Health Affairs

Most experts agree that primary care needs to be re-invented. There are a lot of promising ingredients of practice redesign: better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing. Linda Green’s intriguing article in the January Health Affairs simulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage.

Even if we make much more effective use of clinical time and energy, however, Green’s formula isn’t going to get us far enough fast enough. The baby boom generation of physicians is fast nearing its “sell by” date. In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older. One in six general internists left their practices in mid-career. Many more hardworking clinicians delayed retirement due to the 2008 financial collapse.

Few manpower specialists have noted the cohort effect likely to manifest itself shortly. A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years. We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks. During this same period, we’ll be adding 3 million new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform. “Train wreck” is the right descriptor of the emerging primary care supply situation.

A Health Affairs Web First study released yesterday finds that five European countries have adopted aspects of patient-centered medical homes, a US model for comprehensive care. However, additional efforts are needed to fully implement this concept outside the United States. The data was gathered through a survey, questioning 6,428 patients who had one of eight common chronic illnesses. Also, 152 primary care providers across five European countries (Belgium, Denmark, Germany, the Netherlands, and England) were queried.

Marjan Faber of Radboud University in the Netherlands and coauthors found that each country offered high quality of care for its patients — between 87 and 98 percent of patients in Germany, Belgium, the Netherlands, and Denmark had a single primary care physician. The rate was lower in England — 74 percent — where more primary care tasks are typically delegated to nurses. Although the survey demonstrated agreement in most areas between patients and physicians in evaluating their primary care experience, significant differences did emerge in the Belgian, Dutch, and English samples on frequency of illness self-management instructions

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal has launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

In the first installment of this series below, patient advocate and cancer survivor Jessie Gruman answers questions submitted to her last week. (You can also read Jessie’s Health Affairs Narrative Matters essay and watch her presentation at the briefing for the February issue.) In addition, watch for a Health Affairs Facebook post today soliciting your questions for PCORI’s Rachael Fleurence, who will answer her favorite questions next Wednesday here on HA Blog.

Q1: “Jessie, your Engagement Behavior Framework demands a lot of patients as well as caregivers. In my research, I have heard so many people express worry and even fear of retribution if they try, especially in their interactions with clinicians, to ask tough questions and volunteer conflicting opinions. My question for you is this: What is the most crucial support that patients and caregivers have to get from their clinicians to support their engagement with their health care?” – Shoshanna Sofaer, Professor of Health Care Policy, School of Public Affairs, Baruch College

Recently, the Institute of Medicine and the National Research Council reported that Americans die earlier and live in poorer health than people in other industrialized countries. This is the latest evidence of the urgent need for health reform, as embodied in the Affordable Care Act.

The ACA’s recent enactment has triggered a series of new and concerted efforts to address some of the many challenges relating to health care cost, access and quality that the U.S. faces today. One of the most important challenges involves the number and mix of health providers that will be needed to meet the demand resulting from changing demographics, more expansive availability of health insurance, and a new emphasis on wellness and preventive care.

In this post, I discuss some of the factors that bear on this challenge, and I suggest some policy steps that we could take to help develop the workforce needed for the post-health reform world.

The US spends far more per person on health care than any other nation. But a growing body of research demonstrates that Americans – rich or poor, minority or not – suffer from a widening “health disadvantage” when compared to citizens of other high-income countries. On January 9, the Institute of Medicine (IOM) and the National Research Council released “U.S. in International Context: Shorter Lives, Poorer Health.” Commissioned by the National Institutes of Health, a panel chaired by Professor Steven H. Woolf at Virginia Commonwealth University painstakingly investigated whether Americans of all ages were affected by a growing health gap previously observed between older Americans and their foreign counterparts.

The panel examined several decades of data from the US and 16 comparable high-income countries, most of which are European. What they found is, or should be, alarming, even for seasoned health advocates and policymakers. The report’s authors sound the alarm at the outset: “We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth.”

What does this report mean for clinicians and health systems, especially at a time when doctors, nurses and other health care professionals are adjusting to a shifting landscape of structural reforms? Is this a clarion call for clinicians, educators and policymakers to engage in realigning the way we deliver care? Or will this news drive clinicians to sound a retreat from the front lines of population health-oriented system change?

On January 11, two days after the release of the IOM report, I talked with one of the IOM panelists behind the report, Paula Braveman MD MPH, Professor of Family and Community Medicine and Director, Center on Social Disparities in Health at UCSF. I spoke with her on behalf of HealthBegins, a social enterprise and online community of clinicians and others committed to improving health care and the social determinants of health. We discussed the report and what it means for America’s clinicians.

You are invited to join us on Wednesday, February 6, when Health Affairs will hold a briefing to discuss its February 2013 issue, “New Era Of Patient Engagement.”

It is widely agreed that meeting the goals of the famed Triple Aim – better health, better health care and lower health care costs – will compel more and different responses from consumers and patients in a number of areas, and far more effort on the part of providers to share decision making and take other steps to more fully engage patients in their care. In this thematic issue of Health Affairs, authors from across the health care and policy spectrum explore the evidence on patient engagement; the challenges in changing the behavior of patients and providers; and the opportunities that exist to enhance patient engagement and activation in a transformed health care system.

Please join us for a briefing at the W Hotel Washington on February 6, 8:00 a.m. – 2:30 p.m., as we unveil the issue. The thematic volume and briefing received funding support from The Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, PCORI, and the California HealthCare Foundation.

Follow live Tweets from the event @HA_Events, and join in the conversation with the hashtag #HA_Patients.

In health care quality improvement circles, the story of England’s East Lancashire has taken on almost mythical status: working with county and borough councils, local hospital organizations, and medical leaders in primary and secondary care, an executive of the National Health System (NHS) managed to close a substantial number of hospital beds — all the... Read the rest of this entry »

You are invited to join us on Wednesday, February 6, when Health Affairs will hold a briefing to discuss its February 2013 issue, “New Era Of Patient Engagement.”

It is widely agreed that meeting the goals of the famed Triple Aim – better health, better health care and lower health care costs – will compel more and different responses from consumers and patients in a number of areas, and far more effort on the part of providers to share decision making and take other steps to more fully engage patients in their care. In this thematic issue of Health Affairs, authors from across the health care and policy spectrum explore the evidence on patient engagement; the challenges in changing the behavior of patients and providers; and the opportunities that exist to enhance patient engagement and activation in a transformed health care system.

Please join us for a briefing at the W Hotel Washington on February 6, 8:00 a.m. – 2:30 p.m., as we unveil the issue. The thematic volume and briefing received funding support from The Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, PCORI, and the California HealthCare Foundation.

WHEN:

Wednesday, February 6, 201
8:00 a.m. – 2:30 p.m.

WHERE:

W Hotel Washington
515 15th Street NW (Metro Center)
Washington, DC

REGISTER NOW

GET MORE INFORMATION

Follow live Tweets from the event @HA_Events, and join in the conversation with the hashtag #HA_Patients.

For the previous Health Wonk Review, Brad Wright chose a Baby New Year theme. However, there were some problems with the new beginning represented by the turnover from 2012 to 2103. For example, with the New Years fiscal cliff deal, one might have hoped that we would leave our budget crisis behind for a while and start with a fresh fiscal slate. But of course, that did not happen. Not only did we not escape our budget crisis, it multiplied into three crises: the debt ceiling, the still looming sequester, and the coming expiration of government funding –“The Trouble With Trillions,” one might say.

So I decided to give us a fresh chance at a new start by choosing an “Inauguration” theme for this Wonk Review, referring both to Monday’s celebration of a new presidential term but also to the word’s broader meaning of a formal beginning. And in the spirit of looking forward, we’ll lead with a post from Health Wonk Review cofounder Joe Paduda laying out his health policy predictions for the coming year. At Managed Care Matters, Joe offers five predictions, including these: most states will end up expanding Medicaid, and there will be a lot more mergers and acquisitions at the highest levels, among providers, health care systems, and payers.

As US health care continues down the path of delivery system transformation, January’s Health Affairs explores areas of opportunities and challenges to achieving better health and better care at lower costs. Other articles focus on a range of topics of interest, including the length of time physicians spend with active and unresolved malpractice claims against them.

Seth Seabury at the RAND Corporation and coauthors report that the average physician spends almost 11 percent of his or her career with an open and unresolved medical claim. A major contributor is the length of the process of adjudicating such claims: The typical medical malpractice claim isn’t filed until almost two years after the incident occurred, and it isn’t resolved until 43 months post incident. When dealing with open claims, physicians spend up to 70 percent of that time with claims that never result in a payment.

Among the various distressing factors involved in this type of adjudication, patients and physicians alike may be more troubled by the length of time of the process than the potential damages, the authors say. They recommend exploring policy solutions that can decrease the time to resolution, including tort reform and alternative dispute management tools that can expedite the process and help limit meritless claims.

The first study to use a nationally representative sample to describe after-hours care in the US, released today as a Web First by Health Affairs, demonstrates that emergency room usage is significantly lower when patients have access to after-hours services with their primary care provider.

According to the study by Ann O’Malley of the Center for Studying Health System Change, 30.4 percent of patients with after-hours access to their primary care providers reported emergency room use, compared to 37.7 percent of those lacking after-hours access. Another key finding: patients with access to after-hours care reported a significantly lower rate of unmet medical need: 6.1 percent versus 13.7 percent of those lacking after-hours access.

Editor’s note: The post below was written in response to Nurse Practitioners And Primary Care, a Health Policy Brief recently published by Health Affairs and the Robert Wood Johnson Foundation.

The American Academy of Family Physicians welcomes discussions about primary care as foundational to a true health care system. Approaches must be multi-faceted and team-based at every level. Changes must be made in education, training, health care access and provision, and payment. Solutions focusing mainly on cutting costs or shortcutting training are short-sighted.

Physicians and advanced practice nurses are not interchangeable. Each has roles defined by training and experience. The best quality patient care depends on these critical members functioning efficiently in teams.

Every American needs and deserves a personal physician and nurse. The educational and training differences are profound: advanced practice nurses follow different paths to their degree, completing 2,300 – 5,350 hours of education and clinical training during five to seven years, compared to family physicians’ standardized path of 21,700 hours and 11 years. Family physicians’ additional training brings breadth and depth to the diagnosis and treatment of all health problems, as well as hands-on knowledge of other disciplines, improving coordination of care within systems.

Following her husband’s stroke, it fell to Beth Ann Swan, a registered nurse and nursing school dean, to coordinate her recovering husband’s care and manage his transitions among several hospitals and home. Swan writes about her experience in the Narrative Matters section of the November Health Affairs.

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines policy proposals that would allow nurse practitioners to practice to their full potential—and the extent to which the medical profession, policy makers, and patients are supportive of that effort.

Currently, about 54.5 million Americans live in areas with shortages of primary health professionals, a situation that may grow worse as the Affordable Care Act increases access to insurance coverage and the population ages and chronic illness increases in prevalence.

In nineteen US jurisdictions (eighteen states plus the District of Columbia), nurse practitioners—registered nurses who have also completed a postgraduate nursing degree—are allowed to diagnose and treat patients and prescribe medications without a physician’s involvement. These practitioners and their capabilities help to fill the void left by the current shortage in some parts of the country of primary care physicians. There is also a growing body of research showing that patients value access to consistent care from one particular provider, whether a nurse or a physician.

It has been 22 years since David M. Eddy—the heart surgeon turned mathematician and health care economist—put the term “evidence-based” into play with a series of articles on practice guidelines for the Journal of the American Medical Association.

But as we have learned in the years since, one person’s evidence-based guideline is another person’s cookbook. For some, a sound body of evidence is fundamental to sound medical decisions. After all, as Jack Wennberg and Dartmouth researchers have pointed out for decades, if the practice of medicine varies so widely from place to place in this country, everyone can’t be right. Yet for others, evidence connotes not just “cookie-cutter medicine,” it is only one step shy of a trip to the death panel. This heavy baggage influences the way evidence-based medicine is discussed from the doctor’s office to the clinic to Capitol Hill.

With this in mind, we and others working under the aegis of the Institute of Medicine set out to find an evidence-based approach to communicate with the public about evidence. The full fruits of our work can be seen in this new IOM discussion paper, “Communicating with Patients on Health Care Evidence.” What we found based on both focus groups and a national poll is that, in the context of shared decision-making, the public does not view evidence-based medicine as an indicator of cookbook medicine. Far from it. Patients actually put significant emphasis on the latest medical evidence.

In July, 2012, the US economy produced roughly the same volume of goods and services as it did five years earlier with five million fewer workers.  Yet, during the first four years of the recession (May 2007 to May 2011), the US health system, despite slowing or declining utilization, added 1.149 million workers.  Key sectors,... Read the rest of this entry »

Editor’s note: For more on ways that the traditional primary care model could be rethought, see the Health Affairs May 2010 thematic issue “Reinventing Primary Care.” Although primary care is regarded as the backbone of the healthcare system, there are serious concerns that we will not have enough primary care physicians to meet the needs... Read the rest of this entry »

In this post, we put forth a social compact intended to define the reciprocal obligations of health care professionals, patients and society that are necessary to achieve truly patient-centered, team-based care.  The compact and recommendations were developed from a working group formed at the March 2010 invitational conference co-sponsored by the American Board of Internal... Read the rest of this entry »

A belated tip of the hat to two Health Affairs articles included in the Robert Wood Johnson Foundation’s five most influential research articles by RWJF grantees in 2011: Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths, by Glenn Mays and Sharla Smith; and Nurses’ Widespread Job Dissatisfaction, Burnout, And Frustration With... Read the rest of this entry »

David Colby, vice president of Research and Evaluation at the Robert Wood Johnson Foundation (RWJF), has announced the lineup for RWJF’s Most Influential Research Articles of 2011. As it has done in past years, the foundation has listed 20 RWJF-funded articles across the broad spectrum of its program areas. The articles were selected based on... Read the rest of this entry »