Passing the Baton, 4 Key Questions for Health System Improvement and the Politics Underlying All Major Health Care Reforms
I would like to thank the publishers of The Journal of Ambulatory Care Management (JACM) for this once-in-a-lifetime professional and personal opportunity to be the editor of a fine health care journal. Yes, being editor of JACM was also a personal growth opportunity as, via JACM, I met accomplished, inspiring, and generous people over the past 25 years. Some have become personal friends, not just professional colleagues. I have encouraged many of these same amazing people to contribute to JACM over the years. I invited some of these colleagues and friends to write specifically for this issue of the Journal. Their contributions address the policy challenges I've struggled with intellectually, organizationally, and politically ever since I finished my health professional training. These are, broadly speaking, from a health systems point of view:
- How can we motivate health care professionals to improve the relationship between individuals, family, and community?
- What incentives can we build into the health system that maximize health outcomes for all but especially for those suffering from socioeconomic disparities?
- How can we measurably include the voice of the individual consumer, the patient in all aspects of health care decision-making?
- What are the most effective ways to give voice to issues pertaining to health and human rights?
I am so pleased to present the articles in this issue. Each article addresses policy challenges that the aforementioned questions raise.
As medical director for research at 3M Health Information Systems, I worked with great pleasure together with significant intellectual stimulation with Rich Averill and Ron Mills for more than 30 years of my professional life. With their involvement right from the beginning in the development of Diagnosis Related Groups (DRGs), both Rich Averill and Ron Mills have made significant contributions to improvement in American and, in fact, worldwide health care systems. Their contribution to this issue of JACM provides an important viewpoint on a technology, DRGs, which dramatically altered the health care delivery landscape over the past 40 years. The DRGs in the 1980s literally saved the Medicare Trust Fund from going bankrupt.
Billy Millwee, who I worked with when he was Texas Medicaid Commissioner starting approximately a decade ago, makes the argument in his article that tools such as Clinical Risk Groups can be used to both adjust capitation rates and improve the health care system. Hopefully, the 2 articles by Averill and Mills and Millwee will stimulate discussion on how these and many other classification tools can best be utilized to improve outcomes and control costs.
Gail Wilensky, former head of the Centers for Medicare & Medicaid Services under G. H. W. Bush and also a colleague for more than 25 years, provides us with an editorial on policy options to answer the following life or death question: 2023 is the year the Public Health Emergency is expected to end: What will happen to the uninsured?
I am a practicing internist at a community health center. Primary care physician payment and reorganizing primary care services have consequently been a great interest of mine since I started practice in 1978. We are fortunate to have 2 excellent articles that deal with these issues in different ways. Harold Miller, who I contacted years ago out of admiration for his health policy work on many topics, focuses his article on payment for primary care. Noah Nesin and colleagues from Maine examine primary care payment as one part of their proposed reorganization of primary care services. Noah Nesin, who I met a scant 4 years ago via my political work (see later), writes from decades of experience linking improved primary care services with a dramatic and positive impact on socioeconomic disparities.
Without leadership we obviously cannot motivate anyone, let alone health professionals. Joe Restuccia and Ron Goodspeed separately address leadership issues in health care organizations. Ron Goodspeed, with whom I had the good fortune to work with directly for 5 years in the 1980s and who went on to become CEO of a hospital system in Massachusetts, has been teaching courses on leadership from many years at Harvard. I met Joe Restuccia in the 1980s when I sought out the developer of a tool, the Appropriateness Evaluation Protocol, that had a significant impact on our health system. For this issue of JACM, Joe Restuccia coauthored the article with Barry Chaiken, someone who I've heard of for many years but have never met. I am looking forward to meeting him and the other coauthors of other articles in this issue who I do not yet know.
I met Graham Atkinson 15 plus years ago when he worked for the Maryland Cost Containment Commission. Trained in both mathematics and health services research, Graham, together with his coauthor Elizabeth Grace Atkinson, is uniquely positioned to delve into a topic that we will only hear more and more about: machine learning. The authors appropriately bring up the important impact, both positive and negative, of machine learning on socioeconomic disparities.
While I never pursued research on the voice of the patient or consumer, its importance was always patently obvious to me from the moment I entered medical school. I remember going to a conference in the 1980s on how to measure the voice of the consumer. I met Gene Nelson at that meeting. He introduced me to John Wasson, and both of them contributed articles to this issue of the Journal. Among many other patient-derived instruments, John Wasson is developer of the What Matters Index. In this article, he has focused on “what matters” for adolescents. Gene Nelson, together with coauthors including the first author Anna Tosteson, has refined the coproduction Learning Health System, which “extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge.”
Giovanni Apolone, who I met more than 30 years ago and is scientific director of an important Italian cancer institution, brings an international perspective to this issue of the Journal. Together with colleague Cinzia Brunelli, Giovanni Apolone summarizes a European-wide cancer initiative focused on the quality-of-life perspective of the patient. This effort holds tremendous promise for improving outcomes, as desired by patients, throughout the world.
I met Celia Larson in the 1980s when I contacted her about her research work measuring patient satisfaction. For this issue of the Journal, she and her coauthors go to the heart of my concerns and explore, in their case study of Nashville, Tennessee, the first 2 questions that I pose earlier. Their case study highlights decades of Celia Larson's work and ties together the important strands of community involvement, workforce development, and data system improvement in an effort to impact socioeconomic disparities.
I worked with Ric Rawson in the 1970s in the field of drug abuse treatment. I eventually went on to pursue health services research working with Rich Averill for more than 3 decades. Ric Rawson, in contrast, and another friend and colleague of mine, Mady Chalk, have focused on drug abuse treatment their entire lives. Together with a number of coauthors, they authored a critical article for this issue of the Journal on contingency management, “a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress.” If we are to make an impact on the tragic substance abuse overdose crisis overwhelming this country, we need to explore every option that has strong scientific underpinnings, and contingency management is one of them.
For years, JACM has had, in every issue, an article focused on human rights, an area that has only become more challenging for health professionals to impact. Most often, Physicians for Human Rights—USA contributed the article to JACM. I am pleased that Physicians for Human Rights—USA senior medical advisor Ranit Mishori, who I've known with great pleasure but for only a few years, together with coauthors, submitted this important article pertaining to the health of asylum seekers in the United States.
The last article in this issue of the Journal is an article of mine that brings together all 4 questions I pose earlier. My work in Israel and the occupied Palestinian Territories via an organization that I founded 18 years ago, Healing Across the Divides (www.healingdivides.org), places these 4 concerns into a political (with a small “p”) context. The mission of Healing Across the Divides is to measurably improve the health of marginalized Israelis and Palestinians via community-based interventions. My article (and the mission of the organization) touches each of the questions I pose earlier and tries to tie together the individual, family, community, and society within a human rights perspective.
By now, we health care professionals largely know the answer to the aforementioned 4 questions. We have excellent tools to adjust payment rates, ample mechanisms to improve organizational effectiveness, and valid user-friendly tools to measure the voice of the consumer/patient. We appreciate the importance of leadership and know how to tie these efforts to improve connections between patients, family, and community. We have a good network of community health centers, albeit not with enough health professionals for the physical and mental health front lines. We know we need universal health insurance coverage.
While JACM will continue to contribute answers to my 4 original questions and pose new ones, the principal barriers to improving health care for all in this country are not intellectual. The answers lie in both organizational and political will. Organizationally, health care entities with differing objectives (eg, hospitals vs managed care organizations) need to overcome their differences and agree to incentives that effectively implement the excellent tools at our disposal. We need the organizational will to implement incentives that place the consumer/patient at the front of the line—no matter how poor they are.
To overcome the barriers between different interest groups and implement these incentives, we also and primarily need political will. Health professionals knew, from almost the start of the COVID pandemic, what we needed to do. We not only didn't implement a national contact tracing effort, among other measures, that Republican health policymakers, Scott Gottlieb and Mark McLelland recommended in early 2020, but also the United States performed the worst during the COVID pandemic compared with any other industrialized country in the world. Universal health insurance coverage is completely a political, not an organizational or intellectual, challenge. The same applies to paying close attention to human rights.
A wish to act on the political dimension to the 4 questions articulated earlier combined with concern about internal threats to this country's stability motivated me to resign from my research work after the 2016 presidential election. In 2018, I started a political consulting firm, Ask Nurses and Doctors (AND), that aims to build on the intellectual and practical foundation formed by journals such as JACM and translate them into political action. Specifically, AND serves to organize local health care professionals to support competitive political candidates who are seeking practical solutions to the 4 questions that I pose earlier. This shift in my professional focus away from research and toward electoral politics prompted me about 1½ years ago to start thinking about passing the editorial baton.
Throughout my tenure as editor, I've tried to incorporate 2 abiding interests into the very fabric of JACM. Community health centers and other institutions serving the most vulnerable in our society have been one of my 2 abiding interests throughout my professional life. Community health centers provide the lion's share of services to the underserved in this country and certainly are a key political force fighting on behalf of the underserved.
Community health workers (CHWs) are the second focus. CHWs can be the glue that brings the strength of the primary care team to bear on socioeconomic disparities. That glue not only improves outcomes quality but can also at least stabilize, if not, over time, decrease the cost of a health system that is by far the most expensive in the world.
These efforts to nudge JACM for decades into these 2 arenas tie into the most important task one must accomplish in one's work as editor: to be constructively engaged in the handoff the reins of editor to a wonderful, accomplished new team. I am so pleased that Wolters Kluwer has accepted my recommendation that Megan Cole and Lee Rosenthal be appointed coeditors and Durrell Fox become the associate editor. These 3 outstanding health researchers and practitioners have focused their professional careers on the 2 areas that JACM has specialized in for the past 15 to 20 years: community health centers and CHWs. I can think of no others better suited to assume joint editorial responsibility. Durrell Fox, Lee Rosenthal, and Megan Cole have all served on the JACM editorial board with distinction. What good fortune to have these 3 accomplished individuals from Georgia, Massachusetts, and Texas take over the reins. While with this issue of the Journal I've passed the baton, I will always be available to help out the new editors in any way that might be useful.
—Norbert I. Goldfield, MD
Editor
