Primary Care

HEALTH REFORM: Necessary Nurses

Allison Levy — Fri, 13 Nov 2009 19:26:00 -0500

If all goes well, and we have a new and improved health care system -- which will have to absorb millions of newly insured people, many of whom have been putting off needed care -- one thing we're going to need is more nurses. And once we have them, we need to use them well.

As the AARP's John Rother and RWJF's Risa Lavizzo-Mourey reminded us earlier this year in Health Affairs:

It is nurses -- of every stripe -- who will deliver, coordinate, and direct care in hospitals, clinics, and physicians' offices, and it is these same most necessary nurses who are in short supply...

Nursing has developed and implemented innovative models of care that promote the goals of policymakers for health reform: expanding access, improving quality and safety, and reducing costs, (but) extending these models of care to the general public will be difficult without action to bolster the future nurse workforce.

A nurse's primary job, as the nurse-of-all-nurses Florence Nightingale once said, is to take "charge of somebody's health." The Institute of Medicine found that nurses are more likely than any other health care professional to both catch medication errors and prevent hospital-acquired pneumonia (which can raise treatment costs by $28,000 and increase hospital length of stay by 5 days.) Research demonstrates that higher levels of hospital nurse staffing is directly associated with nearly 25 percent fewer adverse outcomes. Yet studies have also found that nurses spend perhaps only 30 to 35 percent of their time actually at a patient's bedside. The Institute for Healthcare Improvement would like to see this number double.

The Institute of Medicine and the Robert Wood Johnson Foundation are working on a joint initiative, The Future of Nursing, to develop a "clear agenda and blueprint for action."

We got a sneak preview of some of what they are thinking about through an IHI audio program. Taking part was the chair of the IoM panel Donna Shalala, PhD, former U.S. Secretary of Health and Human Services who is now president of the University of Miami; Sue Hassmiller, PhD, RN, FAAN, director of the RWJF Initiative on the Future of Nursing; and IHI vice president Pat Rutherford, RN, MS. (Listen to the program here.)

What changes can be made to address the nursing shortage (which some estimate could reach half a million by 2025), increase nurse retention rates (turnover is highest in hospital surgical units, and each time a nurse leaves, it costs the hospital $50,000 to $65,000 to replace her), and enable nurses to do what they do best -- provide quality direct patient care?

Among the problems and solutions the experts noted:

Stress and disruptive behavior is often reported within health care settings. Conflicts amongst nurses, and between doctors and nurses, lead to unsafe and stressful working conditions. Work environments should reduce waste and inefficiencies, improve communication and decrease the time nurses spend "hunting and gathering" for supplies and information etc.
As we have written before, the widespread (and smart) adoption of health information technology will help improve the safety, efficiency and effectiveness of the U.S. health care system. Nurses should be involved in the design, and be thoroughly trained in using the technology.
All nurses should go through quality improvement training with a focus on patient care.
Health reform includes an emphasis on primary, preventive and patient-centered care -- and nurses should be central to this. Rutherford argued that it is wrong to think that we can substitute nurses for primary care physicians -- but we can utilize nurses' skills to improve and expand the scope of primary care.
Nurses need to be more involved in transitional care; patients have better outcomes (and reduced rates of rehospitalization) when they have good transitional care following hospitalization. Hospitals, as an example, could establish nursing "SWAT teams." Nurses would go into a patient's home and ensure that it is adequate for the patient's post-hospitalization return. (Will the patient be able to easily get to the bathroom? Will the patient trip on throw rugs? Are the medications right?) Hospital nurses should also be encouraged to communicate more with community providers so they have appropriate information for successful patient "hand offs."
Nurses should have a bigger voice in the boardrooms of organizations that oversee the health care quality agenda in the United States. Nurses learn quite a bit about quality and safety -- and they know "what works" on the ground, not just in theory. (Right now, only two percent of all health care company board slots are occupied by nurses.)
One way to address the nursing school faculty shortage (which perpetuates the nursing shortage) may be to have top national nurse educators record lectures, webcasts and podcasts for widespread use, and have the local faculty focus on teaching students how to apply these classroom lessons directly in a patient care environment.
Clinical practice and education need to be more closely tied together. Hospitals should encourage mentorship amongst experienced and newly-minted nurses -- a bit like young doctors have internships. (Studies demonstrate that on-the-job-training lowers turnover rates of nurses.)
Nurses need more training in geriatrics because of the aging population.
Health care settings need to permit flexible working schedules to encourage older nurses to remain in the workforce longer. (We don't recall hearing this on the audio, but flexibility might help more nurses with young children remain on the job at least part time.)

Several hospitals and states are already making efforts to improve the "future of nursing." For example:

The Coalition to Protect Massachusetts Patients would like to restrict the number of patients that a nurse can care for at any time and ban mandatory overtime.
The New Jersey Hospital Association's Institute for Quality and Patient Safety received a $732,000 grant from the Robert Wood Johnson Foundation to help New Jersey hospitals implement RWJF's Transforming Care at the Bedside program. This program will "provide education and training in performance improvement for front line staff nurses so that they can identify, test and implement improvements on their units."
Mississippi and South Carolina have increased faculty salaries.
As we wrote last year, in 2004, the Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses who guide them as they acquire more complex skills.

Too soon to know which of these the IoM group will consider to be top priority, or how quickly we can act on them. But if we're going to fix our health care system and give people the care they need, we're going to need more nurses and we're going to have to use them more wisely.

HEALTH CARE: Medical Home Model Catching On

Joanne Kenen — Tue, 20 Oct 2009 18:18:00 -0400

People hear "medical home" and they aren't exactly sure what it means. Judith Graham of the Chicago Tribune explains.

It's a new model of primary care that can address a lot of what drives us crazy in U.S. medicine (at least those of us with doctors and insurance). There isn't yet precise agreement on what a medical home is, or who it should serve, but usually the idea is a way to improve primary care, with particular emphasis on prevention and control of chronic conditions such as asthma or diabetes.

So instead of long waits and rushed visits, Graham writes, imagine this:

The phone rings and it's the doctor's office reminding you that it's time for your flu shot and to have your cholesterol levels tested.

"Oh, and Mrs. Smith, I know you have diabetes," the nurse continues. "How is everything going? Do you need anything from us?"

A week later, there's an e-mail from your physician on your BlackBerry. "Mrs. Smith, I adjusted your medications at our last visit. If you're having any side effects, please call," he writes.

The medical home concept usually entails a team approach. A physician or physicians works with nurses, physicians' assistants and health coaches. The doctor directs the overall care, and takes the lead on the more complex or compelling conditions. (For other posts we've written on successful medical homes in a variety of settings, including some adapted by solo practitioners, see here, here, here, and here)

A pioneer in this field is Seattle-based Group Health Cooperative (part of the Health Care CEOs for Health Care Reform) Early data show that its medical homes have reduced emergency room visits by 29 percent and hospitalizations by 11 percent while improving quality of care, according to a September report in the American Journal of Managed Care.

Routine tests are arranged before an appointment, not after, so the doctor has the results when the patient comes in. Nurses follow up by phone when a patient goes to the ER or the hospital. Doctors make phone calls and email patients -- activities which can be very efficient for follow up and monitoring but which doctors in traditional care settings don't get paid for.

For medical homes to work we'll need to change how doctors are paid (which health reform would do, up to a point, and which private insurers are also starting) Electronic health records are also essential. People sometimes worry that medical homes will be like the HMOs of the 1990s -- and in some ways they will. But the HMO model easily became about restricting care because that's how the economic incentives worked. The medical home model, in contrast, has built-in rewards for quality of care. Medical homes thrive when and only when the patients thrive.

IN THE STATES: Doing Primary Care Right -- In Alaska (Part 2)

Joanne Kenen — Fri, 18 Sep 2009 14:27:00 -0400

Yesterday we posted about innovations in primary care and quality improvement in a medical center that serves Alaska Native people. Today Dr. Doug Eby, a family physician and medical director of the nonprofit Southcentral Foundation nonprofit health system, talks about items on his care quality "to-do" list and what dimensions of health reform can help him achieve them.

Dr. Eby spends a lot of time thinking about end-of-life care -- specifically how to "improve the conversation." Many experts in the field of palliative medicine have found that better communication, earlier in the course of disease, can both improve care and save money. Those conversations give patients a clearer idea of the likely course of their disease, and physicians have a greater understanding of patients' values, choices, and wishes.

"We can do a much better job, at less cost," Eby said, adding his goal would be to "help people transition out of life in a wonderfully celebratory way," with their pain controlled, their wishes respected, their stories heard.

Second, he and his colleagues want to address the "high utilizers," the people who are coming in 15 or more times a year. "How do we learn more about them? How do we better meet their needs?"

"We need to understand the social complexity of their lives much better," Eby said. That will require more than managing physical symptoms. They will also have to examine homelessness, social supports, and mental health. "We need to bring in behavioralists to understand their story," and find ways of addressing their needs in the community.

Third, they want to build on the healthy habits of pregnant women to create a continuum of childhood health from preconception through the first few years of life.

"We know that a large number of pregnant women, and their families, will make very positive lifestyle changes. They'll stop smoking and drinking, they'll get enough sleep, they make a bunch of healthy changes. We've convinced people as a society that that's important to do, and they are a lot healthier. Then, on day one after their pregnancy -- it's over. That's a lost opportunity -- for the mother and the child." Some lifelong patterns, including eating habits and other factors contributing to obesity "are pretty much in place by the time you start school."

Eby's team is exploring how to change patterns of care to create more continuity, instead of repeated broken relationships. For instance a woman may switch from primary care to obstetrics or a midwife, back to primary care, while the child goes off to a pediatrician. "We engineer three or four or five breaks by design" instead of leveraging that magic moment of a baby's birth into a health opportunity for the child, parents, "aunts, uncles and grandparents."

Speaking by telephone recently from Anchorage, Eby sounded ready for health reform -- if it gives him the tools he needs to improve care not only of individuals but of a complex community. "The U.S. health care structure is the dumbest thing created by human beings in the history of mankind," he said. "There are good things in it, of course, but the system is insane."

What he's looking for -- besides of course, help for the uninsured -- is change in the underlying way the system works.

He wants to be paid for "doing the right stuff" for improving the health of the population over the long term. He wants to be rewarded for good outcomes, now and over time. He wants a system that will reimburse him for things he knows work -- like care coordination, complex case management, and a robust medical home -- that aren't highly valued, if they are valued at all, in the current payment system.

"Build in the incentives. If I can improve the health status and drop the total cost -- if I'm on the hook to do that -- hold me accountable. And incentivize me."

And he wants a system that takes into account the social complexity of the clientele for whom we provide services and partner with. "If you pay only for the services, the incentive is for health care providers or organizations to skim the relatively healthy, and avoid or underserve the high-need, high-complexity cases. "It's got to be calibrated... if that isn't built in, you're screwed."

In short, he wants a world which enables him to deliver culturally-sensitive, economically-efficient, integrated health care that addresses the physical, emotional and spiritual needs of individuals, families and communities. Tall order, but he's already started.

IN THE STATES: Doing Primary Care Right -- In Alaska (Part 1)

Joanne Kenen — Thu, 17 Sep 2009 15:47:00 -0400

I've met Dr. Doug Eby twice, exchanged emails, spoken on the phone, read articles by and about him, and I'm still not quite sure how he ended up practicing medicine in Anchorage, Alaska. But I do know that the innovations and quality he and his colleagues have achieved in a challenging setting is attracting notice in the lower 48.

Eby is a family physician and the medical director of a nonprofit health care system that serves Alaska Native people in Anchorage and far flung remote communities, some accessible only by air.

He has learned that a diagnosis and a pill don't necessarily make a patient well. And he has helped organize Southcentral Foundation (SCF), the tribal-owned system that has attracted notice nationally for its innovation and ability to find a better way to deliver quality health care

Before the makeover, he wrote:

The system misunderstood the core product as being tests, diagnosis, pills and procedures. When individuals sought health care services, providers would take their signs and symptoms, perform a physical examination, and produce a differential diagnosis. Then providers would do what health care does really well: order a bunch of tests. That would lead to a definitive diagnosis, which would then result in pills being prescribed, procedures and tests being ordered, and perhaps some advice being delivered. When the visit was done, the provider thought the work was done.

But really, that isn't the model that works best for chronic illness, long-term conditions, prevention and wellness.

The customer decides whether to pick up the medicine the provider prescribes, whether to take it as prescribed, whether to share it with a neighbor, whether to split it in half so it lasts longer, whether to stop taking it in a few days, whether to exercise, what to eat, whether to drink too much, whether to smoke... All of these things are determined by the customer and not always in the provider's presence.

SCF, which runs outpatient centers focusing on primary care and jointly operates a 150-bed hospital with the Alaska Native Tribal Health Consortium, regards patients as both its owners and its customers. SCF focuses on community and primary care (broadly defined). The consortium is responsible for more specialized inpatient care.

The clinics provide about 400,00 outpatient visits a year, integrating primary care, behavioral health, and, when appropriate, traditional healing and complementary medicine such as acupuncture. For complex historical and economic reasons, they have to do it efficiently. As Eby explained, they have no choice.

SCF isn't a purely safety net hospital, but it has a safety-net component. Many customers are educated, health-literate and insured. They could seek care outside the tribal system, and, before the SCF makeover about a decade ago, they did. But now they choose to get their care there.

But Eby and the other providers also see poverty, unemployment, and a fair amount of dislocation and family disruption as people transition from a rural subsistence lifestyle to an urban, cash-based environment. "It's fair to say that our population has higher than the general community's averages of risk factors," Eby said. Health care, therefore, must include getting a handle on stresses, smoking, alcoholism, nutrition.

The patient mix means there is also a payment mix -- Medicare, Medicaid, private insurers, and a payment from the federal government based on the tribal status. The federal money gives SCF some flexibilty and room to innovate -- but it also never keeps up with the rising cost of care, Eby said. "We have to become smarter about how we design and deliver services every year," said Eby, who has been there nearly 20 years.

"In our system, every bit of outpatient care is delivered through an integrated primary care team," he said. The team has access to "immediately available advice and support" from cardiologists or other specialists but they are "truly consultants, and not primary care givers." Specialists do see the patients, of course, when needed, but at about one-fourth the rate elsewhere. And when a patient (or customer) does need to see, for instance, the cardiologist, he or she is seen that day or soon after. No weeks of waiting. It's fast and convenient -- the specialists are right across the street, and next spring they will move into the primary care building.

When patients need something, they call their care team -- not via a clerk at a front desk.The team assesses whether they need to come in, and can usually arrange an appointment that day. The team includes primary care provider, a case manager, two medical assistants, and there's one behavioralist for every three teams.

Because the team works so closely, they pack as much of the routine annual care into a visit. For instance, if a child comes in with an ear infection, the team will make sure they do the appropriate preventive care, immunization, screening and wellness services at the same time. That way there's no need for a special "well-child visit" (unless the child never gets sick enough to need the doctor in between scheduled checkups). A woman who comes in with a sprained ankle may also get caught up on her routine OB/GYN care. If a 45-year-old man comes in for the first time in five years, and he's happy and healthy other than, say, an ingrown toenail, he'll get the relevant routine checks and maybe a tetanus shot. But if he's not so happy and healthy, he may get some help with diet and exercise, smoking cessation, lowering his risk for things like diabetes and heart disease.

It is all holistic -- and scientific. They measure outcomes -- both through standard HEDIS measures and patient satisfaction surveys. Eby lists successes:

Hospital days per 1,000 people have dropped by more than half
They have 40 percent fewer inpatient admissions
Emergency room visits have plummeted
Specialty visits dropped by 60 percent
Diabetes is being better controlled
They have high immunization rates
They have high rates of screening for colorectal cancer and depression

In part two of this post, Eby shares his "to do" list -- What problems have not yet been solved, what they are doing about it -- and how health reform can help.

Photo copyright Southcentral Foundation

IN THE STATES: Indiana Leads the Way on Prevention

Allison Levy — Fri, 11 Sep 2009 16:29:00 -0400

We all know you can earn rewards for frequent flying. But what about for routine trips to your doctor?

Emphasizing primary care and preventive services is a key goal of health reform and many contend the savings from such programs can help finance a health care overhaul (and make us a healthier country). Yet, the details of how these savings might be realized are less clear.

Indiana is one state to find some answers. Contributing to a statewide effort to improve population health, Managed Health Services, one of three Medicaid plan administrators in Indiana, now offers the CentAccount Healthy Rewards Program. Participants accrue dollars on a CentAccount Mastercard debit card as a bonus for participating in appropriate preventive care services -- in the appropriate care settings. LIke the doctor's office, not the E.R.

For example, a patient will earn $15 for seeing a primary care physician within the first three months of joining, and can get additional money if they get certain screenings, for instance for cervical cancer or chlamydia. (which can cause complications in pregnant women and their newborns.) They earn $10 each time they take their newborn baby to the doctor's office for a recommended checkup.. The money on the card can then be used to pay for health-related items at participating grocery and convenience store, including over-the-counter medicines, diapers, and bottles.

Pat Rooney, president and CEO of Managed Health Services, recently told the AP, "What we're trying to do is promote the healthy behavior and make sure the people are getting the right things that they need." Rooney contends that "Just getting people in to see their primary care doctor is always a challenge with this population."

Realigning incentives is a central goal of reform. As we've written before, small changes can have a big impact on personal behavior, health, and system savings. Often, the return on investment from primary care and prevention depends on how you define these programs. The results from Indiana's initiative expand our definition and refine our discussion of such efforts.

QUALITY: Primary Care Doctors Pay For Med School Through Public Service

Meredith Hughes — Tue, 09 Jun 2009 15:36:00 -0400

The shortage of primary care doctors is a big problem across the nation, but it's an especially big problem in underserved areas, where people are more likely to struggle with poverty and less likely to have health insurance.

In Boston the other day, HHS Secretary Kathleen Sebelius announced that $200 million from the economic stimulus package would help recruit primary care doctors, according to the Boston Herald. In exchange for federal aid in paying off medical school debt and student loans for medical, dental, and mental health professionals (up to $50,000 in repayment), clinicians pledge two years of service through the National Health Service Corps. Through this organization, clinicians will be assigned to an underserved area designated as a Health Professional Shortage Area. Those can be populous urban centers or poor, rural areas where there are simply not enough doctors to meet the needs of the population.

Sebelius' choice of Massachusetts was particularly significant to this issue. The state has managed to extend health care coverage to approximately 97 percent of the population, but it's still striving to increase the number of primary care physicians in the state.

Sebelius stated that increasing the number of primary care doctors was vitally important to the President's goal of national health care reform, and the funding is expected to bring more than 3,000 new health professionals into the National Health Service Corps. Primary care doctors are the key to health reform goals such as lowering cost and providing more comprehensive, preventative care to patients. Given that many doctors feel pressured out of primary care by financial concerns including large medical school debt, investing in the National Health Service Corps is a smart investment in the future health of all Americans.

HEALTH CARE: Where Have All the Medical Students Gone?

Joanne Kenen — Wed, 20 May 2009 16:42:00 -0400

Where have all the medical students gone?

No, Pete Seeger has not written the anthem for health reform circa 2009. (Although it's not a bad idea).

It's the headline of a blog post from Bob Doherty of the American College of Physicians, who spends a lot of time peering into the primary care equivalent of a crystal ball, trying to see if anyone's home. (We are mixing our metaphors here but at least it reflects the fragmented nature of our health care system).

Doherty, Senior Vice President of Governmental Affairs and Public Policy for the ACP, accompanied 100 med students and internal medicine residents at a recent ACP leadership day on Capitol Hill. Their goal was to help restore primary care to its rightful place in the American medical universe.

He knows that unless something changes, preferably as part of an overhaul of the whole health system to improve access to preventive care and to improve coordination of care, young doctors are not going to enter primary care in adequate numbers.

Doherty writes:

Right now, about one out of three doctors in the U.S. are in primary care specialties, compared to the 50/50 mix found in other countries with higher performing health care systems. This would be bad enough, but unless next year's graduating class (and the ones that follow) are given a reason to look more favorably on primary care, fewer than one in five physicians will be in primary care. We know this because only 17% of U.S medical school graduates in 2008 expressed a desire to go into primary care, an all time low. We also know from studies that without more primary care physicians, the American people will experience higher cost of care and lower quality.

Doherty believes that we can't place the blame on young doctors for shunning primary care; we created the system that thwarts them. "If we really believe that patients should have a personal physician who is trained in comprehensive and longitudinal care, then we would show this to our medical students. We would pay primary care doctors better, reduce the paperwork and hassles ...associated with primary care, pay off their debt, and expose them to the joys of primary care in their training."

The ACP earlier this month put out a white paper on the primary care workforce. Among the key points:

Establish a permanent national commission on the health care workforce to plan and set targets for increasing primary care capacity to meet the present and anticipated US health care needs.
Med school loan forgiveness and related incentives for doctors-in-training to go into primary care.
Better Medicare payments for primary care—not necessarily at the expense of specialists.
Growth of patient-centered medical homes and other innovations designed to improve prevention, wellness, and care coordination.

These aren't the only ideas out there for fixing primary care. (Ask any nurse practioner). But if we don't take action soon, Pete Seeger may revise his folk classic, "If I had a Hammer." After all, what good's a hammer if there's no one to test your reflexes with it?

COVERAGE: The Pandemic Motivator

Joanne Kenen — Thu, 30 Apr 2009 17:39:00 -0400

We write all the time about the economic and moral imperative for covering all Americans. Today, we'd like to address the public-health we're-all-in-it-together pandemic flu imperative for covering all Americans.

We don't yet know how bad the outbreak will become, and it goes without saying that along with everyone else on the planet, we hope it is mild. But the fact that we have 46 million (probably more given the recession) people who are uninsured and don't have easy access to care, outside the emergency room, is making us nervous. The border States have particularly high rates of insurance. One-in-four Texans lack insurance, nearly as many New Mexicans, one-in-five Arizonan s and Californians, (and that's 2007 data, it may well be higher now). And think about all the people who do have some insurance but may still postpone going to the doctor because they have a bare bones or high-deductible insurance policy. Times are tough, and they'll try to ride it out because they can't afford the co-pay or deductible. Delayed care can mean more serious illness—and more spread of disease.

We know we don't have a good enough primary care system in this country, and people are going to flock to emergency rooms in an epidemic or a pandemic. But think of how much WORSE that could be because people are already flocking to overcrowded emergency rooms because they don't have any place else to go. And we wonder, are our ultra-specialized specialists going to help take care of flu patients? Will they know how? Maybe the answer to this is some part of an emergency plan we haven't read yet. Comment, please, if you know—and no, we don't mean specialists are heartless or don't care about patients, we just don't know how well someone who's only done cornea transplants or rotator cuff surgery for 30 years can deal with patients with severe respiratory distress. We did see that AHRQ has resources for hospitals to plan surge capacity and to train more non-respiratory therapists to run respirators, and USA Today reported that many communities are activating their emergency plans.

Then there's the whole sick pay problem. President Obama told us to stay home if we're sick, and think about what to do if our kids' schools close. That's easy enough for those of us who can telecommute or who have paid sick days. But as our colleague, Julie Barnes, pointed out long before the current flu outbreak, we don't all have paid sick days. Or paid days to take care of sick kids. As the National Partnership on Women and Families has reminded us, nearly half the private sector workers don't have paid sick leave, and nearly 100 million workers don't have a paid sick day they can use to care for a sick child.

We know that in the past few years (partly because Sen. Edward Kennedy and former Sen. Bill Frist, who wisely seized a bipartisan post-anthrax moment and figured out how to use bio-terror defense legislation to beef up the weakened public health infrastructure for natural disease outbreaks as well, and partly because of the response to SARS and bird flu) we began improving public health capacity that had severely eroded. But the recession has taken its toll, draining "hundreds of millions of dollars and thousands of workers from the state and local health departments" the New York Times reports.

We know that some of the response to a severe flu outbreak will be via public health channels and emergency capacity and clinics, not through our everyday health infrastructure. (And the emergency response is going to have to take illegal immigrants—the third rail of health politics—into account, because no matter what you think about our nation's immigration policy, having an untreated contagious disease among illegal immigrants isn't good for any of us) But a public health crisis superimposed on a tattered health safety net and a broken delivery system makes the job harder. Even if this flu is contained, or turns out to be relatively mild, there will be another crisis. And another one after that. So reforming health care and covering everyone isn't just the morally correct and economically sensible thing to do. It's the self-interested healthy thing to do. So let's do it.

IN THE STATES: Primary Care Progress in New Orleans

Joanne Kenen — Thu, 05 Feb 2009 14:28:00 -0500

Having visited New Orleans and the Gulf Coast 18 months after Katrina, and having seen first-hand the stresses on the hospitals, ERs, clinics, mobile health vans and other health centers, it's heartening to hear even a little bit of good news emanating from that struggling city. Good news is what we heard yesterday about the progress toward building a viable, community-based primary care system in a city that had long been focused on big downtown hospitals, costly specialist care, and very, very busy, crowded ERs. In fact, storm-ravaged, long-suffering, stressed-out (add your favorite cliché here) New Orleans may show the rest of us a thing or two about how to create a patient-centered primary care system.

The Kaiser Family Foundation has done a lot of work tracking the Katrina recovery, and keeping it in the public eye. We've brought you some of their surveys and reports before. They also helped fund a recent Katrina documentary, "The Old Man and the Storm." Filmmaker June Cross (friend and colleague disclosure) showed part of the film and led a panel discussion about the Gulf Coast at Kaiser's Washington headquarters Wednesday. You can watch the whole documentary on Frontline's web site, and learn more, including some of the public and mental health challenges, on June's ongoing "Katrina Road Home" reporting project.

But what caught our attention at the Kaiser forum were remarks from Clayton Williams of the Louisiana Public Health Institute, who was on hand for the panel. We originally met Williams in New Orleans in 2007 and his briefing then left us rather overwhelmed by the daunting tasks of recovery. He left us more upbeat this time. With a $100 million grant from CMS, 80 primary care clinics in neighborhoods and schools are now serving people in four storm-struck parishes (aka counties). The network of clinics includes neighborhood primary care centers, school-based care, behavioral/mental health centers, dental care, and mobile clinics that can reach into particularly under-served areas. And they are providing primary care the right way—38 of the centers have been certified as patient-centered medical homes. Williams said they are hoping for a waiver that will let New Orleans spend more of its DSH money (usually for hospitals that serve a disproportionate share of the poor) in the community, instead of in a hospital.

Williams' goal isn't to create a health system for the uninsured. He just wants to create a good health system for everyone, focused on primary and preventive care. Given the economic status of New Orleans, though, many of the patients are in fact uninsured. He told us that the clinics served 140,000 people from September 2007 to September 2008. About 45 percent were uninsured, 26 percent on Medicaid, and the rest with commercial insurance or Medicare. That doesn't mean the clinics have reached everyone who needs health care in New Orleans. Nor can they provide all the follow-up specialist care that's needed. So this isn't a rewoven safety net. But it's a step toward recovery. And a step toward making at least a portion of New Orleans' health care system better than it was before the levees broke.

HEALTH REFORM: Have Scalpel-- Will Travel

Joanne Kenen — Tue, 13 Jan 2009 19:26:00 -0500

We've written a lot about the shortage of primary care physicians, but recently we've also seen several articles about the shortage of general surgeons, particularly in rural areas and smaller communities. Today's Wall Street Journal takes a look at the problem, and the imperfect solution—the surgical equivalent of circuit riding judges.

General surgery is on the decline because of "increasingly grueling schedules, shrinking payments and the temptation of more profitable surgical niches," the subspecialties like cardiovascular surgery or neurosurgery. Odd as it may sound to readers, some general surgeons just can't pay the bills (including big med school loans) So they become traveling surgeons, spending a week here, a week there, removing gall bladders, spleens and the like. An estimated five percent of the 17,000 US surgeons spend at least some of the time in temporary practice.

It may make sense for the surgeons, who don't have as many on-call hours, administrative headaches, overhead costs, or patients they can't collect from. Although they are spending part of their time on the road, they also can control their schedules and on-call hours more. But it can be costly for hospitals. The cost for a temporary surgeon (arranged through a staffing agency, which gets a cut) is about $1,500/day plus travel and lodgings. Critics also worry about safety lapses when surgeons operate in unfamiliar settings, or when there are more handoffs for follow-up care.

As we've noted before, all this underscores the need for health care reformers to take a good hard look at how we rebalance the health care workforce between generalists and specialists, and a payment system that shifts away from the procedure-oriented specialists toward a system of more coordinated primary care.