Faculty Bibliography

Policy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients. CONTEXT: While hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the public's interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the state's ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves. METHODS: We explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review. FINDINGS: The vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state government's perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers' understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path. CONCLUSIONS: Few other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery.

Health systems around the United States are embracing new models of primary care using interprofessional team-based approaches in pursuit of better patient outcomes, higher levels of satisfaction among patients and providers, and improved overall value. Less often discussed are the implications of new models of care for health professions education, including education for physicians, nurse practitioners, physician assistants, and other professions engaged in primary care. Described here is the interaction between care transformation and redesign of health professions education at the largest integrated delivery system in the United States: the Veterans Health Administration (VA). Challenges and lessons learned are discussed in the context of a demonstration initiative, the VA Centers of Excellence in Primary Care Education. Five sites, involving VA medical centers and their academic affiliates in Boise, Cleveland, San Francisco, Seattle, and West Haven, introduced interprofessional primary care curricula for resident physicians and nurse practitioner students beginning in 2011. Implementation struggles largely revolved around the operational logistics and cultural disruption of integrating educational redesign for medicine and nursing and facilitating the interface between educational and clinical activities. To realize new models for interprofessional teaching, faculty, staff, and trainees must understand the histories, traditions, and program requirements across professions and experiment with new approaches to achieving a common goal. Key recommendations for redesign of health professions education revolve around strengthening the union between interprofessional learning, team-based practice, and high-value care.

BACKGROUND: Pharmaceutical advertisements have been argued to provide revenue that medical journals require but they are intended to alter prescribing behaviour and they are known to include low quality information. We determined whether a difference exists in the current level of pharmaceutical advertising in print general medical journals, and we estimated the revenue generated from print pharmaceutical advertising. METHODS: Six print general medical journals in Canada, the United States, and the United Kingdom were sampled between 2007 and 2012. The number of advertisements and other journal content in selected issues of the Canadian Medical Association Journal (CMAJ), Canadian Family Physician (CFP), Journal of the American Medical Association (JAMA), New England Journal of Medicine (NEJM), British Medical Journal (BMJ), and Lancet were determined. Revenue gained from pharmaceutical advertising was estimated using each journal's 2013 advertising price list. FINDINGS: The two Canadian journals sampled (CMAJ, CFP) contained five times more advertisements than the two American journals (JAMA, NEJM), and two British journals (BMJ, Lancet) (p<0.0001). The estimated annual revenue from pharmaceutical advertisements ranged from pound0.025 million (for Lancet) to pound3.8 million (for JAMA). The cost savings due to revenue from pharmaceutical advertising to each individual subscriber ranged from pound0.02 (for Lancet) to pound3.56 (for CFP) per issue. CONCLUSION: The volume of pharmaceutical advertisements differs between general medical journals, with the two Canadian journals sampled containing the most advertisements. International and temporal variations suggest that there is an opportunity for all general medical journals to reduce the number of pharmaceutical advertisements, explore other sources of revenue, and increase transparency regarding sources of revenue.

Incentives under the Affordable Care Act are making more health care systems assume the risk of paying for patient care, making boundaries between care delivery organizations and insurers less clear-cut. Bundled payments, value-based purchasing, and accountable care organizations transfer financial risk from payers to health care systems. The goal of health care systems that adopt risk contracts is to contain costs due to the increase in financial pressures as Medicaid expands and reimbursements for Medicare and fee-for-service care shrink. Accountable care organization contracts have shown promise in slowing the increase in medical expenditures for public and private payers. Some health care systems hold ownership in an associated health plan, with increasing numbers of systems developing new ways of engaging with health plans. Physicians and hospitals must distinguish between different types of arrangements. A full ownership partnership encompasses joint governance between the insurance plan and health care system; all participants in the plan receive care from the associated health system. In partial ownership, the health care system owns a stake in the insurer, but governance and care relationships are not totally overlapping. In a partnership, the formal relationship with the insurance plan preferentially refers patients to the health care system, and the system enters into risk contracts for the patients. Finally, in contractual arrangements, health systems enter into risk-bearing contracts with insurance plans for specific patient populations. For health systems that assume risk, the arrangement drives integration, such that most of a patient's health care needs and associated payments are addressed by a single network, allowing care to be better coordinated. Care provided outside the network is paid for by the insurer. Cost savings are generated by decreasing volume-based incentives in fee-for-service payment systems that can create overuse. Linking health care systems and payers can also overcome a lack of price transparency. One challenge is whether health care system-insurer partnerships will conflict with existing state and federal regulations designed to maintain a competitive marketplace. These include antitrust regulations, bans on the corporate practice of medicine, and prohibitions on fee-splitting. Another concern is that the health care system and insurers do not necessarily have the same goals and human resources. Merging these models will require significant investments of energy and capital that may distract from core activities. In addition, most health systems are ill-equipped to handle the complex operations of the insurance business. Systems must maintain adequate capital reserves to be a financially viable health plan. Therefore, health systems must be more judicious about assuming risk and managing population health and costs. Successful partnerships between health care systems and insurers will require certain components. (1) The integrated arrangement must rest on a foundation of high-functioning primary health care. (2) It must incorporate system-wide processes for quality improvement. (3) It must engage patients with outreach initiatives for disease self-management and preventive care. (4) Systems must be able to manage costs of care. With care delivery transformation as the ultimate goal, the leaders of health systems must nurture and build on momentum in a sustainable way.