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.
Following is the Quote of the Day from September 12, 2001.
The New York Times, September 12, 2001
“But this is an age when even revenge is complicated, when it is hard to match the desire for retribution with the need for certainty. We suffer from an act of war without any enemy nation with which to do battle. The same media that brought us the pictures of a collapsing World Trade Center shows us the civilians who live in the same places that terrorists may dwell, whose lives are just as ordinary and just as precious as the ones that we have lost.”
The New York Times, September 10, 2011
“A decade later, we’re still trying to understand, looking back and looking ahead. It is not enough simply to remember and grieve.”
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.
Health Care Reform and the Health Care Workforce — The Massachusetts Experience
By Douglas O. Staiger, Ph.D., David I. Auerbach, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.
The New England Journal of Medicine, September 7, 2011
In 2006, Massachusetts enacted legislation to provide universal health insurance coverage that later served as a model for the national health care reform legislation passed in 2010.
Since implementing these provisions, Massachusetts has achieved near-universal insurance coverage but has also seen continuing growth in health insurance premiums, a net increase in state spending on health care, and growing political pressures to control cost growth. Polls of the public and of physicians indicate that the state’s health care reforms are generally viewed favorably, though physicians are concerned about access to primary care and administrative burdens.
The Massachusetts reform experience has been watched closely for indications of what might occur throughout the country as national health care reform is implemented under the Accountable Care Act (ACA). One aspect of the Massachusetts experience that has remained unexplored is the impact on the health care workforce, particularly the question of whether greater numbers of health care professionals or support personnel were needed to ensure the success of the reform in increasing access to care.
Since Massachusetts enacted the Health Care Reform Plan in early 2006, total health care employment per capita in the state has grown more rapidly than that in the rest of the country.
Most of the divergence in employment growth between Massachusetts and the rest of the country occurred in 2006 and 2007, when the Massachusetts reforms were being phased in. Had health care employment in Massachusetts grown at the same rate as in the rest of the country, approximately 18,000 fewer people would have been employed in health care by 2010.
Most of the difference in health care employment growth occurred in administrative occupations. From 2005–2006 to 2008–2009, employment per capita in administrative occupations grew by 18.4% in Massachusetts, as compared with 8.0% in the rest of the country. These administrative occupations include management, business and financial operations, and office and administrative support (including medical records and health information technicians). In contrast, employment levels in nonadministrative positions in Massachusetts increased by 9.3% after health care reform, an increase similar to that of 8.6% in the rest of the United States.
The Massachusetts experience provides lessons for national health care reform. First, reform may accelerate the trend toward health care’s being the dominant employment sector in the economy. More important, our analysis supports physicians’ concerns about the administrative burden of health care reforms, an issue that will have to be addressed as the ACA is implemented. Finally, rather than requiring greater numbers of physicians and nurses, reform may require larger numbers of people supporting the work of such health care professionals.
With today’s high unemployment rates, some have celebrated the fact that employment in the health care sector has continued to grow. This study confirms that health care employment in fact has grown within the state of Massachusetts, which has served as a model for our national reform through the Affordable Care Act. Should we be celebrating these newly generated jobs?
When the Massachusetts plan was proposed the policy experts at Physicians for a National Program warned that the additional administrative excesses would add to the already very heavy administrative burden that uniquely characterizes the U.S. health care system. PNHP issued the same warning when the Affordable Care Act was under development.
And what are these new jobs in Massachusetts? According to this report, “Most of the difference in health care employment growth occurred in administrative occupations.” More administration!
Although there is much interest in finding new employment opportunities for residents of the United States, there is also a compelling interest in controlling runaway health care costs. With a single payer system, one of the most important efficiency targets is to reduce this profound administrative waste. Instead, our legislators brought us changes that dramatically increase this waste!
We do need more jobs, but not more administrative jobs in a profoundly expensive health care system that is now almost sinking under the costly added burden of administrative excesses. There are far more important potential employment opportunities throughout society that would benefit all of us if Congress were to enact the type of jobs program that we need.
Instead of adding to our profound administrative waste, let’s use our health care dollars for, of all things, health care!
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.
Downward Mobility from the Middle Class: Waking up from the American Dream
By Gregory Acs
The Pew Charitable Trusts, Economic Mobility Project, September 2011
The idea that children will grow up to be better off than their parents is a central component of the American Dream, and sustains American optimism. However, “Downward Mobility from the Middle Class: Waking up from the American Dream” finds that a middle-class upbringing does not guarantee the same status over the course of a lifetime. A third of Americans raised in the middle class — defined here as those between the 30th and 70th percentiles of the income distribution — fall out of the middle as adults.
Extensive studies have shown that over the past few decades income has dramatically shifted upwards to the wealthiest individuals. This study adds to that data base by showing the impact on the middle class. A third of Americans raised in the middle class have fallen out of the middle (and this was before the economic downturn).
Because health care costs are now so high the middle class can no longer afford to fund an insurance pool that would be adequate to cover their collective health care needs. If the middle class is to receive adequate health care then it is imperative for the wealthy to contribute a greater amount through a progressive financing system (i.e., taxes).
What won’t work is an underfunded welfare program for the poor (Medicaid) and exchanges of low actuarial value under-insurance plans for the middle class, yet this is what the Affordable Care Act is bringing us.
What will work is a single comprehensive risk pool that is equitably funded and includes everyone. If the wealthy were allowed to have a higher standard for themselves with a lower, mediocre standard for everyone else then their support for the health plans serving the “commoners” would diminish. By having a single high standard for everyone, the wealthy would use their influence to see that the health care system met their standards, thereby pulling up the standards for everyone else.
Of course, that is precisely the goal of an improved Medicare for all.
Democrats’ Plan B For Medicare: Medicare For All
By Sally Pipes
Forbes, September 6, 2011
Democrats know the individual mandate might go up in smoke. So they’ve started strategizing a constitutionally sound means of achieving the ever-elusive goal of “universal coverage.”
Their preferred remedy? “Medicare-for-All,” a term popularized by the late Senator Edward Kennedy (D-Mass.) who supported a single-payer, government run healthcare system.
Former Clinton labor secretary Robert Reich laid out the basic idea in a recent op-ed for the San Francisco Chronicle. “So what do Obama and the Democrats do if the individual mandate in the new health care law gets struck down by the Supreme Court?” Reich asked. “Immediately propose what they should have proposed right from the start — universal health care based on Medicare-for-All, financed by payroll taxes.”
This notion has been floated in progressive policy circles in the past. It’s a pure distillation of their government-heavy approach to health care reform. Typically, though, the idea’s been shelved out of fears of political blowback.
Today, when the government extracts Medicare taxes from people’s paychecks, it’s forcing them to assent to this deal: Hand over a slice of your paycheck now, and get government-sponsored health insurance in old age.
Of course, Americans are not allowed to opt out of that deal — just like they won’t be able to opt out of the individual mandate. But unlike the mandate, the taxes that finance Medicare are not in danger of being deemed unconstitutional.
If the individual mandate is actually struck down, Medicare-for-All may become the new rallying cry for progressive luminaries. And if President Obama wins a second term, he may look to heed that cry.
As a Canadian libertarian now serving as President and CEO of the Pacific Research Institute, an organization advocating for free market solutions to America’s problems, Sally Pipes is issuing a warning that “Medicare-for-All may become the new rallying cry for progressive luminaries.” Further, “if President Obama wins a second term, he may look to heed that cry.” Don’t we wish!
Private exchanges offer yet another alternative to group health plans
By Emily Berry
American Medical News, September 5, 2011
With potentially more than 50 state-based versions of a public health insurance exchange set to emerge by 2014, another version of a post-health reform insurance market is emerging: the private exchange.
A private exchange is an existing concept taking on a new name. The idea also has been pitched as a “defined benefit” plan and has been part of a package with a health reimbursement account. Simply put, a private exchange is an alternative to a group health benefit plan. Rather than paying a portion or all of a premium, an employer pays each of its workers a flat amount and sends each to choose his or her plan.
Here’s how a private health exchange works:
An employer decides what it can afford to pay for health benefits — for example, $1,000 per employee per month. Rather than enrolling every employee in the same plan and using the $1,000 to pay for a portion of a premium, the employer puts $1,000 in an account for each worker.
Then one of two things happens: One, the employee works with a third party that acts as a clearinghouse. The worker chooses from any plan available in the individual market, with the clearinghouse administering the employee’s HRA, and helping connect brokers and health plans with the employees who want to buy coverage.
Under the second scenario, the employer sends the worker to a third party that gives him or her a limited set of choices, for instance a range of plans offered by the state’s Blues plan.
A private exchange would be a better deal for the employer than not offering health benefits, because the company can still reap the tax advantage of offering health benefits and avoid the penalty that would apply to companies with 50 or more employees if they decided not to offer benefits, analysts said.
Employers who want to reduce their roles in providing health insurance for their employees, yet do not want to turn their employees over to the state insurance exchanges and pay penalties for doing so, seem to have another option – private exchanges.
One of the greatest benefits for the employer is that they can convert their health benefit programs from a defined benefit to a defined contribution. This shifts the burden of future health care cost increases onto their employees.
In the next couple of years we can anticipate seeing many other similar efforts to skirt the provisions of the Affordable Care Act. It is really tragic that we are going to have to wait until far too many more people are destitute and suffer and die before we are ready to enact the reform we really need – an improved Medicare for all.
Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans
By John Geyman, M.D.
What are the dimensions of the crisis in primary care? How did we get here? How and why have past efforts to resolve it failed? And how can we succeed in rebuilding our crumbling foundation of health care in this country? In Part I, we will outline the dimensions of this crisis; its impacts on our system, patients and their families; and consider what we can learn from failed attempts to rebuild primary care. In Part II, we will look at various policy alternatives, summarize what can be learned from other countries, and propose a comprehensive agenda for rebuilding primary care.
This is admittedly a challenging problem that requires a long view, most likely over one or two generations. Present trends are very unfavorable, and a complete re-orientation of the goals of health care, the roles of physicians and other health care professionals, and fundamental changes in the way we finance health care will be required if we are to deal effectively with the primary care problem.
Both the book and the Kindle ebook are available at Amazon.com:
In “Breaking Point,” John Geyman explains why it is crucial for us to rebuild our primary care infrastructure, and how we can do it. Highly recommended!
By Josh Freeman, M.D.
Originally posted on Medicine and Social Justice blog, Aug. 31, 2011
During the health reform debate, one option we were assured was never seriously “on the table” was “single payer,” or Medicare for All. President Obama, who as a senator had indicated his support for this solution, backed away from it as fast as he could. In this he was undoubtedly encouraged by his many advisors, who have also encouraged bank bailouts, “compromise” on the debt ceiling, etc. (see June 18, 2009,“No Single Payer”: Sebelius – making policy for the powerful). This is not to say that there were not supporters of single payer within government; there were and are. HR 676, “The Improved and Expanded Medicare for All” act, principally sponsored by Rep. John Conyers of Michigan, had nearly 100 co-sponsors in the House. Sen. Bernard Sanders of Vermont introduced a single-payer bill in the Senate. Vermont, in fact, has become the first state to move toward a form of single payer on a statewide basis.
As anyone who has been reading this blog for any amount of time knows, I am a strong advocate of single payer. (A few of the many MSJ references: April 28, 2011 Perception and reality of economic inequality; July 22, 2010, Improving quality and access still requires coverage for all; April 10, 2009, Does the nation need a clear policy on a right to basic health care?).
My reasons for support of single payer are several:
In 1964, President Johnson signed the Medicare Bill in Independence, MO, giving cards #1 and #2 to former President Harry Truman, who had fought for national health insurance in the late 1940s and lost, and his wife Bess.Forty-seven years later, Medicare has proven its importance in providing a single-payer program for seniors. It is the largest payer in the country, and the rates that it pays for services determine those paid by other insurers. While expanding Medicare to everyone should be the centerpiece of health policy, it has instead become the target of proposals to cut coverage to those who already receive it, particularly from the right. This has led to a lot of bad ideas from politicians such as Rep. Paul Ryan and Sen. Joseph Lieberman (see Medicare: We need to expand it, not cut it!, July 1, 2011).
The “poster child” for a single-payer system is Canada, which has had it since the early 1970s. Based on the principle of social solidarity, not often apparent in the US, the Canadian federal government set the criteria for the program (which is also called “Medicare”) and the individual provinces set the specific terms and fund it. There is local (provincial) autonomy within the boundaries established by the federal government (see December 14, 2009, Tommy Douglas and the Canadian Health System; May 27, 2010, Universal Coverage and Primary Care: The US needs both). Several recent articles have addressed the degree to which changes in the primary care system to create “medical homes” in Ontario, Canada’s largest province, have enhanced the quality of patient care, access of patients, lowered cost, and increased the income of primary care physicians (see Rosser et al, “Progress of Ontario’s Family Health Team model: a patient-centered medical home”  ). It is critical to note that this Family Health Team program was really only possible on such a scale because Ontario, like the rest of the country, has a single-payer system.
The importance of increasing, or at least not decreasing, the income of primary care physicians relative to other specialist, has been addressed in several other posts. What about all physicians, as a group? The AMA and other physician groups were, after all, largely responsible for the defeat of Truman’s national health insurance program and were major opponents of the US Medicare and Medicaid programs. Surveys by Physicians for a National Health Program (PNHP, see especially “Single Payer National Health Insurance”) have shown increasing support for single payer among the physician community, with universal health coverage being supported by a majority of US doctors in 20 (Support for national health insurance among US physicians: 5 years later).
A new study may help to persuade physicians that single-payer systems are actually in their financial interest. Writing in August 2011 in Health Affairs, Morra and colleagues report that “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers” (hyperlink to abstract). The title basically says it all. While both Canadian and US physicians spent time (translated into money!) interacting with insurers, the single payer in Canada and hundreds of payers in the US, about patient benefits and payment, the staff of US physicians spent 10 times the amount of time in such activities as did their Canadian counterparts. The authors estimate the cost to US physicians at $82,975 per physician per year, nearly 4 times the $22,205 cost to Ontario physicians. In addition, these costs fall disproportionately highly on small physician practices, which are more likely to be primary care. They conclude that “If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”
From a financial point of view, we have an apparent dilemma in the US. The cost of Medicare is very high and creates financial threats to the economy. The reimbursement from Medicare to providers is often too low to make them a desirable payer. But there is a solution. It involves getting control over costs. First, do not pay for harmful or questionable interventions, do not pay major markups to generate excessive profit for private companies, and use the large scale of government purchasing to get good prices for drugs, unlike the boondoggle of Medicare Part D, the prescription drug program in which Medicare pays retail prices to pharmaceutical companies.
The solution is also to emphasize more primary care and prevention (October 18, 2010 Lower Costs in Grand Junction: More Primary Care, Less High Tech). The next steps will be harder, for they will involve making difficult decisions about the cost/benefit ratios of different types of care, particularly as the availability of new, expensive, high-tech interventions provide allure, if not always results.
The way not to do this is for policies restricting access for a part of the population (working and poor people) to be made by another part of the population (big businesses, politicians, and lobbyists) who will not be affected by those decisions. A single-payer system in which we are all covered by the same benefits does not automatically save money, but at least makes it possible.
 Rosser WW et al, “Progress of Ontario’s Family Health Team model: a patient-centered medical home”, Ann Fam Med. 2011 Mar-Apr;9(2):165-71.
 Carroll A, Ackerman R “Support for national health insurance among US physicians: 5 years later” Ann Int Med 1Apr2008;148(7):566-7.
 Morra D, et al, “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”,Health Affairs August 2011 vol. 30 no. 8 1443-1450.
UnitedHealth Buys California Group of 2,300 Doctors
By Anna Wilde Mathews
The Wall Street Journal, September 1, 2011
UnitedHealth Group Inc. will acquire the operations of a major southern California physician group, in the latest example of how lines are blurring between insurance companies and health-care providers.
The purchase of the management arm of Monarch HealthCare, an Irvine, Calif., association that includes approximately 2,300 physicians in a range of specialties, establishes United’s Optum health-services unit as a formidable presence in the region. Optum had previously taken over the management arms of two smaller southern California groups, AppleCare Medical Group and Memorial HealthCare Independent Practice Association.
In California, deals involving control of medical groups are structured to comply with rules that block most entities from directly employing practicing physicians. Typically, a company like Optum might buy non-clinical assets and sign a long-term management agreement with an independent practice association of physicians such as Monarch.
United has said in the past that providers acquired by Optum will not work exclusively with United’s health plan, and will continue to contract with an array of insurers. But in one sign of the potential complications that might ensue, Monarch is currently in an arrangement with United competitor WellPoint Inc. to create a cooperative “accountable-care organization” aimed at bringing down health-care costs and improving quality.
Consolidation is accelerating, and the largest insurers are positioning themselves to be at the top of the heap.
Excuse a personal note, but this particular merger is difficult for me to observe. Having practiced in Orange County, I watched the founding and expansion of Monarch HealthCare until they dominated health care in our region. As an early opponent of managed care as it was playing out, I certainly had no interest in joining them. Probably because my practice included large numbers of Medicaid, uninsured, and undocumented patients (so many that they crowded out my privately insured patients even though I worked extended hours), Monarch also never communicated an interest in including me in their panel.
What defines a successful health care system? It always seemed to me that success would be when everyone could receive quality health care that was appropriate and without financial barriers that would impair access. Yet The Wall Street Journal implies that success is when you can organize and control the delivery system and corner the portion of the market that has the highest monetary resources.
Although I was far busier than other primary care physicians in our region, I ended up retiring earlier than I intended because the composition of my practice eventually resulted in an unsustainable negative cash flow.
By most standards, at least by the dominant standards of today, I was unsuccessful, and Monarch HealthCare was highly successful. I’m not sure that my patients who couldn’t get past the appointment desks of Monarch physicians would agree when they had success in negotiating past my appointment desk.
Not to be defeated, I made a decision to devote my remaining productive years to promoting a concept of success that serves patients – all patients – without the intrusion of intermediaries such as UnitedHealth and Monarch HealthCare that glom onto the money and try to keep all that they can. Haven’t we had enough of Wall Street’s version of success?
Changes To Medigap Plans Meet Resistance
By Susan Jaffe
Kaiser Health News, August 30, 2011
A provision of the 2010 federal health law seeking to increase Medicare beneficiaries’ share of health care costs is meeting resistance from an unlikely group of 33 state insurance regulators, health insurers and consumer advocates charged with revising Medigap insurance policies that cover most out-of-pocket expenses.
The National Association of Insurance Commissioners assembled the group to come up with ways to raise the beneficiaries’ cost for the most popular and generous Medigap policies, a task Congress assigned to the association in the health law. Since then, the idea of shifting some costs to beneficiaries in Medigap policies has emerged as one of several proposals to reduce the federal deficit.
The proposals suggest that if Medigap policies cover less of beneficiaries’ costs, some seniors will be less likely to overuse Medicare-covered health care services.
“Some of those proposals are fairly dramatic in the cost shifting effect onto seniors,” said Mary Beth Senkewicz, Florida’s deputy insurance commissioner, who chairs the NAIC’s senior issues committee, which includes the Medigap group.
Bonnie Burns, a policy specialist at California Health Advocates and another member of the Medigap group, questioned whether patients need incentives to reduce their use of medical services.
“Beneficiaries don’t order services, providers do,” she said. “To suggest that Medicare beneficiaries overutilize services on a whim because they don’t have ‘skin in the game,’ is pretty disturbing.”
Although some studies have found that seniors with Medigap policies use more Medicare services, Burns said they may be sicker than the average Medicare beneficiary, which is why they bought Medigap coverage.
Several members have suggested that Medigap policies aren’t responsible for Medicare’s growing costs.
William Schiffbauer, a member of the group and an independent health care attorney who has represented insurers, said the health law requires the group to suggest raising beneficiary cost-sharing in Medigap plans in order to encourage more appropriate use of physicians services, based on evidence published in medical journals. Schiffbauer said that the medical literature reviewed so far does not identify which services are inappropriate and should be discouraged by making them more expensive for patients.
The group is being asked to decide what’s medically necessary — an impossible task, he said.
A review of proposed Medigap changes by the Kaiser Family Foundation in July found that one in five Medigap beneficiaries would face higher out-of-pocket expenses, primarily those with health problems and low incomes. The study also noted that the savings to the Medicare program and Medigap members depend on patients seeking less medical care, including treatment they may really need.
Reducing Medicare spending for the wrong reason – by making it inaccessible – also worries members of the Medigap group, including Ruch.
“There may be seniors who would forego medically necessary care because they can’t afford it – even though they have a Medigap policy,” he said.
The Medigap working group established by the National Association of Insurance Commissioners (NAIC) has reinforced the view presented in yesterday’s message that we should be very concerned about forcing out-of-pocket cost sharing onto patients.
Sec. 3210 of the Affordable Care Act (ACA) states, “The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages (in Medigap plans) to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under Part B (of Medicare).”
As stated yesterday, the alleged need for cost sharing is a concept so deeply entrenched within the political and policy communities that a requirement was placed in ACA to mandate the introduction of cost sharing to Medigap plans – plans which have been designed to cover the patients’ exposure to cost sharing. There is something really weird about requiring co-payments for a plan that insures co-payments.
Again, as stated yesterday, cost sharing has only a nominal impact on controlling total health care spending, but it clearly impairs access and imposes financial burdens on those who need care.
As today’s article demonstrates, members of the NAIC working group are appropriately alarmed at the prospect of making recommendations that would impair the ability of Medigap plans to improve access and reduce financial risk. They should be.
Instead of protecting Medigap plans, think what would happen if we were to eliminate the need for Medigap plans by eliminating cost sharing from Medicare – providing first dollar coverage as is commonplace in other nations which spend far less on health care.
Remember that Medigap plans are private health plans with low actuarial values that burn up too much of the premiums for their own administrative purposes and profits. Also they place an additional administrative burden on the providers who must deal with two payers – Medicare and the private Medigap plans.
When we speak of an improved Medicare-for-all, one of the improvements would be to eliminate cost sharing. We would have better access, less burden on people who need care, and at a negligible cost for this particular benefit alone. These costs would be more than offset with the multitude of other savings that would be made possible by a single payer Medicare-for-all program.
Of course, we’d have to go back to Congress… (It seems like there’s a flaw in every plan… in this case depending on Congress to do the right thing.)
For those who didn’t read yesterdays’ crucial message on moral hazard and welfare gain which explains the concerns expressed here, you have another chance by clicking on this link (or at least save it for weekend reading):
As the last three posts have shown, the primary care infrastructure of the U.S. health care system is crumbling, overrun by specialization, sub-specialization and market forces. As a result, access to primary care is not available to a growing part of our population, costs go up as value, quality and outcomes of care go down, and any accountability within the market-based system remains out of reach. The “reform” legislation of 2009 cannot be expected to alleviate these fundamental problems, “building” as they do on our present flawed system of financing and delivering health care. Since all incremental efforts to reverse these trends have failed, we need more fundamental approaches.
Space here does not permit fleshing out the necessary steps to real system reform that would also facilitate the rebuilding of primary care. Briefly, however, most if not all of these approaches will inevitably be required. In their approximate order of priority, they are:
1. Adopt universal health care coverage through single-payer national health
insurance (NHI). This is the only way we will ever get universal coverage so essential for optimal care of individuals as well as our population. It will help to enable the other elements of needed reforms by forcing new approaches to financing care. Exploitive profiteering can be eliminated while simplification of administration can bring greater efficiencies.
2.Rethink the goals of medicine and the paradigm of health care. We have developed a health care system that overemphasizes the reductionist biomedical model, gives short shrift to behavioral and social aspects of illness, and all too often, continues high technology interventions to the point of futility. These are some of the steps that could help to improve the health of individuals as well as our population: closer collaboration between medicine and public health; increased emphasis on health promotion and disease prevention; improvement of chronic illness care; increased emphasis on mental health services; and earlier shift to palliative care when cure is not possible.
3. Change how physicians are paid. Payment systems for physicians are complicated and are subject to being gamed for maximal profit by many physicians and their employers. Managed care of the 1990s placed many restrictions on care in an effort to increase the profits of HMO plans. Overvalued reimbursement of many specialized and procedural services is a major factor in the decline of primary care. By contrast, its services are time-consuming, require broad clinical competence, are more cognitive and less procedural, and are under-reimbursed. While there is room for various reimbursement methods, essential primary care services are best offered without cost-sharing with patients, and the wide gap between compensation of specialists and generalists must be narrowed.
4. Shift to evidence-based coverage decisions. We can no longer afford to offer services that don’t work, are not cost-effective, or are even harmful. But our present methods of deciding on coverage and reimbursement are heavily influenced by politics, lobbying, and the interests of industry and vested medical organizations. Many new technologies are brought to market without objective assessment of their benefits and value by disinterested experts. Other industrialized countries around the world have developed effective ways to apply the best available clinical evidence to this decision-making process, but market forces have resisted such approaches in this country.
5. Re-design primary care based on generalism and interdisciplinary team practice. Past ways of organizing primary care practice no longer work for a variety of reasons. Given the pressures of time and the complexities of practice today, many primary care physicians are burning out and not being replaced. The delivery of primary care services needs to be re-engineered, with primary care physicians seeing a smaller number of patients with more complex problems, working with other team members in their areas of expertise, and coordinating care being provided by consulting specialists.
6. Re-establish a generalist orientation in medical education. Despite the development of new education programs in medical schools and hospitals over the last three decades, the aura of specialization has dominated medical education. Medical school graduates have opted in droves for the increased compensation and more attractive life styles of non-primary care specialties. A physician workforce goal needs to be established for a 50:50 balance of generalists and specialists, together with financing changes that favor institutional change, changes in medical school admissions policies, and expanded scholarship and loan repayment programs for students and residents bound for primary care careers.
7. Create a new ethical environment of accountability in medical practice, education and research. We have a medical-industrial complex, wherein the higher the volume of services that is delivered to patients, the higher the revenues to the providers and suppliers. About one-third of health care services are either inappropriate or unnecessary, some even harmful. (Wennberg, JB, Fisher, ES, Skinner, JS. Geography and the debate over health care reform. Health Affairs Web Exclusive W- 103, February 13, 2002) This problem is driven by widespread conflicts-of-interest among physicians, industry, and others, as described in my 2008 book Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy? All past efforts to rein in these conflicts-of-interest have been ineffective, and the patient is at a disadvantage in evaluating what services are, or are not, worthwhile.
8. Expand primary care and systems-oriented research. The annual budget for the National Institutes of Health (NIH), with its focus on biomedical and disease-oriented research, is about 75 times that of the Agency for Healthcare Research and Quality (AHRQ), the principal source of federal funding for primary care and systems-oriented research. Given the urgency of building a better delivery system based on primary care, we need a far greater investment toward that goal.
9. Tighten regulatory processes and policies. Our regulatory apparatus is too industry-friendly, is understaffed, and needs more federal funding and independence from industry. Right now, the fox is in the hen house. One of many examples: an artificial hip manufactured by a subsidiary of Johnson & Johnson was designed to last about 15 years, but has been failing worldwide at unusually high rates after just a few years. It had been approved through a loophole with lax testing requirements. The company continued marketing its defective product even after whistle-blowing efforts by orthopedic surgeons, and the U.S. still has no tracking system to monitor the experience of artificial hips. (Meier, B. The implants loophole. New York Times, December 17, 2010: B1))
10. Increase protections for patients and physicians against medical malpractice liability. Patients need protection from medical injuries due to negligence while physicians need protection from frivolous lawsuits. But this issue is typically exaggerated (especially by conservatives) as a major cause of health care inflation. That is not the case. Though “defensive medicine” is common, the annual costs of the medical liability system make up only 2.4 percent of total health spending. (Mello, MM, Chandra, A, Gawande, A, Studdert, CM. National costs of the medical liability system. Health Affairs 29 (9): 1569-77, 2010) While this whole issue is immensely complicated, useful steps that will help to protect patients from injury and physicians from unwarranted liability for malpractice include: increased emphasis on patient safety in medical education and clinical practice; increased use of evidence-based practice guidelines as “safe harbors” for physicians; and increased use of arbitration.
Although the current political landscape is unfavorable for this kind of forward thinking, time will probably tell that what seems utopian now is absolutely required not too far down the road.
Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011)
John Geyman, M.D.
Professor Emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program
Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.
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