and contentiousness and narcissism is the rule

There is no solution on the horizon nor are the American people ready for radical change.  We as Americans apper to be satisfied to  pay twice as much per capita and be 27th to 41st. on population health as compared to other westernized/industrialized nations.

Implications: Health plans have merely followed the payment (reimbursement) profile created in the 1940's by the trade unions of hospitals and physicians who were dominated by specialists and special interests. Only primary care physicians have had a real drop in real income in the last 7 years while specialists enjoy income increases equal to or above real inflation.  This discourages physicians in specializing in the primary care specialities Many physicians in the 60's and 70's gave 20% of their patient care time free to our poverty segments, a plan that pays even at Medicaid levels for care for this segment has replaced this professional commitment and does pay for some fixed costs. The arrogance in our physician system towards being a primary care physician has equally played a major role in devaluing physicians who choose to practice in Pediatrics, Family Practice, and Internal Medicine.  This represents a major barrier for residents to seek these specialities.

Analysis: The dearth of practicing Primary (or Principle) care physicians is related to many root causes.  The two that have been most enduring is the historical underpayment for services (what you do for patients including thinking and organizing their care) as compared to interventional specialties that "do to patients" and are based on an ever increasing technological platform.  The "Blues" created this "system" in the 1940's from both physician (Blue Shield) and hospital (Blue Cross) trade unions.  Since Blue Shield was heavily controlled by specialists and doing "to" patients is easy to measure, the proposed payment system (called inappropriately reimbursement) was heavily weighted towards specialists.  Hospitals covet specialists , not primary care physicians.    Specialists still enjoy a 97 percentile position of all Americans and nearly in most states their income is 3X to 10X the average Primary care physician.  Hence, the allocation of dollars available within the physician payment system is highly slanted towards what is easily measured (procedures) and influence by specialists since 1943.  Both the lack of action of specialists to right this wrong and also with the consolidation of hospitals resulting in a bigger piece of the pie, there is no money to allocate towards the primary care plight.

Additionally, there is unspoken arrogance from within the physician specialty community towards the primary care specialities.  Specialists often feel superior (and like it) because of their financial earning power (million dollar incomes in Florida for dermatologists are common).  There is a cast system that remains in the shadow.  Specialists often feel also intellectually superior and behind closed doors reflect this attitude.  All of this being true, why would a caring, intellectual person seek to become a primary care physician?  The answer is with much commitment and tolerance of the injustices of both the historical system and our specialty peers. Both of these two factors are exhausting their commitment and their fiduiciary responsibility to their familities of those who wish out of interest (not lack of intellect)  to become primary care physicians.

Healthplans merely allocated whatever dollars is given to it in the manner it has for decades to the detriment of primary care.  The silence of the Specialty societies is deafening.  Greed trumps principles of many.

A more realistic re-allocation of dollars within the physician community is what is needed, but alas is politically unthinkable.  Primary care do not understand globally that hospitals and specialists are primarily responsible for their financial plight and are fighting the wrong fight.  The HMO model provided a platform for "PCPs" to elevate their standing both in the eyes of their specialist peers and financially--but fell to the siren song of many stakeholders with pockets of money who invested in the status quo.

If an appropriate  re-allocation of dollars occured and "PCPs" got paid in accordance with their value,  then poverty plans as seen in Massachuetts could be embraced by "PCPs" as did their fathers/mothers who gladly gave care for free.

Implications: Consumers and physicians alike must become more cost conscious to attend to our medical inflation rate that is mostly technologically driven--both immaging diagnostics and pharmaceuticals. Physicians will always play the role as the patient's medical fiduciary to inform the patient on relevant and appropriate diagnostics and tools. Consumers must with the cooperation and engagement of their physicians eliminate non evidence based diagnostics and therapeutics in our system Health plans should seek to encourage consumer engagement through benefit design yet not eliminate appropriate care choices

Analysis: Both Dr. Dort and Mr. Goldstein are correct.  Their viewpoints are not mutually exclusive.  Our nation's healthcare cost is mostly driven by the innapropriate diffusion of expensive technology (both diagnostics and pharmacy) to eargerly awaiting Americans.  Americans in past and many today relate quality of medicine to the amount of testing done and the expensive drugs dispensed.  Education can only help physicians withhold innapropriate diagnostics and designer drugs when they have sound medical basis.

Compared to other counteries our populations see physicians and use prescriptive drugs on a par with more efficient and cost effective Westernized systems.  It is the diffusion of costly technology to population segments that are medically inappropriate that is remarkably different than those counteries who experience 50% per capita of our 3 Trillion dollar system.

There is much space in high deductible and consumer designed health products to deliver quality care--innapropriate expenditures must be eliminated.

Implications:   Dr. Parish has a rather shortsighted view of the role of third party administrators in general and appears not to appreciate their intended role in our "system." Both Cost and Quality have and are suffering from the "stepping back" and demonization of HMOs by stakeholders who do not relect on their professional fiduaciary role to Americans. Physicians need to realize that the AMA (allocation of dollars under RBRVS) and lack of responsiveness of government and the abandonment of the true HMO model has led to super inflation and subsequent frustration for providers--especially those in primary care.

Analysis:  I believe Dr. Parish needs to view the global drivers why HMOs came into existance in great numbers in 1983--They offered a solution to run away medical inflation mainly caused by physician ordering habits with goal to integrate the financiang of medical care with the care givers.

They have and still do have a major influence on Quality focus that did not exist before under physicians leadership.

The intent was to have the physicians yp determine issues around medical appropriateness using evidence based knowledge and to restrain the wide variation of cost for the same diagnosis (Winnberg and Vanderbilt and many studies).  To not allow consolidation of hospitals and healthplans with the help of Peter (Robert) Starke so as to liven the free market and competitive pricing--now hospital consolidation and continued CON in many markets leads to stratospheric hospital and technology unit costs.

Exactly upon moving away from HMOs, major inflation occurred to the detriment of Americans.  

Implications: In response respectfully to Dr. Rieser, MD and the original article, the emergence of "Retail Convenience Clinics" was encouraged by the failure of Primary Care for a growing American Population.

If one does their homework, it is clear that no one can question the quality of ARNPs who have provided primary care for 50+ years in America with academic studies showing equivalency to family physicians

All surveys to date, show impulse has no relevancy--it is timely access to care for common disorders well within the scope of a masters level nationally certified Nurse Practitioner.

This is not another supplemental health care cost, it has been shown to be highly cost effective and decisions are evidence based and monitored unlike Family Physicians in practice today.

It is a superior method to manage minor common illnesses than those who have a more robust and deep understanding of complicated medicine--7 years to become a family physician to treat a sore throat seems practicing way beneath their training and scope.

Analysis: Although I cannot comment on Dr. Rieser's engagement in the research of the emergence of "retail convenience clinics," it is clear to me that bias is lurking.

To bring up the idea of convenience in a pejorative setting and question the quality of ARNPs practicing within narrow scope of common family disorders is ignoring the preceding 50+ years of their unquestioned high quality service to this nation. Primary care nurse centers providing exclusive NP care without on-site physicians in rural America and in our Academic centers have shown their value--in cost and Quality. Both the government who has been the principle sponsor of nurse primary care providers and academic medicine have published ubiquitously about their outcomes and quality--guess what? No difference than a board certified family physician which included the full scope of family practice. Raising the Quality issue suggests either being uninformed about the training or the care setting or perhaps is a stalking horse for the real issue of Turf and Money.

I see as a family physician a complete failure of this specialty (Family Physicians) to meet the needs of today's and tomorrow’s population. I believe the board certified specialists should continue to be the primary care physicians dealing with difficult and holistic issues and since their numbers are declining (many historical reasons) and allow episodic minor care when the primary care physician is not either timely or available to be seen by one of these "Access Clinics."

Pure convenience has a minor component in the consumer decision making today but should not be deemphasized in this ever complex world for all Americans. The primary component is timely access, which only few a enlightened family physicians have responded to this consumer issue.

The growing deficiency of primary care, their lack of consumer focus, and their unavailability after 5pm and weekends demands that such services be created to meet consumer needs in a documented quality cost efficient manner--as opposed to going to a very expensive Emergency room or some Urgent Care when most insured and cash clients are now experiencing the entire total cash cost.

I could see the time when family physicians care about cost and would refer after 5 pm and weekends to these clinics and have the patient return to them with documentation of the issue and treatment. 30% of insured patients entering these clinics do not have a primary care physician. Family physicians and the clinics should be advocates, since financial/turf issues when looked at critically have no merit. Excellent quality is a given.