Health Affairs

If primary care is the foundation of the evolving health care system in this country, and if access to primary care for all is the goal, then nurse practitioners will be increasingly crucial to achieving these aims. Let’s face it, in our current system, there just aren’t enough primary care providers to meet the nation’s need while containing costs and focusing on quality outcomes. With an estimated 30 million more people who will be covered and require access to full primary care based on the Patient Protection Affordable Care Act (ACA) numbers, we will need additional providers functioning to their fullest preparation.

2013 National Resident Matching Program Data

The 2013 National Resident Matching Program (NRMP) released in March is not good news for primary care. Although matching rates were up overall, the primary care numbers are still very low given the national need. According to the American Academy of Family Physicians (AAFP, 2013), only an additional 92 U.S. graduate medical students were matched to primary care specialties compared to a year ago. That translates to 39 more family medicine resident positions filled, 14 more internal medicine positions, 3 more pediatric and 36 pediatric/internal medicine positions filled, compared to 2012. The bottom line is 1,916 U.S. medical school grads were matched to primary care residency programs, with a total of 3,715 primary care matches when international graduates are included (AAFP,2013; NRMP, 2013) .

Primary Care Nurse Practitioner 2012 Graduation Rates

At the same time, the 2012 nurse practitioner (NP) graduation rates announced recently by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties (AACN/NONPF 2013) showed a continued increase in primary care. Primary care NP graduates include those prepared as pediatric, family, adult, gerontological, adult/gerontological, and women’s health NPs. They numbered 11,764 in 2012 compared to 9,708 in 2011, an increase of 18.6 percent or 2,228 NPs.

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits.

“Medical home” has become a term of art within the current wave of health reform. It’s in the medical literature, on the internet and embedded in the Patient Protection and Affordable Care Act of 2010.

There is much debate over what “medical home” means and whether or not it works. The Patient Centered Primary Care Collaborative published an overwhelmingly positive compilation of evidence last year supporting the concept. At almost the same time, the Agency for Healthcare Research and Quality released a review of the literature that was much less positive, suggesting that the impact of practice transformation to the medical home is much less certain. So, in the end, what are we to believe when the messages are so mixed?

Given how the concept has evolved over time, it is not surprising that we are confused. Historically, the term “Medical Home” comes from the American Academy of Pediatrics, which, in 1967, coined the term to describe a repository of records that would offset the dispersal of records between pediatric offices, health departments and hospitals. Over the next 30 years, the concept developed into one of relationship between children, families and pediatricians. Pediatric medical homes were primary care pediatric practices, partnering with families to serve children and youth with special health care needs, and emphasizing the need for care coordination within the many systems that serve the needs of children.

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 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.

Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.

Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?

Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

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

No one expects a scalpel to perform surgery by itself. Similarly, no one should be surprised by the conclusion of a widely cited article in the January 2013 edition of Health Affairs (“What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology”) about the unrealized promise of health IT to lower costs and improve care.

Electronic health records (EHRs) are a tool, not a solution. But our experience at the New York City Department of Health and Mental Hygiene with the Primary Care Information Project (PCIP) demonstrates that with the proper support, EHRs can be a powerful tool for improving clinical care and managing population health. Now we are about to turn another corner on our journey, to see if we can use the data we collect from New York City EHRs to paint an accurate picture of the population at large.

Since 2005, PCIP has helped more than 3,200 providers implement EHRs, and we currently provide assistance to more than 7,700 providers in New York City. Our staff members help with everything from choosing an EHR to billing, coding, and documenting workflows, to assisting providers with navigating the federal EHR incentive program, to reviewing their clinical quality measures and helping them with numerous quality improvement (QI) activities. We are the home of New York City’s Regional Extension Center (REC), one of 62 such centers nationwide that are funded to support primary care providers through the transition to an EHR and help them achieve the federal Meaningful Use standards.

Use rates for inpatient and certain hospital outpatient services are declining in many areas of the country, reflecting fundamental change brought by the new business model. Importantly, as evidenced by trends in Chicago and Minnesota, there also appears to be a correlation between the level and pace of a market’s shift toward value-based care and the level and pace of utilization decline.

We believe this trend is here to stay and that it has significant strategic and financial implications for health care providers. Specifically, providers that embrace the migration to value-based care will need to work aggressively to eliminate unnecessary and/or ineffective activities in order to thrive under risk contracts. This requires a fundamental change in mindset, culture, and attitude about volume and activity. It also requires providers to rethink the organization and structure of their delivery networks to avoid supporting unnecessary capacity, and to drive patients into the lowest-possible cost setting in which quality care can be delivered.

The goal will be to manage a population’s health across the care continuum, keeping patients healthy through preventive and primary care services, and out of acute care facilities whenever possible. The right place to provide the right care at the right time with the right quality, cost, and access increasingly will be a setting other than a hospital. By eliminating waste and redirecting patients to ambulatory centers, physician offices, clinics, and online and/or telephonic interactions, less work will be done in the hospital. To reduce well-documented overutilization, tests and services deemed inappropriate or unnecessary based on medical evidence will be eliminated in all settings. (See Note 1) Acute care will be one, and only one, component of the population-centric health management services continuum.

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 loud cries warning that rising health care costs are going to destroy the nation’s economy have been shouted so often that the will to move firmly in any one direction has almost halted. We’ve all heard them: health care costs are unsustainable, excessive spending is fueling our nation’s debt, and despite high costs, health outcomes are behind much of the world and aren’t improving.

The way doctors are paid is one of the most significant drivers of escalating health care costs. The National Commission on Physician Payment Reform, which we chair, was formed by the Society of General Internal Medicine to provide the public and private sector with recommendations for transforming the way we pay doctors in order to rein in spending and improve quality.

On Monday, after a year of intensive study, the 14-member Commission issued a blueprint for exactly how to move the nation toward a physician payment system that will yield better results for payers and patients.

Health literacy is the essential backbone of informed patient engagement, said Howard Koh, Assistant Secretary for Health at the Department of Health and Human Services, at a February 6 Health Affairs briefing. The event was held to unveil the journal’s February issue, “New Era Of Patient Engagement.”

Health literacy is particularly important now as tens of millions of Americans are faced with new choices about coverage and treatment under the Affordable Care Act, said Koh, a physician who also has a master’s degree in public health. Yet only about 12 percent of Americans have the skills necessary to navigate the health care system, leaving the vast majority of Americans at greater risk for unnecessary hospital admissions and readmissions, medication errors, and failure to manage their health conditions effectively.

Physicians and other health care providers often assume that patients understand what they are told unless they indicate otherwise, Koh noted. But the health system has gotten so complex that it challenges the comprehension even of sophisticated patients. The answer is to change the paradigm from a focus on correcting individual deficits in understanding to a systems approach: “The assumption is that everybody is at risk for not understanding, and that we should institute what we call ‘health literacy universal precautions.’”

It is as natural for doctors, hospitals, health plans and others to aggressively affirm their “patient-centeredness” as it is for politicians to loudly proclaim their fealty to the hard-working American middle class. Like the politicians, the health care professionals no doubt believe every word they say.

The most accurate measure of “patient-centered” care, however, lies not in intentions but implementation. Ask one simple question ­– what effect does this policy have on patients’ ability to control their own lives? ­­­– and you start to separate the revolutionary from the repackaged. “A reform is a correction of abuses,” the 19^th-century British Parliament member Edward Bulwer-Lytton noted. “A revolution is a transfer of power.”

With that in mind, which purportedly patient-centric policy proposals portend a true power shift, and which are flying a false flag?

Falling Short Of Shifting Power

The two most prominent examples of initiatives whose names suggest power sharing but whose reality is quite different are so-called “consumer-driven health plans” (CDHP) and the “patient-centered medical home” (PCMH). Both may be worthy policies on their merits, but their names are public relations spin designed to put a more attractive public face on “defined contribution health insurance” and “increased primary-care reimbursement.

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.

States are in the midst of deciding whether and how to expand their Medicaid programs to nonelderly individuals with income below 133 percent of Federal Poverty Level (FPL), as permitted under the Affordable Care Act (ACA). The group that perhaps stands to benefit the most from Medicaid expansion is women of childbearing age and their future children.

One of the ACA’s main goals was to address the upstream determinants of health, shifting the focus of the health care system “sick care” to “well care.” However, the promise of preventive care will not be realized if women of childbearing age are denied access to health insurance coverage. Medicaid expansion has the potential to drive meaningful improvements in maternal and child health by promoting health at every stage of life, including before and between pregnancies.

Today, Medicaid coverage is unavailable in most states to childless women who are not pregnant.

As a result, low-income women may have little or no source of regular health care before or between pregnancies, or after their childbearing is concluded. These women often lack a medical home and go without both regular preventive care and acute care for illness or injury. This lack of preconception and interconception care can have a significant impact on women’s health, and on the health of future pregnancies and children. The ACA has the potential to transform this dynamic.

Currently, most hospitals and health systems focus on patient engagement because of their mission to deliver patient-centric care. These efforts are pursued despite the neutral or even negative economic consequences to these organizations, which operate within the fragmented, fee-for-service payment system. For example, care coordination attendant to patient engagement efforts will, at times, reduce demand for services and, thereby, reduce fee-for-service payments to providers.

As public and private sector health care purchasers shift payment models towards value and as demographic changes result in more chronically ill patients entering the health care system, patient engagement efforts will become increasingly important to the financial sustainability and clinical success of these hospitals and health systems.

New patient engagement efforts shift focus from the inpatient core of hospitals to ambulatory care settings and to the integration of care into the homes and communities of patients. To succeed at these efforts, organizations must build longitudinal partnerships with patients to drive ongoing management of chronic conditions and utilization of preventive care services to drive long-term quality and cost outcomes.

The dramatic expansions in health insurance coverage included in the Patient Protection and Affordable Care Act (ACA) will give millions of low-income Americans greater choice in where and how they receive their health care. Until now, most of the discussion around our changing healthcare landscape has focused on the goals of payers and providers, rather than the needs and desires of patients. Although policymakers have emphasized the importance — and necessity — of engaging patients differently under reform, there have been few data to inform these discussions.

Against this backdrop, Blue Shield of California Foundation commissioned a series of representative, random-sample surveys of Californians aged 19 to 64 with household incomes less than 200 percent of the federal poverty level. The ultimate goal of these surveys is to bring the voices of low-income Californians into the conversation about how best to deliver care in the ACA-shaped future in order to inform policy choices and help providers prepare for a reformed healthcare system.

Resetting Expectations

The first report, On the Cusp of Change: The Healthcare Preferences of Low-Income Californians, based on a spring 2011 survey, revealed that fewer than half of low-income residents feel satisfied with their current health care and six in ten report being interested in switching to a new facility if they had the insurance to cover it. With full implementation of the ACA rapidly approaching in 2014, providers serving low-income Californians will have to change the way that they practice in order to retain their current patients, and attract those who are newly eligible for coverage.

On January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.

Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.

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 »

Arthur Kellermann’s post on the tragic shootings at Sandy Hook Elementary School was the most-read Health Affairs Blog post for December. Kellermann’s post was followed by posts discussing primary care, stakeholder engagement, and bundled payments.

The full list appears below.

Will pay for performance in health care backfire? That was the question addressed through the lens of behavioral economics by Steffie Woolhandler, Dan Ariely, and David Himmelstein in the most-read Health Affairs Blog post for 2012. Next on the most-read list were two posts, one by Diane Archer and the other by Archer and Theodore Marmor, contrasting Medicare and private insurance. They were followed by Rushika Fernandopulle’s rethink of primary care and Ken Kaufman’s post suggesting that the recent slowing in health care cost growth reflects more than just temporary effects from the economic slowdown.

Many thanks to our readers and authors for making 2012 a good year for Health Affairs Blog. We had 369 posts and over 50 million pageviews, more than a 60 percent increase from 2011. Since we had many good posts that were closely grouped in the readership numbers, we’ve expanded this year’s most-read list to a “top 15″ rather than a “top 10.” The full 2012 list is below.

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.