“We talk about access as if that’s the only thing in patients’ best interest. But if they are accessing something that doesn’t provide quality care and good supervision and good accountability, is that what we want?”


lative session, TMA fought off several proposed scope-of-practice expansions for nurse practitioners and other health care professionals.


home, which now contracts with three major payers under a value-based pay- ment system.


But even for groups like his that suc- ceeded in improving access to care and in reducing readmissions in the short term, “you don’t necessarily get an im- mediate bang for your buck, so we have to take a multiyear approach in these models to see the cost and quality ben- efits,” he said.


A team-based approach Physicians agree it also takes a team- based approach to realize those benefits and to truly integrate care. That includes making the most effective use of allied health professionals, another option pre- sented in the ERS report.


The study suggested that expanding


allied professionals’ scope of practice beyond their expertise would translate to expanded and more affordable access to care.


“Our population has increased so much and we have such a severe short-


28 TEXAS MEDICINE November 2012


age of physicians that patients do not have access to care. They end up in the emergency department, and that is the costliest kind of care we could have,” said former State Rep. Arlene Wohlge- muth. She is executive director of the Texas Public Policy Foundation (TPPF) and director of the nonpartisan research organization’s Center for Health Care Policy.


Advanced practice nurses could help fill those gaps, she says, but Texas strict- ly limits their ability to do so. TPPF advocates scaling back those


regulations, e.g., requirements for phy- sician supervision of nurse practitioners, and it favors permitting nurses to prac- tice more independently.


Rather than helping costs or quality,


however, the idea of unsupervised inde- pendent practice of allied professionals creates the risk of diagnoses and treat- ments that can harm patients, increase costs, and diminish accountability, says Les Secrest, MD, chair of TMA’s Coun- cil on Legislation. During the last legis-


The Dallas psychiatrist agreed there is no way for health care teams to ad- dress access-to-care shortages without using allied professionals to the maxi- mum limit of their licenses and abilities. That could be a pharmacist freeing up an emergency physician by reviewing medi- cations with a patient or a physician del- egating patient follow-up to a nurse or physician assistant. But as the highest- trained team member, the physician is the most qualified to diagnose patients and direct their care, and that doctor is ultimately accountable for those clinical activities. “We know it’s going to be a challenge as we move forward in developing de- livery systems, but we have to do it in a way that is sensible and efficient and yet still preserves the patient-physician relationship,” he said. “We talk about ac- cess as if that’s the only thing in patients’ best interest. But if they are accessing something that doesn’t provide quality care and good supervision and good ac- countability, is that what we want?” A Sept. 18 report by the American Academy of Family Physicians echoes that concern. It also stresses that the best, most efficient care is provided by teams of health professionals in a pa- tient-centered medical home model, not independent practice by a single health professional.


Physicians and others agree upon at least this one thing: The patient is an important member of that team, and perhaps among the best opportunities for ameliorating the cost curve — and creating some common ground — are initiatives that engage patients in their own health care. That could be through raising ERS members’ financial contributions to their own health care coverage, offering incentives for participating in disease management programs, or encouraging employee wellness programs, according to proposals in the ERS report. “These are things we did think par- ticipants could be doing to lower health care costs,” Mr. Kukla said. “On the flip


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76