Pennsylvania – Contrasts and Challenges

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Tom Demko_Stante_cropped.Lessons learned from the VA

By Tom Demko

Pennsylvania is the 6th most populous state in the nation with over 12 million residents, and an economy that ranks 6th in the United States in terms of Gross Domestic Product (GDP).  While broad statistics like this make our state look comparatively strong and competitive, Pennsylvania has a unique demographic profile that challenges healthcare delivery.

According to the World Bank, both the world population in general, and US population specifically, are trending toward an urban bias – with 17% of the US population living in rural communities in 2012, down from 20% in 2002. However, Pennsylvania has a rural population of 3.5 million – or about 27% of its population, a 2% increase in the same 10 year period. In contrast to demographic trends that number is projected to climb through 2030 by another 3%. Pennsylvania has the largest rural population in the country.

There are severe challenges to delivering health care in rural areas including provider shortages, isolation, long travel distances, scarcity of specialty care, under-resourced infrastructure, and an older population with multiple chronic conditions. The Pennsylvania Legislature and the PA Department of Health report the following Pennsylvania statistics:

  • Rural counties have fewer primary care physicians than urban counties. In 2008, there was one rural primary care physician for every 1,501 residents. In urban counties, there was one primary care physician for every 981 residents.
  • Along with fewer primary care physicians, rural counties also have fewer dentists. In 2009, there was one practicing dentist for every 2,662 residents. In urban counties, there was one dentist for every 1,814 residents.
  • An estimated 14 percent of rural residents under 65 years old did not have health care insurance. An estimated 11 percent of those under age 65 in urban counties did not have health care insurance.
  • What can we learn from the above statistics to help the healthcare system grow and prosper — not just tread water or worse, disappear — in today’s environment? Here is one way a health care system might approach the strategic challenges: Don’t fix a bad system.

We know from local history that, in the long term, global economic pressure will win over localized resistance to change. In retrospect, the decline of big steel, the trend from integrated mills producing steel from ore, coke, and limestone to the electric arc furnace was unstoppable. The mini-mills that embraced reinvention are the survivors of that industry.

The healthcare enterprises that survive the current paradigm shifts will be those that embrace changes and design systems that address the economic challenges with retooled information technology and delivery-of-care models. The survivors will focus on customer value, innovation, and successful business models outside the organization and the industry. Those organizations that enter bankruptcy tend to have a much higher internal focus on cost-cutting and bottom-line results. Both strategies are short-term and unsustainable.

Could the Veterns Administration provide some answers?

Consider the Veterans Health Administration (VA) approach to healthcare reform.

The challenge the VA faces is coincidentally similar to the unique challenges of the Pennsylvania healthcare landscape. Similar to Pennsylvania, veteran care is largely rural-based. The profile of the veteran population is one that is widely dispersed – not connected by geography – but by a common thread of service to country. 

Despite the recent bad press, the VA is in the midst of redesigning its delivery of care modal around the Patient Aligned Care Team (PACT) system. PACT is intended to transform the way veterans receive care by providing patient-driven, proactive, personalized, team-based care, oriented toward wellness and disease prevention. The desired result is improved veteran satisfaction, as well as healthcare outcomes and costs. The PACT model is built on the well-known concept of the patient centered medical home, staffed by high-functioning teams.

PACT encourages health care professionals to plan for the whole-person care and life-long health and wellness. The focus is placed on:

• Partnerships with patients

• Access to care using diverse methods

• Coordinated care among team members

• Team-based care with the patient as the center of their PACT

A PACT offers many ways to access health care. In addition to personal visits with their primary health care provider, visits may be scheduled with other members of the team. Veterans also have access to group clinics and educational seminars, plus a wealth of information available on the internet through My HealtheVet (https://www.myhealth.va.gov/index.html). Patients can communicate with members of their PACT by telephone or through secure messaging via My HealtheVet.

A PACT team approach has multiple spokes of care. The vet is the center of the care team that also includes family members, caregivers and health care professionals – primary care provider, nurse care manager, clinical associate, and administrative clerk. When other services are required to meet their health goals and needs, another care team may be called in.

Many Pennsylvania healthcare enterprise leaders and strategists are actively developing new models of healthcare delivery and would do well to take a look at a team-based approach similar to the VA. While very recently it would have been unthinkable to use a government model as an example for the private market to deliver health care efficiently, with the enactment of the Affordable Care Act and the foresight of an overhauled VA delivery system, the time might be right to align the delivery model with the reimbursement model.

Tom Demko is a Principal in the Stantec Butler, Pennsylvania Office.

Tom can be reached at tom.demko@stantec.com.