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.

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.

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.

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.

Section 1115 of the Social Security Act gives the Secretary of Health and Human Services authority to approve innovative demonstration projects that are likely to assist in promoting the objectives of the Medicaid program. The purpose of these demonstrations, which give states additional flexibility to design and improve these programs, is to demonstrate and evaluate state-specific policy approaches to better serving their Medicaid populations. More than a year ago, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) issued a letter to governors affirming the federal government’s partnership with states to improve the integrity and effectiveness of the Medicaid program for low-income beneficiaries. Traditional Medicaid approaches have not always been effective at eliminating barriers to access, and lack adequate focus on a goal of achieving long-term health and economic independence. Section 1115 demonstration projects present an opportunity for states to pursue innovations that go beyond routine medical care, focusing on evidence-based interventions, including directing Medicaid funds toward workforce development, to enhance access to highquality, cost-effective care. In this article, we propose that community health centers (CHCs) can meet many of the objectives of state-level Medicaid innovations. The CHC mission is to provide affordable care for lower-income and medically underserved populations in urban and rural communities. Studies consistently show that CHCs improve the health status of individuals and the communities where they are located. CHCs often deploy interdisciplinary teams to provide comprehensive services, including dental, vision, behavioral health care, pharmacy, as well as transportation and financial advice, which typically are not provided by health care facilities or covered by health insurance. CHCs rely on a mix of funding to cover their cost, including Medicare, Medicaid, private insurance, and patient payments. Other revenues come from competitively awarded Health Resources & Services Administration (HRSA) grants, other grants, and contracts with state, local, and private sources. In fiscal year (FY) 2015, 43% of CHC revenue came from Medicaid, and federal grants accounted for 22%. Affordable Care Act funding of CHCs has been previously described. In FY 2018, the HRSA CHC program supports nearly 1400 grantees, providing care to 27 million patients. The HRSA FY 2018 budget provides $3.86 billion in mandatory resources, and $1.6 billion in discretionary funding, an increase of more than $300 million over the prior year. CHCs face difficulties in recruiting the primary care workforce to meet needed growth, and many currently are unable to accommodate additional patients even prior to demand increases under Medicaid expansion. One approach to CHC expansion is for teaching health centers (THCs) to train the necessary health care workforce. Given this, state Medicaid support of THC programs will be essential. We propose that a state Medicaid demonstration of the recently described Mega THC paradigm would meet the goals of the Section 1115 waiver. A recently published detailed description of the Mega THC documented how this paradigm would maximize quality, increase access, and minimize cost for Medicaid, achieving many of the goals of Section 1115 demonstrations (BOX 1). We review key components of the Mega THC, with description of features designed to address Section 1115 goals, and discuss the structure and benefits of a proposed CHC/Mega THC State Medicaid demonstration project. DOI: http://dx.doi.org/10.4300/JGME-D-18-00371.1

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.

Primary care and public health have a shared goal of health improvement for each person and their populations. Public health isthe science and art of promoting health, preventing disease and prolonging life (adding life to years and years to life) through the organized efforts of society. Public health needs to be person- and people- centered taking into account the biomedical, social, cultural, psychological, and spiritual elements that are crucial to understanding the whole person and the community at large.This paper provides a review of the International College of Person Centred Medicine’s Declarations, which have formed a platform for the development of the ICPCM’s London Declaration on Primary Care and Public Health. Person-Centered Primary Health Care is by its very nature integrative by involving a broad knowledge of all sectors of health care and a strong understanding of community resources and other social determinants of health.Through trusted and healing relationships, a person-centered approach with people over time can achieve the required integration and coordination of care that leads to better health, effective health care and lower cost. Systems of care need to be built around primary care as the core foundational element to ensure that all people are seen and helped at the right time, by the right providers, for the right reasons, and in the right locations. By integrating primary, secondary, tertiary, preventive, and end-of-life care, we will collectively produce healthier persons, healthier people, and healthier nations. The London Declaration sets out a 10-point plan to achieve this by establishing a shared goal of improvement in the health and well being of the population through person and people centered primary care and public health.

Objective: To examine the opportunities and challenges in achieving person centered integrated care through the life course. Methods: Critical literature review and evidence based analysis of person-centered integrated care through the life course, combined with expert consultation. The World Health Organization’s “Global Framework on Integrated People-Centred Health Services” is used as a basis. Results: Using the approach of the life cycle allows connection of persons’ current health status to their sociocultural, biological, and psychological context. Person centered medicine has as its central precept the relationship between the health professional and person seeking care. This principle is the link to primary health care, which is built on a lasting relationship with individuals and populations in their social context. The patient’s medical home provides one promising model of how health services can be organized to support the full achievement of person centered integrated care. Re-orientation of the health professional education towards generalism, and the development of metrics for measurement of person centered integrated care are required. In 2016 the global crisis in refugees is a particularly prominent challenge for the delivery of person centered integrated care. Conclusion: Universal health coverage can provide equitable access to person centered integrated care throughout the life course. Specialized expertise and skills are important for caring for persons with specific conditions at particular times in the life course. When care is well-integrated, transitions of care are smooth and the critical paradigm of person-centeredness is retained.

Background: Person-centered primary health care provides first contact care that is comprehensive, continuous, accessible, compassionate, caring, team-based, and above all else person-centered. Primary care by its very nature is integrative in design and process. It connects and coordinates care for the person and uses shared decision making to help value and respect the person’s choices as they navigate through a complex and fragmented health care system. Objectives: To demonstrate the effectiveness of primary care in achieving the triple aim of better health, better health care, and lower cost. Methods: Critical literature review and evidence based analysis of person-centered primary health care across the world. Results: Primary care is a systems integrator and improves both the quality of care and the lowering of cost to both people and populations. It has been found that the better a country’s primary care system is, the country will have better overall health care outcomes and lower per capita health care expenditures. Evidence also demonstrates that person-centeredness contributes to higher quality care and better health outcomes. Comprehensiveness of care leads to better health outcomes, lower all-cause mortality, better access to care, less re-hospitalization, fewer consultations with specialists, less use of emergency services, and better detection of adverse effects of medical interventions. The use of the relationship of trust established through primary care health professionals in shared decision making is an effective and efficient means to promote behavior change that results in the triple aim of better health, improved healthcare, and lower costs. Conclusions : All nations must build a robust and vibrant person-centered primary health care system based on the principles of continuity, comprehensiveness, and person-centeredness. This is important now more than ever to prioritize and rebalance health care systems to address the health care needs of the people that are served.

ContextAn important consideration determining health outcomes is to have an adequate supply of physicians to address the health needs of the community.PurposeThe 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.MethodsThe 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.ResultsThe 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.DiscussionThe 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.

Introducao: Community factors play a key role in the recruitment and retention of physicians to rural and underserved healthcare settings. The Community Apgar Program developed by researchers, educators and clinicians helps to organize these community factors for action. Objetivos: The Community Apgar Project identifies factors and their relative importance in recruiting physicians to rural communities. It provides specific strategic planning information to communities for solutions while aggregating information on trends in practice, finance, and community integration. Metodologia ou Descricao da Experiencia: The Community Apgar Questionnaire (CAQ) assesses a community’s capability to recruit family physicians. The CAQ consists of questions incorporated into five classes (geographic, economic, scope of practice, medical support, hospital/community support). Each class contains ten factors, for a total of fifty factors/questions representing specific elements related to recruitment and retention of rural family physicians. The CAP utilizes the results compiled over a two year period to provide a real time assessment of a community’s ability to develop and execute action plans for improvement. A national data base trending this data has been constructed for geographic and historical analysis. Resultados: In the United States, rural communities in six states have utilized the Community Apgar Program to identify the highest priority areas of improvement for recruiting family physicians to their situation. Likewise, findings are used for specific advertising to match the best suited physician. The information gathered in aggregate is also used in policy development such as increasing mental health support, use of technology, economic factors and physician integration into rural community life. This session will discuss the most important advantages and challenges identified and seek to elicit audience participation regarding factors well known in other countries outside the United States. Conclusao ou Hipoteses: The Community Apgar Project is a research tool assisting individual communities in prioritizing resources in the recruitment of rural family physicians. In the United States a national database has been constructed to analyze trends and impact policy to improve the circumstances of rural health. The authors welcome international perspective and feedback in adapting the project for broader use.

The Patient-centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we aspire. However, there is an element running implicitly through these joint principles that is difficult to achieve yet indispensable to the success of the entire PCMH concept. The incorporation of behavioral health care has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH. Therefore we offer a complementary set of joint principles that recognizes the centrality of behavioral health care as part of the PCMH. This document follows the order and language of the original joint principles while emphasizing what needs to be addressed to insure incorporation of the essential behavioral elements. It is intended to supplement and not replace the original Joint Principles document, which still stands.

Person-centered care at the end of life is an area of medicine we must all be familiar and comfortable with. This is the case as it will involve not only the people we care for but also our own family members, loved ones, and eventually ourselves. Forty percent of all health care dollars in the United States health care system are spent in the last two years of a person’s life unless meaningful person-centered discussions occur. Providing person-centered care for the remaining months of a person’s life is of extreme importance in helping people achieve their wishes and goals, maximize palliation, comfort, dignity, and quality of life. This paper will focus on maximizing person-centered approaches of active listening and discussion, advanced care planning, clear communication, timely engagement of support services, family support, and compassion. Our goal with person-centered care at the end of life is to allow as many people as possible a good death.

Medicine and health care in general are fascinating careers. It is important to recognize that health care and its provision should be focused on the people we are caring for , rather than on the system and the providers who provide that care. It's about our patients and not about us. In order to provide the best person-centered health care to people we must understand who they are as people and the context of their illness and their lives. The seven dimensions in which the context of care becomes important are: family/social, physical, mental/emotional, financial, occupational, spiritual, and health literacy. This paper explores these seven dimensions as they provide insight and meaning to caring for people and underscore the importance of the physician-person relationship as the central axis of trust in which health care not only occurs but succeeds.

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).

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.

Person-centered care is regaining importance in North America. The concepts of the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACO’s) is re-focusing attention on the need for the person to be at the center of the healthcare system. Strategies to teach person-centered care are aimed at gaining a deeper appreciation of the life story of the person seated across from the physician in the examination room. These strategies include active listening, providing praise, direct observation through videotaping and shadowing, role playing during Observed Structured Clinical Evaluations (OSCE’s), narrative medicine, motivational interviewing and seeing patients as teachers. All of these strategies are aimed at deepening the doctor-patient relationship, humanizing the doctor-patient interaction and returning the joy of being a physician with decreasing physician burnout.