A Medical Student’s Perspective

By Glenn Kautz, MPH

For the average medical student in their first two years, the words “health systems innovation,” provokes a similar reaction as “quantum mechanics;” a vague concession that the concept exists, followed by a momentary consideration of why that might be important, a shrug, and finally a resumption of trying to memorize 1023 facts before dawn.

While our most basic motivation stems from helping our future patients, the daily Sisyphean pursuit of medical knowledge shapes us into experts at deciphering what we must learn in order to survive academically. Thus, the focus is most often on the what, and not the why.

That is, until we interact with patients in weekly clinical rounds, or through volunteer work. It is then that the why becomes perfectly lucid. We find ourselves saying, “aha,” as the lectures, notes and mnemonics suddenly manifest in perfect order as the basis for a metabolic disorder, or the clearing of an infection. We become reinvigorated with wonder and motivation for understanding all we can.

As a research intern studying health systems innovation, the same process applies. My head swirls as I grapple with impossible complexities; hospitals, state and federal policies, study designs and alternative payment models (APM). But when I visit a Federally Qualified Health Center (FQHC) utilizing an APM to best serve their patients, the minutia comes to life, the dots connect and I realize why learning the details is so important.

Medical students are invariably curious people who learn how to approach knowledge acquisition in the most efficient possible way. The shear magnitude and complexity inherent in health system innovation can be daunting and often acts as a barrier to medical students’ pursuit of knowledge in this critical area of health care. But these same barriers exist for biochemistry and physiology. What keeps us going is a faith that this knowledge will help us to help others.

When they see the why for learning about this vital component of their future profession, I believe the task becomes imperative, and much less daunting. I hope that many of my fellow students will share my good fortune and see innovation, because only by engaging can we hope to make a positive impact on our patients and communities.

Glenn Kautz, MPH, is a second-year medical student at Oregon Health and Science University (OHSU), working with OCHIN and OHSU Family Medicine as a summer research intern through a grant from the Oregon Academy of Family Physicians.  He is interested in a primary care, underserved populations and health policy analytics. 

APM: Empowering New Ways Of Providing Care

Part 2

By Erika Cottrell, Jill Arkind and Sonja Likumahuwa 

In Part 1 of this post, we discussed how the shift of the payment model allows community health centers the opportunity to leverage the care team to provide better care. We conclude by offering more examples of  team collaboration made possible by the new payment model. 

(Note: This article originally appeared in Health Affairs Blog on July 21, 2014. An edited version is being reposted here as part of the research effort investigating the impact of Alternative Payment Methodology (APM) on the delivery of primary care in safety-net populations. Through this website, Frontiers of Health Care, we are sharing lessons learned and perspectives from key stakeholders on the frontlines of reform.)

Team Meetings And Huddles

In addition to the changes discussed in part one, another is the weekly care team meetings. Before APM, VG staff tried to do team meetings, but “we didn’t feel like we could pull people off the floor” and some providers resisted dedicating an hour a week to meetings in lieu of seeing more patients. Now, VG provides sample agendas to help to structure the content of the weekly team meetings and a centralized area for posting notes and sharing best practices and lessons learned. Sample agenda items include discussion of ways to improve workflow, how to proactively address patient panel needs, and group exercises on how to efficiently utilize the various skills of the team members.

Team functioning has been quite varied, and much of it depends on the physician who is leading the team. “Some teams have done well and some teams have needed a lot more guidance. The task of structuring and leading care team meetings has largely fallen on the physicians, who aren’t really trained to be group facilitators or team leaders,” says Hill. Despite the variations, team meetings have given care teams more dedicated time for panel management, and at VG, they give care teams a lot of leeway to try new things.

They also started having “huddles,” where either part of the care team or just a provider and medical assistant meet in the morning to discuss the patients that they will see that day. Guerreiro admits to having mixed feelings about the weekly full team meetings. However, he has found smaller group “huddles” to share panel information and plan the day to be extremely useful. Continue reading

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Link Round Up

Today’s link round up is personal,  here are two links to news articles featuring some of our very own APM stakeholders:

  • The Oregonian addressed the rise in Medicaid enrollees in Oregon, and they interviewed Dr. John Guerreiro of Virginia Garcia Memorial Health Center. Dr. Guerreiro was one of the featured physicians in our post focused on new ways of providing care. The article, available here,  mentions Virginia Garcia is using the innovative methods allowed by APM to care for this influx of patients:

“The Virginia Garcia Memorial Health Center, which comprises nine clinics in northwestern Oregon, serves 36,000 patients in Washington and Yamhill counties. The center has been working through a backlog to link thousands of people to doctors, using innovations such as group visits and telemedicine.”

  • CNN asked OCHIN leader Jennifer DeVoe to provide an Op-Ed on the Affordable Care Act, from the point of view of a practicing family physician. You can read the full article by clicking here. Here is an excerpt from this article:

“I have been involved in efforts as a physician-scientist working to discover new cures for the American epidemic of ‘uninsurance’ and finding new treatments for our nation’s ‘inequitable access to care’ disease. Recently, I heard several top scientists debating whether we should keep asking the question: ‘Does health insurance matter?’

Consider the following two questions. Are you willing to drop your health insurance policy immediately and go without health insurance indefinitely? Are you willing to enroll in a study where you are randomized to receive health insurance or go without health insurance for a long period? If your answer to either or both of these questions is ‘no’, then we should stop asking whether insurance matters and move forward toward insuring every American.”

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APM: Empowering New Ways Of Providing Care

Part 1

By Erika Cottrell, Jill Arkind and Sonja Likumahuwa 

(Note: This article originally appeared in Health Affairs Blog on July 21, 2014. An edited version is being reposted here as part of the research effort investigating the impact of Alternative Payment Methodology (APM) on the delivery of primary care in safety-net populations. Through this website, Frontiers of Health Care, we are sharing lessons learned and perspectives from key stakeholders on the frontlines of reform.)

The Alternative Payment Methodology (APM) demonstration project enables participating Oregon community health centers to receive a monthly payment based on the size and composition of their patient population. This payment replaces the model of earning revenue based on the number of individual patients seen, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

So what are the real changes physicians are seeing on the ground in clinics where APM is being implemented?

According to Dr. Chris Hill, a physician and co-director of the Virginia Garcia (VG) Hillsboro Clinic and Medical Center, primary care was once so focused around payment it was like a “hamster wheel” of patient visit after patient visit. Under the new Alternative Payment Methodology (APM) pilot in community health centers throughout Oregon, care teams are freed up to do other things, such as managing panels of patients and designing programs to promote healthy behaviors and prevent illness. Dr. John Guerreiro, also a physician at VG, is enthusiastic; he sees APM as a pathway to realizing the full promise of team-based care.

Team-Based Care, Longer Visits, And New Ways To Reach Patients

The changes at VG, a federally qualified health center with multiple locations in Oregon, started about five years ago with a shift to the patient-centered primary care medical home.

“That’s when we first put a group of staff into a care team,” explains Hill. Care teams are typically comprised of a physician lead, physician assistants or nurse practitioners, nurses, and medical assistants. At VG, these teams are the hub of patient care. “What’s changed with APM is that we’ve really put the focus on the care teams to be the place where we start managing the panel.” Continue reading

The Price of Health Insurance

By Heather Angier, MPH

Health insurance increases access to healthcare services. This is true whether providers are paid on a fee for service or capitated basis. A recent study concluded increases in uninsured middle-income families over the past decade are likely due to their inability to afford private insurance, which has been steadily increasing in price yet they make too much money to be eligible for public health insurance (i.e., Medicaid). (Changes in Health Insurance for US Children and their Parents: Comparing 2003 to 2008)

Research teams at OHSU and OCHIN interviewed Oregon parents who corroborated these findings:

  • “Even if two people are working, they’re making barely enough money but to the state it’s too much to cover them under their health care [Medicaid].”
  • “We made too much money for it [Medicaid]. It was only $200 [to pay for insurance] at the time, which doesn’t sound like a lot but the other two kids would be another $200, so it’s $600 a month.”
  • “You can make like $50,000 a year. It’s a reasonable amount…but at the same time I can’t afford $1000 a month for insurance.”

Luckily, the Affordable Care Act (ACA) has provided solutions for middle-income families. A private health insurance marketplace and expanded Medicaid eligibility began covering Americans at the start of the year, but there is another controversy brewing with regard to the subsidy made available through the ACA to help Americans afford coverage. One court has ruled that only states with their own exchange can provide the subsidy, while another has contradicted that ruling. (Implementing Health Reform: Appellate Decisions Split On Tax Credits In ACA Federal Exchange)

An Oregon parent the teams interviewed commented on health reform, saying: “I think that in the future it’s still not going to be good because lots of people will be left without insurance still.  We hope not, we hope that they will continue making change to the system each year to improve it.”

Decisions about the subsidy have consequences; a potential 7 million Americans may remain uninsured if the subsidy is not upheld. This is in addition to the 5 million who remain uninsured because they live in a state that did not expand Medicaid. These numbers beg the question: how many uninsured Americans is our country willing to continue to tolerate?