Healthcare's Biggest Issue: What to do with Primary Care?

There is agreement among most healthcare officials and experts that the most important and challenging issue facing the future of the industry is the disintegration of primary care. The field has become underpaid, overworked, and has had some serious issues with recruiting its own next generation; the latter partly due to the former. Aside from the lack of medical students pursuing primary care, our current batch are bailing out of the field or opening boutique/alternative practices to keep the bills paid. It has become cliche to talk about "once the baby boomers start getting sick, forget it," but I personally repeat this to everyone I speak to about healthcare.

In the first days of of my first year of medical school I remember the professors taking a poll of who wanted to enter what specialty. Literally, I saw two hands go up for primary/family medicine and surely my school is not alone in these kinds of figures. I don't blame students for having the desire to earn more and its not just that, what we as students hear of primary care makes us cringe. Of course we want to help people (at least most of us) but who wants to spend half of their career on the phone dealing with managed care or insurance companies. We want to spend our time taking care of people, doing what we will be trained to do, and deal with less beauracracy. My point is this, we have a huge problem, and the problem lies within the system not within the physicians or students.

The discussion and debate rages on. Obviously politics and elections plays a big role, but aside from Obama's election and its affect on these issues there have been pushes from all sides to reform if nothing else how we deal with primary care. There needs to be incentive to go into the field and there needs to be reimbursement changes. Lots of good ideas are proposed, and again there needs to be a compromise as a change in payments has affects across the professional board. This is evident by the recent uprising of specialists toward the Baucus healthcare reform legislation. The specialists are insiting that this reform unfairly cuts their salaries to pay primary care doctors more. Surely this is a valid argument, any profession would be against legislation that literally cuts their salary the moment it is signed. So we need to do this carefully, patiently yet swiftly, and we need to compromise. But above all something needs to be done or the backbone of the system will start crumbling, or rather imploding.

Check out the NEJM debate on this issue HERE.

Pay-For-Performance, Setting Patients up for Higher Bills?

The letters to the editor, in response to the Times article I wrote about previously, viciously point out the inherent problems with a PFP reimbursement approach. You can read some of them HERE. A good point: "If hospitals are forced to provide free corrective treatment to victim patients, those costs will become part of hospital overhead, which we will all pay for anyway." Is that all that PFP does, skips the bill so that both providers and patients are left with the difference?

Another question we have to ask when debating PFP is whether this system demands no errors in an industry that cannot exist without some errors. Although we would love to avoid every preventable accident in medicine, it may be dangerous to punish an industry that relies on risk/benefit ratios, experimental treatments, and other efforts to treat diesease. From one of the letters:

"It is important to understand the context in which medical events like catheter-related urinary tract infections and pressure ulcers occur in hospitalized patients.

These patients have multiple chronic medical problems and are often immobile and institutionalized, having lost the ability to care for themselves because of diseases like Alzheimer’s or severe stroke. Others are in intensive care units suffering from multisystem organ failure and on the verge of death.

Therefore the analogy to use should not be one of an auto mechanic accidentally breaking the windshield while repairing the engine. Rather, it should be of the mechanic who is required to perfectly repair a vehicle that arrived at the shop totaled."

One Step Closer to Pay-For-Performance Medicine

There is a current running through healthcare policy think-tanks, insurance company board rooms, and government offices. Pay-for-Performance (PFP) is coming and coming fast. Not a soul is selling PFP as a key to medical utopia, but it is a decisive movement toward broad reform of medical reimbursement. PFP restructures reimbursement of providers from the current quantity-driven method to a what is supposed to be a quality, error-minimizing way. It does this not only by providing incentives for positive outcomes but also withholding payment when treatment is due to a "reasonably preventable" error. Its proposed benefits to the system are financial incentives toward quality control and minimizing preventable accidents, infections, and injury by providers. Its critics however have a decent leg to stand on. They claim that under these plans physicians begin cherry-picking low-risk patients, for instance for cardiac bypass surgery. This way, their successful outcomes looks very high upon analysis by medicare or an insurance company, and they recieve bonuses and/or high recommendations by what would be a public rating system of doctors and hospitals.

The most recent and apparent shift toward PFP is medicare's plan to withhold reimbursement for medical errors. This is the beginning, as most insurance companies will follow medicare as they normally do. This New York Times article lays out the new plan by medicare. What I found interesting was that although this is supposed to be a money-saver for these insurers, studies and experiments have shown little if any savings. The article points out that:

"The real money, many health economists believe, may come from reorienting the payment system to encourage prevention and chronic disease management and to discourage unnecessary procedures."

This astonished me. Have insurers and the government finally realized that investing in these preventable and manageable diseases now, you will have a healthier and thus cheaper patient population later? Who knows, and beyond that question, we don't know if this reimbursement plan will even redirect the medical community's attention to these issues. Time will tell, but now we know that PFP is on its way, whether physicians like it or not. I think it is now our responsibility to educate ourselves about it, so that we can make informed decisions in our future as physicians.

Green Medicine?

Thought this was interesting. The concept of health care professionals practicing as environmentally safe as possible doesn't seem like that profound of a concept. After all, we should be promoting "health" any way we can. It seems that responsible doctors and business people have begun a transforming movement in the industry.

Check out this ARTICLE.

PNHP: Healthy Americans Act is the "Wrong Model"

Well, it comes as no surprise that not everyone would agree on this broad reform proposition. The PNHP has posted an article extremely critical of the Healthy Americans Act. It states that: "the bill depends on the 'mandate' model of private insurance." This is truly a core issue in health care reform, mandating insurance. Through a social lens, a mandate whether private or for a federal plan, resembles how we deal with car insurance. If you drive a car you MUST purchase insurance, however there are differences in this scenario since your personal health does not have as direct affects on those around you (unlike running over a pedestrian in your hummer.) Mandating people to purchase private health insurance is tricky. The issue of compliance and enforcement is an obvious talking point for the critics. A national health plan provides a mandate, but a mandate for government to cover all individuals. As we know there is strong conservative opposition to government fitting the bill for everyone's healthcare. They believe that centralizing and growing the so-called beauracracy limits an efficiently run health care system. So this issue is of primary concern when trying to reform the system. It seems the idea of this bill is to pull away from employer based insurance but to stay in a private market for insurances to compete for this new pool of health care consumers.

The bill also provides a framework of 3 risk pools and government subsidies are to support the lowest (medicaid) of them. It assumes that the problem with medicaid is not that the program is not comprehensive, just that it is underfunded, it underreimburses providers and therefore is limited in where it is accepted. Further subsidies would be provided to those plans so as to increase where medicaid and the like would be accepted. This seems like a simple thing to write in a bill, but not easy to execute in reality. The idea however, is a concrete solution to the lack of acceptance of medicaid.

The article in PNHP went on to attack two more principles of the act:
"healthy behavior to promote personal responsibility by giving premium discounts for controlling your blood pressure or diabetes (hard to imagine the kind of gaming that occurs here), and the Republican favorite - market forces, based on transparency in prices and quality and individuals presumably shopping around for cheaper and better care."

Most people probably agree that our health care system should include some kind of incentives for personal responsiblity. That concept is not foreign even to socialized medical systems like the German system. Here is an example of some German social security code regarding health care personal responsibility:

• Services must only be used insofar as necessary
  
• Copayments are to be requested where treatment is required as a result of a criminal activity, deliberate self harm, or a "non-medically indicated measure such as cosmetic surgery, a tattoo, or a piercing"
  
• Financial incentives are to be provided to those taking part in preventive measures, screening, and check-up programmes, those taking part in managed care programmes, or those who do not use general practitioner or hospital services over prescribed periods
  
• Threshold for copayments of chronically ill and cancer patients are to depend on their compliance with screening and treatment regimens

How these incentives are provided fairly and uniformly is a burden for any piece of legislation and this act shows its vulnerability on the issue.

As for the issue of market forces, it has plenty of arguments on both sides. In our system dominated by employer based health insurance, the competition my be limited by the big players purchasing the plans. Competition may not be acting to fully improve the health care provided and the efficiency with which it is run. For instance, costs of insurance company infrastructure have been estimated as enormous percentages of the entire healthcare spending in this country, noone can argue that that is efficent. The insurance companies themselves also rake in huge profits and are really the biggest winners in the system, wheras physicians and other providers struggle to get their share. Also, if the market was maximizing efficiency then our system should prove to be a better medical system than a universal coverage system, but we lag behind many nations' in a plethora of statistical data measuring the effectiveness of our healthcare. The opposing argument is that we cannot write of the market in health care. If the system was weaned off employer based insurance, it could be possible that a higher level of competition would arise from the huge pool of independent consumers looking for private plans. This could lower prices and improve the efficiency of our system. There is obviously something wrong with the way the current insurance/market system is set up. If we are to maintain the private system that we have, it has to be changed so as to encourage improvement.

Regardless, the debate is healthy and going strong. At least if nothing else, we seem to be making something happen. Party players are coming together and working on compromise which is when the country tends to actually move forward. The next blog will continue with this discussion.

Health Reform On Its Way?

The most recent legislation with any hope of being passed is a bipartisan supported bill called the "Healthy Americans Act." Click here for a PDF download. Anyone with a future in medicine should be paying very close attention to the progress of this bill. Although it will likely change once a president is elected, the meat of the bill could remain. Whether this will actually come through is another story. As the battle goes with reforming healthcare in this country, it is not so easy. So let's examine what a co-author of the bill says it will do. The next blog I will go into more of the debate and look at other perspectives of this bill.

These are the main concepts of the bill from Senator Bob Bennet's website:

The Basic Principles of the Healthy Americans Act

1. CHOICE – Gives Americans choice in what type of coverage best suits their individual and family’s needs and a choice in where they receive health care services.
2. PORTABILITY – Because the individual will now own their health policy, insurance becomes portable from job to job and individuals will no longer feel tied to their job because of health benefits.
3. TAX REFORM – Breaks the link between employment and insurance, giving employees instead of employers the tax benefit, which will strengthen incentives to shop for lower cost plans, as well as improve health care quality.
4. HEALTHY BEHAVIOR – Promotes personal responsibility and preventative medicine by creating incentives for individuals to engage in healthy behavior.
5. MARKET FORCES – Provides for patient-driven health care through market forces by allowing more transparency and competition, thereby forcing insurance companies to compete on price, benefits, and quality.

Hello Health: Dr. Parkinson Launches in Williamsburg

The MSBA's first speaker was Dr. Jay Parkinson back in April. His patience has paid off as he is finally launching the "storefront" of Hello Health in Williamsburg, Brooklyn. The hip "Racked" blog published a recent post about the new Brooklyn doctor's office - or "hub" as Parkinson would prefer. We would like to congratulate the launch and wish Dr. Parkinson and his associates good luck.