Tuesday, June 30, 2009

Does President Obama have the right Rx for primary care?

Last week, President Obama made his most extensive comments yet on the crisis in primary care. In his responses to two questions - one from a nursing student and the other from a medical student - during a town hall meeting hosted by ABC News, Obama had this to say:

"Well, first of all, we need more people ... who are going to school and committed to the kind of primary care that's going to be critical to us bringing down costs and improving quality. We're not going to be able to do it overnight. Obviously training physicians, training nurse practitioners, that takes years of work. But what we can do immediately is start changing some of the incentives around what it takes to become a family physician.

Right now, if you want to go into medicine, it is much more lucrative for you to go into a specialty. Now, we want terrific specialists, and one of the great things about the American medical system is we have wonderful specialists and they do extraordinary work. But, increasingly, medical students are having to make decisions based on the fact that they're coming out with $200,000 worth of loans. And if they become a primary care physician, oftentimes they are going to make substantially less money, and it's going to be much harder for them to repay their loans.

... But what we're also going to have to do is start looking at Medicare reimbursements, Medicaid reimbursements, working with doctors, working with nurses, to figure out how can we incentivize quality of care, a team approach to care, that will help raise and elevate the profile of family care physicians and nurses as opposed to just the specialists who are typically going to make more money if they're getting paid fee-for-service.

... And one of the things that I'd like to explore -- and I've been working with the administration and with Congress -- are their loan forgiveness programs where people commit to a certain number of years of primary care. That reduces the costs for their medical education. That would make a significant difference.

If we provide the right incentives I think we're going to start seeing more young people say that going into medicine is a satisfying, fulfilling profession -- especially if we can eliminate some of the paperwork and bureaucracy that they have to deal with right now ...

But I also think that one of the big potential areas where we can make progress is ... how can we get nurses involved in more effective ways. If you look at what's happening in some states, like Massachusetts, where they tried to create a universal system -- and they haven't quite gotten there yet -- they have had a problem with an overload of patients.

... One of the areas where we can potentially see some saving is a lot of those patients are being seen in the emergency room anyway, and if we are increasing prevention, if we are increasing wellness programs, we're reducing the amount of emergency room care, then that frees up doctors and resources to provide the kind of primary care that will keep people healthier, but also allow them to see more patients and hopefully give more time to patients, as well."

It is good to hear the President describe primary care as "critical" to improving quality and bringing down costs. He also seems to have a good grasp of the reasons that young people aren't going into primary care, including high student debt, poor pay, and excessive paperwork.

Obama doesn't believe, though, that the answer is to just train more primary care physicians and pay them more. Instead, he wants reforms to "raise and elevate" the roles of both primary care physicians and advanced practice nurses under a "team approach" that "incentivizes" quality of care. And he wants to help reduce the debt of both doctors and nurses that go into primary care.

Today's question: Do you agree with Obama's prescription for the primary care workforce crisis and the roles of both physicians and nurses?

Friday, June 26, 2009

House proposal moves policies in the right direction

Yesterday, the House Committee on Energy and Commerce wrapped up three days of hearings on a draft bill to provide health coverage to all Americans, to establish policies to ensure an adequate physician workforce, and to revamp payment and delivery systems to get more value for each dollar of health care spending.

In a statement submitted for the hearing record ACP expressed broad support for the goals of many of the specific policies proposed in the bill. Like ACP's own plan, the bill expands Medicaid to cover everyone at or modestly above the Federal Poverty Level; provides individuals and small businesses a choice of health plans offered through an exchange (similar to that offered to federal employees); provides sliding scale subsidies for individuals to purchase coverage through such an exchange; requires that that all health plans, both within and outside the exchange, abide by rules relating to acceptance of all individuals without regard to pre-existing conditions or health status, guaranteed renewability, modified community rating; and requires that they offer essential benefits, including preventive and primary care services, as recommended by an expert commission. Employers would have to contribute to coverage or face a penalty and individuals would be required to obtain coverage once it is available and affordable, with appropriate hardship exemptions.

On workforce, the bill would create a national advisory group to recommend national health workforce goals, greatly expand funding for primary care training programs and create new ones to provide scholarships and loan forgiveness to primary care physicians who serve in areas of need, allocate more graduate medical education slots to general internal medicine and family medicine residency programs, allow residents to defer their debt through completion of their residencies, provide grants for primary care training and enhancement, eliminate barriers to teaching in non-hospital based primary care practices, and provide grants to address health care disparities and education on team-based models of care. Many of these provisions were taken directly from the bipartisan Preserving Patient Access to Primary Care Act, introduced by Representative Allyson Schwartz (D-PA) and Senator Maria Cantwell (D-WA), which is based principally on ACP policies and has received the College's strong endorsement.

The legislation also advances payment and delivery reforms aligned with patient-centered primary care. It would eliminate the pending 21 percent Medicare payment cut from the Sustainable Growth Rate and completely wipe out all of the accumulated costs resulting from the failure of past Congresses to enact a long-term SGR solution. (This accumulated cost -- running running into hundreds of billions of dollars -- has been a principal barrier to getting rid of the annual cycle of Medicare doctor pay cuts). The current SGR formula would be replaced with two separate spending targets for physician services, one for primary care and prevention (GDP plus 2 percent) and the other for all other physician services (GDP plus 1 percent). ACP has expressed concern, though, that continuing to benchmark physician updates on growth in the U.S economy, as measured by GDP (even with the additional percentage allowances for each category), could result in future payment cuts to physicians.

The draft bill provides more than $1 billion to fund two national Medicare pilots of the patient-centered medical home, one of which would pay qualified practices directly for prevention and care coordination of high risk patients and another that would pay community-based organizations for providing care coordination services to physician practices and provide payment to the practices themselves that use such services.

Primary care physicians would also receive a bonus payment for designated services. The amount of the bonus, 5 percent for most primary care physicians and 10 percent for those who practice in health professional shortage areas, is considerably less than ACP has requested. The College will continue to press for a more substantial primary care bonus. Primary care physicians would also see their Medicaid payments increased in every state until they are equal to Medicare.

Finally, the bill proposes new rules to streamline and standardize the administrative costs of health plan interactions, which impose a disproportionate burden on primary care physicians.
Although it is certainly true that "You can't always get what you want" from legislation (although I don't think Mick Jagger was thinking about health reform when he coined this refrain), the House proposal goes a long way toward advancing our goals on coverage, workforce, payment and delivery reform and administrative simplification.

Today's question: what do you think about the House proposal, and particularly, its impact on health coverage and primary care?

Tuesday, June 23, 2009

The end of the road for health care reform? (Hardly)

Today, I am blogging from the end of the road - literally.

I write from the beautiful shores of Homer, Alaska, famously described by former resident and "All Things Considered" commentator Tom Bodett as being the "end of road." I am here because later this week I will be meeting with internists attending the annual ACP Alaska chapter meeting in Anchorage, and Homer, a little over 200 miles away on the Kenai Peninsula, is a nice side trip. (Each year, I try to attend as many as a dozen ACP chapter meetings across the country. This allows ACP members to hear my perspectives on what is going on in Washington, and in turn, I get an earful on what's on their minds, especially from notoriously independent Alaskan physicians!)

The end of the road might be an apt description of how some commentators now view President Obama's prospects to achieve lasting health care reform.

The Congressional Budget Office's report on the cost of health care reform, followed by the decision by the Senate Finance Committee to delay release of its draft plan, have led some to conclude that President Obama's push for health care reform is in deep trouble. Roll Call reports that the price tag and partisan bickering could "derail" Senate passage of health care reform.

After months of mostly upbeat reports, it's as if the press suddenly awakened to the fact that reforming health care won't be easy. But why? - all of the negatives from the past week were entirely predictable.

Health care reform will cost a lot of money? Well, yeah.

Republicans and Democrats will bicker? Duh.

Democrats will have difficulty reaching agreement amongst themselves? What else would you expect from a party that has made internal dissension a celebrated art form?

But amidst all of the gloomy reports, there actually was quite a bit of positive news for President Obama and his congressional allies.

First, the drug industry reached an agreement to reduce the costs of drugs paid for under the Medicare Part D program. This is important because the White House and Congress need savings and offsets that will not be fought by the affected stakeholders.

Second, House Democrats produced a draft bill that includes measures designed to win broad support among key constituencies - including doctors. It not only eliminates next year's 21 percent cut in Medicare's payment to doctors, but would also get rid of hundreds of billions of dollars in accumulated doctor pay cuts - a top priority of the medical profession. The bill includes scholarships, loan forgiveness, and payment reforms to support physicians in primary care. I will write more about the House proposal later this week, but I believe that there are enough positives in it to keep physicians at the table in a way that help move things forward.

Finally, despite all of the hand-wringing in Washington, a new poll shows that the public remains strongly in favor of health care reform. 85 percent of respondents said that health care must be completely rebuilt or fundamentally changed - with a strong majority favoring a greater government role in health care. The poll also showed strong support among Democrats, Independents, and even a majority of Republicans for a "public plan" option, one of the most controversial issues in Washington.

Instead of reaching an end of the road, health care reform continues to move forward - as it does, it will run into speed bumps, pot holes, and perilous turns along the way. The whole effort could yet crash and burn, but from where I sit, at the end of a road overlooking Kachemak Bay, the finish line remains very much in sight.

Today's question: Do you think health care reform is in deep trouble - or will it continue to move forward to enactment?

Wednesday, June 17, 2009

CBO score slows down drive to health care reform

Maybe because I have two teenage daughters who dream about a big wedding with all of the bells and whistles (way, way in the future . . . of course!), the Congressional Budget Office reminds me of the frugal father who adds up the tab and is forced to put the brakes on a beloved daughter's plans for the "perfect" wedding.

The Congressional Budget Office told the Senate that the cost of their health reform legislation could be about 2.6 trillion dollars over the next decade - and still leave tens of millions without health insurance. The CBO also told Congress that plans to expand coverage to more Americans could cause an unsustainable increase in the federal deficit - unless offset by enforceable cuts in spending - and expressed skepticism that investments in prevention would achieve substantial savings. It acknowledged that primary care is associated with lower costs, but suggested that increasing the numbers of primary care physicians would help only if linked to policies to curb the numbers of non-primary care specialists:

"One study of the relationship between Medicare spending and the composition of the workforce of physicians found that, with the total number of physicians held constant, states with more general practitioners had lower spending. Achieving that outcome, however, involves reducing the number of specialists in line with increasing the number of primary care physicians, and the mechanism for accomplishing that change (for example, the appropriate adjustments in payment policies) is unclear. Savings would be less likely if the number of specialists remained the same while the number of primary care physicians increased."

The CBO report is causing Congress to hedge on its plans to have legislation passed before the August recess. The Democratic majority also is looking for ways to scale back how many would be covered, to find more revenue (tax) increases, and to find other measures that to save money - such as more cuts in payments to hospitals and other providers. The problem, though, is that tax increases and provider cuts will increase the level of opposition.

As Congress looks for ways to trim the cost, I worry that it will look in the wrong places. For instance, plans to spend more money to increase payments to primary care physicians and to train more of them could be at risk. One can anticipate the "we wanted to do more, but we couldn't find the money" excuse.

On Thursday, the leaders of the American College of Physicians, American Academy of Family Physicians, and the American Osteopathic Association are coming to Washington to make the case to Congress that failure to fund primary care will inevitably cost the country far more in the longer run . . . even if the CBO won't "count" such savings in the budget.

Today's questions: do you think Congress should scale back its plans because of the cost? How?

Monday, June 15, 2009

Obama's homecoming wows AMA

Who would have thought that an organization, whose legacy includes opposition to the creation of Medicare, would be brought to its feet (repeatedly) by a Democratic president who has vowed to remake American health care? Yet this is precisely what happened today in Chicago when Barack Obama took his case to the AMA House of Delegates.

I was one of those present to witness Obama's speech. It was, in my opinion, a masterful exercise of political persuasion. One very sage observer of the AMA, who has been active in the organization for decades and has himself served in one of AMA's top elected positions, told me after the speech that Obama's political skills are akin to Franklin Delano Roosevelt and Ronald Reagan at the height of their power.

Why did Obama get such a positive response from a group of doctors whose political views can generously be described as leaning right of center?

First, he made the case, as he has done to so many other audiences, that the status quo is not sustainable. He analogized U.S. health care to General Motors - that rising health care costs will ultimately bankrupt the country. He told the AMA that "the alternative to ... reform is a world where health care costs grow at an unsustainable rate. And if you don't think that's going to threaten your reimbursements and the stability of our health care system, you haven't been paying attention." In other words, work with me now to make it better, or allow the system to collapse, with dire consequences for physicians and patients.

Second, Obama acknowledged the reasons why many physicians have reservations about health care reform saying, "There's a sense out there among some, and perhaps some members who are gathered here today of the AMA, that as bad as our current system may be -- and it's pretty bad -- the devil we know is better than the devil we don't." To reassure physicians, he promised that no one would be forced to give up their doctor or their own health plan. He skillfully took on the arguments that he knows will be made against health care reform - that it will lead to "socialized medicine" and "rationing" of care or that a public plan would be a "Trojan Horse" for a single payer system.

Third, he clearly laid out his vision for health care reform: health coverage for all, subsidies for individuals to buy coverage from health insurance offered through an exchange, a ban on pre-existing condition exclusion, and paying doctors based on the quality - not just the quantity - of care provided.

Fourth, he was honest about issues where he knew there would be disagreement. He expressed a willingness to work with the AMA on reducing the costs of defensive medicine but told them he would not support a cap on damages. He explained why he supported including a public plan option "to keep insurers honest" but also said he wanted to design a plan that physicians could support.

Fifth, he spoke to issues that physicians care deeply about. He credited the AMA for getting Congress to enact sweeping legislation to allow the FDA to regulate tobacco. He emphasized prevention and the need "to do more to reward medical students who choose a career as a primary care physician." He received a standing ovation when he articulated the frustrations physicians have with health insurance paperwork.

He did two other very important things. He appealed directly to physicians' tradition of professionalism. When describing the incentives created under current payment systems for doctors to order unnecessary tests, Obama said, "That's not why you put in all those hours in the Anatomy Suite or the O.R. That's not what brings you back to a patient's bedside to check in, or makes you call a loved one of a patient to say it will be fine. You didn't enter this profession to be bean-counters and paper-pushers. You entered this profession to be healers. And that's what our health care system should let you be. That's what this health care system should let you be."

And he acknowledged their power and influence of the medical profession and the AMA itself, making an unabashed appeal for their support: "We need your help, doctors, because to most Americans you are the health care system. The fact is Americans -- and I include myself and Michelle and our kids in this -- we just do what you tell us to do. That's what we do. We listen to you, we trust you. And that's why I will listen to you and work with you to pursue reform that works for you."

This had to be music to the ears of a group of physicians whose voices had become increasingly marginalized.

Today's question: Do you think most doctors will rally behind Obama's call for help in reforming the health care system?

Friday, June 12, 2009

The shape of things to come?

Health care reform is at the stage where everything will start coming together - or fall apart. Congressional leadership is putting together legislation that it hopes to get through its committee process before the Independence Day recess. President Obama is on the campaign trail again - this time, campaigning for his vision of health care reform. And the stakeholders who can make or break health care reform are moving from the happy talk phase to articulating what they can - and will not - accept.

Although some of the most contentious issues (like how to pay for it) are far from being resolved, it seems to me that we are beginning to see the outlines of potential consensus legislation:

1. People who can't afford coverage, or whose employer does not offer it, will be given sliding scale subsidies (most likely, advance, refundable tax credits based on income) to purchase coverage from one of hundreds of qualified health plans offered by a health exchange.
2. Qualified plans will be required to offer a package of essential benefits, accept anyone without regard to pre-existing conditions, be prohibited from cancelling coverage (guaranteed renewability), and will not be able to vary the premium they charge except for age and gender (modified community rating). Some kind of public plan (more on this later) will likely be offered, in addition to qualified private insurers.
3. The Medicaid program will be expanded to more low-income persons and a uniform standard of eligibility will be adopted.
4. Expanded coverage will be financed in part by hundreds of billions of dollars in savings from the Medicare program - mostly in the form of cuts to different "health care providers" or payment reforms that place providers at financial risk for excess costs. Such payment reforms will be pilot-tested on an accelerated basis, with the federal government having broad authority to expand the most effective models.
5. Despite the Medicare cuts, physicians will fare pretty well. President Obama and Congress are likely to offer to eliminate the hundreds of billions of dollars in accumulated Medicare payment cuts to doctors from the sustainable growth rate (SGR) formula, without requiring that Congress offset the cost by cuts somewhere else - in exchange for doctors getting behind the health care reform legislation. Look to Obama to make some kind of statement about this when he addresses the AMA House of Delegates on Monday. (I'll be there, blogging from the AMA, so will let you know what I think I hear.)
6. Primary care physicians can expect to fare relatively better than other physicians - that is, there likely will higher Medicare payments to primary care doctors and increased funding for primary care training programs and expansion of GME slots for internal medicine and family practice. However, since under Congress' budget rules any increased funding to primary care needs to be paid for with cuts somewhere else, and non-primary care physicians are making it clear that it can't be from them, the initial increases in payments to primary care may be much more modest than primary care physicians had hoped for or might have expected. It remains to be seen if this will be a case of "too little, too late" for primary care.

On the public plan, there are signs that there is movement toward reaching a compromise. The American Medical Association, which was quoted in The New York Times on Wednesday as opposing a public plan, subsequently issued a statement suggesting a willingness to support a public plan provided that it doesn't pay doctors based on Medicare rates and physician participation isn't mandated.

To be sure, a lot of tough issues - like tax increases and employer and individual mandates have to be worked out, and the entire effort could still collapse. But it does seem to me that we are seeing movement to a possible consensus on the key ingredients for health care reform.

Question: What do you think of the outlines for a possible consensus as described above?

Wednesday, June 10, 2009

It's the physicians, stupid!

Rarely does a magazine article grab the attention of policymakers, like Dr. Atul Gawande's piece in the New Yorker Magazine on "The Cost Conundrum: What a Texas town can teach us about health care." The article, adorned with a photo of a physician wearing an ATM machine, examines the community of McAllen, Texas, which has the dubious claim of having the second most expensive health care in the nation (Miami, Florida, which has much higher labor and cost of living expenses, takes first place). President Obama has reportedly referenced the article in discussions with congressional leaders. Citing the same, Steve Pearlstein writes that "the central challenge of health reform, then, is to make sure doctors have the scientific evidence about what works and what doesn't -- and then to change the way they work and realign their financial incentives so that this evidence guides their practice."

Why all of the interest in McAllen? Because, as Dr. Gawande writes, "Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns." He concludes that the higher spending is a consequence of a prevailing medical culture fueled by money:

"Beyond the basics, however, many physicians are remarkably oblivious to the financial implications of their decisions. They see their patients. They make their recommendations. They send out the bills. And, as long as the numbers come out all right at the end of each month, they put the money out of their minds.

Others think of the money as a means of improving what they do. They think about how to use the insurance money to maybe install electronic health records with colleagues, or provide easier phone and e-mail access, or offer expanded hours. They hire an extra nurse to monitor diabetic patients more closely, and to make sure that patients don't miss their mammograms and pap smears and colonoscopies.

Then there are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don't pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patients' scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.

In every community, you'll find a mixture of these views among physicians, but one or another tends to predominate. McAllen seems simply to be the community at one extreme."

Gawande writes that the debate in Washington largely misses the mark. "Whom do we want in charge of managing the full complexity of medical care?" he writes. "We can turn to insurers (whether public or private), which have proved repeatedly that they can't do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone - because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world."

If it is true that culture largely drives practice, it will be exceedingly difficult to change. History is full of examples where Washington has passed laws to change entrenched cultural behaviors that are not considered to be in the public interest, without much success unless there is buy-in by those who they want to change.

I believe it will require an unprecedented degree of leadership within the medical profession itself to get every physician to accept the idea that they need to be just stewards of resources, as the ACP-endorsed charter on professionalism demands:

"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

Without such physician leadership, Washington almost assuredly will fail in its effort to control costs.

Today's question: Do you agree that there is a culture in medicine that leads to excess health care spending? If so, what should the profession do to change it?

Monday, June 8, 2009

Are the right questions being asked about the public plan?

As expected, the debate over health care reform is now centered on whether or not the public should have the option of enrolling in a Medicare-like plan financed and administered by the federal government. Last week, President Obama sent a letter that expressed his strong belief that "Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest."

Obama's decision to stake out a firm position in support of a public plan resulted in an immediate backlash from Republicans, dampening the already diminishing chances that health care reform will have substantial GOP support.

In the meantime, the Senate Health, Education and Labor and Pensions Committee, chaired by Senator Ted Kennedy (D-MA), has released a summary of its health care reform proposal, which includes a requirement that the public be offered a qualified public plan that would set "provider reimbursement at Medicare rates plus 10 percent. The government plan would be deemed to be licensed in each state. Premiums must be sufficient to cover the costs of the government plan."

For liberal and conservative true-believers, the debate over a public plan has become a surrogate for the broader debate over the role of government in our health care system. If you believe that the government needs to take on more responsibility for financing and organizing health care in the United States, you want a public plan. (Many of those who favor a public plan option would like it to be the only option - like Canada - but have decided that this is the best they can get right now.) If you believe that the problem with American health care is too much government and not enough private initiative and responsibility, then you are opposed to a public plan.

Largely missing from the discussion, though, are the details of the "it" that everyone is arguing over. There is general agreement among policy wonks that the current Medicare payment structure is dysfunctional - it undervalues primary care and rewards volume instead of value. If so, then, does it make much sense to create a new public plan that takes this same flawed payment structure and add 10%?

Would there be safeguards to ensure that payment rates under the public plan are competitive with private insurance and high enough to ensure sufficient participation by physicians and other "providers"? Or would it end up looking more like Medicaid, where low levels of payment have resulted in low levels of physician participation and generally, poor access to care?

Medicare also does not cover most preventive services. Does it make sense then to replicate this same benefit structure in a new public plan?

One could imagine a public plan that is better than Medicare. It would pay primary care doctors more, create incentives for value, rather than volume, and cover preventive services that largely are left out of Medicare. It would pay enough to ensure sufficient participation by physicians. It would compete with qualified private insurers, but on a fair playing field.

It is legitimate to raise ideological or philosophical points for or against a public plan. But at some point the debate needs to move from philosophy to defining the "it" - what kind of public plan are we talking about? Only then can voters, most of whom are principled pragmatist, make a decision on support.

Today's questions: Should the public be offered a public plan? And if so, should it look like Medicare? Or something different and better?

Wednesday, June 3, 2009

Guess which "cost driver" was overlooked by Obama's economic team?

Yesterday, President Obama's top economists released a report on how health care reform will improve the economic health of the country.

The President's Council of Economic Advisers estimate that "expanding health insurance coverage to the uninsured would increase net economic well-being by roughly $100 billion a year, which is roughly two-thirds of a percent of GDP" and that "[With health care reform] the real income of the typical family of four could be $2,600 higher in 2020 than it otherwise would have been and $10,000 higher in 2030." The report makes the case that, "slowing the growth rate of health care costs will prevent disastrous increases in the Federal budget deficit" because, absent reform, "Medicare and Medicaid expenditures are projected to rise from the current 6 percent of GDP to 15 percent in 2040..."

The report identifies seven "drivers" of inefficiency that need to be addressed in health care reform:

1. Provider incentives that reward providers for volume of services rather than quality, cost and efficiency.
2. Limited financial incentives for consumer to consider price, quality and choice of health care setting.
3. Pricing of medical treatments that are slow to adjust for productivity improvements and decreasing marginal costs of production.
4. Fragmentation caused by patients receiving care from independent and competing organizations instead of vertically integrated groups like Geisinger and the Mayo health systems.
5. Lack of information for providers on the clinical risks and potential health benefits of alternative treatments.
6. Lack of comprehensive performance measurement and feedback to providers on how well or poorly they are doing on providing recommended care.
7. Lack of information to consumers on the effectiveness of different treatments.

What's missing? That the growing lack of internists and other primary care physicians in the U.S. is a principal driver of higher costs and a major reason why we lag behind other countries.

Oh, to be fair, they did mention primary care in passing:

"Though we describe them separately, it is important to note that there may be interactions between expanding access to coverage and slowing cost growth. For example, wider access to primary care, with an emphasis on prevention, is likely to help restrain cost growth."

That's it. No other mention of physician workforce issues. No mention of medical home. No mention of internal medicine, family medicine, or pediatrics. No mention of "patient-centered" care except for once in the introduction. No statement about the urgency of reversing the imminent collapse of primary care medicine.

This, despite the evidence that primary care is consistently associated with better outcomes and lower costs of care.

That such bright people overlooked the importance of having an adequate primary care physician workforce suggests several possibilities. One is that they are unpersuaded by the evidence. Another is that they simply overlooked it. A third is that they are aware of the evidence, but have decided for political reasons not to make it a priority. Or maybe they just forgot.

No matter the explanation, the Obama administration needs to make physician workforce issues, and especially the need to avert a collapse of primary care medicine, a higher priority. The urgency of the issue deserves a lot more attention than 17 words out of a 51 page report that was supposed to make the definitive economic case for health care reform.

Today's question: What else do you think should be done to get White House policymakers to make primary care a priority that matches the urgency?

Monday, June 1, 2009

A Tale of Two States

For Massachusetts, it may be the best of times, and worst of times, for health care, but for California, it is only the worst of times.

I spent this weekend at a planning retreat of the governing council of the ACP Massachusetts chapter. These internists view the Massachusetts experiment as a very flawed one that is not sustainable and should not be replicated on a national scale.

What is wrong with Massachusetts? In the views of these internists, Massachusetts promised the newly insured that they would have access to a doctor, something that it could not deliver on, when the state is experiencing the same hemorrhaging of primary care physicians happening everywhere else.

A new Health Affairs study backs them up. It found that Massachusetts "has sustained gains in insurance coverage and access to care stemming from its landmark 2006 health reform and coverage expansion. However, some of the early gains in reducing barriers to care and improving the affordability of care had eroded by the fall of 2008, roughly two years after the Bay State began implementing its reform." Specifically, "about one in five adults in Massachusetts reported that they were told that a doctor's office or clinic was not accepting patients with their type of coverage or was not accepting any new patients. These problems were reported for both primary and specialty care (66 percent and 56 percent of those reporting such problems, respectively.)"

Then, as I flew back to DC, I read in the New York Times the shocking news that California may terminate its Children's Health Insurance Program (SCHIP):

"If lawmakers sign off on closing the health insurance program for children whose families make too much to qualify for Medicaid, California would be the first state in the nation to close the popular program. Begun in 1997, the program, known as S-CHIP, reimburses states at a higher rate than for Medicaid to deliver health insurance to children and teenagers. With the cuts to Medicaid, the state would probably increase its number of uninsured people by nearly 2 million, the California Budget Project says."

This, just four months after President Obama proudly signed into law an SCHIP extension that was supposed to cover four million more kids nationwide.

I think there are several important take-home lessons. First, health reform on a state-by-state basis won't work, at least over the long term. It is beyond the power of a state to institute comprehensive reforms of payment and workforce policies to increase the numbers of primary care physicians or to provide sustainable financing when times are tough. Only the feds can do this.

Second, Americans' aversion to tax increases is a dagger at the throat of health care reform. There are many reasons, including mismanaged spending when times were good, that got California in the mess it is in right now, but the current crisis also is due to the unwillingness of California voters to approve tax increases to sustain programs for the poor.

Finally, the California melt-down may be a glimpse into the health care Armageddon that may occur across the country if the United States Congress does not enact comprehensive health care reform, with sufficient cost controls, workforce, and revenue to sustain it over the long-term.

Today's question: What do you think can be learned from the Massachusetts and California experiences?