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By Harold Ambler
By Harold Ambler
Bob Hackey is a professor of health policy and management at Providence College and a visiting fellow at the Pell Center for International Relations and Public Policy at Salve Regina University. His most recent book, “Cries of Crisis: Rethinking the Health Care Debate,” was published in 2012 by the University of Nevada Press. He has published numerous articles on health care reform, hospital regulation, and certificate-of-need laws. In 2008, he was recognized as Professor of the Year for the State of Rhode Island by the Carnegie/CASE U.S. Professors of the Year Program. His current research interests focus on the rhetoric of health care reform, public opinion, and health care in popular culture.
PBN: In what ways does the word “crisis” distract people from the structural changes that the health care system requires?
HACKEY: Since Richard Nixon first declared that the health care system faced an impending crisis in 1969, public officials, providers, and the media embraced a fear-based strategy to galvanize public support for health care reform. In my book, I argue that continued talk of crisis misdiagnoses what ails our health care system. The problems we face – rising costs, uneven quality of care, a growing shortage of primary care providers, and too many Americans without affordable, comprehensive health insurance to name but a few – are chronic conditions, not crises. In each case, the problems are well known and continue to worsen over time, but no clear “tipping point” is evident that will compel policymakers to act. Few people are satisfied with the status quo, but individuals’ perceptions of the health care system reflect their own experiences with hospitals, insurers, and other providers.
Despite decades of crisis talk, most Americans remain highly satisfied with their interactions with doctors, hospitals, and insurers, and most rate the quality of their care as “good” or “excellent.” Such high levels of satisfaction with health care services are inconsistent with the notion that the US health care system is on the brink of collapse. The most significant shortcoming of crisis rhetoric, however, is that it is ill-suited to mobilize public support to manage – not cure – the complex chronic problems plaguing the U.S. health care system. No quick fixes exist for long-term, chronic problems such as rising costs, medical errors, the shortage of health providers, and the uninsured. To tackle our most pressing problems, supporters of reform must first focus public attention on the need for change and then persuade the public that change is both possible and desirable. The continued unpopularity of the Affordable Care Act nearly four years after its passage suggests that we’ve yet to achieve a consensus on the proper role of government in leading health care reform.
PBN: How does Rhode Island’s health care system excel, and how does it fall short compared to other states?
HACKEY: Rhode Island is a national leader in promoting public health. The state’s comprehensive flu vaccination program is an excellent example of this, but our work in protecting vulnerable children and elders is also noteworthy. After several high profile cases brought the issue of nursing home quality to the forefront, the Department of Health established a comprehensive system to monitor the quality of nursing home care and to help patients and families shop for high quality care. This system, and the regulations which accompanied it, created a safer environment for some of our state’s most vulnerable citizens. The state also organized an aggressive campaign to reduce lead poisoning over the past two decades – a debilitating problem affecting children in our core cities. Both demonstrate the type of leadership needed to address chronic problems. No “quick fix” was possible in either case. Instead, state officials worked with providers and community groups to identify at-risk groups and institutions and target them for intervention. We established new monitoring systems and policies that are now national models. The challenge, of course, in the context of Rhode Island’s continuing economic problems, is sustaining state funding for such essential public health programs.
Rhode Island falls short in financing both public health programs and paying providers. The lead poisoning example is a case in point, as the state scrambled to replace funding for the program – which is credited with a dramatic reduction in lead exposure among kids – during last year’s budget cycle. Cutting funding for prevention programs like this is simply shortsighted. Similarly, Governor Chafee’s proposed cuts in Medicaid reimbursement for providers are short-sighted and ill advised. The fiscal health of the state’s nonprofit hospitals continues to erode, and the proposed cuts in provider payment will place new pressure on hospitals and nursing homes to reduce staffing, which is the largest single expense for most health care institutions. Staffing cuts undermine the quality of patient care; numerous national studies demonstrated a strong link between nurse staffing and patient outcomes such as medical errors and re-admissions. Further cuts to provider payment may also lead many physicians to limit the number of Medicaid patients they treat, or to stop accepting Medicaid altogether.
PBN: What is the best health care change to take place in Rhode Island in the last two years?
HACKEY: The development of Patient Centered Medical Homes (PCMH) in primary care demonstrates the unique opportunities we have in Rhode Island as a result of our small size and close-knit working relationships between payers and providers. Several of our largest physician groups such as Coastal Medical and Rhode Island Primary Care Physicians Corporation are leading the way to improve the quality of primary care in the state. PCMHs empower patients by coordinating care, providing better access to information, and also emphasize the importance of prevention to manage chronic health care problems such as high blood pressure, asthma, and diabetes. The result is more cost-effective care for tens of thousands of Rhode Islanders. Over the past few years, we’ve seen tremendous innovation here, both among the provider community and from the state’s largest health insurer, Blue Cross, which has supported the development of PCMH initiatives across the state.
PBN: How is social media improving the delivery of health care information, and even health care itself, in Rhode Island and in the country as a whole?
HACKEY: Social media enables patients to access more information than ever before, and can also [help] public health officials, providers and other groups to raise public awareness of emerging issues such as flu vaccination campaigns. Many physician practices now have an online presence using Facebook or Twitter to keep in touch with patients. According to a recent poll sponsored by the Pew Research Center, more than a third of all Americans are now “online diagnosers” who turn to the Internet to learn more about their health care conditions. Most subsequently schedule an appointment with a doctor to follow up on this information.
PBN: Conversely, are there segments of the Rhode Island citizenry getting left behind in terms of health care information delivery in the digital age?
HACKEY: The gaps in information literacy we see in our larger society are particularly evident in health care. It’s not enough to be online. Patients need to know how to identify the information needed to make important decisions. Choosing a health insurance plan, for example, is a complicated process. Individuals need to ensure that their plan meets their needs. Since many Bronze and Silver plans offered through the state’s health insurance exchange include very high deductibles, patients need to carefully assess their own health conditions and projected expenses to choose a plan that fits their needs. UnitedHealthcare’s decision to end its relationships with many physicians serving Medicare patients in Rhode Island also created widespread anxiety among thousands of seniors who were forced to either switch providers or insurers in 2013. As more health care information moves online, we need to ensure that all Rhode Islanders are equipped to access and understand it.