Comments on: Beyond Health Insurance Reform: Transforming Health Care Delivery http://www.healthpolcom.com/blog/2009/08/21/beyond-health-insurance-reform-transforming-health-care-delivery/ Health Policy Consulting and Writing to Improve Quality, Reduce Costs, and Increase Value in US Healthcare Wed, 04 Jan 2012 09:15:15 +0000 hourly 1 http://wordpress.org/?v=3.2.1 By: Michael D. Miller MD http://www.healthpolcom.com/blog/2009/08/21/beyond-health-insurance-reform-transforming-health-care-delivery/#comment-21276 Michael D. Miller MD Fri, 21 Aug 2009 19:10:48 +0000 http://www.healthpolcom.com/blog/2009/08/21/beyond-health-insurance-reform-transforming-health-care-delivery/#comment-21276 Thanks Christopher - Great comment. I absolutely agree that increasing teamwork - which is critical for successful medical homes - is important, as are initiatives focused on non-physician clinicians such as NPs, PAs, etc. The ACP is advocating for national health care workforce policies, and this should clearly address the entire range of clinicians, like diabetes educators, etc. And the ACP and MedPAC do address non physician supply issues - as does Kaiser Family Foundation. I didn't get into those policies because most of those clinicians are already working in primary care so expanding their supply is more about increasing training and education slots as opposed to retraining - which would certainly be quicker... Although retention is also an important issue for both physicians and other clinicians, and telemedicine may provide an opportunity for more "experienced" clinicians who may have trouble working in direct clinical settings to continue providing care to locations where services are very limited. I know telemedicine is usually thought of as a tool for specialty services, but it can be used for primary care as well - particularly for remote locations.... which actually reminds me about a discussion I had with someone many years ago about a company that provided medical radio consultations to ships at sea - and of course there was no video component back then. And lastly, yes, free parking is a very minimal "perk," but the point is that one of the reasons that medical students are being discouraged from going into primary care is that the current physician/medical culture looks at primary care as the bottom of the prestige pyramid, and medical students get this message either directly or indirectly from their teachers and mentors, so we need to find someway to reverse this. After all, in a reformed delivery system with PCPs coordinating care, they should be viewed as the quarterbacks and/or sideline coaches rather than the blockers and tacklers or equipment managers. (I know the analogy doesn't hold up completely, but I hope you get the idea, and that nobody in the NFL takes any offense at any of this since they are all a LOT bigger than I am.) Thanks Christopher – Great comment. I absolutely agree that increasing teamwork – which is critical for successful medical homes – is important, as are initiatives focused on non-physician clinicians such as NPs, PAs, etc. The ACP is advocating for national health care workforce policies, and this should clearly address the entire range of clinicians, like diabetes educators, etc. And the ACP and MedPAC do address non physician supply issues – as does Kaiser Family Foundation. I didn’t get into those policies because most of those clinicians are already working in primary care so expanding their supply is more about increasing training and education slots as opposed to retraining – which would certainly be quicker… Although retention is also an important issue for both physicians and other clinicians, and telemedicine may provide an opportunity for more “experienced” clinicians who may have trouble working in direct clinical settings to continue providing care to locations where services are very limited. I know telemedicine is usually thought of as a tool for specialty services, but it can be used for primary care as well – particularly for remote locations…. which actually reminds me about a discussion I had with someone many years ago about a company that provided medical radio consultations to ships at sea – and of course there was no video component back then.

And lastly, yes, free parking is a very minimal “perk,” but the point is that one of the reasons that medical students are being discouraged from going into primary care is that the current physician/medical culture looks at primary care as the bottom of the prestige pyramid, and medical students get this message either directly or indirectly from their teachers and mentors, so we need to find someway to reverse this. After all, in a reformed delivery system with PCPs coordinating care, they should be viewed as the quarterbacks and/or sideline coaches rather than the blockers and tacklers or equipment managers. (I know the analogy doesn’t hold up completely, but I hope you get the idea, and that nobody in the NFL takes any offense at any of this since they are all a LOT bigger than I am.)

]]> By: Christopher Langston http://www.healthpolcom.com/blog/2009/08/21/beyond-health-insurance-reform-transforming-health-care-delivery/#comment-21273 Christopher Langston Fri, 21 Aug 2009 18:29:46 +0000 http://www.healthpolcom.com/blog/2009/08/21/beyond-health-insurance-reform-transforming-health-care-delivery/#comment-21273 Wow! What an impressive description of the issues facing "delivery system reform" as part of health care reform. As I'm sure you would agree, some of the proposals for increasing primary care capacity are clearly a bit week - anytime you find yourself using special parking spaces as an incentive you are clearly grasping at straws. But retraining, increasing use of hospitalists, along with better pay, and working conditions (inc. prestige), will at least eventually draw people in. I did wonder why the proposals don't include making more use of nurses and others as PCPs. Clearly the need for increased primary care capacity is such that there will be more than enough work for all who want it and there is every reason to believe that NPs and others can deliver quality care in well designed systems. Which brings me to my last point, "well designed systems." Not only is primary care weak in the US because it is underpaid, but practices are typically not "designed" to deliver highest quality care, particularly for patients with chronic diseases. As Ed Wagner's work over the decades has shown, there are many additional aspects to delivering high quality primary care to a population that is aging and has a high burden of chronic disease. It requires additional skills in patient activation, team work, practice process redesign (even to benefit from the opportunities created by EMRs), and a shift in mindset from reactive episodic care to proactive planned care. I think we need an even broader agenda for delivery system reform, workforce policy, and training standards, if we are to get the health outcome improvement and cost reductions we are looking for in health reform. Wow! What an impressive description of the issues facing “delivery system reform” as part of health care reform.

As I’m sure you would agree, some of the proposals for increasing primary care capacity are clearly a bit week – anytime you find yourself using special parking spaces as an incentive you are clearly grasping at straws. But retraining, increasing use of hospitalists, along with better pay, and working conditions (inc. prestige), will at least eventually draw people in.

I did wonder why the proposals don’t include making more use of nurses and others as PCPs. Clearly the need for increased primary care capacity is such that there will be more than enough work for all who want it and there is every reason to believe that NPs and others can deliver quality care in well designed systems.

Which brings me to my last point, “well designed systems.” Not only is primary care weak in the US because it is underpaid, but practices are typically not “designed” to deliver highest quality care, particularly for patients with chronic diseases.

As Ed Wagner’s work over the decades has shown, there are many additional aspects to delivering high quality primary care to a population that is aging and has a high burden of chronic disease. It requires additional skills in patient activation, team work, practice process redesign (even to benefit from the opportunities created by EMRs), and a shift in mindset from reactive episodic care to proactive planned care.

I think we need an even broader agenda for delivery system reform, workforce policy, and training standards, if we are to get the health outcome improvement and cost reductions we are looking for in health reform.

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