I have a long garden full of random types of daylilies that I have purchased, borrowed from friends, traded for from neighbors, and once in a while "adopted" from uncared for flower beds here and there!
If you know lily gardens, you know that every four or five years, you need to dig up the garden, separate and thin the lilies, and then replant them. This process renews the garden and makes each remaining daylily more vibrant. Besides being hard work, this process is nerve-wracking because there are always unexpected consequences. Lilies you long have loved may get thrown away by chance during the thinning process. And, favorite lilies that used to be front and center may end up in the back of the garden.
As I dug up my lily garden in early fall, I kept thinking that what I was doing is a bit like what's going on in our health system right now. The amount of energy being devoted to "health system change" is amazing: hospitals are rethinking their business plans; physician groups are reorganizing themselves; and payers are working on new ways of reimbursing the wide array of health care providers.
This emphasis on change and replanting the health care garden is driven in part by the coming increased enrollments that will accompany the federal health reform insurance expansions (assuming they in fact remain on track after the November election) and in part by a realization among providers and payers that the old fee-for-service payment system is no longer viable: we cannot continue to encourage more and more utilization of health care services using reimbursement systems that pay for volume rather than outcomes.
But, all of this system change also is imprecise. We don't really know exactly where we are headed. It leads me to think about what unexpected outcomes might happen as we change the system. As we work to expand access to health care and preventive services, to improve quality and efficiency, and curb costs, what might we lose? And, what might end up being better than expected?
Here are four parts of the health system that could come out very differently than we might expect:
1) The concept of primary care: When I talk to medical students and new doctors, particularly those going into primary care, I often hear, "I just want to care for my patients!" They are not enamored with the prospects of being managers or financial stewards. But, much of the action in primary care "transformation" is for hospitals to purchase physician practices or for small groups of physicians to band together into much more corporate type models of practice. Working at a larger scale is essential to the success of many of the promising changes afoot: accepting more financial responsibility for the medical care of a population of people, having viable electronic medical records, and using physician extenders to help with a range of care management processes. The unexpected consequence could be a generation of physicians who entered the profession expecting one type of work environment but experiencing a very different approach to a profession. Will this work? Or, will both patients and physicians miss the concept of a family physician?
2) Specialized services such as school-based health centers: When we first think about health care, we focus on physicians and hospitals. But there are a range of "boutique" type service providers that play small but important roles. One of these types is the school-based health center. More than 200,000 children and adolescents get affordable primary care services in New York State's 220 school-based health centers. Evaluations of these centers consistently show that they are good at what they do, deliver vital services and are efficient. Right now, these centers can bill the state government directly for their services to low-income children covered by Medicaid. However, in an effort to expand Medicaid managed care to better coordinate services for Medicaid recipients all across the state, these school-based centers will now bill managed care plans (rather than the state government) for services. This sounds straightforward, but could unexpectedly make collecting reimbursements more complex for these small organizations or subject them to inadequate payments. The consequence could be financial catastrophe. My bias is that these school-based centers need "favorite lily" status; we need to pay extra attention to ensure that they remain financially viable in a managed care environment.
3) Care-management "jewels" for special populations: The idea of the Health Home -- a new Medicaid demonstration program that provides payments for care management for patients with serious chronic illnesses -- isn't entirely new. For decades, care for patients living with conditions like HIV/AIDS and tuberculosis has incorporated exactly the kind of care management and coordination that is the backbone of the Health Home model. But as the broader Health Home approach spreads, it will likely subsume those tailored, disease-specific care management approaches. My hope is that emerging Health Homes will learn from and contract with experts in disease-specific care management approaches, but I fear that the knowledge, experience and relationships may be lost as providers and payers pursue new models of care and payment.
4) The benefits of market forces: One positive result of the restructuring of the health system could be the emergence of new approaches to delivering care when existing approaches are disrupted. Some hospitals in our state will be at high risk of closing if better primary care systems begin to reduce the need for people to be hospitalized. Traditionally, we are afraid of the side effects of success: decreased hospital use can mean that people are being kept healthier, but we fear that shrinking volumes could mean some neighborhoods lose their hospitals.
The New York Times recently told the upbeat story about what is happening in Greenwich Village and Chelsea following the closure of St. Vincent's hospital. Early indications suggest that the market is responding to emerging needs and opportunities. New physician practices have been established in the neighborhood and new models of low-cost ambulatory care are developing as pharmacies and urgent care centers begin to employ physicians to deliver basic primary care. And patients seem to like it.
But, we should also realize that market forces may not help in neighborhoods that are less well-off than Greenwich Village and Chelsea. As hospitals face potential closure in places like central Brooklyn, can we expect the same type of market forces to serve the needs of very vulnerable New Yorkers, including immigrants and others who will remain uninsured even after federal health reform is fully implemented? I doubt it, and I worry that those who are left out of the health insurance expansion may ultimately be left without needed health care services.
I have no doubt that the implementation of health reform will lead to a better system: more New Yorkers with health care coverage, new models of delivering health care that emphasize teamwork and coordination to keep patients healthy, and more sensible payment approaches that reward good health care outcomes rather than tests and procedures. But as we work toward a reformed health system, we perhaps need to tag a few prized blooms as "must keep" before we dig up the entire health care garden and plant anew.
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