When it comes to health care, who should be driving system change?
Since the passage of national health reform, politicians and pundits have dominated the debate. But for health reform to truly take root, we should take our cue from the millions of low-income Californians who have the most at stake -- and let their expectations inform implementation.
People who fall into this category generally earn less than 200 percent of the federal poverty level, which is about $45,000 a year for a family of four. They also tend to be health-stressed. Evidence indicates a significant amount of their medical needs go unmet. But, as a result of the law, this circumstance could change. The vast majority will either qualify for Medicaid or be eligible for health insurance subsidies to purchase coverage from the state health insurance exchanges.
Findings released this week from a survey of low-income adults in California offer such cues as well as insights into how the ranks of these newly insured might take advantage of expanded access to care, and how the health system will accommodate the resulting increased demand for care and quality. The statewide survey was conducted by Langer Research Associates for Blue Shield of California Foundation.
For starters, more than half of low-income adults are less than "well satisfied" with their current health care, and more than four in 10 say they have no choice of healthcare provider today. This points toward a potentially vast transformation in the delivery of health care as key elements of the federal health law take effect, giving patients greater access to coverage and a choice of providers.
In addition, low-income Californians are ready to exercise the expanded choices that health reform might offer them. Fifty-eight percent -- the equivalent of more than 3.8 million state residents -- are very or somewhat interested in changing their primary care provider.
The healthcare system, particularly the primary care providers currently caring for low-income patients, must prepare for a world of expanded coverage and expanded choice. Their patients tell us they will vote with their feet to have a regular personal doctor and to access care in a facility with perceived high quality.
So, based on these findings, what are the prescriptions for change that will ensure that the healthcare system is ready to respond to the expectations expressed here?
First, when health reform is fully implemented, simple math suggests that there will not be enough doctors or existing health facilities across the state to meet the additional demand. Existing care models will not be able to sustain a diverse population of low-income Californians who will have health insurance -- and want to use it.
Delivering primary care will have to expand from single patient-physician visits at one facility. Solutions include improved processes for primary care practices to increase efficiency and improve quality; team-based care that leverages the skills and experiences of non-physicians; and greater online communication between the patient and provider between office visits.
Secondly, the survey findings indicate that the low-income adults most likely to change primary care providers are those least satisfied with their current quality of care. If existing providers want to hold onto their patients as they gain insurance coverage -- and choices, they must improve their own quality of care.
They can do this by improving the courtesy of staff and keeping the facility clean; assigning a highly regarded personal provider for all patients; incorporating greater patient involvement in decision making; and allowing patients more time with their providers.
Lastly, studies done by the California HealthCare Foundation and others have shown that low-income individuals face tremendous barriers in receiving specialty care and continuous care for chronic conditions. The health overhaul presents an opportunity to improve both, but providers must fulfill this promise through strategies such as real-time information sharing between county health facilities, private community health centers, and other safety net providers. Another approach would involve enhanced communication between primary care doctors and specialists, and expanded use of telehealth and telemedicine for diagnoses, procedures, and consultations to reduce the need for in-person specialty appointments.
Based on evidence from the private and public sectors, the number one prerequisite to bring about these important systemic changes -- in other words, to fill these prescriptions -- is the identification of effective leaders who are committed to providing the best healthcare experience possible.
Far from the Supreme Court or Washington, D.C., how well our state and local health leaders respond to the expectations of low-income Californians will ultimately determine the success of national health reform for this population.
Peter Long, PhD, is president and CEO of Blue Shield of California Foundation. Ian Morrison is an author and independent healthcare consultant.