Archivi Categorie: Primary healthcare

Does integrated care deliver the benefits expected? @RANDCorporation @Medici_Manager @pash22

Findings from 16 integrated care pilot initiatives in England

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Practice Redesign Isn’t Going To Erase The Primary Care Shortage @Medici_Manager

Jeff Goldsmith 

Most experts agree that primary care needs to be re-invented.  There are a lot of promising ingredients of practice redesign:  better scheduling, electronic medical records with patient portals, redesigned clinician workflow, and work sharing.  Linda Green’s intriguing article in the January Health Affairssimulates a strategic combination of these changes and argues if they all happened at once, we would have no primary care physician shortage.

Even if we make much more effective use of clinical time and energy, however, Green’s formula isn’t going to get us far enough fast enough.  The baby boom generation of physicians is fast nearing its “sell by” date.  In 2010, one quarter of the 242,000 primary care physicians in the US were 56 or older.  One in six general internists left their practices in mid-career.  Many more hardworking clinicians delayed retirement due to the 2008 financial collapse.

Few manpower specialists have noted the cohort effect likely to manifest itself shortly.  A continued economic recovery and, more importantly, a recovery in retirement plan and medical real estate asset values will lead as many as 100,000 physicians of all stripes to leave practice in the next few years.  We will be replacing a generation of workaholic, 70-hour-a-week baby boom physicians with Gen Y physicians with a revealed preference for 35-hour work weeks.  During this same period, we’ll be adding 1.5-1.7 million net new Medicare beneficiaries a year and enfranchising perhaps 25 million newly insured folks through health reform.  “Train wreck” is the right descriptor of the emerging primary care supply situation.

Green suggests that this demand pressure could be accommodated with a much smaller replacement cohort of primary care docs if we:  increased each physician’s patient visits slots to 28 per day; enabled more same-day scheduling; had physicians practice in pods of 3-8 docs where any doc in the pod could see one anyone else’s patients; leveraged patient portals to substitute electronic visits for in-person ones; and plugged in physician “extenders.”  Implementing all these innovations across the entire health system has the effect of doubling physicians’ patient panels to more than 5,000 and, voila, no physician shortage.

Real-World Problems With The Model Green Lays Out

Several of these redesign elements aren’t going to be well received either by physicians or their patients.  I’ve visited real-world group practices organized this way.  They reminded me of nothing so much as “I Love Lucy’s” famous chocolate factory assembly line.  It was exhausting simply watching the physicians sprint through their days. You wanted to install oxygen carrels for them to catch their breath.  Gen Y docs aren’t going to practice 28-slot days, with intensive “break times” to answer their emails and make phone calls.  Neither are Gen Y nurse practitioners.

And without the sustaining influence of genuine relationships with their patients, the new generation of primary care physicians are likely to burn out even faster than their boomer elders did.  Moreover, aging patients will need relationships with physicians who understand the context for their chronic disease risks and can motivate them to manage those risks.  Even though they will like on-demand scheduling and e-visits, baby boomer patients, in particular, aren’t going to embrace a “bullpen” approach to their primary care coverage.  Twenty-eight-slot physician work days staffed by physician pods is an inferior primary care product.

In Group Health’s Factoria medical home practices, panel sizes went the other way, shrinking to 1,800 rather than growing to 5,400.  Visit times were doubled, to about 30 minutes, not halved.  Previous Group Health primary care practice redesigns improved physician productivity, but at a terrible price:  increased turnover and markedly reduced professional satisfaction.

The Factoria redesign leveraged Group Health’s successful patient portal, physician extenders, and better scheduling and resulted in improved clinician morale and patient satisfaction.  And, most importantly for Group Health’s business model, the redesign markedly reduced emergency visits and hospital costs per-member per-month.  Similarly, the widely cited ProvenCare Navigator model developed at Geisinger Clinic achieved panel sizes of about 2,500, less than half of Green’s 5400 panel target.

The Limitations Of Potential Strategies To Increase Productivity

Better use of nurse practitioners.  Leveraging physician extenders is a key to making more “medical homes” work properly.  Here too, however, there are cohort problems.  The current nurse practitioner population is even more “boomer intensive” than the physician population is.  In 2008, 63 percent of nurse practitioners in the US were over the age of 45, and 15 percent over the age of 60.

While Green suggests that nurse practitioners have been growing faster than population (e.g. faster than 0.8 percent a year), that growth won’t be anywhere near enough to offset the impending retirement of the baby boom NP cadre, many of whom work a lot of unpaid overtime completing their documentation tasks.  And many of the new NP’s are being snarfed up by the expansion of federally qualified health centers and by non-traditional care providers like the Minute Clinics.  There won’t be many left over for redesigned primary care practices.

Electronic health records.  Green’s optimism about the potential productivity improvements from electronic health records might also be misplaced.  Despite, or perhaps because of, the pressure from meaningful use to automate office practices, physician offices added 162,000 workers from 2007 to 2011, even with a 10 percent shrinkage of visit volume.  Many of these new hires were medical secretaries, physician assistants, and the like.

If there are productivity offsets for practicing physicians from automating medical records, they are hard to detect.  Most physicians I’ve talked to about their EMR conversions are spending less time with patients and more time feeding their EMRs coding information and complying with new Medicare documentation requirements.   The result:  richer coding and more dollars from fewer patients.   Unless documentation requirements are reduced, it is not clear that the EMR will actually make it easier for physicians, or other clinicians for that matter, to see more patients.

A Potential Way Forward

There are potential solutions in addition to the ones Green identified.  They include payment models that markedly consolidate payment transactions (bundling or partial capitation), and more targeted documentation requirements focusing more tightly on patient safety and outcomes.  We can also, per Green, reduce “unnecessary” visits by markedly improving patient communication and leveraging texting, email and social media linkages.

Green does not address the market barriers to adequate primary care physician supply.  Presently, primary care physicians earn about 55 percent of the income of their procedure oriented colleagues, a number that will be barely dented by the Affordable Care Act’s nominal increase in Medicare’s evaluation and management payments.  Unless you’re a trust funder, or someone with no medical school debt, selecting primary care as a specialty doesn’t make a lot of economic sense.  Primary care docs will still be paying off loans in their sixties.

To surmount this problem, we must markedly increase per-hour compensation for primary care physicians, or they will continue selecting life-style friendly subspecialties instead.  We’ll all have great skin, but we’ll be waiting three months to see a primary care physician.

This problem isn’t going to wait for Commissions, Blue Ribbon panels and learned pontification.  And it isn’t going to be wished away by clever economic modeling.  Despite Green’s optimism, we are going to experience a horrendous shortfall of front-line caregivers in the next decade.  Medicare beneficiaries whose physicians retire in the next ten years are going to have great difficulty replacing them.  Making more intelligent use of caregiver time is an urgent priority, but it is not going to be enough to meet the rising demand for primary care services in the next 20 years.

Medical Schools Need to Change Approach in Training Primary Care Physicians @Medici_Manager

By James Arvantes

Most medical school faculties are not well versed in the fundamental changes taking place in the nation’s health care system, which makes it difficult for them to adequately prepare medical school students and residents for practicing in the changing health care environment. That was a central theme that emerged from a primary care policy forum held here recently by the American Board of Family Medicine.
Larry Green, M.D., speaks about primary care residency programs training for the future

Larry Green, M.D., founding director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, says primary care residency programs are working to change to better meet the needs of an evolving health care system.
“If we are going to talk about innovation and change, we often have to change the faculty, because their national inclination is to teach what they have been doing their whole careers and what they were taught,” said George Thibault, M.D., president of the Josiah Macy Jr. Foundation, who spoke as part of a three-member panel. “That is different from what we want to transform the health care system into,” he added.Thibault said transformation of the health care system requires transformation of the educational process, a goal that can only be attained by having teachers in place to train students and residents about new and emerging health care payment and delivery models. “If we are going to have a reformed health care system, we need to pay attention to the workforce — not just the numbers of the workforce, but the composition of the workforce,” said Thibault.

What medical school professors teach is an accumulation of their work and educational experiences, he noted. “They can’t teach what they don’t know. We talk about new models of clinical education (moving) out of the academic center and into the community. It is integrated rather than fragmented. Those experiences were not the experiences faculty had when they were working.”Thibault also addressed interprofessional education, saying that most faculty members did not receive their training in an interprofessional setting. “They didn’t learn from other faculty and leaders in other professions.”

Moreover, most medical school faculties are unfamiliar with online learning and other technologies. “We want to and need to develop future leaders and innovators in education,” said Thibault. But, he added, changes in medical school education will succeed only if entire faculties buy into the process. “The redesign of the education system and the redesign of the delivery system are only sustainable if they become the standard way we do business,” Thibault noted.

Thibault and the two other speakers on the panel, Barbara Brandt, Ph.D., director of the National Center for Interprofessional Practice and Education, and Larry Green, M.D., professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care at the University of Colorado, Denver, pointed out that medical education is undergoing fundamental changes in some parts of the country to better align with changes taking place in the health care system as a whole.

“There are physicians all across this country who are doing their (best) to change the training programs,” said Green, who was the founding director of the AAFP’s Robert Graham Center for Policy Studies in Family Medicine and Primary Care. In fact, he added, the three main primary care residencies — family medicine, internal medicine and pediatrics — are all engaged in efforts to redesign their residency training programs to achieve better health care.

As an example of the changes occurring within medical education, Thibault described a primary care faculty development initiative spearheaded by the American Board of Family Medicine, the American Board of Internal Medicine and the American Board of Pediatrics to develop some common goals and competencies around curriculum development.

The initiative, funded by the Josiah Macy Jr. Foundation, the Health Resources and Services Administration (HRSA) and private foundations, has identified particular skills or competencies needed for the primary care workforce of the future. These include

  • teamwork,
  • change management,
  • leadership,
  • population management and
  • clinical microsystem skills.
Brandt, meanwhile, said the push to develop competencies for interprofessional education is exemplified by the National Center for Interprofessional Practice and Education. The center is funded by HRSA and private foundations, making it a true public and private partnership. One of the main goals of the center is to transform the siloed U.S. health care system into one that engages patients, families and communities in collaborative, team-based care, said Brandt.To achieve this goal, the center will create and test new health care organizations and structures while training a workforce that operates in team-based delivery systems to improve health care quality, safety and access.

“We really do not have a lot of evidence as far as what works in training and education for this type of practice,” said Brandt. “That is going to be one of the marks of distinction of this particular national center.”

The ultimate goal, Brandt said, “is better alignment of the health care system and higher education.”


  • The ability to change the nation’s health care system will require a primary care workforce that is trained in team-based and collaborative care, said three speakers at a recent American Board of Family Medicine policy event.
  • Most medical school faculties are not trained in new and innovative health care models, making it difficult for them to properly train a primary care workforce to meet the needs of an evolving health care field.
  • The speakers cited examples of how public and private partnerships are working to train a workforce that meets the needs of the health care system and the community at large.

Does Primary Care Need To Be Retooled? @Medici_Manager @HealthLeaders

Joe Cantlupe, for HealthLeaders Media, March 14, 2013

The president of Partners Healthcare and a Harvard University economist contend that primary care in the U.S. needs to be restructured to improve physician business practices and provide more value for patients.Under this “subgroup management,” primary care physicians would oversee improved coordination of care for greater efficiencies and clinical outcomes.

So say Thomas H. Lee, MD, network president of Partners Healthcare, and Michael E. Porter, PhD, the Bishop William Lawrence University Professor at the Harvard Business School, and director of The Institute for Strategy and Competitiveness, both in Boston, in a Health Affairsarticle this month. I spoke to both of them about their primary care challenge. (Erika Pabo, MD, MBA, a resident at Brigham and Women’s Hospital in Boston, was a co-author.)

“If we’re going to make primary care as effective as we want to, we have to start with a clear overreaching goal and try to restructure primary care,” Porter says. “It starts with value and that’s the true north compass. Primary care isn’t really one thing. It’s a lot of different things for a lot of different patients with very different needs.”

“If we can segment the needs and take patients and group them into fairly straightforward categories, such as healthy adults, or someone with one or two chronic conditions or very disabled people, we can understand the needs of a defined group of patients, and change the nature of primary care,” Porter adds.

The primary care framework isn’t working now, they say. As Lee sees it, too many physicians are “stumbling down a road, not sure where they are trying to go, as opposed to a bunch of people effectively moving down a road.” For doctors, it’s a vital question: their livelihoods are at stake.

“Market share is going to places that can meet patients’ needs and do it more effectively,” Lee says. He warns that physicians who “won’t be able to get their act together to adopt a strategic framework will be less successful and lose market share to organizations that can.”

Under their plan, a physician practice would divide patients into small groups reflective of differences of “core needs and circumstance,” Porter and Lee write. A practice may refer some patients to other providers better equipped to meet particular needs.

As it is now, an absence of a “robust overall strategy” is one of the causes of primary care’s problems, according to Porter and Lee.

“Thinking about primary care as a single service not only undermines value but also creates a trap that makes value improvement difficult, if not impossible. We will never solve the problem by trying to do primary care better,” they write. “Instead, primary care must be redefined, deconstructing the work that goes on within those practices and rethinking how it is performed.”

Examples of the team focus: integrated cancer teams that increasingly include both palliative care specialists and a psychiatrist to measure patient outcomes. Or, patients with end-stage renal disease may be referred to a dialysis team that provides primary as well as nephrology care.

As Porter and Lee envision a new primary care structure, they say care teams and delivery processes can be designed for each patient subgroup, with measurable outcomes. Such data measurement is woefully lacking under current primary care, they say.

The possible changes would touch not only on clinical care, but also go into the day-to-day function of existing primary care practices, which includes scheduling or patient visits. Patients with common chronic diseases can be “preferentially” scheduled to facilitate more efficient visits that may include group educational programs, they write.

Diabetes sessions could include an expansive team of specialists such as endocrinologists, podiatrists, and nephrologists. Especially complex case sessions with patients could involve mental health specialists, palliative care consultants, and social workers.

It’s no surprise, they say, that some of the best work in primary care is now focused on specialty care, especially the complex needs of elderly and disabled patients. “Various organizations have built a whole care model for those people,” Porter says.

He pointed out some examples, including the Commonwealth Care Alliance , which includes multidisciplinary teams and home visits. Others having integrated delivery care, where primary care and specialists work hand-in-hand, include CareMore, Intermountain Healthcare, Cherokee Health System, and the Department of Veterans Affairs.

To finance all of these primary care changes, Porter and Lee endorse the bundled payment model for a “total package of services for a defined primary care subgroup during a specific period of time, the approach most aligned with patients.”

While some healthcare organizations are moving in the right direction to improve primary care, much is lacking. Lee was even tough on his own health system. “We’ve got 65,000 employees, and the number of people whose job it is to improve the value of our care for healthy people, which is most people out there? The number is zero,” Lee says of Partners. “It’s not anyone’s job right now. Therefore, no one does it in a systematic way.”

Indeed, there is much discussion about population health, medical homes and Accountable Care Organizations with primary care physicians playing important roles. That’s nice, Porter and Lee say, but those models still fall short of the multidisciplinary, collaborative teams needed to augment primary care.

“We’re saying ‘let’s take it one step further,'” Porter says. “What are the primary care needs of different individuals?”

Porter and Lee acknowledge that their model certainly poses difficulties for small practices, but they insist small physician groups should not be excluded.

“There are a whole bunch of forces challenging the one and two doctor practice going forward,” Lee admits. “I don’t think anyone will look back and say this paper by Mike Porter and Tom Lee put them over the edge. There are ways to get physicians spread out, even in rural settings, to work together. They have to be ready to want to work together and collaborate with colleagues to improve the value of care for patients over time.”

Change must be in the offing for primary care, Lee insists. “I don’t think anyone feels like things are stable and that all (physicians) need to do is just show up for work and work as they currently are working and be OK,” Lee says. “We want to provide this strategic framework to make something happen, as opposed to fretting about it.”

Joe Cantlupe is a senior editor with HealthLeaders Media Online.

An excellent primary care doctor is your trusted health care advisor @Medici_Manager @kevinmd


Assembling the right medical team is important to keeping you healthy and saving money. Besides you, one of the most important people on this team is your regular doctor. For many people, this is their primary care physician (PCP) or primary medical doctor (PMD). A highly trained and well-qualified primary care doctor can advise you on what preventive tests and treatments are truly necessary to stay healthy.

If you view your primary care doctor as a person to simply get referrals from to get better care, think again.

One health insurance plan focused on having patients see primary care doctors first to help them figure out how to proceed. Without primary care doctors helping patients, 60 percent of the time patients chose the wrong specialist. Selecting the wrong doctor wasn’t the only issue. On average, $1,500 was spent on various tests and diagnostic services visits over an eleven-month period before patients were told that the specialist could not help them. Result? Wasted time and money. By pairing patients with primary care doctors, the use of specialists fell by 14 percent, emergency room use decreased by 16 percent, prescriptions declined by 11 percent, and patients received the right care. Less time and money wasted.

Because of differences in training, primary care doctors, like family physicians, internists, pediatricians, and obstetricians, are not the same. Family medicine physicians have trained to care for patients as young as newborns and as old as their grandparents. Internists care for adults as well as seniors. Pediatricians, not surprisingly see patients age eighteen and younger. Obstetricians-gynecologists (ob/gyns) often are considered primary care doctors, but, unlike the other three specialties, these doctors also do surgeries such as C-sections, hysterectomies, and bladder lifts or suspension repairs.

The trait that they all share is that an excellent primary care doctor can make a difference between mediocre care and great care. One report found that “adults with a primary care physician rather than a specialist had 33 percent lower cost of care and were 19 percent less likely to die” after controlling for age, gender, and health condition. An excellent primary care doctor can help you stay up-to-date on your immunizations and preventive screening tests, as well as diagnose problems that bother you.

Should your care require more expertise, your primary care doctor can determine which specialist to send you to and coordinate the care among many specialists if needed. Specialists often work in a vacuum, focused exclusively on their field. To ensure that all of them are on the same page, it is helpful to have one person oversee the overall treatment plan to maximize the benefit and minimize duplication of tests and procedures. While you might be that person, wouldn’t it also be nice if you also had someone else help you? It might be your regular doctor, who knows you and sees the whole person rather than a set of specific organs or diseases.

An excellent primary care doctor is your trusted health care advisor.

The challenge is finding a stellar primary care doctor. This could be harder, as fewer medical students are choosing the fields of internal medicine and family medicine due to increasing administrative hassles, decreasing compensation relative to specialists, and high medical school debt. Of those about to complete a three-year internal medicine residency program in 2003, only 27 percent planned to be internists, down sharply from 54 percent in 1998.  Those already practicing medicine are leaving for similar reasons. As more baby boomers age and require additional medical care, there will be fewer primary care doctors available despite the increase in demand for their services. It’s expected that in 2020, the nation will need about 147,000 internists, up 38 percent from 106,000, yet the number of doctors in training will be inadequate to close the gap.

Davis Liu is a family physician who blogs at Saving Money and Surviving the Healthcare Crisis and is the author of The Thrifty Patient – Vital Insider Tips for Saving Money and Staying Healthy and Stay Healthy, Live Longer, Spend Wisely.

2° Conferenza nazionale sulle cure domiciliari – CARD – Roma, 22-24 maggio 2013 @Medici_Manager

Home care e Distretti

L’assistenza e cura integrata (integrated home care) nei distretti italiani

“Tra tecnologie (high-tech) e competenze relazionali (high-touch) un distretto HIGH-TEACH che cresce nel prendersi cura della persona a casa”

Assistenza primaria. Confronto shock tra UK e USA @Medici_Manager

Inserito da  on 14 marzo 2013 – 11:06


Gianfranco Damiani, Serena Carovillano, Andrea Poscia e Giulia Silvestrini

L’Inghilterra, ideatrice e promotrice del modello Beveridge, apre le porte del suo NHS al privato. Mentre gli Stati Uniti, storicamente affezionati all’idea di una sanità di  libero mercato,  iniziano a sperimentare modelli di assistenza universalistica.

Alla luce delle quasi contemporanee riforme di due dei principali sistemi sanitari mondiali (Regno Unito e Stati Uniti) ci si propone di descrivere gli approcci di questi due Paesi nell’ambito della Primary Health Care (PHC). In particolare nel presente post verrà proposto un focus sulla componente di PHC di pertinenza medica (Primary Medical Care), indagando le differenti modalità organizzative proprie dei Medici di Medicina Generale (MMG) proposte nei due contesti presi in esame.

Per una più chiara comprensione delle trasformazioni avvenute, è necessario ripercorrere le principali tappe di costituzione e sviluppo dei Sistemi Sanitari in questione.

Regno Unito

Il Sistema Sanitario del  Regno Unito (National Health Service – NHS), nasce nel 1946 con il “National Health Service Act“, con il proposito di garantire a tutti i residenti sul suolo britannico, senza distinzioni geografiche, assistenza primaria, ospedaliera e servizi specialistici.

Successivamente nel 2010 viene pubblicato il libro bianco “Equity and Excellence: Liberating the NHS”[1], divenuto legge nel marzo 2012 “Health and Social Care Act 2012″[2]. Sebbene i principali obiettivi dichiarati di tale riforma sembrino essere una semplificazione dell’apparato burocratico volta a recuperare la centralità del paziente[3], molti dubbi, già ampliamente discussi in questo blog[4,5,6], hanno caratterizzato e ostacolato il suo percorso legislativo[7,8,9]. Molte delle trasformazioni introdotte dalla riforma interessano i MMG Inglesi, in particolare una delle principali innovazioni previste è l’abolizione dei Primary Care Trust (PCT, un equivalente delle nostre Aziende Sanitarie Locali –ASL) e delle “Strategic Health Autorities” (SHA – Strutture che esplicano funzioni simili ai nostri assessorati Regionali alla Sanità). Questi enti verranno sostituiti sia fisicamente che funzionalmente dai Clinical Commisionig Group (CCG), ovvero grandi consorzi di medici di famiglia (General Pratictioners – GPs-). (Vedi anche Dossier NHS)

Stati Uniti

Per quanto riguarda gli Stati Uniti, il sistema sanitario americano è basato prevalentemente sul settore privato, sia sul versante del finanziamento, tramite le assicurazioni, sia su quello dell’offerta e della produzione dei servizi, anche con una rilevante componente assicurativa pubblica, finanziata dal Governo federale e statale[10,11]. Da qui la definizione di tale sistema sanitario come fondato sul libero mercato. Dalla campagna elettorale del 1912 del candidato progressista Theodore Roosevelt, negli Stati Uniti, si dibatte sulla necessità di una riforma che assicuri l’assistenza sanitaria a tutti i cittadini[11]. Barack Obama, con l’approvazione  il 23 marzo 2010 della riforma sanitaria, pur avendo rinunciato all’idealistico obiettivo di una Assicurazione Sanitaria Pubblica, è stato di fatto il primo Presidente Americano a far approvare una riforma che punta a contenere la spesa sanitaria, ma anche a ridurre i larghi margini di inappropriatezza, di iniquità e di inefficienza che affliggono la sanità in questo paese, con l’obiettivo ultimo di migliorare gli outcome di salute della popolazione, contrastando in particolare la diffusione delle malattie croniche (in primis obesità e diabete)[12,13]. In questo contesto di cambiamento ha iniziato a muovere i primi passi un nuovo modello di erogazione di assistenza di primo livello, le Accountable Care Organization (ACO). Un modello assistenziale rivolto esclusivamente a quella parte di  popolazione americana beneficiaria dell’assistenza sanitaria “gratuita” offerta da  Medicare e Medicaid (entrambi programmi assicurativi statali che la Sanità Americana offre a tutti i cittadini ultrasessantacinquenni e pazienti dializzati senza limite di età, e a gruppi di popolazione a basso reddito come bambini, donne in gravidanza, disabili, anziani indigenti e malati di AIDS)[14,15].

L’intento di questo approfondimento sarà quello di analizzare i principali punti di forza e debolezza finora evidenziati in letteratura dei due modelli di ”Medical Primary Care” proposti nell’ambito delle due riforme: i Clinical Commissioning Group (CCG) e le Accountable Care Organization (ACO).

Modello Regno Unito: Clinical Commissioning Group

I CCG sono organizzazioni private, formate da gruppi di GPs con almeno un accountable officer, che hanno l’obiettivo di garantire assistenza ai loro iscritti. Tale assistenza dovrà essere erogata direttamente o commissionando i servizi, promuovendo l’uguaglianza e coinvolgendo il paziente e la comunità nella definizione dei percorsi assistenziali più idonei e nella successiva valutazione.  I CCG collaborano con altre figure sanitarie e con le “Local Communities” e le “Local Authorities”. Ogni associazione di medici di famiglia (GP practice) deve appartenere ad un CCG, che deve formarsi in modo tale da assicurare “la migliore assistenza ed i migliori risultati in termini di salute”. Sebbene sia prevista la libertà del paziente, che sceglie a quale practice iscriversi, i CCG dovrebbero avere confini che “normalmente” non oltrepassano quelli delle Local Authorities e con un numero di pazienti oscillanti tra i 100.000 ed i 750.000. Il finanziamento, basato sugli iscritti alle practice (e quindi non più in riferimento all’area geografica come avveniva prima della riforma) proviene da un organismo centrale autonomo (NHS Commisioning Board) con funzione di “accreditamento” e controllo dei CCG. Infatti l’NHS Commisioning Board può anche assegnare, qualora lo ritenesse necessario, una practice ad un CCG. A livello locale, invece, sarà il “New Health and Wellbeing Boards“, con sede nelle Local Authorities, ad assicurare la soddisfazione dei bisogni dei cittadini, raccogliendo ogni eventuale necessità proveniente dagli utenti. Tale organismo vedrà la partecipazione di rappresentanti dei CCG, esperti di sanità pubblica, altri servizi per l’assistenza di minori e adulti, nonchè rappresentati della società civile (Healthwatch).

Tra i principali punti di forza dei CCG spicca sicuramente il maggior coinvolgimento (ed al tempo stesso responsabilizzazione) dei clinici, in particolare dei GP, associato ad una conseguente riduzione della burocrazia a livello centrale, con un consistente trasferimento delle funzioni di programmazione e controllo al livello locale. In questo senso, alcuni definiscono questa non come una rivoluzione, ma la naturale evoluzione del ruolo di committenza svolto dai GP già a partire dagli anni ‘90[16]. Nell’ottica sponsorizzata dal Governo di mettere il paziente al centro dell’NHS, si predispone il sistema alla generazione ed erogazione di un’offerta di qualità che, costituendo sicuramente un vantaggio dal punto di vista dell’iscritto “malato”, potrebbe comportare un potenziale indebolimento dell’attenzione all’iscritto “sano”, in termini di medicina preventiva e di comunità. D’altra parte, la letteratura ha messo in evidenza, già in questo breve periodo, rischi e punti di debolezza della riforma, tra i quali spicca la riduzione dei servizi offerti dall’NHS, solo parzialmente delegati alle “Local Autorities”, con un incremento del ricorso al privato con pagamento “out of pocket”[17]. Su quest’ultimo aspetto molto forti sono le preoccupazioni legate al rischio di una massiccia “commercializzazione” dei CCGs, destinati a entrare nell’orbita di multinazionali  ampiamente coinvolte, già prima della riforma, nel “mercato” sanitario (un rapporto di luglio 2010 riferiva che grandi compagnie private, tra le quali spiccavano Virgin, Care UK e Chilvers McCrae, controllavano 227 GP[18], mentre un recente articolo del Guardian ammonisce sul potenziale conflitto d’interesse che sembra coinvolgere almeno la metà, se non tutte, le GP afferenti ai nascenti CCG[19]). Uno dei rischi è che la “competition”, elemento distintivo del libero mercato ed esaltata dall’attuale riforma, potrebbe diventare “consolidation”[20], con ripercussioni negative non solo nella lotta tra i medici di medicina generale appartenenti a diversi CCG per assicurarsi un maggior numero di pazienti, ma anche nell’attività di committenza, per la quale ogni CCG gode della propria autonomia. In questo modo può avvenire che due cittadini della stessa zona e con lo stesso bisogno (manifesto o meno), ma iscritti a due CCG diversi, possano ricevere trattamenti (o attività di prevenzione) differenti per tipologia e costi.

Ma le perplessità principali provengono dal fronte della Sanità Pubblica per gli aspetti legati all’incertezza dei confini geografici e alle modalità di costituzione dei CCG che si potrebbero ripercuotere negativamente sulla tutela dei soggetti che vivono all’interno di determinate aree geografiche. Vi sono infatti numerose riserve in merito al potenziale rischio di selezione dei pazienti da parte dei CCG che potrebbe facilmente aumentare le iniquità e diseguaglianze[21]. Rischi che potrebbero essere acutizzati anche dalla modalità di allocazione delle risorse da parte dell’NHS, non più pesata sulla base dello studio dei bisogni di una determinata area geografica, ma dipendente principalmente dalla composizione dei pazienti afferenti ai vari CCG. D’altra parte, l’equità nell’accesso è un “vago dovere” e non un outcome voluto e valutato nell’ottica del miglioramento continuo[22].

Un ulteriore problema riguarda i sistemi informativi informatizzati. Infatti gli attuali studi di prevenzione e di analisi dei bisogni utilizzano flussi di dati sanitari raccolti su base geografica (flussi dei PCT) che facilmente si interfacciano con quelli derivanti da altre istituzioni (ad esempio le Local Authorities). Mentre i dati raccolti dai CCG, oltre a poter risultare incompleti, faranno riferimento alla lista degli iscritti senza alcun riferimento alla zona geografica di residenza, rendendo difficile l’esecuzione di analisi di popolazione che hanno da sempre caratterizzato l’attività della Sanità Pubblica inglese[23].

Modello USA (Medicare/Medicaid): Accountable Care Organization (ACO)

La sezione 3022,  “Medicare Shared Savings Program” dell’ “Affordable Care Act” propone un nuovo modello di erogazione dell’assistenza, mediante l’istituzione delle “Accountable Care Organizations”.  Attraverso  le ACO ci si propone  di ridurre i costi relativi alla quota di spesa sostenuti da quella piccola fetta di assistenza pubblica fornita da Medicare e Medicaid. Di fatto però, tramite la loro istituzione si costituisce un nuovo modello di assistenza con l’obiettivo ultimo di implementare qualità e coordinamento dell’assistenza sanitaria nell’ambito della PHC[24,25,26]. Il termine ACO è stato coniato per la prima volta dal Dottor Elliott Fischer nel 2006 per descrive lo sviluppo di partnership tra Ospedali e Medici al fine di fornire e coordinare un’assistenza sanitaria  efficiente nell’ambito di Medicare[27].

Come riportato dal testo di legge le ACO sono costituite da medici che si occupano di assistenza primaria, Ospedali, ed Operatori sanitari di altro tipo che si uniscono “volontariamente” per coordinare e fornire un’alta qualità di assistenza ai pazienti fruitori di Medicare che decidono, anche questi volontariamente, di essere inseriti all’interno di queste modalità assistenziali. L’obiettivo del coordinamento dell’assistenza  è quello di garantire che gli stessi pazienti, in particolare i malati cronici, ottengano risposte adeguate ai loro bisogni di salute al momento opportuno, evitando inutili duplicazioni di accessi ospedalieri, nonché di prevenire gli errori medici[27,28,29].

L’Affordable Care Act specifica che l’ACO è costituita da Professionisti ACO (ad esempio, i medici e gli ospedali che soddisfano i criteri di legge ed inseriti nel sistema Medicare) in modalità associativa, ma anche reti di pratiche individuali dei medici ACO, partnership o accordi di joint venture tra ospedali e medici delle ACO e tra ospedali che impiegano i medici delle ACO[27].

Il Dipartimento dei Servizi Sanitari e Assistenziali Americano (MSSP) nell’ambito della istituzione e gestione delle singole ACO sostiene che debbano essere rispettati alcuni punti considerati imprescindibili nella gestione delle stesse[30].

Ad esempio: in ogni ACO deve essere presente un numero congruo di medici di famiglia, i pazienti potranno usufruire di tutti i medici che faranno riferimento a tale sistema senza distinzione tra un ACO e un’altra.

L’ACO si fa inoltre promotrice della Evidence Based Medicine e del coinvolgimento del paziente e in ognuna verrà istituito un sistema di reporting e di valutazione dei costi. Il coordinamento dell’assistenza avverrà tramite l’utilizzo della Telemedicina, ed il monitoraggio del passato del paziente attraverso l’utilizzo di altri dispositivi tecnologici[27].

Come sostenuto dal New England Journal of Medicine il modello ACO combina i principi fondamentali di assistenza primaria (primo contatto,  continuità assistenziale) con le innovazioni del 21° secolo come l’uso dei sistemi informativi elettronici, la gestione informatizzata di tutto il percorso di cure con particolare attenzione alle malattie croniche, e al miglioramento continuo della qualità delle cure stesse. Una delle pietre miliari di questo modello è il focus sulla soddisfazione delle esigenze e sulle preferenze dei pazienti, e sulla riforma di pagamento che migliora il rimborso per le pratiche di assistenza primaria[28,31,32].

Ad oggi il modello delle ACO è stato approvato dai contribuenti, dai medici e dai gruppi di pazienti e attualmente sono in essere numerosi progetti pilota in tutto il paese, tuttavia é ancora necessario affrontare le barriere culturali, giuridiche, legali e di risorse per la creazione di nuove organizzazione di “Providers di Cure” nei  vari Stati Americani.

Alla luce della rielezione del Presidente Obama ora che la minaccia di abrogazione è svanita, quale sarà  il futuro della riforma  sanitaria? Quali saranno  le sfide ed i conflitti  soprattutto a livello dei singoli Stati federali che si prospetteranno sulla lunga strada di implementazione della  riforma stessa?[27]

L’analisi della letteratura effettuata sulla riforma in corso sia nel Regno Unito che negli Stati Uniti, sebbene narrativa e nonostante le riforme siano ancora in una fase preliminare di attuazione, ha messo in evidenza diversi aspetti. In particolare per quanto riguarda il Regno Unito vi sono state fortissime critiche ai CCG da parte dei principali esponenti di Sanità Pubblica e della Medicina Generale (rappresentati dalla British Medical Association) comunemente preoccupati per quella che hanno definito una “legge da uccidere”[33] per evitare “la fine del Sistema Sanitario Inglese”[34].  Di fatto l’Inghilterra, ideatrice e promotrice del modello Beveridge, apre le porte del suo NHS al privato. Mentre gli Stati Uniti, storicamente affezionati all’idea di una sanità di  libero mercato, in cui la salute viene equiparata ad una “merce di consumo” che può essere venduta al miglior offerente, iniziano a sperimentare modelli di assistenza “universalistica sotto la positiva scia del sogno del New National Health Plan” del presidente americano Barack Obama[11].

È come se d’improvviso la “deriva dei continenti” avesse invertito la sua “rotta” e l’America e l’Europa avessero iniziato il loro riavvicinamento: sarà di nuovo “Laurasia”? Noi osserviamo i cambiamenti e dalla nostra prospettiva e sarebbe interessante capire se in questa tettonica delle zolle l’Italia resterà unita alla “placca” Inghilterra, oppure tenterà di aggrapparsi alla “placca” USA o, perché no, darà origine ad un nuova e separata “Isola”.

Gianfranco Damiani, Professore Associato Istituto di Igiene e Medicina Preventiva – UCSC. Serena Carovillano, Andrea Poscia, Giulia Silvestrini, Scuola Specializzazione Igiene e Medicina Preventiva – UCSC.


  1. Department of Health. Equity and excellence: Liberating the NHS. The Stationery Office Limited on behalf of the Controller of Her Majesty’s Stationery Office: 12 July 2010
  2. Health and Social Care Act 2012CHAPTER 7 [PDF: 214 Kb]. 27th March 2012.
  3. Gavino Maciocco. Liberating the NHS. Svolta shock nella sanità inglese. Salute Internazionale, 02.09.2010.
  4. Gavino Maciocco. I medici inglesi contro la riforma del NHS. Salute Internazionale, 02.11.2010.
  5. Gavino Maciocco. La fine del sistema sanitario inglese. Salute Internazionale, 07.02.2011
  6. Gavino Maciocco. È tempo di uccidere la legge. Salute Internazionale, 07.10.2011.
  7. Dalamothe T, Goodle F. Dr. Lansley’s Monster. BMJ 2011; 342:d408.
  8. Whitehead M, Hanratty B, Popay J. NHS reform: untried remedies for misdiagnosed problems?Lancet 2010; 376:1373-5.
  9. Des Spense. Greed isn’t good. BMJ 2011; 342:d524.
  10. World Health Report 2000. Health Systems: improving performance. WHO, Geneva, 2000. Il Rapporto è stato interamente  tradotto, ed integrato per la  realtà italiana, nel  numero  monografico  di  Igiene  e  Sanità  pubblica  2001; 2:1-176.
  11. Gavino Maciocco. Riforma sanitaria e cure primarie negli USA. [PDF: 80 Kb]. CARE 2010; 3: 29-30
  12. Armando Muzzi. La riforma sanitaria degli USA. Ig. Sanità Pubbl. 2010; 66: 147-154
  13. Phillips RL, Bazemore AW. Primary care and why it matters for US health system reform. Health Aff 2010; 29: 806-810
  14. Robert L. Phillips .Case Study of a Primary Care–Based Accountable Care System Approach to Medical Home Transformation. J Ambulatory Care Manage ;34(1): 67–77.
  15. Managed Care – Understanding Managed Care., ultima visita 01.05.2012
  16. Letter. Health reforms ‘will benefit most vulnerable in society’. The Telegraph, 10.05.2011.
  17. Pollock AM,  Price D, Roderick  P. Health and Social Care Bill 2011: a legal basis for charging and providing fewer health services to people in England. BMJ 2012;344:e1729 doi: 10.1136/bmj.e1729
  18. More than 200 GP surgeries now run by private companies. Circle News, 15.07.2010
  19. GPs’ shares in private healthcare firms prompt conflict of interest fears. The Guardian, 27.03.2012.
  20. Nunns A and NHS support federation. The year of cataclysm for the NHS. NHS Support Federation
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  22. Hawkes N. Allocation of NHS resources: are some patients more equal than others? BMJ 2012;344:e3362
  23. Pollock AM, Macfarlane A, Godden S. Dismantling the signposts to public health? NHS data under the Health and Social Care Act 2012. BMJ 2012;344:e2364 doi: 10.1136/bmj.e2364
  24. Grunbach K, Bodenheimer T. A primary care home for Americans, JAMA 2002; 288: 889-893.
  25. Whitcombe ME, Cohen JJ: The future of primary care medicine. NEJM 2004; 351: 710-712.
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  27. “The Patient Protection and Affordable Care Act” disponibile on line al sito USA.GOV, ultima visita il 26.11.2012
  28. Brook RH, Young RT. The primary care physician and health care reform. JAMA 2010; 303: 1535-1536.
  29. Rieselbach RE Kellermann AL. M.P.H.A Model Health Care Delivery System for Medicaid. N Engl J Med 2011; 364:2476-2478
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  31. Patient-Centered Primary Care Collaborative. Evaluation/evidence of PCMH. Washington (DC), 2009.
  32. Oberlander J. The Future of Obamacare. N Engl J Med 2012, DOI: 10.1056/NEJMp1213674
  33. Editorial.  It’s time to kill this Bill [PDF: 27 Kb]. Lancet 2011, DOI:10.1016 /S0140-6736(11)61555-9
  34. Editorial. The end of our National Health Service. Lancet 2011; 377: 353.

It is both a privilege and an honor to be a primary care physician @Medici_Manager @kevinmd

by  on October 21st, 2012 in PHYSICIAN

With all of its frustrations and challenges, I love my job.  In fact, the very things that make primary care so difficult and often times exhausting are also what make it in my opinion the most awesome field in medicine.

When I was in grade school, I wanted to be a physician.  My parents would take me to the pediatrician for routine check-ups or when I wasn’t feeling so great and I remember admiring my pediatrician like no other.  To me, he was amazing.  I was of course always pretty nervous going to see him, like that time my legs and face were covered in the itchiest rash I had ever experienced with overlying fluid-filled blisters.  I was a mess.  My cheeks and forehead were swollen so badly I couldn’t even open my eyes so I wore sunglasses so no one would hopefully notice.  I was scared and miserable and even more so because I was going to see my doctor.

He calmly sat there and listened to me explain my story to him which consisted of a weekend shooting hoops in the backyard—I kept having to go retrieve the ball from the bushes which were situated behind the basketball net.  He then asked me to pop up on the exam room table.  After he had thoroughly examined me, he calmly diagnosed me with poison ivy and gave me a prescription for prednisone.  I left and within one week, all of my symptoms had resolved.  Gone were my excoriations as well as my sunglasses and life was back to normal.  Looking back, he represented all that a real doctor truly was.  He listened, empathized and healed.

When I was in medical school, although I entered certain that I would pursue a field in primary care, I found myself gravitating towards the ROAD (radiology, ophthalmology, anesthesiology, dermatology).  For everyone who is not familiar, these are considered to be the “sexy” fields of medicine with lucrative pay … the so-called “lifestyle” fields.  I don’t know exactly how it happened– perhaps it was the confused look on the faces of my attendings as I rotated through the ROAD fields when they asked me what field I planned to pursue and I proudly stated internal medicine.

Or maybe it was the flat-out “WHY would you do that when you could be a radiologist?!” that had an effect on me.  Whatever it was, come match time, I found myself swayed down the most sought-after ROAD.  I had applied and matched in radiology.  Me, of all people!  Someone who loves patient contact and dreads vitamin D deficiency!  I had ended up from the furthest place I could have ever imagined myself happy.  But I was in a hot field and everyone told me radiology would eventually make me happy—that I would be able to get home on time and patient contact was overrated anyway.  Right?  Well, I did get home on time.  While I was at the gym and planning the menu for dinner that night, my internal medicine counterparts were moaning and groaning about call schedules and wanting to gouge their eyeballs out because they were getting out around 10 pm on non-call days.  This of course led to not having time for the gym and scarfing unhealthy food down their throats for most days of the week and needless to say lots of undesired weight gain and baseline agitation.  I figured I had clearly chosen the right field for myself.

I should have noticed that this was not the case early on because it was pretty obvious, at least to an onlooker.  When many of my colleagues needed to actually interact with a human — like place a phone call to clarify what study they had actually ordered or locate a physician with the results of an abnormal finding — they were visibly irritated.  It was as though this was the most painful part of the day.

Whereas, this was the highlight of mine.  Abnormal appendix?  I would call the surgeon and ask him/her to bring the entire team down to the dark reading ream to go over findings.  I yearned for human contact. I secretly wished every medicine team would conduct “radiology rounds” and come visit me in the dark room so we could discuss cases together.  And I looked forward to rotations like breast diagnostic imaging and interventional radiology where I would have the opportunity to actually speak with a patient and find out how they were doing.  I always knew something was missing but I couldn’t quite put my finger on it.  And years later, it dawned on me.  That something was … people!

I ended up switching fields finally to internal medicine where I was able to develop and nurture long lasting relationships with my patients.  To me, internal medicine is both the most challenging and the most rewarding of fields.  We have the privilege to become involved members of our patient’s lives and to advocate for our patients so that they receive the best care possible.  As internists, our ultimate goal and desire is that each and every one of our patients is happy and lives well.  By dedicating ourselves fully to overall patient wellness, in return our patients reward us by sharing their life experiences with us.  This in turn makes us better humans.

Solmaz Amirnazmi is an internal medicine physician who blogs at All is Well That Eats Well and can be found on Twitter @DrSolmazA and Facebook.

Medical Students Call For Leadership Training @Medici_Manager

University of Washington medical students — recognizing that health care equity will require physicians who are great leaders, not just great clinicians — call for leadership training at their school.By Nasim Babazadeh

During my first year of medical school, I attended a public meeting on a new bill that would fund clean energy jobs for residents of the Puget Sound region.  There I met a woman who was ecstatic that medical students were present at the meeting.  At the age of 65, her husband was laid off work, and consequently they were no longer able to pay for health insurance.  After a long life as healthy, middle income, working members of society, the couple, now in their 60s, lost their insurance at the time when they both felt they needed it most.  This new piece of legislation was a promising proposition for getting people back to work and insured again.

As a future physician and, therefore, a health care advocate, I understand that the health of a community and its members is often achieved outside of the clinic.  Acknowledgment of this fact is what brought my classmates and me – members of a student group called the Health Equity Circle – to this event 30 miles south of campus, despite the hours of studying that lay ahead before class early the next morning.

The medical knowledge required for practicing clinical medicine today has grown to the degree that medical schools find it practically impossible to teach students the entirety of what is needed to care for patients.  Instead, we learn the foundation of medicine and then practice the skills we’ll use to embark on a lifetime of learning.  This lifelong learning will include some skills that have nothing to do with anatomy and physiology or the practice of recommending treatments, skills such as leadership and advocacy.  We’ve seen some physicians fail and others excel at these when they leave the clinic to instate new guidelines for the treatment of a disease or propose changes to health care policy.

Recently in Washington State, the need for physicians to be advocates and leaders was felt acutely.  Cuts to the funding for our Basic Health Plan, which helps thousands of low-income families maintain health insurance, left nearly 100,000 qualified people on a wait list.  Needless to say, physicians are not helping these patients inside the clinic.  In addition to the need for doctors to treat sick patients in the clinic, there is an increasing need for them to step outside of the clinic to help make sure that people get the opportunity to see a doctor in the first place.  This requires physicians to lead others in their community and advocate for solutions.  Yet the skills needed to do this are glaringly absent from most medical school curricula.

Learning to address the social determinants of health, which will require leadership and action outside the clinic, should not be a supplemental, but rather an essential part of our medical school education. That’s why my peers and I partnered with the Seattle Sound Alliance, whose resources helped us bring leadership trainings for health professional students to campus.

The Health Equity Circle also worked with other student associations to convince our curriculum committee to offer an elective course on African American health disparities.  This action reflected our medical school’s commitment to respond to student interests and our determination to address the need for cross-cultural competence and health disparities awareness in medicine.

Other actions my peers and I have taken include working each year with the Washington State Medical Association to meet with legislators at the State Capitol in Olympia and advocate for programs that will expand access to care for all.  Finally, students and faculty have recently worked with the Rotary Club to open a student-run free clinic in partnership with the RotaCare Lake City free clinic.  Students now have greater opportunity to engage in service learning while providing the community’s under- and uninsured residents with improved access to health care.

Medical student engagement in and with our greater community is crucial to the development of physicians who can take the lead in improving the health of our state and nation.  Making sufficient quality primary care accessible for everyone will require primary care physicians who are leaders and advocates.  The projects that students at the University of Washington School of Medicine have undertaken demonstrate the ways that medical schools and students across the country can begin to address the need for leadership and advocacy in health care reform.

I recently helped teach one of the leadership trainings that we brought to campus, which both health professional students and outside community members attended.  One attendee shared that his wife had received a heart transplant at the University of Washington Medical Center, and how thankful they both were for the exceptional care that they received.  I was reminded of my goal to become a physician who, like his wife’s providers, delivers exceptional care to patients.  To achieve this goal, I’ll need superior clinical skills.  However, as the training day continued, I also remembered that it is equally important for everyone to have access to the type of care this man’s wife received.  To achieve this goal, we will all need to be leaders.

Nasim Babazadeh is a second-year medical student at the University of Washington School of Medicine. She graduated from UW with degrees in Neurobiology and Near Eastern Languages & Civilizations.  She is determined to develop advocacy and leadership skills to help her patients outside of the clinic.

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10 Guiding Principles for Patient-Centered Care @Medici_Manager @HarvardSPH_ECPE

Written by Sabrina Rodak | October 18, 2012

In August, Mountain States Healthcare Alliance, a 13-hospital integrated healthcare delivery system based in Johnson City, Tenn., received the 2012 National Quality Healthcare Award from the National Quality Forum, recognizing the system’s achievement of multiple quality-focused goals. Rather than just representing a culmination of efforts, the award is spurring the system to continue providing quality care, according to Dennis Vonderfecht, president and CEO of MSHA.

“No matter how many quality awards we receive, we can never sit back and say we are satisfied with the level of quality we have achieved,” he says. “So while we are extremely gratified to be recognized at this level, we will continue to work just as diligently to ensure that we are providing the best care possible to the people of our region.”

One of the areas NQF praised MSHA for was its commitment to patient-centered care. MSHA follows 10 patient-centered care guiding principles to ensure the health system puts the patient first in every decision. Tamera Parsons, vice president of quality and patient safety at MSHA, describes the 10 patient-centered care guiding principles.

1. All team members are considered caregivers. Under this principle, everyone in the workforce, from housekeeping staff to the CEO, is part of patients’ care experience. Regardless of one’s role, each person is expected to put the patient first. To create a patient-centered culture, MSHA has patient-centered care training for new employees. “They learn from day one that all team members are caregivers,” Ms. Parsons says. In addition, MSHA recognizes employees through thank you notes and awards for demonstrating patient-centered care principles.

2. Care is based on continuous healing relationships. This principle reinforces a focus on the continuum of care for patients rather than episodes of care. “We’re here to not only provide care, but also to provide healing — a more personal level of healthcare,” Ms. Parsons says.

3. Care is customized and reflects patient needs, values and choices. The principle of customizing care recognizes that each patient is different and may have different needs and preferences. In addition to customizing the care plan for each patient, MSHA works to make the environment comfortable to individual patients. For example, one patient may want music in the room, where another patient may not. “It allows the patient’s individuality to be a component of care,” Ms. Parsons says.”

4. Knowledge and information are freely shared between and among patients, care partners, physicians and other caregivers. In a patient-centered environment, all members of the care team — including the patient — need to be aware of the patient’s status and care plan. “If the patient is going to be the center of care, [he or she] absolutely needs to be informed and part of the decision-making,” Ms. Parsons says.

5. Care is provided in a healing environment of comfort, peace and support. Part of a patient-centered culture is the environment. MSHA has several features that create a healing environment for patients, including music, healing gardens, soothing color schemes and pet therapy programs. The hospitals also ensure rooms have pleasing scents, such as lavender or the smell of baked cookies, according to Ms. Parsons.

6. Families and friends of the patient are considered an essential part of the care team. MSHA recognizes that family and friends are essential supports for the patient’s healing process. Family and friends support patients not only emotionally, but also physically, as they can help patients understand physicians’ instructions. In the health system’s Very Important Partner program, patients identify an individual to listen to care information with them. “Patients [may be] in a state of discomfort and pain or fear, and don’t always hear information, so it [allows] a trusted family member or friend identified by the patient to participate in the sharing of information and guidance we give before sending patients home or to the next level of care,” Ms. Parsons says.

7. Patient safety is a visible priority.
 Making patient safety a visible priority demonstrates the organization’s commitment to patient care. MSHA implements policies and procedures to enforce patient safety best practices. For example, the system had a campaign around employee immunization and hand hygiene. MSHA also has a balanced scorecard called the blue print. The scorecard tracks the system’s performance in key areas, such as heart failure, pneumonia and surgical care.

8. Transparency is the rule in the care of the patient.
 This principle recognizes that true patient-centered care requires transparency between providers and patients and among providers. Providers should be “upfront and honest with information so [patients] can make informed decisions with us,” Ms. Parsons says. One way MSHA supports transparency is by posting its quality and safety performance on its website.

9. All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient. All processes at MSHA, even those that don’t involve patients, should be performed from a “patient-value” perspective,” Ms. Parsons says. For example, she says the coding and billing process is done from the perspective of the patient; staff has worked to make bills clear and easy to understand for patients.

10. The patient is the source of control for their care. A core tenet of patient-centered care is that the patient controls his or her care. “Making patients the source of control of their care is the result of effective deployment of all other guiding principles,” Ms. Parsons says. “To be the source of control, you have to have transparency and share information, create an environment that allows the patient to heal and focus work on the patient.
After discharge, patients can still have a degree of control by participating in a patient advisory group that meets regularly at each MSHA facility to provide input on how the system can improve care and become more patient-centered. The groups are composed of six to 12 patients who provide input on specific care models, such as diabetes programs. Soliciting suggestions from those on the receiving end of healthcare gives patients some control over future healthcare services and helps MSHA continue to put patients first in their decisions.

Embedding principles in everyday work
To emphasize the importance of these principles to all MSHA operations, system leaders explicitly connect policies to one or more of these patient-centered care principles. For example, MSHA’s social media policy states, “MSHA seeks to optimize communication and social presence through the official use of social media and also recognizes the importance of supporting team members in shaping industry conversation through their responsible use of social media.” The policy then lists “All team members are considered caregivers” and “Patient safety is a visible priority” as applicable patient-centered care principles. By clearly linking policies to these principles, MSHA brings patient-centered care from an abstract philosophy to a concrete practice.

More Articles on Hospital Quality:

National Association for Healthcare Quality Offers 5 Recommended Practices for Quality
How Health Systems Can Create a Robust, Enterprise-Wide Patient Safety Program 

Pay-for-Performance May Backfire on Quality, Report Suggests

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Why is there a primary care shortage? @kevinmd @Medici_Manager

by  on September 28th, 2012in POLICY

Health care reform is a locomotive barreling down America’s tracks. In two years, the Affordable Care Act (ACA) will cover some 30 out of 50 million of us that currently lack health insurance, provided neither the Supreme Court nor a new president overturns the law. Political beliefs aside, it would seem that supplying insurance to protect the health of more people is a societal good. Though the costs of reform will be debated for years to come, one major question remains that has not been adequately addressed:

Who will see all the new patients?

It’s no secret that there’s a looming crisis in primary care. Estimates place the shortfall of doctors at 30,000 in the next couple of years. Yet medical schools are flush with applicants. Residency slots are filling at higher rates than ever before as new medical schools have been chartered and class sizes have expanded. So where are all the new doctors?

In a word, the hospital.

“Hospital medicine is the fastest growing specialty in American medical history,” said Dr. Robert Wachter, chief of the division of hospital medicine at the University of California, San Francisco, and the man credited with coining the term “hospitalist” in 1996. According to statistics compiled by theSociety of Hospital Medicine (SHM), the number of doctors practicing as hospitalists has increased 172 percent from 2003 to 2010. There are now more than 30,000 doctors nationwide that are classified as hospitalists: physicians who take care of hospitalized patients but no longer have office-based practices or do primary care.

To understand how difficult it will be to find a primary care doctor in two years, look no further than Massachusetts. In 2006 the state passed a health care law mandating that everyone obtain insurance (sound familiar?). For those unable to afford the cost, subsidies were made available.

Within weeks, the “uninsurance” rate in Massachusetts dropped precipitously. Commensurate with that was a rise in both the number of “closed” office practices and the length of time it took to get a new patient appointment. Nearly six years after the law passed, more than half of the family practice and internal medicine offices in the state are closed to new patients. According to the Massachusetts Medical Society, the average wait for a new patient to be seen by an internist is 48 days. Turns out insurance doesn’t guarantee access after all.

For young doctors just finishing residency, practicing as a hospitalist has many attractions. The most enticing aspects are financial and lifestyle considerations. A starting hospitalist (depending on what region of the country they practice in) can earn around $200,000 per year (a starting office-based internist will make in the neighborhood of $150,000). Perhaps more importantly, many hospitalist groups operate with “seven-on/seven-off” schedules. This means that a hospitalist earns that salary working seven consecutive days followed by seven days off. This option is extremely popular with doctors that are parents, as well as those that want to earn extra income or volunteer during their off time.

During the three-year internal medicine residency (like the kind I administer), doctors-in-training will spend about two-thirds of their time on hospital-based rotations. If familiarity breeds comfort, then it’s not a surprise that recent residency graduates choose to stay in an environment to which they’re well-adapted. And since hospital work is shift work, there is no on-call or after-hour responsibilities to handle. When a hospitalist leaves the hospital, they’re done — unlike office-based internists who still carry pagers and get middle of the night phone calls.

Couple the lifestyle and the training experience with the huge debt burden that U.S. medical students accrue, and deciding on a hospitalist career becomes a rational choice. Dr. Wachter of UCSF compares hospital medicine to site-based specialties that came before it: emergency medicine and critical care. All of these specialties represent a convergence of high-complexity and high-cost care in a single location, where it makes sense to have well-trained specialists who handle the specific set of problems encountered there.

Since the severity of illness seen by hospitalists tends to be high, specialization improves safety and quality, which are key metrics for hospitals as insurers now tie payment to such indices. Hospitals have almost all transitioned to hospitalist models to at least some degree. According to SHM data, the larger the hospital, the more likely it is to have hospitalists. Management likes the efficiency and improved patient satisfaction that comes with having doctors on the premises at all times. Earlier discharges and shorter lengths-of-stay for patients keep the hospital beds turning over and consequently the reimbursement dollars flowing in.

Contrast all of this to the realities of office practice: Fifteen-minute visits with patients on multiple medications, oodles of paperwork that cause office docs to run a gauntlet just to get through their day, and more documentation and regulatory burdens than ever before (e.g. new IT and compliance mandates). Students see the high pressure that primary care docs are under and are increasingly making the logical choice.

A colleague of mine recently sent shock waves through our community by leaving her internal medicine practice after 23 years to become a hospitalist. Her patients were devastated, as they had grown deeply attached to her. Yet with a child entering high school, my colleague felt that the seven-on/seven-off schedule and increased pay would dramatically improve the quality of her life and time available for her family. She was frustrated after spending all day seeing patients in an office only to come home and have at least two more hours of documentation to complete most nights.

Yet despite all of the negativity surrounding primary care, there are still holdouts.

Dr. Diane Fingold, an internist at Massachusetts General Hospital in Boston, gave voice to the downtrodden in a piece published in the New England Journal of Medicine in December. In “The Road Less Travelled,” Fingold wrote beautifully of her attachment (and the above and beyond care she provided) to a patient who’d suffered a stroke and was immobilized and unable to speak. These medical complications made it nearly impossible for the patient to advocate for herself when the pharmacy withheld her medications due to an insurance snafu. After a number of phone calls, Fingold succeeded for her patient.

It’s that deep commitment over time, all the ups and downs of her patient’s many hospitalizations that keep Fingold in the game. She writes:

I get the call and head over to the ED. As I pull back the curtain, a smile of recognition spreads over Mary’s face. She can relax now. She knows I care, that I’ll figure out her story and make sure the ED docs know all her meds, allergies, and complications; I’ll let her specialists know she’s here. She knows that if her medicines change, I’ll contact her pharmacy to ensure she gets a new blister pack. She lies back and breathes more comfortably.

Familiarity has built a fortress of trust between this patient and her doctor. Fingold concludes: “And at times like this, I recognize my deep satisfaction with the road I’ve chosen to travel.”

When I called Fingold, she told me that her hospital wants to transition as quickly as possible to a hospitalist system. But pockets of resistance remain. In her practice (which is on the hospital’s campus), all of the doctors see their own patients when they are hospitalized. In her case, proximity (and desire) allows her to be directly involved in her patients’ care. But for most of us, the luxury of having our own doctor treat us in the hospital is a thing of the past.

“Ultimately, I believe we will have to give it up,” Fingold told me. “I think it will be sad.”

John Schumann is an internal medicine physician who blogs at GlassHospital.  This article originally appeared in The Atlantic.