Category Archives: Health care delivery system
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 senior program officer 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.
In the more than two years since the launch of the Future of Nursing: Campaign for Action, state-based coalitions around the country have been working to strengthen the nursing profession to improve health and health care. These Action Coalitions have identified priorities and strategies specific to their states, and forged diverse partnerships to help reach their goals.
A new series of videos on RWJF.org features leaders from some of those Action Coalitions discussing their work and successes, and some of the unique challenges and opportunities they’ve faced.
Julie A. Fairman, PhD, RN, FAAN, is Nightingale Professor of Nursing at the University of Pennsylvania School of Nursing, and director of the Barbara Bates Center for the Study of the History of Nursing. She is a predoctoral fellow at the Penn Nursing Center for Health Outcomes and Policy Research and recipient of an RWJF Investigator Award in Health Policy Research. Safiyyah Okoye, BSN, RN, and Jill Vanek, BSN, MSN, are students at the University of Pennsylvania School of Nursing.
The 2011 Institute of Medicine (IOM) report “Future of Nursing: Leading Change, Advancing Health” pointed out that because nursing scope of practice regulations vary across states, and because there is little rationale for these variations, the federal government, through the Federal Trade Commission (FTC) and the Antitrust Division of the Department of Justice, “is well situated to promote effective reforms [related to regulation of APRN scope of practice] by collecting and disseminating best practices from across the country and incentivizing their adoption.”
The IOM recommended that the FTC and the Department of Justice review existing and proposed state regulations related to advanced practice registered nurses (APRNs) to identify those that limit competition without contributing to the health and safety of the public, and urge such states to allow APRNs to provide care to patients in all circumstances in which they are qualified to do so.
Created in 1914 to promote consumer protection by eliminating and preventing anticompetitive, unsafe, or deceptive business practices, the FTC is the logical agency to address scope of practice laws. The FTC’s responsibility is to promote competition, inform consumer choice, and protect consumer safety. All are directly related to APRN scope of practice regulations, including those mandating physician supervision and oversight of APRNs when there is not “a compelling consumer protection rationale” for doing so. That includes evidence justifying restrictions on APRNs’ ability to provide health care services that could override the public interests with regard to choice, cost or competition.
Elliott Fisher, MD, MPH, a health policy researcher and alumnus of the Robert Wood Johnson Foundation Clinical Scholars program (1983-1985), was recently named director of the Dartmouth Institute for Health Policy & Clinical Practice. Fisher coined the term “Accountable Care Organization” (ACO). In this Clinical Scholar Health Policy podcast, he discusses the origins of ACOs and the effort to develop them in the nation’s health care system. Watch his interview with RWJF Clinical Scholar Chileshe Nkonde-Price, MD, (2012-2014). The video is republished with permission from the Leonard Davis Institute.
This blog post offers perspectives from seven Robert Wood Johnson Foundation Nurse Faculty Scholars who attended TEDMED 2013 last week.
Seeing things in new and different ways will advance nursing practice, research, and education. We need to think of creative strategies to raze perceived boundaries. One way for nurses to enter new frontiers is to engage in interprofessional dialogue with consumers, health care providers, researchers, entrepreneurs, technology experts, designers, and artists. We experienced this interchange at TEDMED 2013—an interprofessional conference for sharing and exploring solutions to health care’s most pressing challenges.
Collaboration is Key
Adejoke Ayoola: The opportunities to explore new advances in technology and interact with innovators remind me of an African Proverb, “If you want to go fast, go alone; if you want to go far, go together.” The outcome is more fulfilling with collaboration. By collaborating with stakeholders (e.g., community residents, community health workers, local agencies), research not only becomes more effective, it becomes more relevant to societal needs. Collaboration with my nursing colleagues promotes scholarly growth and may involve writing manuscripts or conducting smaller studies associated with a bigger study.
This is part of a series introducing programs in the Robert Wood Johnson Foundation (RWJF) Human Capital Portfolio.
What policies optimize nurses' role in solving the shortage of primary care practitioners? What approaches will promote and incentivize interprofessional education and practice in health care so as to improve the quality and safety of care? What promising state and federal initiatives are likely to achieve the Institute of Medicine's recommendation to increase the proportion of nurses who hold a baccalaureate or higher degree to 80 percent by the year 2020?
These and other crucial issues confronting nursing and the health care system are the focus of the Robert Wood Johnson Foundation (RWJF) Charting Nursing’s Future policy briefs. Launched in 2005, the series now includes 20 briefs covering a range of topics, including:
- Unlocking the potential of school nursing;
- Expanding the nation’s capacity to educate nurses through state-level partnerships;
- Improving the recruitment and retention of older and experienced nurses as a way to stem the looming nursing shortage;
- Understanding the relationships among such issues as access, cost, payment systems, and quality of care;
- Optimizing nurses’ role in closing the health care quality and safety “gap”;
- Addressing the nurse faculty shortage through public and private partnerships;
- Strengthening public health nursing;
- Driving policy change with data collected and analyzed by state nursing workforce centers;
- Easing the nursing shortage through government, school and employer collaborations; and more.