PNHP

Can we afford preventive services?

Can we afford preventive services?

American Journal of Public Health
April 2003
Primary Care: Is There Enough Time for Prevention?
By Kimberly S. H. Yarnall, MD, Kathryn I. Pollak, PhD, Truls Østbye, MD,
PhD, Katrina M. Krause, MA and J. Lloyd Michener, MD

Abstract

Objectives: We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

Methods: We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

Results: To fully satisfy the USPSTF recommendations, 1773 hours of a physician’s annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

Conclusions: Time constraints limit the ability of physicians to comply with preventive services recommendations.

Discussion (excerpt):

Choosing the best available services is a laudable goal in light of the time pressures faced by physicians. It would be preferable, however, to pursue solutions that do not require clinicians to abandon applicable and effective services. Alternatives that extend beyond the current model of face-to-face patient care, such as group visits with physicians and nurses, use of health educators or dietitians for counseling, and various forms of patient education through telephone or print or electronic media, should be explored further.

It has also been suggested that physicians and nonphysician clinicians should work together, providing illness care and wellness care, respectively. This is perhaps the most promising model currently available, especially because the number of nurse practitioners and physician assistants is expected to increase. This form of practice will require new relationships among physicians, nurse practitioners, and physician assistants that build on their complementary strengths. Delivery of services through other health care professionals or new media will require changes in the current method of reimbursement for preventive services, as well as further research to develop strategies for organizing such delivery.

Currently recommended preventive services for the US population require an unreasonable amount of physician time. The magnitude of the problem is likely to increase as new genetic tests become available. Our current system of preventive care delivery-provided by physicians seeing patients for acute visits and for periodic preventive health evaluations-no longer meets national needs. New methods of preventive care delivery are required, as well as a clearer focus on which services can be best provided, and by whom.

http://www.ajph.org/cgi/content/abstract/93/4/635

Comment: There is no argument about the benefit of evidence-based preventive services and that they should be included in any system of healthy care delivery. There is some dispute about the cost of such services. A frequent claim is that such services reduce costs by preventing more costly medical problems. Considering the tremendous amount of resources that would have to be devoted to this effort brings into question whether cost savings can be achieved, especially when you consider that preventing some disorders will not prevent individuals from eventually developing other costly pathological conditions. Nevertheless, the benefit of prevention in maintaining a better quality of life makes it imperative that we should pursue methods of providing access to proven preventive services.

It is quite clear that our current system has been incapable of meeting this challenge, and, as structured, will never find enough resources to fund these services, not when we continue with policies that prioritize funding administrative waste over “unnecessary” preventive services.

It is impossible for primary care physicians to devote over seven hours a day to preventive services. But a single, integrated system, funded with a global budget, could allocate resources specifically to these services. It is also clear that these services could be delivered at a lower cost if we changed from primary physician micromanagement of the preventive services to “specialists” in this field. Such specialists might include nurse practitioners, physician assistants, or even a new category of prevention professionals, working within the integrated health care team. Establishing streamlined protocols that could efficiently process large numbers of individuals, supervised by individuals specifically trained in preventive services, could greatly expand access to these beneficial services in a much more cost-effective manner.

This is yet one more reason to abandon our inefficient, fragmented system of funding health care and adopt a single publicly-administered program of health care coverage.

Cost-sharing reduces likelihood of receiving effective care

Kaiser Commission on Medicaid and the Uninsured
March 2003
Health Insurance Premiums and Cost-Sharing:
The Impact on Low-Income Populations

Cost-sharing has a disproportionate impact on low-income people. A number of the research studies have used data from the RAND Health Insurance Experiment (HIE) – a randomized, controlled experiment supported by the federal government in the 1970s that remains the most comprehensive, rigorous study of cost-sharing, health care utilization and outcomes that exists. Analysis of RAND data showed that low-income children in cost-sharing plans had only a 56% likelihood (85% for higher-income children) of receiving highly effective care for acute conditions relative to those with no cost-sharing (Lohr et al, 1986). Similarly, low-income adults in cost-sharing plans had a 59% likelihood of receiving highly effective care relative to those with no cost-sharing. Higher income adults in cost-sharing plans fared better – they had a 71% likelihood of receiving highly effective care.

Conclusions

Research shows that premiums can discourage enrollment in health insurance programs and cost-sharing disproportionately affects low-income people, reduces the use of beneficial, cost-effective services, preventive care and prescription drugs and can result in worse health outcomes. Limiting access to services through cost-sharing, particularly outpatient care, may result in higher costs overall, if more expensive services, such as hospital care, are used instead. In view of the greater health needs and limited resources of low-income individuals, these findings warrant caution as policymakers consider the use of premiums and cost-sharing in public programs for people with modest or low incomes.

Fact sheet: http://www.kff.org/content/2003/4072/4072.pdf

For the full report: http://www.kff.org/content/2003/4071/4071.pdf

Comment: Much discussion regarding controlling health care costs has centered around the theory that patients waste resources by obtaining care that they don’t really need, and that they wouldn’t do so if they had to share in the costs of that care. But this report confirms that studies have shown that cost-sharing reduces the likelihood of receiving “highly effective” medical care. This impact is severe for low-income individuals, but it is important to realize that it negatively impacts higher-income individuals as well.

Other studies have confirmed that over-utilization is a very real problem. But in the physician-patient relationship, it is the physician who has the knowledge and expertise to decide on optimal use of our resources. The patient is not deliberately seeking ways to over-utilize the system, but rather is turning to the physician for the best advice on health care. A better approach to over-utilization (and under-utilization, also a problem) is to have an integrated system which can identify provider outliers. Then a corrective educational process can be instituted. Punitive measures would be considered only for those providers who fail to respond to the educational process.

We need policies that contain costs through mechanisms that do not prevent people from accessing effective health care. Rather than erecting financial barriers in the form of financial disincentives, we can corral costs through global budgeting. The funds would still end up in the hands of the providers, but, in an integrated system, patients would receive the care that they really need.

Radiology opinion article: It is time for a change

Radiology
April, 2003
Rationing in Health Care: Changing the Patterns of Health Care
By Richard M. Friedenberg, MD

Managed care has been our first attempt at cost-efficient medicine. It has achieved many of its goals and in many ways has improved upon the cost-effectiveness of third-party insurance. However, it has failed totally in producing universal health coverage, and as a nation, we cannot afford to allow this to continue. More than 1.4 million Americans lost their health insurance last year, with our uninsured population exceeding 41 million (18). Health care insurance rates increased 12.2% in 2001 and 8.1% in 2002, and they are projected to increase 13.6% in 2003 (18). It is time for a change. We have two choices; we can attempt a blend of private insurance and government subsidies or go directly to a single-payer system.

http://radiology.rsnajnls.org/cgi/content/full/227/1/5 (controlled access)

Comment: To see a call for universal coverage in this leading journal for radiologists is a major step forward. We do have the two choices mentioned, but the better one would eliminate the source of much of the grief in our system today – the private insurance plans. But Dr. Friedenberg is certainly correct when he says that it is time for a change.

This helping hand for the uninsured is empty

Daily Press
April 1, 2003
A helping hand to the uninsured
By Alison Freehling

RICHMOND — You need a medical treatment to save your life, but you don’t have health insurance and you don’t qualify for public assistance. You don’t have money to pay for care. You’re stuck – and you’re dying.

Those are the people that state health officials are trying to reach with the Uninsured Medical Catastrophe Fund, a little-known program that’s now aiming to get more attention and financial support.

The fund, administered by the state Department of Medical Assistance Services or DMAS, can cover the cost of inpatient and outpatient care, laboratory tests, X-rays, medicine, some transplants and rehabilitation programs for uninsured patients who meet certain criteria. The program runs strictly on donations.

The program – the first of its kind in the nation – has gotten off to a slow start, and it remains unclear how many people it will be able to help. So far, just one patient has qualified for aid. The fund has about $100,000 in it, not a lot of money given the price of medical care.

The gradual start has had an advantage, (DMAS manager Debbie) Giffen said: It allowed the state to avoid a rush of applications before the program’s framework – and some money – was in place. “My fear was that we would be overwhelmed with need,” she said.

If Sen. George Allen has his way, the state fund soon will become a national model. Allen and Rep. Virgil Goode, both Virginia Republicans, recently introduced a bill in Congress that would create a similar federal program. “Working families who are not able to afford health insurance can quickly find themselves in a desperate situation,” Allen said.

http://www.dailypress.com/news/local/dp-76896sy0apr01.story

Comment: A state program of voluntary donations for the uninsured that has been a miserable failure should become a national model? Sen. Allen, get serious!

D. Light on administrative costs

Donald W. Light, Ph.D., Professor of Comparative Health Care Systems, University of Medicine & Dentistry of New Jersey, responds on the administrative costs in health care:

When Scott Serota, the CEO of the Blue Cross and Blue Shield Association explains that 85.7% of commercial premiums go to pay medical claims, he is wrong and misleads the American public. It is not true, as he states, that “This report clearly demonstrates that the majority of premium dollars are being spent on healthcare services,” unless he means more than 51%.

After BCBSA takes its 14.3%, which is lower than many other insurers, doctors’ offices pay out 35-45% for administration, billing, collections, and related services which do not go to medical services or claims to pay for them. Hospitals take out somewhat less, about 25-28%. Then, beyond the cost of premiums are the high search and benefits costs of employers or other contracting groups as well as all the administrative costs of clinicians trying to get paid for services to sick patients who do not have insurance.

These high costs are due to a highly inefficient structure of voluntary, competitive health care in highly inefficient markets with many features of market failure that give less care and less choice for more cost. Such a system wastes money for businesses and for government. President Bush’s new plan to use state power to coerce people into a private Medicare market, will increase transaction costs further. All this waste and inefficiency, however, provides parasitic industries with their bread and butter. Inefficiency and market failures are good for health care business!

(These comments are in response to the following Quote of the Day: https://pnhp.org/news/archives/001674.php)

J. Gordon on administrative costs

Jeoffry Gordon, MD, MPH, responds on administrative costs:

It is important to point out that Professor Donald Light underestimated the actual administrative costs for most of us here in California. Here many insureds are in HMOs and the insurance companies do not contract directly with physicians but through intermediary physician independent practice associations or IPAs. Most IPAs consume 10 to 15 per cent of the money available for its adminstrative functions ( some of which may provide value but all of which are diverted from direct medical care.)

Fiction of higher quality through private systems

Independent.co.uk
April 2, 2003
Private hospital’s Caesarean rate is twice the national average
By Matthew Beard

The rate of Caesarean births at the private-sector Portland Hospital in London is double the national average, a report says. The study found the clinic wanting in six out of eight standards for maternity services.

Inspectors from the National Care Standards Commission (NCSC) called for an audit of Caesarean births at the 88-bed hospital after discovering they accounted for 43 per cent of deliveries in a draft report.

http://news.independent.co.uk/uk/health/story.jsp?story=393106

Comment: Opponents of government involvement in health care frequently cite the private sector of the British system as an example of the need to escape public systems in order to receive a higher standard of care. Is a 43% Caesarean section rate representative of the “higher quality, more advanced technology” that they are seeking?

Labor-management negotiations will not solve the health care crisis

Detroit Free Press
April 1, 2003
For UAW, health pay is a crisis nationally
By Jeffrey McCracken

The head of the United Auto Workers put automakers on notice Monday: You can’t stem rising health-care costs by shifting the burden to workers and retirees. The auto industry alone can’t solve “America’s health care crisis.”

“A lot of people, especially in the press, are curious about how we are going to solve the problem of rising health-care costs during this year’s auto talks. The answer is, we’re not. It’s a national problem that demands a national solution,” UAW President Ron Gettelfinger told the Detroit Economic Club at Cobo Center.

“We need a universal, comprehensive single-payer health-care program to cover every man, woman and child in the United States. You can’t fix the health-care crisis in America at any one bargaining table with any one employer or within any one industry.”

http://www.freep.com/money/autonews/uaw1_20030401.htm

Med student to lead rally on insurance

By Matt Leingang
Democrat and Chronicle

(March 26, 2003) — A certain realization comes over medical students during their training, argues Corey Fehnel, a first-year medical student at the University of Rochester.

“You see how fragmented the payment system is in health care, and you realize that it’s not sustainable,” says Fehnel, 24. “There are too many questions about who has insurance, who doesn’t and how that affects quality of care.”

The solution, Fehnel argues, is a single-payer health care system for the United States, and he’ll lead a rally for it at 5:30 p.m. Thursday at the UR Medical Center’s Flaum Atrium. Some veteran physicians in the Rochester community are also expected to lend their support.

Fehnel is a member of the American Medical Student Association, which has long advocated national health insurance.

Congress has remained largely deadlocked for years over how to approach reforms to the U.S. system, where costs continue to rise at more than 10 percent each year and more and more consumers find themselves unable to afford private health insurance premiums.

About 41 million Americans lack health insurance.

Patchwork reforms won’t work, Fehnel says.

The AMSA single-payer plan calls for the federal government to finance health care, but it leaves the delivery of health care to mostly private control.

Patients would have their choice of provider; physicians would no longer be constrained by a patient’s insurance status; hospital revenue would be more stable; and much of the bureaucracy needed for handling the dizzying array of private insurance plans would be eliminated.

“There’s no question, based on the Canadian experience with a single-payer system, that health care that is financed and delivered this way is far cheaper and less confusing to consumers,” says Dr. Kevin Fiscella, a family practitioner in Rochester who will attend Thursday’s rally.

The downside of a single-payer system, critics argue, is that thousands of people who work in the insurance industry would lose their jobs, and politicians would be left in control of deciding which hospitals would get funding for new technology and other capital improvements.

Questions of quality — long waits for specialty services, such as CAT scans and MRIs — also dog the Canadian system.

No system is absolutely perfect, but lessons can be learned from Canada about how the United States can develop a single-payer plan that ensures both low cost and high quality for everyone, Fiscella says.

http://www.democratandchronicle.com/news/forprint/0326story8_news.shtml

Breaking the backbone of primary care

American Academy of Family Physicians
Press release
March 20, 2003
Medical Student Interest in Primary Care Continues to Decline

In the United States, graduating medical school seniors pursuing careers as doctors are more apt to choose a non-primary care specialty in 2003. Preliminary information released today by the National Resident Matching Program indicates that the 2003 initial fill rate for family practice residency programs is 76.2 percent or 2,239 positions filled out of 2,940 positions offered. This represents a 5 percent decrease from last year’s initial fill rate and continues a six-year trend that began in 1997.

James C. Martin, M.D., FAAFP, President, AAFP:

“This continuing decline in the number of future family physicians will be devastating to the health of the American people. Family doctors conduct almost 200 million office visits each year – that’s 75 million more visits than any other medical specialty. Family physicians are the backbone of the American health system.”

“The current U.S. health care system does not appropriately value the essential function of family physicians. This undervaluation is especially apparent in two areas: the system’s inadequate reimbursement for patient services, including those provided by the federal government to Medicare patients, and a negative medical school educational environment.”

“The AAFP identified this trend of declining fill rates for family medicine more than five years ago and funded major studies from 1998 to 2000 at the University of Arizona, Tucson, to determine the cause.”

“Results of the Arizona University studies indicate that medical schools need to address the important role the following factors play in whether medical students pursue a family practice residency: medical school admissions policies, poor faculty role models, and a medical school culture prone to disparaging family medicine. Initial results from the FFM research point to extraordinary hours worked for inadequate reimbursement, a limited scope of practice, and the general feeling that family physicians, with their breadth of training, are not as highly valued as a sub-specialist with a very narrow scope of practice.”

“With the health care needs of millions of Americans at stake, our medical schools must provide a positive training environment for future family physicians. The federal government can help by supporting programs that enhance medical school and residency educational efforts, and patient care initiatives. Such support would require a reversal of current proposed budget cuts – the Bush Administration’s proposed 2004 budget slashes federal funding for primary care training programs by an alarming 96.28 percent. These are the only federally funded programs designed to address the shortage of primary care physicians in America.”

“As noted by Barbara Starfield, M.D., M.P.H., ‘There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service. In a major cross-national comparison…, countries with strong primary care systems were found to have lower health care costs than those countries with weaker primary care infrastructures… States in the U.S. that have more primary care resources have better health outcomes for just those indicators that would be expected to respond to primary care alone, even when income inequalities within the states are taken into account.'”

http://www.aafp.org/x20089.xml

Comment: This problem should not be formulated as a conflict between specialization and primary care. Specialized care has its own set of issues which include proper allocation of our finite resources, access to advanced technologies, fragmentation of services, inequitable compensation, isolation from the rapidly expanding body of knowledge in general medicine, and other deficiencies that can result from being isolated in a small niche of medicine. An integrated health care system can more readily address these issues, providing guidelines to improve the role of specialists within the global health care system.

On the separate issue of primary care, Dr. Starfield is absolutely correct when she states, ‘There is no longer any doubt of the importance of primary care as the key to an effective and efficient health service.” Every effort must be made to sustain the primary care fields, including family physicians, general internists, pediatricians, nurse practitioners and, in some instances, obstetrician-gynecologists. Once we are ready to transform into an integrated system we must have in place the substrate and foundation of a primary care system.

As a first step, we should adopt a universal, publicly-administered system of funding health care. Under the single payer model, regional allocation of our resources would ensure the support a strong primary care system.

Don McCanne, M.D., FAAFP Charter Fellow, American Academy of Family Physicians Charter Diplomate, American Board of Family Practice Life Member, American Academy of Family Physicians

(Although I have revealed my past bias for family practice, my current bias in my work on health care reform is for an affordable, efficient, effective, accessible, high-quality, universal health care system. That system needs a strong primary care base supported by appropriate specialized services.)

Longtime activist died deciding whether to call for help

Robar held key roles at SDC, moved well between cultures

By AMY RABIDEAU SILVERS
asilvers@journalsentinel.com

Last Updated: Nov. 2, 2002

Audrey Robar, a longtime community activist, died of an apparent heart attack while trying to decide whether to call for medical help.

Robar had worked at the Social Development Commission until Sept. 9. Her health insurance had expired at the end of September. Robar had found a part-time job with benefits but had not yet decided whether to begin paying the cost of temporary insurance.

She was 63.

After a couple weeks of being unable to shake cold symptoms, Robar began to feel much worse Oct. 23. She called a sister, Aldene Egan, after 4:30 a.m.

“I’ve got this pulling in the muscles across my chest and my arms,” Robar said, according to her sister.

Egan told her that it sounded like a heart attack and that she should call 911 right away.

“But I don’t have any insurance,” Robar said.

Robar went to get her paperwork, then told her sister she felt dizziness and pain in her neck.

Egan heard her sister fall and the sound of her gasping for breath. Then there was silence.

Egan hung up and called for help. Emergency personnel broke the door down at Robar’s northwest side home. Efforts to revive her failed.

Robar worked for the SDC twice, for a total of 18 years, most recently since 1996. In 1999, she was promoted from manager in the education, employment and training department to director of research, planning and evaluation, reporting to executive director Deborah Blanks.

“I don’t think anyone at that agency could give more than Audrey did,” said Norma Madison, a friend from SDC who now is with the Milwaukee Urban League.

Friends said Robar was relieved to have landed a new job and planned to start Nov. 1.

Janice Wilberg, an elected commissioner with the SDC, said she knew Robar for 20 years in Robar’s many community roles.

“She worked in the Hispanic community, the African-American community,” Wilberg said. “She had an emerging role in the Hmong community. She was all over the map. . . . She could cross all this cultural junk that traps other people.

“She just had a lot of energy. She was tireless. She never did it for the pay – she sure never did it for the pay. She just put her shoulder to the wheel and did it.”

Robar, born in Milwaukee, was the second of seven children. She would sometimes share stories of poverty during her own childhood. Her father, often absent, moved the family around the Midwest. For years, they lived without any kind of permanent shelter, often without water or electricity.

Once her father built a sort of house on the back of a flatbed truck. At other times, the family lived in a makeshift trailer, an Army barracks bus and a tent.

“That was where she got her intuition and inspiration,” said daughter Alice Orlich, of her mother’s work with the poor.

Robar’s mother eventually returned with the children to Milwaukee, where Robar graduated from South Division High School.

She began working with community programs, earning an undergraduate degree in community education from the University of Wisconsin-Milwaukee and later a master’s degree, also from UWM. Positions included working in leadership with the Bay View Community Center and Career Youth Development, and with the board for the Sixteenth Street Community Health Center.

Robar and her husband, Sam Orlich, divorced in 1972. She is survived by daughters Eva Robar-Orlich and Alice Orlich; son Sam Orlich; mother Alice Kowalski; sisters Aldene Egan and Arlene Zakhar; and brothers Alfred, Arlen and Allen Robar.

A memorial gathering will be from 5 to 9 p.m. Monday at Milwaukee Friends Meeting house, 3224 N. Gordon Place. A service will begin at 7 p.m.

A version of this story appeared in the Milwaukee Journal Sentinel on Nov. 3, 2002.

http://www.jsonline.com/news/nobits/nov02/92735.asp

A health plan for the rotating pool of uninsured

(In reading today’s quote, please ignore the deficiencies of a verbatim transcript of a spontaneous response given during the Q&A segment of the presentation, but concentrate instead on the message.)

Alliance for Health Reform March 21, 2003 Washington, DC

“Dynamics of the Uninsured”

ED HOWARD: Let me just ask each of our panel members if we don’t have any other questions from the floor if they care to take about 30 seconds and sum up what you think folks ought to take away from this discussion. We have a budget resolution that’s making its way through at least one House of the Congress and probably the other House soon at least in some iterations it will have some money that is intended to address the problems of folks without insurance. How should that money get spent? How should we apply it to this discussion that we’re having this afternoon? And what next steps ought to be at the highest priority in that context? Or you can tell us anything else you want.

PAMELA FARLEY SHORT, Ph.D., Professor of Health Policy and Administration and Director, Center for Health Care and Policy Research, Penn State: Well I guess one idea or thought that I’d like to share and I haven’t had a chance to share so far is just that to say that one of the things that seems to me is really lacking in our patchwork kind of system of health insurance is a source of coverage that’s reasonably priced and that people can hang onto as their personal circumstances change. So whether – and that is an impediment to – it complicates the issue and the problem of using almost any kind of financing strategy for example if we have tax credits you still have the problem of where are people going to buy reasonably priced insurance on terms that are just not as favorable as large employers offer at least closer to that than people can buy on the individual market. So one of the reasons why there’s so much turning and so much turnover is that there really is no place that people can be insured as their incomes go up and down particularly as their incomes kind of float around some eligibility limit so that if we had whether it be and there are lots of different ideas on the table as to what such a universal source of individual health insurance might be ranging from expanding and allowing people to buy into public programs of Medicaid or Medicare at older age levels, purchasing cooperatives, the federal employees plan, the state employees plans and there’s a lot of ideas about what that might be but at the moment nothing like that exists and so what happens is that as soon as people’s income goes up so that the state will know and the federal government will no longer pay for them to have coverage for Medicaid they have to leave that source of coverage and find another it’s not and if we could move towards the direction of some of a system where the coverage could stay put you just are covered from a given place and you keep that plan and your kids they’re covered with you but what changes as your circumstances change is who’s paying for it and that may be a way of getting ourselves out of some of the problems that we currently confront so that as your income rises you pay more, if you have a job your employer doesn’t necessarily provide you with the coverage but pays into you know contributes towards your coverage you know this is kind of a system that you know in essence union employees have that sort of situation because their jobs change so much and maybe if we could figure out a way to get a place that everybody could buy then almost any financing strategy from you know tax credits to buying it yourself even for those high income people would be a lot easier.

http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=806

Comment: There is growing recognition that the pool of uninsured is not a single relatively stable (though expanding) group of individuals. In fact, it is quite unstable as individuals rotate in and out of various programs based on eligibility or ability to pay. Change in employment status changes eligibility for employer-sponsored programs. Moving in and out of poverty status changes eligibility for public programs for low-income individuals. Change in health status affects eligibility for individual coverage. Change in age affects eligibility for SCHIP or Medicare coverage.

Dr. Short is quite correct. We need an affordable, comprehensive health insurance product that will always be ours, regardless of employment status, health, age, income level, or any other arbitrary determinant of insurance eligibility. But which insurer will offer that kind of product?

Why is there a deafening silence in response to this question?

It’s quite clear that only a universal, public-insurance program can ever fill that bill. Once we accept this principle, it would be very easy to develop a strategy for equitably financing the system.