This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions
By Carl van Walraven MD MSc, Alison Jennings MA, Monica Taljaard PhD, Irfan Dhalla MD MSc, Shane English MD, Sunita Mulpuru MD, Saul Blecker MD, Alan J. Forster MD MSc
CMAJ (Canadian Medical Association), August 22, 2011
Urgent, unplanned hospital readmissions are increasingly being used to measure institutional or regional quality of care. The public reporting of readmissions and their use in considerations for funding suggest a belief that readmissions indicate the quality of care provided by particular institutions. However, urgent readmissions are an informative metric only if we know what proportion of them are avoidable. If they are rarely avoidable, they would be a poor gauge of the quality of patient care.
Current estimates of the proportion of urgent readmissions that are avoidable are unreliable. In a systematic review of 34 studies that reviewed how many readmissions were avoidable, 3 of the studies relied solely on combinations of administrative diagnostic codes, and most used undefined or subjective criteria. In addition, most of the studies were conducted at a single centre and used only one reviewer. The proportion of readmissions deemed avoidable varied widely, from 5.1%6 to 78.9%,7 which reflected in part the lack of standardized and reliable methods to identify avoidable readmissions.
We conducted a multicentre prospective cohort study to elicit judgments from multiple practising physicians who used standard implicit review methods to determine whether urgent re admissions were potentially avoidable. We analyzed these judgments using a latent class analysis. We also measured the proportion of readmissions deemed avoidable and compared hospital-specific proportions of all-cause and avoidable readmissions.
Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions of those whose readmissions were deemed avoidable.
Given the variety of causes and circumstances of the potentially avoidable readmissions in our study, interventions to decrease the risk of readmission need to be multifactorial in nature and malleable to be appropriately tailored for each situation.
Our study has important implications for research into the quality of hospital care. First, determining whether urgent readmissions were avoidable is a subjective judgment that requires detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. Such judgments cannot be determined accurately on the basis of administrative data alone, given the infinite combinations of patient, hospital, treatment and post-discharge factors that can influence urgent readmissions. Second, we found no association between hospital-specific proportions of all-cause and avoidable readmissions. Therefore, urgent readmissions should be used with caution to gauge the quality of hospital care.
This Canadian study provides a great example of how we, in the United States, “think up” policies to control health spending while improving quality, and then apply those policies simply because they “should work.” Many of these policy decisions are used to divert our attention from much more effective measures such as a single payer national health program.
In this instance, the theory is that unplanned readmissions after a previous stay in the hospital are avoidable with appropriate in-hospital and post-discharge management. If the professionals and other personnel would do their jobs right, quality would improve and the costs of re-hospitalization would be avoided.
Although the Canadians, with their single payer system, evaluated readmissions from the perspective of improving quality, the emphasis in the United States, with its market medicine, has been on costs (e.g., refuse payment for re-admissions).
This study demonstrates that the reasons for readmission are very complex and highly variable and have very little relationship to either human or systems failure. Readmission rates should not be a major driver of policy.
Through this distraction, we’ve been fooled again. It’s not lousy health care professionals who are the source of our problems, it is the inhumane and outrageously expensive market-based health care financing and allocation system that is the problem. That’s what we need to fix. Then we could set aside issues of greed and concentrate on health care quality instead, like the Canadians are doing.
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
March 5, 2006
“When you’re sick, you present your medicare card, not your credit card. New Democrats will not stand idly by. We will be fighting each and every day for our precious medicare system.”
(July 18, 1950 – August 22, 2011)
Letter from Jack Layton, MP, Député Toronto – Danforth
Leader of the Official Opposition/Chef de l’Opposition officielle
Leader, New Democratic Party/Chef, Nouveau Parti démocratique
August 20, 2011
To young Canadians:
All my life I have worked to make things better. Hope and optimism have defined my political career, and I continue to be hopeful and optimistic about Canada. Young people have been a great source of inspiration for me. I have met and talked with so many of you about your dreams, your frustrations, and your ideas for change. More and more, you are engaging in politics because you want to change things for the better. Many of you have placed your trust in our party. As my time in political life draws to a close I want to share with you my belief in your power to change this country and this world. There are great challenges before you, from the overwhelming nature of climate change to the unfairness of an economy that excludes so many from our collective wealth, and the changes necessary to build a more inclusive and generous Canada. I believe in you. Your energy, your vision, your passion for justice are exactly what this country needs today. You need to be at the heart of our economy, our political life, and our plans for the present and the future.
My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world.
All my very best,
With accelerating growth of medical technologies, specialization and sub-specialization since World War II, the U.S. now has 24 specialty boards and more than 135 certified subspecialties. As a result, a unified voice from the profession about how best to serve patients in a rational health care system has largely disappeared. At the same time, tensions and jurisdictional disputes have increased between generalists and specialists, as well as among specialists themselves. It is not surprising, then, that confusion, myths and misperceptions have developed over the role of primary care—the purview of generalists—both within the profession and the lay public.
We are indebted to the late Dr. Barbara Starfield of the Johns Hopkins School of Public Health for this basic definition of the four pillars of primary care: (1) first-contact care; (2) longitudinal continuity over time; (3) comprehensiveness, with capacity to provide care for the majority of health problems; and (4) coordination of care with other parts of the health care system. (Starfield, B. Is primary care essential? The Lancet 344 (8930): 1129-33, 1994) Dealing as they do with a broad spectrum of patients’ problems, generalist primary care physicians necessarily think and practice differently than specialists, who deal with a deeper level of knowledge and skills in a far narrower area.
These are some of the most common myths and misperceptions about the generalist primary care role in the U.S. today, together with brief responses to clarify them.
1. As a generalist, it’s impossible to know everything.
This is true—nobody can know everything. But the generalist’s knowledge is different from that of the specialist, both in kind, breadth and depth. This widespread sentiment reveals a fundamental misunderstanding about the nature of knowledge and information. It is based on the faulty assumption that all specialized knowledge must be vertical, in-depth knowledge about a narrow subject. Dr. Gayle Stephens, an early pioneer in the evolution of family medicine since the 1960s, reminds us that:
“None of the certifiable medical specialties were established on epistemological grounds. Most of them sprang up like Topsy and exist by virtue of political, economic, and technological factors that have little to do with a theory of knowledge. . . All of medicine is derivative, secondary, and applied.” (Stephens, GG. The Intellectual Basis of Family Practice. Tucson. Winter Publishing Company, Inc, 1982, p3)
2. Primary care deals with trivial content and problems.
Generalist physicians are attracted to the front-line nature of their work, dealing as they do with a wide spectrum of care spanning the entire life cycle (in the case of family medicine), medical emergencies, screening and prevention, diagnosis and management of acute and chronic illnesses, counseling and long-term care. They are prepared to definitively manage the majority of the problems brought to them, arrange for consultation with appropriate specialists when necessary, and then co-manage many patients with consulting specialists thereafter. A recent study comparing the relative complexity of patient encounters in three fields—general/family practice, cardiology and psychiatry—concluded that the practice of generalists is one-third more complex than that of cardiologists and five times more so than that of psychiatrists. (Katerndahl, D, Wood, R, Jaen. CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Amer Board Fam Med 24 (1): 6-15, 2011)
3. Anyone can do primary care.
Many specialists, with little experience, knowledge or understanding of primary care practice, denigrate it as “simple” and nowhere near as challenging or complex as their own specialty. Such a self-serving attitude often dates back to their own experiences in medical school, where they heard similar sentiments from some of their sub-specialist mentors with little of no experience in community practice.
In fact, generalist physicians today have three or more years of residency training after medical school, are willing and able to cope with the intellectual challenges and ambiguity of primary care practice, enjoy working closely with people, and have a mindset looking for patterns of illness beyond the shackles of arbitrary specialty boundaries.
4. Specialist care is better than generalist care.
Since our culture tends to worship technology and specialization, it follows that many Americans naturally assume that specialty care is of higher quality than that provided by generalists. A major review of the literature in 2007 attempted to answer this question, but yielded mixed results. Forty-nine studies compared the quality of care provided by generalists vs. specialists, but were limited by their focus on single discrete medical conditions, thereby advantaging specialists over generalists. We still don’t have a solid answer to this important question, since these studies failed to deal with multiple chronic conditions, little attention was paid to coordination and integration of care, case-mix adjustment was often inadequate, and characteristics of physicians’ practice settings (such as use of clinical practice guidelines and electronic medical records) were ignored. (Smetana, GW, Landon, BE, Bindman, AB, Burstin, H, Davis, RB et al. A comparison of outcomes from generalist vs. specialist care for a single discrete medical condition. Arch Intern Med 167 (1):10-20, 2007) At the macro level, however, a 2005 analysis of 100 ecological studies of the relative benefits of generalist vs. specialist care in various health care systems concluded that “primary care helps prevent illness and death . . .and . . . that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations.” (Starfield, B, Shi, L, Macinko, J. Contribution of primary care to health systems and health. Millbank Q 83: 457, 2005)
5. Since medicine has become so specialized, generalists are no longer needed.
Actually, there has never been a greater need in this country for generalist physicians rebuilding the deteriorating primary care infrastructure. Current projections call for a shortage of 45,000 primary care physicians by 2020 (Krupa, C. Physician shortage projected to soar to more than 91,000 in a decade. American Medical News. Amednews.com, October 11, 2010). If the 2009 health care reform legislation ever gets fully implemented, some 32 million Americans will be newly covered by health insurance (including 16 million on expanded Medicaid) in 2014. But replacements of our dwindling supply of primary care physicians are nowhere in sight. Already, only 42 percent of patients’ annual visits to physicians for acute medical problems are made to their personal physicians; all the rest are made to emergency rooms (28 percent), to specialists (20 percent), or to hospital outpatient departments (7 percent), often with difficulty in arranging follow-up care. (Pitts, SR, Carrier, ER, Rich, EC, Kellerman, AL. Where Americans get acute care: Increasingly, it’s not at their doctor’s office. Health Affairs 29 (5): 1620-28, 2010) So we’re facing a growing crisis in having generalist primary care physicians available for patients to see that they know. More to be expected—continued growth in the numbers of patients without a primary care physician who are forced to seek care from strangers through emergency rooms, urgent care centers and other facilities without access to the full benefits of primary care.
Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Health Care, 2011.
John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program
This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.
Large Employers’ 2012 Health Plan Design Changes
National Business Group on Health
August 18, 2011
Medical Plan Costs
In 2012, 63% of employers will increase the employee percentage contribution to premium costs, and 39% will increase in-network deductibles.
Consumer-Directed Health Care
More employers will be offering a consumer-directed health plan (CDHP) in 2012 than in previous years, with 73% planning to offer at least one CDHP next year. In addition, 17% of employers have or will move to a full replacement CDHP design in 2012. The most common type of CDHP employers will offer next year is a high-deductible health plan (HDHP) with a health savings account (HSA) (75%).
The most common method employers use to load health accounts is by contributing a predetermined amount per participant, with 59% of employers with HSAs doing so, and 84% doing the same for health reimbursement accounts (HRA).
To manage pharmacy benefits, most employers use prior authorization (76%). The next most popular techniques are:
• quantity limits (72%)
• step therapy (65%)
• three-tier design (59%)
Fewer employers offer retiree benefits to current active employees, with 26% covering all current actives and 38% covering a portion of their actives. Very few employers offer retiree health benefits for new hires, with 12% offering coverage to pre-65 retirees and 7% offering post-65 supplemental coverage to new hires.
The top strategies being used to control retiree health care costs are capping company contributions (45%), increasing employee contributions (31%) and eliminating coverage for future retirees (28%).
Survey: Employers shift rising health costs to their workers
By Sam Baker
The Hill, August 18, 2011
Businesses are shifting away from co-pays, wherein employees pay a fixed dollar amount for healthcare services and the plan picks up the rest. Instead, they’re charging workers a percentage of the total costs. That can help make consumers more aware of the total cost of the healthcare they use.
“We are clearly seeing a march toward a more aggressive consumerist system,” said Helen Darling, president of the National Business Group on Health.
Darling said Thursday that shifting from co-pays to coinsurance is “a more subtle way to increase what the consumer pays.” She predicted that eventually, only governments and unions will keep offering fixed co-pays.
Employers are reducing the transparency of the massive shift of health care costs to their employees by using many different methods that individually do not look too onerous, but cumulatively have a major impact.
Some of the methods of shifting more health care costs to their employees include greater premium contributions, greater use of large deductibles and consumer-directed health plans, greater restrictions on pharmacy benefits, and a sharp reduction or elimination of retiree health benefits. One of the more subtle but important methods is reducing the use of co-payments (a fixed dollar amount for a service or product) and instead using coinsurance (a percentage of the amount charged). The percentages are usually much larger than the co-payments would be.
Most of the businesses surveyed are very large corporations (83 percent have over 10,000 employees). Their corporate executives and their passive shareholders have done very well in the last few decades, being beneficiaries of the upward transfer of wealth in our society. Their employees have not done so well and have experienced greater difficulties in managing their personal finances.
Rising health care costs are a problem for all of us. They are now so great that we need progressive methods of financing health care. Yet shifting costs from the wealthy corporate plutocracy to the employees is a regressive form of financing.
Supposedly employers are still contributing a large share of the premium, but only nominally. Most economists agree that employees pay the employer component of the premium though forgone wage increases, and wages have certainly been flat. Again, this is regressive financing.
In crafting the Affordable Care Act, efforts were made to protect employer-sponsored plans so that they would still be the largest source of health care coverage. Is this wise?
Not only is the financing regressive, it leaves in place the administratively wasteful private health plans that intrude on health care by taking away certain benefits and taking away choices of health care providers. It leaves in place the fragmented financing model of private plans that has been incapable of slowing the rate of growth in costs to a level closer to those of other industrialized nations. Furthermore, it leaves health policy decisions in the hands of corporate executives who are beholden above all to their investors, whereas the employees are mere pawns to be used to create wealth for the investors. Why else would they be using so many means to shift more health care costs to the employees?
Every time I write one of these commentaries, I think that the logic of an improved Medicare for All would make it an imperative. Maybe the problem is that logic would lead to health care justice, and that seems to be unthinkable in the United States.
Health Policy Schizophrenia
By John Goodman
National Center for Policy Analysis, August 17, 2011
An example of an IDN (Integrated Delivery Network) that is already doing what the Obama administration wants to try out with expensive pilot programs is IntegraNet of Houston, an organization with a network of about 1,200 doctors. Every Medicare patient has a medical home. The physicians follow evidence-based practices. Care is integrated and coordinated. Electronic records are being introduced. It appears that quality is higher and costs are lower than in conventional Medicare.
So what’s not to like? If the folks at CMS had any sense, they would camp out in Houston and try to find out how all this works. Instead, they have been spending their time and your tax dollars producing a 427-page book of rules on what Accountable Care Organizations (ACOs) have to look like….
In the meantime, there is no doubt in my mind that IntegraNet doesn’t satisfy all the government’s requirements by a long shot. For one thing, it pays its doctors fee-for-service. The Obama folks are convinced fee-for-service payment is the problem, not the solution. For another, IntegraNet intentionally pays doctors more than Medicare’s standard rates. Yet the administration’s Plan B for cost control is squeezing provider payments, not increasing them.
A third problem is that it is producing a medical loss ratio (MLR) of 70% or less for its insurance company clients. As previously reported that is 10 percentage points less than the minimum MLR the Obama administration thinks insurers should have. But that extra 10 percentage point profit (shared by the IDN and the insurer) is the whole reason IntegraNet is in business. No one is going to take risks and try new things if they can only get a regulated-utility rate of return.
(Understandably, John Goodman would prefer that excerpts from his articles not be read out of context. The entire article can be accessed at this link.)
Don McCanne says:
August 17, 2011 at 3:38 pm
With health care costs for a family now averaging over $18,000, not including insurer administrative costs (Milliman Medical Index), how can one justify adding another 43 percent to those costs (the administration and profit add-on for 70 percent MLR plans)?
The Affordable Care Act isn’t a whole lot better since it allows 18 to 25 percent add-on for qualified private plans.
We now have a new report from the IG of HHS that shows an important difference between private and public health care purchasing. When quality is controlled, government administered pricing is much lower than private sector pricing. Specifically, the government Medicaid program was able to obtain a 45 percent price reduction in brand-name drugs whereas the private Medicare Part D intermediaries were able to negotiate only a 19 percent reduction for those same drugs of identical quality.
Health care costs are now an issue for 80 percent of Americans. We can no longer afford to waste our funds catering to superfluous, intrusive, outrageously expensive, private sector insurance bureaucracies.
Since risk pooling remains an imperative, we do need some form of insurance, but without these wasteful private bureaucracies. It is no wonder that so many conservatives warn that we’ll end up with a single payer system. It seems inevitable.
Larry Wedekind says:
August 18, 2011 at 10:08 am
John, well said..thanks for the recognition of our efforts at IntegraNet.
To Dr. Mittler (the author of another response not reproduced here),
The nature and benefit of competition is that private companies develop unique and better methodologies or products and in our free market they can become proprietary for awhile – this aspect of our society has produced many lasting benefits that would never have existed without the ability to patent or service mark unique ideas and products. I can tell you though that IntegraNet has not been able to keep our proprietary methodologies private very long due to the fact that physicians, Health Plan partners and our patients all experience our methods quickly and so they become public quickly. Its also very difficult to service mark our methods for the same reason.
Note also that insurance companies and IDN’s do not make any extra money in our Shared Risk/Savings Model unless the physicians make a lot of extra money. This is a unique feature of the Medicare Advantage Model that is easily forgotten. Why would you loath insurance company executives receiving more money for their wisdom in promoting the Shared Risk Model when physicians are paid the extra money first for their efforts?
Don McCanne says:
August 18, 2011 at 10:41 am
To Larry Wedekind,
Let’s see. The formula for success at IntegraNet is to use secret methods to reduce spending on actual health care (70% MLR) and keep more of the premiums so that “physicians make a lot of extra money”? With our outrageously expensive health care system, unique to the United States, can we really afford to perpetuate that kind of thinking, celebrating it as free market competition of private companies?
Value is what we should be striving for. In this model, the supposedly free market is being used to destroy value. When free markets fail in providing value for essential needs, it’s time for the government to step in. That might not appeal to those ideologically opposed, but one thing we can say: single payer systems do provide much better value in health care.
Larry Wedekind says:
August 18, 2011 at 11:16 am
To Don: I’m sorry, but you are very confused about the MA (Medicare Advantage) system. The fact that IntegraNet and other IDN’s consistently reduce the MLR to below 70% means that great value has accrued to the Medicare beneficiaries! To suggest otherwise is simply ignorant. Why? When a Health Plan experiences a 70% or less MLR because of the Care Coordination efforts of their IDN partner, this nearly always means that the beneficiaries are healthier and need the hospital less frequently. I submit to you that it is impossible to have a 70% or lower MLR without healthier patients.
This extra profit derived from the low MLR that is shared with the doctors in the IDN empowers the doctors to then spend even more time with their beneficiaries; this empowering the beneficiaries even more.
Remember that, due to the transfer of complete financial risk to the HMO and IDN, we have almost complete freedom to care for our beneficiaries under the MA Program the way we deem best. There is very little interference from CMS in our methods for caring for our beneficiaries under the MA Program.
The MA/IDN Risk Sharing model is actually the best example of free market competition within the healthcare market yet.
As John Goodman said in this same article in an entirely different context, “It’s so bizarre that not even J.K. Rowling could make up a story like this.”
Higher Rebates for Brand-Name Drugs Result in Lower Costs for Medicaid Compared to Medicare Part D
Office of the Inspector General
Department of Health and Human Services, August 2011
Prescription drug rebates reduce the program costs of both Medicare Part D and Medicaid. Medicaid rebates are defined by statute; additional rebates are required when prices for brand-name drugs increase faster than inflation. Unlike the Medicaid program, Part D sponsors (or contractors acting on their behalf) negotiate rebates with drug manufacturers without any statutory requirements on rebate amounts. In fact, the law establishing the Part D program expressly prohibits the Government from instituting a price structure for the reimbursement of covered Part D drugs.
In this review, we found that Part D sponsors and State Medicaid agencies paid pharmacies similar amounts for most brand-name drugs under review. However, statutorily defined Medicaid unit rebate amounts for brand-name drugs exceeded Part D unit rebate amounts by a substantial margin. As a result, Medicaid collected nearly two-thirds as much as Part D in rebates for the 100 brand-name drugs ($2.9 billion vs. $4.5 billion), despite having only about one-fourth of the expenditures ($6.4 billion vs. $24 billion).
Overall, rebates reduced Part D expenditures by 19 percent for the 100 brand-name drugs under review (from $24 billion to $19.5 billion) in 2009. Medicaid rebates accounted for a substantially higher percentage of total expenditures, reducing Medicaid spending for the 100 drugs under review by 45 percent (from $6.4 billion to $3.5 billion).
We are inundated with nonsense about how private health insurance competition in the marketplace brings us higher quality at lower costs when compared with government-administered programs. This study by the Inspector General of Health and Human Services provides an enlightening test of that theory by controlling for quality while measuring the differences in cost. Both Medicaid (government) and Medicare Part D (private) use the same brand-name drugs with identical quality, so cost becomes the sole variable.
Our government-run Medicaid program has been able to negotiate a 45 percent discount on these brand-name drugs, whereas the private Medicare Part D sponsors or contractors have been able to extract only a 19 percent discount on these same drugs. Clearly, when quality is controlled, the private sector brings us much higher prices than does the government.
Under a single payer national health program – an improved Medicare for All – these highly wasteful middlemen would be eliminated and the government would use its monopsonistic buying power to get the prices right. Payment would be based on actual costs, including legitimate research, plus fair profits.
Having to change the rhetorical framing of the dialog from “markets and competition” to “social solidarity” is a small price to pay for achieving the efficient use of our health care dollars. Thinking about that, being able to dump the ideology behind the intrusive, wasteful middlemen is not a price that we would be paying, but a superb benefit that we would be gaining.
Can We Have Health Reform Without an Individual Mandate? Yes, It’s Called ‘Medicare for All’
By John Nichols
The Nation, August 13, 2011
The individual mandate was always a bad idea. Instead of recognizing that healthcare is a right, the members of Congress and the Obama administration who cobbled together the healthcare reform plan created a mandate that maintains the abuses and the expenses of for-profit insurance companies — and actually rewards those insurance companies with a guarantee of federal money.
Those who think that the for-profit (or even not-for-profit) insurance industry has to control any healthcare reform initiative have every right to be upset with the 11th Circuit’s ruling — which almost certainly will send the case of the Obama healthcare plan to the US Supreme Court.
But those of us who have no desire to perpetuate the insurance industry can and should recognize that the proper — and entirely constitutional — reform is an expansion of Medicare to cover all Americans.
While Medicare is exceptionally popular, polling shows that the individual mandate is not — according to recent surveys, roughly 60 percent of Americans oppose it.
It also passes constitutional muster.
As former Labor Secretary Robert Reich notes: “[No] federal judge has struck down Social Security or Medicare as being an unconstitutional requirement that Americans buy something. Social Security and Medicare aren’t broccoli or asparagus. They’re as American as hot dogs and apple pie.”
“So if the individual mandate to buy private health insurance gets struck down by the Supreme Court or killed off by Congress,” says Reich, “I’d recommend President Obama immediately propose what he should have proposed in the beginning — universal health care based on Medicare for all, financed by payroll taxes.”
The insurance companies would, of course, scream.
But let them complain.
Americans don’t need mandates. They need healthcare.
And they have every right to ask, as activists with Physicians for a National Health Program have, that Medicare be expanded to cover all Americans — affordably, efficiently, capably and constitutionally.
Americans overwhelmingly support Medicare, yet an unequivocal majority oppose a government requirement to purchase private health insurance. Why should we have to wait until we’re 65 to have Medicare, while in the interim being required to buy something we don’t want? Let the Supreme Court rule that the individual mandate is unconstitutional, and then maybe we can convince a newly elected Congress to pass the reform that we really need.
We are pleased that Washington correspondent John Nichols of The Nation has joined with Physicians for a National Health Program and the growing chorus of other enlightened voices who call for a vastly superior model of reform that actually would pass constitutional muster – an improved Medicare, expanded to include everyone.
Up to the middle of the last century, most Americans could count on good access to generalist primary care physicians with the training and commitment to evaluate and treat their medical problems, whatever they might be. Those days are long gone. The ratio of generalist physicians to specialists in this country reversed from about 80:20 percent in 1930 to 20:80 percent in 1970. Since then we have seen the generalist tradition being carried on by family physicians, general internists, general pediatricians, and osteopathic physicians, but their aggregate numbers today are no more than 30 percent. And that number is falling fast as more medical graduates seek out the higher pay and more attractive life styles of the non-primary care specialties.
These are some of the major ways by which Americans are hurt by the growing deficit of generalist physicians:
1. Can’t get a primary care physician.
It is getting harder and harder to find a generalist primary care physician still open to accepting new patients. In Massachusetts, for example, the passage of legislation in 2006 expanding insurance coverage for many people exposed a critical shortage of primary care physicians. (Fitzgerald, J. State medical group sees severe shortages in 10 specialties. Boston Herald, October 20, 2010) Patients on Medicare and Medicaid have particular problems finding a physician willing to take them on due to low reimbursement through those programs. Under the banner of fiscal austerity, many states are cutting Medicaid to the bone. In California, for example, where Medicaid (Medi-Cal) covers one in five Californians, Medi-Cal payment rates for physicians and other providers have been cut by 10 percent to just $11 a patient visit (Corcoran D. Doctors say Medi-Cal reimbursement is too low. San Francisco Chronicle, August 4, 2011) Even if one has a primary care physician today, the likelihood of a continued relationship in the future is becoming increasingly clouded due to physician retirements, mobility among physicians, and changes of providers in insurer networks that often force changes of physicians.
2. No access to breadth of primary care.
People without a primary care physician don’t get access to the breadth of primary care anywhere else in our “system”. Specialists are not trained or equipped to provide preventive services across the board, care for acute and chronic problems for patients of all ages, continuity of comprehensive care for all medical problems for years, with knowledge and understanding of their patients’ family and community setting. Emergency rooms and urgent care centers can focus only on the most acute problem at the time, with little follow-up, while so-called “retail clinics” for walk-in care are limited to non-emergency and low-acuity problems. As a result, many of the potential advantages of primary care are not available to a growing part of our population.
3. Higher costs and unaffordability of care.
Specialty care costs more than primary care—a lot more, for a number of reasons. For new medical problems, specialty physicians have to start “cold”, without context or knowledge of the patient, often ending up repeating tests and procedures that have been done previously, charging more than primary care physicians, and in the case of multiple medical problems, typically having to call upon other specialists for care. Since primary care physicians know their patients better, they order fewer tests than specialists, and help to protect their patients from inappropriate and unnecessary care. (Schoen, C, Osborn, R, Doty, M, Bishop, M, Peugh, J et al. Toward higher-performing health systems: adults’ health care experiences in seven countries. Health Affairs (Millwood) 26: w 717-34, 2007)
4. Foregone necessary medical care.
Foregone care is widespread and increasing. These markers document this growing trend:
• In the last year, one in three Americans skipped care, did not fill a prescription, or get other care because of cost. (Parashar, A. Compared to other countries, U.S. patients have more access to specialists, less to primary care. Kaiser Health News, November 18, 2010)
• One-third of uninsured adults have a chronic disease for which they
don’t get needed care. (Wilper, A, Woolhandler, S, Lasser, KE, McCormick, D, Bor, DH et al. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med 1249 (3): 170-6, 2008)
• Two million cancer patients are now foregoing necessary care each year due to unaffordable costs. (Weaver, KE, Roland, JH, Bellizzi, KM, Ariz, NM. Foregoing medical care because of cost: Assessing disparities in healthcare access among cancer survivors living in the United States. Cancer online, June 14, 2010)
•. The number of annual patient visits to physicians has declined sharply since the onset of the Great Recession in 2008. (Johnson, A, Rockoff, JD, Mathews, AW. Americans cut back on visits to doctor. Wall Street Journal, July 29, 2010: A1)
5. Decreased coordination and integration of care.
Coordinated and integration is a huge problem, especially for patients with multiple medical problems, the norm for older patients. The electronic medical record does not substitute for close communication between specialists for such patients. According to the Joint Commission on Accreditation of Healthcare Organizations, 80 percent of serious medical errors are associated with lack of communication or teamwork among specialists in hospitals. (Health blog. Joint Commission-Hospital Collaboration targets hand-offs. Wall Street Journal, October 21, 2010)
6. Decreased quality of care with worse outcomes.
Compared to those without primary care, patients with primary care receive earlier diagnosis and treatment of illness and better outcomes of care (Ferrante, JE, Gonzales, E, Pal, N, Roetzheim, RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 13: 408-14, 2000), including lower mortality rates (Baicker, K, Chandra, A Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs (Millwood) 23: w 184-97, 2004)`
Unfortunately, the essential role of primary care in any health care system is not widely understood. In the next post we will consider some of the many misperceptions about it, and how they represent barriers to building a better health care system in this country.
Adapted in part from my recently released book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011, soon to be available as an Ebook on Amazon.
John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President, Physicians for a National Health Program
Implementing Health Reform: Premium Tax Credits
By Timothy Jost
Health Affairs Blog, August 13, 2011
On August 12, the Departments of Health and Human Services and Treasury (Internal Revenue Service) issued three notices of proposed rulemaking (NPRM) as part of their continuing effort to implement the Affordable Care Act (ACA).
This post will describe the Treasury NPRM, the shortest of the NPRMs but also the one that deals with the most complex and unsettled issues.
The Basic Rules Regarding The Tax Credit
The consequences of underpayments and overpayments.
Although the tax credit is paid on a monthly basis, the actual amount of the credit will in fact be finally determined based on the household’s income as determined on the annual income tax return. At that point “reconciliation” must occur. If over the course of the year household income turns out to have been greater or less than projected, or if household composition or compliance with other eligibility requirements has changed, the final tax credit may turn out to be greater or less than the amount already paid. If the taxpayer turns out to have been eligible for more than had been paid, the taxpayer gets a refund.
If, however, the government has paid more than the taxpayer in fact turns out to be entitled to, the taxpayer must pay the money back. There are limits to this liability for taxpayers with household incomes up to 400 percent of the FPL (which have been amended twice since the ACA was adopted to increase liability), but the amount owed back can be substantial (up to $2500 for families at the upper ranges), and if final income exceeds 400 percent of poverty, even by one dollar, the entire premium tax credit must be paid back.
No help for those who owe money back because of overpayments.
A taxpayer must file a return to claim a tax credit, even though the taxpayer otherwise has no obligation to file a return. As noted above, at the time the return is filed, the tax credit will be reconciled with actual reported household income and the taxpayer will have to pay the IRS if there was an overpayment in tax credits. Overpayments in fact will be common, not only because income and household composition will change over the course of a year, but also because a person who loses or gains a well-paying job over the course of the year may end up with a high end-of-the year income even though, at the time the taxpayer applied, the credit was accurate for the taxpayer’s then-current income level. A taxpayer with income under 400 percent of poverty level could receive a credit through out the year based on anticipated income, but then receive an end-of-year bonus putting the taxpayer over the 400 percent limit and have to pay back the entire credit for the entire year.
Consumer advocates hoped that Treasury would use its statutory rule-making authority to meliorate these consequences, but Treasury does not believe it has the authority to do so and offers no mercy.
Department of the Treasury – Proposed regulations for the Health Insurance Premium Tax Credit:
Throughout the reform process Professor Timothy Jost has been very helpful in clarifying the impact of the Affordable Care Act, especially on health care consumers. As one example, here he shows how an individual who appropriately receives monthly premium tax credits for purchase of a plan through an insurance exchange could be required to pay back the entire credit for the entire year merely because of a year-end bonus that lifted income over the 400 percent poverty level. For most individuals, this could create a severe financial hardship.
As another example, if the employee’s premium contribution for an employer sponsored plan is over 9.5 percent of income, then the employee is free to accept the tax credit and purchase a qualified plan through the insurance exchange. However, the employee’s contribution to the premium for the family does not count. Thus the employee, with an individual contribution under 9.5%, could have to pay much more than 9.5 percent of income to insure the entire family, and yet not be eligible for the option of accepting a tax subsidy for an exchange plan. Again, family coverage could create a significant financial hardship for the employee.
There is a profusion of complexities in the Affordable Care Act that adversely impact patient-consumers, many of which Professor Jost has described in this and other articles. Although, as an academic, he has limited his advocacy to supporting rules that benefit patients, we don’t have to limit our own advocacy so narrowly.
The Affordable Care Act is an abomination of inequitable and unjust administrative complexities and waste that can never achieve an equitable health system that serves everyone. Let’s continue to do our best to make sure that everyone understands this and understands that health care justice for all is achievable by the adoption of a single payer national health program.
In the meantime, the IRS does not believe that it has the authority to alter the provisions of the Affordable Care Act and thus offers no mercy. Mercy is left in the hands of us would-be reformers.
Medical Professionalism in the New Millennium: A Physician Charter
Annals of Internal Medicine
February 5, 2002
A project of the American Board of Internal Medicine Foundation, American College of Physicians–American Society of Internal Medicine Foundation, and European Federation of Internal Medicine
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients’ interests. To maintain the fidelity of medicine’s social contract during this turbulent time, we believe that physicians must reaffirm their active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. This Charter on Medical Professionalism is intended to encourage such dedication and to promote an action agenda for the profession of medicine that is universal in scope and purpose.
Government Policies in Violation of Human Rights as a Barrier to Professionalism
By Farrah J. Mateen, MD; Leonard S. Rubenstein, JD, LLM
JAMA, August 3, 2011
In recent decades, a set of reciprocal obligations between physicians and society have been identified as central to the concept of professionalism. In return for the high degree of autonomy society grants physicians, including licensure and self-regulation, the profession is expected to serve patients’ interests. At the heart of professionalism lie 3 fundamental principles: primacy of patient welfare, founded on altruism, trust, competence, and patient interest; patient autonomy, including educating and empowering patients to make appropriate medical decisions; and social justice, which considers available resources and the needs of all patients while taking care of an individual patient. However, deeply embedded institutional and organizational impediments often beyond the control of the physician (eg, inequitable access to care and reimbursement systems that create disincentives to proper care) can undermine physicians’ ability to adhere to these professional obligations in clinical practice.
The Charter on Medical Professionalism was established almost a decade ago. It reaffirms physicians’ active dedication to the principles of professionalism, which entails not only their personal commitment to the welfare of their patients but also collective efforts to improve the health care system for the welfare of society. How are we doing?
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