EPA-1438 – USA Health System Performance

The Road Ahead

APhA advances provider status initiative

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

Patient-Centered Outcomes Research: Early Evidence From A Burgeoning Field.

Unintended Consequences of Health Care Legislation

Holding on to a huge victory for American health

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

The Affordable Care Act (ACA), signature legislation of President Obama, was arguably the most consequential and comprehensive health care reform since Medicare was introduced as part of President Lyndon B. Johnson’s great society. It has been claimed that many of the law’s reforms are now so integrated in the health system that full repeal would be impractical, while others including President Elect Trump have rejected that idea and called for full repeal and replacement claiming ACA law cannot be fixed. A tsunami of increasing regulatory burden over the past 8 years, the current health care milieu has moved independent practitioners towards hospital employment in great numbers. In addition, public opinion has been slowly climbing against ObamaCare with 54% of Americans now opposing the law. President Obama has indicated that the law has accomplished many of its goals, including increasing accessibility, affordability, and quality of health care. However, others have contradicted these assertions and described the ACA as “insurance for many with coverage for few.” Some believe that the ACA might be more appropriately labeled the “Medicaid Expansion Act.” There are multiple plans developed over the years by republican members of the congress; however, of significant consequence and importance are President-elect Trump’s proposals and the plan developed by Speaker Paul Ryan to repeal and replace the ACA. The President-elect has described the problems he perceives with the ACA; rapidly rising premiums and deductibles, narrow networks, and limits of coverage imposed by health insurance companies. The Presidentelect has indicated that his goal will be to create a patient-centered health care system that promotes choice, quality, and affordability with health insurance and health care, and take any needed action to alleviate the burdens imposed on American families and businesses by law. Key words: Affordable Care Act, ObamaCare, Medicaid, exchanges, Trump plan, repeal, replace

Almost 10 years ago, JGIM published a seminal report from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. Boldly titled “The Future of General Internal Medicine”, the report challenged the field of general internal medicine to take responsibility for addressing the “chaos and dysfunction” the Task Force believed characterized medical care at that time. Many of the innovations they proposed, including team based care, enhanced information systems, and the abandonment of the fee-for-service financing model, seemed pie-in-the-sky at the time, but are now accepted by most as essential for improving health care delivery and curbing costs. While much has changed in the past decade, in many ways, general internal medicine still stands at the crossroads. While the options may not be quite so bleak as Woody Allen suggests, general internal medicine continues to face some critical challenges in research, education and clinical practice. In this issue of JGIM, Armstrong et al. (on behalf of the 2012–2013 SGIM Council) articulate these challenges and present a vision for the future of general internal medicine. They point out that the pressure to reduce health care costs and increase value along with the historic passage of the Patient Protection and Affordable Care Act (ACA) will lead to new initiatives in primary care and GIM, featuring population management, team-based care and innovative use of electronic health records. Changes in medical education spurred by duty hours reform and enhanced workforce diversity have resulted in a shift to more training in the ambulatory setting and a shift in focus to measuring competencies rather then medical knowledge. For researchers in academic GIM, they argue that these changes bring both challenges and opportunities. GIM researchers are ideally situated to study the impact of practice transformation and payment reform that will be brought by the Affordable Care Act (ACA), but despite optimism fueled by the Patient Centered Outcomes Research Institute (PCORI), funding challenges will persist. The United States spends almost $3 trillion on health care. According to some analysts, up to 1/3 of these expenditures are wasted on inappropriate, equivocal, misapplied, or inefficient care. If just 1 % of health care payments were applied to scientific evaluation of what works and what doesn’t in health care, a pool of $30 billion would become available to generate answers our country sorely needs. Several articles in this issue of JGIM showcase the value of rigorous empirical research in evaluating innovations in health care practice and policy. The Patient Centered Medical Home (PCMH) has been touted as a solution to the current crisis in primary care, but most evaluations to date have been observational. In two related articles, Fifield, et al. describe the implementation and experimental evaluation of the PCMH model in small-medium sized practices. In their cluster-randomized trial, most practices were successful in achieving NCQA recognition, but there were few consistent differences in processes and outcomes between PCMH and control practices. An accompanying editorial by Landon puts the data in context. The PCMH has implications not just for patients and practitioners but for physicians-in-training. Chang et al. describe a consensus meeting leading to a set of 25 “entrustable professional activities” that residents will be encouraged to perform with varying degrees of independence. Some of the activities are familiar (e.g. “devise a longitudinal care plan for chronic disease”), but others (e.g., “lead an interprofessional health care team”) will require new skills and new curricula to support their development. Workforce development is key to maintaining a robust primary care infrastructure, and medical schools must do their part. Are they contributing in fair measure? An article by Choi and Ayanian suggests not. Research intensive schools produce fewer primary care graduates than their less research-intense counterparts. Lest readers be too quick to judge the Harvards of the world, a Capsule Commentary by Jackson points out that other factors besides medical school orientation (things like salary, prestige, and lifestyle) are likely to be much more important as causes of the primary care workforce crisis. Published online April 12, 2013 JGIM

Report of the AACP Task Force on Patient-Centered Medical Homes and Accountable Care Organizations

Long-Term Care Reforms Live On With Court Ruling

For over four decades, Americans have enjoyed near universal access to treatment for ESRD irrespective of age, lack of qualifying disability, or their ability to pay. However, the health insurance benefits of the Medicare ESRD program do not extend to individuals in earlier stages of CKD, even to

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

This chapter examines the Obama presidency, the politics of race and health care, and the role that African Americans played in shaping the Affordable Care Act (ACA). We argue that race—and specifically the elimination of racial and health disparities—was very much part of the ACA’s development. From the perspective of Black lawmakers health equity and patient protection advocates, who worked hand-in-glove with the Obama administration, the ACA was not race-neutral or indifferent to Blacks and the working poor. The law had special significance for African Americans despite Obama publicly discussing its impact in deracialized terms. Daniel Dawes, a leading advocate for health equity and author of the groundbreaking book 150 Years of Obamacare, called the ACA the “most comprehensive minority health law” and the “most inclusive [health] law” in the history of the United States. He identified sixty-two provisions that “directly address inequities in health care” that are embedded in the ACA.” This chapter thus argues that Obama’s ACA was substantively accountable to the coalition of Black lawmakers and activists—what we refer to as a policy ecosystem—who were purposeful about incorporating provisions in the bill designed to reduce racial disparities and income-based inequities in health care.