Primary Care

We don't often post raw links or pictures without commentary, but the last few weeks have involved a few great ones that we couldn't pass up.

First: via the new Washington Post Wonkblog (congrats on the new site, guys!), Dr Seuss explains the medical arms race in the video to the right! (Watch it fullscreen--it's worth it!)

Welcome to the first installment of our “Health By The Numbers” daily feature! Each day, we’ll be presenting a surprising number with some significance to health care, whether it be the implementation of the Affordable Care Act implementation, federal health spending, or the storage capacity of the human brain (4 Terabytes!) Let us know what you think of this feature or suggest a Number of the Day via email or Twitter!

All too often, patients facing elective surgeries are not given the chance to learn about the full range of options available to them.  Many go into the operating room unaware of the unique risks and benefits of the procedure they're about to undergo.  Some even fail to understand the elective nature of the treatment, that the decision to go under the knife is actually theirs -- and not their doctor's -- to make. The result? Patients often don’t get the treatment they would have preferred had they been if fully empowered and informed.

Today marks the unveiling of a new report from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making that illuminates this enormous problem.  And it is enormous. As many as 70 percent of patients undergoing certain surgical procedures would have chosen a different option had they had a chance to be fully informed, and to share the decision with their provider.

For Medicare patients with conditions that can be treated with surgery, whether or not they undergo elective surgeries depends largely on where they live and the clinicians they see. According to the report:

Researchers found Medicare patients living in Casper, Wyoming are nearly six times more likely to undergo back surgery than patients living in the Bronx.  Medicare patients with heart disease in Elyria, Ohio, were 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu. And women over 65 living in Victoria, Texas were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Indiana.

(Full report available here)

To highlight the dramatic findings of this study, the New America Foundation will host a roll-out event at 3:00pm on Friday, February 25^th.  (Register here) Shannon Brownlee, the lead author of the study and Acting Director of New America’s Health Policy Program will open with a short presentation of the Atlas’ findings, followed by remarks from Len Nichols, the Director of the Center for Health Policy Research and Ethics at George Mason and Christine Bechtel, Vice President of the National Partnership for Women and Families.

The report used Minnesota as a case study to highlight that even in a state widely known as a leader in patient-doctor collaboration, there remains room for significant improvement.

(Pioneer Press)

Variations of this magnitude are the byproduct of a system in which physicians and patients are often unequal partners in the decision making process. What patients truly want may not be taken into account when medical decisions are made.  In addition to analyzing data on practice patterns, the report advocates for shared decision making, a process by which a patient is fully informed about the potential risks and benefits of available procedures before choosing a treatment plan with their doctor. 

In the absence of clear, evidence-based guidelines for care, rates of surgery can vary wildly based on non-medical criteria. Rates in small communities, for example, can swing based on the opinions of one practice or a small number of doctors. Some prefer surgery, while others might be motivated by lucrative reimbursements for the procedures. "The goal really is to get patients and others to see the extraordinary range of the variation," said Shannon Brownlee to the Star Tribune. "While some differences are to be expected, she said, "those differences are swamped in many cases by the variation that is driven by [a doctor's] opinion."

The release of this newest Atlas will advance the conversation about appropriate rates of medical care and about truly patient centered care. We've been making the case that overtreatment is rampant in our health system, from implanted defibrillators to early induced delivery to mammography.  We simply don't know what the "right" rates are, but we know that when patients are fully informed, they may want less care, or less invasive care.  According to Dr. Michael Barry, President of the Foundation for Informed Medical Decision Making, a patient engaged in shared decision making chooses a more conservative course of treatment for a variety of conditions on average 20 percent more often. With the health system's current cost crisis, supporting conservative -- often less expensive-- treatment is an essential tool to lowering utilization and controlling runaway health expenditures. Doing so with shared decision making can tackle this problem WHILE improving patient outcomes and satisfaction. It beats the alternative of waiting until impending fiscal catastrophe forces more draconian decisions.

But the more important reason to advance shared decision making is that it's the right thing to do for patients.  We hope you can join us in bringing attention to this critical issue.

Like many American patients, the American health care delivery system suffers not only from acute crises, but also from a chronic, poorly managed and debilitating disease. Primary care is in trouble. Not only are primary care physicians (PCPs) fleeing the profession in droves, but fewer and fewer medical students express an interest in pursuing a primary care career. Those entering the profession don't last long - 1 in 5 general internists become specialists by their tenth year in practice. The workforce pyramid needed to support effective health care reform – with a broad base of primary care providers – is being steadily eroded.

The coming crisis was the topic of a recent conference hosted by the American Board of Family Medicine and the Robert Graham Center. Dr. Robert Phillips, director of the Graham Center, emphasized that while the average ratio of individuals in the U.S. to PCPs is 1500:1, that ratio ranges from 500:1 to 5000:1 depending upon the region you’re talking about. While we don’t know the “right” ratio, we do know that rural communities are particularly barren of PCPs.

With all the focus on health reform, we sometimes sort of forget that the Department of Health and Human Services is responsible for a whole lot of other aspects of health policy. Like about a zillion. Someone I know over there suggested I check out the HHSinnovates program on the department’s HHS.gov/Open website, and it was interesting to see how this big sprawling department with 300-plus programs is trying to create a “culture of innovation.” (I know, it can be a cliché, but take a look.)

Basically everybody in HHS no matter who they are or where they work can submit a bright idea. They aren’t supposed to be abstractions, but ideas that work and can be replicated and spread and expanded. Dozens of promising ideas get posted on a secure internal website, and then everyone at HHS votes. HHS Secretary Kathleen Sebelius recognizes the top ones.

Let's zoom in on one aspect of the new report on "The Future of Nursing: Leading Change, Advancing Health" -- nurses' role in primary care aimed at managing chronic disease, particularly in high risk, underserved populations.

The report, the result of a two year initiative from the Robert Wood Johnson Foundation and the Institute of Medicine, will fuel the ongoing fight, federally and in the states, over "scope of practice" - ie letting nurses with post-graduate degrees do more complex care, with less supervision from physicians. People who see Advanced Practice Nurses as part of the solution to the primary care workforce like this; doctors generally don't. (My colleague Meredith Hughes has posted on this topic here, here, and here and Mary Agnes Carey and Andrew Villegas at Kaiser Health News did a really good job of illustrating the crosscurrents.)

Several of us from New America spent some time at the Agency for Healthcare Research and Quality’s big annual conference this week, its first since health care reform with all its potential for primary care was enacted. It’s a bit hard to sum up (keynote speaker Atul Gawande called it being "in the trenches with the data") so I’ll jump off from the opening plenary -- "21st Century Health Care: What Does it Mean to Achieve Success in Quality, Value, and Access to Care."

AHRQ director Carolyn Clancy (we had a chance to talk to her this summer here) moderated, and the panelists were Maulik Joshi, president of the Health Research & Educational Trust and senior vice president for Research at the American Hospital Association, James Mold, professor and director of research in the Department of Family and Preventive Medicine at the University of Oklahoma College of Medicine and Debra Ness, president, National Partnership for Women and Families (and the fact that Ness was there, keeping the focus on what patients/consumers/families want, was itself telling).

The discussion started with the observation that "patient-centeredness" is a bit of a Rorschach test, but panelists agreed (more or less) that people want coordinated care from someone who knows them, and can treat the whole person, not just an organ or a condition. They want to be engaged, and share in the decision-making. And getting there is tough.

This is a story I loved writing: a family with three generations of doctors (It appeared in the Washingtonian print edition over the summer, it’s now on the magazine web site.) It’s narrative, not Policy with a capital P, but the family story encompasses so much of what's happened in American medicine over the last half-century, good and bad, and a lot of what we need to keep in mind as we redesign our health care system for the future..

Here is my latest contribution to the Altarum Institute's Health Policy Forum, another in my series of "what works" posts. This one is about an innovative Medicaid Managed Care plan in Oregon.

Care Oregon, the state’s main Medicaid managed care plan, had two choices a few years ago, after many commercial partners in the Oregon Health Plan decided to get out of the money-draining business.

It could go broke. Or it could change its world.

It opted for the latter. Today, the Portland-based nonprofit CareOregon is a bit savvier about the business end of its mission. And it’s still trying to change its world.

With our medical costs rising, coverage set to expand dramatically, and a shortage of primary care doctors looming, finding more efficient ways to deliver care is essential. One solution to the shortage of physicians is to expand the roles of non-physician health professionals, such as advanced practice nurses and physician assistants. The National Health Policy Forum explored this topic in a recently background paper, Tapping the Potential of the Health Care Workforce: Scope-of-Practice and Payment Policies for Advanced Practice Nurses and Physician Assistants.

First some basic definitions: an advanced practice nurse (APN) has specialized training and certification beyond what is required for an RN. APNs include nurse practitioners, nurse anesthetists, clinical nurse specialists, and nurse midwifes. Physician assistants (PAs) can hold either a bachelor or masters degree, but are all required to have several years of experience in the health care field and, like APNs, specialized training.