With the mania of the presidential election in full tilt and the election just days away, it’s hard to have a rational public discussion about health care. Supporters of the two presidential candidates have drawn a deep and divisive line (or rather a tectonic fissure) in the sand about health care reform. This is due, in great part, to the bombastic, and ultimately unhelpful, language about Obamacare used by the candidates.
You’ve heard it. Obamacare is a “complete disaster” where premiums are rising faster than hot air (note: they are rising, but not close to level that Donald Trump has stated). Or it’s a landmark law that should “never be turned back over” to the insurance industry (note: it kind of already is). Hillary Clinton is leaving out that private insurance companies were influential in the reform process, have benefitted from increased enrollment, and are still doing cartwheels to the bank.
There are saner discussions to be had about health care. And I was in great need of having one.
On this blog, I’ve previously written about my conversations with a former director of a state Department of Health and a former director of a Federally Qualified Health Center (now heading my university’s academic primary care practice) about ways to improve primary care. Those were inspiring visions of primary care.
A few months back, a short commentary caught my eye in Medical Care written by Thelma Mielenz, John Allegrante and John Rowe of Columbia University. They titled it, “Patient-centered Medical Home, Make Room for Your New Neighbor: The Person-centered Wellness Home“. I found it be a thoughtful piece on better connecting primary care offices with the community, so I wanted to interview Dr. Mielenz to learn more.
We share the belief that primary care must be firmly rooted in the community. In fact, a core principal of primary care is taking responsibility for the health of a defined population and then orienting or tailoring that care in a way that best meets the needs of the community. In theory, this means taking steps to learn about the community and, where possible (as Dr. Mielenz so nicely said), “reaching outside the four walls of the clinic and into the community”.
But accomplishing this is difficult in practice.
If you ask providers in any primary care office in the U.S. whether they know their community, you’ll probably get many reassuring nods. But if you get specific and ask whether they have looked at detailed health data about their community or city, have a grasp of their local community health and social resources for patients, or whether they’ve taken time to check some of their own patients’ records to assess the major community health issues…you’ll hear crickets. And, honestly, how could we expect them to do this?
Primary care providers are already overworked. I often hear in my work with primary care providers that they wish they could get their patients to adopt healthier lifestyles. Despite their efforts, patients often don’t follow their recommendations. Any health behavior change–like exercising more, eating healthier meals, or even adjusting to taking medications regularly–is hard. And without support, even patients with the best intentions have difficulty following through.
This is where Dr. Mielenz and colleagues offer primary care some ways forward.
Dr. Mielenz has an interesting background as a physical therapist in academic medicine transitioning to academic public health as a behavioral epidemiologist. She gets quite well the frustrations that providers feel, and explained how she would encounter patients in her physical therapy practice with good intentions, but little community support for wellness care.
Expressing some frustration with the limits of clinical practice, Dr. Mielenz had an overarching message: “So much of health happens in the community… The clinic is not the most efficient place for wellness to happen.” I wholeheartedly agree. And from our conversation, I found two of her ideas to bridge the gap particularly ready for amplifying to a policy audience.
First, Dr. Mielenz made the point that primary care offices need a structure upon which to extend into the community for wellness care. Primary care providers right now have little way of connecting with many of the existing community evidence-based wellness programs available. And community programs don’t often have a stable source of funding. There is essentially no scaffolding (physical or financial) to readily connect them.
Dr. Mielenz suggests this scaffolding could arise through community health workers (or “lay leaders”), who are trained to implement the community wellness programs. These individuals would serve as local, neighborhood-based connectors who could direct people to wellness resources, help people set goals and meet them, and then reconnect them with their primary care offices. According to Dr. Mielenz, the ultimate goal is to establish a more regular flow of patients from the clinic to community wellness programs.
Second, Dr. Mielenz made the case that policy is already moving toward requiring these connections, but directing financial resources is critical. She cites the requirement that patient-centered medical homes have linkages with self-management programs (Element 4 – one of the must-pass elements). She argues that these policies need to come with financial support for these community programs and to help create the structure for these linkages between the clinic and community. Specifically:
“If there was a way that future revisions to the Affordable Care Act included funding for such community-based wellness programs, say if there was a menu of 25 programs to which all people could have access, I would call that a win. The primary care office gets to check their boxes in terms of providing self-management, and the patient gets broader wellness support as a person living in their community.”
Her article mentions that the Affordable Care Act does, in fact, support reimbursement for community health workers and that Medicare and Medicaid reimbursed for disease self-management programs. But consistent financial support (or reimbursement) for the wide array of “wellness care” that is needed to promote population health is not part of any regular, widespread, or national reimbursement scheme. Without this, she argues, the great potential value of connecting primary care more closely with the community will remain untapped.
Gregory Stevens