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Tuesday, March 31, 2015

Change From the Inside Out: Health Care Leaders Taking the Helm

Even as politicians and pundits continue to debate the merits of the Affordable Care Act (ACA), it is time to look beyond it to the next phase of US health care reform. Although many physicians contributed to the development and implementation of the ACA, the forces that have steered it so far have been primarily governmental.

The ACA has set the stage. The law has 2 major thematic aspects. The first, and by far the most visible in public discourse, extends health care coverage through a combination of Medicaid expansion and subsidies on newly established private insurance marketplaces. The second aspect of the ACA, far less often discussed in the public arena, is not about coverage; it is about changing the way in which health care is delivered and experienced. The mechanisms the ACA offers are numerous and the potential is profound. The response to this second theme, changing care, has been substantial, accelerating the adoption of new care structures in both the public and private sectors

Continued reliance on the ACA alone is wholly insufficient to accelerate delivery system reform to the level needed.

Leaders from within health care should now more firmly take the tiller. To borrow a phrase contributed by Splaine and colleagues.   it is time to move from change forced from the “outside in” to change led from the “inside out.”

Today’s polarized politics too often prevent authentic dialogue and exploration in the public arena that are essential in designing a better system of care. For example, the toxic and ill-informed “death panel” rhetoric in Washington stalled meaningful policies to improve the care of those with advanced illness

Needed, and now forming under the aegis of the Institute for Healthcare Improvement, is a Leadership Alliance of major health care organizations that commit publicly to partnering with their patients, and
their communities.

The current ongoing discussions about repeal of the ACA are moot, and assembling a littany of complaints  skirts the real issues.

The Supreme Court is currently reviewing the ACA

Oral Arguments for King V. Burwell

The arguments have little to do with health care and paient welfare, and much to do with the balance of powers in the three powers of government,  constitutional law, and self-interest groups.

Author commentary:

Local communities of providers, hospitals and organizations now should come to the table, and mold what little is left to adapt to practical, viable and credible trustworthy solution to another miscarriage of congressional law.  ..  Nancy passed it, we read it, and now will fix what you were paid to legislate.  It can be done.........IOM, AHRQ, and other lofty non clincal health leaders please move to the back of the

We should not expect national government to fix our own local health issues.


Published Online: March 26, 2015. doi:10.1001/jama.2015.2830.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.


1. Splaine M, Batalden P, Nelson E, Plume SK, Wasson JH. Looking at care from the inside out: a conceptual approach to geriatric care.J Ambul Care Manage. 1998;21(3):1-9. 
2. Leavitt Partners. Growth and dispersion of accountable care organizations: June 2014 update. -dispersion-accountable-care-organizations -june-2014-update/. Accessed March 12, 2015. 
3. National Committee for Quality Assurance. Patient-centered medical homes. http://www.ncqa .org/Portals/0/Newsroom/2013/pcmh%202011 %20fact%20sheet.pdf. Accessed March 12, 2015. 
4. Berwick DM, Nolan TW, Whittington J. The Triple Aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769. 
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6. US Department of Health and Human Services. New HHS data shows major strides made in patient safety, leading to improved care and savings. /patient-safety-results.pdf. Accessed March 12, 2015. 
7. Centers for Medicare & Medicaid Services. Projections of national health expenditures: methodology and model specification. -and-Systems/Statistics-Trends-and-Reports /NationalHealthExpendData/Downloads /ProjectionsMethodology.pdf. Accessed March 12,

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