By Dr. Ken Dolkart
Concord (N.H.) Monitor, March 19, 2017
Have you ever heard people talk nonsense? Perhaps you’ve had a laugh when you hear people talking through their hat about a machine you work on, or a technique you know. Primacy care doctors recently found it less than amusing to hear politicians misapply the concept of “patient-centered care” to promote a poorly designed replacement for Obamacare.
The idea of “patient-centered care” dates back at least half a century, and was widely disseminated in 2001 by the article “Beyond the Healthcare Chasm.” Patient-centered care was defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. ”
In the context of safe, effective, equitable, efficient and timely care, “patient centered” means the moral obligation to respect the values, wishes and unique needs of the person before them. It promotes communication and care systems to help honor those values as possible.
In an era of increasing complexity of care and care delivery, this goal can sometimes be undermined by health care systems. For instance, fee-for-service billing might give a doctor incentive to do more procedures for more reimbursement, but not necessarily the right overall care.
With capitated HMO systems there exists a potential to provide the incentive of withholding of valuable services to limit insurance pay-outs or physician penalties. Such perverse incentives can interfere with the fiduciary responsibilities of some all-too-human clinicians. And it’s true that medical systems can be poorly designed to serve the needs of the hospital or clinic rather than their patients. But none of this has anything to do with Obamacare.
The ACA is certainly not perfect, but it does not prescribe which insurance types are offered in a particular state marketplace, nor the choice of which medical practices to attend, nor what tests, procedures or hospitals a clinician can use.
The ACA does mandate that insurances sold in the government-subsidized marketplace provide a minimum of 10 essential services, not just profit for the seller. Preventive services, outpatient and inpatient care, mental health and substance abuse services are among them.
The GOP argues that this restricts “patient choice.” Why not allow underinsurance to be sold, as in the bad old days? Why not circumvent state consumer protection law by selling near valueless insurances across state lines?
Perhaps because it is immoral. Primary care clinicians have watched their patients go bankrupt by illness by coverage not worth the paper it was printed on. It is not “patient centered” nor “patient choice” when the person needs to delay or forego lifesaving tests or therapy not affordable under such flimsy coverage.
The ACA does increase the income level above previous poverty benchmarks at which Medicaid can be provided. And the ACA does encourage states to develop their own unique experiments in care delivery, such as the Hoosier Indiana Plan in Mike Pence’s own state of Indiana or of that in Vermont.
The actual “patient-centered medical home” arose in the 1960s when pediatricians encountered complex, very sick kids requiring multiple specialists. There was natural confusion over who was responsible for care issues. The “medical home” was designed to enable the primary care provider to respond to acute and chronic problems, and coordinate the complex care provided among specialists.
This care team concept was applied thereafter to the adults and the elderly, who often have complex, multiple competing medical issues, and receive numerous, potentially interacting medicines provided by various sub-specialists.
The patient-centered medical home is often made up of nurses, medical assistants, clinicians (physicians, nurse practitioners, physician assistants and social workers) working with pharmacists.
There is certification by the Agency for Healthcare Research and Quality in this designation. There is a defining necessity to provide comprehensive, patient-centered and coordinated care that is easily accessible and provides expertise. Many doctors believe this type of practice provides the best, patient-centered care for the complex patient.
The reader may not be aware that many programs recommended by the Institute of Medicine were incorporated by the AHRQ into Obamacare. These have resulted in at least 50,000 lives saved yearly from improved hospital safety incentives, 150,000 fewer avoidable hospital readmissions due to incentives for coordination of care and reforms to provide reimbursement for overall quality rather than quantity in our national Medicare health system.
Perhaps it is simply ignorance when “patient-centered care” is invoked by politicians to promote the withdrawal of expanded Medicaid and other critical measures.
However, Tom Price, the former senator-orthopedist, and secretary of health and human services, is not so ignorant of terminology or health policy.
One of the earliest stated goals of Price and conservatives was to defund the AHRQ, which sponsors research and accreditation for the patient-centered medical home and the U.S. Preventive Services Task Force. Is it ironic or just cynical for Price to roll out and erase the meaning of the word “patient centered” as they decimate AHRQ?
There is consensus that there are workable ways to improve the ACA. The major sticking point for conservatives remains the mandate to purchase insurance.
However, for insurance to accomplish eliminating pre-existing condition clauses, cover the costs of prevention and also treat illness, there must be enough premiums coming in from healthy people to keep the system solvent. The costs of private health premiums has been rising independent of the ACA, largely related to drug and technology costs. Lack of competition in any state’s marketplace can certainly contribute. But predictions of economic catastrophe and “death spirals” of the ACA are about as factual as Sarah Palin’s claims of “death panels.”
Medicare for all
Simply allowing Medicaid and Medicare to negotiate prices with drug producers, as does the Veterans Administration, would rein in medical costs dramatically.
New Hampshire is now covering 50,000 citizens via expanded Medicaid. Ten thousand New Hampshire residents are having their treatment for opioid addiction covered under these services. As to what to do about the working poor who will lose their coverage under expanded Medicaid, Paul Ryan states, “We’re going to have to find solutions that accommodate (those) concerns.”
Stay tuned for the return of the “high-risk pool,” unused and unobtainable, which died a deserved death with the ACA. It will likely return as a zombie to pretend to exist as coverage for various unsolved problems under Trumpcare.
A randomized, bipartisan survey of 1,000 primary care physicians was performed this year by the American Medical Association, and published in the New England Journal of Medicine. Only 15 percent of primary care physicians (all Republicans) supported outright repeal of the ACA, and 74 percent favored minor changes that maintained the key elements.
Since 1965, Medicare was gradually developed into the popular national system that serves those Americans with the greatest intensity of medical need, and is widely accepted by care providers. Seventy percent of New Hampshire primary care clinicians support a single-payer, universal health care program, as do 60 percent of all Americans. Even two-fifths of all Republicans would opt for expanded Medicare for all.
Since Secretary Price and the right is intent on repealing Obamacare and Medicare thereafter, know that this is not “patient centered” and that Americans and their first-line doctors would prefer Medicare for all.
Ken Dolkart of Grantham is a recently retired geriatrician and primary care doctor who practiced in New Hampshire for 34 years. He is also a member of Granite State Physicians for a National Health Program.