Reshaping Health Systems: What Drives Health Care and How You Can Change It

Health systems textbooks tend to come in one of two types: thick tomes that focus more on health care legislation and policy than effects on individual patients 1 and concise overview texts for clinicians that gloss over key details. 2,3At a minimum, family physicians should understand the health care system's basic functions in order to navigate it on their patients' behalf.As a residency educator, I support the more aspirational vision of training graduates who are familiar enough with the drivers and limitations of health systems to advocate for policy changes at local, state, and national levels.Only one in three family medicine residency programs has a formal advocacy curriculum, however. 4In Reshaping Health Systems: What Drives Health Care and How You Can Change It, internists Joshua Liao and Joseph Joo and family physician Jonathan Staloff aim to bridge the gap between advocacy and the clinic by using a case-based format to illustrate the effects of health systems factors on the care of a hypothetical patient.The book is divided into two parts: "Factors That Drive Health Care" and "Solutions to Change Health Care."The first part, comprising more than two-thirds of the text, consists of eight chapters representing different care settings: ambulatory, emergency, hospital, post-hospital transitions, post-acute, urgent, home-based/virtual, and community.Readers follow Jessica, an older woman with type two diabetes and worsening memory problems, through a series of interactions with clinicians and other health professionals.Each clinical case update is followed by discussions of relevant systems factors.For example, after Jessica visits her new primary care physician, the authors review the Relative Value Units-based outpatient payment system, legislation mandating electronic health record interoperability, and care coordination and afterhours coverage in the patient-centered medical home model.When Jessica goes to the emergency department (ED) for a postsurgical knee infection, readers learn about the Emergency Medical Treatment and Active Labor Act (EMTALA), patient handoff tools, and time-based metrics for emergency care.Each chapter concludes with several multiplechoice questions and answers and an extensive bibliography.The case-based format of Reshaping Health Systems provides a rational (and to clinicians, familiar) basis for organizing the content.To the office-based family physician, who may or may not provide inpatient care, the book emphasizes that many essential health care services for patients-provided at home and in acute rehabilitation and skilled nursing facilities-have only a tenuous connection to the doctor-patient relationship.As Jessica's cognitive impairment and other chronic illnesses progress and her visits to the office become less frequent, primary care supervision consists of little more than reviewing and signing care plans from a home health agency or nursing home.The forward-looking chapter on community-based care (pp.196-242) explores the potential of value-based payment models, community-oriented organizations, and community health workers to facilitate integrated care and extend the reach of the patient-centered medical home.However, these models are not available or financially viable in most communities and seem unlikely to flourish in the current environment of fiscal austerity gripping US health care.