HEALTHCARE REFORM ON THE GROUND

One of the most rewarding aspects of being a healthcare administrator is having the opportunity to watch committed doctors and other providers interact around improving the care of patients. Over the years, this has usually been in the context of discussing the care being provided to individual patients during of rounds in the Intensive Care Unit or discussion of patients in the Cancer Tumor Board. In this context, the only focus is the patient, and the different disciplines bring their perspective on how an individual patient should be treated. I feel particular pride on these occasions because I experience the knowledge and dedication of wonderful healthcare providers being brought to bear on determining the best care for an individual patient. During those moments, all the administrative and process issues that occupy much of my time seem to vanish. It’s all about the patient.

Recently I’ve had the opportunity to observe a similarly dedicated group of health professionals, mostly primary care physicians and healthcare policy makers, grappling with the issue of how you improve care and affordability on a macro basis—for the population of a state. The Executive Committee of the Chronic Care Sustainability Initiative (CSI), which is actually the Patient Centered Medical Home project in Rhode Island, is reviewing the available evidence to determine how patient centered medical home (PCMH) practices in other states have affected measureable health outcomes and the cost of care.

We are fortunate to have a group of incredibly smart and dedicated providers and policy makers in our state leading the transformation of primary care.

As with traditional research studies to determine the efficacy of treatment interventions, such as new drugs, there are many variables to deal with in assessing the effectiveness of PCMH practices, and the pilot projects are different in each state. Although almost all the pilot projects require that practices be recognized as Patient Centered Medical Homes by the National Committee on Quality Assurance, we know there is still wide variability in how they function. In addition, it is difficult to control for the differences in patient populations and the relation of the practice to other resources in the community, such as hospitals. Some practices are part of an integrated system with hospitals and other community health providers, while others are stand-alone practices whose patients use various hospitals.

Despite the difficulty in controlling for all these variables, there is mounting evidence that Patient Centered Medical Home practices improve outcomes for patients, particularly those with chronic conditions; these practices reduce costs by reducing expensive emergency visits and hospitalization; and the patient and provider’s experience of care is enhanced. A recent study entitled “Impact of Medical Homes on Quality, Healthcare Utilization, and Costs,” in The American Journal of Managed Care, compared a large cohort of insured patients in PCMH practices and non-PCMH practices and found significant differences in all three categories. Other insurers have reported similar findings and many are investing in pilot programs around the country.

As a friend whose opinion I greatly respect pointed out, the PCMH movement is not the sole answer to obtaining greater value for our healthcare dollar, but I believe it is a very important component. We are fortunate to have a group of incredibly smart and dedicated providers and policy makers in our state leading the transformation of primary care. Their efforts may ultimately transform the entire healthcare system in our state.  In my forty-five years in healthcare, I don’t think I’ve seen the same focus and energy to find solutions, which energizes me to want to be a part of that change.

BALANCING ACT: JOBS VERSUS HEALTHCARE PLANNING

There is a growing body of evidence that the demand for inpatient acute care beds will decline over the next ten years, despite the aging of the population. This, on top of data suggesting that current inpatient bed capacity is underutilized, has led many policy experts to believe that RI has too many hospitals. Overlooked in this conclusion is that hospitals are much more than inpatient beds. They serve as a nexus for healthcare delivery in a community and increasingly are responsible for recruiting and managing traditional physician practices and other outpatient services. There is also the issue of the distribution of hospital beds and what constitutes reasonable access, particularly in an emergency. That said, there is a strong argument to be made for fewer beds and morphing some hospitals into strong ambulatory care delivery systems that are focused on population health management.

Some people, myself included, felt that we had an opportunity to pursue a rational plan for healthcare delivery and population management in Woonsocket and Westerly, as the hospitals in both communities found it impossible to sustain their current profile of services. In both instances, the communities and the staff fought to preserve a full-service hospital. Although there was concern about access to services by the communities, maintenance of employment was the primary goal of hospital staff and the communities. In both instances, the staff were willing to make concessions related to working conditions to preserve the hospital and their jobs. In the case of Landmark Hospital in Woonsocket, the staff are apparently faced with an unknown out-of-state bidder as the only remaining option after Steward Healthcare System withdrew after three years of negotiations.

"Although there was concern about access to services by the communities, maintenance of employment was the primary goal of hospital staff and the communities."

There is clearly a dilemma here as health planning goals appear to conflict with disruption to people’s employment and their lives. One wonders if there isn’t a way to pursue a more balanced approach. The first step in such an approach is to better understand the health needs of a community and, in conjunction with residents of the area served by a hospital, determine what services are necessary to meet those needs. It’s impossible to do this in a crisis, but in the case of Woonsocket we had four years to think this through. The second step is to consider what kind of healthcare roles will be necessary in the new system and where the jobs will exist. Finally, retraining may be necessary to prepare workers for the new roles.

These situations raise the question of whether we will ever be able to plan the healthcare delivery system of the future or whether we will stumble from one crisis to the next? Maybe my approach is oversimplified, but there has to be a better way to approach these situations, particularly if demand for hospital beds is going decline and we’re going to face more situations like Westerly and Woonsocket in the future.

I look forward to your comments. --Lou Giancola

IS THIS PROGRESS?

The Health Insurance Commissioner in Rhode Island has long advocated for increased emphasis and investment in primary care to improve outcomes and decrease costs. I must admit to being a skeptic as to whether investment in primary care was the most efficient way to achieve improved outcomes. I also wasn’t sure how you could shift dollars away from hospitals and specialists. Although the evidence that these investments will turn the tide on outcomes and quality is still mixed, I’ve become a strong believer, a convert if you will, that Christopher F. Koller was right. It makes sense that if primary care is the foundation of the system, and we strengthen the foundation, the whole system will be stronger. The Chronic Care Sustainability Initiative (CSI), which is really the Patient Centered Medical Home (PCMH) Project in RI, has now shown that patient outcomes improve and utilization can be reduced for patients receiving their care from PCMH practices.

It makes sense that if primary care is the foundation of the system, and we strengthen the foundation, the whole system will be stronger.

The Health Insurance Commissioner has, with the cooperation of the insurers, mandated that the insurers increase their spending on primary care by 1% per year from 2010 to 2014. He has further required that this increased spending on primary care not be included in rate increase requests. His Office has reported that the plans have met the spending target through 2011 and in their projected spending for 2012. This is a credit to the Health Insurance Commissioner, the insurers, and the primary care physicians who have embraced the concept. It also shows that change in the healthcare system is possible if you develop a specific intervention with clear targets and create a mechanism for tracking progress. This should give us hope that larger change in the system is possible.

On another note, I want to recommend that you read the statements of the Presidential candidates on healthcare reform published in the June issue of the New England Journal of Medicine and “The Conservative Case for Obamacare” in the Sunday Review Section of the New York Times.