Community Health Centers: a Key Partner to Achieve Medicaid Expansion.

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

The Shared Principles of Primary Care: A Multistakeholder Initiative to Find a Common Voice.

As America's health care system continues to transform, the foundational importance of primary care becomes more clear. The Joint Principles of the Patient Centered Medical Home are now more than a decade old. As delivery reform continues, the importance of seven essential shared principles have emerged from a dynamic, collaborative, and iterative process of consensus building across multiple stakeholders. These seven principles will help the public, policy makers, payers, physicians, and other clinical providers speak with a unified voice about these core principles that define the enduring essence and value of primary care. The seven shared principles of primary care consist of: (1) person and family centered, (2) continuous, (3) comprehensive and equitable, (4) team based and collaborative, (5) coordinated and integrated, (6) accessible, and (7) high value. When used together, these shared principles provide a solid platform on which to build all further health care reform.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center.

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Alzheimer Disease: Pharmacologic and Nonpharmacologic Therapies for Cognitive and Functional Symptoms.

Alzheimer disease comprises a syndrome of progressive cognitive and functional decline. Treatments should target cognitive and functional symptoms. Cholinesterase inhibitors, memantine, and a combination of a cholinesterase inhibitor and memantine have produced statistically significant but clinically small delays in various domains of cognitive and functional decline in select patients with Alzheimer disease. Vitamin E has been shown to delay functional decline in patients with mild to moderate Alzheimer disease, especially when taken in combination with a cholinesterase inhibitor. Structured programs of physical exercise improve physical function and reduce rates of neuropsychiatric symptoms in patients with mild to severe Alzheimer disease. Cognitive stimulation programs show benefit in maintenance of cognitive function and improved self-reported quality of life in patients with mild to moderate Alzheimer disease.

Assessing Idaho Rural Family Physician Scope of Practice Over Time.

CONTEXT: An important consideration determining health outcomes is to have an adequate supply of physicians to address the health needs of the community. PURPOSE: The purpose of this investigation was to assess scope of practice factors for Idaho rural family physicians in 2012 and to compare these results to findings from a 2007 study. METHODS: The target population in this study was rural family physicians in Idaho counties with populations of fewer than 50,000. Identical surveys and methods were utilized in both 2007 and 2012. RESULTS: The physician survey was mailed to 252 rural physicians and was returned by 89 for a response rate of 35.3%. Parametric and nonparametric statistical analyses were conducted to analyze the 2012 results and to assess changes in scope of practice across the time periods. DISCUSSION: The percentage of rural family physicians in Idaho in 2012 who provided prenatal care, vaginal deliveries, and nursing home care was significantly lower than the results from the 2007 survey. Female physicians were more likely to provide prenatal care and vaginal deliveries than males in 2012. Male physicians were more likely to provide emergency room coverage and esophagogastroduodenoscopy or colonoscopy services than females in 2012. Younger physicians were found to be more likely to provide inpatient admissions and mental health services in 2012 than older physicians. Employed physicians were more likely to provide cesarean delivery, other operating room services and emergency room coverage in 2012 than nonemployed physicians. Further research is needed to assess the root causes of these changes.

A proposal for reform of the structure and financing of primary care graduate medical education.

BACKGROUND AND OBJECTIVES: Accessible, high-quality, cost-effective health care systems are anchored in primary care, yet decreasing production from graduate medical education (GME) jeopardizes the primary care workforce and the nation's health. The GME Initiative recommends Congress (1) invigorates primary care physician (PCP) supply through GME benchmarking and enforcement by creating a workforce that is at least 40% PCPs, holding teaching hospitals accountable, and increasing the primary care residency position cap, (2) establishes a GME system supported by all insurers-public and private-and implements a fixed floor funding of direct GME (DME) at $100,000 per resident per year for residencies that produce graduates who truly go on to practice primary care, (3) reallocates some indirect GME (IME) to support primary care residency education, including enhanced PCP education outside hospitals, including teaching health centers, (4) restores funding for the 1997 full-time equivalent (FTE) PCP residency slots cut for training outside the teaching hospital, (5) allows states expanding Medicaid through the Patient Protection and Affordable Care Act (ACA) to increase PCP education capacity through Medicaid DME and/or IME at the enhanced Federal Medical Assistance Percentage (FMAP).

Association of "grit" and satisfaction in rural and nonrural doctors.

BACKGROUND: One potential psychological construct, grit, may help to explain the non-cognitive traits that account for both rural physician satisfaction and retention. We investigated (1) the psychological construct grit among rural and non-rural primary care/specialty care physicians, (2) satisfaction levels and (3), the relationship between the psychological construct grit and satisfaction across combinations of rural/non-rural and primary care/specialty care physicians. METHODS: We mailed a cross-sectional questionnaire to 2126 active members of the Idaho Medical Association and Idaho Academy of Family Physicians measuring their self-reported level of grit, satisfaction level and area of specialty. RESULTS: We received responses from 564 physicians (26.5%). Idaho physicians have relatively uniform levels of grit independent of specialty or practice location. Specialty care physicians reported significantly higher levels of ambition, regardless of practice location. Most physicians were satisfied with their practice (91.7%). Specialty care physicians reported a significantly higher difference in their levels of satisfaction with their practice compared to primary care physicians. CONCLUSIONS: Idaho primary care and specialty care physicians in both rural and non-rural settings reports themselves as individuals who work hard, persevere despite setbacks, and are ambitious. Furthermore, Idaho physicians are satisfied with their current practices.

The patient-centred medical home in the USA.

RATIONALE: The Patient-Centred Medical Home (PCMH) is a new model of health care delivery in the USA at the primary care level that emphasizes integrated and coordinated care around the patients' needs and desires. The PCMH emphasizes a practice-wide team approach to provide high quality, accessible and cost-effective health care for acute, chronic and prevention-oriented problems. METHOD: This article is a descriptive overview of the PCMH in the USA. RESULTS: The data on the PCMH have shown decreased mortality, morbidity and increased patient and physician satisfaction with care. Additionally, quality of care and patient access have improved. There has been decreased emergency room utilization, decreased hospitalization and decreased cost per patient. CONCLUSION: The PCMH in the USA has been an outstanding transformative model change to re-centre health care back to cost-effective, quality, accessible primary care.

Rural Idaho family physicians' scope of practice.

CONTEXT: Scope of practice is an important factor in both training and recruiting rural family physicians. PURPOSE: To assess rural Idaho family physicians' scope of practice and to examine variations in scope of practice across variables such as gender, age and employment status. METHODS: A survey instrument was developed based on a literature review and was validated by physician educators, practicing family physicians and executives at the state hospital association. This survey was mailed to rural family physicians practicing in Idaho counties with populations of less than 50,000. Descriptive, bivariate and multivariate analyses were employed to describe and compare scope of practice patterns. RESULTS: Responses were obtained from 92 of 248 physicians (37.1% response rate). Idaho rural family physicians reported providing obstetrical services in the areas of prenatal care (57.6%), vaginal delivery (52.2%) and C-sections (37.0%); other operating room services (43.5%); esophagogastroduodenoscopy (EGD) or colonoscopy services (22.5%); emergency room coverage (48.9%); inpatient admissions (88.9%); mental health services (90.1%); nursing home services (88.0%); and supervision to midlevel care providers (72.5%). Bivariate analyses showed differences in scope of practice patterns across gender, age group and employment status. Binomial logistic regression models indicated that younger physicians were roughly 3 times more likely to provide prenatal care and perform vaginal deliveries than older physicians in rural areas. CONCLUSION: Idaho practicing rural family physicians report a broad scope of practice. Younger, employed and female rural family medicine physicians are important subgroups for further study.

Treatment of lateral epicondylitis.

Lateral epicondylitis is a common overuse syndrome of the extensor tendons of the forearm. It is sometimes called tennis elbow, although it can occur with many activities. The condition affects men and women equally and is more common in persons 40 years or older. Despite the prevalence of lateral epicondylitis and the numerous treatment strategies available, relatively few high-quality clinical trials support many of these treatment options; watchful waiting is a reasonable option. Topical nonsteroidal anti-inflammatory drugs, corticosteroid injections, ultrasonography, and iontophoresis with nonsteroidal anti-inflammatory drugs appear to provide short-term benefits. Use of an inelastic, nonarticular, proximal forearm strap (tennis elbow brace) may improve function during daily activities. Progressive resistance exercises may confer modest intermediate-term results. Evidence is mixed on oral nonsteroidal antiinflammatory drugs, mobilization, and acupuncture. Patients with refractory symptoms may benefit from surgical intervention. Extracorporeal shock wave therapy, laser treatment, and electromagnetic field therapy do not appear to be effective.

The LIFE program: a wellness approach to weight loss.

The LIFE (lifestyle change, individual readiness, fitness excellence, eating healthy) wellness program was an intensive, out-patient, healthy lifestyle change program with participants from the Army, Navy, Air Force, and Marine Corps. Our objective was to describe the LIFE program and to present before and after test results for this 1-year program. Fifty-three participants completed the 5-day intensive outpatient and 1-year follow-up program and maintained average weight losses of >10 pounds and 14 pounds for men and women, respectively. Most of the weight loss occurred by 6 months. Participants who completed the program also showed increases in healthy eating attitudes, well-being, and overall quality of life. The LIFE change model has implications for improved service retention, health, and overall quality of life or patient evidence that matters (POEMS). The program is both portable and flexible and can be tailored to the demands of the dynamic military environment.

Traumatic stress disorders following first-trimester spontaneous abortion.

Provide counsel and support to women after a spontaneous abortion. Research indicates that many women will talk with their physician about their emotional distress and that physicians provide good information after the spontaneous abortion. Evaluate women for acute stress disorder (ASD) after a spontaneous abortion. Research found that women reporting physical, emotional, or sexual abuse are more likely to experience ASD. Patients should be assessed for post-traumatic stress disorder in follow-up visits 1 month after the initial visit. Research has found that up to 25% of women meet criteria for PTSD 1 month post the spontaneous abortion and 7% met criteria at 4 months. Physicians should refer women who are experiencing traumatic stress to a behavioral health professional.