We are happy to announce that the authors of Primary Care Breakfast Club published a perspective piece in the New England Journal of Medicine on September 6, 2012. Our piece, titled "The Developing Vision of Primary Care", has received a lot of feedback from all sides. If you are interested in continuing the conversation, feel free to leave a comment.
To read the piece, visit the following link: http://www.nejm.org/doi/full/10.1056/NEJMp1204487
We hope you enjoy and would love to hear your feedback!
Showing posts with label health reform. Show all posts
Showing posts with label health reform. Show all posts
Saturday, October 27, 2012
Tuesday, May 1, 2012
Primary Care Spring
IBM is launching what they are calling the "Primary Care Spring." At the risk of upstaging Occupy Spring they are seeking to revolutionize the way they take care of their employees by widely promulgating the Patient Centered Medical Home (PCMH). They are certainly not the first, but they represent a growing number of large insurers that have jumped on the wagon.
In a YouTube video presentation by Dr. Paul Grundy of IBM that can be found at the above link he describes 3 trends he is seeing:
1. Cost: good comprehensive coordinated patient-centered care saves money
2. Data: we can now help physicians make better clinical decisions because we now have the data needed to do so (how could he give a presentation without mentioning "Watson"?)
3. On-line asynchronous care: medical homes succeed because they allow for on-line and asynchronous care where you don't have to see your doctor to be treated and they don't have to see you to get paid. In this new information age our children will not put up with receiving care any other way.
In short, this is nothing new but it is all coming together across the country. The government, insurers, employers, providers, and patients are all recognizing that accessible, coordinated, patient-centered care really does save money and make people healthier.
You CAN have your cake and eat it too.
-JKR
In a YouTube video presentation by Dr. Paul Grundy of IBM that can be found at the above link he describes 3 trends he is seeing:
1. Cost: good comprehensive coordinated patient-centered care saves money
2. Data: we can now help physicians make better clinical decisions because we now have the data needed to do so (how could he give a presentation without mentioning "Watson"?)
3. On-line asynchronous care: medical homes succeed because they allow for on-line and asynchronous care where you don't have to see your doctor to be treated and they don't have to see you to get paid. In this new information age our children will not put up with receiving care any other way.
In short, this is nothing new but it is all coming together across the country. The government, insurers, employers, providers, and patients are all recognizing that accessible, coordinated, patient-centered care really does save money and make people healthier.
You CAN have your cake and eat it too.
-JKR
Monday, April 30, 2012
It's the Hospitals Stupid!
Massachusetts has been leading health reform at the state level since passing far-reaching legislation in 2006 that was the blueprint for the Affordable Care Act. They are at it again. As Martyna Skowron, a colleague from Harvard School of Public Health writes, the Massachusetts House and Senate are close to releasing their versions of comprehensive payment reform legislation for the state healthcare system. What they're likely to propose may surprise you.
Much has been made of the problem of prices in our health care system. Uwe Reinhardt, back in May 2003, wrote an article in Health Affairs titled It's the Prices Stupid: Why the United States Is So Different From Other Countries. He's been writing about the issue ever since. In short, payers in the US system pay far more for the same services in absolute dollar amounts than payers in other health systems around the world.
What follows is an excerpt from the Massachusetts Attorney General's Preliminary Report on the drivers of health care costs in the state. It is titled Investigation of Health Care Cost Trends and Cost Drivers and was released last year.
Much has been made of the problem of prices in our health care system. Uwe Reinhardt, back in May 2003, wrote an article in Health Affairs titled It's the Prices Stupid: Why the United States Is So Different From Other Countries. He's been writing about the issue ever since. In short, payers in the US system pay far more for the same services in absolute dollar amounts than payers in other health systems around the world.
Why? Extending the argument one step further, as I did in this post late last year, we find ourselves at the doorstep of the hospitals who set those prices.
"We focused our investigation on contracting practices and contract prices (i.e., the prices negotiated between health insurance companies and hospitals and physicians for hospital inpatient and outpatient care, and professional services) for commercial health insurance for the period 2004 through 2008. While our investigation continues and our analysis is not final, our preliminary review has revealed serious system-wide failings in the commercial health care marketplace which, if unaddressed, imperil access to affordable, quality health care. In brief, our investigation has shown:
- Prices paid by health insurance companies to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service.
- Price variations are not correlated to (1) quality of care, (2) the sickness or complexity of the population being served, (3) the extent to which a provider is responsible for caring for a large portion of patients on Medicare or Medicaid, or (4) whether a provider is an academic teaching or research facility. Moreover, (5) price variations are not adequately explained by differences in hospital costs of delivering similar services at similar facilities.
- Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.
- Variation in total medical expenses on a per member per month basis is not correlated to the methodology used to pay for health care, with total medical expenses sometimes higher for globally paid providers than for providers paid on a fee-for- service basis.
- Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts.
- The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing."
Does this surprise you? In a nutshell, hospitals have been able to set high prices for their services which insurance companies must pay because hospitals possess monopolistic market share in specific health care markets. While we would hope there is more sense to the prices we pay for health care, such that we are paying more for better care, more timely care, or because we have more complex disease, this is not the case.
The question now is: what do we do about it? The free market can only help if competition is introduced into the market. Instead, hospitals have been consolidating, making the problem worse. Is it now time for the government to step in again? The Massachusetts legislature will likely unveil proposals that endorse a multi-pronged approach. The biggest prong will be encouraging global payment and setting "milestones for growth." Furthermore, they are likely to enable the state to step in if growth is not limited to these milestones. Additionally the proposal will likely include provisions to increase price transparency, ensure more competitive market behaviors, and promote further research into cost drivers and policies that encourages providers and consumers to utilize more cost-effective care.
It should be interesting and may again influence decisions made on the national stage in regards to price reform in the future.
-JKR
Tuesday, November 22, 2011
An Evening with Dr. Blumenthal
I just got home from a fascinating 3 hour talk with Dr. David Blumenthal. You can read more about him here, but he is basically one of the leaders in the quality field of health care and recently spent 2 years working in the Obama administration as the head of Health Information Technology (HIT). He came to speak to our US health policy class at the Harvard Kennedy School of Government and a smaller group of us had dinner with him afterwards. I wanted to share a couple things he spoke about that I found compelling.
Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.
My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.
Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:
-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.
Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.
Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.
This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.
JK-R
Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.
My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.
Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:
-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.
Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.
Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.
This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.
JK-R
Wednesday, November 9, 2011
Can the United States Learn from Brazil's Primary Care Model?
Brazil has seen huge changes in the past several decades in their political and social structure. Prior to democratization in the 1980’s, the country had been under several decades of military rule. After the authoritarian rule, socio-political reformation began to take shape which included an overhaul of their health care system. The belief that health is a universal human right became more widespread throughout the Brazilian culture and with this in mind, the National Health System (SUS) was created in 1988 and implemented in 1990. Since implementation of SUS, Brazil has seen huge improvements in health outcomes including increased life expectancy, decreased infant mortality, and decreased deaths from infectious diseases.
A cornerstone of the SUS is the Family Health Program (PSF) which functions as their primary care delivery system. The PSF was established in 1994 as a way to meet universal access goals, better coordinate care, and focus on prevention. The PSF’s focus is on family and community health which encompasses prevention and public health goals. Under PSF, family health teams, which consists of one doctor, a nurse, an auxiliary nurse, and 4-6 community health workers cover a geographic area which includes no more than 5,000 patients. Community health workers are vital to the team as each community health worker is responsible for about 120 families and they make home visits to each of these families once per month. The community health workers’ primary focus is on child and maternal health, but they have been instrumental in health promotion, education, medical adherence, public health actions (i.e. sanitation), chronic disease management, and triage support.
The PSF is highly decentralized with most authority placed on the municipalities. The PSF program has been successful in getting to the majority of the population as family health teams are found in 85 percent of municipalities serving over 98 million people. Despite the large coverage, the PSF program only takes up 8 percent of the federal health care budget.
The PSF program has been shown to be very effective in improving health outcomes for Brazil. Access to care has increased by over 25 percent since its origination in 1994. Life expectancy has increased from 67 to 72 years, immunization rates for Tetanus, Diphtheria, and Pertussis is over 95 percent for all children 1 year of age, and infant mortality has decreased from 48 per 1000 to 17 per 1000. A reputable study by Guanais and Macinko focused on postneonatal mortality as a proxy to assess success of primary care delivery. It is argued that the postneonatal period, ranging from 30 days to one year, reflects success in primary care goals of nutrition, immunization, sanitation, breast feeding, and prevention of respiratory and diarrheal infections. They found that between 1998 and 2006, the postneonatal death rate decreased from 14.24 to 6.92 per 1000 children while at the same time PSF coverage increased from 8.74 percent of municipalities to 60.90 percent. Their published paper accounted for increases in clean water, decreased illiteracy rates, and other confounders and through regression analyses determined that the family health teams decreased postneonatal death rates by 0.86 per 1000 compared to communities without teams.
The PSF does not come without some problems, however, and need to be mentioned. The decentralized nature of the program makes it difficult to ensure quality between geographic regions. The federal government collects money, but the money is allocated to municipal governments who are ultimately in charge of managing their budget and health care delivery. Problems seem to arise most in the northeast region which is more socioeconomically depressed than the central or southern regions. As a result, the northeast has a higher infant mortality rate, more deaths from infectious diseases, and lower life expectancy. Not surprisingly, many municipalities in the northeast do not have family health programs, partly because it is difficult to recruit and retain health providers for this region. Additionally, corruption is a problem with some municipalities which results in allocated money not being used for health care expenditures. These problems create conspicuous disparities in access and health care outcomes between different municipalities.
Another problem faced is the difficulty of integrating the family health teams with local hospitals and specialist care. Some municipalities have more success than others in working with the private sector. Naturally, the more coordinated and integrated the care is, this results in better available health care for Brazilians. Lastly, the emphasis on improving primary care has come at the sacrifice of providing good hospital and tertiary care. Brazil’s public hospital system only provides 35 percent of hospital beds in the country with the remainder made up of by private hospitals. The public hospital system is overcrowded and has large variability in quality.
As the United States works to come up with solutions for improved primary care delivery and access, it may be prudent to look outside of Europe and Canada for ideas. Arguably, Brazil’s primary care model has seen some of the greatest health improvement of any country in the world through their innovative decentralized method. I feel that U.S. could benefit from a team based approach. Teams are seen to an extent in our patient centered medical homes, but the addition of community health workers could facilitate improved chronic disease management, health promotion, behavior change and support, and medical adherence. Most importantly, Brazil has shown us that by investing in primary care, the health of the population can be greatly improved. As we continue to work towards improved health systems and primary care delivery, let’s not forget to keep Brazil in mind.
BWC
Resources:
Frederico C. Guanais and James Macinko, The Health Effects of Decentralizing Primary Care in Brazil, Health Affairs, 28, no 4 (2009): 1127:1135
Michael Kemp, Cracks Appear in Brazil’s Primary Health Programme, The Lancet, vol 372 (2008): 877
Mathew Harris and Andrew Haines, Brazil’s Family Health Program, BMJ 2010; 341: c4945
Paim, J., Travassos C., Almeida, et al., The Brazilian Health System: history, advances, and challenges, The Lancet, 2011; 377: 1788-97
A cornerstone of the SUS is the Family Health Program (PSF) which functions as their primary care delivery system. The PSF was established in 1994 as a way to meet universal access goals, better coordinate care, and focus on prevention. The PSF’s focus is on family and community health which encompasses prevention and public health goals. Under PSF, family health teams, which consists of one doctor, a nurse, an auxiliary nurse, and 4-6 community health workers cover a geographic area which includes no more than 5,000 patients. Community health workers are vital to the team as each community health worker is responsible for about 120 families and they make home visits to each of these families once per month. The community health workers’ primary focus is on child and maternal health, but they have been instrumental in health promotion, education, medical adherence, public health actions (i.e. sanitation), chronic disease management, and triage support.
The PSF is highly decentralized with most authority placed on the municipalities. The PSF program has been successful in getting to the majority of the population as family health teams are found in 85 percent of municipalities serving over 98 million people. Despite the large coverage, the PSF program only takes up 8 percent of the federal health care budget.
The PSF program has been shown to be very effective in improving health outcomes for Brazil. Access to care has increased by over 25 percent since its origination in 1994. Life expectancy has increased from 67 to 72 years, immunization rates for Tetanus, Diphtheria, and Pertussis is over 95 percent for all children 1 year of age, and infant mortality has decreased from 48 per 1000 to 17 per 1000. A reputable study by Guanais and Macinko focused on postneonatal mortality as a proxy to assess success of primary care delivery. It is argued that the postneonatal period, ranging from 30 days to one year, reflects success in primary care goals of nutrition, immunization, sanitation, breast feeding, and prevention of respiratory and diarrheal infections. They found that between 1998 and 2006, the postneonatal death rate decreased from 14.24 to 6.92 per 1000 children while at the same time PSF coverage increased from 8.74 percent of municipalities to 60.90 percent. Their published paper accounted for increases in clean water, decreased illiteracy rates, and other confounders and through regression analyses determined that the family health teams decreased postneonatal death rates by 0.86 per 1000 compared to communities without teams.
The PSF does not come without some problems, however, and need to be mentioned. The decentralized nature of the program makes it difficult to ensure quality between geographic regions. The federal government collects money, but the money is allocated to municipal governments who are ultimately in charge of managing their budget and health care delivery. Problems seem to arise most in the northeast region which is more socioeconomically depressed than the central or southern regions. As a result, the northeast has a higher infant mortality rate, more deaths from infectious diseases, and lower life expectancy. Not surprisingly, many municipalities in the northeast do not have family health programs, partly because it is difficult to recruit and retain health providers for this region. Additionally, corruption is a problem with some municipalities which results in allocated money not being used for health care expenditures. These problems create conspicuous disparities in access and health care outcomes between different municipalities.
Another problem faced is the difficulty of integrating the family health teams with local hospitals and specialist care. Some municipalities have more success than others in working with the private sector. Naturally, the more coordinated and integrated the care is, this results in better available health care for Brazilians. Lastly, the emphasis on improving primary care has come at the sacrifice of providing good hospital and tertiary care. Brazil’s public hospital system only provides 35 percent of hospital beds in the country with the remainder made up of by private hospitals. The public hospital system is overcrowded and has large variability in quality.
As the United States works to come up with solutions for improved primary care delivery and access, it may be prudent to look outside of Europe and Canada for ideas. Arguably, Brazil’s primary care model has seen some of the greatest health improvement of any country in the world through their innovative decentralized method. I feel that U.S. could benefit from a team based approach. Teams are seen to an extent in our patient centered medical homes, but the addition of community health workers could facilitate improved chronic disease management, health promotion, behavior change and support, and medical adherence. Most importantly, Brazil has shown us that by investing in primary care, the health of the population can be greatly improved. As we continue to work towards improved health systems and primary care delivery, let’s not forget to keep Brazil in mind.
BWC
Resources:
Frederico C. Guanais and James Macinko, The Health Effects of Decentralizing Primary Care in Brazil, Health Affairs, 28, no 4 (2009): 1127:1135
Michael Kemp, Cracks Appear in Brazil’s Primary Health Programme, The Lancet, vol 372 (2008): 877
Mathew Harris and Andrew Haines, Brazil’s Family Health Program, BMJ 2010; 341: c4945
Paim, J., Travassos C., Almeida, et al., The Brazilian Health System: history, advances, and challenges, The Lancet, 2011; 377: 1788-97
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