Welcome to the Blog of the Duke Center for Research on Prospective Health Care

The mission of the Duke Center for Research on Prospective Health Care is to support the development and implementation of prospective health care, a personalized, predictive, preventive and participatory approach to care that is based on the integration of three key elements: (1) personalized health planning, (2) coordination of care, and (3) rational reimbursement. On this blog we discuss current issues in prospective health care and personalized medicine, including ongoing research and outreach in the Center, the work of other leaders in the field, and innovations in science and technology that can promote this model of care. We invite you to this important conversation and look forward to your thoughtful comments and ideas.

The views, opinions and positions expressed by the authors and those providing comments on these blogs are theirs alone, and do not necessarily reflect the views, opinions or positions of Duke's Center for Research on Personalized Health Care.

Wednesday, March 2, 2011

If States Opt-Out of the ACA, Will They Opt-In to Creating Better Models of Care?

Earlier this week, President Obama indicated his support for legislation that would let States opt-out of the Accountable Care Act in 2014 rather than in 2017. The President stipulated that States would be free to provide their own approaches for health care delivery as long as they cover as many people as the Accountable Care Act and not increase the federal budget. Whether this proposal will foster a compromise between Democrats and Republicans is highly doubtful, but the proposal raises an important question. Where will innovation come from to allow health care coverage for tens of millions of more Americans while not increasing the already unsustainable national burden of health care expenditures? I am pleased with the flexibility the President is showing in allowing States, rather than the Federal Government alone, to innovate in developing new models for health care delivery. States may be much better prepared to understand the needs of their constituencies than the Federal Government and may have greater flexibility to innovate.

Stimulating innovation in health care delivery and removing barriers to such innovations are critical to solving our dilemma of increasing health care costs. Expending roughly 17% of our gross national product on health care would not be a terrible thing if our country was getting its money worth. Clearly, this isn’t the case by any objective standard as the health of the American public is below that of many western countries despite our spending far more for care than any other country. The problem, of course, is that our current system is uncoordinated, reactive, and focused on intervention for episodes of late-stage, preventable, chronic diseases. The reimbursement system rewards such interventions, particularly if they involve complex procedures. Conversely, the reimbursement system punishes innovation in strategic, coordinated approaches to disease prevention and minimization. It is becoming increasingly recognized that when individuals are engaged in their care, that when delivery is coordinated and care is proactive, outcomes are improved. This leads me to point out an opportunity that States will have, if indeed, an early opt-out from the Accountable Care Act is permitted.

State budgets are greatly overburdened and their mounting deficits are the subject of national news on a daily basis. State expenditures for Medicaid and CHIP programs ($123.2 billion in 2009) are amongst the greatest financial burdens that they have and the Accountable Care Act increases this burden. Herein lies a great opportunity and need for their innovation. As an example, Community Health Centers funded by the Health Resources and Services Administration (HRSA) provide an important component of delivery systems for the indigent and for many Medicaid recipients. Currently, Community Health Centers are often the last bastions of health care for those with Medicaid or the uninsured because there is nowhere else to go. These centers are generally underfunded, overcrowded, understaffed, and often have great difficulty in meeting anything other than the individual’s most urgent needs. I encourage HRSA to allow States to work with their Community Health Centers to facilitate their transformation from over-crowded clinics to models of innovative approaches to coordinated care using personalized health planning. The National Association of Community Health Centers has already indicated a desire to lead in a primary care solution. I suggest that States begin working with their Community Health Centers to develop better approaches by applying what we know works: proactive, coordinated care with patients engaged in their own health plans. We have been strong proponents of personalized health planning as an operational means to provide patient-centered care in a coordinated, strategic fashion. To this point, the Duke University Health System found that it was less expensive and more humane to provide such programs, free of charge, for the indigent in Durham County with certain chronic diseases, thereby avoiding the cost of non-reimbursed services in its emergency rooms. The underlying principles were personalization of care, patient engagement, and mentoring. Solving the dilemma of health care reform will require better approaches to how care is delivered. Our 50 States and more than 1250 Community Health Centers can serve as innovators of such change.


  1. In its publication,"Crossing the Quality Chasm: A New Health System for the 21st Century," the Institute of Medicine presented a strategy for improving the quality of of nation's healthcare delivery system. One of the main strategies for improvement was identified as a need for "patient-centeredness," which was described as care that is respectful and responsive to patient needs, values, and preferences, and encourages shared clinical decision making.
    What if patient-centered care were not only the right thing to do, but conserved heatlh resources as well? A study examining this was presented at the annual meeting of the European Association for Healthcare Commiunications held in Verona,Italy in September, 2010:

    Purpose: This paper uses an interactional analysis instrument to characterize patient-centered care in the primary care setting and to examine its relationship with healthcare utilization. Methods: 509 new adult patients were randomized to care by family physicians and general internists. An adaption of the Davis Observation Code was used to measure a patient-centered practice style. The main outcome measures were their use of medical services and related charges monitored over one year. Results: Controlling for patient gender, age, education, income, self-reported health status, and health risk behaviors (obesity, alcohol abuse, and smoking), a higher average amount of patient-centered care recorded in visits throughout the one-year study period was related to a significantly decreased annual number of visits for specialty care (p=0.0209), less frequent hospitalizations (p=0.0033), and fewer laboratory and diagnostic tests (p=0.0027). Total medical charges for the one year study were also significantly reduced (p=0.0002), as were charges for specialty care clinic visits (p=0.0005), for all patients who had a greater average amount of patient-centered over that same time period. For female patients, the regression equation predicted 15.47% of the variation in total annual medical charges, compared to male patients where 31.18% of the variation was explained by the average percent of patient-centered care, controlling for socio-demographic variables, health status, and health risk behaviors. Conclusions: Patient-centered care was associated with decreased utilization of healthcare services and lower total annual charges. Reduced annual medical care charges may be an important outcome of medical visits which are patient-centered.

    The full paper is currently in press at the Journal of the American Board of Family Medicine (JABFM).

  2. Your comments supporting the expansion of community health centers are right on target. These patient-governed organizations provide high-quality, cost-effective primary medical, dental, pharmacy, and enabling services to this country's most vulnerable patients. Recently, the Health Resources and Services Administration established a relationship with NCQA to assist CHCs achieve Patient Centered Medical Home recognition - with a goal for all centers to reach NCQA Level 3 by 2014. PCMH includes personal health planning in its approach. I look forward to discussing this, and other aspects of the community health center program, at your conference later this month.