Daniel Skinner

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor–patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

Maximizing the Patient-Centered Medical Home (PCMH) by Choosing Words Wisely

Background: Culture is transmitted through language and reflects a groups values, yet much of the current language used to describe the new patient-centered medical home (PCMH) is a carryover from the traditional, physician-centric model of care. This language creates a subtle yet powerful force that can perpetuate the status quo, despite transformation efforts. This article describes new terminology that some innovative primary care practices are using to support the transformational culture of the PCMH. Methods: Data come from the Agency for Healthcare Research and Quality–funded Working Conference for PCMH Innovation 2013, which convened 10 innovative practices and interdisciplinary content experts to discuss innovative practice redesign. Session and interview transcripts were analyzed using a grounded theory approach to identify patterns and explore their significance. Results: Language innovations are used by 5 practices. Carefully selected terms facilitate creative reimagining of traditional roles and spaces through connotations that highlight practice goals. Participants felt that the language used was important for reinforcing substantive changes. Conclusions: Reworking well-established vernacular requires openness to change. True transformation does not, however, occur through a simple relabeling of old concepts. New terminology must represent values to which practices genuinely aspire, although caution is advised when using language to support cultural and clinical change.

Health care reform, American style

From the vantage point of most developed nations, the American health care system is perplexing. Frankly, even from the perspective of many developing nations, it still does not make much sense. In...

The impact of the Affordable Care Act on hospital-led community health evaluation in the U.S. Appalachian Ohio region

In recent years, policy developments in the United States have dramatically changed how nonprofit hospitals interact with surrounding communities. However, despite the importance of these changes encoded in Internal Revenue Service regulations, little is known about how these requirements have affected how nonprofit hospitals are approaching community health evaluation. We present qualitative findings from interviews with hospital employees and consultants overseeing preliminary rounds of community health needs assessments, as required by the Affordable Care Act. The sample comes from the Appalachian region of Ohio, an area targeted because of significant health challenges. Our findings suggest that the Affordable Care Act has led hospitals to formalize their processes, focus on developing an evidence base, cultivate local partnerships, and reflect on the role of the hospital in public health.

Evangelical Protestants and the ACA: An Opening for Community-Based Primary Care?

Evangelical Protestants make up the largest religious subgroup in the United States, and previous research has shown that Evangelical churches are disproportionately active in community engagement and efforts toward social change. Although Evangelical Protestant perspectives have been considered with regard to persistent socioeconomic stratification and racial discrimination, less focus has been given to how churches interpret poor health outcomes within the United States. In particular, this research addresses how enduring health disparities are understood within the larger discussion of healthcare reform. Due to the similarity of approaches favored by participants in this study and community-based philosophy, a suggestion is made for future health policy dialogue. Although Evangelical Protestants have been most likely to reject all aspects of the Affordable Care Act, in many ways the findings of this study suggest the potential for successful future health policy collaboration. In particular, community-based primary care might appeal to Evangelicals and health professionals in the ongoing effort to improve population health and the quality of healthcare in the United States.

When Hospitals Join the Community: Practical Considerations and Ethical Frameworks.

Abstract:Written from the perspective of hospitals, this article examines, in theory and in practice, challenges associated with hospitals’ efforts to engage in neighborhood development more fully with the communities that neighbor them. Increasingly, these efforts include significant investments in housing, safety, and educational initiatives. These investments stretch the traditional expertise of medical practitioners and administrators and raise ethical and political questions about how best to engage and work with communities. After first describing the contexts within which hospital-community relationships arise, we examine ethical and political considerations likely to bear on the success of these projects. We conclude with recommendations to hospitals for operating within communities in a way that is consistent with hospitals’ ethical commitments.

What should churches do? Evangelical perspectives on church involvement in an era of community health

Abstract Health disparities in the US pose a significant challenge to scholars, providers, and community activists. An ongoing transition to population health shifts the focus away from individual health outcomes to the prevention of disease and the wellbeing of communities. This approach, however, requires developing partnerships with communities to enact appropriate interventions. In this article, Evangelical churches, an important community institution in the US, are considered potential stakeholders in future health initiatives. We present qualitative findings from 29 Christian Evangelical Protestants, on how Evangelicals themselves view their role in caring for the health of their communities. Our findings suggest a need for: better understanding of the boundaries between (a) domains that require elite expertise, (b) domains in which non-elites such as pastors and parishioners can play a role, and (c) domains in which elites within churches might play an important role through volunteer efforts.

Training Physicians with Communities

The last decade has seen a groundswell of scholarly support for rooting health care in communities (Farmer et al. 2006; Wallerstein and Duran 2006; Israel et al. 2010). Despite an emerging consensus that community-based medicine is well positioned to reduce inequalities in access, improve outcomes, and reduce aggregate costs, American health-care institutions have been slow to adapt. Change, however, is occurring. American hospitals, for example, are morphing from isolated medical campuses into centers that are increasingly integrated into communities. Regardless of the partisan perspectives from which they arise, health policy proposals often include at least components of community-based health care.

Automatic Medicine? Technology and the Future of Primary Health Care

How do emerging medical technologies stand to impact primary care services? Drawing from theoretical literature on the effects of technology on human interaction, we explore three developments in medical technology. The goal of this analysis is to assess how each technology may contribute to the goals of improved population health outcomes, while revealing the politics of technology at work in American health care. Primary care, in contrast to the ubiquitous use of technology in medical specialty care, is of particular interest because of the focus on preventing illness and improving wellness on the level of populations, rather than individual patients. We assess the extent to which technology promotes the aims of primary care to engage patients in a collaborative relationship and improve population health outcomes.

What Challenges Do Nonprofit Hospitals Face in Taking on Community Health Needs Assessments? A Qualitative Study From Appalachian Ohio

PURPOSE The purpose of this study is to understand the experiences of Appalachian hospitals in undertaking Community Health Needs Assessments (CHNAs). Of particular interest is whether new requirements to undertake regular evaluation and public health programming pose challenges for rural, Appalachian hospitals. METHODS Using a sample of nonprofit hospitals in Appalachian Ohio, we conducted in-depth qualitative interviews with hospital administrators overseeing community benefit activities and external consultants hired to complete assessments. Following a grounded theory approach, we coded interviews to ascertain major themes. FINDINGS Our findings suggest that there are several challenges faced by nonprofit hospitals that may relate to their status as rural hospitals. In particular, we found that these hospitals struggle to hire staff to oversee CHNAs, often lack the material resources to address needs identified in reports, and seek more concrete guidelines from the IRS on carrying out these new activities in their communities. CONCLUSIONS The results from these interviews suggest that there is significant support for new CHNA activities in Appalachian Ohio, but challenges remain to translate these efforts into improved health outcomes in this region. Because rural Appalachia, in particular, faces significant health disparities and a relative lack of health care providers, there is a potential for hospitals to take on an important role in public and preventive health if initial challenges are addressed.