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C A S E S I N G L O B A L H E A L T H D E L I V E R Y Educational material supplied by The Case Centre Copyright encoded A76HM-JUJ9K-PJMN9I Order reference F297564 Project ECHO: Expanding the Capacity of Primary Care Providers to Address Complex Conditions “Medical knowledge is exploding, but it’s often not traveling the last mile to ensure that patients get the right care in the right place at the right time. If we can leverage technology to spread best practices through case-‐‑based learning and mentoring of providers, we can move knowledge—instead of patients—to get better care to rural and underserved communities across the country.” —Sanjeev Arora, MD, Project ECHO Founder and ECHO Institute Director In December 2016, Sanjeev Arora, MD, spoke to a group of primary care and specialist physicians from across the globe interested in joining Project Extension for Community Healthcare Outcomes, or Project ECHO®. Arora had developed Project ECHO—a web-‐‑based guided practice model—at the University of New Mexico in 2003 to address the tremendous need for hepatitis C care, particularly in medically underserved areas. At the time, he was one of the only liver specialists in New Mexico, and patients were waiting for months and traveling hundreds of miles to see him. Using videoconferencing, Arora began training primary care providers in remote areas to manage and treat their hepatitis C patients. Arora and his team worked hard to spread and grow the model, using grants to fund their work. By December 2016, more than 100 institutions in over 20 countries were using the Project ECHO model to train primary care providers to treat more than 55 complex medical conditions. Dozens of peer-‐‑reviewed studies showed Project ECHO was improving provider self-‐‑efficacy and job satisfaction, increasing patient access to specialty care, and, in some cases, saving costs by reducing emergency room and hospital visits. In December 2016, the United States Congress passed the ECHO Act, mandating that the federal government study the implementation and impact of Project ECHO’s collaborative learning model. Arora and his team had been thinking hard about how to balance fidelity to the model with ensuring local partners could adapt it as needed. He was unsure how the results of the government study might impact his ability to scale Project ECHO to meet the demands of new and current partners. Amy Madore, Julie Rosenberg, and Rebecca Weintraub prepared this teaching case with assistance from Claire Donovan for the purpose of classroom discussion rather than to illustrate either effective or ineffective health care delivery practice. Cases in Global Health Delivery are produced by the Global Health Delivery Project at Harvard. Financial support was provided in part by GE Foundation. © 2017 The President and Fellows of Harvard College. This case is licensed Creative Commons Attribution-‐‑ NonCommercial-‐‑NoDerivs 4.0 International. We invite you to learn more at www.globalhealthdelivery.org and to join our network at GHDonline.org case centre Distributed by The Case Centre www.thecasecentre.org All rights reserved North America t +1 781 239 5884 e info.usa@thecasecentre.org Rest of the world t +44 (0)1234 750903 e info@thecasecentre.org Purchased for use on the IT for Business Transformation, at University of Baltimore. Taught by Rajesh Mirani, from 29-May-2017 to 23-Jul-2017. Order ref F297564. Usage permitted only within these parameters otherwise contact info@thecasecentre.org GHD-‐‑036 MARCH 2017 Project ECHO GHD-‐036 The United States of America The United States of America is located in North America, bordered by Canada to the north and Mexico to the south (see Exhibit 1 for map). It comprises 50 states and several unincorporated territories. In 2016, it was the world’s third-‐‑largest country in terms of population and land area (9,147,420 km2). Educational material supplied by The Case Centre Copyright encoded A76HM-JUJ9K-PJMN9I Order reference F297564 During the 16th and 17th centuries, Europeans colonized the eastern territory of North America, displacing indigenous populations (known as “American Indians” or “Native Americans”). After settlers established the United States of America (US; see Appendix for common abbreviations) in the late 18th century, the agricultural industry in the southern part of the country grew rapidly. Americans imported more than 100,000 African slaves to work the land.1 In the 19th century, the federal government forcibly moved Native Americans to “reservations” to make way for expansion. Following a civil war (1861–1865), the US ended slavery and gave Native Americans citizenship; however, these groups continued to be treated as second-‐‑class citizens.2 The US became increasingly powerful and wealthy during the 20th century; however, not all Americans benefitted equally. Discriminatory policies curtailed the rights of Americans of color, particularly black Americans. Organized protests against this treatment, known as the Civil Rights Movement (1954– 1968), culminated in the Civil Rights Act of 1964.3 The Act outlawed discrimination based on race, color, religion, sex, and nationality.4 Nevertheless, discrimination continued through redlining—the denial of services to certain areas based on their racial or ethnic makeup—in the decades that followed. Inequities persisted between ethnic groups and geographic regions.5 Demographics and Economy In 2014, most of the US population was white (77.4%); the remainder was black (13.2%), Asian (5.4%), Native American or Alaskan Native (1.2%), or mixed-‐‑race (2.5%). About 17% were of Hispanic or Latino origin.6 Almost one-‐‑fifth of Americans lived in rural areas,7 which tended to be poorer than suburban and urban areas.8 In 2015, 88% of adults had a high school education; less than one-‐‑third held a bachelor’s or higher degree.9 More than 46 million Americans, including 11 million “working poor,”* lived below the US poverty line (USD 11,670 per year for an individual; USD 23,850 per year for a family of four).11,12 Median household income was USD 53,657 in 2015.13 Income inequality was on the rise: In 2014, the average income of the top 10% of households was nearly nine times higher than the bottom 90%.14 White households had 13 times more wealth than the median black household and 10 times more than the median Hispanic household.15 In 2015, unemployment was 5.3%, down from 9.6% in 2010.16,17 The US was the largest national economy in terms of gross domestic product (GDP).18 * The US identified anyone who spent more than half the year working or looking for work and whose income was below the poverty line as “working poor.”10 2 Purchased for use on the IT for Business Transformation, at University of Baltimore. Taught by Rajesh Mirani, from 29-May-2017 to 23-Jul-2017. Order ref F297564. Usage permitted only within these parameters otherwise contact info@thecasecentre.org History GHD-‐036 Project ECHO INDICATOR YEAR UN Human Development Index ranking 8 out of 188 2014 Population (thousands) 318,857 2014 Urban population (%) 81 2014 Population using improved drinking water sources (%) Households with children living under USD 2 per day (millions) 98 2012 1.65 2011 Gini index 41.1 2013 GDP per capita (current USD) 55,837 2015 Adult literacy (%) 86 2013 Educational material supplied by The Case Centre Copyright encoded A76HM-JUJ9K-PJMN9I Order reference F297564 New Mexico In 2015, New Mexico was the 5th largest US state, roughly the size of Vietnam, and the 15th smallest in terms of population (2,085,109).19 One-‐‑third of the population was rural,20 and 18% lived in poverty.21 Most New Mexicans were white (82.8%), 10.4% were Native American or Alaskan Native, and 2.5% were black. Nearly half were Hispanic or Latino.22 Health in the United States In 2014, the top causes of death were heart disease and cancer, followed by chronic lower respiratory diseases; accidents; stroke; Alzheimer’s disease; diabetes; influenza and pneumonia; kidney disease; and suicide.23 Drug overdose deaths were rising; opioid-‐‑related deaths increased 200% from 2000 to 2015.24 Health System The US health care system was decentralized, fragmented, and complex. A variety of public and private institutions handled payment, insurance, and delivery functions. Governance The Department of Health and Human Services was the federal agency responsible for health promotion and service delivery.25 It oversaw other agencies that addressed public health (the Centers for Disease Control and Prevention) and health care quality and safety (the Agency for Healthcare Research and Quality), the two main public health insurance programs (Medicare and Medicaid), and the needs of indigenous populations (Indian Health Service; IHS).26–28 The Veterans Health Administration (VHA) was the largest integrated health system in the country in 2016, with 152 medical centers serving 8.76 million military veterans at 1,700 outpatient clinics annually.29 † Compiled by case writers using data from World Bank, the World Health Organization, UNESCO, UNDP, and the US Department of Education. 3 Purchased for use on the IT for Business Transformation, at University of Baltimore. Taught by Rajesh Mirani, from 29-May-2017 to 23-Jul-2017. Order ref F297564. Usage permitted only within these parameters otherwise contact info@thecasecentre.org Basic Socioeconomic and Demographic Indicators† Project ECHO GHD-‐036 States were also responsible for health services, including epidemiological surveillance; public health emergency response; health promotion and disease prevention; environmental health; prison health care; federal program administration; and some lab services.30 Service Delivery Federally qualified health centers (FQHCs), rural health clinics, and other qualifying facilities received federal funding to deliver preventive and primary health care services to underserved populations.31 In 2013, there were more than 1,200 FQHCs serving more than 21 million patients.32 Half of FQHC patients were members of ethnic or minority groups, and 28% had no health insurance.33 In 2016, over 80% of physician offices used electronic health records.34 Clinicians also had access to computerized reminders, clinical guidelines, patient data reports, and diagnostic support. Educational material supplied by The Case Centre Copyright encoded A76HM-JUJ9K-PJMN9I Order reference F297564 Financing In 2014, just over half of US health spending was private; the rest was public.35 Although Americans could purchase private health insurance, most participated in voluntary employer-‐‑sponsored health insurance plans, sharing premium costs with their employers.27 In 2015, over two-‐‑thirds of people under age 65 had private health insurance.36 About 36.5% of the population relied on government-‐‑sponsored health insurance—primarily Medicare and Medicaid.37 People age 65 or older or those with certain disabilities or end-‐‑stage renal disease qualified for Medicare.38 Medicaid, one of the largest payers for health care, provided coverage to qualifying low-‐‑income families, the elderly, people with disabilities, and residents of institutional programs.39 Each state ran its own Medicaid program and determined its payment model. States were moving away from fee-‐‑for-‐‑service models toward private managed care organizations (health management organizations; HMOs) and paying HMOs a capitation rate (per patient, per period of time). HMOs then negotiated compensation plans with providers. Specialist providers often received more than general practitioners. Medicaid payments to providers often were lower than private insurance payments. Certain Medicaid recipients (e.g., children, the terminally ill) were exempt from out-‐‑of-‐‑pocket costs; the rest paid a small copayment.40 Medicaid “super-‐‑utilizers” (about 5% of enrollees) with complex needs accounted for half of total Medicaid spending in 2011.41 In 2015, the number of uninsured Americans was the lowest it had been in decades (34.5 million, or 10.7% of the population). This was due in part to the 2010 Affordable Care Act (ACA),42 which increased the income cap for Medicaid eligibility. Between 2013 and 2016, Medicaid enrollment grew by over 15 million (27%). In 2016, more than 72 million Americans were insured through Medicaid.43 Many newly insured Americans suffered from chronic conditions, had had little to no previous contact with health care providers, and lived in underserved rural areas.44 Many private providers did not accept Medicaid. Congress expanded the FQHC system to support the Medicaid-‐‑eligible population.44 In 2014, the US had the highest per capita and total health expenditures globally (USD 9,403 and USD 3 trillion, respectively).45,46 Health spending represented 17.5% of GDP and was climbing,47 but the US had poorer access, equity, and health outcome measures than other high-‐‑income countries. 4 Purchased for use on the IT for Business Transformation, at University of Baltimore. Taught by Rajesh Mirani, from 29-May-2017 to 23-Jul-2017. Order ref F297564. Usage permitted only within these parameters otherwise contact info@thecasecentre.org Private providers delivered a majority of health care in the US, even when publicly financed. Americans typically received primary health care from private outpatient clinics or community-‐‑based health centers. Specialist clinics or hospitals provided secondary care and typically required patients to obtain a referral from their primary care provider. Large hospitals delivered tertiary care. GHD-‐036 Project ECHO Most primary care payment in the US was fee for service, typically ranging from USD 90 to USD 230 per visit at FQHCs, with additional fees for tests.27 FQHCs offered a sliding fee scale to patients.48 INDICATOR YEAR Average life expectancy at birth (total/female/ male) Maternal mortality ratio (per 100,000 live births) 79/ 81/77 14 2015 2015 Under–five mortality rate (per 1,000 live births) Infant mortality rate (per 1,000 live births) Vaccination rates (% of DTP3 coverage) 7 6 94 2015 2015 2014 Undernourished (%)
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