Sunday, October 30, 2016

Insurance coverage and access to care in the US

In the New York Times’ “Upshot” of October 24, 2016, Dr. Aaron E. Carroll discusses “Why the U.S. Still Trails Many Wealthy Nations in Access to Care”. He notes the increase in insurance coverage of the American people since Obamacare, but also that insurance coverage is not the same as access to care. He cites the most recent Commonwealth Fund survey of international health systems to demonstrate that, compared to most of the other ten wealthy countries that were studied, Americans have greater difficulty getting an appointment and being seen. (Canada is worse than the US in many of these measures, but not all; see discussion below.) Indeed, he also notes that when the populations of these countries are divided up between above-average and below-average incomes, the folks with below-average income in most of these other countries have better access than the above-average in the US.

A major reason that Carroll cites for the poor access is the low percent of primary care physicians in the US, a fact supported by data from the Organization for Economic Cooperation and Development (OECD, the “rich countries” group). It is true. There are not enough primary care doctors -- family physicians and general internists and general pediatricians -- to meet the access needs of the people of this country. There are plenty of excellent specialists; in fact, in many major metropolitan areas there are too many of them, sometimes leading to too many interventions that both increase the cost to the system and the risk to patients. Traditional “supply and demand” economics would suggest that limits on demand would force a constraint on the number of specialists, but it hasn’t happened yet; none of them are starving. This is because, in medicine, supply often drives demand rather than vice versa. When are people finally getting enough procedures, and when does it cross into too many? People don’t understand medical care, what is “good” for them and what is “too much”, much less the cost-benefit ratio. Indeed, doctors usually do not. But they do know what they know how to do, and that it will make them money.

This is a major area that having sufficient primary care physicians would help. If everyone has a family doctor that they can trust, whose income is not tied to procedures or referrals, they can help you to understand these complex issues. But there are far from enough; less than 30% of doctors in the US are in primary care, compared to 50%+ in other wealthy countries, and that is dropping as fewer students choose primary care careers. Many reasons for this are cited by studies (the culture of academic medical centers, status, work-life balance, etc.) but the real bottom-line reason is the bottom line: primary care physicians earn way less than most other specialists. Not just a little, but often half or a third as much as the highest paid specialists. Pay for primary care is going up with demand, but 10-15% increases will not change specialty choice; between income increases for primary care and decreases for specialties (heaven forfend!) the ratio needs to be at least 70%. Specialists know this; they want primary care doctors to do all the things that they themselves are not able or don’t want to do for their patients and are not opposed to primary care salaries going up -- although of course they themselves don’t want to see their own incomes go down.

Getting the care you need is a combination of having enough providers for you to be able to find and get in to see, and adequate coverage. Insurance, as we have long seen even before Obamacare, is not all the same; there is good insurance (although hardly, any longer, great insurance) and lousy insurance, and there is no insurance that is both cheap and of high quality (although, again, there are plenty of plans that are costly and of poor quality). Premiums are the tip of the iceberg; deductibles (how much you have to pay out of pocket before your insurance kicks in), co-pays (how much you have to pay each time you access care), co-insurance (what percent of “covered” care you have to pay) also impact on out of pocket costs. As, of course, does the overall cost of care (by providers) and drugs (by drug companies), and what services are not covered by your insurance.

As an example, if you are over 65, try figuring out what plan to buy for your Medicare Drug Coverage (“Part D”). There are the monthly premiums. And the deductibles. And the co-pays. And those vary by type of drug (generic vs. brand-name, preferred vs. non-preferred), and sometimes they are by a fixed $-per-prescription amount and sometimes by a percent. And if you order by mail it is different. On the bright side, most vendors offer you a calculator into which you can put the drugs you take, and it puts it all together and tells you which is cheapest for you. Until, of course, the drugs you take change.

This is insane, of course, but only if you happen to care about what works best for actual people, and not what makes the most money for private for-profit companies like insurers. Drew Shenaman, cartoonist for the Newark Star-Ledger, in the accompanying editorial cartoon, makes it very clear what the real reason is that insurers are pulling out of Obamacare. Their interests are not our interests. Surprise!
So we have excellent quality medical care available in the US, if you are geographically and financially able to access it, except sometimes it is not needed and done anyway. We have too many doctors in some specialties and far too few primary care doctors, and even they are not distributed well across the US. We have insurance companies that are focused on making profits, rather than on providing access, and sell complex, difficult-to-understand products that often have a “gotcha” at the point when we are most vulnerable. While access to appointments may be a little better in the US than in Canada (but not other countries), cost to the individual is way higher in this country than in Canada; access to care has both financial and non-financial components.

Not everything can be reduced to dollars, but a lot can. The money spent on health care in this country should be spent on providing health care, not on profit for insurance companies, providers, drug companies, and the like. If private insurance is to be part of the system, it needs to be non-profit and highly regulated. There need to be more primary care doctors, and the way to make this happen is for them to get paid much closer to the same amount of money for the work that they do as other specialists. Medicare can and should lead the way on this. Physician distribution should be fixed by augmenting the incomes of doctors in rural areas, not punishing them. None of this guarantees quality care, but without it quality is a pipe dream.

Obamacare was good insofar as it went. It didn’t go far enough, and now we need to fix it.


Matthew Anderson said...

Last September Tom Bodenheimer published a Perspective article entitled: Rethinking the Primary Care Workforce — An Expanded Role for Nurses. (link: Bodenheimer notes that by the year 2020 the number of MD's going into primary care will not make up for those leaving; in plain English this means that within five years the primary care MD force will begin to decline while the population grows older and suffers increasingly from chronic disease. Bodenheimer does not bemoan this fact (it's been obvious for some time that this was bound to happen) nor does he linger on it; the article is on how NP's, PA's and RN's will take up the slack.

My own sense is that for at least the past decade we have been hearing our leadership tell us how valuable primary care is and how all the politicians support it and will provide us with additional funds. It's hard to decide whether they are just plain dumb or are deliberately misleading us because they have been bought off. (I tend to favor the second hypothesis) This was all just "happy talk" based on some alternate universe that - I suspect - is based on someone making a lot of money. Even today, provides nutritonal advice to chldren that is underwritten by Coca-Cola. Link:

I do not believe that NP's, PA's and RN's will provide inferior service. But a dwindling number of MD's in primary care will have other negative consequences. It will further ghettoize the field, those who remain in it will have increasing work-loads, they will necessarily function as supervisors of others rather than primary providers, and we are likely to see less primary care research.

It is a damning indictment (as if we needed any more) that our healthcare system is headed in the wrong direction. There are straightforward solutions to the primary care issue - requiring that GME produces the doctors the country needs - but they are off the table. Until we get a single payer system.

Thank goodness there are still people who speak truth to power. Thanks for the good work, Matt Anderson, MD

stephanie Charron said...

I think that it is very interesting to find out that when the populations of these countries are divided up between above-average and below-average incomes, the folks with below-average income in most of these other countries have better access to healthcare than the above-average in the US. We probably ought to pay physicians whatever amount is needed to obtain an “adequate” supply of physicians. In many countries, costs for attending medical school are minimal to nothing and thus their true take home pay is much higher than those that are required to pay debt. Is there any question of whether Medicare is what started this slippery slope process of lowered reimbursements, and thus, can be considered the root cause of the general collapse of our health care delivery system?

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