In my role at CHRT, I work daily with the best research minds in the country and I work with communities and “grass roots” groups. I often describe what I do as bridging two worlds and helping to translate and balance between them. The work engages solid research design but in ways that are practical and able to be translated into community settings.

The two most gratifying aspects of this are when I get to see research put into action (as when results are used to improve a program, a policy or the way services are delivered) and when through the research process, we are able to pair human faces and stories to the conclusions we draw. Research is a scientific and logical process but it is also very much a human, creative enterprise. It can provide data and generate important conclusions, but it can also put a human face to the issues we are trying to address.

An excellent example involves some recent work in Genesee County. The Genesee Health Plan (GHP) is a community-based health care program for low-income individuals. In order to delve into the growing health and social service needs of families in the county, GHP received a planning grant from the Community Foundation of Greater Flint to engage the community in the research and planning process.

The research design was qualitative and included focus groups with community members, interviews with front-line health and social service intake workers and a series of community partner engagement sessions with representatives from all the major health care and social service organizations in the county. This triangulation of methods provided us with three very important but different perspectives on what gaps exist for families in Genesee County and how best to address them.

From the most conventional research perspective, this kind of work can be messy and has its known limitations. The research had to be done quickly—over the course of a few months—and within a very small budget. There were limited opportunities for creating comparison groups. One could argue that the participants were a self-selected group, and therefore may not be fully representative of the population and issues about which we are trying to learn, but nonetheless, the data—the stories—generated from this work say a lot about the needs of the community:

• Person after person describing confusion about their health coverage. One woman admitted she just presented her insurance card to her provider and thought to herself ‘Well, I hope what I need is covered.”
• A mother who had employer-based insurance—a high deductible plan that carried a $4,000 deductible – estimated that she spent about $300 a month out of pocket on prescriptions for her daughter, who had chronic health conditions. By the time she had finally reached her annual deductible, the year was almost over and she would have to start all over.
• A husband/father of three who was laid off in the most recent round of auto industry troubles in Flint described losing his job and health benefits after two decades of working. Although he recently received coverage through the Genesee Health Plan and was extremely grateful that such a resource existed, he still found himself frustrated and confused about his new status.
• A woman who described, with great pain in her voice, making a choice between spending $5 on a co-pay for a prescription or putting gas in her car which she needed to get to work.
• Another mother, who said she knew what she should do to make her child’s life healthier but felt severely constrained by her neighborhood, where gun shots and shootings were regular occurrences, making it too dangerous for her son to go outside and play.
• A young woman who had strep throat and was told she couldn’t get an appointment with her primary care doctor for two weeks. After missing a week of work, she ended up going to the emergency room.

The next steps of the process in Flint will involve taking the data – and these compelling stories – and working with the community to develop a viable plan for addressing the gaps they reveal. This process will carry the human element forward, and translate this research into the kind of action that can truly improve lives.

Melissa Riba is a health policy consultant at CHRT, responsible for the research and evaluation design components of CHRT projects and identifying researchers and research partners in both major project categories: care delivery/financing systems and population health/access to care.

Ever since Bill Clinton took a turn at health care reform, the issue has often been discussed as an economic one. Bill Clinton first framed the health reform issue in 1992 before he took office. He had famously kept as a center piece of his campaign the idea that “it’s the economy, stupid” and health care became part of that dialog. He heard from the CEOs of many businesses, including the three Detroit automakers, that they were having a hard time competing in the global economy because they had to bear the cost of health insurance whereas their foreign competitors did not. So, when President Clinton convened his economic summit in Arkansas after he was elected but before he took office, health care was front and center.

Ever since that time, politicians advocating for some form of universal coverage have tried to give some urgency to health care reform based on the idea of making American businesses more competitive, workers more productive, hospitals more solvent, or all of the above. In other words, the emphasis has been on the economics of health care. This context of the health care discussion was quite evident in the debate about health reform last year and was also what President Obama generally led with in his calls for sweeping change to the health care financing system. And, many of the comments in the House repeal discussions occurring over the past week echoed this view from another perspective with their “job killing” (or in the kinder, gentler Congress, “job destroying”) rhetoric.

I believe this is fundamentally the wrong framing of the issue. While there are clearly economics involved, basing the need for health reform on these issues perpetuates the debate about what actually works to change the financial trajectory we have experienced with health care in this country. It allows the opponents of government provided or enabled universal coverage to mask their beliefs in the technical details of the program. In fact, the question of whether or not we should have universal health care coverage in America is essentially an issue of philosophy and beliefs. How one answers this question is truly more about one’s views of what constitutes the proper role of government and a civil society than it is about how to “bend the health care cost curve” (or not).

Every developed country in the world other than the U.S. has come to the conclusion that health care should be part of the social compact with citizens. That is: that is a fundamental right – as much as education is a fundamental right. Even with the passage of the Affordable Care Act, the U.S. has not come to a clear view on this issue. President Obama has spoken to it when he talks about his uninsured mother and I believe his emphasis on the moral imperative to cover the uninsured last January was a powerful message that helped propel the final passage of health reform.

But, this message is more often than not buried in the discussion of health care in America.

It wasn’t always this way. In fact, over the past 100 years, most of the serious efforts to change health care financing in America have embodied a philosophical statement at their core. One of the ones I find most fascinating is what was said by President Nixon in 1974 when he introduced his plan called CHIP (Comprehensive Health Insurance Plan). He said:

“Without adequate health care, no one can make full use of his or her talents and opportunities. It is thus just as important that economic, racial and social barriers not stand in the way of good health care as it is to eliminate these barriers to a good education and a good job.”

This is an extraordinary statement – especially from a Republican leader whose rhetoric was generally considered to be conservative. Whether or not you believe, as President Nixon did, that government-enabled universal health care coverage is essential to provide equal opportunity for all citizens, isn’t it time to discuss that question? Theatrics of repeal votes aside, what is it we truly believe and want for America? We need to get back to the basics and really consider: When it comes to health care, what are our core values?

The terrible shootings in Arizona have been described, mourned and their causes much discussed.  There has been a particular debate about whether these crimes could possibly have been encouraged by some of the more heated political discourse that has occurred in this country over the past year or so. While it seems likely that when all is said and done, the causes of the Arizona shootings will be put down to a unique set of factors/mental state of the individual who did the shooting, the nature of the discussion about these causes is a separate and concerning issue in and of itself.

One of the issues that people speculated might have raised the anger level towards Congresswoman Giffords was her vote and active support for health care reform.  As the media has noted, her office windows were vandalized after that vote and she received an increase in threats against her as a result of her commitment to health care reform.  Even if this issue is totally unconnected to the shootings, how is it possible that credible individuals could even consider that Congresswoman Gifford’s vote on health care reform resulted in violence against her/her office and so many other people?

Why would health care reform ever be a catalyst for any break down in civil order?  What we are talking about in health reform is providing more coverage to more people.  It is hard to even conceive of the idea that an expansion of health coverage could produce so much anger.  Such an action would never trigger a backlash in another developed country (cutting coverage might – but, not expanding it).  That health care reform has produced considerable anger in America has been evident over the past couple of years since the 2009 town hall meetings with their death panel rhetoric.  And, the Affordable Care Act is not the only health care reform to produce great anger in America. Remember 1988 and Medicare Catastrophic Coverage?  At that point, seniors were throwing rocks at Congressman Dan Rostenkowski’s car.  Shortly thereafter, Medicare Catastrophic was repealed, though it would have provided much better coverage to seniors than they have today.  Why?

There is something unique in America when it comes to considering anything approaching universal health coverage.  This American view is reflective of some of the core values we seem to have as a people – core values as reflected in parts of our Declaration of Independence and Constitution, Westward migration and Horatio Alger view of the world.  Core values that speak to the importance of individual initiative, merit based success and a dislike for being told what to do.  These values differ from the more communitarian view of most other developed countries. The tension between these American core values and the mandate embodied in health care reform were not resolved last March when Congress voted for and the President signed the Affordable Care Act.

Most other countries accept the need for tradeoffs and shared sacrifice in a way that Americans often don’t.  They understand the concept of shortages, queuing and limited resources.  These concepts are just not part of the DNA of this country.  In many ways, the refusal to accept limits and to resist mandates has led to a great deal of creativity and positive growth in America.  But, it also makes it difficult to establish a consistent and coherent social policy.  In Europe the idea of health care as part of the social compact was settled long ago.  In America, despite Medicare, Medicaid and now the Affordable Care Act, it is still an issue of hot debate.

Of course, no matter how passionately any of us feel about an issue of public policy, it should never lead to any act of violence. But, the fact that health care reform raises so many strong feelings is something we really must pay attention to.

Of course, I would be remiss if I didn’t conclude by noting that the Affordable Care Act also includes a number of provisions that will expand mental health services for many people.  And, who could argue with the need for that?

The Arizona Medicaid program has been much in the news lately for its decisions to deny Medicaid coverage for certain transplants. The state has variously argued several things about these decisions. First, that these are evidence based decisions; that is, that the transplants were denied because the research shows that they don’t actually work. But, when challenged by transplant surgeons and others, the state has given other reasons for their denial, with cost being at the top of the list.

How ironic that during the debate on health care reform, the threat of rationing health care was used by opponents as a reason to oppose the Affordable Care, and here is a state with leadership that strongly opposed the Affordable Care Act but that are implementing rationing their own way.

To many health policy ethicists/analysts, the idea of explicit rationing of health care has much conceptual appeal. The idea is that we don’t have enough resources to pay for all the things we want as a society and therefore, we should choose what health care services to cover based on a transparent public process that takes into account both medical evidence and public preferences. Certainly, other countries with national systems and national health policy have made these kinds of choices, at least to some degree.

Some in Congress used Don Berwick’s favorable comments about the British Health Care system as a reason to oppose his appointment to head CMS because they noted that the British system rations health care. Indeed, in Great Britain, there are some explicit discussions about trade- offs in coverage and a valuation of the benefit of certain services in terms of “Quality of Life Years”obtained.

But, the practice of explicit health care rationing – vs. the more implicit approach we take in the U.S. today: rationing through price and lack of any coverage for broad segments of the population – is far more difficult than the theory. When one looks more deeply at the British system, the limits of rationing are apparent. But, perhaps, the best example of this issue in the U.S. is what happened many years ago in Oregon.

In 1987, Oregon had its own transplant controversy in the Medicaid program. At the time, the state denied coverage for leukemia treatment for a child. A physician, John Kitzhaber, was head of the Oregon legislature at the time and rather than pushing through support for the transplant coverage, he argued that with so many people uninsured, it was unfair and unethical to pay for a few high priced services for some but leave many without even basic care. Thus ensued a long path that resulted in the passage of the Oregon Health Plan, which was implemented in 1994 and supposed to be an explicit form of health care rationing where all procedures would be arrayed on a list based on value and a line drawn at a certain point based on the state resources available for the Medicaid program.

As chronicled in a terrific article written in 2001 for the Canadian Medical Association, Jon Oberlander and colleagues described the reality of what happened in Oregon and noted that it was far different from what the framers of the OHP originally envisioned. Indeed, they concluded that the system in Oregon actually excluded very few services and as a result, saved very little money (in fact, transplant coverage was actually expanded under the program). For those services that were excluded, the list was circumvented by physicians on a fairly routine basis as they found ways to get those services covered for their patients; and over time, the list was less and less reflective of objective, scientific theory and very much influenced by interest-group pressure.

Arizona’s approach today is essentially rationing by price: picking high ticket procedures and then looking for the evidence to support their exclusion from coverage. This approach undermines a legitimate public debate.

But, Oregon demonstrates that even when we try a transparent process to this issue, it, too, has difficulty being true to the conceptual framework it is based on. In Oregon’s case, the plan actually became more about expanding coverage than about choosing which resources to use.

It would be ideal if we could ask how much medical care we can afford and who should pay – and doing it thoughtfully, comprehensively, and in the full light of day. Arizona’s approach certainly doesn’t do that. While Oregon’s experience might say that we can’t get there, they tried and had a rich public debate as part of the process. It would be better if Arizona could at least have an honest and open approach to what they are doing.

One of the big issues that prompted the passage of health reform last year was the 39 percent rate increase proposed by Anthem California for the individual market. That action both strengthened the will of the Democrats to enact health care reform and provided a clear cut talking point about the need for reform. As a result, one of the provisions included in the reform law was that health insurance premiums could not increase at “unreasonable rates”.

Initially, the proposal was for there to be some federal oversight in health insurance rate increase requests. A clear cut federal process was not included in the Affordable Care Act. Rather, this issue was left to the states with some federal oversight.

For almost a year, people have been asking for a definition of “unreasonable” and what process would be used to determine what it. On December 21, the U.S. Department of Health and Human Services (HHS) issued rules to answer that question. Specifically, as noted in this press release, in 2011, the answer to the question is 10 percent. After that time, the specific state rate increases will be based on state specific information and trends.

Time will tell how this rule gets implemented and whether it actually provides any relief for consumers, but it seems quite a stretch to think that this rule will do much to stabilize the market and make health care more affordable.

The immediate critique from the insurance industry was that this rule does nothing to deal with the underlying causes of increases in health care costs: provider prices and the use of services. And, while it is easier to put pressure on health plans to get them to try and deal with these issues, there are also things in the Affordable Care Act that could make it more difficult for health plans (I am still a skeptic on the concept of Accountable Care Organizations).

And, of course, we haven’t yet heard from state insurance commissioners about how they will handle the administration of this rule and whether they have the resources to review all premiums that would fall into this category – even with the extra funds provided under the ACA.

HHS notes that they will take over this function for any state insurance office that can’t do what is required. But, HHS is having its own challenges in getting funding from the current Congress, much less the new Congress – many members of which ran on a platform to repeal the ACA.

Finally, it strikes me that this rule is rife for a “playing to the test” strategy. Let’s see how many 9.9 percent rate increases go through next year and/or how many benefit changes occur to justify higher rates.

The 10 percent rate increase concept is, of course, very easy for consumers to understand. It has the virtue of enabling the administration to describe something about the Affordable Care Act that is easy to grasp and appealing to individuals. The same can’t be said about many other provisions of the Affordable Care Act, which are quite technical. In general, Congress and the administration have done a poor job communicating the benefits of health care reform to consumers. This piece could improve the administration’s success at communications.

The concept of a strong regulatory structure to oversee the insurance industry is a good one. It is necessary for confidence in the industry and for ensuring a level playing field for competition. And, of course, it is essential for ensuring that the core components of health care insurance expansion are implemented in compliance with the law and fairly at the state level. The idea of setting a single, specific number and declaring that anything that exceeds that is potentially considered “unreasonable” may be good politics but I am less certain it is good policy.

Much has been written this past week about the Virginia federal court decision about the constitutionality of the Affordable Care Act. While many have described the decision as politically motivated and delved into the politics of the various judges who have ruled or are about to rule on the Affordable Care Act, the more interesting question is: What is likely to happen at the Supreme Court level and what could happen to the Affordable Care Act based on that likely outcome?

Jason Mazzone had an interesting opinion piece in the New York Times interpreting the Virginia court’s decision. In his December 17 piece, he comments on the distinction between Congress regulating activity vs. inactivity, and asserts that the Virginia court made a credible case for its decision. I am not an attorney and can’t comment on the merits of his argument. But he certainly believes that this opinion could well be upheld by the Supreme Court.

Linda Greenhouse, the Supreme Court reporter for the New York Times, gives a much more attenuated interpretation of Judge Henry Hudson’s decision in her December 16 opinion piece. Regardless of the merits of his reasoning, if his opinion holds, what will that do to the law?

Well, first and foremost, the Virginia decision was actually more narrowly constructed than some media reports would lead one to believe – in two ways: first it only challenged the part of the law that deals with the individual mandate. Even though Congress did not include a severability provision with regard to this part of the law, the court decision was limited to the provision that requires people to carry health coverage or pay a fine. The Virginia court ruled that this provision both went beyond the Commerce Clause and that the fine was not a tax but rather, a penalty. The decision did not, however, invalidate any other parts of the law and it did not grant a stay of implementation of the law (in large part because the provision that would be invalidated by this ruling doesn’t go into effect until 2014). So, based on this ruling, the implementation of the Affordable Care Act will proceed apace while the ruling is appealed in the courts.

But, what would this decision mean for the law should it ultimately be upheld by the Supreme Court?  That is a complex question. The problem with invalidating the individual mandate is that there are many other provisions – let stand by the Virginia court – that are popular and integrally tied to the mandate. These include prohibitions on exclusions for pre-existing conditions, requirements for guaranteed issue, prohibitions on rescissions, and requirements to enable children up to 26 to stay on parents’ policies. Adverse selection is a serious problem with these parts of the law if they are not tied to some provision that ensures all (or, at least, most) people have health insurance.

So, what could Congress do that preserves these insurance-related provisions of the Affordable Care Act in the absence of an individual mandate?  Those who advocate for a single payer system will correctly note that this problem would have been avoided had Congress passed and the President signed a bill that worked entirely through the tax system, similar to the Canadian health system. But, the reality is that the votes were never there for this system and they are less there now with the change in Congress.

So, if there is a negative ruling in the Supreme Court, is there a feasible political alternative?   There might well be – one that was proposed during the original reform debate. In that debate, some advocated that instead of a mandate there should be a market based incentive system designed somewhat akin to Medicare Part B: a graduated rate depending on how early you get in. That is, health insurance would be cheaper if you signed up when you are relatively young and healthy than if you waited until you were older or sick. Among other economists, Mark Pauley recommended that approach (along with some other features) in his February 2010 perspective in the New England Journal of Medicine. And, that concept is one that is more likely to appeal to the new Congress – at least after much of the hardnosed “repeal and replace” rhetoric has passed. And, it is an approach that would save the fundamental principles of health reform through a different avenue. The mandate may ultimately prevail in the courts. But, if it doesn’t, it is well to keep in mind that all may not be lost.

In 2007, the COURAGE trial (aka: Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation –a mouthful!) results were reported in the New England Journal of Medicine. This study concluded that for those with stable coronary artery disease, the insertion of stents was no better than medication and lifestyle changes at preventing future heart attacks or strokes, nor did it extend life. There were different side effects from each approach but clinically, this trial supports the concept that the choice of treatment ought to be based on patient preferences unless there were unique clinical factors present. The COURAGE trial results were widely publicized and use rates of these procedures have declined overall since then.

Given all the evidence around treatment of patients with stable coronary artery disease, it was shocking to read a particular story about cardiac treatment as reported in the Dec 6, 2010 New York Times. The New York Times article is stunning in its depiction of some core issues about why US health care spending is high and how incentives in the current system can compromise patient care.

The article is about Dr. Midei, a Baltimore, Maryland cardiologist, a highly productive cardiologist. As an example of his productivity: the New York Times reported that on one particular day, Dr Midei inserted  cardiac stents in 30 different patients!  And, he was richly rewarded for this level of surgical intervention. In addition, of course, to obtaining a very high income (millions) as a result of all of these procedures, he was also courted and rewarded with perks and bonuses by Abbott Laboratories, the maker of the stents. The Centers for Medicaid and Medicare Services (CMS) has been investigating Dr Midei and has concluded that over a two year period he may have inserted almost 600 stents in Medicare patients that were medically unnecessary.  Dr Midei’s hospital, St Joseph, was accused of providing kickbacks in exchange for patients (each procedure can bring $10,000 in revenue to the hospital) and paid a fine to CMS of $22 million and let hundreds of patients know that they may have had stents inserted that they did not need. Many of these patients are now suing Dr. Midei. And even after all of these issues came to light, Abbot Laboratories put Dr. Midei on staff as a consultant in return for all the “help” he had provided to them over the years.

What an amazing illustration of many of the issues in the health care system today! Dr. Midei was not a fly by night doctor. He was trained at Johns Hopkins and considered a “star” in the Baltimore market.

This is clearly an illustration of the perversity of the incentives in the system at many levels. In fee for service systems, providers earn more by doing more. And, in our current physician reimbursement structure, procedural interventions are valued much more highly than are interventions that take time, thought and dialog with patients. Hospitals earn more by keeping their beds filled and device manufacturers/pharmaceutical makers’ profits are all dependent on increased sales whether the care is medically needed or not. How far we are from the concept of compensation based on how effective those providing health care services and supplies are at improving outcomes for patients!

Until we change the fundamental incentives in the system, we will never change the picture of health care spending in this country. Indeed, that’s what the parts of health care reform that deal with ACOs, PCMH, value based purchasing and the like are all about.

What is most concerning about this particular case is that – though Dr Midei was certainly extreme – the unnecessary provision of procedures for profit is more common in health care than most patients know. Let’s hope that the lawsuits are instructive to all practitioners who are tempted by the money in the system: over treatment/inappropriate treatment should not pay.

Many analyses of the impact of health reform focus on the large increase in expected Medicaid enrollment.  Indeed, our own analysis of potential Medicaid enrollment in Michigan showed as many as 452,000 people could be enrolled come 2014 (link to Cover Michigan) who are not enrolled today. Kaiser’s numbers were slightly higher, at 590,000 potentially new Medicaid enrollees, and more recent Census data suggest the numbers could be even higher. Whatever the actual number, all analysts expect a significant increase in Medicaid enrollment in Michigan over the 1.9 million enrolled in 2010.  Providers, states, businesses and community groups are all planning based on these expected increases in Medicaid enrollment.

But are these numbers real? And, does it truly make sense to plan on this basis? The November 24 New England Journal of Medicine had an important article on this topic.  Their analysis highlights how important it is to understand what’s behind the numbers as we think about what must happen in 2014 for these projections to become a reality – actual people enrolled in Medicaid.

A significant percentage of individuals identified in our study and counted as part of the expected increase in Medicaid enrollment in 2014 are not actually those who will be newly eligible for Medicaid in 2014.  Rather, they are eligible for Medicaid today and not enrolled. In our report, of the 452,000 who are not now but could be enrolled in Medicaid come 2014, 165,000 are already eligible. That means that almost 16 percent of individuals who are uninsured today are already eligible for but not enrolled in Medicaid.

Why is that? It’s a combination of reasons.

In some cases, individuals don’t enroll in Medicaid because they don’t want the stigma of being in a public program.  In other cases, it has to do with the difficulty inherent in the enrollment process, especially in Michigan. Staff at the Department of Human Services are overwhelmed with applications and their numbers are too few to handle even current demand.  The Department recently migrated to a new information system that should be helpful in the future but is not right now. And, many fast track options adopted by other states have not been adopted here in Michigan. So, the enrollment process is unpleasant and difficult for many.

The question is: will these issues be fixed with health care reform? Is there any reason to believe that the Medicaid take-up rate will be higher post 2014 than it is today?  The answer is that it could be, but that depends on a number of factors.  These include both changes that are inherent in the health care law and those that relate to the way the state implements the Medicaid expansion.

There are many incentives in health care reform that are different from today’s incentives and could encourage more enrollment in Medicaid. The most significant is the mandate requiring individuals to purchase health insurance. This mandate (assuming it withstands court and political challenges) is a significant departure from the current health care environment.  While the mandate can significantly change the environment, enforcement will be an issue.  First, those who don’t have any reportable income are exempt from the mandate. And second, it isn’t clear there will be adequate funding to enforce it as intended, or that this low income population would be the focus of enforcement.  So, this component of health reform may have less impact than some think.

The state has choices in Medicaid enrollment today.  It could have adopted many of the fast track options that were implemented by Wisconsin and other states. So far, it has not adopted all that it could. Going forward, the state could simplify Medicaid enrollment and engage in aggressive outreach to those who are eligible but not enrolled.

But even with the much higher match for the newly eligible population, the state will still need to find matching funds for almost 300,000 of those newly eligible and a higher match rate for the 165,000 who are eligible for the existing program but not enrolled. Will the state be aggressive as it could be in its enrollment efforts given the state budget challenges? We hope that 2014 will be a better economic year for Michigan than 2010 has been, but Medicaid already represents 22 percent of the state budget and its costs will continue to go up between now and then.  Will the revenue picture be such that the state will want to try and get everyone eligible enrolled?

Predictions are hard to make and our choices about the future are important.  For those counting on another half million individuals moving out of the ranks of the uninsured and into Medicaid, the decisions we make as a state over the next several years will be vitally important.

The Patient Centered Medical Home Model (PCMH) generates much discussion in health care circles. PCMH demonstration projects are widespread, accreditation organizations are developing and implementing certification programs for PCMH-based practices, and payers – including the federal government – are exploring new reimbursement policies to support medical home-based care.

There is a sense of urgency about implementing medical home capabilities. Yet many people express the concern that all of this is happening in advance of having a clear definition of a medical home or what the PCMH model actually means. Others say, “I’ve been providing a medical home to my patients since I started my practice. There’s nothing new here. This is just creating extra work for no purpose.”

I’m a bit surprised when I hear these comments and concerns. While multiple organizations have articulated PCMH definitions, the essential elements are always the same. And the sources of the ideas, which are very firmly grounded in common sense, are also identical.

In the 1960s, the pediatric community began describing the need for a medical “home” to identify needs and coordinate care for children with complex, chronic illness. These concepts informed the thinking of people at the MacColl Institute who described the Chronic Care Model, broadening the reach of these ideas to encompass all patients with chronic illness.

The Advanced Medical Home model was described by the American College of Physicians (ACP), expanding the scope further by applying the same principles to all patients, including those at risk for future illness and for whom preventive clinical services are indicated. The PCMH model was a direct outgrowth of the Advanced Medical Home model, representing a more refined articulation of the concepts which undergird all of these models. A summary statement from the ACP describes the model as a:

“…team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.”

A foundational concept is that the care be relationship based, involving an active partnership between caregivers and patients. The patient takes an activated role, owning the responsibility to identify personal health goals, work with the care-giving team in developing treatment plans, and actively engage in health behaviors, self-care, and health care seeking behaviors that advance his or her goals. The medical home team is responsible for assuring that care is coordinated across settings of care (e.g., specialists, ED, hospital, other facility) and over time.

While this vision is consistent with what most health care providers hope they can offer their patients, the scope of responsibility, level of engagement with patients, and systems needed to fulfill the vision go well beyond “what we’ve always done for our patients.”

An extension of the responsibility to coordinate care focuses on both the care patients receive during health care visits and the follow up on decisions and plans made at those visits. It also includes proactively identifying the needs of a population of patients, including their preventive and curative needs, and reaching out to people between visits to catalyze action to meet those needs.

The challenge isn’t so much about defining or describing the vision, but rather implementing the information systems and care processes necessary to achieve it and expanding access to medical home-based care.

There are no ruby slippers. You can’t click your heels three times and have a medical home. Simply paying providers to offer medical home-based care, hoping they do so, and then examining whether such payments yield better outcomes is a strategy which isn’t grounded in reality.

It is yeoman’s work to transform clinic practices from their current, acute-care focused, fragmented state and incorporate new systems and processes designed to reliably achieve the goals that flow from the PCMH vision for an entire community of patients.

The required capabilities include, for example, comprehensive patient registries to identify and track the needs of individual patients, manage the needs of a population of patients, and support performance measurement used in the process of continual self-assessment and practice improvement.

They also include modern information systems and team-based care management processes designed to meet the needs of patients with chronic illness. Achieving integration of these clinical systems and processes across medical home-based practices, and between those practices and their facility and specialist partners, is an even greater challenge.

This becomes clear when talking to people who are considering transforming clinical systems and clinic processes in an effort to modernize their practices. A common refrain is “I don’t know how to do this. You can’t get there from here.”

The challenge is daunting. For this reason, physician organizations in Michigan, in partnership with Blue Cross Blue Shield of Michigan, have created regional learning collaboratives designed to train physician organization leaders and staff in the workings of the PCMH model and in change management facilitation techniques so they can incorporate sophisticated process re-engineering skills into their core business. These efforts have catapulted physicians’ practices over the usual barriers to change and helped them incorporate new information systems and care processes, achieving improved efficiencies while doing so.

As evidence of this impact, PMCH-based practices in Michigan have already demonstrated improvements in access to primary care and reductions in the use of emergency department and inpatient services for chronic conditions. This work is not for the faint of heart, but can be transformative when practice teams are empowered to take it on.

Payers and purchasers, and the community in general, will see a much better return on their investments in the long run if they devote attention and resources to catalyzing and supporting provider organizations in their efforts to transform their office practices and integrate them into a system shared by their community of caregivers guided by the PCMH model.

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David Share serves as Executive Medical Director, Health Care Quality, at Blue Cross Blue Shield of Michigan. Dr. Share also is the Medical Director of The Corner Health Center in Ypsilanti, a community-based health center for teenagers and their children, serving in this role since 1981. Dr. Share serves on the board of directors of the Michigan State Medical Society (MSMS), where he chairs the Committee on Michigan’s Public Health and the MSMS Task Force on the Future of Medicine.

Dr. Share is a key advisor to CHRT on many of its research and demonstration projects. He will be speaking about Blue Cross Blue Shield of Michigan’s PCMH implementation at CHRT’s December 2, 2010 symposium, Patient Centered Medical Home: Obstacles and Opportunities.

In 2006, there were 4.3 million children born in the United States. Approximately 55,000 of those children were born prematurely. Premature births have been increasing consistently since 1990 (though there appears to have been a slight drop in the rate of prematurity in 2007). In 1990, 10.6 percent of children were born prematurely; in 2006, that percentage had increased to 12.8 (preliminary numbers show a 12.6 percent rate in 2007 – still considerably higher than the rate in 1990). Last week, our center released an issue brief on this topic because we think it is such an important issue.

Why are premature births important? First and foremost, children who are born prematurely are at much greater risk for health problems than are children born at full term. The impact on families and the children themselves is enormous. In 2006, prematurity/low birth weight was the single largest cause of infant mortality in Michigan. In addition to being at higher risk for infant mortality, children who are born prematurely are at greater risk of developmental and behavioral problems later in childhood – problems that have a significant impact not just on the children themselves but also on families, schools, and the broader community.

Second, preterm births are costly. In 2007, the average charge for a premature birth/low birth weight delivery was $102,000 in Michigan ($119,000 in the U.S.), approximately 14 times higher than the average charge for a normal delivery. And, the cost differential continues in the first year of life. Average first year costs for preterm children in 2008/9 for Blue Cross and Blue Shield of Michigan (BCBSM) were $41,700 compared to $4,300 for children born at full term. Children born preterm with BCBSM coverage represented 10.3 percent of total births but accounted for 52.6 percent of total spending for all children in the first year of life.

Preterm births are not evenly distributed across the population. Black infants are 70 percent more likely to be born preterm than are white infants. And, prematurity is significantly more deadly for black infants than it is for white infants. In 2006, 5.6 percent of white infants in the U.S. died, about one third of those related to prematurity. In that same time period, 13.4 percent of black infants died with almost half due to prematurity.

And the extra tragedy is: we really don’t know why. We know that certain prematurity related risk factors (smoking, teen mothers) are more likely to occur with black mothers than whites, but even adjusting for these differences does not explain the disparity. Other theories have been posed but none have fully explained this difference or provided good guideposts on how to change this picture. And, children will keep dying or living compromised lives until we understand what is going on here.

Prematurity is unquestionably an area where we need further research to understand the causes and to develop more effective interventions to make a difference. Good research here could help save lives; improve the quality of lives of our children; reduce the burdens on our schools and communities who must deal with the longer term effects of prematurity; and, save significant dollars in the health care system and elsewhere in society. This is truly what public health is all about. So, let’s hope that with all the innovations and research being funded through the Affordable Care Act, particularly with the significant funding provided in the Prevention and Public Health Fund, the issues surrounding prematurity become a priority. After all, we are talking about our children and our future. What could be more important?