Wednesday, September 2, 2009

Do internists really want everyone to have health insurance?

Politico and other media outlets are reporting that President Obama plans to make a major speech to communicate to the public what he wants from health care reform, and how it will benefit them. The change in approach recognizes that "we're in the eighth or ninth inning here, and so there's not a lot of time to waste" as David Alexrod, one of Obama's top strategists described the situation to Politico.

As the President re-evaluates his approach, it may be time for internists to also take a step back and consider what they want from health care reform.

If you asked me a few months ago, I would have told you that internists were generally in agreement that the current health care system needs major reform. Now, I am less sure. Like the American people as a whole, my sense is that more internists are having second thoughts about whether they really want health reform to happen. Some, of course, have already made up their minds.

This is somewhat surprising, since internists have long championed the need for health care reform. In fact, health reform was a cause celebre for ACP long before President Obama was elected.

More than fifteen years ago, ACP called for reforms to make health insurance universal and "portable" - not dependent on place of employment, residence, or health status. In the late 1990s, we published a landmark paper on the scientific research linking lack of insurance coverage to poorer outcome. The paper, titled "No Health Insurance? It's Enough to Make you Sick" found that uninsured Americans tend to live sicker and die earlier than insured Americans.

ACP developed its own proposal - released in 2002 and updated this past year - to provide coverage to all Americans with seven years. It calls for income-based tax credits to help people buy coverage, insurance market reforms, and group purchasing arrangements - not unlike the legislation being considered today by Congress. (Bills based on ACP's proposal were introduced on a bipartisan basis in the past three Congresses.)

In 2004, we published research on the costs of not providing coverage to all Americans, and in 2007, the Annals of Internal Medicine published a paper (disclosure: I was a co-author) comparing U.S. health care to other countries and drawing lessons from them. Notwithstanding the oft-stated argument in this political season that the U.S. has the "best health care in the world" we found that the U.S. lagged behind other countries on many measures of effective care and that most effective systems had certain common features - including coverage for everyone and a strong primary care physician workforce - even though they differed on how to provide coverage.

In April, 2009, the ACP Board of Regents adopted a statement on the organization's "desired future" for the health care in the United States, which says this:

"The U.S. health care delivery system provides access, best quality care and health insurance coverage for 100% of our citizens."

Not 80 or 90 percent of our citizens, but every American.

Today, we have a chance to achieve this desired future, or to at least put the steps in place to make it possible in the near-term future.

The question is: How many internists still want Congress to enact legislation to provide coverage to all our citizens? How many prefer that they fail?

I know and respect the fact that some ACP members have principled reasons for opposing elements of the bills being considered. They tell me that they are concerned about whether the country can afford to provide coverage to everyone, and believe there is too strong a role for government in the bills being considered. I also know and respect the fact that some internists, on the other side of the political spectrum, feel passionately that a single payer system is the only answer. Many internists also believe that the bills fall short - I am with you on this - on important issues like medical liability reform and support for primary care.

The current bills will be changed, and with the continued support of ACP members, we have an opportunity to get improvements in them.

But health care is at make-or-break point. Internists - like all the rest of us - will need to decide if they are willing to support the compromises needed to get legislation enacted into law that provides all our citizens with access to insurance coverage. Just as the president has to decide what compromises he is willing to offer and accept to achieve the same.

I also believe that if the current effort fails - and physicians will have a lot to do in deciding the outcome - we will be consigning tens of millions of Americans to a future with no health insurance coverage. And, as ACP said in 1999, that's enough to make you sick.

Today's question: At this critical decision point, do you think that most internists want Congress to succeed in passing legislation to provide just about everyone with access to affordable coverage?


Robert J. Sobel, M.D. said...

Independent physicians have little room left to manuever. Of course we want coverage extended to all, but, by being the last nation in line, we need to learn from those before us. The growth curves of France, UK, and Canada are just as steep as ours. We cannot survive in Medicaid and give quality. We cannot survive in Medicare without stabilization of fees and reassessment of how ancillaries are paid. We cannot succeed if a quality paradigm leads to more time defending ourselves than actually doing our jobs.

Fair fee for service is the best option out there. It doesn't make us do more. It allows us to do what is needed and get reimbursed. If Washington wants to listen to internists, they will see what really goes on and how much unreimbursed care we give.

Unless we reform drug costs in a way that doesn't require further bureaucratic meddling, we are better off delaying the process until everyone sees how ludicrous the payment system is. We fight everyday to do well by our patients. If we really want to pay for quality, we should experiment with congressional salaries first?

Jay Larson MD said...

Yes, most internists want Congress to succeed in passing legislation to provide everyone with access to “affordable” coverage. There are, however, several road blocks to accomplish the “affordable” part that are not being addressed. The only way to make insurance affordable is to bend the cost curve.

If every one has health coverage, where will they go for care? If the system does not change, care will be provided by ERs, Urgent cares, and specialists, none of whom have been shown to be cost efficient especially for chronic disease management. Chronic disease affects the 20% of the population that consumes 80% of health care costs. Quality chronic disease management does not occur with episodic care by several different providers.

Massachusetts’ health care has shown that the more people with insurance coverage, the greater the need for primary care. Massachusetts has the highest primary care to population ratio than every other state. Yet even with a greater amount of primary care providers, the wait to see one is months. Even with universal insurance coverage in Massachusetts, the health care cost curve has not been bent.

Then there is the outrageous cost of medications, procedures, hospitalizations, and diagnostic imaging. General internists have no say in the cost of the tools they need to use to provide quality care. Yet general internists are being held accountable for the cost of care.

Yes, universal access to “affordable” insurance cover would be nice, but the barriers to bending the cost curve have to be addressed or the “affordable” part will not be achieved.

hlr said...

We all probably want everyone to have health insurance.
Nobody will want to be on the side of a sick person being denied needed care, or being forced to choose between bankruptcy for their family and appropriate health care.

We have to make a system where people are responsible for some of their own choices.
If cigarettes are costing someone over $100 per month, why should they continue to have that money while choosing elective health care services.
Yes they are the ones who need the flu shots the most. But if they have $100 extra per month, surely they can use some of their own discretionary money for a flu shot.
Or a pneumonia shot?
Or a physical exam?

Why should health insurance cover things that fit under the guise of discretionary spending?

Why can't we be left to compete with each other for patients by charging for things that aren't covered?
Things that the patients can pay us for directly?

Maybe the government can empower patients as consumers for some things, and for other things that we all acknowledge as much less discretionary... well for those things we are simply covered and the only choice there may be between competing local health plans.

I think that some of us think that all of this would be so much simpler with a single payer system.
I used to think so too.
But it wouldn't.
The problem is us. And the hospitals. And the system we work with and the incentive structure.
A single payer system would not change that.
We would still be paid, and therefore we would still have an incentive system.

Unless we are simply given a salary.
And then....well. I don't know.
We've not tried that in this country.

I know in Marshfield, WI there was a time when all the specialists and primary care physicians all made the same amount of money. They would divide up the collections equally -- and not pay attention to who was generating what money.
All practicing physicians in the group practice regarded each other as equal colleagues.

Not anymore.
Neurosurgeons start at $1 million.
And they are quite sure they are worth every penny from the moment they leave residency.
Try to find one who would go back to a system of sharing money with internists on an equal footing.

It is not just health insurance that needs reform.
It is the culture of the practice of medicine.
And it is changing.
Change is inevitable.

It may not happen this year.