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:
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 thePatient-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.
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