Successful Health Care Reform Needs Students and Physicians Trained in Health Insurance Policies, System
U-M physicians call for national curriculum in health policy at medical schools in New England Journal of Medicine article
ANN ARBOR, Mich. (February 24, 2011) — Changing medical student and resident education to include instruction in how health care systems function is critical, especially with the implementation of national health care reforms, University of Michigan physicians say.
In an article published February 24 by the New England Journal of Medicine, two U-M physicians and a U-M Medical School graduate argue for a national curriculum in health policy for medical students and residents.
“Without education in health policy and the health care system, physicians are missing critical tools in their professional toolbox,” said Matthew M. Davis, M.D., M.A.P.P., associate professor at U-M in Pediatrics and Communicable Diseases, Internal Medicine and Public Policy and a co-author of the NEJM article.
In previous research, Davis found that less than half of graduating medical students in the U.S. say they received adequate training in understanding health care systems and the economics of practicing medicine.
“As a resident, I routinely care for patients who cannot afford their medications or don’t have access to regular medical care,” said Mitesh S. Patel, M.D., M.B.A., a 2009 U-M Medical School graduate and lead author of the article.
“These issues have a major impact on the delivery and cost of health care. However, they are rarely discussed in educational lectures or during teaching rounds,” says Patel, who is currently a second year internal medicine resident at the University of Pennsylvania School of Medicine.
Physicians who don’t understand the health care system or health insurance policies do a real disservice to their patients, said Monica Lypson, M.D., M.H.P.E., assistant dean of Graduate Medical Education at U-M and a co-author on the article.
“The health care system is complicated, but it’s no more complicated than the other things we expect medical students and residents to learn,” Lypson said. “Regardless of partisan persuasion or political beliefs, physician trainees and medical doctors in general should have the knowledge needed to engage in meaningful discussions regarding health policy.”
In the article, authors call for a common national curriculum — with content tailored to regional and local needs. The authors recommend early pilot projects as a precursor to a standardized national curriculum and propose a focus on four concentrations: health care systems, health care quality, value and equity, and health politics and law.
The authors call for implementing the new curriculum without jeopardizing other topics. Davis said policy discussions can and should be integrated with clinical instruction and permeate the educational training. They advocate for a multidisciplinary faculty to conduct the health policy training, including experts in health economics, sociology, business, and psychology.
“We don’t expect them to learn to practice medicine simply by saying, ‘Go take care of patients now,’” Lypson said. “That doesn’t work for clinical knowledge, and it doesn’t work for policy knowledge, either.”
Idaho Lawmakers Sink Efforts to Protect Patient’s Legal Rights
AARP Disappointed as House State Affairs Cmte. Rejects Measure to Fix “Conscience” Law & Ensure Advance Directives are Honored
BOISE, Idaho (February 23, 2011) — Idaho lawmakers affirmed a new state law allowing a health care professional’s conscience to trump a patient’s legal end-of-life rights. In a disappointing move, a majority of members of Idaho’s House State Affairs Committee rejected a measure, introduced by Representative Phylis King, which would have fixed the state’s problematic “conscience” law to protect advance directives and living wills.
The AARP-backed measure would have simply removed language dealing with end-of-life care, which has spurred much controversy since the passage of the “conscience” law last year. The Idaho law currently allows all health care professionals in Idaho to refuse to honor living wills or advance directives – legal documents often registered with the Idaho Secretary of State’s Office. AARP says the law is government overreach, and a clear violation of patients’ legal end-of-life rights.
“Someone’s end-of-life legal rights are an area most Idahoans wouldn’t expect state law to intrude – the conscience law proves that expectation wrong,” said Jim Wordelman, State Director for AARP in Idaho. “In spite of thousands of phone calls, letters and emails urging legislators to fix Idaho’s so- called ‘conscience’ law, lawmakers continue to ignore their constituents’ voices and stand up for their legal rights.”
King’s measure is the latest to sink in the House State Affairs Committee, Chaired by Rep. Tom Loertscher. The committee has also stalled House Bill 28, introduced by Rep. Leon Smith, which says advance medical directives should be guided by the state law that guarantees they are honored instead of ruled by the conscience law.
AARP has concerns about a bill introduced earlier this week by Rep. Julie Ellsworth and supported by Rep. Loertscher and Senators Chuck Winder and Bart Davis, which attempts to correct the law – the measure still allows for health care professionals to refuse a patient’s legal end-of-life rights and is inconsistent with existing Idaho statute. AARP expects the bill to move forward.
“Some lawmakers are content to play politics with Idahoans’ legal rights as expressed in their advance medical directives, legal documents – we’re saying that’s wrong and it’s time to fix the law,” added Wordelman.
Earlier this week, AARP joined with a bipartisan group of legislators, Reps. Leon Smith, Tom Trail, Phylis King and Elfreda Higgins, to call for legislative action on fixing the conscience law. The Association also recently launched a statewide “Fix It” campaign, aimed at engaging its members and the public in the efforts, establishing the Patient’s Rights Hotline (1-800-232-0581), connecting people to their legislators on the issue, and implementing a paid media campaign hitting the airwaves, print and web, educating the public about the law and its impact, and urge lawmakers to tackle it.
Fixing the law is a priority issue for AARP Idaho, during election season members rated the issue as one of the most important for those they elect to tackle, second only to the state budget.
NQF-Commissioned RAND Report Points Way to Using Health Performance Measures to Support Innovative Payment Reforms
First-of-its-kind report signals important step for measure use and development to drive quality
WASHINGTON, DC (February 23, 2011) — A first-of-its-kind RAND report commissioned by the National Quality Forum (NQF) provides important direction for achieving payment reforms designed to improve healthcare quality. Based on a thorough review of 90 different payment models planned or in place across the nation, the report identifies uses of available performance measures for 11 payment reform models, as well as five key areas where new measures are needed to support payment reforms that reward value over volume.
With support from the Robert Wood Johnson Foundation, NQF commissioned this groundbreaking research to consider the types of measures needed to support innovative payment reforms. “Commissioning the RAND research into measures to support payment reform is one of many ways NQF is proactively working to respond to current and emerging needs,” said Janet Corrigan, PhD, MBA, president and CEO of the National Quality Forum. “In addition, NQF is convening a partnership of stakeholders, including consumer representatives, from across the healthcare arena to help identify the right measures for payment reform approaches.”
Because the most common fee-for-service payment methods can perpetuate unnecessary care, new initiatives that pay for healthcare in ways that improve quality are increasing in this country. The new payment models vary from withholding payment for avoidable errors to paying bonuses for better results. Performance measures play a key role in paying for better care and detecting potential harms that could arise through cost cutting.
“In an environment that emphasizes more value for every healthcare dollar, refinements in measurement are key to successful payment reform,” said Thomas Valuck, MD, JD, NQF’s senior vice president of strategic partnerships. “These measures will be important in not only ensuring that payment rewards the right care, but also in preventing unintended consequences that could result from hand picking the healthiest patients to achieve a higher payment.”
“Employers want to tie more and more of the payments to healthcare providers to the quality and efficiency of the care they deliver,” added Suzanne F. Delbanco, PhD, executive director of Catalyst for Payment Reform, an independent organization led by large employers, with active involvement of providers, health plans, consumers, and labor groups working to improve quality and reduce costs by identifying and coordinating workable solutions to improve how we pay for healthcare in the United States. “This study charts the path for building out the measures employers need to achieve paying for value instead of volume.”
To date, more than 600 NQF-endorsed® healthcare performance measures are in use across the nation, but the number applicable to any given setting or clinical area is far more limited. Some measures focus on specific steps in providing care, such as whether heart attack patients receive necessary prescriptions. Other measures use a wide-angle lens to look at results — for example, whether patients sent home from the hospital have improved health or end up returning with complications that could have been avoided. Each tool provides a different view, assessing performance from a specific angle.
According to the RAND report, the following types of measures will be the key to payment reforms aimed at improving healthcare and achieving better health for individuals and communities:
- outcome measures that focus on patient results — from avoidable harms to improved health;
- care coordination measures that capture appropriate patient follow-up care needed to keep patients on track to improved health;
- patient engagement measures to assess whether care empowers patients and their caregivers to improve health;
- organizational capability measures that assess whether new systems (accountable care organizations and medical homes) are sufficient to deliver high-quality care;
- composite measures that combine the results of individual measures into an overall indicator of quality, allowing for a more comprehensive assessment of the care delivered to patients;
- efficiency measures that combine quality and resource use measures; and
- disparity measures that ensure efforts to cut costs don’t lead to favoring certain types of patients.
“These findings should signal those who develop measures, and the sponsors who invest in this work, to focus on the kinds of measures needed to ensure that payment reforms achieve their intended goal of improving care and reducing costs,” said RAND’s Eric Schneider MD, MSc, FACP, principal author of the report.
The NQF portfolio includes measures in each of these areas, but there are important gaps in available measures and limitations in the ability to generate measure results. For example, about one-fourth of currently endorsed measures assess outcomes of care, but these tend to focus on outcomes proximate to a healthcare encounter (e.g., hospital mortality), not long-term outcomes (e.g., three-year cancer survival). NQF has also identified 35 “disparity-sensitive” measures that focus on areas where there are known disparities in the care, but data on race, ethnicity, and language are not systematically collected in many healthcare settings. Measures of patient engagement are few in number, and significant resources will need to be invested in measure development and testing to fill this gap.
Over the past 10 years, NQF-endorsed measures have become a common point of reference for those who provide, receive, and pay for healthcare. NQF endorsement starts when measure developers, such as the National Committee for Quality Assurance, the Physician Consortium for Performance Improvement convened by the American Medical Association, The Joint Commission, and others submit proposed measures to NQF for review. NQF convenes steering committees composed of diverse stakeholders across the healthcare field, from patient to provider to payer, to consider each measure’s importance, validity, and usefulness.
To access the full report, go to: http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx