I have compiled key publications and resources on some current topics in health care policy. Below are descriptions of the key topic areas, which also can be accessed using the menu on the right side of this page.
Health Care Reform: Opportunities to Advance Patient-Centeredness and Equity
With the historic enactment of national health care reform in March 2010, it can be a little overwhelming to understand all the details and implications of this huge structural shift in national health care policy.
As I continue to refine my own knowledge and understanding of the national health care reform law, I will share my analyses and presentations here. I will be highlighting what I call the “patient-centeredness” and “equity” elements of the legislation, two of the components of health care quality identified by the Institute of Medicine.
The federal government health care reform implementation website also has useful information and is available in Español (Spanish).
I also have compiled some of the publications and resources that I have found most useful in understanding the Patient Protection and Affordable Care Act.
Finally, I am compiling publications and resources on some of the key topics and issues emerging from the implementation of health care reform:
Medical Homes: A Promising Model for Advancing Patient-Centeredness and Equity
One of the emerging models of health care delivery system re-design is the concept of a “medical home”. In 2007, the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association issued a Joint Principles defining patient-centered medical homes.
While the specific terminology and elements of a medical home (also being called a “health care home”, “primary care home” or “advanced primary care practice”) vary, the core idea is that everyone should have a partnership with a primary care provider who will provide access to comprehensive, coordinated, high quality health care.
Medical homes will be given a huge catalyst with the imminent widespread adoption of health information technology by physician practices, community health centers and hospitals.
I have compiled some key analyses and background resources on the concept of medical homes.
Some key articles are:
Berenson RA, et al. “A house is not a home: Keeping patients at the center of practice redesign.” Health Affairs (2008); 27(5):1219-1230
Pham HH. “Good neighbors: How will the patient-centered medical home relate to the rest of the healthcare delivery system?” J Gen Intern Med (2010); 25(6):630-634
Merrell K and Berenson RA. “Structuring payment for medical homes.” Health Affairs(2010); 29(5):852-858
There have been many medical home demonstration projects, many coordinated by the Patient-Centered Primary Care Collaborative. The Centers for Medicare and Medicaid Services is beginning a national multi-payer advance primary care demonstration project.
The next National Medical Home Summit will be March 14-16 in Philadelphia, PA.
Accountable Care Organizations: Experimenting with Payment Reform
One of the most interesting concepts which is being promoted in the national health care reform legislation are “accountable care organizations” (ACO) – new or existing health care organizations which would assume responsibility (“accountability”) for improving the health outcomes of a defined number of patients (at least 5,000) in a specific geographic area. The ACO would be required to engage a sufficient percentage of the local providers (hospitals, physicians, community health centers, etc.) so that it could establish appropriate goals for quality outcomes and then take the cost savings from that quality improvement (for example, reduced number of avoidable hospitalizations) and distribute those savings among all the providers.
What is somewhat surprising about the degree of support and interest in the concept is that this is still largely an idea based on cost analyses and savings projections from Medicare claims data, with little practical evidence that it actually works to sufficiently change the current cost and payment incentives in our health care system. Moreover, while not excluding the ability of a hospital/health system, independent practice association or health plan to be a local ACO, the model contemplates a new type of administrative organization solely focused on these issues of quality improvement and shared cost savings. Finally, there are many actuarial, measurement and legal issues to overcome to make this concept viable.
The “thought leaders” who have developed the concept of an accountable care organization are Mark McClellan, former Administrator of the Centers for Medicare and Medicaid Services and now at the Engleberg Center for Health Care Reform at the Brookings Institution and Elliot Fisher of Dartmouth Medical School. They have created a learning network with useful tools for developing an ACO.
Some of the best analyses of accountable care organizations have been published by:
Key articles are:
Fisher ES, et al. “Fostering accountable health care: Moving forward in Medicare.”Health Affairs (2009); 28(2):w219-w231
McClellan M, et al. “A national strategy to put accountable care into practice.”Health Affairs (2010); 29(5):982-990
A National Accountable Care Organization Congress is being held on October 25-27, 2010 in Century City, California.
Comparative Effectiveness Research: Improving Quality and Containing Costs
One the more controversial concepts in contemporary health care policy is comparative effectiveness research (CER). This research attempts to directly compare the effectiveness of different treatments and interventions for various diagnoses and conditions. For example, when a woman is diagnosed with breast cancer, what is her best choice for treatment – surgery, chemotherapy, radiation, or a combination of all three? In what sequence and what dosage? The attention to comparative effectiveness research was significantly raised when $1.1 billion was made available to support CER in the American Recovery and Reinvestment Act.
The concern is that this research will be used to deny coverage or payment for certain treatments or interventions, or otherwise “ration” health care services. Accordingly, the Patient Protection and Affordable Care Act no longer used the term “comparative effectiveness research” and instead established the Patient-Centered Outcomes Research Institute.
I have compiled some key background documents on the $1.1 billion being invested in CER as well as some policy analyses of what implications comparative effectiveness research might have for health care quality improvement and cost containment.
The October 2010 edition of Health Affairs is focused on comparative effectiveness research. Among the key articles:
Patel K. “Health reform’s tortuous route to the Patient-Centered Outcomes Research Institute.” Health Affairs (2010); 29(10): 1777-1782
Garber AM and Sox HC. “The role of costs in comparative effectiveness research. Health Affairs (2010); 29(10): 1805-1811
Health Information Technology: Advancing Patient-Centeredness and Equity through Technology
The other major health care policy legislation enacted within the past two years is the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the economic stimulus legislation, the American Recovery and Reinvestment Act. The HITECH Act provides up to $30 billion to hospitals, physicians, community health centers and other “eligible providers”. The federal funds will be available through incentive payments paid through Medicare and Medicaid. Hospitals and physicians must demonstrate “meaningful use of certified electronic health records” to qualify for the incentive payments. The Office of National Coordinator for Health Information Technology is overseeing most of the implementation of the HITECH Act, in collaboration with the Centers for Medicare and Medicaid Services, which is overseeing the Medicare and Medicaid incentive payments.
I have compiled some key resources on the implementation of the HITECH Act, with a focus on how it might impact safety net health care providers, and patients and health care consumers, especially from underserved communities.
The best overview of the HITECH Act was published by the California HealthCare Foundation. Manatt Health Solutions recently published an insightful “one year after enactment” review of the implementation of the HITECH Act. Other useful resources include:
I have been most interested in how the implementation and utilization of health information (and communications) technologies can advance patient-centeredness and equity.
And here are some useful resources for understanding how patients and consumers, particularly from communities of color and other underserved populations, could benefit from health information and communications technologies:
One of the concepts I have been promoting is the process of identifying the specific issues or needs for underserved populations – for example, the need for tailored, adaptable patient education materials in multiple languages and formats – and then developing and implementing “universal” solutions that benefit everyone – for example, the ability to archive and access multiple versions of patient education materials from an electronic health record system. This would mean educational materials about asthma care would be available electronically from an electronic health record system in English, Spanish, Chinese and Vietnamese, at a literacy level usable by patients and families with lower health literacy in each of those languages, and could be printed in a large fonts for persons who would benefit from increased readability.
There are many useful articles that have been published about the implementation of the HITECH Act:
Brailer DJ. “Guiding the health information technology agenda.” Health Affairs (2010); 29(4): 586-595
Bates DW and Bitton A. “The future of health information technology in the patient-centered medical homes.” Health Affairs (2010); 29(4): 614–621
Tang PC and Lansky D. “The missing link: bridging the patient-provider health information gap.” Health Affairs. (2005);24(5):1290-1295.
Torda P, Han ES and Scholle SH. Easing the adoption and use of electronic health records in small practices.” Health Affairs (2010); 29(4): 668–675
Miller RH , et al. “The value of electronic health records in solo or small group practices.”
Health Affairs, (2005); 24(5): 1127-1137
Lee J , et al. “The adoption gap: Health information technology in small physician practices.” Health Affairs, (2005); 24(5): 1364-1366
Miller RH and West CE. “The value of electronic health records in community health centers: Policy implications.” Health Affairs,(2007); 26(1): 206-214
Shields AE, et al. “Adoption of health information technology in community health centers: Results of a national survey.” Health Affairs (2007); 26(5): 1373-1383
Millery M and Kukafka R. “Health information technology and quality of health care: Strategies for reducing disparities in underresourced settings.” Med Care Res Rev.(2010) Jul 30. [Epub ahead of print]
Baig AA, et al. “The use of quality improvement and health information technology approaches to improve diabetes outcomes in African American and Hispanic patients. Med Care Res Rev. (2010) Jul 30. [Epub ahead of print]
Ngo-Metzger Q, et al. “Improving communication between patients and providers using health information technology and other quality improvement strategies: Focus on Asian Americans.” Med Care Res Rev. (2010) Jul 30. [Epub ahead of print]
I will continue to add more content on sub-topics for this huge change in health care delivery in the U.S., as well as catalog and comment on additional resources as they become available.
Demographic Data: The Baseline for Advancing Equity
Collecting data from patients about their income, education, race, ethnicity, language, sexual orientation, gender identity and expression, health literacy and other demographic information will enable health care providers and systems to better understand individual patient needs as well as identify and address disparities at a population level.
Hospitals, health plans and physician practices are all beginning to collect more data on patient demographics.
The meaningful use requirements for Medicare and Medicaid incentive payments under the Health Information will require hospitals and physicians to collect race, ethnicity and language data on at least 50 percent of their unique patients. These requirements will further stimulate data collection activities over the next few years.
Meanwhile, it is important to consider other demographic data which could identify disparities for other underserved populations. For example, there is recent discussion about how best to collect data about sexual orientation and gender identity/expression to improve the quality of health care for lesbian, gay, bisexual and transgender patients and their families.
Language Access: Ensuring Meaningful Access to Health Care
There is a growing body of evidence that language barriers for individuals with limited English proficiency has a direct relationship to the quality of health care. Providing language assistance services can improve the quality of care and reduce health care disparities among individuals with limited English proficiency. Language assistance services include both verbal interpretation services and written translation services.
With funding from the Robert Wood Johnson Foundation, a special November 2007 supplement of the Journal of General Internal Medicine is focused on language access issues, with open access to all the articles.
There are many useful resources that can help support the many reasons for improving language access, including legal and regulatory requirements, patient safety, risk management, quality improvement and disparities reduction.
Here is my presentation on how to make the multiple “cases” for language access.
There are important background resources which support the legal and regulatory requirements for language access that apply to all health care providers that receive any type or amount of federal funding (almost all health care providers):
There is growing evidence for other reasons for ensuring language access:
Hospitals, health plans, community health centers and physician office practices have all demonstrated the feasibility and importance of ensuring language access:
And a national program for the certification of health care interpreters has been created by the Certification Commission for Healthcare Interpreters, which is conducting its first test cycle in October and November 2010.
Finally, here are some publications which explain how federal matching funds from Medicaid and the Children’s Health Insurance Program can be used by states to reimburse health care providers for language assistance services.
Cultural Competency: Customizing Health Care for Diverse Patients
The Institute of Medicine identified patient-centeredness as one of the elements of quality health care. The definition of patient-centeredness includes responsiveness to the needs and preferences of the patient. There is a conceptual overlap between patient-centeredness and cultural competence:
There are many useful frameworks and resources for understanding and applying cultural competency in health care:
Many health care organizations are integrating concepts of cultural competency into their quality improvement and disparities reduction activities:
Health professions education and training programs also are integrating cultural competency into their curricula:
The May 2010 Supplement 2 to the Journal of General Internal Medicine is focused on cultural competency and health disparities issues in medical education – all the articles in the issue are available through open access (scroll down to bottom of right side of page)
Health Care Disparities: A Continuing National Challenge
There is now overwhelming, irrefutable evidence of health care disparities in the U.S.:
Fortunately, many health care organizations have recognized the persistence of health care disparities and have begun to develop and implement interventions to reduce those disparities:
Health Workforce Diversity: The Quality and Economic Imperatives
Given the historic discrimination against African Americans, American Indians and other racial and ethnic minorities and their exclusion from the health professions in this country, it remains a national challenge to diversify the racial and ethnic background of students entering the health professions. While almost all of the business world recognizes the value and benefits of workforce diversity, there is still strong resistance within admissions committees and faculties of health professions educational institutions to changing traditional admissions criteria (grades and standardized test scores) to account for the qualities of the “whole person” that would make a student a successful health professional.
As our nation’s health care systems undergo continued reform, there is also growing maldistribution of health professionals, both geographically as well as type of practice and specialization. There are chronic and increasing shortages of health professionals for rural and urban underserved areas, especially in primary care. These shortages will only be exacerbated by the increased demand for health care services as the previously millions of uninsured and underinsured Americans obtain health care coverage under national health care reform and begin to seek their own regular providers of health care.
Finally, as models of health care delivery move toward more patient-centered and team-based approaches such as medical homes, physicians and other clinicians will need to be more than knowledgeable, technically proficient providers of procedures, medications and medical devices. The abilities to manage and supervise teams, to conduct motivational interviewing, to engage in care management and support behavior change, and to effectively communicate with and coordinate care with other providers, patients, families and caregivers will become more and more important skills. Having more diverse providers reflective of the patient populations served who can build rapport and trust with patients will be essential.
Here are some key background resources on the imperative for health workforce diversity:
Lesbian, Gay, Bisexual and Transgender Health Issues
Lesbian, gay, bisexual and transgender individuals and communities have largely been overlooked by health care systems and providers. Unfortunately, there is evidence that many lesbian, gay, bisexual and transgender patients and health care consumers continue to experience discrimination and exclusion from health care services, and also experience disparities in health care and outcomes.
Similar to many underserved populations and communities, one of the central issues for improving the health care for lesbian, gay, bisexual and transgender individuals is demographic data collection – being able to voluntarily and safely identify as lesbian, gay, bisexual and transgender to one’s health care provider, or on a health survey.
In addition, there are important issues of providing clinically appropriate care for lesbian, gay, bisexual and transgender patients and health care consumers, cultural competency training and workforce development.
Improving health care for lesbian, gay, bisexual and transgender patients and their families is another important step towards patient-centered and equitable health care for all.
Patient-Centeredness: The Promise of Quality and a Pathway to Equity
One of the six components of quality health care identified by the Institute of Medicine is patient-centeredness. While there has been significant attention on the components of safety, timeliness, effectiveness, efficiency, there has been less attention on the components of equity and patient-centeredness.
I have begun to use patient-centeredness as a key concept to drive change and improvement in our health care systems, as well as a pathway to health equity. To me, patient-centeredness means providing the best care to all patients at all times, based on their individual, contextualized needs and preferences. It means customizing and tailoring health care and services for diverse individuals while expecting and achieving the same (highest) quality outcomes for everyone. If we can really transform our current health care systems into more patient-centered ones where patients really are more engaged as partners in their own health care and their own health, we are likely to see quality improvement, reduction of health care disparities, more engaged clinicians and health care providers, and patients and health care consumers with greatly improved experiences of health care.
Here are some key resources on patient-centeredness:
Some key articles on the concept of patient-centeredness are:
Epstein RM, Fiscella K , Lesser CS Stange KC. “Why the nation needs a policy push on patient-centered health care.” Health Affairs (2010); 29(8):1489-1495
Bechtel C and Ness DL. “If you build it, will they come? Designing truly patient-centered health care.” Health Affairs (2010); 29(5):914-920
Berwick DM. “What ‘patient-centered’ should mean: Confessions of an extremist.” Health Affairs (2009); 28(4):w555-w565
Davis KA, et al. “A 2020 vision of patient-centered primary care,” J Gen Int Med (2005); 20 (10): 953-957