Health Care Reform Is Dead—Long Live Health Care Reform

The 1993 Clinton health care reform effort was not the end of reform but the inauspicious start of a fiercely contested round of reform that may take another decade or two to complete. The 1993 Clinton plan was just the latest stage of a battle for national action on health care than began with Teddy Roosevelt's promise of compulsory health insurance in the 1912 presidential campaign. [Dionne EJ Jr, Hacker JS: Health care reform is dead—long live health care reform. Ann Emerg Med December 1997; 30:742-745.]     

Health Care Reform and the Primary Care Workforce Bottleneck

To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the “silver tsunami” of 80 million Americans retiring over the next 20 years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.     

Students Delivering Health Care to a Vulnerable Appalachian Population Through Interprofessional Service-Learning

Interprofessional student service-learning experiences are integrated into the preventive care of older adult residents of public housing in Appalachia. Receiving a Health Resources and Services Administration grant provided the College of Nursing at East Tennessee State University the opportunity to expand interprofessional clinical experiences for students by partnering with the College of Pharmacy, the College of Clinical & Rehabilitative Health Sciences, and the local public housing authority. Select faculty from each college met and developed a plan to form student teams from all three colleges to conduct in-home comprehensive medical and nutrition assessments and medication chart reviews of high-risk older adults. Following the in-home visit, students and faculty discuss the assessment findings at planned interprofessional meetings. Students present their findings from each discipline's perspective and collaboratively set health priorities and develop intervention strategies and an inclusive follow-up plan. Excerpts from students' reflective narratives discussing the impact of the interprofessional service-learning experiences are shared.     

Innovation in the Safety Net: Integrating Community Health Centers Through Accountable Care

BACKGROUND

Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers.

OBJECTIVE

This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers.

DESIGN

Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013).

PARTICIPANTS

One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs.

MAIN MEASURES

Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software.

KEY RESULTS

Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise.

CONCLUSIONS

A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.     

Transforming Health Care Through the Medical Home: The Example of Heart Failure

Amid ongoing legislative efforts to achieve universal coverage and reduce costs while improving quality of care, heart failure represents a major public health problem, challenging us to restructure systems of reimbursement and care. The “medical home” represents the best option for aligning and incentivizing multidisciplinary groups of providers to optimize decision-making for individual patients and the population, at large, and to compete based on quality and cost. For the medical home to meet the needs of patients with heart failure, it must eliminate barriers and facilitate collaboration among specialists, primary care physicians, and other providers. It must provide sufficient expertise for the complex and diverse population of heart failure patients to individualize recommendations that range from heart transplant to palliative treatments. Where appropriate, patients should be offered the choice between an emphasis on quality versus quantity of life. Although rewards and penalties based on specific externally driven metrics may be useful as an intermediate step in the current fee-for-service environment, this approach has important limitations and should transition quickly to a medical home approach. The current drive to change US health care should seek to transform our system of reimbursement and care to one that provides for continuous multidisciplinary management of all patients, including those with complex, chronic conditions such as heart failure.