Notes on Prevention, Disease Care and Delivery Systems

May_30_Health_Care_Rally_NP (641)

May_30_Health_Care_Rally_NP (641) (Photo credit: seiuhealthcare775nw)

I have, for some years now, said that, for all our talk as a nation about our “health care delivery system,” we do not actually HAVE one!  Rather, I believe that we have a “disease care industry” that thrives as a market-driven economic engine to the tune of over $2 trillion and approaches one-fifth of our national economy.   And that is a good thing, as far as it goes.  It just doesn’t help us get healthier!  Today’s Health Affairs Blog entry, “It’s Too Late to Turn Back Now – A Transformation to Wellcare is Underway,” got me started thinking.

What would a true “health care delivery system” look like?  Here’s my take:

  • It would focus on primary care, providing a more robust and better-paid primary care workforce, including interprofessional teams of nurses, physicians, pharmacists,  dentists, psychologists, nutritionists and social workers
  • There would be a single-payer reimbursement system (could be public or private), where a basic level of care would be covered for everyone.  Basic coverage must include preventive services, and the full services of a Patient-Centered Medical Home (PCMH)
  • A PCMH would be defined as a clinical practice in which
    • Every patient has a designated primary care provider (doctoral-trained physician or nurse – we can’t train enough physicians for this to only be a role for physicians – the need is too great, and our nursing colleagues bring a lot to the table for this role)
    • Every patient has a documented care plan with benchmarking and accountability, both for the patient and the practice team
    • All patients in the practice have access to the full-scope interprofessional team as needed
    • The practice manages the health of its patients as a population
    • The practice has a fully functional electronic health record (EHR) that includes robust capacity for patient registry functions and data mining
    • The practice commits to regular practice quality improvement and patient safety as a hallmark
    • Each patient undergoes a formal health risk appraisal, and all risks get managed through evidence-based primary, secondary or tertiary prevention efforts as part of the patient’s documented care plan
    • All patients have access to a smart-phone, tablet computer or similar technology to interact with the practice electronically
    • The practice gets reimbursed to interact with patients by telephone, electronically, and using telemedicine technology.
  • A local mechanism for accountability, through regional planning boards, report cards, or other similar mechanisms would give public feedback about performance of each PCMH, and about the health outcomes of the populations they serve.  To read an interesting piece about the current status of such accountability options, take a look at the following articles:  Consumer Reports Starts Rating Primary Care Practices (American Medical News) and Evidence-Based Policy Making (Health Affairs).

I know that some elements of what I propose are controversial, including the provision that not all PCMH practices are led by physicians.  I actually believe that the “work” of primary care physicians will be something different from anything we have ever seen, but I will save that content for another post.

What would YOUR definition of a “true health care delivery system” look like?  Post your comments, and let’s begin a conversation!