From time to time, we will include a blog posting from a Marino Center clinician on a topic of interest. The first issue is on the topic of resiliency in tough times authored by Deb Morrill MPH, RNCS, APN. Deb is a long time Marino Center clinician who focuses on women’s health.
As a seasoned health care provider, I have witnessed loss and crisis in many patients and most recently have experienced a tragic and sudden loss in my own family. Many individuals seem to show strength and resiliency during the most heartbreaking losses. A common armament of character, belief and coping strategies seem to be common among this group.
Resiliency is the ability or process by which people adapt successfully to life’s difficulties and challenges. It is the capacity to bounce back from a traumatic event or to thrive under seriously stressful situations
Three characteristics seem to be common among resilient people: a staunch acceptance of reality, a deep belief often buttressed by deeply held values, (that life is meaningful) and an uncanny ability to improvise.
This is often accompanied by a strong sense of community. The majority of individuals look to support from a formal or informal community. This is often a spiritual/faith community but may also be a bereavement group, AA meeting, work group, or chat room. I found myself reaching out to my co-workers and friends to organize a prayer wheel during my nephew’s catastrophic illness. I found much support and solace in the prayer, support, and community via email communication.
Spirituality and religious traditions may play a key role in providing solace and comfort. This outlet may offer shared belief systems, ritual and spiritual practices, community gatherings, support, care, and outreach. Communities seem to be a strong factor in resiliency. Altruistic behavior also may be beneficial for emotional health by releasing the hormone oxytocin which has sustained anti-stress effects. This means that providing service or doing good is actually good for you. You no longer need hesitate to ask a friend to pray or provide a favor, as the health effects will come back to that person. You can return the favor.
A regular meditation program can also strengthen resiliency. Herbert Benson’s studies show an association between relaxation response and positive neurochemical changes in the brain.
We will all need to test our resilience many times over in life.
Perhaps this is the time to reexamine our life beliefs, spirituality, and community involvement. It is not too late to develop a resilient self.
Special Note:
This article was written by Deb in memory of her nephew Eric J. Gaffney who died September 6, 2009 and his resilient, loving parents.
Wednesday, October 7, 2009
Tuesday, September 29, 2009
NIH GRANT AWARDED to MARINO CENTER
Studies in Patient-based Informatics for Comparative Effectiveness Research (SPICER)
The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.
With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.
Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.
Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.
2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.
3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.
4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.
Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick
University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD
The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.
With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.
Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.
Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.
2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.
3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.
4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.
Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick
University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD
Wednesday, September 9, 2009
What’s Wrong/Right with the U.S. Health Care System
Recently, a young person applying to medical school asked me for assistance in getting information about our health care system so she could complete a section on the application that asked her to comment on what’s wrong with the health care system. Naturally, I was able to provide a lot of articles, papers, as well as my own analysis of the issues. After giving her the information necessary to do a decent job of responding to the question on her application, I began to think about how I would respond to such a question. I thought of two alternative responses; one that articulated the problems and deficiencies of the system and the other that concluded that there is really nothing fundamentally wrong with the system. Below is how I might have responded in each of these parallel universes, addressing the underpinnings of any health care system Access, Quality, and Cost.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
Thursday, August 20, 2009
Americans Spend $34 Billion on Complementary and Alternative Medicine
Over the past few months, there has been a lot of talk about health care, or more accurately, health insurance reform. Obviously, any significant change coming from the Federal or State level will impact the Marino Center. It is my sense that our focus on primary care within an integrative delivery model will put us in a good position for the coming changes.
Within the currently proposed legislation, the value of primary care is being touted as a key to getting better health status outcomes through prevention and wellness leading to less dollars spent on “fixing” health problems that could have been prevented. Further, a recent a survey conducted by the CDC’s, National Center for Health Statistics reported that $34 billon dollars, or 1.5% of total medical costs were spent on Complementary and Alternative Medicine. The biggest single expenditure was for non-vitamin, non-mineral herbal supplements and other products (almost $15 billion) followed by practitioner visits ($12 billion), stretching and meditation-related classes such as yoga, tai chi, and qigong (($4 billion), homeopathic medicines ($2.9 billion) and relaxation techniques ($0.2 billion). Chronic pain, especially back pain, is by far the biggest reason that people turn to complementary and alternative treatments.
Other highlights from the report include:
- In 2007, 38 million adults made an estimated 354 million visits to CAM practitioners
- Two-thirds of the out-of-pocket spending were for treatments that did not involve a practitioner, such as over-the-counter herbal therapies and other therapies, classes and materials
Previously reported figures based on the same national survey showed that 38% of adults and 12% of children under the age of 18 used some type of alternative medicine in 2007.
Note: portions of he above was extracted from a WebMD Health News article
Within the currently proposed legislation, the value of primary care is being touted as a key to getting better health status outcomes through prevention and wellness leading to less dollars spent on “fixing” health problems that could have been prevented. Further, a recent a survey conducted by the CDC’s, National Center for Health Statistics reported that $34 billon dollars, or 1.5% of total medical costs were spent on Complementary and Alternative Medicine. The biggest single expenditure was for non-vitamin, non-mineral herbal supplements and other products (almost $15 billion) followed by practitioner visits ($12 billion), stretching and meditation-related classes such as yoga, tai chi, and qigong (($4 billion), homeopathic medicines ($2.9 billion) and relaxation techniques ($0.2 billion). Chronic pain, especially back pain, is by far the biggest reason that people turn to complementary and alternative treatments.
Other highlights from the report include:
- In 2007, 38 million adults made an estimated 354 million visits to CAM practitioners
- Two-thirds of the out-of-pocket spending were for treatments that did not involve a practitioner, such as over-the-counter herbal therapies and other therapies, classes and materials
Previously reported figures based on the same national survey showed that 38% of adults and 12% of children under the age of 18 used some type of alternative medicine in 2007.
Note: portions of he above was extracted from a WebMD Health News article
Monday, August 3, 2009
Senators Seek Coverage for Alternative Therapies
Last week, the Boston Globe reported that Senator Tom Harkin of Iowa is leading an effort to win insurance coverage for naturopathic doctors, herbal healers, mind-body specialists, and acupuncturists as part of health care reform. Backers of this amendment claim it could save tens of billions of dollars in the long run by providing less expensive and better alternatives to drugs and surgery in a variety of cases.
It is interesting to note that the amendment has bipartisan support as it is backed by Senator Mike Enzi, the ranking Republican on the Senate committee on Health, Education, Labor and Pensions. This committee agreed to pass the measure onto the Senate Finance Committee, which is working on companion legislation that may include crucial language regarding potential reimbursement.
Supporters of this amendment greet this action as a real breakthrough, regardless of the final outcome. It certainly confirms the model of care offered at the Marino Center.
In a general sense, the bigger picture here is that more attention is being paid to the front end of the health care system, i.e., prevention, wellness, and management of chronic conditions. This would be real health care reform if things move in this direction. Stay tuned.
It is interesting to note that the amendment has bipartisan support as it is backed by Senator Mike Enzi, the ranking Republican on the Senate committee on Health, Education, Labor and Pensions. This committee agreed to pass the measure onto the Senate Finance Committee, which is working on companion legislation that may include crucial language regarding potential reimbursement.
Supporters of this amendment greet this action as a real breakthrough, regardless of the final outcome. It certainly confirms the model of care offered at the Marino Center.
In a general sense, the bigger picture here is that more attention is being paid to the front end of the health care system, i.e., prevention, wellness, and management of chronic conditions. This would be real health care reform if things move in this direction. Stay tuned.
Wednesday, July 22, 2009
Health Care Reform - Progress
Health care reform is front and center at both the Federal and State levels. The prominent theme at the Federal level is universal coverage, that is getting a major portion of the 45 or so million people who are not insured to get coverage, and somehow do this without breaking the Federal bank. In reality, this is not health care reform but health insurance reform. It seems the words "health insurance reform" are being used by President Obama. The belief is that the health care system itself can be transformed through health insurance reform. At the Massachusetts State level, the focus is on payment reform to control costs. For all intents and purposes, Massachusetts has achieved near universal coverage, with less than 3% of the population uninsured, the lowest in the nation.
Federal Reform Initiatives
Key elements in the proposed Federal reform bill (House Version) entitled: "America’s Affordable Health Choices Act" include:
Federal Reform Initiatives
Key elements in the proposed Federal reform bill (House Version) entitled: "America’s Affordable Health Choices Act" include:
- Requires individuals to obtain and maintain health insurance coverage. Those who do not obtain coverage will pay a penalty of 2.5% of modified adjusted gross income above a specified level. Subsidies would be provided to low wage earners through a sliding scale of affordability credits.
- Creates a Health Insurance Exchange to serve as a marketplace for individuals and small employers to comparison shop among private and public insurers. The bill proposes the creation of a public health insurance option that is supposed to operate on a level playing field with private plans included in the "Exchange" offerings. The public option is the most controversial aspect of the bill.
- Prescribes essential benefit design and administrative rules for health insurance products. Insurance companies will no longer be able to refuse to sell or renew policies due to an individual’s health status or to exclude coverage treatments for pre-existing conditions. The bill also prohibits lifetime and annual limits on benefits and limits the ability of insurance companies to charge higher rates due to health status, gender, or other factors. Premiums can vary only based on age, geography, and family size. Health insurance plans would have to submit an application to become a Qualified Health Benefits Plan (QHBP) in order to participate in the Health Insurance Exchange program.
- Promotes primary care, mental health services, and coordinated care within the Medicare program through a Patient Centered Medical Home Pilot Program. A patient centered medical home provides patients with direct and ongoing access to primary care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such patients. The medical home serves a coordinating role for all of a patient’s care needs.
Administration of the health reform plan would fall under the authority of a new independent agency in the Executive Branch called the Health Choices Administration that will be headed by a commissioner appointed by the President. The Health Insurance Exchange would fall under the auspices of the Health Choices Administration.
There are many more provisions and aspects of the America’s Affordable Health Choices Act contained in its over 1,000 pages. Given the uncertain nature of the bills future and the certainty that it will be modified, it is not worth delving into the details at this point.
Massachusetts Reform Initiatives
Given the relative success of Massachusetts’s universal coverage initiative over the past several years, the issue at hand now is cost, which is stressing the state budget and the private sector employers and individuals who must purchase health insurance. To address the cost issue, the State in 2008, mandated the creation of a Special Commission on the Health Care Payment System to "investigate reforming and restructuring the system to provide incentives for the efficient and effective patient-centered care and to reduce the variation in the quality and cost of care". The recommendations of the Special Commission were published and made public on July 16th. The report identified the perverse incentives of the Fee for Service (FFS) payment system as the main culprit driving costs. As stated in the report, "FFS rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth". The Special Commission recommends moving to a global payment system.
Key components of the Global Payment system are:
- Develop Accountable Care Organizations (ACOs) that accept responsibility for all or most of the care that enrollees need. ACOs will be composed of hospitals, physicians, and/or other clinician and non-clinician providers working as a team to manage both the provision and coordination of care for the full range of services that patients are expected to need.
- Foster patient-centered care and a strong focus on primary care. ACOs will receive global payments and in turn will disburse those payments among participating providers, using methodologies, including episode based payment and medical home models, of their choice.
Use pay-for-performance (P4P) incentives to ensure appropriate access to care, and to encourage quality improvement, evidence based care, and coordination of care among providers and across sits of care. - Share financial risk between ACOs and payers. Payers, including private insurers and self-insured employers, will retain their current role as holders of insurance risk for health insurances contracts and employee health plans. To ensure that ACOs are not subject to insurance risk, global payments will be risk adjusted for clinical and socioeconomic case mix and geography. Clinical case mix adjusters will reflect patient’s health conditions and differences in consumer incentives associated with benefit design. Socioeconomic adjustments will recognize other patient characteristics such as income status, to the extent that they have been demonstrated to influence health.
- Encourage widespread adoption of medical home models of care. The Special Commission recommends that steps be taken to ensure that the primary care practices in each ACO undergo the necessary practice redesign to become effective patient-centered medical homes ad that they are compensated in a manner that supports their operation.
The Special Commission recommendations call for implementation of the global payment system over a five year period.
How Will the Proposed Federal and State Health Reform Initiatives Affect the Marino Center?
A key question for us is what organization will undertake the role of the ACO that the Marino Center will be part of and how we will fit into the overall structure of the ACO. Based on our current limited information, the ACO will likely be at the Partners Community Healthcare, Inc. (PCHI) level. This is the organization that encompasses all of the Partners Healthcare hospitals (MGH, B&W, Newton Wellesley, North Shore. Faulkner), and all physicians who are part of the PCHI network. Since the ACO will be assuming "performance risk", it remains to be seen how cost controls and distribution of funds will take place. With the emphasis on primary care, the Marino Center should play a larger role in the overall health delivery system. Further, we will be called upon to deliver on P4P quality measures. We are well positioned in this regard given the advanced state of our electronic medical system.
Our current strategy is to continue our focus on providing quality care and increasing our capacity to deliver more primary care services by expanding the number primary care provider resources.
Thursday, July 2, 2009
The Role of Electronic Communication in Providing Care
Our society is moving rapidly toward communicating electronically using email and social networking tools such as Twitter, FaceBook, MySpace, etc. It is inevitable that this form of communication will have a greater impact on the delivery of heath care, especially for Primary Care services, as more patients use electronic means to communicate with their health care providers.
In theory, the electronic communication was supposed to reduce the number of phone calls that a doctor receives from patients seeking medical advice or for follow-up after an in person visit. At first this sounded great as it was assumed that doctors could respond more quickly to emails than engage in lengthy phone consults. However, as with many great ideas, there are unintended consequences. While there is some evidence that the number of phone contacts between patients and physicians has decreased, the complexity of the email communications have increased to a point where some patients are seeing this communication as a substitute for a face to face visit with their doctor. Clearly minor problems can be addressed in a quick and safe manner with a very succinct response by a doctor. Other more complex situations are a different story.
Obviously, in these cases the correct response is to not provide a detailed response but to indicate that a face-to-face visit is in order.
There are a series of questions that get raised in this brave new world. Where is the line? How do you define medical standards? How do you educate patients regarding the appropriate use of electronic communication? How do you keep this communication secure and private? How does a doctor get paid for providing this service?
At this point, some clinical practices, like the Marino Center, have established a secure messaging system that allows, and some might say encourages, patients to communicate with their doctors through an electronic format. However three significant challenges arise; one is the increased volume of emails and the time necessary to respond, the second is the length and complexity of the communication requiring more time and thought to respond, and the third is the lack of compensation for this service. While patients may like the convenience it does place an added burden on the doctor. This was not supposed to be the case.
Possible solutions the electronic communication challenges are to:
Not permit electronic communication at all
Limit the length of the message (like Twitter)
Assign a triage nurse or administrative assistant to screen all electronic communication and respond directly to the simple questions and direct patients to make an emergent or urgent visit, if warranted.
Under any circumstance, adequate payment for these services by third party payers should be required. This would provide an incentive for practices to develop this form of care delivery, which will happen one way or another.
In theory, the electronic communication was supposed to reduce the number of phone calls that a doctor receives from patients seeking medical advice or for follow-up after an in person visit. At first this sounded great as it was assumed that doctors could respond more quickly to emails than engage in lengthy phone consults. However, as with many great ideas, there are unintended consequences. While there is some evidence that the number of phone contacts between patients and physicians has decreased, the complexity of the email communications have increased to a point where some patients are seeing this communication as a substitute for a face to face visit with their doctor. Clearly minor problems can be addressed in a quick and safe manner with a very succinct response by a doctor. Other more complex situations are a different story.
Obviously, in these cases the correct response is to not provide a detailed response but to indicate that a face-to-face visit is in order.
There are a series of questions that get raised in this brave new world. Where is the line? How do you define medical standards? How do you educate patients regarding the appropriate use of electronic communication? How do you keep this communication secure and private? How does a doctor get paid for providing this service?
At this point, some clinical practices, like the Marino Center, have established a secure messaging system that allows, and some might say encourages, patients to communicate with their doctors through an electronic format. However three significant challenges arise; one is the increased volume of emails and the time necessary to respond, the second is the length and complexity of the communication requiring more time and thought to respond, and the third is the lack of compensation for this service. While patients may like the convenience it does place an added burden on the doctor. This was not supposed to be the case.
Possible solutions the electronic communication challenges are to:
Not permit electronic communication at all
Limit the length of the message (like Twitter)
Assign a triage nurse or administrative assistant to screen all electronic communication and respond directly to the simple questions and direct patients to make an emergent or urgent visit, if warranted.
Under any circumstance, adequate payment for these services by third party payers should be required. This would provide an incentive for practices to develop this form of care delivery, which will happen one way or another.
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