Archivi delle etichette: Primary healthcare

Clinicians do not have the luxury to not care about costs @kevinmd @Medici_Manager @WRicciardi


In a large lecture hall of fellow clinicians-to-be, I was told that my job as a physician is not to be concerned with costs but rather to treat patients. My wrist, moving frantically left to right on my page taking notes, stopped. I looked up and my mind wandered: What an odd message to tell those who will be listening to ill people’s symptoms, prescribing medicine, ordering tests and orchestrating people’s care to not worry about.

We have set up this dichotomy of treating the patient or being concerned with costs. We have soaked medicine with the belief that cost-conscious care is rationing at the bedside and the public fear messages that clinicians who care about costs are limiting their care.

How can we teach future clinicians to be so out of touch with one of people’s greatest concerns when seeing a clinician? We know that people forgo medications because of high prices, medical bankruptcy plagues many and some cannot seek care due to cost. What other industries allow someone so crucially involved in controlling costs immunity from worrying about them? Does medicine’s unique role of saving lives exempt it from keeping an eye on the register? Is good care not cost-conscious care?

Clinicians do not have the luxury to not care about costs. The American Medical Association and the American College of Physicians realize this and are blurring the line between the “treat patient” or ”be concerned with cost” dichotomy. They are framing the argument of physicians caring about costs as an ethical issue of the stewardship of limited resources and of providing parsimonious care by using health care resources wisely.

This is a good first step, because bringing costs of care out of the dark eliminates this taboo, hush-hush culture of who’s paying the health care bill when it arrives at the table. Programs across the U.S. recognize this, too, and are weaving into their curriculum how physicians can be aware of costs in medicine. Research is advancing in this area as we explore in greater detail why prices vary so much: implementing comparative effectiveness research, continuing consumer-driven health care efforts and piloting interventions to control health care costs, like holding health communities accountable for the care that they provide.

National campaigns like the American Board of Internal Medicine Foundation’s Choosing Wisely call attention to unnecessary care. We have seen health care costs become more exposed with Steven Brill’s Time article revealing the rates that hospitals bill to patients or use as a starting point for negotiations with insurance companies. And the Centers for Medicare and Medicaid Services made public charges for 100 of the most common inpatient services and 30 common outpatient services, displaying variations in charges across the country for services.

This is not enough though. We need to continue to build this cost-conscious culture in the exam room where medical decisions are made, including both the patient and clinician, because 1) people care about costs; 2) the medical industry is not exempt from concerns about costs; and 3) good care is cost-conscious care.

People care about costs. People have premiums to pay, co-pays to fork over, deductibles to reach, prescription drugs to purchase and co-insurances to manage. This is a lot of financial information for people to keep straight and to be in charge of on top of the responsibilities they have to manage an illness or care for a loved one. We worry about how much health care services will cost us. In May 2012, the Henry J. Kaiser Family Foundation reported that a quarter of polled people had difficulty paying medical bills in the past year. Six in ten have “cut corners” to avoid health care costs, such as skipping a recommended medical test or filling a prescription medicine. As one might imagine, it’s even worse for those who are uninsured, have lower incomes and are in poorer health. Clinicians need to be on the same page as their patients: Costs for their health care matter to them, and people may be afraid to talk about them with a clinician and do not have the tools to know what constitutes a reasonable price for care.

Medicine’s unique ability to save lives is not exemption status from a cost-conscious culture. Just because medicine saves lives, it is not stamped “exempt” from having to think about costs. A good amount of health care is not emergency care, but rather preventive care and treatment of illness. Though health care may be a unique good in our society, the system should not be excused from having to consider sustainable models of spending. When the costs of health care are not transparent to both patients and clinicians, the temptation/decision to limit care may be hidden behind closed doors of obscure insurance policies. Other sectors of society save lives – police departments, prison systems, national security measures – and we still have to consider the costs of financing these services.

Good care is cost-conscious care. Was it worth it or should I buy it? We constantly, prospectively and retrospectively, evaluate how we spend our money: taking that vacation, buying a car, eating out. Was that a valuable use of our money compared to what we gained (pleasure/utility) and would we do it again? Though fewer choices may be available in some emergency situations or medically necessary circumstances where the decision process is accelerated or removed, we still can assess whether the care that we received is worth the cost. Have I been feeling better taking this medication? Has the pain subsided and is the out-of-pocket cost manageable? Has my health improved since seeing my doctor for “X”? These questions tumble around in our minds during our treatments and after in recovery.

Tools for clinicians and tools for health care costs. We are chipping away at this culture of unaccountable spending, of “running dad’s credit card,” when it comes to health care costs. But we aren’t giving clinicians and people the tools they need to partner together to take on this dragon of costs. Partly because people and clinicians don’t know how much health care services cost. Resources like Healthcare Blue Book are slowly becoming places where people can get estimates of how much their care will cost and insurance companies can give rough estimates prior to care. But these are outside of the exam room and can vary considerably.

If we continue to make the standard of treatment a more expensive option when cheaper, equally effective alternatives exist, tools need to be developed for the clinical encounter, in the exam room, where the clinician and patient can participate in shared decision making by incorporating costs: “No, I don’t want that medicine if it costs that much out of pocket,” or “I’d rather try treatment ‘X’ if it will save me that much money.”

Though having these conversations in the exam room may be a tall order for some, neglecting to include such an important issue is bad care. Sending someone home with a fancy procedure and large out-of-pocket costs may not have improved his health, but rather increased anxiety and stress over having to pay for his care. He may have chosen a different course of action had he known in advance the price he’d be paying for years to come. Likewise, prescribing a medication that a person will not pick up because it costs too much does nothing to help improve that individual’s health.

We have a long way to go in delivering cost-conscious care that incorporates the patient’s and the clinician’s views. Evidence-based tools need to be developed for both the clinician and patient to be able to weigh the risks and benefits of a test, procedure or course of treatment, and conversations need to be started between clinician and patient about costs.

I want a cost-conscious clinician who is aware of what I’m being charged and in touch with the challenges I face in paying for my health care. I want to be part of system that acknowledges people’s concerns with costs. People should demand from their clinicians this aspect of their care, and clinicians should demand from their health care organizations the tools to be able to deliver this information. Let’s stop clinicians from passing the buck on the costs of care, and let’s teach future and current clinicians to care about costs.

Patients already do.

Sarah Jorgenson is a medical student who blogs at the Prepared Patient blog and the self-titled site, Sarah R. Jorgenson.

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


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

Findings from 16 integrated care pilot initiatives in England

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Una politica per gli anziani @Medici_Manager

Gavino Maciocco

In Italia non c’è una politica nazionale per gli anziani. Come non esiste alcuna politica nazionale per qualsivoglia settore della sanità (se non quella dei tagli).  Questa mancanza di una identità nazionale nelle politiche  per la salute rende il sistema estremamente vulnerabile anche sul piano dei principi e dei diritti.

Pisa. 7 Maggio 2013. Aula Magna della Scuola Superiore S.Anna. Seminario internazionale su “Cure primarie, anziani e cronicità”. Per la Svezia interviene Eva Nilsson Bågenholm MD, coordinatore nazionale dell’assistenza agli anziani. E’ una presentazione molto ricca di dati e di utili informazioni.  Viene descritta l’intera filiera d’interventi che riguardano l’assistenza agli anziani partendo dalle cure primarie all’assistenza specialistica, fino all’assistenza residenziale.

In Svezia le cure primarie sono basate su team multidisciplinari, “primary care units” (ne  esistono 1100 in tutto il paese, libera scelta tra team pubblici – due terzi del totale – e team privati). Il team è composto da medici di famiglia, da 2 a 8, infermieri distrettuali specializzati,   assistenti infermieri, assistenti sociali,  psicologi, fisioterapisti, terapisti occupazionali, logopedisti, dietisti.  Per quanto riguarda l’assistenza residenziale, la Svezia dal 1992 ha abolito le “long term care institutions”, equivalenti alle nostre Residenze Sanitarie Assistenziali (RSA), sostituendole con unità abitative composte da 10-15 mini-appartamenti, dotati di servizi comuni il cui uso è facoltativo (come mensa, soggiorno, libreria, lavanderia, etc) e di assistenza alla persona per l’arco dell’intera giornata: attualmente sono 90 mila gli anziani residenti in queste strutture.  La presentazione tratta di investimenti, di linee guida nazionali, di progetti di larga portata e con risultati eccellenti, come quello relativo all’assistenza ai pazienti con Alzheimer.

Durante l’intervento della collega svedese cresceva in me lo sconforto nel confronto con la situazione italiana. Pensavo ad esempio che mentre, agli inizi degli anni novanta, in Svezia abolivano le RSA in Italia scoppiava lo scandalo “Italsanità”, un’operazione speculativa per la diffusione in tutta Italia dei “ghetti d’oro”, le RSA appunto.

Cercavo di collegare la situazione dei due sistemi sanitari, quello svedese e quello italiano, molto simili per alcuni versi: entrambi appartenenti al modello Beveridge, sistemi sanitari nazionali finanziati prevalentemente attraverso la fiscalità generale, con un forte decentramento nel governo e nella gestione della sanità, affidata alle Contee in Svezia e alle Regioni in Italia.

Ma il decentramento in Svezia prevede – a differenza che in Italia –  un ruolo centrale del governo centrale e del ministero della sanità nella programmazione nazionale e nella definizione dei modelli organizzativi, anche in presenza, come oggi, di un governo conservatore, favorevole a politiche market-driven anche in sanità.

Cercavo di immaginare un equivalente italiano della Eva Nilsson Bågenholm che partecipa a un seminario internazionale in Svezia sullo stesso tema di quello organizzato a Pisa. Lo cercavo, ma invano.  Perché non c’è una politica nazionale per gli anziani. Come non esiste alcuna politica nazionale per qualsivoglia settore della sanità (se non quella dei tagli).  Questa mancanza di una identità nazionale nella politica (o meglio nelle politiche: nelle strategie, nei programmi) per la salute rende il sistema sanitario estremamente vulnerabile anche sul piano dei principi e dei diritti. Chi ha a cuore il diritto alla salute in Italia, chi vuole difendere il sistema universalistico, dovrebbe non solo preoccuparsi dei tagli e dei ticket, ma anche battersi per correggere la devolution in sanità,  prodotta dalla modifica del titolo V della Costituzione avvenuta nel 2001.

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.

Building European reference networks in health care. Exploring concepts and national practices in the European Union @Medici_Manager

Under the European Directive on the application of patients’ rights in cross-border health care, the development of European reference networks was promoted as one of the prime areas for cross-border cooperation among Member States. These networks are meant to improve access to and provision of high-quality specialized health care to those patients who need it, and to act as focal points for medical training and research, information dissemination and evaluation, especially for rare diseases.

The idea of pooling resources in this way parallels moves to concentrate specialized health care services driven by financial constraints, workforce shortages and growing attention to quality and safety.

This book examines the ways in which reference networks have developed in European countries, for what kind of medical conditions or interventions, the motivations behind their establishment, the regulatory and administrative processes involved, and the financial arrangements needed. This study outlines the key policy implications and challenges of developing the concept of reference networks at national and European levels, and will assist policy-makers, health professionals, administrators and others involved in implementing the Directive.

Helping patients to die well @Medici_Manager @giovanimedici @specializzandi

Fiona Godleeeditor, BMJ @fgodlee

There is more than one way to die well, say Katherine Sleeman and Emily Collis in their article on caring for dying patients (doi:10.1136/bmj.f2174). The trouble is that far too many people die badly. Whatever your definition of a good death, dying in hospital when you would prefer to die at home, or dying in pain, distress, isolation, or uncertainty will not be part of it. Yet, as the authors explain, over half of all deaths (in the UK at least) occur in hospital, many patients die with unmet needs, and more than half of complaints referred to the Healthcare Commission are about the care of dying people. All of this is despite the growing recognition of the need for good end of life care. And of course the risk of dying badly matters not only to the person who is dying but to their relatives and friends. The authors quote Cicely Saunders, founder of the hospice movement: “how we die remains in the memory of those who live on.”

But there is good news. While modern medicine often seems to actively promote bad end of life care, doctors can do a great deal to help patients achieve a good death. Early identification of the dying phase, good communication with patients and relatives, sensible prescribing, effective management of physical symptoms, and understanding of the patient’s social, psychological, and spiritual needs must all play their part.

Sleeman and Collis have targeted their advice towards doctors in training. But clinicians at all levels of experience will benefit from reading their article. Senior doctors will, in any case, want to model the highest professionalism and humanity when dealing with dying patients. Knowing that younger doctors will be taking their cues from you provides an additional incentive.

The article usefully tackles some of the misconceptions that have dogged the Liverpool care pathway in recent months. The pathway is a framework, not a treatment, so doesn’t need formal consent, but the decision to start someone on it should be made by a multidisciplinary team and should be discussed with the patient where appropriate and always with the relatives. While on the pathway, patients should be supported to eat and drink; and if the patient’s condition improves, the pathway can be stopped.

Essential to good end of life care is the ability to recognise that a person is dying. Sadly, this is a prognostic skill that doctors are “notoriously poor at,” say the authors. But do patients need to know that they are terminally ill in order to receive good care? The same authors take part in our Head to Head debate this week, arguing that patients should be told, since this knowledge is necessary for informed decisions (doi:10.1136/bmj.f2589). But Leslie Blackwell argues against what she calls “prognostic disclosure” (doi:10.1136/bmj.f2560). This is, she says, “a failed model for medical decision making that creates more suffering than it relieves,” and “for most people the apparent choice between comfort and prolongation of life is a false one.” I’m not convinced, but I would like to hear your views.

Cite this as: BMJ 2013;346:f2656




Vaccines and Autism: CDC Study Says No Connection @Medici_Manager @WRicciardi

Frank DeStefano, MD, MPH

New CDC Study of Vaccine Doses and Autism

Concerns about childhood vaccinations and the risk for autism persist for many parents and some members of the public. A new CDC study published in the Journal of Pediatrics [1]addressed a current concern about the relationship between autism spectrum disorder (ASD) and vaccination, which centers on the number of vaccines and vaccine antigens given to infants and children, according to the recommended childhood immunization schedule.

The study evaluated the association between the level of immunologic stimuli received from vaccines during the first 2 years of life and the development of ASD. The findings showed that neither the number of antigens from vaccines received on a single day of vaccination, nor the total number of antigens received during the first 2 years of life, is related to the development of autism.

About This CDC Study

This study is the first of its kind to evaluate the issue of “too many vaccines too soon” and the development of ASD. The study was conducted in 3 managed care organizations (MCOs), involving 256 children with ASD and 752 control children matched by birth year, sex, and MCO. In addition to ASD, researchers evaluated autistic disorder and ASD with regression and found no relationship with the number of vaccine antigens received in either of these categories.

Study data were obtained from immunization registries and medical records. The data used in this study had been collected and analyzed previously.[2] Children eligible for the study were born between January 1, 1994, and December 31, 1999, and were 6-13 years old at the time of data collection.

Each child’s total vaccine antigen exposure was determined by adding the number of different antigens in all vaccines that each child received in 1 day, as well as all vaccine antigens each child received up to 2 years of age. The number of vaccines and number of vaccine doses administered according to type of vaccine are shown in the Table.

Table. Antigens in Vaccines and Total Doses Administered by Vaccine Type

Vaccine Type Antigens per Dose Dosesa
Diphtheria toxoid/tetanus-diphtheria (DT/TD) 2 14
Diphtheria-tetanus-pertussis (DTP) 3002 235
DTP – Haemophilus influenzae type B (Hib) 3004 1659
Diphtheria-tetanus-acellular pertussis (DTaP) 4b 1165
DTaP 5b 789
DTaP 6b 492
DTaPHepatitis B 6b 3
Influenza 10 95
Hib 2 2123
Hepatitis A 4 22
Hepatitis B 1 3085
HepatitisB-Hib 3 215
Measles, mumps, rubella (MMR) 24 1093
Measles 10 2
Meningococcusc 2 285
Mumps 9 1
Pneumococcusd 8 698
Polio 15 3385
Rabies 5 1
Rotaviruse 14 57
Rubella 5 2
Typhoid 3000 4
Varicella 69 917
Yellow fever 11 1
aTotal vaccine doses administered in the study population from birth to 2 years of age
bNumber of antigens in DTaP vaccines varied by manufacturer
cMeningococcal C conjugate vaccine administered as part of a clinical trial at 1 MCO
dPneumococcal conjugate (7-valent) vaccine; some doses administered in a clinical trial at 1 MCO
eRotaShield® (no longer marketed)

The number of vaccine antigens has decreased in recent years although the number of recommended vaccines has increased. The routine immunization schedule in 2013 contains more vaccines than the schedule of the late 1990s. The maximum number of vaccine antigens that a child would be exposed to today by 2 years of age is 315, compared with several thousand in the late 1990s. This is the result of changes in vaccines that allow them to more precisely stimulate the immune system. For example, the older whole-cell pertussis vaccine induced the production of approximately 3000 different antibodies, whereas the newer acellular pertussis vaccines (such as DTaP) stimulate the production of 6 or fewer different antibodies.

This study strengthens the conclusion of a 2004 comprehensive review by the Institute of Medicine of the scientific evidence that favored a rejection of the causal association between certain vaccines types and autism.[3]

Knowledge, Attitudes, and Beliefs About Vaccines and Autism

Some parents are concerned that there is a link between vaccines (such as MMR) or certain vaccine ingredients (such as thimerosal) and autism. However, several large and reliable studies of MMR vaccine have been done in the United States and other countries.[3,4] None has found a link between autism and MMR vaccination. Furthermore, research[2] does not show a link between thimerosal in vaccines and autism. Although thimerosal was taken out of childhood vaccines in 2001, autism rates have continued to climb.

Although scientific evidence shows that vaccines do not cause autism, a 2012 HealthStyles survey showed that slightly more than 15% of parents are concerned that they do (LaVail K, Fisher A, CDC; unpublished data). Data from the survey found that 22.8% of parents are concerned that children receive too many vaccines at a single doctor’s visit, and 22.8% of parents are concerned that children receive too many vaccines by the age of 2 years. The vaccines, they believe, can cause learning disabilities, such as autism. In another recent survey,[5] more than 1 in 10 parents of young children refuse or delay vaccinations in the belief that delaying vaccines is safer than giving vaccines according to the CDC-recommended immunization schedule. Children do not receive any known benefits from delaying vaccines. Delaying vaccines puts children at risk of becoming ill with vaccine-preventable diseases.

What Clinicians Can Do

CDC research with parents about their vaccine attitudes and vaccination behaviors has found that most US parents believe that vaccines are important, and they vaccinate their children. In fact, coverage for most of the routine childhood vaccines remains at or exceeds 90% in children aged 19-35 months. CDC and other agencies and organizations continue to conduct research to learn more about the causes of autism.

Healthcare professionals are the main determinants of parents’ decisions about whether to vaccinate their children. This study provides evidence that clinicians can use to reassure parents that the number of vaccines received early in life is not associated with the development of autism. Clinicians can help parents to learn the signs of ASD and act early so that action can be taken to help their children reach their full potential. Online resources, tools, and educational materials for clinicians to use to communicate with parents and caregivers are found at the end of this article.

Web Resources

CDC. Developmental Milestones

CDC. Autism Spectrum Disorders. Screening and Diagnosis for Healthcare Providers

American Academy of Pediatrics. Community Pediatrics. Act Early on Developmental Concerns: Partnering with Early Intervention

Frank DeStefano, MD, MPH, is Director of the Immunization Safety Office of the Centers for Disease Control and Prevention (CDC). He is a graduate of Cornell University and the University of Pittsburgh School of Medicine. He received training in public health and preventive medicine in the Epidemic Intelligence Service and preventive medicine residency at CDC. He obtained a Masters of Public Health degree at Johns Hopkins University School of Hygiene and Public Health. He has had extensive epidemiologic research experience at CDC, the National Institutes of Health, and at non-governmental research organizations. His areas of research have included immunizations, autism and other developmental disabilities, reproductive health, veterans’ health, diabetes, cardiovascular diseases, and other chronic diseases. Dr. DeStefano is an author on over 150 publications in leading scientific and medical journals. For the past 16 years Dr. DeStefano has had a focus on vaccine safety.

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”

NHS group to consider weekend services @Medici_Manager @tkelsey1 @specializzandi

A group is to be set up to examine why the NHS in England cannot provide some routine services at weekends – like day surgery – the BBC understands.

The NHS Commissioning Board is due to announce the move on Tuesday, when it publishes its planning guidance for the NHS for the first time.

The group will include patient representatives, health providers and people from outside the health service.

The government said it “fully supported” a seven-day service.

The health minister, Lord Howe, said patients needed the NHS “every day”.

“Offering easier access to hospital consultants, GPs and routine hospital services seven days a week will reduce delays and ensure that patients get seen and treated by experienced healthcare professionals,” he said.

The British Medical association said it was “open to discussion” about the changes.

The setting up of the group follows research that suggests patients are more likely to die if they are admitted to hospital over the weekend.

Board medical director Sir Bruce Keogh told the BBC the new group would look at “the barriers that stop us heading in the direction of a seven-day service.”

‘Moral case’

He said the new group would “invariably have to look at terms and conditions [of hospital staff] and see what incentives there might be”. But he stressed that “this is not about forcing people”.

“I am just trying to build a practical, moral and compassionate case on behalf of patients.

“You have got to get people to believe in the moral case,” he said.

Sir Bruce added: “It is time for the NHS to offer more routine services at the weekend, in addition to emergency services. This will be a big cultural change, but our focus should be on convenience and compassion for those seeking our help.”

He also said the focus of the new NHS Commissioning Board – which was set up under the government’s re-organisation of the health service – is to be patient focused, and that that was why he was setting up the group.

Our political reporter, Susana Mendonca, says Sir Bruce has long been a supporter of the idea that patients would be better served if routine services – like scans – were available at weekends.

Research suggests that patients are more likely to die in hospital if they are admitted at the weekend.

Earlier this year, research, carried out at University College London and the universities of Birmingham and East Anglia, was published showing patients in England were 16% more likely to die if they were admitted on a Sunday, rather than mid-week.

Staffing – and in particular the presence, or absence, of senior doctors – has been highlighted as a key factor.

The Department of Health said some hospitals were already thinking about treating patients at weekends for non-urgent operations and procedures.

For example, in Birmingham and Torbay, hospitals have had scanners open to provide tests over the weekend, as well as operations being carried out.

They also have more more senior staff and consultants around at weekends.

Responding to Sir Bruce’s comment, the British Medical Association – which represents doctors – said it was “open to discussions on ways of further improving the service patients receive at evenings and weekends”.

“Flexibility will be key – solutions that work for one specialty may not work for others,” a spokesman said.

4 essential elements of true health reform @kevinmd @Medici_Manager


I recently said I would describe the essential elements of “true reform.” I realize others might add or subtract from my list, but here it is – at least for today:

Payment reform. I put this first because no matter what form or structure healthcare takes, without payment reform it will be doomed to failure. And by “payment reform” I mean switching from the “fee for service” model I discussed in an earlier column – which basically pays more for doing more whether or not it is needed – to some kind of “outcomes” payment system.

There are many “outcomes” payment ideas – bundling, global, etc. – but they are all designed in theory to force providers to live within a certain budget for a given patient. Obviously, this is a huge culture change and will require many years – and many mistakes – to figure out.

But I think it is probably the most essential ingredient of true reform. (I would also include malpractice reform in this category; by switching to a no-fault system we would remove a large incentive to do unnecessary testing and treating.)

Electronic records. While I recognize there are many issues (privacy, compatibility, etc.) to be yet worked out before electronic records can become near universal in our hospital and personal healthcare, I believe it will be impossible to intelligently cut costs and improve safety without them. Imagine, again, the U.S. commercial airline industry in this country without computers able to “talk to each other” with the same language no matter the location.

Comparability data. And once such a computer system is widely in place, we can start making better use of “outcomes” data – i.e., data from studies that tell us what works best at the lowest cost.

Another name for this would be “cost effectiveness” data but those two words strike fear – understandably – in the hearts of doctors and patients who assume that means choosing the cheapest option regardless of quality concerns.

Right now there is a paucity of such data – in part because the “medical industrial complex” has often fought true comparison studies. But the need for such data will only grow as cost issues become paramount.

Primary care. Ultimately, all of the above will only work well in the setting of good primary care – meaning a place and professionals readily available, at least by phone, when a person thinks they (or a member of their family) might be sick.

The phrase so often used to describe this “place” today is “the medical home.” Obviously a “medical home” – like any home – can physically exist in many different kinds of settings ranging from a traditional office to a clinic to a setting in a hospital.

But the key ingredients of such a home, in my judgment, are the traditional three A’s: availability, affability, and affordability.

Timothy Johnson trained as an emergency room physician but switched careers in 1984 when he joined ABC News as its first full time Medical Editor. Although he retired from that role in 2010, he continues as Senior Medical Contributor.  He blogs atTimothy Johnson, MD: On Health.

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.


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