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2 The Ongoing Transformation of Health Care Charles de Gaulle once asked, “How can you govern a country in which there are 246 kinds of cheese?” Allied health may be in a similar position, said Edward O’Neil, director of the Center for Health Professions at the University of California, San Francisco. With more than 200 occu- pations included within the term allied health, it is a somewhat artificial grouping without a clear center or cohesiveness. Yet allied health is a criti- cal component of health care reform. TRANSITION OF THE CURRENT HEALTH CARE SYSTEM O’Neil listed eight features of the current health care system that are undergoing major change, all of which have direct implications for allied health. From Acute Treatment to Chronic Prevention and Management Although the population is increasingly burdened by chronic disease and disability, health care remains oriented around acute care, O’Neil observed. In the long run, prevention will be emphasized. But the largest returns in the immediate future will be from managing chronic disease and disability more effectively without relying as extensively on the expensive institutions used to manage care today. 5
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6 ALLIED HEALTH WORKFORCE AND SERVICES From Cost Unaware to Price Competitive Despite all the efforts made to manage costs over the past 2 decades, most people are still unaware of the expenses associated with health care. The health care system has been “abjectly unresponsive to the consumer,” said O’Neil. As a result, consumers have a tendency to go elsewhere for care that they find compelling, whether to Walmart or to Costa Rica. From Professional Prerogative to Consumer Responsive Because of the inpatient orientation of health care, the prerogative of the professional still reigns, whether the professional is a physician, a nurse, a dentist, or a community health worker. Health care professionals train for acute care settings and make much of their money in those set- tings. Even the cultural icons of health care, such as Dr. House from the television show House, remain focused on acute care. “When Dr. House puts a preventive strategy in place and breaks into the patient’s house to monitor that patient’s exercise and medication, we’ll know” that change has arrived, said O’Neil. From Inpatient to Ambulatory—Home and Community Part of the health care reform movement today is focused on building the patient-centered medical home. “But that’s just a way station to locat- ing primary care in the home using new technology,” said O’Neil. New arrangements will be made for the provision of emergency care, the storage of medical information, and services such as health coaching. From Individual Professional to Team In the past, large teams of providers with many different areas of exper- tise have managed individual patients, but that approach was too expensive, says O’Neil, and evidence is scarce that large and diverse teams functioned well. New technologies make it possible for teams to work together without gathering everyone around a large table. The challenge for team members now is to know that information about a patient exists and how to access it. “I love the Fred Hutchinson Cancer Institute,” said O’Neil, “where you can’t really tell who is the oncologist, the housekeeper, the nurse, or the nutritionist, because they all respond in a consumer-oriented way.”
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7 THE ONGOING TRANSFORMATION OF HEALTH CARE Other Trends O’Neil mentioned, but did not discuss in detail, three other trends which move the health care system: • From traditional practice to evidence-based medicine • From information as record to information as tool • From patient passivity to consumer engagement and accountability LEGISLATIVE DRIVERS Two major pieces of federal legislation are driving changes in health care—the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. O’Neil said that he views these acts as a framework that can be used to produce a better health care system. The two pieces of legislation are reasonably well aligned with the di- rections in which external forces are pushing the health care system, said O’Neil, including demographic forces and technological changes. Neverthe- less, the form change takes will be created by plans, practices, professionals, and schools—not by legislation. The hard work will be done by the people and organizations that create accountable care plans, integrate care, think differently about primary care, relate differently to each other, and create more deeply innovative systems. The policy environment now supports and encourages their efforts, but it does not dictate what they should do. The alternatives to change are limited and unpleasant, said O’Neil. The health care system could limit the access of patients to things they want, but he noted that we have been doing that for a while and patients are not going to stand for that much longer. Everyone in medicine could take a large pay cut, but O’Neil labeled that idea a nonstarter and said that it is not going to happen. The only other way to change health care is to change the practice model, he said. “How is it that we deliver a unit of care? Where does that take place? Who are the professionals that provide it? How is it financed?” Once these changes begin, they will be the vehicle by which allied health care professionals can transform their professions. “Strategic success comes with how well you understand this and move forward.” DEMOGRAPHIC CHANGES O’Neil pointed to three broad demographic changes that will have a profound effect on health care. The first is the aging of the population. Between 2010 and 2025 the over-65 population will grow from about 12 percent of the population to 17 percent of the population (U.S. Census Bureau, 2008b). This change alone will drive many of the dynamics in
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8 ALLIED HEALTH WORKFORCE AND SERVICES the health care system. The second broad change is increasing diversity. By 2040 the United States will not have a majority ethnic or racial group. This trend has already started on the coasts and is moving into the interior, though the interior already has many pockets of change and diversity. The third trend is simply population growth. By 2025, the United States will have grown by 15 percent (U.S. Census Bureau, 2008a). The health care system will need to become a more effective and efficient system, but it also will need increased capacity to provide services for a larger population. “Demography does not always mean destiny, but it’s pretty close,” O’Neil stated. “This means there is another opening for us to think about the practice model. How are we going to go about altering the practice model and utilizing allied health workers in new kinds of ways?” THE END OF THE FLEXNERIAN PARADIGM In 1910, Abraham Flexner published a report that transformed medi- cine by calling for substantially upgraded educational standards for physi- cians (Flexner, 1910). Future doctors got university degrees rather than professional training, medical schools were accredited, and doctors were licensed by the state. This transition led to an alliance between medicine and government that has strengthened over time, according to O’Neil. The growth of federally sponsored research after World War II created a need for even more training, both for researchers and for specialists. Specialists in turn advocated for their own research institutes, resulting in multiple institutes for various organs and diseases. Reimbursement became tied to accreditation and to research. “Every profession over that time has taken that as the model—higher and higher credentials for entry, more and more specialized knowledge,” said O’Neil. “It is the model we still operate on.” For some professions this model never worked very well, according to O’Neil. There may be other and better ways for people to be trained and enter into practice. The current time of change may be an opportunity to reexamine that model. A prominent feature of the allied health professions is that they are heavily dependent on state-subsidized education. But the states are “broken financially,” O’Neil said, and even if they do recover eventually, the allied health professions will not be high on their agendas. “It was hard enough to make [the case] when there were lots of resources.” Allied health needs a better model for the location and financing of allied health education and for the reintegration of allied health into the care delivery system. Many if not most of the allied health professions are driven and defined by technology. Allied health education typically has been one step removed from the parts of the system that own and operate these technologies. The allied health professions need to think about involving
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9 THE ONGOING TRANSFORMATION OF HEALTH CARE the manufacturers of technologies in new ways, said O’Neil. “There are some conflicts,” he acknowledged, “but I think those conflicts are exactly where we need policies to help us understand. I am not suggesting this as an exclusive option. I’m suggesting that we have a richer set of balances between where schools are organized and structured and who is interested in having them that way.” Proprietary education also is in serious need of regulatory structure, O’Neil said. Proprietary schools sometimes prey on the students who are most ambitious and least sophisticated, and the professional lives of these students can be put in jeopardy because of a lack of effective policy. Private capital needs to be available within a regulatory frame that makes sense. DISCUSSION During the discussion period, O’Neil was asked if disparity is another demographic characteristic that should be on his list. He acknowledged that the health care system has considerable disparities, though disparity has dif- ferent sources. One complication in addressing disparities is that health care programs for diverse populations tend to be oriented toward middle-class majority populations, but some people are much more concerned about feeding their children than they are about typically middle-class concerns. The health care system needs to be concerned about disparity, but it also needs to look critically at its efforts to address disparity. In response to a question about the obesity epidemic, O’Neil called obesity a good example of why the health care system needs to change. The system will not be able to address obesity by putting more money into health care delivery. “We will amputate some more feet. We’ll treat some chronic obstructive pulmonary disease. We’ll treat congestive heart disease. But we won’t address obesity.” The cause of obesity is outside the health care system. Variations in state and institutional licensure are important issues and will require thorough data on the people being trained. Changing practice acts through political action is a long, hard road. But large integrated health care systems have considerable political power, and they can use their un- derstanding of technology to demonstrate how improvements are possible. A low-cost way to rationalize health care is to lower the boundaries around practice, O’Neil observed. Demonstrating the advantages of such a step at the state level will be critical, after which it may be possible to standardize policy at the national level.
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