Category Archives: Health care delivery system
In his first two years in office, New York State Health Commissioner Nirav Shah, MD, MPH, has been deeply engaged in the state’s ambitious Medicaid redesign process. Shah oversees the $50 billion state public health agency and has been praised for his health system reform efforts. Moving forward, he is focusing on issues such as securing federal funding for “supportive housing” to offer chronically ill, low-income individuals subsidized living quarters in building complexes that also contain in-house medical and social services.
Shah, an RWJF Clinical Scholar alumnus, discusses this and more in the latest Robert Wood Johnson Foundation (RWJF) Clinical Scholars Health Policy Podcast, a monthly series co-produced with Penn’s Leonard Davis Institute of Health Economics and hosted by RWJF Clinical Scholar Chileshe Nkonde-Price, MD.
The video is republished with permission from the Leonard Davis Institute.
Paula Lantz, PhD, is professor and chair of the Department of Health Policy in the School of Public Health and Health Services at the George Washington University (GW). Before joining the GW faculty, she was professor and chair of health management and policy at the University of Michigan School of Public Health, where she served as the director of the Robert Wood Johnson Foundation (RWJF) Scholars in Health Policy Research Program. In addition, Lantz is an alumna of the Scholars in Health Policy Research Program. She recently co-authored a study with Jeffrey Alexander, PhD, professor emeritus at the University of Michigan, where he was the Richard Jelinek Professor of Health Management and Policy in the School of Public Health.*
It is not uncommon for state governments to periodically reorganize, and this often involves creating new agencies/departments or consolidating ones that already exist. Some in the health field have voiced concerns about such reorganizations when they involve the consolidation of a state’s public health department and the Medicaid agency. The main fear has been that when public health functions are combined with the invariably larger and growing Medicaid program, public health loses out in terms of economic resources and a sustained focus on disease prevention and health promotion. By virtue of the sheer size and focus on medical care, there would be a “giant sucking sound” of economic resources and priority attention going to the Medicaid program and away from the smaller and often less visible activities of public health.
Michelle L. Odlum, BSN, MPH, EdD, is postdoctoral research scientist at Columbia University School of Nursing in nursing informatics. She has more than ten years of experience as a disparities researcher working on a variety of research, evaluation, and health promotion initiatives affecting vulnerable populations. Odlum is a recent recipient of the Robert Wood Johnson Foundation’s (RWJF) New Connections Junior Investigator award.
At this time when our nation’s health care reform is promoting new approaches to primary care, an exploration of health care models from around the globe is essential. With my interest in the transformative role of nursing care, I decided to attend the scientific session [at the American Public Health Association’s annual meeting] entitled: Think Global, Act Local: Best Practices Around the World. Panelists presented on a variety of interesting care models from Europe to Central America.
As we explore initiatives to improve care coordination, it was interesting to hear Erin Maughan, RN, PhD, APHN-BC, an RWJF Executive Nurse Fellow, talk about Scotland’s care coordination approach to children’s health. Maughan discussed home visitors, who provide care to children from birth to five years of age. An important aspect of the relationship forged with children and families is to allow for early identification of developmental needs, thus allowing for timely utilization of resources and services to address these needs. Interestingly, to support effective care outcomes for children with chronic illnesses over the age of five, each family is assigned a district nurse who is a chronic disease specialist.
Scotland has also coordinated health forms utilized by police, schools, and health care facilities; this is a team-centered approach for identifying and working with at-risk children. Scotland’s pediatric care model demonstrates the effective utilization of public health nurses and the implementation of inter-agency care coordination. We, as a nation, can certainly benefit from further understanding of these approaches.
Linda Wright Moore, MS, is a senior communications officer at the Robert Wood Johnson Foundation (RWJF).
Developing a vision for a national “culture of health” has been central to internal discussions at the Foundation, as we’ve engaged in a deliberative process of strategic planning for the future.
For the past year since marking our 40th anniversary, we’ve been asking ourselves where we should set our sights and focus our energies in a rapidly changing world, in order to advance our mission to improve health and health care for all. Consider: the population is aging, becoming more diverse. Technological advances are transforming how we communicate, how we provide health care, and more. “Big data” is making once tedious and time-consuming calculations and analysis routine. Out of our deliberations—a new vision of the way forward has emerged, presented in the 2013 President’s Message from Risa Lavizzo-Mourey, MD, MBA: "We, as a nation, will strive together to create a culture of health enabling all in our diverse society to lead healthy lives, now and for generations to come."
To begin to informally road test that vision, we posed a question to RWJF grantees and alumni at an RWJF-sponsored reception at the AcademyHealth meeting in Baltimore last summer. In impromptu interviews, we asked, “What is a culture of health? What does it take to get there?”
Linda Burnes Bolton, DrPH, RN, FAAN, is vice president for nursing, chief nursing officer, and director of nursing research at Cedars-Sinai Medical Center in Los Angeles. She was vice chair of the Institute of Medicine Commission on the Future of Nursing, and is a trustee of the Robert Wood Johnson Foundation. It has been three years since the Institute of Medicine issued Future of Nursing: Leading Change, Advancing Health.
Developing the Institute of Medicine report, Future of Nursing: Leading Change, Advancing Health and working to implement its recommendations has been a magnificent journey. It hasn’t been about nursing, but rather about health and health care. We focus on nursing, because it is one of the keys to improving health and health care. But our success, and the reason people are joining us on this journey, is because the report and its recommendations mean better health for the public and a stronger health care system for the country.
What began as a report has become a groundswell. It is doing exactly what we hoped it would do, bringing people together to strengthen our health care system. Today a large, multidisciplinary, national movement is engaging nurses, consumers, and other health professionals in local and regional efforts to bring this report to life. There are great examples, for instance, of people from diverse fields coming together to remove practice barriers, physicians saying they believe medicine must be a “team sport,” consumers working to improve care in their communities—and much more.
Sarah M. Miller is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research (cohort 19). She has a PhD in economics from the University of Illinois at Urbana-Champaign. Her dissertation examines the effect of the 2006 Massachusetts health care reform on emergency room (ER) use. Miller will soon become an assistant professor of economics at the University of Notre Dame. Read all the blog posts in this series.
The Emergency Medical Treatment and Active Labor Act (EMTALA) guaranteed all patients the right to receive urgent care in an emergency department regardless of their ability to pay. While the intent of the EMTALA was to ensure no patient was refused emergency care simply because they did not have health insurance, by covering only emergency department care, and not primary or preventive care, the EMTALA created incentives for patients to use the health care system inefficiently. These incentives may be especially salient for low-income or uninsured patients who have limited access to health services outside of emergency departments and community health centers.
The law established that patients could always receive care in the emergency department even if they didn’t have the cash to pay upfront, or an insurance company picking up the tab, but the mandate did not extend to private physicians’ offices. Some state laws go so far as to dictate that uninsured patients can receive free care in the ER if they have sufficiently low incomes.
Matthew M. Davis, MD, MAPP, is associate professor of pediatrics, of internal medicine, and of public policy at the University of Michigan in Ann Arbor and co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program. In February, he coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Davis and his coauthors, both RWJF Clinical Scholars, as well as others from RWJF programs, to respond to the question. Davis’ response follows. Read all the blog posts in this series.
The debate about whether health care is a right or a privilege is familiar and polarized. A quick online search in this topic area yields strong statements, deeply held convictions, and stern admonishments for those who hold opposite views.
As RWJF Clinical Scholars Kate Vickery, MD, and Kori Sauser, MD, (2012-14) point out in their recent blog posts, primary care physicians and emergency physicians can agree that the Emergency Medical Treatment and Active Labor Act (EMTALA)—by focusing exclusively on assuring access to emergency care—fails to ensure that health care is a right for all individuals in the United States across all health care settings.
As the three of us wrote in a Journal of the American Medical Association commentary earlier this year, the Patient Protection and Affordable Care Act (PPACA) will likely fall short of ensuring health-care-as-a-right-for-all as well. That’s largely because one-to-two dozen Americans (or more) will likely remain uninsured even with implementation of all of the coverage provisions of the PPACA. Congress did not have the appetite for even broader coverage initiatives that were considered in PPACA discussions but ultimately left out of the legislation.
Katherine Vickery, MD, is a family medicine resident and a Robert Wood Johnson Foundation (RWJF) Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Vickery and her coauthors, both affiliated with the RWJF Clinical Scholars program, as well as others from RWJF programs to respond to the question. Vickery’s response follows. Read all the blog posts in this series.
Before I joined the Robert Wood Johnson Foundation’s Clinical Scholars program, I trained in family medicine at a federally-qualified, or community health center, United Family Medicine, in St. Paul, Minn.
Many of my patients, and the struggles they faced in trying to access health care, motivate the work I’m doing as a scholar. At the top of this list is “Juan,” a 35-year-old Mexican man working as a day laborer to support his family.
I became Juan’s doctor after a hospitalization where his toe was amputated due to advanced infection resulting from his undiagnosed type II diabetes. He had no insurance and had not seen a doctor in years. The preventability of Juan’s amputation and treatability of his disease was always a frustration to me, and I began to wonder, “What kind of backwards system do we have that ensures a man’s access to a costly hospitalization to remove his toe but bars him from the primary care which can prevent or diagnose and easily treat his disease?”
Carmen R. Green, MD, is an alumna of the RWJF Health Policy Fellows program. She is the associate vice president and associate dean for health equity and inclusion at the University of Michigan Health System, and a professor of anesthesiology, obstetrics and gynecology, and health management and policy. This is part of a series of posts looking at diversity in the health care workforce.
More than a decade into the 21st century, Americans still face diminished health and tremendous variations in health care, depending on what they look like, where they come from, where they live, what they earn, and other factors. Significant and persistent variability in clinician decision-making also exists based upon these factors.
The reasons for these inequities lie in part in disparities in the infrastructure for screening, diagnosing, treating and supporting patients leading to unequal treatment.
In an increasingly aging, female, and diversifying society, it is vital to have a diverse workforce to not only help put patients of varying backgrounds at ease but to provide care that is responsive to their needs and to achieve the best health care outcomes. It may be difficult for underrepresented and vulnerable people to trust the health care system if the employees largely come from the same place and have one perspective. Some of those perceptions actually become realities as biases can negatively affect patients that are marginalized and lower on the socioeconomic totem pole.
Lori Melichar Gadkari, PhD, MA, is a director at the Robert Wood Johnson Foundation (RWJF), in the Research and Evaluation Unit.
Yesterday the New England Journal of Medicine published the results of a study co-funded by the Robert Wood Johnson Foundation, Johnson & Johnson, and the Gordon and Betty Moore Foundation. “Perspectives of Physicians and Nurse Practitioners on Primary Care Practice” finds that 96 percent of nurse practitioners and 76 percent of physicians agreed with the Institute of Medicine report recommendation that “nurse practitioners should be able to practice to the full extent of their education and training.” The new study is authored by Karen Donelan, ScD, EdM, Catherine M. DesRoches, DrPH, Robert S. Dittus, MD, MPH, and Peter Buerhaus, PhD, RN.
When asked how increasing the supply of nurse practitioners would potentially affect the United States health care system, the authors found that the majority of physicians (73%) said increasing the supply of primary care nurse practitioners (PCNPs) would lead to improvements in the timeliness of care. A much smaller majority of physicians (52%) said increasing the supply of PCNPs would lead to improvements in access to care for people in the country.
However, the new survey found significant disagreement between primary care physicians and PCNPs about whether increasing the supply of PCNPs would improve patient safety and the effectiveness of care, and whether it would reduce costs. There was also a large professional divide about proposed changes to PCNPs’ scope of practice, putting PCNPs in leadership roles, and the quality of care that PCNPs provide.