David Grande, MD, MPA, is an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine, a senior fellow at the Leonard Davis Institute of Health Economics, associate director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and an alumnus of the RWJF Health & Society Scholars program. This is part of a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.

It’s a time of unprecedented upheaval in U.S. health care. Big changes are bursting through on virtually every front. Legislators and administrators in Washington and 50 state capitals struggle daily to reinvent their health care systems even as they lack an exact blueprint for the new things they’re supposed to be building.

This was nowhere more evident than at the recent AcademyHealth National Health Policy Conference, where state and federal officials and interest groups lined up to present long lists of policy questions that confront them as they grapple with implementation of the Affordable Care Act and mounting public budgetary pressures.

Managing 'Churn'

For instance, in the “Opportunities & Challenges for State Officials” session, New Mexico’s Medicaid Director Julie Weinberg described the unknowns surrounding how “churn” between private and public coverage will change and how new Medicaid eligibility standards will impact enrollment processes.

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is the first in a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.

Like Goldilocks wandering through the house of the Three Bears, policy-makers in search of a health care payment model have found it difficult to settle on an option that is "just right."

Fee-for-service—paying doctors separately for each service they provide—leads to too much unnecessary and duplicative care (too hot!). Capitation—paying doctors a fixed fee for caring for patients—leads doctors to skimp on care and avoid costly populations (too cold!). A "just right" payment model should give providers incentives to provide all the clinically necessary care to patients while keeping costs low.

Shared savings models—allowing providers to keep a portion of the money they save caring for patients—have been touted as one method for aligning the incentives of providers and payers. Most prominently, shared savings is a central element of the Affordable Care Act's Accountable Care Organizations (ACOs).

An ACO is a network of providers that have agreed to accept a bundled payment for treating patient populations, and in return stand to gain incentive payments for meeting performance targets (or to lose money for missing targets). In the "happily ever after" version of ACOs, groups of providers will finally have a business case for coordinating patient medical records, reducing costly visits to the emergency room, and improving patient compliance with chronic disease therapies without leading to excessive procedures or gaps in care. Healthy patients, healthy profits.

But will it work?

This is part of the March 2013 issue of Sharing Nursing's Knowledge.

For three years, Congress has failed to fund a federal panel that was created to address a dire shortage of health care professionals—and now the news media is beginning to take note.

The unfunded panel broke through the media silence in January when Politico, an inside-the-Beltway publication that covers Congress and the White House, ran a story about it. In February, the New York Times followed up with its own piece.

Officially called the National Health Care Workforce Commission, the panel was created in 2010 under the health reform law to address concerns over a short supply of health care providers at a time when demand is growing, thanks to the aging population and an influx of newly insured people expected to enter the health care system next year.

A leading nurse researcher, Peter Buerhaus, PhD, RN, FAAN, a professor of nursing at Vanderbilt University, was tapped to chair the commission and 15 members were appointed. But Congress never appropriated funds for it—a phenomenon that was noted at a recent hearing before a U.S. Senate subcommittee.

“It’s a disappointing situation,” Buerhaus told the New York Times. “The nation’s health care work force has many problems that are not being attended to. These problems were apparent before health care reform, and they will be even more pressing after health care reform.”

Carole Pratt, DDS, is an alumna of the Robert Wood Johnson Foundation (RWJF) Health Policy Fellows program, where she worked in the office of Senator John D. Rockefeller (D-WV). Pratt was a practicing dentist in rural southwest Virginia for 32 years. This post is part of the "Health Care in 2013" series.

The Times Square ball has dropped, crisp new calendars have been affixed to office walls, and clean new agenda pages gape at us from computer screens, signaling prudent resolution makers that it is time to get serious about 2013. February 10 will mark another New Year, the beginning of the Chinese New Year festival ushering in the Year of the Snake. Parades will be held, people around the world will celebrate, and for a time at least, inherent fear of reptiles will be set aside.

In a century-long history that is somewhat convoluted, the American medical profession has come to be represented by the winged staff and serpent symbol, the Caduceus. So during 2013, the Year of the Snake, it may be no coincidence that things are looking up for the health care profession and the health of the nation in general. In its 2013 annual ranking, U.S. News & World Report announced the top ten most attractive jobs based on factors such as opportunity for employment, salary, work-life balance, and job security.  Six of the top ten spots were claimed by jobs in health care.

Arthur Kellermann, MD, MPH, FACEP, holds the Paul O’Neill-Alcoa Chair in Policy Analysis at the nonprofit, nonpartisan RAND Corporation. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and the RWJF Health Policy Fellows program. This post is part of the "Health Care in 2013" series.

For the first month of my medicine internship at the University of Washington, I was assigned to Seattle’s VA Hospital.  I was stunned to learn that my attending physician would be Paul Beeson, widely regarded at the time as one of the giants of American medicine. [i]  At an age when most doctors are enjoying their retirement, Dr. Beeson was still doing what he loved best—caring for patients and teaching.

I have forgotten most of the clinical pearls Dr. Beeson taught that month. But one that still stands out is the way he questioned the need for every lab test, x-ray and treatment my team ordered. “Why do you want that?” he’d ask.  “What will you do with the result?” Throughout the month, he urged us to forego interventions that offered little benefit to our patients, but exposed them to potential side effects or complications. His message was clear.  Do only what’s needed, not more. 

Today, we need Dr. Beeson’s message more than ever before.  In the three decades since I trained under him, America’s health care system has grown so large, it claims a bigger share of the gross domestic product than American manufacturing or wholesale and retail trade. [ii]  As a result, the federal government spends more on health care than national defense and international security assistance.  In several states, health care is crowding out spending for education. In the past decade, health care cost growth has wiped out the hard-won earnings of middle-class families. [iii]

Carolyn Montoya, RN, MSN, CPNP, is a fellow with the Robert Wood Johnson Foundation (RWJF) Nursing and Health Policy Collaborative at the University of New Mexico. A PhD Candidate, Montoya serves on the New Mexico Medicaid Advisory Committee, an advisory body to the Secretary of the state’s Human Services Department and the Director of the Medical Assistance Division Director. The RWJF Human Capital Blog asked scholars and fellows from a few of its programs to consider what the election results will mean for health and health care in the United States.

Human Capital Blog: Do you think there will be fewer challenges to the Affordable Care Act and more attention to how to implement it?

Montoya:  Now that the election is over, the reality is that the Affordable Care Act (ACA) will not be repealed. As we go forward with the ACA in place, a strong emphasis should be placed on evaluation. Outcome measures, such low rates of diabetes complications or increased immunization rates, will be essential in terms of being able to establish what aspects of the ACA are working and which ones need to be revised.

Frank J. Thompson, PhD, is a professor at the School of Public Affairs and Administrations and at the Center for State Health Policy at Rutgers, The State University of New Jersey.  Thompson is a 2007 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, studying Medicaid: Political Durability, Democratic Process and Health Care Reform.  The RWJF Human Capital Blog asked scholars and fellows from a few of its programs to consider what the election results will mean for health and health care in the United States.

Human Capital Blog: What do you think the election will mean for the country’s health care system?

Thompson: It means that the country can go forward with implementing the Affordable Care Act (ACA).  My research focuses on Medicaid—the federal grant program to the states that insures some 65 million low-income people. Under the ACA, Medicaid is slated to cover most people with incomes up to 133 percent of the poverty line as of 2014. In the recent election, the differences between the two parties on the ACA and Medicaid were stark. The Romney-Ryan ticket pledged not only to repeal the ACA but to convert Medicaid to a block grant and to cut funding for the program by more than 30 percent over ten years. The degree to which a Romney administration would have achieved these objectives remains an open question. But the reelection of President Obama curtails the likelihood of major Medicaid reductions over the next four years.

The United States will need 52,000 additional primary care physicians by 2025 to meet demand that is growing due to three trends: population growth, population aging and insurance expansion. That is a key finding from a study published in the November/December issue of the Annals of Family Medicine. The researchers estimate that population growth will account for the majority of the needed increase in primary care doctors.

Given the current number of visits to primary care physicians and an expected population increase of 15.2 percent, the researchers predict that office visits to primary care physicians will increase from 462 million in 2008 to 565 million in 2025. This trend will be especially evident among people 65 and older, a segment of the population that is expected to grow by 60 percent. Population growth will require an additional 33,000 physicians, the study says, and aging another 10,000.

Insurance expansion under the Affordable Care Act will also require additional physicians, the researchers find. Eight thousand physicians will be needed to meet that growth.

The 52,000 additional primary care physicians would represent a 3 percent increase in the workforce.

Read the study.

Tiffany D. Joseph, PhD, is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research at Harvard University (2011-2013).  This post is part of a series in which RWJF scholars, fellows and alumni who are attending the American Public Health Association annual meeting reflect on the experience.

It was incredibly exciting to attend the American Public Health Association (APHA) meeting for the first time! As a sociologist and current RWJF Health Policy Research Scholar, I am thrilled to be at a multidisciplinary conference with an explicit focus on all aspects of health: outcomes, disparities, coverage, service utilization. You name it, there is a session for it.

The opening was especially motivating and inspiring as Dr. Reed Tuckson and Gail Sheehy provided insightful talks on the relevance of preventive health throughout the life course and how public health professionals must continue to work to improve access to, and quality of, health care for a U.S. population that is increasingly racially, ethnically, and socioeconomically diverse.

U.S. Representative Nancy Pelosi also stopped by, unannounced, to welcome the APHA to San Francisco and thank its members for their steadfast commitment to, and support for, passage and implementation of the Patient Protection and Affordable Care Act (PPACA or ACA).  Needless to say, everyone in attendance was thrilled and excited by her surprise visit and warm words.

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Michelle Scott recently graduated from Rowan University and is an intern at RWJF, working with The Future of Nursing: Campaign for Action.

I’m 22 and uninsured. I’ve only had health insurance for the four years I went to college, and now that I’ve just graduated, I no longer have that luxury. I survived the first 18 years of my life without it, but thanks to the Affordable Care Act, I don’t have to live without it for the rest of my life.

The day I received my college health insurance card in the mail, that flimsy piece of laminated paper with my name on it, I vividly remember thinking, “Wow. I’m allowed to be sick.” During my time at college I never got sick, nor injured in a serious accident of any kind where I actually needed medical attention. There was a brief period where I thought I smashed my hip and orbital bone in a skateboard incident my senior year of college, but after sitting on the ground at the skate park for a minute, and contemplating whether my family could afford to patch me up, I decided to walk it off. From my very early childhood, that’s how I learned to treat any kind of issue: Walk it off, or rest up until you can walk it off.