Columbus Monthly / December 2010 / Healthcare reform, healthier people?

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Healthcare reform, healthier people?

The Columbus Medical Association and members of the medical community reflect on the lessons to be learned from the healthcare reform debate.

Changes in healthcare are coming.   

While it remains to be seen exactly what effect the November elections will have on President Obama’s Affordable Care Act, signed into law in March, one thing is certain: The debate over how to fix the nation’s broken healthcare system will continue.

One valuable side effect of the political wrangling over reform is that many important healthcare issues have been brought to the forefront of American conversation. And whatever the eventual outcome, these discussions have emphasized various ways patients can take control of their own health and, working in partnership with their physicians, design personal wellness plans.

As written, the new healthcare law would bring changes in everything from health insurance and mandatory coverage to adjustments in Medicare and Medicaid.

Many of these changes would be phased in over the next few years, while others already have taken effect. This potential sea change begs a series of questions:

“Would more people get the care they need?”

“Would healthcare reform result in healthier people?”

“Would costs be better controlled?”

Perhaps the most crucial lesson to be learned from the ongoing debate is that Americans need to understand how to use the system in a way that maximizes their healthcare in a cost-effective way. In essence, we need to better utilize healthcare services and adopt an attitudinal shift from a “sick care” system to a “wellness” system.

Nearly all American citizens are  scheduled to have healthcare coverage by 2014. There will be numerous vehicles to accomplish this goal, so Americans will need to pay attention as the plans unfold. Unfortunately, as a nation, we haven’t been good at this in the past.

Health literacy is defined as “the capacity to obtain, process and understand basic health information to make appropriate health decisions.” According to the U.S. Department of Education, more than one-third of adults in the United States have only basic (22 percent) or below basic (14 percent) health literacy. Around 12 percent have “proficient” health literacy skills.

These results are not surprising to Philip Cass, CEO of the Columbus Medical Association. “We’ve known historically that the healthcare system is confusing; it has been getting more confusing, and at times in conflict with itself,” he says. “Some of the major challenges in front of us include: learning how to best utilize the healthcare system when we are sick and selecting the health plan that is best for us; optimizing our health in everyday practices; using the system for health needs to be learned and practiced; when we are sick, asking some questions such as, ‘What is emergency care?’ ‘What is urgent care?’ and ‘Can this wait until tomorrow?’ ”

Healthcare fast food

A “fast food” or instant gratification mentality has been part of our culture for some time. We’ve come to expect everything immediately, like pulling up to the drive-through. The same holds true for many of us as we deal with our health.

The healthcare system has responded to this McDonald’s mentality by the proliferation of urgent care centers designed to handle immediate, episodic care and the creation of minute clinics in pharmacies and grocery stores. Now hospitals are building stand-alone emergency rooms.

We don’t have enough primary care physicians in the U.S.—and it’s not uncommon for patients who do have a primary care physician to utilize urgent care, emergency rooms or walk-in clinics at retail locations. One of the most important things this country needs in the future is more primary care physicians.

“Urgent care and other similar access points certainly have their place in the healthcare system, but unfortunately they are far too often being substituted for ongoing primary care and a medical home,” says family physician Randy Wexler, MD. “Unfortunately, patients do not necessarily think about how the location they receive care might fit into their overall health and wellness. Even though many primary care physicians offer same-day scheduling, the rise of episodic, walk-in medicine continues, and the fragmentation in care this creates has serious consequences”

Emergency rooms are particularly appealing because they provide a 24/7 one-stop shop for whatever ails a patient, from the routine to the complex. However, ERs are an expensive and inappropriate place to get primary care. Having no medical history means additional tests and other expenses are required to help diagnose the problem.

Attitude adjustment

Does it really matter? The answer is unquestionably “yes.” Improper utilization of healthcare services in the long run results in fractured care, drives up the cost of healthcare and ultimately does not produce the best health outcomes for the patient.

“We’re at a crossroads. Right now, for the most part, the healthcare delivery system is responding to market-driven factors and competing for patients. But what patients are receiving is often fragmented, unrelated and expensive units of care. What we need is an approach that supports integrated (whole person), seamless care that involves a patient-centered medical home. Both approaches cannot ultimately exist together,” says internist Pat Ecklar, MD.

The assurance of health reform to improve care and health status will only be achieved with the increased engagement of individuals. It’s not just the attitudes of the  30 million newly insured, but of all of us that need to shift from a focus on “sickness” to one of “wellness.” Healthcare professionals, health plans, consumer advocates, hospitals and government agencies all have essential roles in reducing barriers to care and integrating care so the whole person is considered.

It will be a challenge.

According to the Center for Advancing Health in Washington, D.C., only one-third of Americans consistently perform many of the actions that would benefit their health, and two-thirds never perform these actions or do so inconsistently or tentatively.

What can be different

How can the system support good healthcare performance? Two of the most discussed approaches in health delivery since the passage of the healthcare reform law are the “patient-centered medical home” and the “accountable care organization” (ACO). While guidelines for these models are still being developed, there are various pilot programs that have been implemented in the past few years around the country, including Columbus. 

ACOs are integrated organizations of care and typically are composed of primary care physicians, physician specialists and a hospital or hospital system. The members of the healthcare team work together to improve the health of those people who are part of their population. The intent is to coordinate care under one organization.

With ACOs, doctors and hospitals would get paid based on the ability to meet the quality-of-care guidelines while containing cost. Payment would be based upon improving care outcomes, not simply delivering more and more care.

Conversely, the ACOs also would be rewarded for keeping patients healthy and meeting national quality standards, such as making sure patients get colorectal screenings and women get their annual mammograms.

Patient-centered medical homes are similar in that they consolidate multiple levels of care for patients. However, the basic premise of the medical home is that healthcare would be delivered by a personal physician who is equipped with the right resources to produce better health outcomes.

By offering patients a relationship with a primary care physician, a primary care team will produce continuous and coordinated care, helping patients navigate the segmented medical system. And when patients are engaged with their doctors, they can take real accountability for their health. This will create savvier consumers of care and ultimately, better health outcomes. Patients also will be required to be active rather than passive participants in their own healthcare. 

Both of these complementary approaches require a fundamental shift in the relationship between patients and physicians, as well as a commitment to wellness.

The push and the pull

Think about it from the perspective of having a heart attack. The physical toll of a heart attack can be devastating, even deadly. Patients who understand their risk factors, seek to reduce them and have regular wellness visits would have a much higher chance of avoiding a heart attack to begin with. The current healthcare system is not optimal in preventing sickness, but rather is skewed toward treating illnesses and events once they occur.

“What we need is a push and a pull,” says Dale Michalak, MD, of Worthington Family Physicians. “Health information and education need to be pushed out by employers, insurance companies and others while physicians are pulling patients in for wellness visits and effectively sharing the patient’s health information with everyone involved in that patient’s care and personal health commitment. That helps create a shift towards a wellness model. But, it will mean everyone must be invested and committed.”

Under healthcare reform, substantial investment in Electronic Health Records is being made to help facilitate this continuum.

Healthcare’s core

Regardless of all the changes that are being proposed, the need has always existed for a strong patient/doctor relationship. No technology or system can replace the knowledge and trust between a doctor and patient.

The patient/doctor relationship is not always simple to define. It exists on numerous levels, and in some cases a certain level may be appropriate for a specific situation. However, when both physicians and patients are asked to describe the ideals of the patient/doctor relationship, they arrive at the same assessment—the desire to relate at a level deeper than they currently do.

“As is the case with every relationship, openness, caring and accountability are required,” says Cass. “The patient/doctor relationship has always been a very powerful, personal partnership, and we believe the basis for good medicine and good health. Understanding and relating to patients on a deeper level can, in the long run, save time and money and has to be a cornerstone as healthcare reform gets implemented. If this does not occur, real change will be extremely difficult.” 

 

Gary Stelluti provides communications and marketing services to the Columbus Medical Association through Health Care Marketing Strategies, LLC.