CLEAR 2011 Annual Educational Conference September 8-10 The Affordable Care Act: Will regulation of the professions be relevant? Ed O’Neil Catherine Dower Pittsburgh, Pennsylvania

Welcome to San Francisco

“My mom Catherine works at UCSF “My mom Catherine works at UCSF. She studies different doctor’s offices around the US, and tries to improve their work and health laws through reports (oral, as well as written).”

Patient Protection and Affordable Care Act

Five ACA categories relate to our work Coverage Workforce Five ACA categories relate to our work Financing Pay for quality Innovations in Care Delivery

Expand Coverage

Workforce Supply and Demand Old formula & assumptions: Ratios of licensees to population Always need more New Realities Teams serving panels Self care and DIY Nuanced supply & demand Workforce Supply and Demand

Counties where the number of RDAs registrations relative to dentistry licenses is large, generally have the lowest dentistry licenses per population ratios. The converse is also true: counties with a high dentistry licenses per population ratio generally have a smaller number of current RDA registrations relative to current dentistry licenses.

Example: California’s Health Care Workforce: Moving Forward under ACA Challenge Growing pressure on safety net providers Geographic maldistribution of workforce Diversity challenges Promise Continued job growth despite the recession HIT leveraged to facilitate new models of care New finance and delivery models may decrease costs --improve access and quality of care

Internet searches for “Accountable Care Organizations” September 2010: 346,000 results January 2011: 1,300,000 results October 2011: 4,200,000 results February 2012: 38,400,000 results Financing: Provider payment policies

Tying payment to quality

Innovative Practice Models Patient-Centered Medical/Health Homes Community Clinics Nurse-Managed Health Clinics School-based clinics Sites using telehealth Retail clinics Yesteryear’s Model Innovative Practice Models

Regulation Modern Regulation Rise of science new knowledge Accumulation of capital in corporations Progressive movements Desire to rebalance power

Regulation Three Purposes Protect the public Protect the Guild or Profession Improve society

Flexner’s Paradigm Higher Income/Status Research More Education University Status 1866-1959 He was born in Louisville, Kentucky, and graduated at Johns Hopkins University. His brother was Simon Flexner. Initially, he worked as a secondary school teacher and school principal, but after 19 years he returned to academia and did graduate studies at Harvard University and in Berlin. He then became a member of research staff at the Carnegie Foundation (1908), which resulted in the "Flexner Report", which examined the state of American medical education and led to far-reaching reforms in the way doctors were trained. Between 1912 to 1925, Flexner sat on the General Education Board, initially as a member and from 1917 as secretary. With Louis Bamberger, he was initiator of the Institute for Advanced Study at Princeton, and he acted as its head from 1930 to 1939. We must not overlook the role that extremists play. They are the gadflies that keep society from being too complacent. Accreditation Licensure

US Health Care: Four Options Drive it less- ration Shift the costs Pay less for it- controls Build a new chassis Expensive Overbuilt Underperforming How we see determines what we see. Self fulfilling prophecy story. Discuss dominant paradigms

Practice Model New Value Proposition Created What Changed? Professional role Management of information Sequencing of care Engagement of consumer Engagement of community Practice model Business model Tell Rose story and then dissect the elements of change: IT to move knowledge, new professional roles, new location of service, new role for patient, new role for family/community, “a” change not “the” change, leadership. Barriers to the change: finance, lack of seeing the whole New Value Proposition Created

We’ve been at this for awhile

Add These Numbers

Add These Numbers 1000

Add These Numbers 1000 40

Add These Numbers 1000 40

Add These Numbers 1000 40 30

Add These Numbers 1000 40 30

Add These Numbers 1000 40 30 20

Add These Numbers 1000 40 30 20

Add These Numbers 1000 40 30 20 10

Add These Numbers 1000 40 30 20 10 = 4100

Getting off the hamster wheel Training & Education Licensure & Discipline Legal and Regulatory Scope of Practice Performance Data

Training and Education Old assumptions Profession control Formal education: university-based Clinical training Siloed New Realities Info: Web-based, available Varied quality Driven by problems Competencies: Tech savvy Work in teams Listen to client Integration

Licensure & Discipline Old assumptions Professions define and control Slow Administrative process New Realities Professional and public roles Real time/immediate access to data Public opinion and market judgment

Legal and Regulatory Scope of Practice Old model example California medical assistants may administer medication by intramuscular injections including flu and pneumonia shots unless at a local governmental or private, nonprofit agency that received vaccine from state department of health at no charge, where administration of vaccine shall be performed by MD, RN, or LVN. New models will push for expansion, clarity and overlapping scopes of practice

Performance Data New Realities Old assumptions Guarded Narrowly sourced Dated New Realities Open sourced: consumer, pro Richly sourced, varied Current, moving to real time

Three Take-Away Themes

INTEGRATION

ACCOUNTABILITY

CREATIVITY

Thank You Ed- eoneil@thecenter.ucsf.edu CLEAR 2011 Annual Educational Conference September 8-10 Thank You Ed- eoneil@thecenter.ucsf.edu Catherine – cdower@thecenter.ucsf.edu 39 Pittsburgh, Pennsylvania 39