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.

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:

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.

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:

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.

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.

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:

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 Arizonans 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. 

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.

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.