The BLUEPRINT for health care reform is in the May 2010 issue of Health Affairs

June 19, 2010

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Health Affairs journal is the premiere journal for healthcare policy. If it appears in Health Affairs then it is generally a done deal. The May 2010 issue of Health Affairs is devoted to the reinvention of primary care. The Patient Protection and Affordable Care Act of 2010 has triggered all sorts of projects that have been in the queue for some time or will soon be put to the test. Make no mistake…what is reported and proposed in this journal edition is here to stay for the next decade. It cannot be unwound. Things are going to change in healthcare over the next three years and for decades thereafter.
The Medical Home will become the organizational centerpiece from which everyone American citizen’s personal healthcare is managed. The image above is how the Qliance Medical Group in Seattle envisions and has implemented the Medical Home concept. The article by Qliance CEO Norman Wu is one of the most compelling in the journal edition because they have anticipated the coming changes and implemented their own model for the past twelves years. I would say the Qliance model is excellent evidence that at least one form of the Medical Home can actually work.
What will be the most dramatic changes? Physicians will spend less time with chronic disease patients and more time with patients with complex diagnoses. Diabetics who are “under control”, e.g., low HbA1cs, decent weight, good labs, may never see the doctor again! Instead they might see a Medical Assistant with extra training (9 months?) who will monitor their “progress” and make referrals to the dietician or health coach. The MA might be the health coach.
Nurse Practitioners will manage their own clinics without MD supervision including all the new clinics slated for establishment in retail stores. NPs will also write prescriptions for primary care medications. Or maybe the pharmacist will write the scripts in his future role as a member of a Medical Home practice team. All health data will be online, secured and accessible from anywhere there is an Internet connection.
Providers will be paid based on their ability to reduce poor health outcomes such as re-admissions to the hospital for the chronically ill or elderly frail. Provider groups will be graded by Accountable Care Organizations. Patients will pay much less for insurance coverage. There are two articles (Wu and Zastrow, both reviewed) that describe how MDs have reshaped their own practices to suit their personal goals vis a vis how they get paid and how they prefer to practice.
I am scratching the surface of what is contained in these articles. For those who may not be interested or have the time to read all of them, I have done it for you! I have attached an 18 page document based upon my review of the articles in the May issue. You can download my summary here. If you want to get the originals (some will) you have to manage that on your own (I went to UCLA biomed library).
Not everyone who has written an article in the May issue is on board with reform as it is proposed. For example, those not enamored with the Medical Home are represented. Despite an effort to represent differing views, I still find that certain issues remain untouched. In particular, most of the models described for increasing the primary care provider workforce, and for paying for increased coverage to the tens of millions of uninsured who will now be insured, are not terribly inspiring. As I have written elsewhere, training more of the same primary care providers is an insufficient solution to fill a workforce chasm. Extending the roles of mid-level providers and especially MAs is just the beginning. I am an advocate for considering the role that appropriately trained CAM providers can play in helping fill the workforce gap. I am co-author on an article about how CAM providers can be used in primary care that will appear soon in Complementary Health Practice Review.
If you wish to comment on this blog I strongly encourage you to post below. For people interested in healthcare policy and the future of the reform movement that is already underway, these articles are essential reading.

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