Fiscal Commission.gov

President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform to address our nation’s fiscal challenges. The Commission is charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run. Specifically, the Commission shall propose recommendations designed to balance the budget, excluding interest payments on the debt, by 2015. In addition, the Commission shall propose recommendations that meaningfully improve the long-run fiscal outlook, including changes to address the growth of entitlement spending and the gap between the projected revenues and expenditures of the Federal Government.

The Commission will meet as a whole once a month while Congress is in session. The Commission will vote on a final report containing a set of recommendations to achieve its mission no later than December 1, 2010. The final report will require the approval of at least 14 of the Commission’s 18 members.

http://www.fiscalcommission.gov/about

And…

Republicans Dominate Medicare Discussions On White House Fiscal Commission

By Brian Beutler
TPM
September 9, 2010

The White House’s fiscal commission has become a target for progressive activists in large part because a number of reports and public statements indicate that the panel will recommend benefit cuts to Social Security.

But the commissioners are also grappling with another sensitive entitlement program: Medicare. For a number of reasons, the commission is farther from consensus on Medicare than it is on Social Security. But the ideological conservatism of the Republicans on the commission — and, indeed, of the commission as a whole — combined with Democratic fatigue over health care reform mean that the center of gravity of discussions is tilted to the right.

“[B]asically you’ve got some Dems saying they don’t want to jump back in the [health care reform] pool, so you’ve mainly got Republicans swimming in there on their own,” says one source familiar with the commission’s proceedings.

“There have been some discussions about cost-sharing. There have been some discussions about Medi-gap policies,” the source says.

At a staff level, this source says, the feeling is that “there needs to be more skin in the game and people need to pay more…the whole argument that people don’t understand how much health care costs and are wasteful.”

“A lot of discussion on the commission has been that people need to get better price signals and be smarter shoppers,” the second source said. “And that is very, very worrisome.”

http://tpmdc.talkingpointsmemo.com/2010/09/republicans-dominate-medicare-discussions-on-white-house-fiscal-commission.php?ref=fpblg

Comment: 

By Don McCanne, MD

Apparently President Obama’s National Commission on Fiscal Responsibility and Reform is considering changes to Medicare that would make beneficiaries “smarter shoppers” by adopting innovations that would require them to pay more out of pocket for health care.

Considerations include reducing or eliminating Medi-gap policies, increasing deductibles and coinsurance, and using vouchers that would establish financial incentives to choose more Spartan private plans.

Although the commission theoretically is politically balanced, all of the Republican members are right-wing conservatives, and the Democrats are split between progressives and deficit hawks who would rather reduce government spending than increase tax revenues. If you check the list of commission members (available at the fiscal commission link above) it is difficult to identify with certainty the five members necessary to block these deleterious “consumer-directed” policies.

Single payer supporters are already finding some resistance from colleagues to the “Medicare for all” label, especially with the continued failure to resolve the SGR (sustainable growth rate) issue. Although we speak of an “improved” Medicare, that distinction is not always clear and certainly would not mean much when holding up a further handicapped Medicare program as a model of reform.

Should the commission end up making these outrageous recommendations, hopefully the 310 million of us would respond by insisting that Medicare be protected and improved, as opposed to latching onto former Senator Alan Simpson’s infamous milk cow.

About the National Commission on Fiscal Responsibility and Reform

Fiscal Commission.gov
President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform to address our nation’s fiscal challenges. The Commission is charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run. Specifically, the Commission shall propose recommendations designed to balance the budget, excluding interest payments on the debt, by 2015. In addition, the Commission shall propose recommendations that meaningfully improve the long-run fiscal outlook, including changes to address the growth of entitlement spending and the gap between the projected revenues and expenditures of the Federal Government.
The Commission will meet as a whole once a month while Congress is in session. The Commission will vote on a final report containing a set of recommendations to achieve its mission no later than December 1, 2010. The final report will require the approval of at least 14 of the Commission’s 18 members.
http://www.fiscalcommission.gov/about

And…

Republicans Dominate Medicare Discussions On White House Fiscal Commission

By Brian Beutler
TPM
September 9, 2010
The White House’s fiscal commission has become a target for progressive activists in large part because a number of reports and public statements indicate that the panel will recommend benefit cuts to Social Security.
But the commissioners are also grappling with another sensitive entitlement program: Medicare. For a number of reasons, the commission is farther from consensus on Medicare than it is on Social Security. But the ideological conservatism of the Republicans on the commission — and, indeed, of the commission as a whole — combined with Democratic fatigue over health care reform mean that the center of gravity of discussions is tilted to the right.
“[B]asically you’ve got some Dems saying they don’t want to jump back in the [health care reform] pool, so you’ve mainly got Republicans swimming in there on their own,” says one source familiar with the commission’s proceedings.
“There have been some discussions about cost-sharing. There have been some discussions about Medi-gap policies,” the source says.
At a staff level, this source says, the feeling is that “there needs to be more skin in the game and people need to pay more…the whole argument that people don’t understand how much health care costs and are wasteful.”
“A lot of discussion on the commission has been that people need to get better price signals and be smarter shoppers,” the second source said. “And that is very, very worrisome.”
http://tpmdc.talkingpointsmemo.com/2010/09/republicans-dominate-medicare-discussions-on-white-house-fiscal-commission.php?ref=fpblg

Apparently President Obama’s National Commission on Fiscal Responsibility and Reform is considering changes to Medicare that would make beneficiaries “smarter shoppers” by adopting innovations that would require them to pay more out of pocket for health care.
Considerations include reducing or eliminating Medi-gap policies, increasing deductibles and coinsurance, and using vouchers that would establish financial incentives to choose more Spartan private plans.
Although the commission theoretically is politically balanced, all of the Republican members are right-wing conservatives, and the Democrats are split between progressives and deficit hawks who would rather reduce government spending than increase tax revenues. If you check the list of commission members (available at the fiscal commission link above) it is difficult to identify with certainty the five members necessary to block these deleterious “consumer-directed” policies.
Single payer supporters are already finding some resistance from colleagues to the “Medicare for all” label, especially with the continued failure to resolve the SGR (sustainable growth rate) issue. Although we speak of an “improved” Medicare, that distinction is not always clear and certainly would not mean much when holding up a further handicapped Medicare program as a model of reform.
Should the commission end up making these outrageous recommendations, hopefully the 310 million of us would respond by insisting that Medicare be protected and improved, as opposed to latching onto former Senator Alan Simpson’s infamous milk cow.

By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens and Andrew J. Madison (from the CMS Office of the Actuary)
Health Affairs
September 9, 2010

Projected National Health Expenditures (NHE)

2010 – $2,600 billion (17.5% of GDP)
2019 – $4,571 billion (19.6% of GDP)

Conclusion

In this analysis, we have shown that the net impacts of key Affordable Care Act and other legislative provisions on total national health expenditures are moderate, but the underlying effects on payer spending levels and growth rates are much more pronounced and reflect the Affordable Care Act’s many substantive changes to health care coverage and financing. As the provisions are implemented over time, their actual impacts may well differ considerably from these estimates.

Many important details of the legislation will evolve through regulatory activity and become more concrete. Moreover, behavioral responses to reform provisions on the part of health care providers and consumers, employers, and insurers are difficult to anticipate. These will become more apparent only after the bulk of reforms have been implemented in 2014.

Report – free download for the next two weeks only:
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0788v1

Comment:

By Don McCanne, MD

What does this mean? Here are some of today’s headlines of articles covering this report:

Health Plan Won’t Fuel Big Spending, Report Says (New York Times)

Gov’t: Spending to rise under health care overhaul (Washington Post/AP)

Government Economists Say Health Overhaul Won’t Significantly Increase Spending (Kaiser Health News)

Health Outlays Still Seen Rising (Wall Street Journal)

Consumers to Pay Nine Percent More Out of Pocket (Fiscal Times)

Is health care spending rising or isn’t it? The confusion stems from the fact that the additional increase in projected national health expenditures (NHE) resulting from the enactment of the Patient Protection and Affordable Care Act (PPACA) is relatively modest when compared to the projection of NHE without enactment of PPACA. Without PPACA, NHE for 2019 was projected to be $4.48 trillion (19.3% 0f GDP), whereas now the projection is $4.57 trillion (19.6% of GDP).

Thus the conflicting reporting reflects the “I told you so” arguments on both sides. The opponents of PPACA are saying that the promises of lower costs are not true, and this is yet one more report that shows that costs will increase. The proponents of reform are saying that this report proves that many more individuals will be covered without a significant increase in costs. This is the wrong debate.

The fact is that national health expenditures had been predicted to increase at a rate well in excess of inflation, and that PPACA will do nothing to slow that increase, though it will not make it much worse. What PPACA is doing instead is that it is rearranging the financing of health care in a manner that will result in more Americans – but not all – having some sort of health care coverage, but it does so in a way that can have a significant negative impact on patients and providers.

How can so many more people be covered without spending much more money? There are some hints in this report.

“For example, higher projected spending by a greater number of insured people is somewhat offset by the projected impact of the Medicare savings provisions and relatively lower prices paid to providers for services to newly insured Medicaid beneficiaries.”

Providers will be paid significantly less for the large influx of Medicaid patients, because of the reductions in Medicare payments, and especially because of the reductions that will be dictated by the Independent Payment Advisory Board. This could be disruptive to the care provided by the physicians and hospitals that are targeted by these reductions.

” By 2018, however, we project out-of-pocket spending growth of 9.6 percent — four percentage points faster than our February 2010 projection. This effect is mainly attributable to the excise tax on high-cost employer-sponsored plans, which is expected to result in greater cost sharing as many affected employers scale back coverage to minimize their tax exposure.”

There are other measures in PPACA that will result in additional cost shifting to patients, such as the low actuarial value of the exchange plans with subsidies that are inadequate to prevent higher out-of-pocket spending. Making health care less affordable for those who need it does reduce spending, but at a terrible cost in impaired health outcomes.

Covering tens of millions more people for about the same spending, using our inefficient fragmented health care financing system, is being accomplished by making patients and their health care providers absorb the much higher costs. Just wait until we all feel the pain.

National Health Spending Projections: The Estimated Impact Of Reform Through 2019

By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens and Andrew J. Madison (from the CMS Office of the Actuary)
Health Affairs
September 9, 2010
Projected National Health Expenditures (NHE)
2010 – $2,600 billion (17.5% of GDP)
2019 – $4,571 billion (19.6% of GDP)
Conclusion
In this analysis, we have shown that the net impacts of key Affordable Care Act and other legislative provisions on total national health expenditures are moderate, but the underlying effects on payer spending levels and growth rates are much more pronounced and reflect the Affordable Care Act’s many substantive changes to health care coverage and financing. As the provisions are implemented over time, their actual impacts may well differ considerably from these estimates.
Many important details of the legislation will evolve through regulatory activity and become more concrete. Moreover, behavioral responses to reform provisions on the part of health care providers and consumers, employers, and insurers are difficult to anticipate. These will become more apparent only after the bulk of reforms have been implemented in 2014.
Report – free download for the next two weeks only:
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0788v1

What does this mean? Here are some of today’s headlines of articles covering this report:
Health Plan Won’t Fuel Big Spending, Report Says (New York Times)
Gov’t: Spending to rise under health care overhaul (Washington Post/AP)
Government Economists Say Health Overhaul Won’t Significantly Increase Spending (Kaiser Health News)
Health Outlays Still Seen Rising (Wall Street Journal)
Consumers to Pay Nine Percent More Out of Pocket (Fiscal Times)
Is health care spending rising or isn’t it? The confusion stems from the fact that the additional increase in projected national health expenditures (NHE) resulting from the enactment of the Patient Protection and Affordable Care Act (PPACA) is relatively modest when compared to the projection of NHE without enactment of PPACA. Without PPACA, NHE for 2019 was projected to be $4.48 trillion (19.3% 0f GDP), whereas now the projection is $4.57 trillion (19.6% of GDP).
Thus the conflicting reporting reflects the “I told you so” arguments on both sides. The opponents of PPACA are saying that the promises of lower costs are not true, and this is yet one more report that shows that costs will increase. The proponents of reform are saying that this report proves that many more individuals will be covered without a significant increase in costs. This is the wrong debate.
The fact is that national health expenditures had been predicted to increase at a rate well in excess of inflation, and that PPACA will do nothing to slow that increase, though it will not make it much worse. What PPACA is doing instead is that it is rearranging the financing of health care in a manner that will result in more Americans – but not all – having some sort of health care coverage, but it does so in a way that can have a significant negative impact on patients and providers.
How can so many more people be covered without spending much more money? There are some hints in this report.
“For example, higher projected spending by a greater number of insured people is somewhat offset by the projected impact of the Medicare savings provisions and relatively lower prices paid to providers for services to newly insured Medicaid beneficiaries.”
Providers will be paid significantly less for the large influx of Medicaid patients, because of the reductions in Medicare payments, and especially because of the reductions that will be dictated by the Independent Payment Advisory Board. This could be disruptive to the care provided by the physicians and hospitals that are targeted by these reductions.
” By 2018, however, we project out-of-pocket spending growth of 9.6 percent — four percentage points faster than our February 2010 projection. This effect is mainly attributable to the excise tax on high-cost employer-sponsored plans, which is expected to result in greater cost sharing as many affected employers scale back coverage to minimize their tax exposure.”
There are other measures in PPACA that will result in additional cost shifting to patients, such as the low actuarial value of the exchange plans with subsidies that are inadequate to prevent higher out-of-pocket spending. Making health care less affordable for those who need it does reduce spending, but at a terrible cost in impaired health outcomes.
Covering tens of millions more people for about the same spending, using our inefficient fragmented health care financing system, is being accomplished by making patients and their health care providers absorb the much higher costs. Just wait until we all feel the pain.

California regulators seek up to $9.9 billion in fines from PacifiCare

By Duke Helfand
Los Angeles Times
September 7, 2010
California regulators are seeking fines of up to $9.9 billion from health insurer PacifiCare over allegations that it repeatedly mismanaged medical claims, lost thousands of patient documents, failed to pay doctors what they were owed and ignored calls to fix the problems.
In court filings and other documents, the California Department of Insurance says PacifiCare violated state law nearly 1 million times from 2006 to 2008 after it was purchased by UnitedHealth Group Inc., the nation’s largest health insurance company by revenue.
“This is about intentional disregard for the interests of doctors, hospitals and patients in California, and the pursuit of cutting costs at any means possible,” said Adam Cole, the insurance department’s general counsel. “It’s a story of intense corporate greed.”
http://www.latimes.com/health/la-fi-pacificare-unitedhealth-20100908,0,6657147.story

The largest health insurer in the nation (in terms of revenue), UnitedHealth Group, through UnitedHealthcare’s subsidiary – PacifiCare, violated California state insurance laws nearly a million times! This is the industry that the Patient Protection and Affordable Care Act was designed to protect instead of replacing, even though that meant that not everyone would be insured and many more would be underinsured. This was a trade-off that resulted in a loss on both ends.
This is more than the gross incompetence of an insurer that has failed to provide the excessive administrative services for which we are being gouged involuntarily. As the insurance department’s general counsel said, “It’s a story of intense corporate greed.”
It’s time to throw these incompetent thieves out, fix Medicare, and then provide it for everyone.

By Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Health Affairs
September 2010

Abstract
 
Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care — treatment for newly arising health problems — are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

http://content.healthaffairs.org/cgi/content/abstract/29/9/1620

Comment: 

By Don McCanne, MD

When you say “my physician,” what do you mean? For most of us, that means the physician whom you call when you have a medical need. It’s the physician who will always be there for you, or who will at least ensure that a colleague is available when taking an off-call breather or when on vacation. Yet, as this study shows, personal physicians or their associates provide care for only 42 percent of acute problems. Increasingly, patients can no longer rely on their doctor’s office when they need acute care.

The policy community certainly recognizes the crisis in primary care. Much attention has been directed toward improving chronic care management within the primary care environment. Unfortunately, much of these efforts remain in the discussion phases, and only limited improvement has been made in the application of these relatively imprecisely defined concepts.

Yet what the primary care professional should be really good at – timely care of acute problems – has been almost completely ignored by the policy community. Physicians are too busy and don’t have time to take care of their patients. (Although that thought certainly can be expanded upon, the irony is inescapable.)

What are some of the solutions?

*  Emergency departments (EDs) already are bearing the largest portion of the overload. Queues in EDs are enough of a problem without adding to the waiting room backlog of many individuals who would be more appropriately cared for in a less intensive environment, such as a primary care practice. Adding to the problems with our overcrowded EDs is the burden of having to care for over one-half of all uninsured individuals with acute care problems.

*  Patients in the next largest sector directly access specialists for their acute problems. Sometimes this may be quite appropriate, yet many times it may result in more expensive care for problems that would be more appropriately managed in a less expensive primary care environment. Also some patients who should be cared for by specialists may not be able to access them for several reasons, and, once again, the primary care physician would be in a better position to enable that access for the patient.

*  Outpatient departments of integrated health systems appropriately may fulfill the role as the acute care provider as long as arrangements are made for access outside of clinic hours. These departments are usually associated with larger institutions, and, as such, would never be much more than a niche provider of acute care services.

*  Retail clinics are capable of providing only the most basic of acute care services, and further fragment the coordinated care that should be provided in the primary care environment. Further, retail clinics skim off the easy, cash paying “customers” (a more appropriate term than “patients” in this retail environment). The same is true of urgent care centers and their customers, though they are usually capable of caring for a greater variety of problems.

*  Concierge physicians do provide greater personal attention, but for very high fees that most of us cannot afford. To provide this higher level of accessibility, they sharply reduce the number of patients in their practices, further compounding the problem of the critical shortage of primary care physicians.

*  Community health centers (CHCs) fulfill an important role in primary care, especially because they usually provide access for underserved patients in underserved communities. They provide acute care services during clinic hours, though patients often must rely on EDs when the clinics are closed. Most CHCs continue to struggle with finances. Also, most have difficulties in obtaining the cooperation of an adequate variety of specialists in providing care for more complex problems.

Members of Congress are quite aware of the profound deficiencies in our primary care infrastructure, so they included some measures in the Patient Protection and Affordable Care Act (PPACA) designed to address this issue. Will they help?

Funds are being allocated for primary care training programs. That is certainly a step in the right direction, but the funds are quite limited and will hardly make a dent in the problem.

More funds are being allocated for community health centers, again certainly a beneficial measure, but one which falls far short of meeting the need.

Some Medicare funds are being shifted from other services to primary care but not enough to even begin to narrow the compensation gap between primary care and the surgical specialists. Why would medical students, saddled with education debt, choose primary care with its long hours and modest pay, when specialties promise higher pay and more free time?

PPACA contains measures to promote the medical home model – theoretically the ideal primary care model. Although medical home demonstration projects are under way, it will be a long time before the specifics of the model will be precisely defined and ready for universal application. Further, the logistics of permeating the nation with medical homes may be beyond the capabilities of our public and private stewards working within the limitations of our dysfunctional financing system. Though the medical home model shows great promise, we need a financing system that will make it much more feasible.

The great hope of PPACA has been pinned on accountable care organizations (ACOs). This Health Affairs article defines ACOs as “integrated or virtually integrated delivery systems that will provide care for a defined population in a range of settings, linked by health information technology.” The supporters of ACOs have described everything from full service integrated health care delivery systems to “virtual” systems that are not connected by much more than an information technology system.

Although the providers of health care may seek to create innovative ACO systems that theoretically would improve patient care, it is likely that the emphasis will be on, not just controlling, but actually reducing spending. The ghost of managed care past will be embellished through the “integrated and accountable” efforts of the insurers partnering with health delivery entrepreneurs. Only the patients, patient-oriented health care professionals, and the patient-oriented hospitals will be losers.

Whatever you need – preventive services, continuing care for your chronic condition, or timely management of an acute problem – wouldn’t it be nice if you always had available your own personal physician’s team to meet your needs? With our fragmented, dysfunctional system
of financing health care, it is unlikely that in the future this will be more than a dream for the majority of us.

If we had our own Medicare-for-all monopsony (single purchaser of health care) it could become a reality for all of us. We would simply insist that a primary care system coordinating a full complement of specialized services is all that we’re going to pay for. The insurers and health profession entrepreneurs can take a hike.

Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office

By Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Health Affairs
September 2010
Abstract
Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care — treatment for newly arising health problems — are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.
http://content.healthaffairs.org/cgi/content/abstract/29/9/1620

When you say “my physician,” what do you mean? For most of us, that means the physician whom you call when you have a medical need. It’s the physician who will always be there for you, or who will at least ensure that a colleague is available when taking an off-call breather or when on vacation. Yet, as this study shows, personal physicians or their associates provide care for only 42 percent of acute problems. Increasingly, patients can no longer rely on their doctor’s office when they need acute care.
The policy community certainly recognizes the crisis in primary care. Much attention has been directed toward improving chronic care management within the primary care environment. Unfortunately, much of these efforts remain in the discussion phases, and only limited improvement has been made in the application of these relatively imprecisely defined concepts.
Yet what the primary care professional should be really good at – timely care of acute problems – has been almost completely ignored by the policy community. Physicians are too busy and don’t have time to take care of their patients. (Although that thought certainly can be expanded upon, the irony is inescapable.)
What are some of the solutions?
*  Emergency departments (EDs) already are bearing the largest portion of the overload. Queues in EDs are enough of a problem without adding to the waiting room backlog of many individuals who would be more appropriately cared for in a less intensive environment, such as a primary care practice. Adding to the problems with our overcrowded EDs is the burden of having to care for over one-half of all uninsured individuals with acute care problems.
*  Patients in the next largest sector directly access specialists for their acute problems. Sometimes this may be quite appropriate, yet many times it may result in more expensive care for problems that would be more appropriately managed in a less expensive primary care environment. Also some patients who should be cared for by specialists may not be able to access them for several reasons, and, once again, the primary care physician would be in a better position to enable that access for the patient.
*  Outpatient departments of integrated health systems appropriately may fulfill the role as the acute care provider as long as arrangements are made for access outside of clinic hours. These departments are usually associated with larger institutions, and, as such, would never be much more than a niche provider of acute care services.
*  Retail clinics are capable of providing only the most basic of acute care services, and further fragment the coordinated care that should be provided in the primary care environment. Further, retail clinics skim off the easy, cash paying “customers” (a more appropriate term than “patients” in this retail environment). The same is true of urgent care centers and their customers, though they are usually capable of caring for a greater variety of problems.
*  Concierge physicians do provide greater personal attention, but for very high fees that most of us cannot afford. To provide this higher level of accessibility, they sharply reduce the number of patients in their practices, further compounding the problem of the critical shortage of primary care physicians.
*  Community health centers (CHCs) fulfill an important role in primary care, especially because they usually provide access for underserved patients in underserved communities. They provide acute care services during clinic hours, though patients often must rely on EDs when the clinics are closed. Most CHCs continue to struggle with finances. Also, most have difficulties in obtaining the cooperation of an adequate variety of specialists in providing care for more complex problems.
Members of Congress are quite aware of the profound deficiencies in our primary care infrastructure, so they included some measures in the Patient Protection and Affordable Care Act (PPACA) designed to address this issue. Will they help?
Funds are being allocated for primary care training programs. That is certainly a step in the right direction, but the funds are quite limited and will hardly make a dent in the problem.
More funds are being allocated for community health centers, again certainly a beneficial measure, but one which falls far short of meeting the need.
Some Medicare funds are being shifted from other services to primary care but not enough to even begin to narrow the compensation gap between primary care and the surgical specialists. Why would medical students, saddled with education debt, choose primary care with its long hours and modest pay, when specialties promise higher pay and more free time?
PPACA contains measures to promote the medical home model – theoretically the ideal primary care model. Although medical home demonstration projects are under way, it will be a long time before the specifics of the model will be precisely defined and ready for universal application. Further, the logistics of permeating the nation with medical homes may be beyond the capabilities of our public and private stewards working within the limitations of our dysfunctional financing system. Though the medical home model shows great promise, we need a financing system that will make it much more feasible.
The great hope of PPACA has been pinned on accountable care organizations (ACOs). This Health Affairs article defines ACOs as “integrated or virtually integrated delivery systems that will provide care for a defined population in a range of settings, linked by health information technology.” The supporters of ACOs have described everything from full service integrated health care delivery systems to “virtual” systems that are not connected by much more than an information technology system.
Although the providers of health care may seek to create innovative ACO systems that theoretically would improve patient care, it is likely that the emphasis will be on, not just controlling, but actually reducing spending. The ghost of managed care past will be embellished through the “integrated and accountable” efforts of the insurers partnering with health delivery entrepreneurs. Only the patients, patient-oriented health care professionals, and the patient-oriented hospitals will be losers.
Whatever you need – preventive services, continuing care for your chronic condition, or timely management of an acute problem – wouldn’t it be nice if you always had available your own personal physician’s team to meet your needs? With our fragmented, dysfunctional system of financing health care, it is unlikely that in the future this will be more than a dream for the majority of us.
If we had our own Medicare-for-all monopsony (single purchaser of health care) it could become a reality for all of us. We would simply insist that a primary care system coordinating a full complement of specialized services is all that we’re going to pay for. The insurers and health profession entrepreneurs can take a hike.