Preparations for reform may leave lasting changes

June 24, 2012

By Mary Flynn
California Health Report

Federal health care reform might not survive after a Supreme Court decision expected this week, but the preparations for an influx of new patients may have already changed the health care system.

The Affordable Care Act allows for about 32 million newly insured Americans by 2019, and three to four million eligible by 2014, and health care systems have been looking for ways to accommodate the increased number of patients.

In one major shift, many private and public sector leaders are embracing the concept of the patient-centered medical home, an approach that allows primary care practices to take responsibility for providing, coordinating and integrating care across the health care continuum. These medical homes place greater emphasis on primary care physicians.

That leaves experts worrying about a shortage of primary care physicians when the changes go into effect.

To help bridge the gap of a stretched-thin primary care system and the expected influx of patients, health care experts are exploring new practices.

Catherine Dower, associate director of research at the Center for Health Professions at UCSF, said that part of the solution lies in broadening the scope of practice for Nurse Practitioners and Physicians Assistants.

“NPs and PAs … could be part of the solution, working in various settings, in teams – primary care teams – with physicians, MDs and sometimes on their own because they can practice fairly independently,” she said. She added that programs to train these workers take a much shorter amount of time and they cost far less then to train a clinical physician.

Another model that incorporated a shift in staffs’ roles has also demonstrated great success in southern California. Electronic health records (EHR) are generally considered another way that providers are improving efficiency and the quality of care for many. The systems allow doctors to access a patient’s records while in the exam room, enter information directly into their records or order tests and prescriptions online.

However, at Kaiser Permanente Southern California, the move to an electronic health records system meant that a lot of the work that support staff (such as Medical Assistants, or MAs, or occasionally, Licensed Vocational Nurses, or LVNs) was doing – patient recordkeeping and filing – was shifted to the provider. This in turn increased the workload for primary care providers, already in short supply, by making them primarily responsible for the patient’s records, scheduling follow-up appointments, and providing patient education.

“We needed to figure out how to get staff reengaged, and also to support the provider as much as we could,” said Kristen Andrews, a Regional Proactive Care Leader with Kaiser Permanente. To address these issues, the staff at Kaiser Permanente Southern California came up with a program called the Proactive Office Encounter where support staff provide an enhanced role compared to their traditional duties.

“They don’t just take blood pressure and take a temperature anymore, they are engaging with the patient, ” Andrews said. Using the EHR, support staff have tools that identify for them screenings the patient is due for, things like a mammogram screening or colon-rectal screening.

Andrews said under the new system, support staff will prepare the exam rooms – ensure they’re stocked, that the patient is dressed in the appropriate gown, and stage orders for the doctors so they’re ready sign when the physician comes into the exam room. . “We’ve taken everything and re-shifted and put work back on MAs,” she said.

The program appears to be having great success so far. Catherine Dower said there is a growing realization that the old model, that of one doctor with a single MA or nurse assisting in the office, is not going to work in the long-run.

“It’s not financially sustainable, and it’s not delivering really high-quality care to a large number of patients,” she said. Dower, along with the Center for Health Professions, has studied the Kaiser model and others similar to it. She said these types of programs that give increased responsibilities to support staff are doing well.

“They’ve got great outcomes for their patients,” Dower said, and added that it’s a good investment in the staff members as well. “We’re seeing better retention rates and higher satisfaction rates among the workers as well on the team,” she said.

“And when you have a really highly functioning team that is working closely with each other and relying on electronic health records,” Dower said, “It’s truly patient-centered, we’re seeing really, really good outcomes.”

Another idea to help with the influx of new patients under the ACA that is gaining attention is the Accountable Care Organization (ACO). An ACO is a health care provider structure that emphasizes accountability of providers across the continuum of care by offering financial incentives to provide quality care to Medicare patients while keeping down costs.

“The way it works is you end up having to coordinate care,” explained Catherine Dower.

Catherine Dower explained that the way the system has been in the past, it has largely been fragmented. “If I go to an emergency room, or if I’m on vacation and I go someplace [to receive medical care], it doesn’t get integrated back to my primary care physician necessarily,” she said. “There’s very little incentive for these groups to work together to try to keep me out of the hospital.”

Dower said that the current system lacks coordination and the fragmentation of care actually adds to the cost of the system, but the ACOs can help draw attention to preventative care, as well as share data, including electronic health records, and work with each other.

“The idea behind the ACO is, while there’s this financial incentive, it’s going to also improve quality, improve safety and improve coordination so you have less fragmentation across the various components of the health system,” she said.

While the increased use of electronic health records is also helping to bridge the gap to healthcare reform, technology is playing an increasingly important role in health care reform. In addition to the electronic health record system, hospitals are relying more on telehealth to improve care and lower costs for patients.

According to the California Telemedicine and eHealth Center (CTEC), telehealth consists of a broad scope of services to include health education, health information and telemedicine, or “the use of electronic information and communication technologies to provide and support health care when distance separates the participants.”

The CTEC categorizes telehealth into three general applications: clinical services, educational services and administrative support. Telehealth educational services include things like patient education or continuing education for clinicians, administrative support includes videoconferencing or multiple-site meetings. Some clinical applications of telehealth that are becoming more common include providing outpatient specialty services for things like dermatology, psychiatry, or neurology.

Dr. Thomas Nesbitt, a UC Davis Professor of Family and Community Medicine and the Associate Vice Chancellor for Strategic Technologies and Alliances, has seen a wide variety of clinical applications for telehealth: rural patients are able to have an interactive video consultation with a remote psychiatrist or endocrinologist. He also gave the example of using a store-and-forward approach, where doctors could take a picture of a diabetic patient’s retina and forward it on to an offsite optometrist or ophthalmologist to determine if the patient is at risk.

“Absorbing an increased number of people would be a challenge if you only had access to local people,” Nesbitt said. “Telemedicine will probably allow you to have better access to more specialists.”

Nesbitt also described how patients are able to use telehealth technology to manage chronic conditions – such as congestive heart failure or diabetes – from home. Patients with a home telehealth system can transmit data to their provider, and in return receive coaching or education from the provider based on that data.

Last October, Governor Brown signed into the law the Telehealth Advancement Act of 2011 (AB 415). The bill sets out to improve parity between health services delivered in person and those delivered via telehealth, remove barriers that had previously hampered implementation of telehealth, and create more opportunities to incorporate telehealth into standard care.

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