Beyond the Affordable Care Act: Alternate Futures for Family Medicine and Primary Care

Changes in the landscape of medical practice in recent years, accelerated since the passage of the Affordable Care Act (ACA) in 2010, have led to further fragmentation of primary care and disruption of the doctor-patient relationship for many millions of Americans. Patients face escalating costs of care and restricted choice of physician and hospital in a largely corporatized health care system. The goals of family medicine are compromised by these system trends. The ACA is unsustainable for a number of reasons, including lack of price controls and cost containment, unaffordable costs for patients and taxpayers, widespread underinsurance, and massive administrative waste. Financing reform through single-payer national health insurance will bring a fairer system of universal coverage for comprehensive care of higher quality at less cost, while enabling a renaissance of family medicine and primary care as an expanding base of our health care system.

Bringing Patient-Centered Outcomes Research to Life

A substantial gap exists between medical evidence that is known and medical evidence that is put into practice. Although the Agency for Healthcare Research and Quality (AHRQ) has a long history of developing the content of evidence, the agency now pivots to close that gap by focusing on evidence dissemination and implementation. Achieving better health outcomes requires both the generation of new patient-centered outcomes research (PCOR) knowledge and the appropriate and timely implementation of that knowledge into practice. The Affordable Care Act provided funds to support both types of PCOR efforts, with AHRQ building on years of experience to advance research dissemination and implementation. This article describes the work the AHRQ has done, is doing, and will do in the future. To communicate PCOR evidence findings, AHRQ is currently synthesizing research findings into convincing collections of evidence that can be best taken up by clinicians, patients and caregivers, and policymakers. The future direction for AHRQ is to improve the context for evidence and practice improvement, thereby creating an environment receptive to PCOR. Toward this goal, AHRQ is actively engaging partners, such as professional societies and insurers, to make evidence central to decision making. In addition, AHRQ recently launched two programs that seek to both understand and encourage the use of evidence in clinical practice. Throughout these efforts, AHRQ will continually assess needs and adapt initiatives to ensure that PCOR translates into improved patient-centered health outcomes.

A new conceptual framework for academic health centers

Led by the Affordable Care Act, the U.S. health care system is undergoing a transformative shift toward greater accountability for quality and efficiency. Academic health centers (AHCs), whose triple mission of clinical care, research, and education serves a critical role in the country's health care system, must adapt to this evolving environment. Doing so successfully, however, requires a broader understanding of the wide-ranging roles of the AHC. This article proposes a conceptual framework through which the triple mission is expanded along four new dimensions: health, innovation, community, and policy. Examples within the conceptual framework categories, such as the AHCs' safety net function, their contributions to local economies, and their role in right-sizing the health care workforce, illustrate how each of these dimensions provides a more robust picture of the modern AHC and demonstrates the value added by AHCs. This conceptual framework also offers a basis for developing new performance metrics by which AHCs, both individually and as a group, can be held accountable, and that can inform policy decisions affecting them. This closer examination of the myriad activities of modern AHCs clarifies their essential role in our health care system and will enable these institutions to evolve, improve, be held accountable for, and more fully serve the health of the nation.

A case for restraint of explosive growth of health information technology: first, do no harm

Information technology has brought significant advances to modern life. We, like many others, believe that IT properly utilized in the delivery of health care ultimately bodes well for the care of our patients. The challenge is that the current technology does not live up to that promised state of multiple elements of improved care through IT. Despite that, legislative mandates have required large-scale adoption of present day health care IT solutions. These regulations have been particularly challenging for independent practitioners.Our efforts at making these points are now supported by a growing body of research including a very important analysis by the ECRI.

Shaping the future of prevention in social work: an analysis of the professional literature from 2000 through 2010

In light of the Patient Protection and Affordable Care Act's goals of better patient care, cost control, and improved population outcomes, prevention has emerged as an important component of health reform. Social work, with its extensive involvement in the health system and deep roots in public health, can benefit from a better understanding of its role in prevention. This study builds on the Social Work Interest in Prevention Study (SWIPS), which evaluated extent, type, and levels of prevention content in nine social work journals from 2000 to 2005. The goal of the expanded study, the SWIPS-Expansion, was to assess whether interest in prevention increased over the years in which health reform was enacted. Of the 3,745 articles reviewed, 9.0 percent (n = 336) met the criteria for "prevention articles." Between 2000 and 2010, prevention articles rose from 4.1 percent to 14.3 percent of all articles. A secondary analysis focused on topics within social work prevention, with violence, aging, and disease as primary focal areas. The findings suggest that although prevention interest appears to be growing, it remains a minority focus in the profession's journals. A national conversation on prevention can help expand the profession's role in health reform at this critical time.

First, do no harm by adopting evidence-based policy initiatives: the overselling of ICD-10 by congress with high expectations

While it appears to be beneficial to apply a detailed disease classification system, the costs, cash flow disruptions, and increased investments with physician time incorporated into learning these processes, patient care might unfortunately suffer. This is essentially an unfunded mandate with much of the burden of transitioning to ICD-10 falling on health care providers,especially small independent practices. This will impact interventional pain management practices substantially.Further, as we have shown in previous manuscripts,the so-called advantages of multiple codes with specificity and granularity does not translate into reality where some specificity is actually lost for various codes. As Grimsley and O'Shea (1) have described in clinical practices, doctors do not treat codes, but they treat patients according to the individual clinical condition.A doctor will be losing valuable time and also will not be able to obtain meaningful information due to burdensome regulations of meaningful use, PQRS,value-based reimbursement, electronic prescribing,and now a major impact with change to ICD-10. Thus,very little benefit will be seen by practitioners, which cannot be said for the health care information industry.With overwhelming regulatory atmosphere created by numerous federal regulations and those including under the Affordable Care Act (15), there is no evidence that ICD-10 is needed, there is no evidence that it will be effective, and, finally, there is preponderance of evidence of adverse consequences. Thus, Congress should be cautious in imposing further regulations on already strained independent practices with ongoing regulations and imposing yet another unfunded mandate on the medical profession.

Dependent coverage provision led to uneven insurance gains and unchanged mortality rates in young adult trauma patients

Insurance coverage has increased among young adults as a result of the Affordable Care Act (ACA) provision that allows young adults to remain covered under their parents' plans until age twenty-six. However, little is known about the provision's effects on the clinical outcomes and insurance coverage of patients with trauma--the most frequent cause of death and physical disability among young adults. Using 2007-12 data from the National Trauma Data Bank, we conducted a difference-in-differences analysis of coverage rates among trauma patients ages 19-25 (compared to patients ages 26-34, who served as the control group), and we examined trauma-relevant outcomes by patient, injury, and hospital characteristics. We found a 3.4-percentage-point decrease in uninsurance status among younger trauma patients following the policy change. The decrease was concentrated among men, non-Hispanic whites, those with relatively less severe injuries, and those who presented to nonteaching hospitals. We did not detect significant changes in the use of intensive care or in overall mortality. The heterogeneous coverage impact of the ACA dependent coverage provision on high- versus low-risk trauma patients has implications for future efforts to expand coverage.

Pediatric versus adult cardiomyopathy and heart failure-related hospitalizations: a value-based analysis

BACKGROUND

Value-based health care is a proposed driver for reimbursement under the Affordable Care Act, with value broadly defined as outcomes divided by cost. Data on value-based health care in pediatric heart failure are scarce.

METHODS AND RESULTS

A retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database and Nationwide Inpatient Sample was performed for pediatric and adult cardiomyopathy and heart failure-related hospitalizations. The study included 5,689 pediatric and 473,416 adult hospitalizations. Pediatric cardiomyopathy and heart failure hospitalizations were significantly longer than adult hospitalizations (mean ± SE 16.2 ± 0.7 days vs 6.8 ± 0.1 days; P < .001). Overall mortality was greater for pediatric hospitalizations (7.7% vs 5.6%; P < .001), although it decreased over time for both pediatric and adult hospitalizations. Charges were greater for pediatric hospitalizations, both overall ($116,483 ± $5,735 vs $40,662 ± $1,419; P < .001) and for all years evaluated.

CONCLUSIONS

In a value-based model, pediatric cardiomyopathy and heart failure-related hospitalizations are associated with worse outcomes and greater charges than adult hospitalizations. More research is needed to understand the cost effectiveness of pediatric heart failure treatment and to reduce the burden on the health care system.

Wait times and national health policy

Many arguments against US healthcare reform appeal to facts about wait times, and wait times are also discussed in debates about national health policy in other industrialised countries. This paper points out that there are several different ways to measure wait times. We currently measure them in one way, and this paper describes an alternative. The most reasonable assessments of US and international health reforms need to rely on the alternative method, and so when critics of health reform rely on the standard method, their arguments are unsound.

The widening U.S. health care crisis three years after the passage of 'Obamacare'

This report presents information on the state of the U.S. health system in 2012 and early 2013, specifically the period prior to the implementation of the individual mandate and full rollout of the Affordable Care Act's online health exchanges. The authors include data on the uninsured and underinsured and their access to health care, on socioeconomic inequality in health care, the rising costs of the U.S. health system, and the role of corporate money in health care, with special reference to the pharmaceutical industry. They also provide updates on Medicare health maintenance organizations, Medicaid, and a prelude to the complete implementation of the Affordable Care Act. In addition, the authors include some results from public opinion polls on health systems and international system comparisons. The article concludes with an assessment of the rapid consolidation in the delivery of health care being driven by the Affordable Care Act.

Patient Protection and Affordable Care Act; exchange and insurance market standards for 2015 and beyond. Final rule

This final rule addresses various requirements applicable to health insurance issuers, Affordable Insurance Exchanges (``Exchanges''), Navigators, non-Navigator assistance personnel, and other entities under the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the Affordable Care Act). Specifically, the rule establishes standards related to product discontinuation and renewal, quality reporting, non-discrimination standards, minimum certification standards and responsibilities of qualified health plan (QHP) issuers, the Small Business Health Options Program, and enforcement remedies in Federally-facilitated Exchanges. It also finalizes: A modification of HHS's allocation of reinsurance collections if those collections do not meet our projections; certain changes to allowable administrative expenses in the risk corridors calculation; modifications to the way we calculate the annual limit on cost sharing so that we round this parameter down to the nearest $50 increment; an approach to index the required contribution used to determine eligibility for an exemption from the shared responsibility payment under section 5000A of the Internal Revenue Code; grounds for imposing civil money penalties on persons who provide false or fraudulent information to the Exchange and on persons who improperly use or disclose information; updated standards for the consumer assistance programs; standards related to the opt-out provisions for self-funded, non-Federal governmental plans and related to the individual market provisions under the Health Insurance Portability and Accountability Act of 1996 including excepted benefits; standards regarding how enrollees may request access to non-formulary drugs under exigent circumstances; amendments to Exchange appeals standards and coverage enrollment and termination standards; and time-limited adjustments to the standards relating to the medical loss ratio (MLR) program. The majority of the provisions in this rule are being finalized as proposed.

The health of healthcare, Part V: Is the very freedom of providers at risk?

When healthcare is fully compliant with the Patient Protection and Affordable Health Care Act, U.S. health care providers lose their one inalienable American right, namely freedom, and can no longer fulfill their fiduciary responsibility to patients.

Getting past widgets and digits: the fundamental transformation of the foundations of nursing practice

Health reform and transformation now call for the creation of a new landscape for nursing practice based on intentional translation application of value-driven measures of service, quality, and price. Nursing is a central driver in the effective recalibration of health care within the rubric of health transformation under the aegis of the Patient Protection and Affordable Care Act. Increasingly relying on a growing digital infrastructure, the nursing profession must now reframe both its practice foundations and patterns of practice to reflect emerging value-driven, health-grounded service requisites. Specific nursing responses are suggested, which position nursing to best coordinate, integrate, and facilitate health delivery in the emerging value-driven service environment.

Seventy-five years of policy on alcohol problems: an American perspective

OBJECTIVE

This article traces the evolution of alcohol-related social policy over the past 75 years.

METHOD

The literature was reviewed and is critically discussed.

RESULTS

The social history of alcohol policies over the last 75 years began with the scientific approach to alcohol in the 1930s and later shifted to a central interest in the disease of alcoholism. Beginning with the National Council on Alcoholism Education, advocates struggled to "mainstream" treatment for this disease into the health care system. Major steps included decriminalization of public intoxication, emphasis of the social respectability of persons with alcohol problems, development of a treatment system that was accompanied by health insurance coverage, and work-based programs to identify and attract employed patients with health insurance coverage. These structures were considerably altered by the War on Drugs, managed care, and the merger of drug and alcohol treatment. The Affordable Care Act, however, has the potential for achieving the mainstreaming goals for alcohol problems originally conceived in the early 1940s.

CONCLUSIONS

Responsible involvement of the alcoholic beverage industry could greatly enhance current activities but is not likely to occur. Stigma persists in part because of associations with prevention and treatment of illegal drug use problems. The Affordable Care Act offers opportunities and challenges to the specialty of treating alcohol use disorders.