By Jennifer J. Salopek
In an address to a joint meeting of the AAMC’s Council of Deans, Group on Faculty Practice, and Council of Teaching Hospitals in Miami last week, University of Miami President Donna Shalala told listeners, “This could not be a more confusing time.”
Addressing the group on the eve of the arguments before the United States Supreme Court regarding the Affordable Care Act, Shalala, who served as Secretary of Health and Human Services during the Clinton Administration, commented that the Act was drafted by “very careful, conservative people.” If it is upheld by the Court, however, she noted that she is “concerned about the [health care] system’s ability to absorb 30 million people who will suddenly have health insurance.”
Shalala conservatively estimated that $1 billion will be put into the system if the Act is upheld. “No one will walk away from that kind of money,” she commented dryly.
The challenge for health care providers, she noted, will be integrating those new patients smoothly and seamlessly. “Specialty services are not well integrated into academic medical centers, and primary care delivery is a mixed bag,” she said, noting that historically, AMCs have focused on acute care. She likened the CEOs in the room to tugboat captains, struggling to turn around heavy, unwieldy vessels.
Shalala moved on to a discussion of payment models, noting that insurance companies are deeply into conversations about rewards for mitigation and avoiding hospitalization. She noted that the move away from fee-for-service will be very difficult, and that health care organizations will have to take more risks. On the upside, she predicted that there would be profit in avoiding the “redundant and necessary.”
Workforce issues were brought to the fore as Shalala revealed that, in her opinion, the key to overcoming many of these significant challenges is “using people up to the extent of their training,” better integrating primary care doctors, nurses, and other health care professionals. “We will never get enough money from the federal government to train a sufficient number of doctors,” she said, recommending more partnerships between medicine and such related professions as pharmacists.
“We must break down the scope-of-practice barriers that we have built,” she said.
Shalala urged the assembled AMC leaders to get out and listen to what people are saying about the health care system. “I learn a lot by asking people how they get their health care and what their experiences have been,” she said. She noted that the people who design government programs are middle-aged and middle-class. “You must understand people’s lives to design effective programs,” she said.
She expressed her belief that people should take some responsibility for their own health, but commented, “It’s not evident that people can live much longer than they do now. The costs are in chronic care, so we really need to get wellness going, although that can be a challenge from a privacy point of view.” She also noted that co-pays and deductibles can really influence people’s behavior.
The landscape is fraught with challenge and opportunity, Shalala concluded. “At the end of the day, We all want the same thing: a high-quality, world-class health care system.”