Committee for assessing progress on implementing the recommendations of the institute of medicine report the future of nursing: leading change, advancing health

Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM’s effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.

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Evidence On The Chronic Care Model In The New Millennium

BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

In the United States, approximately 14 million people have had cancer and more than 1.6 million new cases are diagnosed each year. However, more than a decade after the Institute of Medicine (IOM) first studied the quality of cancer care, the barriers to achieving excellent care for all cancer patients remain daunting. Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence. The cost of cancer care also is rising faster than many sectors of medicine--having increased to $125 billion in 2010 from $72 billion in 2004--and is projected to reach $173 billion by 2020. Rising costs are making cancer care less affordable for patients and their families and are creating disparities in patients' access to high-quality cancer care. There also are growing shortages of health professionals skilled in providing cancer care, and the number of adults age 65 and older--the group most susceptible to cancer--is expected to double by 2030, contributing to a 45 percent increase in the number of people developing cancer. The current care delivery system is poorly prepared to address the care needs of this population, which are complex due to altered physiology, functional and cognitive impairment, multiple coexisting diseases, increased side effects from treatment, and greater need for social support. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis presents a conceptual framework for improving the quality of cancer care. This study proposes improvements to six interconnected components of care: (1) engaged patients; (2) an adequately staffed, trained, and coordinated workforce; (3) evidence-based care; (4) learning health care information technology (IT); (5) translation of evidence into clinical practice, quality measurement and performance improvement; and (6) accessible and affordable care. This report recommends changes across the board in these areas to improve the quality of care. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis provides information for cancer care teams, patients and their families, researchers, quality metrics developers, and payers, as well as HHS, other federal agencies, and industry to reevaluate their current roles and responsibilities in cancer care and work together to develop a higher quality care delivery system. By working toward this shared goal, the cancer care community can improve the quality of life and outcomes for people facing a cancer diagnosis.

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Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis

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The New Economics for Industry, Government, Education

The “patient-centered medical home” has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish—from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

http://www.practicechangefellows.org/documents/A_House_Is_Not_A_Home.pdf

A House Is Not A Home: Keeping Patients At The Center Of Practice Redesign

Background Despite the growth of managed care in the United States, there is little information about the arrangements managed-care plans make with physicians. Methods In 1994 we surveyed by telephone 138 managed-care plans that were selected from 20 metropolitan areas nationwide. Of the 108 plans that responded, 29 were group-model or staff-model health maintenance organizations (HMOs), 50 were network or independent-practice–association (IPA) HMOs, and 29 were preferred-provider organizations (PPOs). Results Respondents from all three types of plan said they emphasized careful selection of physicians, although the group or staff HMOs tended to have more demanding requirements, such as board certification or eligibility. Sixty-one percent of the plans responded that physicians' previous patterns of costs or utilization of resources had little influence on their selection; 26 percent said these factors had a moderate influence; and 13 percent said they had a large influence. Some risk sharing with physici...

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A national survey of the arrangements managed-care plans make with physicians

The Affordable Care Act's financial penalty for “excessive” readmissions may be too weak to overcome the substantial counterincentives currently at work. But a “warranty” payment would provide a stronger business case for hospitals to get with the program.

Medicare's Readmissions-Reduction Program — A Positive Alternative

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed.

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Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the “hamster on a treadmill” problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients’ best interests. Most payers don’t employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, “time is money;” extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.

Robert A. Berenson

Papers

A House Is Not A Home: Keeping Patients At The Center Of Practice Redesign

A national survey of the arrangements managed-care plans make with physicians

Medicare's Readmissions-Reduction Program — A Positive Alternative

Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

US approaches to physician payment: the deconstruction of primary care.