The new health care team. (Part 2: Health Care Trends).

IN ALMOST EVERY STATE, allied health professionals, alternative practitioners, and other non-physician providers already have or are looking for licensure, Increased reimbursement, prescriptive privileges. expanded scopes ofpractice, or direct access to patients.

The list Includes acupuncturists, certified nurse midwives, chiropractors, dietitians, homeopaths, massage therapists, naturopaths, nurses, nutritionists, optometrists, physical therapists, physician assistants, podiatrists, and respiratory care therapists.

State medical associations and specialty societies oppose most of these legislative and regulatory initiatives, but only a few have enough clout to get their way In Indiana, the state medical association successfully lobbied against bills to license lay midwives and to allow physical therapists to treat patients without a referral from a physician.

In Texas, a bill that would allow optometrists to treat glaucoma and perform laser surgery on the eye has again been introduced. A similar measure never made it to the floor for debate during the last legislative session. It was opposed by ophthalmologists and the Texas Medical Association, who argue that optometrists don't have the training or the experience to do what they're asking for.

But Indiana and Texas are exceptions. Nationally, the trend is going the other way For example, 32 states already allow health plan enrollees direct access to a physical therapist and 36 states allow optometrists to prescribe, administer, and dispense drugs to treat glaucoma. (2)

Ironically one of the boldest moves by non-physician providers didn't need any new laws or regulations. In 1997, nurse practitioners affiliated with the Columbia University School of Nursing opened Columbia Advanced Practice Nurse Associates (CAPNA), a primary care practice in midtown Manhattan. CAPNA is the first advanced nursing practice in the United States to be reimbursed at the same rate asphysicians by major health plans and Medicare. When necessary, CAPNA nurses refer to specialists at Columbia-Presbyterian Hospital, where they also have admitting privileges.

Nurse practitioners had actually been providing care to poor and underserved populations in New York for years under a state law that requires nurse practitioners to have a collaborative relationship with a physician. Now CAPNA nurses compete with primary care physicians in midtown Manhattan for patients who are neither poor nor underserved. The nurses' slower-paced, more holistic approach to primary care has attracted a loyal and growing following. After 18 months, the original practice moved to a larger space and a second CAPNA location opened in upper Manhattan.

Twenty-seven states now allow nurse practitioners to work independently of physicians, (3) and the number of independent nurse practitioners is expected to increase as a result of federal action. In 1997. the Department of Veterans Affairs decided to formally accept nurse practitioners without links to physicians, and a federal law allowing direct Medicare reimbursement of nurse practitioners who work in cities and suburbs, not just In rural areas, took effect in January of 1998. (4)

Pharmacists may be the next nonphysician pro viders to play a bigger role in patient care. In 1998, Mississippi became the first state to reimburse pharmacists for pro vi ding patient evaluation, compliance assessment, patient education, drug therapy review, and disease management services to Medicaid patients. To qualify, pharmacists must complete a disease-specific certification program. For now, the program is limited to patients with asthma, coagulation disorders, diabetes, and hyper-lipidemia. Patients can only be referred to a pharmacist by a physician under a written care protocol.

This "pharmaceutical care" experiment in Mississippi is being closely watched because it may be a way to reduce the sizeable costs associated with avoidable acute care for patients with chronic diseases. It also has the blessing of the Health Care Financing Administration (HCFA), the federal agency that regulates Medicare and Medicaid and charts the course private insurance typically follows.

Mean while, alternative medicine is booming. A recent article in The Journal of the American Medical Association (5) estimates that 40 percent of Amen cans have used some form of alternative medicine.

In the following discussion, our six panelists talk about the reasons for this remarkable proliferation of non-physician providers, what the provider team may look like in the future, and why physicians may be sharing more decision-making with other practitioners.

The Physician Executive: In addition to pharmacists, we may have physical therapists and lay midwives legislatively authorized to provide direct patient care in some states. What are the forces operating here?

Reinhardt: It's really what we call the market, which retrofitted what used to be called patients into consumers, and these consumers are supposed to make buying decisions on the basis of price and quality. Once you introduce this concept into our health system, it seems only reasonable that consumers should have the freedom to decide whether they want to get health care from someone with an RN degree or from someone with an MD degree. The ball is now in the consumer's court, and if there is a worry about quality, that's a trade-off the consumer would make, and physicians really cannot argue with that.

Copeland: I agree with you. One of the reasons we're in such foul shape right now in our health care system is that we have this amazing triad. For the most part, we have the provider on one side, the consumer of that service on the other side, but in the middle is the payer. We've kind of eased the consumer out of the decision-making. So many now have their insurance through their employer that they really don't have a choice. I think It'd really be nice to get the consumer back into the loop and let them decide what type of plan they want.

The Physician Executive: Now that we see fairly strong consumer demand for so-called alternative therapies. can we then look for acupuncturists and herbalists to join the health care provider team?

Mundinger: I think they'll join the team if they can do what JAMA started to publish before [former editor] George [Lundberg] was fired, which is to show that they have outcomes that make a To the extent that any show that they make a difference. To the extent that any provider can show that they make a difference in health, they're going to be the team in a big way.

Reinhardt Why should non-MD members of the health care team have to prove that their services are efficacious before they are allowed to join the team? Since the consumer is king, or queen, even if they choose to buy a service whose efficacy hasn't been demonstrated, they should have the right to do so. Almost anyone who has an MD degree will tell you that an awful lot of what MDs do has never been demonstrated scientifically to be efficacious and valid. The whole evidence-based medicine movement is basically an admission that a lot of what doctors do has never been empirically demonstrated as efficacious. So if consumers are required to accept from physicians procedures whose efficacy hasn't been demonstrated, then it's kind of hard to say that they can't ever accept from a non-MD a service whose efficacy hasn't been demonstrated. I think consumers will buy whatever pleases them, whether or not its efficacy has been demonstrated. That is what free markets are all about. If you don't like that, you don't like the market that drives health care.

Mundinger: It'd be nice, though, if they could get insurance coverage for services they wanted other than physician services.

LeTourneau: I think they are getting insurance coverage in many states now. I don't think there's any doubt that consumers will use non-traditional providers. But the question of whether these providers join the traditional provider team is very different. Just because consumers use them doesn't necessarily bring them into the team, which implies acceptance by traditional providers.

More non-physician practitioners may provide primary care

The Physician Executive: Primary care physicians particularly have been in the position of coordinating patient care. For example, when the patient is referred to a specialist, the report comes back to the primary care physician. The patient looks to the primary care physician as command central, in a sense. What happens to that role if we have these alternative providers coming into the picture who may not even be sanctioned by the medical establishment?

LeTourneau: I've thought a lot about that question, and I think the answer is nobody really knows. Arguably, other people besides primary care physicians can do a very good job of coordinating care. Many hospitals have nurses or social workers or others coordinating the care. So it's an open question. But what I'm wondering is, what would the role of the physician be if primary care can be provided by PAs, nurse practitioners. and possibly others? Why would we even need doctors, and why would anyone go to medical school, if they're going to be able to do primary care with a nurse practitioner or a PA degree?

Reinhardt There of course comes a point where only a physician will have the skill and the knowledge to handle a certain problem. I don't think any nurse practitioner would pretend, or want to pretend, that they could replace a physician in everything that a physician does. There's only a certain overlap of functions where they could compete head-on and do equally well, and it's been empirically demonstrated that they do equally well. But I don't think anyone would argue that the pediatric nurse practitioner is going to do neurosurgety.

LeTourneau: No, but then neither is the pediatrician. Short of wanting to do surgery, why would anybody go to medical school to be a family practitioner or a primary care internist or a pediatrician or even an OB/GYN? Maybe physicians will all be specialists and they'll be referred to by nurse practitioners and PAs who will do the primary care. I'm not being critical. I'm trying to be realistic. If you can do primary care as a nurse practitioner or a physician assistant, and do it equally well as a family practitioner or pediatrician, physicians wouldn't do family practice and pediatrics anymore. They would go into more specialized medicine, referral internal medicine, or general surgery.

Reinhardt: That might be all for the good.

LeTourneau: But what about the consumer who wants a physician and not a nurse practitioner or a PA?

Reinhardt: Well, if the consumer wants it, they'll be willing to pay for it. There'll be a demand for physician care, and physicians will respond. The market would take care of that.

Nelson: I think there's a point that needs to be made here, and that is what is primary care? From the PA's perspective, primary care is a model of delivery in which a physician/PA team delivers that care. Now. PAs certainly make autonomous judgments and provide services, but that still happens in a team context, with the physician providing the ultimate direction. As Uwe pointed out, there are things that the physician is going to need to do because it's not within the skill level of a physician assistant.

Copeland: We have to go back to the training and how we prepare people. There are PAs and nurses who have skills that certainly physicians do not. And because of the scope and the length of our training, I think that we have skills that these others do not.

Advanced practice nurses attract primary care consumers

The Physician Executive: Why do we need Columbia Advanced Practice Nurse Associates [CAPNA] in addition to the physicians who have been serving people in Manhattan?

Mundinger: There are several good reasons for a practice like CAPNA. We're in midtown Manhattan, where there's a doctor every 12 inches, and we set up an independent nurse practitioner practice to see if people would choose us, not by default, but because our style of practice was different. And the answer is that they do choose us. They pay the same premium, the same fee-for-service co-pay as they would with a physician, and we've enrolled a lot of patients. We're currently enrolling about six or seven new patients a week, and less than 1 percent have left after a year and a half. So they like it.

The reason CAPNAs important is because the style is different. Our visits are longer. They're much more prevention-oriented. We incorporate individualized risk assessment with every visit. If they're too busy to sit in our waiting room, we'll sit in theirs if they're willing to pay for it. That kind of patient-centered, prevention-oriented, interactive, patient empowerment kind of process isn't for everybody, but the people who want it have been looking for it and they don't find it in traditional practices. That's one reason.

The other answer is that if primary care by a nurse practitioner has the same quality and outcomes and competence as primary care by a physician, it becomes a public policy issue because of the enormous public funding that goes into the training of physicians. If you can get the same product with a nurse practitioner at a much lower cost, that says a lot for where our country ought to be putting scarce resources.

But I wanted to go back to something Barbara said because I think it's very important. Why would doctors go into primary care? I think we're seeing, and we will increasingly see, because of the marvels of modern medicine, that a lot of people by the nature of the disease process they're living with probably need to see a specialist for their primary care. Therefore, even those who choose to practice in specialties must still learn the process and content of primary care. Some physicians who go into specialties like diabetes or cardiovascular hypertension are going to be appropriately taking care of some patients as their primary care patients. So I think there's going to be a leveling of who does primary care, and if nurses can do it for a less costly public investment, and do it as well and still offer a choice to patients who want a different process in their care, that's why we have a practice like CAPNA.

LeTourneau: Would you see nurse practitioners then taking care of the basically well patient and physicians taking care of the chronically ill patient?

Mundinger: No. We thought we'd get a lot of patients who were looking for fitness and wellness. We thought we'd get the genXers in our practice. But our average patient is over 40 and has three diagnoses. They're sick people. They want somebody to help them work through what it means to carry chronic illnesses on a daily basis, with acute episodic illnesses imposed on that. These people are really wrestling with a lot of really heavy-duty medical problems, and they're three-quarters of our practice.

LeTourneau: Well, I thought I just heard you say that the primary care specialists would be taking care of the ...

Mundinger: Life-threatening kinds of things.

Lelourneau: The diabetic or the hypertensive.

Mundinger: Especially a brittle diabetic who's out of control, who needs to be seen on a regular basis, who's probably going to be seen by an endocrinologist. Somebody who's in control and is going to manage their diabetes with good self-care is probably going to do well with a nurse practitioner. But, you know, Uwe's right. The patient's going to decide who's going to manage their care, but they need to have some choices, and if they want a different model than traditional medicine, then we've got to have a practice like CAPNA available to them.

Copeland: It'll be interesting to look at your data as time goes on about the cost, referrals, things like that.

Mundinger: Well, we've been funded since the day we opened the practice by The Kellogg Foundation to look at all those things.

Copeland: I'd like to respond to your comment about subspecialists being the primary care physicians. In my 22 years, and most of that has been out in rural areas. I guess it's anecdotal, but I've just seen my patients with chronic illnesses get lost in the shuffle from one specialist to another. I think as a primary care physician, I look at a patient differently than a subspecialist.

Mundinger: I agree with you. There's a different perspective. But there are going to be some people, just by the nature of the ongoing and critical nature and unstable potential of their illness, that are going to be better seen for primary care by a specialist. Somebody with metastatic cancer is probably going to be getting their primary care from an oncologist.

Copeland: Well, I think it's a clinical decision to make that call. The other point that I would make is that I practice in a very small town and I'm now teaching in a residency program. We are down in the southwest part of Georgia where there are some of the poorest counties in the nation, in a town of 85,000, and we have one endocrinologist. Diabetes is rampant and there's just no way that these people could get their primary care, say, from an endocrinologist.

Mundinger: And the other problem is that if you had a lot of endocrinologists. everything that patient presented with would be seen as an endocrinology problem.

Copeland: Right.

Mundinger: So that's not good, either.

Bluml: I would say that provider teams are needed for a number of different reasons. As Lanny was just saying, in rural areas you get into issues of access. I always look at the number of patient contacts that you have as a provider team in helping to move patients along in their level of understanding, their level of empowerment in the management of their disease. and hopefully in continuously improving their level of knowledge about their health. So you have to look for other members on the team that you can complement and actually deliver the service that's needed for the total care of the patient. In some cases, that may be a nurse practitioner, a pharmacist, or a PA. But you have to look at who's available to deliver the care.

The Physician Executive: PAs don't seem to be getting as much publicity these days as some of the other providers we've been talking about.

Nelson: PAs are not necessarily interested in the press. I think what we're interested in is working with physicians to deliver care in an increasingly complex environment. The nature of the training of a physician assistant is. in fact, to expand and extend the ability of physicians to provide high quality. compassionate care. We're not looking to be recognized as independent providers of care. Now, we all have our own needs to be recognized and respected as professionals, and the relationship that we have with physicians is based on mutual respect. trust, and professionalism.

I don't think anybody's an independent provider of health care in today's environment. We have to function in an interdisciplinary team model, and we feel very strongly that the physician/PA model is one of the best ways to address that, whether it's in primary or specialty care. We do not see PAs substituting or replacing physicians, but that the physician/PA team will be even more effective and efficient in working in a managed care environment where market forces, payer services, and patient demands just add to the complexity.

The Physician Executive: Under certain circumstances, say in under-served areas, do PAs provide direct care to patients?

Nelson: Certainly. PAs provide direct care in all settings, in specialties and in primary care. I practice in a rural clinic, Lanny pointed out that there's one endocrinologist in his community. The community I'm in has 900 people and we don't even have one endocrinologist. Is the physician I practice with there every day? No, part of the time she's in the hospital, part of the time she's at another office, but we provide care very effectively in a team model to a rural underserved community. It also doesn't mean that we exclude those alternative practitioners out there that the marketplace is demanding. But we really believe strongly that this physician/PA model is very effective at trying to address some of these needs.

Pharmacists increase access and may improve outcomes

The Physician Executive: The Health Care Financing Administration (HCFA) is now reimbursing pharmacists for providing drug therapy and disease management services to Medicaid patients in collaboration with physicians in Mississippi. What's the anticipated payoff here?

Bluml: As I understand It from the folks in Mississippi. the anticipated payoff is a reduction in emergency room visits and in acute care spending. The model is to compensate pharmacists to spend time on a regular basis with patients who have asthma, diabetes, hyperlipidemia, or if they're on anti-coag therapy. In large part, it relates back to the issue of access to care in rural communities that was raised earlier. It depends on the population, but in many circumstances. one of the unique things that the pharmacist brings to the table as part of the team is significantly greater access to patients than other providers.

Pharmacists have a collaborative practice model mindset very similar to the one Ron was just describing. We believe that the opportunity for the pharmacist to collaborate with the physician, the nurse, the PA comes after the patient has been diagnosed and therapeutic decisions have been made. We see pharmacists focused on the medication use process and helping folks make the best use of their medications. We have a medication use problem in this country. Depending on whose studies you look at. the numbers are a little bit different, but for this discussion I'll hang my hat on Jeff Johnson and Lyle Bootman's study. (6) which points out that the cost for drug misadventuring on an annual basis in this country actually approximates the cost of medication use. Their number was about $76.6 billion, and I think we were looking at about $80 billion in drug use during the year they did their study.

The short story here is that collaborative practice models really do represent an unrealized opportunity to improve morbidity and mortality in our health care delivery system. If you look at hyperlipidemia, since that's one of the areas that's being focused on in Mississippi, we have a demonstration project' that's ongoing in 29 pharmacies in 14 different states with more than 700 patients enrolled for over two years now. Patients, pharmacists, and physicians are all working together to help patients better manage their dyslipidemic disease state in this project. Studies show that 60 percent of patients on lipid-lowering therapy discontinue their medication within 12 months of initiating it. In this particular demonstration project, we've seen 84 percent of patients continue with their therapy over an average duration of 14 months. One of the other really exciting things that we've managed to achieve in the first 14 months is a 44.3 percent treatment to the NCEP [National Cholesterol Education Program] goal. compared to about 8 to 33 percent in the literature.

Copeland: In that pilot program in Mississippi. the pharmacists are working in a collaborative team, right? They're not independent?

Bluml: It's a collaborative effort. And one of the reasons HCFA approved the Medicaid plan amendment is because they have such a low provider-to-patient ratio in Mississippi. When you look at pharmacists' access to patients, their potential contacts to actually get those patients into the loop and keep them from falling through that safety net is really huge.

The Physician Executive: Helen Wetherbee, the Medicaid Director in Mississippi, told me the objective is to reduce $90 million a year in unnecessary hospitalizations because these chronic diseases aren't being managed as well as they could be. Do you see the role of the primary care physician changing, not only as more providers get in on the care of a patient, but as patients themselves are taking more of an initiative in their care?

CopeHand: You know, I live in South Georgia because I figured if the world ever comes to an end, I'll have an extra ten years. But even down there, people have found the Internet. I tell my residents that we've really become more of' a counselor to patients, that we need to stay up-to-date and inform them of what they need to be doing. Physicians are also going to have to learn how to work with data like vaccination and mammogram rates. I still think that the relationship between the patient and the physician is sacred, but our role will be evolving. The other thing I would say is I agree that the team concept is really the future.

Blumi: I might just Interject one -- thing from a project that's fairly close to you, Lanny. It's called the Ashville Project in Asheville, North Carolina, and again the pharmacists in were incented to deliver pharmaceutical care to patients with a number of different conditions. In addition to the fact that the approach did reduce hospitalizations, emergency room visits, and intensive care costs, one of the interesting observations was that physician visits in the treated group actually increased. So the relationship between the physician and the patient, at least that's what they argued when they presented the information, was actually enhanced as a result of more providers communicating with the patient.

Patients are in pharmacies all the time to get medications refilled, and what a huge opportunity that is to reinforce the good behavior, to refer patients back to their physician when that needs to occur, and to really be involved instead of just focusing on product and package and price. I think that the focus for pharmacists is shifting towards helping people make the best use of their medications.

Physicians may share leadership role with other providers

The Physician Executive: I've been thinking of leadership in at least in two ways. One is actually coordinating patient care with other providers and counseling the patient. Then there's what a physician executive does, which is lead in a corporate hierarchy. With that as a preface, what advice would you non-physician providers give to physicians who want to lead either in the first sense or second sense?

Nelson: I think physicians are very much beginning to take the leadership role and have a greater understanding of their impact on the delivery of care, not just in the clinical sense but in all of the other factors that affect how patients get care. If there's something to be learned out of this, it's to recognize that it is a team delivery model, as just talked about in the Asheville Project. That project was pulled together by the county medical society in conjunction with all the providers to ensure a group of people received care. And it's working. It's proving that the team model is the way to do that.

Unfortunately, I see an awful lot of time and effort wasted on issues of who's in charge and who's responsible, when I could see a lot of that effort being spent on how to find more effective ways for us to function as teams and to respond to the market. I think that it's clear that the individual with the greatest knowledge and education in this process is the physician, along with a whole range of other individuals with education and knowledge to contribute. I would hope that physicians see that there's an opportunity to utilize those individuals and that the individuals involved recognize that they really have an opportunity to provide additional support and do a better job of meeting patient care needs.

The Physician Executive: Is the concept of leadership outmoded? Do we still need leaders?

Copeland: I think we do. I have great respect for physicians like Barbara who are going to form the new system. Medicine today is the last mom and pop operation in the country. In the past we've always been reimbursed by what I term piecework, where we put all these things down on our coding sheet. We need to get past that and determine what's best for the patient and how can we deliver that. I've always thought that we could deliver the same product or a better product for a lower price, and physician leaders are the ones who are going to get us there.

LeTourneau: I agree with that. The whole concept of how health care is provided is slowly but surely undergoing a change. Taking care of a patient, any but the most routine patient anyway, is becoming far more complex than what can be managed by one person. It's become very clear that pharmacists, experts in nursing care, in medical care, in dietetics, and physical therapy, whatever the patient's need is. all need to be at the table for the patient to get the best care. When there's a decision to be made around physical therapy, for example, I would see the physical therapist as being a leader in that. If there's a physiatrist involved, then maybe it's the physiatrist. But it seems to me that whatever decision has to be made, that the most knowledgeable and experienced person should be making that decision. So to me, it really puts the concept of the team leader up for grabs because I'm not exactly sure what that means anymore. It very seldom happens that there's one major decision to be made and that the doc tor makes it.

Bluml: I guess I would agree with every thing that's been said. In my practice experience and dealings with physicians, nurses, and PAs, when we focus on an opportunity for improvement in the medication use process, while we may be the expert in pharmacotherapeutic considerations, ultimately the decision-making and the coordination, the leadership if you will, is still typically referred to the physician who's prescribed that particular therapeutic approach. In many cases it ultimately ends up being the primary care provider. But again, when you look at collaborative practice, you've got to stay focused on the patient. That's when providers really work together best as a team, when you've got some common goals. We're all trying to improve patient care and the level of communication and feedback among patient and providers.

In terms of information management, we want to try to increase the objective measures that demonstrate improved outcomes, or surrogate markers that demonstrate progress, and to make sure that all providers on the team have access to that information so that we can reduce the total cost for care in the system. Hopefully, that's where we're going with all of this.

In regard to the leadership question, you've really got to look at the future of quality health care. Historically reimbursement has come for products, procedures, and tests. Wouldn't it make sense for compensation and reimbursement to be based on outcomes and for the system to be incentivized that way? To get there, we have to understand the steps along the way so that we can establish systematic approaches to equitably compensating folks. We need to have decisive and effective systems and processes in place for evaluating efficiency, certainly ethical decisions, and resource utilization, Social accountability and maybe even geographic accountability are some of the underlying themes that keep coming up in pilot projects. We need to focus on delivering care within geographic regions and having that team of providers all work together and be accountable for the health and wellbeing of every man, woman, and child in a geographic area. I think this is some of what the future looks like.

Diverse providers, information brokers, universal coverage, empowered consumers

The Physician Executive: How will the health care provider team be different in five to ten years?

LeTourneau: It will be much broader, include many different types of care providers than we see now, each one with their own area of expertise. And I think it remains to be seen if the physician will lead, or how leadership will be determined in that team.

Reinhardt: Because information is going to be so central, J could certainly see a role for an information broker in the middle who may not necessarily even be a docior, to whom one could go for information, who would help you get information off the Web, for example, so that before you even go to a doctor you already are fairly well informed. So that would be a new member of a team.

But when I hear this talk about teams taking responsibility for the health care of entire populations, I have two reactions. Number one, I've heard this for 30 years now and I don't think it'll ever happen. And number two, I think it's good that it won't, and let me tell you why. We are a very heterogeneous population in our lifestyle and our income levels, and it would be extremely difficult for an organization or a team to actually be held responsible for the health status or the health behavior of a group of heterogeneous people, some of whom never outgrow adolescence, and some of whom never were adolescents, they were so smart. I think if you'd really want to make that effective, you need something like a Chinese commune with the power that goes with it. You know, Nurse Ratchett sees you have a meringue pie when you shouldn't because it ruins your HMO's average health statistics.

I think this whole notion of teams or integrated systems being made responsible for the health status of entire populations is a very dangerous path to think about or to go down. We have so much more to do just serving individuals who want to be served. If we just could get that done in the next 20 years, that every American who wants a service could actually get it, then I think I would declare victory. I dread the thought of ever having population-based health care systems.

Copeland: I find your comments interesting, Uwe. I agree, one of the real problems in this country is our individualism and this tremendous appetite we have for instant access to health care, and the attitude that more is better and somebody else should pay for it. I have a real interest in universal coverage and getting that back out on the table nationally. When we talk about people accessing the system and paying for it, I think we ought to remember that we have 42 or 43 million people out there who have no health insurance.

Reinhardt: Well, that's what I'm talking about.

Copeland: If we look at any other system in the world, and of course every system has its faults, but these systems are built on a 50/50 split of generalists versus specialists. And in this country we presently have about two-thirds being specialists. Five and ten years down the road, we're going to have to look more and more at evidence-based medicine and where do we get the best bang for the buck.

Another point that I would make about the health care provider team is that at some point, the human genome project is going to give us a printout of what someone's genetic makeup is, and we'll have this roadmap to kind of help guide our patients through their life. But I don't want to see the ice cream police either, Uwe, coming up to somebody eating an ice cream cone and saying, "You know, you're ruining our health care system."

Bluml: I understand and agree with the points you made as well, Uwe. I think that the availability and the seamless flow of information in electronic health records that folks need to help them make the best use of the delivery system is ultimately where it will go. We have some socioeconomic barriers now, but the question is, can the information technology that we develop lower those barriers and create an opportunity for folks in virtually every walk of life to be involved and make better choices? Ultimately, we're going to see location-independent, secured, authenticated access to relevant patient care records by qualified health care professionals that will take us to that next level.

Nelson: Access is going to be a significant issue, and we're going to have to fix that problem. However, I believe that there needs to be some structure to the delivery models. Whether you call it a team or a delivery system, in fact we get all kinds of different services being provided at some pretty interesting costs and even with questions of appropriateness. I think we're going to move to evidence-based medicine. Information and our ability to use information will ensure that appropriate care is provided. But probably most importantly, I think that the patient has to be brought back into the decision-making. In the past, our system has taken them out of that. Someone purchases your health care services, you have not a lot to say about that, and here's where you're going to get services. I think we'll see a change in that, but there will clearly be an integrated team delivery model that will supply those services.

References

(1.) Rothouse, M. "Alternative Providers." Health Policy Tracking Service, National Conference of State Legislatures. April 1999.

(2.) Rothouse, M. "Scope of Practice/Prescriptive Privileges." Health Policy Tracking Service, National Conference of State Legislatures. April 1999.

(3.) Annual Update on How Each State Stands on Legislative Issues Affecting Advanced Nursing Practice. Nurse Practitioner, January 1999. vol 24, no 1, p 18-19.

(4.) As Nurses Take On Primary Care, Physicians Are Sounding Alarms. The New York Times. September 30. 1997:Al.

(5.) Eisenberg et al. Trends in Alternative Medicine Use in the United States. 1990-1997. JAMA. 1998:280:1569-1575.

(6.) Johnson. J.A., Bootman. L. Drug-Related Morbidity and Mortality: A Cost -of-illness Model. Archives of Internal Medicine. 1995:155:1949-1956.

(7.) Bluml, B.M., McKenney, J.M., Czlraky, M.J., Elswick, R.K. Interim Report from Project ImPACT: Hyperlipidemia. Journal of the American Pharmaceutical Association. 1998:38:529-534.

RELATED ARTICLES: PANELISTS WHO PARTICIPATED IN THE PANEL DISCUSSION

Benjamin M. Bluml, RPh, is Senior Director far Research at the American Pharmaceutical Foundation, where he directs the Practice-based Research Initiative. He chairs the American Society of Testing and Materials E31.10 Subcommittee on Pharmacoinformatics Standards. He has 12 years of pharmacy practice experience and is the author of several health care software programs.

Lanny R. Copeland, MD, is President of the American Academy of Family Physicians. He had been in private practice for 19 years when he became Vice President of Primary Care Development at Phoebe Putney Health Systems in Albany Georgia in 1994. He is Professor of Family and Community Medicine at the Mercer University School of Medicine, Associate Clinical Professor of Family Medicine at the Medical College of Georgia, and on the faculty of the Southwest Georgia Family Practice Residency Program.

Barbara LeTourneau, MD, MBA, FACPE, is Vice President of Medical Affairs, North Region, of Allina Health System. Her responsibilities include leadership of the 700-physician staff of Mercy and Unity Hospitals in Minneapolis, Minnesota. She is a practicing emergency room physician and past President of the American College of Physician Executives.

Mary ONeil Mundinger, RN, DrPH, is the Centennial Professor in Health Policy and Dean of the Columbia University School of Nursing. She is the driving force behind Columbia Advanced Practice Nurse Associates (CAPNA), the first practice in the United States in which advanced practice nurses are reimbursed at the same rate as physicians by major insurance companies. She is a member of the Institute of Medicine of the National Academy of Sciences and the author of Autonomy in Nursing. She sits on the board of directors of United HealthCare and Cell Therapeutics.

Ron Nelson, PA, is President of the American Academy of Physician Assistants. He is President and Founder of Health Services Associates, Inc., a management consulting firm specializing in reimbursement and management issues for practices using physician assistants, nurse practitioners, and other non-physician providers. He is a frequent speaker on delivery systems in rural and underserved areas and serves on the AMA's expense advisory committee.

Uwe Reinhardt, PhD, is the James Madison Professor of Political Economy and Professor of Economics and Public Affairs at Princeton University. He has received several honorary doctorate degrees and has served on a number of government committees and commissions. His memberships include the Institute of Medicine of the National Academy of Sciences and the External Advisory Panel for Health, Nutrition and Population of the World Bank, He is widely published and serves on numerous editorial boards.

Bob Carlson produces and moderates these panel discussions. He lives north of Indianapolis, where he thinks and writes about health care. He can be reached at 317/769-4609 or [e-mail].