In the City of Angels, 
Health Reform Takes Wing

At my South Los Angeles community clinic, we have been recruiting for a newly created position to develop a more robust disease-management program. If, under health care reform, we will be paid for the quality of care we provide and not just for the volume of services, it makes sense to invest more resources in monitoring our outcomes.

A recent applicant let me know that she had already received several similar offers from other community clinics in the Los Angeles area. “I guess I have been lucky that so many clinics are looking to fill similar positions,” she told me.

In fact, her “luck” is actually hard evidence of how successful the health care reform movement has been. The Obama administration has not only invested in the health care industry but also drafted the incentives carefully to make sure that those dollars are invested in information technology, in enhanced communication within the broader health care network, and in enriching services at individual clinics that are focused on keeping the sickest people healthier.

The first infusion of money, which came in the form of a stimulus package as part of the American Recovery and Reinvestment Act, created opportunities to invest in health information technology and to give up the paper chart in favor of an electronic medical record. Meaningful use incentives followed, providing funding for clinics that can demonstrate that they are using their new IT systems to gather data on the effectiveness of clinical care rendered; to generate electronic prescriptions, aided by automated safety measures; to allow patients access to an on-line medical record; and to promote the secure transmission of health information from the primary care provider to consulting physicians. A more recent national initiative supports the Patient-Centered Medical Home, a model of health care delivery that promotes the coordination of care for patients with complex health needs who must access multiple specialty-care providers. A new certification process enables clinics to demonstrate that they meet the standards of this model.

In November 2010, California concluded negotiations with the federal government to enact a Medicaid waiver called “Bridge To Reform.” Many states participate in the waiver system, which allows them to modify Medicaid regulations in order to gain flexibility in meeting the needs of specific populations. The nearly $10 billion waiver has positioned California as a pioneer by making expanding access to health care a top priority, with specific provisions for safety net communities, enhanced coordination of medical care, and pilot programs to reform the health care delivery system.

Six months ago, I found myself at a preliminary meeting to develop an accountable care organization, or ACO, in South LA. At the time, I had only a loose understanding of what such an undertaking might entail. Our first several meetings were spent clarifying basic principles. The ACO is intended to function as an integrated health care network that includes hospitals and primary and specialty care. The organization determines a reimbursement strategy based on the quality of services provided rather than the sheer quantity. The network’s members work together to gain efficiencies and reduce costs, and they share in the savings achieved; moreover, they shoulder the risk of financial losses. Just how much risk is yet to be determined.

As this organization has picked up steam, an astonishingly representative group of health care providers in South LA has come to the table: financial specialists, clinicians, CEOs, lawyers and community organizers. Members draw from two major hospitals, several local community health centers, the LA County Department of Health Services, and a labor union, in addition to several independent physicians who represent the larger community. I remain awed by this chance to contribute to the conversation. How often does an opportunity like this present itself in the career of a physician?

While health care reform still feels precarious, I am deeply inspired by the changes that the Obama administration has set in motion. The plan is clear and specific. It has created momentum at all levels of the health care system, from hospitals to clinics. The agenda has been set. The future, full of promise, remains to be seen.