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How Community Health Workers Can Reinvent Health Care Delivery In The US


January 16th, 2015

As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.

This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large.

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How Policy Makers In Emerging Health Systems Can Advance Innovative Care For The Chronically Ill


January 15th, 2015

Editor’s note: This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

Discussions of innovation in health care often focus on new technologies, big data, and refined population health strategies within the context of mature Western health care systems. But innovation is just as important, with perhaps greater impact, in evolving systems where more foundational opportunities exist to deliver affordable, quality care to the most expensive and challenging patients: those with chronic illnesses. In that context, public policy and regulation can spur innovation.

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Graduate Medical Education: The Need For New Leadership In Governance And Financing


January 14th, 2015

With the creation of the Medicare program in 1965, a funding stream was established to support the training of medical residents who provided care for Medicare beneficiaries. In subsequent years, Medicare has maintained these payments to teaching hospitals and remains the largest payer for Graduate Medical Education (GME), with expenditures totaling about $10 billion annually. This represents two-thirds of Federal GME support, with another $4 billion per year provided to hospitals through State Medicaid GME support.

This expenditure was a major motivation for the Senate Finance Committee to request the Institute of Medicine (IOM) to issue a report entitled “Graduate Medical Education That Meets the Nation’s Health Needs.”  The Report proposed major reforms to create a GME system with greater transparency, accountability and strategic direction, in order to increase its contribution to achieving the nation’s health goals. Prior to publication of this long awaited report on July 29, 2014, GME financing policies received substantial attention in the last two sessions of Congress, with a particular focus on increasing the number of federally funded GME positions. The House and Senate committees with GME jurisdiction produced multiple legislative initiatives.

However, there was considerable opposition from primary care stakeholders to some of the proposed changes because of inadequate emphasis on ambulatory training. Possible redistribution of Medicare GME funding was also of concern to many. This seemed to dissuade Congress from passing reform of GME policies. Nevertheless, 1,500 new GME positions were authorized in the recent Veterans Health Administration legislation.

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Transforming Rural Health Care: High-Quality, Sustainable Access To Specialty Care


December 5th, 2014

Editor’s note: This post is also authored by Kate Samuels, a project manager at Brookings. It is informed by a case study, the fourth  in a series made possible through the Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership in health care delivery and financing reform. The case study will be presented on Monday, December 8 using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers.

Health care for patients in rural communities across the United States remains a unique challenge.  Despite many programs aimed at improving access to physicians and hospitals, access to health care providers remains limited.  While 19.3 percent of Americans live in a rural area, only about 10 percent of physicians practice in rural areas.  Similarly, 65 percent of all Health Professional Shortage Areas are in rural areas.  Rural residents often face long travel distances to see a specialist after what can be months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC).  The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

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Dear Governor-Elect: Some Health Policy Counsel


November 18th, 2014

Congratulations on your election on November 3. It is a mandate for your vision and leadership.  Now, like the proverbial dog who has caught the meat truck — where to begin with this business of governing?

As you contemplate the work in front of you, I would like to offer some (unsolicited) advice about a possible state health policy agenda, borne from my own work and observing states across the country. The recommendations are non-ideological and substance-neutral.  You will look hard to find a reference to the Affordable Care Act (ACA) here. The challenges states face in health care are so large they defy simple solutions and require collaboration across our widening ideological divide; energy spent attacking the ACA is energy diverted from these challenges.

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Resources Don’t Solve Design Flaws


October 21st, 2014

The first three sessions of a conference I recently attended tackled some complex and important questions: How do we extend health insurance to people such as migrant and informal workers who don’t fit neatly into mainstream coverage programs? As we increase our investment in primary care, how do we assure that the performance of the primary care system is at the highest possible level? What types of evidence should we use as we make decisions in a dynamic health care system with limited opportunities for “gold standard” randomized controlled trials?

These are excellent questions, and they were perfect topics for a cutting-edge conference discussing the challenges facing the U.S. health care system.

But this conference was not about the U.S. health care system. These were opening “satellite” sessions at the Third Global Symposium on Health Systems Research held in Cape Town, South Africa.

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Teaching Health Centers: An Attainable, Near-Term Pathway To Expand Graduate Medical Education


October 17th, 2014

Stakeholders in Graduate Medical Education (GME) and members of Congress eagerly anticipated the long delayed but recently released Institute of Medicine (IOM) GME report. While perceptively characterizing the defects in our GME system, recommendations of the report generated substantial controversy among participants at a recent GME forum hosted by Health Affairs. The IOM proposed limited and gradual changes in Medicare GME financing, but the lack of support for GME expansion was not well received by some.

At present there are multiple legislative GME proposals, but none has gained broad support among the various stakeholders. Congressional committees responsible for GME funding view this lack of consensus among GME stakeholders as a major obstacle.

We describe a near-term and attainable pathway to expand GME that could gain consensus among these stakeholders. This approach would sustain and expand Teaching Health Centers (THCs), a recent initiative that directly funds community-based GME sponsoring institutions to train residents in primary care specialties, dentistry and psychiatry. We further propose selectively expanding GME to meet primary care and other demonstrable specialty needs within communities, and building in evaluations to measure effectiveness of innovative training models.

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Engaging Patients: Interviews With Patients, Providers, And Communities Across The Country


September 25th, 2014

As the Affordable Care Act (ACA) reaches deeper into the daily lives of Americans, one impact is sure to hit home. The ACA encourages patients and providers to become more active partners in making the crucial strategic decisions over improving individual health. Three new videos, produced in partnership with Health Affairs and the Patient Centered Outcomes Research Institute (PCORI), show how people all over the United States are learning that involving patients – teaching them, soliciting their input, and communicating with family-members and other caregivers right from the start – can result in better, more efficient health care outcomes.

There is growing evidence that patients, once engaged, take better care of themselves. They’re more likely to monitor their own health, take their medicines, and communicate more thoroughly with their care providers. They have a better understanding of the treatment strategy. And they are more likely to participate in clinical studies or other research to find better, more efficient treatments.

I was privileged to report on and host these videos on the new era of patient engagement. I interviewed nearly two dozen people across the country – patients, doctors, researchers, care-providers, academics and community activists – all of whom have inspiring stories to tell about the benefits of focusing on patient centered outcomes. Time constraints meant that many of their important points landed on the cutting-room floor during the video editing process. It’s another privilege to be able to offer some of those additional insights in this blog.

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Revisiting Primary Care Workforce Data: A Future Without Barriers For Nurse Practitioners And Physicians


July 28th, 2014

With the full implementation of the Patient Protection and Affordable Care Act (ACA), there have been major concerns about the looming primary care provider shortage. The National Center for Health Workforce Analysis predicts shortages as high as 20,400 physicians by 2020, and increases in medical school graduates entering primary care residencies have been anemic.

Physician shortages can be addressed by the rapid growth of nurse practitioners (NPs), trained in primary care, along with the redesign of primary care to include teams that can be led by both physicians and NPs. But our nation’s primary care needs can only be met if states allow NPs to practice to the fullest extent of their training without unnecessary requirements for physician supervision.

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Shifting Motivations: Rethinking Primary Care Physician Incentives In Health IT Implementation


July 21st, 2014

Clinician adoption and implementation of health information technology (IT) has increased significantly since the passage of the HITECH Act in 2009. Dedicated efforts and large financial incentives have spurred innovation and motivated progress in many aspects of information technology, including information exchange and community-level health IT implementation. Yet poor usability of systems and overwhelming reporting burden still present barriers to optimal use of health IT.

Health IT capabilities — such as automated performance feedback; shared documentation with patients; population health tools; and clinical decision support, facilitating evidence-based health care — can potentially drastically improve quality of care, particularly in primary care practices. However, the current incentive and payment structures are not aligned with productive use and spread of health IT innovation. When many primary care physicians use electronic health records (EHRs), the problems they are now tasked to solve relate to billing and coding compliance and to achieving “meaningful use” through the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Programs; many clinicians and systems are not encountering or using EHRs as productive clinical tools.

Perhaps the focus of providers and health systems on meeting the technical and administrative requirements of “meaningful use” has obscured the creative opportunity for clinicians to explore how to use EHRs to improve care, and to see their own actions as part of the solution to effective implementation. Strategies that focus on creating space for discovering ways that IT can support effective health care — e.g., more flexible payment models with emphasis on population health outcomes — may be more successful than those that focus on health IT adoption.

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The Alternative Payment Methodology In Oregon Community Health Centers: Empowering New Ways Of Providing Care


July 21st, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.

The Alternative Payment Methodology (APM) demonstration project enables participating Oregon community health centers to receive a monthly payment based on the size and composition of their patient population. This payment replaces the model of earning revenue based on the number of individual patients seen, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

So what are the real changes physicians are seeing on the ground in clinics where APM is being implemented?

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A Health Reform Framework: Breaking Out Of The Medicaid Model


July 10th, 2014

Editor’s note: This post is coauthored by Joseph Antos and James Capretta.

A primary aim of the Patient Protection and Affordable Care Act (ACA) is to expand insurance coverage, especially among households with lower incomes. The Congressional Budget Office (CBO) projects that about one-third of the additional insurance coverage expected to occur because of the law will come from expansion of the existing, unreformed Medicaid program. The rest of the coverage expansion will come from enrolling millions of people into subsidized insurance offerings on the ACA exchanges — offerings that have strong similarities to Medicaid insurance.

Unfortunately, ample evidence demonstrates that this kind of insurance model leaves the poor and lower-income households with inadequate access to health care. The networks of physicians and hospitals willing to serve large numbers of Medicaid patients have been very constrained for many years, meaning access problems will only worsen when more people enroll and begin using the same overburdened networks of clinics and physician practices.

It does not have to be this way. It is possible to expand insurance coverage for the poor and lower-income households without reliance on the flawed Medicaid insurance model. Opponents of the ACA should embrace plans to replace the current law with reforms that would give the poor real choices among a variety of competing insurance offerings, including the same insurance plans that middle-class families enroll in today. Specifically, we propose a three-part plan that includes a flexible, uniform tax credit for all those who lack employer-based coverage; deregulation of Medicaid; and improved safety-net primary and preventive care.

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Call For Papers: Care Of Older Adults


June 27th, 2014

Health Affairs encourages submissions from authors on topics surrounding the care of older adults, including new models of care and the management of multiple chronic conditions among this population. We are interested in work that spans the full range of care settings, including primary care and specialty practices, hospitals, nursing homes and other long-term care settings.

In addition to exploring topics that are directly related to the provision of care, we also welcome papers on a broad array of related dimensions that affect care, access, and affordability, such as financing models, coverage, and size and composition of the workforce. We are grateful to The John A. Hartford Foundation for providing support for our ongoing coverage of these topics.

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Correcting The Blind Spot In Accountability: The Role Of Pharmacy Care


June 25th, 2014

Editor’s note: In addition to William Shrank, this post is also coauthored by Andrew Sussman, Patrick Gilligan, and Troyen Brennan.

The Centers for Medicare and Medicaid Services (CMS) recently issued a Request for Information (RFI) to solicit suggestions about how to improve the Accountable Care Organization (ACO) programs. CMS stated that they seek recommendations about how the ACO program might evolve to “encourage greater care integration and financial accountability.”

The RFI explicitly stated that they seek information about how to better integrate Part D expenditures into ACO cost calculations to make pharmaceuticals part of the approach to care delivery and health care transformation.

The deadline for comments about encouraging Part D integration in ACOs has now passed. But the issue extends beyond ACOs. In addition, bundled payments and patient-centered medical home programs target hospitals and primary care providers to promote higher quality and lower cost care. All these programs have largely excluded prescription drug costs in their calculus, and offer no direct incentives for Part D plans to participate in and improve care.

Nonetheless, retail pharmacies and Part D plans have developed a number of strategies to participate. As CMS and policymakers reconsider ACO regulations to stimulate greater integration of prescription drug use in delivery system reform, we thought it important to offer a description of the marketplace response to payment reform activities at large.

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This Is Not Your Mother’s Payment Model: Reflections On The APM Pilot


June 18th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation.

In early 1994, as I went about finding a practice to join after residency, every physician with whom I spoke discussed managed care at length. As a young family physician dedicated to prevention and early intervention, I was convinced that managed care answered many of the historical challenges faced by primary care physicians. At last we’d be able to pay for the social workers who could facilitate important mental health care and human services for our patients and for the group nutrition classes we wanted to run in our practices.

Yet just four years later, as I left private practice to return to academic medicine, managed care was virtually dead. All its promise had been undermined by a range of structural and environmental challenges.

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Implementing Health Reform: Premiums And Choice In The 2014 Health Insurance Marketplace (Updated)


June 18th, 2014

In the fall of 2013 the headlines were full of stories of individuals facing steep premium increases as the Affordable Care Act’s market reforms went into effect. The question was raised repeatedly whether Affordable Care Act premiums were really affordable. Commentators observed that major national commercial insurers were avoiding the exchanges and that in some states the ACA marketplace offered few choices and little competition.

On June 17, 2014, the Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) released a report surveying Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014. ASPE examined over 19,000 2014 marketplace plans within the four bronze, silver, gold, and platinum metal levels in each of the 501 geographic rating areas in the 50 states and the District of Columbia; the office analyzed premium levels, available choices, and market variables that might affect cost. It is always possible to find negative anecdotes (particularly if one is not too careful in checking their veracity), but when we look beyond anecdotes at the actual data, it is clear that the ACA was largely successful in achieving many of its goals for 2014.

One of the primary goals of the ACA is to make health insurance affordable to lower-income Americans. During the 2014 open enrollment period, 5.4 million individuals selected a plan in the 36 states served by the federal exchange (which are the states primarily covered by the report since state exchange data is still being assembled and analyzed). According to the report, 87 percent of these individuals qualified for a premium tax credit. They paid a premium that was, on average, 76 percent less than the full premium that they would have owed before the premium tax credit was applied.

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Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

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Chinese Doctors In Crisis: Discontented And In Danger


May 27th, 2014

Chinese doctors are unhappy about their pay and work conditions.  Moreover, they are in danger of physical attack by angry patients and families.  The Ministry of Health estimated that in 2010, 17,243 attack and agitation incidents occurred in Chinese hospitals, an increase of almost 7,000 over five years. Patients, bereaved families of patients who have died in hospitals, and sometimes paid protestors called yinao or “medical troublemakers,” invade hospitals, berate or attack staff, create loud disruptions, and stage mock funerals.

About 30 percent of the attacks were carried out by patients, 60 percent by family members, and the remainder by others, including yinao. About 75 percent of attacks were aimed at doctors.  According to a 2012 survey of nearly 6,000 Chinese physicians in 3,300 hospitals, 59 percent of doctors had been verbally assaulted and 6 percent had been physically assaulted. News accounts for 2002-2011 yielded 124 incidents of “serious violence” against hospitals, including 29 murders and 52 serious injuries. Often violence accompanies demands for cash compensation for harm to patients, including patient deaths in hospitals.

In response, the Chinese Ministry of Public Security has recently announced a new set of security measures for hospitals. Approximately one thousand top-tier hospitals will now have a police presence in addition to their own security guards; alarm systems linked with local law enforcement; enhanced audio-visual surveillance systems; and security posts at entrances similar to those at airports.

The wave of violent attacks on doctors and other medical workers constitutes a significant problem in its own right.  But it is also a reflection of a broader set of problems faced by today’s generation of Chinese doctors.  They are badly paid, both in relation to doctors in other countries, and in relation to other Chinese professionals. As a result, doctors often supplement their low salaries in ways that strengthen the popular impression that they are corrupt, fostering still greater distrust and anger among their patients and patients’ families. A recent survey showed that 67 percent of the Chinese public does not trust doctors’ professional diagnoses and treatment.

The doctors themselves are also dissatisfied with the current state of affairs. A 2011 Chinese Medical Association survey of its members showed fewer than 20 percent of responding doctors to be satisfied with their medical practice environments, while 48 percent rated them “poor” or “very poor”. Doctors were particularly dissatisfied with their pay. They were also concerned about their work conditions.

When respondents were asked to identify sources of work pressure, the most frequent response, at 77 percent, was “high patient expectations.”  Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.

In this post, we review that system and highlight sources of doctors’ discontent and the distrust between doctors and patients.

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Agenda Overload In Primary Care: A Call To Protect The Real Capital Of Caring


May 15th, 2014

“When you go in to see a patient, you need to be focused. You need to have your agenda clearly in mind.”

As a physician educator offered this advice to hundreds of clinicians at a recent primary care update conference, heads nodded in agreement. It seemed like reasonable counsel given the wide range of complex goals of today’s primary care. But my heart sank as the address continued. Underlying the call for focus was a perspective that patients often bring up issues during a visit that distract us from priorities.

Both the sentiment expressed and the audience’s acquiescence indicate how far we have moved away from our patients’ agendas. I don’t think any of us in that convention center chose our careers thinking we would someday experience patients’ concerns as distractions in our work day. This incident was a sign to me that we need to chart a course back to the type of care that listens to and responds to patients.

The conference encapsulated a tension I had been feeling in my own practice for years. I was a family physician in what I consider an excellent, mission-driven community health center. We had motivated staff, interdisciplinary team care, electronic medical records, and many organizational efforts for quality improvement. Clinically, I found myself moving from room to room, pressured by time, trying to keep up with a multitude of health maintenance or quality metric items, and often feeling unable to engage with “yet another” issue that the patient in front of me wanted to talk about. While it was my goal and the goal of our practice to give compassionate, holistic care to patients, too often it seemed that the time and mental/emotional reserve to listen to patients were crowded out.

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Beyond Access: High Quality Care For All


April 30th, 2014

In medical school, I had an epiphany about my role as a doctor during my obstetrics-gynecology rotation at the county safety-net hospital in Fresno, California. I loved the thrill and satisfaction of delivering babies, but after about 10 births, it hit me that virtually all the women for whom I had delivered babies were teenage girls, as young as 13. They and their children would face uphill battles. As a clinician, I was too often a cog in a machine, fixing immediate needs but not addressing underlying problems to prevent poor health outcomes.

The Affordable Care Act tears down a fundamental barrier preventing vulnerable populations from accessing care by reducing the number of uninsured and underinsured Americans. But expanded access to coverage will not, by itself, guarantee high quality care for all. It would be a serious mistake to assume that insurance will eliminate disparities in health outcomes. In Chicago, a person with diabetes living in an African American neighborhood is five times more likely to have his or her leg amputated than a person living in a white neighborhood. Insurance alone won’t close that gap. Indeed, many who needlessly lose limbs are already insured.

I have spent a great deal of my career caring for inner city patients and working with other professionals to research the health of the public. If we really want to end disparities in the health care system, here are some things we should be doing:

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