The COVID-19 pandemic has challenged the U.S. healthcare system in unprecedented ways. In a webinar hosted by the Commonwealth Fund, a nonprofit organization promoting health policy reform, experts look at some of the lessons that the new U.S. administration can learn from the pandemic.
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The Commonwealth Fund — a nonprofit private organization dedicated to improving access to healthcare, particularly for more vulnerable groups — hosted a webinar discussing the steps that the new United States administration can take to achieve this goal.
The discussion featured experts from the organization’s Task Force on Payment and Delivery System Reform, and tackled how healthcare in the U.S. is organized, paid for, and delivered.
The webinar featured the following experts:
Dr. Mark McClellan, MD, Ph.D., Robert J. Margolis Professor at Duke University in Durham, NC, and Director of the Duke-Margolis Center for Health PolicyKaren Dale, RN, MSN, Chief Diversity, Equity, and Inclusion Officer at AmeriHealth Caritas in Washington, DCDr. Julian Harris, MD, MBA, Adjunct Professor of Medical Ethics and Health Policy at the University of Pennsylvania and Partner at Health Care Services & Technology Investment, Deerfield
The discussion was moderated by Dr. David Blumenthal, MD, president of the Commonwealth Fund and former professor of medicine at Harvard Medical School.
Some of the priorities and recommendations that the experts discussed included:
strengthening the healthcare delivery system for future health crisesstrengthening primary healthcare, particularly regarding vaccine distributionpromoting racial health equity during and after this crisis
In this article, MNT highlighted some salient points from the discussion, particularly around rebuilding trust in the medical establishment, promoting health equity, and diversifying and strengthening primary care.
The speakers also discussed a value-based healthcare model as a potential alternative to the current fee-for-service model that predominates in the United States. Value-based healthcare focuses on the idea that healthcare providers should not be rewarded based on the number of healthcare services that they provide, but on the health outcomes of their patients.
The panelists’ responses have been lightly edited for clarity.
‘A more comprehensive way’
Dr. Blumenthal: How can changes in our workforce help us be more prepared for an emergency like the COVID-19 pandemic and others that we may anticipate in the future?
Karen Dale, RN, MSN: The first thing is to think about the healthcare workforce in a more comprehensive way. If we widen our lens, we will consider both those people who are clinicians, and those other personnel, such as community health workers, peer supports, and others, who are so important in helping people navigate the healthcare system in a way that is more easily accessible and more readily understood.
Two bonuses come from taking that approach. [Firstly,] community health workers and other nonclinical personnel — when they are part of the system and recruited from the communities they serve — are more likely to build trust and easy engagement with those communities because they reflect who lives there and that diversity. [Secondly,] we would be helping create jobs and economic security.
[F]rom the task funds perspective, we should be funding those efforts. So, having something like a national program that focuses on the continued education, recruitment, and training of nonclinical personnel would be important.
Dr. Blumenthal: Should we transition towards a different form of payment, one that emphasizes value, not volume, and that may be more resilient and more effective? What is the role of value-based payment, what have we learned about it from the pandemic, and what should be its role going forward?
Dr. Mark McClellan, MD, Ph.D.: [W]e started the process of [recommending transitioning to a value-based payment system] before the pandemic, but [COVID was a] wake-up call for needing to move to a different mechanism of financing our healthcare, to get what we want. Care that’s upstream, care that can do the kinds of things that Karen was describing, reaching out proactively to people at risk, rather than just trying to keep your door open because utilization is down and you have to lay off staff.
I think COVID was a huge wake-up call, and […] we now have lots of examples of how [value-based care] can be done really well. Many organizations around the country are doing what Karen described. I was talking with a healthcare group today that’s moved into one of these advanced alternative payment models, way away from fee-for-service, where they’ve prepositioned at-home COVID tests for all of their high-risk beneficiaries. And if any of them have any COVID symptoms, they do a telehealth call right away to get an evaluation.
[…] If they [do test] positive, there […] are some treatments for people who haven’t been vaccinated yet, who are in high-risk groups, and they get put into a pathway to get access to monoclonal antibodies. […] We’re seeing some of the same programs being implemented for addressing vaccination.
So, that’s the kind of healthcare we want, taking that beyond the pandemic context, we need to move more care upstream, with community health workers, with assistance from apps and digital technology to help identify people who have risk factors and meet them where they are. […] Moving beyond traditional medical services to address social needs — all of that is hard to do without moving away from traditional fee-for-service.
So that’s why the report makes some very strong recommendations for the pandemic and beyond, to accelerate the adoption of alternative payment models.
‘Meaningful discussion’
Dr. Blumenthal: How can the federal government assist healthcare systems in actively confronting and fighting racism and building back trust among populations of color?
Karen Dale, RN, MSN: “In order to build trust, I often say […] that health happens at the speed at which trust exists or is being built. If you are simply going to tell me what I should do and how I should do it, and I’ve never had a seat at the table in the design, the discussion about the policies and its implications, […] then I’m not sure I will trust you.”
We also need to reckon with our history of racism in this country, and not try to wash it away but, rather, face it squarely. And when we do that, we acknowledge that it’s not that everyone is a bad person because they have bias, but we know that we have bias, and that’s a human trait. However, being aware enough, and making changes in our practice, our behaviors, and our decisions — that’s where the rubber hits the road.
[The Department of Health and Human Services (HHS)] should have an office of engagement, which is one of our recommendations, so that we’re saying: “It’s required for you to engage and have those whom you serve at the table!” It changes the conversation.
We know over years of research and just from looking at corporations that, when you have diverse boards and leadership, it makes a huge difference in how decisions are made and what the decisions look like.
So, having this office of engagement would be huge to send that message. We can also do more and have more requirements around collecting data, using data and sharing it, and being much more transparent with the information we gain over time about the disparities and the plans of improvement.
When all of that is right out there, we can have meaningful discussion, we can talk about change, and it will all [improve] the trust of those we intend to serve.
Dr. Blumenthal: How can the pay-for-value system be adapted to promote health equity?
Dr. Mark McClellan, MD, Ph.D.: [M]ost of the efforts that have looked at [defining value] carefully do include equity as a high priority. […] The recommendations in our report include putting a bigger emphasis on setting up programs in a way that reflects the input and participation of those they serve. […]
If [we are using] measures for accountability, […] that accountability should include accountability for equity.[…]
If we had more explicit measures built-in, and designed our value-based care reforms and the payment reforms to support them, to reinforce taking those on directly, just imagine how much more progress we could make!
So, whether it’s vaccination in the COVID context, or maternal mortality, or cardiovascular disease outcomes, or access to […] substance use disorder care, you can imagine a limited number of measures that could really change how the value-based system takes these on directly.
Karen Dale, RN, MSN: [In our report w]e’ve included some process measures around social care — so, are you referring those patients who are facing food insecurity, who need certain items such as diapers, etc.? — so we have those other measures to capture whether this practice is focused on the social care component more holistically.
If we share the data with that practice […], if we share our analysis to say, “based on race, ethnicity, language, and other factors, here’s a report for you where you have clear disparities,” if we’re doing that on an aggregate level over our membership […] — just in the same way that we’re sending them report cards about how they’re doing on their value-based measures, […] — then we’re giving them information that they didn’t necessarily have before.
And if we provide them with tailored technical assistance, then [the practices] are now getting the support they need, the coaching, and the ability to see how they’re doing with creating change.
[I]f we reduce some of the administrative burden, [practices] have more time to look at data and [continue to improve] in terms of their outcomes.
‘Expanding representation’
Dr. Blumenthal: What are some of the things that we could do to strengthen primary care and get them to participate in the vaccination of their panel?
Dr. Julian Harris, MD, MBA: [W]e have an opportunity to broaden the pipeline, particularly as we think about expanding representation from communities of color among the ranks of physicians, [and] across all of the subsectors or subspecialties within medicine.
I think primary care is particularly challenging because of the way that we’ve structured reimbursement. [W]e can significantly increase what we reimburse or how we compensate primary care providers if they’re doing all the right things to both improve quality for the patients that they serve and help them manage the health of populations.
If we think about the delta between reimbursement for primary care versus specialty care, it really is a deterrent for students who have significant student loan debt, who have to make trade-off decisions, and who, in many cases, may be the first person in their family to go to college, not to mention to pursue a graduate degree.
Some of the things we need to do to make primary care more broadly attractive will also help actually diversify those who end up selecting primary care as their chosen profession, because we’re closing that gap between primary and specialty care.
This enables folks to make different kinds of trade-off decisions as they think about how to close what is an economic and wealth gap in the country as well, between communities of color and others.
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