Who Are Providers? Over the next decade our nation will experience the systematic implementation of the
The Senate Appropriations Committee FY'11 recommendations for the Health Resources and Services Administration (HRSA) would have provided $40 million to begin the newly authorized Medical Home demonstration program, which would include community health teams and community-based collaborative care networks. Under these authorities, funds would be used for the creation and support of interdisciplinary patient care teams, assistance to low-income individuals to access care, case management, benefit enrollment, and other assistance. Funding would also have been available to initiate Accountable Care Organizations (ACOs) within which providers and hospitals would be encouraged to join together to form groups covering at least 5,000 patients each, which would be accountable for cost, quality, and overall care. Health policy experts have suggested that these ACOs would essentially be Health Maintenance Organizations (HMOs), which were the vision of President Richard Nixon.
A careful review of the actual statutory language for both the Medical Home and Accountable Care Organization initiatives reveals that a functional/programmatic rather than structural/discipline approach was adopted by the Congress, providing the Secretary of Health and Human Services (HHS) with broad authority to issue implementing regulations. For example, although "physician services" will be provided, who is a "physician" and who will administer the local entity is not specified. For rural
Since the definitions of "medical home" and "ACO" are not agreed to, either in statute or within the national health policy community, there undoubtedly will be an extended debate around which entities will ultimately qualify for such designation and specifically, if non-physician providers (e.g., nurse practitioners) or non-physician provider-led practices, may qualify. Most likely the answer will depend upon a number of factors, including relevant statutory definitions, the financing setting (e.g., Medicaid), promulgation of relevant regulations or guidance; and in some cases, state practice acts. We should expect that how the underlying issues are resolved for Medical Homes and Accountable Care Organizations will be similar, given the many shared legislative goals of these two models.
The Medicare Shared Savings Program (MSSP), established by PPACA Sec. 3022, allows for the inclusion of non-physician providers, by reference to existing definitions. Section 3502 of PPACA establishes a grant program to create health teams that provide support to primary care providers and provides capitated payments to these providers. It defines "primary care" as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community." Similarly, Sec. 5405 defines a "primary care provider" as "a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing a sustained partnership with patients, and practicing in the context of family and community, as recognized by a State licensing or regulatory authority." Another section of PPACA states: "TREATMENT OF QUALIFIED DIRECT PRIMARY CARE MEDICAL HOME PLANS. – The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan." We should expect that non-governmental accrediting agencies will soon begin addressing this important policy void. Typically, such entities have provided significant flexibility given the differing conditions which exist across our nation, particularly in rural
Research To Practice: Last year the
Throughout the IOM report there was the distinct call for broader public engagement, especially to build the necessary trust to achieve the IOM vision. Public policy and public awareness lag behind the technical, organizational, and legal capacity for reliable safeguarding of individual privacy and data security in mining clinical data by new technologies. It was felt that there is a fundamental conflict between whether health care data should be viewed as a public good or a private commodity. This relates directly to underlying privacy concerns often espoused by organized psychology and the fear by patients of discrimination. "In many respects, the greatest challenge associated with establishing a medical care data system to serve the public interest lies in the fact that such data largely reside in the private sector, where commercial interests and other factors inhibit sharing." Ultimately advancing the notion of clinical data as a public good is essential to a healthcare system that learns. The utility of clinical data was viewed a transformative agent for our nation's health care system, especially as technology becomes increasingly sophisticated.
A modern evidence and value-driven healthcare system must have the capacity to learn and adapt – to track performance in real-time and generate and apply information for future improvements in safety, quality, and value of care received. Today, there are enormously misaligned incentives which have evolved from an obsolete reimbursement system. Research must become a normative part of health care, in which every intervention with a patient is seen as an opportunity to learn. In essence, it is time to adopt an entirely new paradigm. Taking a broader perspective, it is possible to integrate data taken on socioeconomic, environmental, biomedical, and genetic factors; individual health status and health behaviors; biomedical and genetic factors, as well as on resource use, outcomes, financing, and expenditures. These data are stored in a variety of electronic silos and data bases and, under appropriate policy conditions, can be meaningfully aggregated and integrated. Change is coming – about half of primary care physicians report that their patients have arrived with research from the Internet. Yet changing the culture of providers to collect data in high-quality ways remains dramatically difficult.
To effectively change behavior, we must directly address incentives and realize that the existing incentive structure discourages information sharing, giving greater weight to possible errors in protecting privacy relative to errors in failing to use existing information to improve public and individual health. To build public support, the value of sharing clinical information must be demonstrated. The public must come to appreciate the significance to them of the National Academy of Sciences' estimate that 25 percent of developmental disabilities (i.e., cerebral palsy, autism, and mental retardation) are caused by environmental factors. And, the American Cancer Society's estimate that one-third of cancer deaths could be prevented through lifestyle and environmental changes. Effectively utilizing clinical data will make a real difference in the lives of many citizens and is critical to the well functioning of integrated primary care. Will psychology take a leadership role in educating society? The three major challenges for the 21st century are culture, communication, and collaboration.
The common workshop themes which emerged were: * Clarity on the basic principles of clinical data stewardship; * Incentives for real-time use of clinical data in evidence development; * Transparency to the patient when data are applied for research; * Addressing the market failure for expanding electronic health records (EHR); * Personal records and portals that center patients in the learning process; * Coordinated EHR user organization evidence development work; * The business case for expanded data sharing in a distributed network; * Assuring publicly funded data are used for the public benefit; * Broader semantic strategies for data mining; * And, Public engagement in evidence development strategies.
In submitting the FY'12 budget request for the National Institutes of Health (NIH) the Director: "This budget request for a $31.987 billion total program level reflects an effort, amid economic uncertainty and fiscal constraint, to fulfill the President's unwavering commitment to international leadership in science and progress in biomedical research. The requested funding will enhance NIH's ability to support research that prolongs life, reduces disability, and strengthens the economy…. (E)nhancing the evidence base for health care decisions: NIH will support rigorous studies for assessing the effectiveness of new therapies and health care interventions within populations and for individuals. Research in comparative effectiveness and personalized medicine is essential to the fulfillment of the agency's mission and will enhance the evidence base for decision making in clinical practice. For example, NIH will fund a Health Maintenance Organization Research Network Collaboratory. This landmark initiative will bring together HMOs caring for more than 13 million patients for the purpose of accelerating research in the high priority areas of epidemiological studies, clinical trials, and electronic-health-record-enabled health care delivery."
The Robert Wood Johnson Foundation(RWJ) recently announced a highly relevant grant program seeking to build the evidence for and strengthen the use of regulatory, legal, and policy solutions to improve public health and help citizens live healthier lives. This would include identifying those laws and legal practices which unintentionally harm health. As always, we live in "interesting times." Aloha,
