By James M. Perrin
The Milbank Quarterly, June 2020

Barbara Starfield built the field of primary care research and galvanized research and policy documenting the central importance of primary care in health and health care delivery. Her work spanned decades, showing how primary care improves population health and lowers health care expenditures. It guided many of us in the quest to improve health and health care, and rates of publications with primary care in the title have more than doubled from fewer than 1,000 in 2005 to more than 2,000 in 2018. The remarkable and comprehensive review that Starfield and her colleagues, Shi and Macinko, published in 2005 in The Milbank Quarterly summarized a wealth of US and international studies demonstrating that a) health is better in areas with more primary care physicians, b) people who receive care from primary care physicians are healthier, and c) the main characteristics of primary care are associated with better health. Those studied characteristics are first contact care, holistic person-focused care over time, comprehensive care, and coordinated care, concepts expanded in various primary care medical home criteria at the national and state levels. Furthermore, better health outcomes are found in communities and countries that distribute health resources equitably, have no or low copayments for health care, have a universal financing mechanism guaranteed by a publicly accountable body (government or government-regulated insurance plans), and have professional incomes for primary care physicians comparable to those for other specialists. Systems with strong primary care orientation and where primary care physicians are identified as the usual source of care are associated with decreased racial and socioeconomic health disparities and with decreased deaths from premature mortality, infant mortality, and overall mortality from chronic pulmonary disease, cardiovascular disease, and heart disease.

What progress has the United States made since the 2005 Starfield publication? During this period, the United States has become even more racially and ethnically diverse, especially among younger groups. Many in the health sector—and elsewhere—have recognized the importance of the social determinants of health and the role the health sector can play in addressing those determinants. Growing rates of mental and behavioral health conditions, often coexisting with other chronic health conditions, have spawned progress in integrating mental and behavioral health in primary care teams. Spurred partly in response to the recognition of the multifactorial antecedents of health and the central role of mental health, general and subspecialty clinical practice has increasingly embraced team-based care, including some combination of nurse care coordinators, mental health personnel, and family health workers—a phenomenon that Starfield recognized while pondering how to maintain important personal relationships between patients and providers with the transformation to teams. Much work has gone into training team members in their collaborative efforts and, through such work, emphasizing the importance of maintaining a productive personal relationship with ongoing patients.

Despite these generally favorable changes in primary care, the United States has recently experienced striking increases in mortality among people aged 15-60 years. Although some of this growth reflects the opioid epidemic and other drug and alcohol use, much mortality comes from suicide (reflecting the increase in mental health conditions) and cardiovascular and heart disease, partly resulting from the epidemic of obesity. Although high-quality primary care could prevent many of these deaths, the United States perpetuates a serious imbalance in financial support for primary care versus other health investments, with primary care and mental and behavioral health chronically underfunded. Starfield noted that greater relative investment in primary care improves population health and decreases health care expenditures. The US strategy limits access to preventive care throughout the life course for some populations, especially those with low income. Coupled with the persistence of poverty among young families in the United States—much worse than in other OECD countries—the lack of adequate primary care creates an unhealthy underclass beginning in childhood (or even prenatally) and continuing to affect health and death over the decades. The persistent rapid growth of US health care expenditures further indicates the lack of systematic work to implement Starfield’s findings and recommendations. For example, although the Affordable Care Act included provisions to lower the growth in total health care expenditures, many provisions required upfront funding that Congress declined to provide. This failure reflects a lack of political will to take on a complex and powerful health care industry driven by specialist investigations and interventions, rather than investment in primary care to increase access, promote prevention, improve overall quality of care, and reduce unnecessary and potentially harmful specialist care. The United States has paid the price of increased disability, mortality, and other indicators of poor health along with rising costs, all highlighted by Starfield and her colleagues.

Are there important points of light? The Centers for Medicare and Medicaid Services have stimulated greater investment in primary care, especially through their State Innovation Models and Primary Care Plus initiative. However, here too strategies have had negligible impact on equitable pay for primary care physicians, with, for example, the resource-based value structure oriented to procedures over cognitive services and, thus, balanced against adequate support for primary care tasks. Several states have worked to increase primary care investment, some through their Medicaid programs and others through broader health policy oversight, including direct calls for identifying and increasing the percent of health care dollars spent on primary care from public and private sources. The National Academies of Science, Engineering, and Medicine recently empaneled a new study on Implementing High Quality Primary Care, the first serious attention to primary care by the Academies in more than a quarter century. We can hope this new attention will lead to stronger political will and policy changes that begin to approximate Starfield’s original vision for primary care.

The Milbank Quarterly, June 2020, “Detailing the Primary Care Imperative–Remembering Barbara Starfield”:
https://www.milbank.org…

The Milbank Quarterly, September 2005, “Contribution of Primary Care to Health Systems and Health”:
https://www.milbank.org…

National Academy of Sciences, Engineering, and Medicine, “Implementing High-Quality Primary Care”:
https://www.nationalacademies.org…

Comment:

By Don McCanne, M.D.

It is interesting to observe how much we already know about how we can improve our health care system thereby reducing its profound waste that makes it the most expensive system in the world while improving its performance and outcomes, and yet we fail to act. Two systemic changes that would greatly improve value and performance would be to reinforce and expand primary care, and to enact and implement a single payer national health program – an improved version of Medicare that would include everyone.

Today’s selection honors Barbara Starfield and the legacy she left with her work in describing the virtues of primary care. We clearly need a single payer national health program built on a strong foundation of primary care. The task would not be at all difficult – simply enacting and implementing the single payer and primary care policies that have been well described in many other venues.

Since we know what is wrong, and we know how to fix it, why haven’t we done it? Without getting into the subject of divisive politics, we should recognize the imperative of single payer and primary care and just go ahead and do it. For those who clamor about politics, let’s just push them to the side and move forward. There should be plenty of others out there who would enthusiastically join together with us as we include other important policies such as improving our public health infrastructure, supporting the black lives matter movement, advocating for a sustainable environment, shielding us from the threat of guns, improving housing, reducing socioeconomic inequities – especially the maldistribution of income and wealth, making public education more accessible and affordable, providing opportunity for the Dreamers, and… well, you know, making our nation and the world a better place for all of us.

Let’s just not let great ideas, like those of Barbara Starfield, slip away from us by defaulting to mere inertia. We’re better than that.

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Medicare Payment Advisory Commission (MedPAC), June 2020

As part of its mandate from the Congress, each June the Commission reports on refinements to Medicare payment systems and issues affecting the Medicare program, including broader changes in health care delivery and the market for health care services.

Realizing the promise of value-based payment in Medicare: An agenda for change

The Commission outlines a multiyear effort to establish a strategic direction for Medicare payment policy and delivery system design that could be implemented by the Congress and CMS. This work will be aimed at identifying changes that broaden the use of value-based payment (which characterizes methods of paying for health care services that provide stronger incentives than fee-for-service to control overall costs while maintaining or improving quality) by encouraging more providers to organize into “accountable entities.” Medicare Advantage and accountable care organizations could serve as vehicles to broaden the use of value- based payment, but both programs need to be improved to realize that potential.

The Commission contends that policymakers will need new approaches to both how Medicare pays providers and how services are organized and delivered to address the currently unsustainable trends in Medicare spending.

Challenges in maintaining and increasing savings from accountable care organizations

CMS has made it a priority to move more Medicare beneficiaries into alternative payment models in which providers are responsible for the cost and quality of care. One such model is the accountable care organization (ACO). ACOs are now responsible for 23 percent of Medicare beneficiaries with both Part A and Part B coverage. Given the rapid growth in ACOs, it is important to evaluate whether they are generating savings for the Medicare program and thus helping make the program more sustainable.

To date, ACOs have generated modest savings, with most evaluations estimating 1 percent to 2 percent reductions in spending from existing ACO models. Some have expressed a concern that the ability of Medicare ACOs to achieve savings has been limited because key constituencies are not sufficiently engaged with ACOs and have incentives that run counter to those of ACOs.

Because Medicare savings from Medicare Shared Savings Program ACOs have been relatively small thus far (although still greater than most care coordination demonstrations), there is a risk that those savings could be eroded, or even completely offset, by unwarranted shared savings payments. Patient selection in ACOs could result in unwarranted shared savings payments, whether the selection is intentional or not. For example, if high-cost beneficiaries are disproportionately shifted out of an ACO in its performance year—while remaining in the baseline years—performance-year spending will decrease in relation to the ACO’s benchmark. This phenomenon could occur if clinicians with high-cost beneficiaries bill under a taxpayer identification number (TIN) that is not part of the ACO or if a clinician bills for patients with low spending under the ACO’s TINs and bills for patients with higher spending relative to their risk score under a non-ACO TIN.

The current system allows an ACO to strategically change the composition of its TINs to increase the likelihood of receiving unwarranted shared savings relative to benchmarks, creating a vulnerability for the Medicare program.

Properly matching the clinicians included in an ACO’s baseline and performance years will allow a more accurate assessment of an ACO’s performance and reduce opportunities for unwarranted shared savings.

Replacing the Medicare Advantage quality bonus program

The Commission maintains that Medicare program payments should take into account the quality of care delivered to beneficiaries, and the Commission has formalized a set of principles for designing Medicare quality incentive programs. Medicare’s quality bonus program (QBP) for assessing and rewarding quality performance in the Medicare Advantage (MA) program is not consistent with these principles, and in Chapter 3 we recommend replacing it with a new quality program: the MA value incentive program (MA–VIP).

In our June 2019 report to the Congress, we outlined multiple significant flaws in the QBP program. Those flaws must be addressed so Medicare can have confidence that the MA program encourages and appropriately rewards high quality in a manner that ensures that program dollars are wisely spent.

The Commission recommends that the Congress replace the QBP with an MA–VIP that includes the following five key design elements:

• Scores a small set of population-based measures.
• Evaluates quality at the local market level.
• Uses a peer-grouping mechanism to account for differences in enrollees’ social risk factors.
• Establishes a system for distributing rewards with no “cliff” effects.
• Distributes plan-financed rewards and penalties at the local market level.

To drive quality improvement, policymakers would need to choose an appropriate amount of payment to fund the reward pool and an effective performance-to-points scale methodology.

In the future, we will attempt to take lessons learned from today’s experience into our assessments of Medicare’s payment systems as we help the Congress grapple with the difficult task of controlling the growth of Medicare spending while preserving beneficiaries’ access to high-quality care and providing sufficient payment for efficient providers.

http://www.medpac.gov…

Comment:

By Don McCanne, M.D.

Medicare for All? Look at what they keep doing to Medicare!

First they decided that Medicare needed to be turned over to the private insurance industry, and so they established private Medicare + Choice to show that the private insurers could provide higher quality care at a lower cost. That didn’t work, so they replaced the program with private Medicare Advantage and provided the insurers with various incentives to establish plans which they claim lowered costs but actually increased costs when considering that the private plans were cream skimming the healthier patients. So then they introduced risk adjustment which provided the private plans with another opportunity – upcoding to make their patients appear sicker than they really were so the insurers could qualify for higher payments. And quality? They learned to game that as well.

The policy community recognized that there were problems so they decided we needed a new concept. Let’s put the providers in charge and make them accountable for the costs and quality of care. Well that hasn’t worked either. The cost savings were negligible, especially when considering the unaccounted for costs of the providers and the very modest bonuses that wiped out the savings for Medicare. Again there is evidence that they still do not have effective measurements of overall quality.

These two models – private Medicare Advantage and accountable care organizations have been a failure and should be abandoned and replaced with efforts to improve the traditional Medicare program – a program that has been neglected by Congress and the administrations of both parties. No, they won’t give up. Instead they want to replace the ineffective tools of these organizations with other tools that we can predict will be just as ineffective, but will prolong the life of these organizations that are designed under principles advocated by the medical-industrial complex while neglecting those who really count – the patients.

From MedPAC’s perspective, the problem is with Medicare Advantage and accountable care organizations, and that is what they want to fix. Well it’s the patient, doggone it, that needs relief. Medicare Advantage and accountable care organizations are incurable simply because they are artificial constructs that are designed to control costs while protecting the industry, but that doesn’t work because they are based on market incentives, and players in the market will always work the system to satisfy their own interests; patients are only their tools.

Medicare has some serious deficiencies, and they need to be fixed, but not by MedPAC since they fail to make recommendations on the deficiencies that negatively impact patients. There is a plethora of literature that demonstrates that the single payer model of Medicare for All corrects most of the deficiencies in the health care financing system such that patients would have free choice of health care that is accessible, effective, efficient, equitable and affordable for each of us. Tens of millions do not have that now but could without increasing our national health expenditures over the current level.

If you are not convinced, read the 244 page MedPAC report to Congress to see where we are headed. Then read PNHP’s Physicians’ Proposal. Then report back.

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By Victor R. Fuchs, Ph.D.
JAMA, June 12, 2020

To simply return to the prepandemic health care system during a presidential election year would be a mistake. This is a time to think more boldly about the future of the US health care system. The health care system is dysfunctional for many individuals in the US; it is too costly, too unequal, and too uncertain in its eligibility and coverage, with an increasing number of uninsured. However, designing and implementing a better health care system will not be easy. In exploring the challenges and difficulties ahead, it is useful to distinguish between those that are primarily technical issues (although these are not exempt from politics) and those that are political obstacles to significant reform.

Technical Issues

The technical issues involve 2 main issues: how to raise the nearly $4 trillion each year to pay for US health care; and how to organize and deliver the care and compensate those who provide it.

An important goal of health care reform should be to replace the current byzantine system of premiums, taxes, tax exemptions, deductions, subsidies, and out-of-pocket payments with a much simpler system of financing health care. An equally important goal is to replace the current multiplicity of public and private health insurance programs with 1 universal program that covers everyone from birth to death. Because the US health care system is so large, it would probably be necessary to approach these goals in stages. It is important, however, to realize that the complexity of the current system is one of the main reasons it is so costly, with high administrative expenses.

A few countries find it more feasible to achieve universal coverage through compulsory health insurance administered by insurance companies under close regulation and supervision by the government. The intent and effect of such programs is similar to that achieved by tax-supported public insurance. For historical and political reasons, the US might prefer this approach in contrast to a so-called single-payer system. Regardless of approach, universal systems have proven to be the best way to ensure that everyone has access to care without bankrupting individuals or governments.

Most health policy experts agree that the prepandemic health care system was inefficient. However, there is no consensus as to what delivery system would be better for the US diversity of health plans. The competition among the plans will have several advantages if the plans follow a few general principles. First, the health plans should be private. Government-run health care would not work well for the US for its entire population. Over the past decade, Medicare has become increasingly privatized, with about 35% of its recipients enrolled in private insurance plans. Second, public insurance would pay for everyone to be enrolled in a health plan of their choice, with open enrollment every year for anyone who wants to change plans. Third, the plans would receive a risk-adjusted capitation fee to compensate plans for the differences in the expected use of enrolled populations.

Capitation reimbursement provides incentives to use resources efficiently, unlike fee-for-service reimbursement that provides incentives for overuse. This is not just a theoretical proposition. The Kaiser Permanente Health Plan has been paid per capita for more than 50 years and has seen its enrollment increase to 12 million patients, one-third more than in the Veterans Health Administration care system. Fourth, within that general framework, each health plan should be free to deploy resources as they deem best. Some plans might want to pay physicians a fixed salary; others might want to have productivity incentives for their physicians. Some plans might choose to deploy many nurse practitioners and physician assistants, others might not. Most plans would probably want to emphasize primary care, reserving specialists and subspecialists for patients who need their attention.

Physician-led health plans that receive risk-adjusted capitation payment are in the best position to allocate resources more efficiently and effectively according to judgments about benefits and costs.

Political Obstacles

Changes in the health care system have always been opposed by many. As Machiavelli observed, proposals for a new order face strong opposition from those who benefit from the old order. This group includes high-income patients who prefer a health care system that caters to their interests and values.

The cost of this system, more than $11 000 per person per year, is tolerable for those with high incomes, but oppressive to most individuals in the US and ruinous for many, leading to missed medicines and bankruptcy.

High-income individuals also prefer US health care research that emphasizes product improvement and ignores cost of care.

Opposition to change will also come from the manufacturers of drugs, devices, and equipment who have made large profits under the old system, and from some physician specialists who have made large incomes.

Most voters do not have high incomes, but another major obstacle is distrust of the government by many in the general population. That sentiment may still be true but may change as current events unfold.

Distrust of the government is difficult to dispel, but it is possible to do so as President Roosevelt proved with his New Deal reforms in the 1930s. Even though it has seemed that major reform of health care would only occur in the wake of a major war, a depression, or large-scale civil unrest that changed the political balance, it now appears that the COVID-19 pandemic may provide the dynamic for major political change. If that occurs, major health care reform will be more attainable.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

For decades, Victor Fuchs has been telling us, “National health insurance will probably come to the United States after a major change in the political climate — the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” He now says, “Even though it has seemed that major reform of health care would only occur in the wake of a major war, a depression, or large-scale civil unrest that changed the political balance, it now appears that the COVID-19 pandemic may provide the dynamic for major political change.”

In the past he has supported government vouchers to purchase private health plans. He apparently still supports competition of private health plans as in the Medicare Advantage program, though he does state, “an important goal is to replace the current multiplicity of public and private health insurance programs with 1 universal program that covers everyone from birth to death,” presumably considering traditional Medicare plus Medicare Advantage health plans to be “1 universal program.” He singles out Kaiser Permanente as an example of a private health plan – a delivery system that would be included in a single payer Medicare for All program anyway.

It looks like we are very close to agreement on the restructuring of the financing system for health care. And we do indeed have a major change in the political climate with the COVID-19 pandemic and its economic consequences. Though some are looking for a rapid end to the pandemic and a quick economic recovery, that is not going to happen. As the reality that we are in this for the long haul sinks in, the nation should be ready to move forward with single payer Medicare for All – a stable health care financing system that can withstand war, depression, large-scale civil unrest, or even a catastrophic pandemic.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Adam W. Gaffney MD, MPH, Laura Hawks MD, David H. Bor MD, Steffie Woolhandler MD, MPH, David U. Himmelstein MD & Danny McCormick MD
Journal of General Internal Medicine, June 10, 2020

We analyzed a nationally representative survey to identify individuals at elevated risk for severe COVID-19 and, among these, those at high risk of financial toxicity from care at the start of the epidemic.

Discussion

At the start of the outbreak, 18 million adults at increased risk of severe COVID-19 were inadequately insured and hence at risk of delay in seeking care because of cost concerns and of financial toxicity if hospitalized. Traditionally disadvantaged groups—racial minorities, low-income persons, and rural residents—were more likely to be at risk of severe COVID-19 (consistent with the experience of previous viral respiratory epidemics) and of financial harm. Those living in states that failed to expand Medicaid or issue a stay-at-home order were also at greater risk of severe disease and inadequate coverage.

Gaps in insurance coverage, and states’ decisions to reject Medicaid expansion and defer prevention measures, may hence exacerbate the damage wrought by the COVID-19 epidemic, as well as health disparities. Rising unemployment after the onset of the epidemic in the USA will likely translate into health coverage losses that could further widen these gaps; our estimates of uninsurance and underinsurance are likely underestimates. These findings provide support for steps taken to address inadequacies in coverage for the diagnosis and treatment of COVID-19 and for the consideration of additional policies that could expand coverage during the economic downturn.

https://link.springer.com…

‘Lethal Inequality’: New Study Shows Millions at High Risk of Covid-19 in US Lack Adequate Health Insurance

By Jake Johnson
Common Dreams, June 10, 2020

Dr. Adam Gaffney, a critical care physician and lead author of the study, said the coronavirus pandemic “is laying bare the lethal inequality of American society and American healthcare.”

“Our ICU has been flooded with poor and minority patients; having Covid-19 is scary enough without worrying that you’ll be bankrupted by medical bills,” said Gaffney, who works at the Cambridge Health Alliance and Harvard Medical School and serves as president Physicians for a National Health Program (PNHP).

“These promises of new protections for patients with Covid-19 are full of holes,” said Dr. Danny McCormick, a primary care physician and senior author of the study. “Covid-19 threatens the health of people everywhere, but only in the U.S. will it also ruin patients financially. When people avoid testing and care because they fear the costs, it fuels the epidemic’s spread.”

Dr. Steffie Woolhandler, distinguished professor of Public Health at CUNY’s Hunter College and another of the study’s authors, said the new research bolsters the case for both an emergency expansion of Medicare to the uninsured—as proposed by Sen. Bernie Sanders (I-Vt.) Rep. Pramila Jayapal (D-Wash.)—and an eventual transition to Medicare for All.

“It’s not just Covid care that’s unaffordable,” said Woolhandler, co-founder of PNHP. “Patients with heart disease, asthma, and diabetes need protection too. Medicare for All is the long-term answer.”

https://www.commondreams.org…

Comment:

By Don McCanne, M.D.

As Steffie Woolhandler states, “Medicare for All is the long-term answer.”

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By Michele K. Evans, M.D., Lisa Rosenbaum, M.D., Debra Malina, Ph.D., Stephen Morrissey, Ph.D., and Eric J. Rubin, M.D., Ph.D.
The New England Journal of Medicine, June 10, 2020

The role of the physician in times of social injustice and societal distress is difficult to navigate. Since the importation of enslaved Africans as chattel to provide the labor that built this country began, Americans have functioned within the intricate injustices that are the vestiges of that institution. Slavery has produced a legacy of racism, injustice, and brutality that runs from 1619 to the present, and that legacy infects medicine as it does all social institutions.

In an effort to engender trust in what they would like to see as a “postracial” society, some U.S. clinicians proclaim that they ”don’t see color.” But color must be seen. By looking through a racially impervious lens, clinicians neglect the life experiences and historical inequities that shape patients and disease processes. They may inadvertently feed the robust structural racism that influences access to care, quality of care, and resultant health disparities.

In the review of systems, we query patients about exposure to toxicants, but we never ask about one of the most dangerous toxicants: racism. The work of David Williams details the morbidity and risk of death related to perceived discrimination. Discrimination and racism as social determinants of health act through biologic transduction pathways to promote subclinical cerebrovascular disease, accelerate aging, and impede vascular and renal function, producing disproportionate burdens of disease on black Americans and other minority populations.

Even as the social contract between the government and the American people has frayed in the complex struggle over the pandemic, racial injustice, and police brutality, physicians must reflect on the condition of medicine’s own contract with society. Our society expects physicians to live up to standards of professionalism, deliver state-of-the-art, timely care with competence and integrity, and promote the public good. To carry out these duties, physician-citizens must recognize the harm inflicted by discrimination and racism and consider this environmental agent of disease as a vital sign — alongside blood pressure, pulse, weight, and temperature — that provides important information about a patient’s condition. Medical skill has allowed us to respond rapidly to a novel virus to save lives; we must also use our expertise to address racism and injustice and to protect vulnerable people from harm.

Now, amid an acute public health crisis that is transforming medicine, perhaps we have an opportunity to reset our priorities to face this deeper, more chronic crisis as well. It is time to reimagine the medical interaction and the doctor–patient relationship, recommitting ourselves to the quiet work of doctoring and building trust with individual patients. We can become more conscious of our biases when we care for minority patients and push ourselves to go the extra mile.

As the vulnerability and inadequacy of our health care system are once again exposed, it is also time to reconceive that system, including the development of its workforce.

Direct action to eliminate persistent health disparities obliges us to redouble our demands for a system that recognizes health care as a human right, providing an avenue to health equity for all.

Although effecting such fundamental transformation may feel impossible, the energy, idealism, and visions of young people have long fueled movements for change. Martin Luther King, Jr., was 26 when he led the Montgomery bus boycott and 34 when he delivered his powerful “I have a dream” oration. If we blend our voices with those of the newest members of our profession to advocate for the most vulnerable and to reinvigorate every aspect of their care, perhaps we can use our current public health crisis as a catalyst to, as Reverend Al Sharpton put it, “turn this moment into a movement.”

The full article can be accessed for free at this link:
https://www.nejm.org…

Comment:

By Don McCanne, M.D.

We’ve heard these phrases before:

• “society expects physicians to promote the public good”
• “As the vulnerability and inadequacy of our health care system are once again exposed, it is time to reconceive that system”
• “a system that recognizes health care as a human right”
• “health equity for all”
• “turn this moment into a movement”

Nowhere in this article did the authors mention a universal, accessible, equitable, and efficiently-administered national health program – a single payer model of an improved Medicare for All – but that would provide a tremendous start and major contribution to a strong foundation for treating systemic racism. It’s doable and affordable.

Let’s turn this moment into a movement.

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