Sylvia Drew Ivie from The Help Everyone Clinic in Los Angeles, representing consumers on the panel, provided a reality check drawn from her experience advocating for the poor, who often present with multiple health challenges and are dealing with a myriad of psychosocial issues. She poignantly asked whether the system changes proposed at the summit would actually help improve the quality of care for the patients and families she serves, and offered this as a test for determining the overall effectiveness of the interventions undertaken.

Concern was raised during the audience feedback that the major social and environmental determinants of health had not been fully considered during the summit. Although the summit was convened to address redesign of the care delivery system, public health issues were emphasized as critically important to improving overall health status. However, time constraints did not permit full exploration of these intricately related factors. Additionally, the audience stressed the importance of treating patients holistically and not artificially segmenting them into single disease categories, as most clinicians are treating patients with multiple chronic conditions (Partnership for Prevention, 2002). Caution was directed at the condition-specific working groups to avoid falling into this trap, and it was emphasized that the strategies from these sessions must be integrated.

Integration of Preventive Care

The audience repeatedly emphasized prevention as an essential component of managing chronic disease. Ongoing preventive strategies were cited as necessary to the treatment and provision of high-quality care for patients with chronic conditions—a case in point being blood pressure control, lipid management, and diet and exercise for patients with heart failure. George Isham from HealthPartners, Inc. in Minneapolis, representing health systems on the panel, suggested that attention be focused on three major behaviors that drive illness in this country—tobacco, exercise, and nutrition. He then offered a two-pronged approach: first, incorporate these three areas into the management of diseases and conditions for which they are significant risk factors; and second, look beyond the face-to-face visit and explore alternative sites for the provision of care, while adopting new technologies to extend care beyond its traditional boundaries.

Change in Roles for Public and Private Purchasers

The panel members underscored the importance of galvanizing both public and private purchasers to reorganize and redesign how health care is currently financed. There was general agreement that additional revenue streams from the public sector would not be forthcoming; thus any strategies put forth must be budget neutral, with resources being redistributed to pay for forms of care traditionally not reimbursed. Strong leadership will be required to decide how to reallocate these resources. Helen Darling from the Washington Business Group on Health, representing purchasers on the panel, suggested that payment be tied to evidence-based practices, seeing this as an opportunity to redirect funds from services known not to be effective to those demonstrated to improve care.

An audience member asked the panel what strategies might be implemented now in the absence of comprehensive finance reform. Examples of system-level approaches that have progressed despite the lack of such a major transformation include implementation of automated health records, integration of evidence-based guidelines into clinical practice settings, and the use of multidisciplinary care teams. However, finance reform was cited as essential to provide momentum for these interventions, now scattered across the country as demonstrated by the communities represented at the summit. It was suggested that small-scale demonstration projects and multilevel collaborations across health systems,



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