Thursday, May 5, 2011

Family Medicine in the era of health reform

At the recent Primary Care Access Conference in San Francisco, I was given the opportunity to present the 21st G. Gayle Stephens lecture. It was a real honor, because it is named for one of the giants of family medicine, and one of the great thinkers on health and medicine of the last half century, in any field. Dr. Stephens was the first director of one of the nation’s first family medicine residencies, at Wesley Hospital in Wichita, KS, and later Chair of the Family Medicine department at the University of Alabama. He was an early and long-time member of the American Board of Family Practice (later Family Medicine) and the author of several of the most seminal articles and books in the field, including “The Intellectual Basis of Family Practice” and “Family Medicine as Counterculture”.  Both of these pieces, along with many others, are discussed in the outstanding “festschrift;[1; put together by another giant of the discipline, John Geyman, in the January 2011 issue of Family Medicine.

Dr. Geyman says of Dr. Stephens that “He has been, and remains, by far the most original, thoughtful, and elo­quent voice in our field and among the few who best represents the mor­al conscience of the entire medical profession.” I have been privileged to have met, corresponded with, and even to a limited extent collaborated with both Dr. Stephens and Dr. Geyman. I can only hope that my talk was worthy of being associated with Dr. Stephens’ name. In this piece, I  would like to discuss a few of the points I made in that talk related to health care reform, or the Affordable Care Act (ACA); in a later blog I will discuss this in terms of the impact on primary care and family medicine.

Unquestionably the health care reform act, or ACA, is the biggest change in health coverage since Medicare and Medicaid in 1965. It remains deeply flawed, but is nonetheless the touchstone of the opposition to the current administration, as President Obama’s opponents apparently see in it everything that we don’t! The fact is that, rather than bringing us a health system in which everyone is covered, like Canada, or the UK, or Germany, or Switzerland, or Taiwan, it is in large part a big bailout of health insurance companies. And the price that for this – the requirement that everyone have to buy health insurance, the “individual mandate”, is what we hear being attacked, not the insurance companies that demanded it as the price for supporting ACA.

There are some of the parts of ACA that are rather non-controversial (except to the extent that they might not be funded as part of the “don’t fund anything” movement), and are good for family medicine, in the sense that they are good for the health of the American people. These include the increased funding for Federally-Qualified Health Centers (FQHCs), the creation of a panel to review the evidence of effectiveness, if it is left in, and the Primary Care/Health Extension services (which thus far have received no appropriation), among others.

One important component of ACA is the creation of “Accountable Care Organizations”, or ACOs, initially for Medicare patients. They are an effort to promote health by having health providers financially responsible for the health of their patients, that is, to have ambulatory care facilities and doctors, hospitals, nursing homes, and community care facilities coordinate their efforts to prevent illness, treat effectively, and have people cared for in the most appropriate setting, rather than perverse “gaming of the system”, where a failure of ambulatory health care can be a “win” for a hospital when a patient is admitted (as long as they don’t stay too long, or get re-admitted too soon). This kind of structure works well in HMOs, such as Kaiser, or other integrated health systems, but there are likely to be flaws in its implementation; for example, Center for Medicare and Medicaid Services (CMS) administrator Dr. Donald Berwick recently published guidelines for Medicare ACOs in the New England Journal of Medicine, Launching Accountable Care Organizations — The Proposed Rule for the Medicare Shared Savings Program.  He says that the ACOs will be “Held to rigorous quality standards (see table). Proposed Measures for ACO Quality-Performance Standards.), ACOs will be expected to be proactive in their orientation and to regularly reach out to patients to help them meet their needs for preventive and chronic health care.”

However, Berwick immediately adds that “Patients who seek care at their ACO will know that their physicians are part of that ACO, but as beneficiaries of fee-for-service Medicare, they will continue to be free to seek care from any Medicare provider they wish. They will not be locked into seeing only particular health care providers.” This sounds relatively benign, and certainly politically wise, but could completely undercut the effectiveness of the program. The reason that Kaiser and other HMOs are effective in managing care that delivers high quality at low cost is because their patients are restricted to where they can seek services; if a Medicare patient who is part of an ACO does not like that they have been “denied” any form of care by their doctor or hospital, no matter how appropriately, can now go “outside the system” to another doctor, hospital, emergency room or pharmacy-based urgent care clinic, all efforts at cost control are at risk. This is, of course, the conundrum: control of costs requires some degree of restriction of unlimited options. It is quite parallel, in fact, to the “individual mandate” that the insurance companies demand, and in this sense they are correct. It will not work to require insurance companies to insure everyone if everyone is not required to have insurance, because then only those who need care will demand coverage, risk goes way up, and so would premiums.

Some politicians and pundits have compared ACOs to the managed care era of the 1990s, and supporters worry it will receive the same backlash from the public that occurred then. I believe that in that period it was not managed care that was at fault but two major characteristics that happened in conjunction with it. The most important was that the entire operation was taken over by for-profit companies, largely insurance companies, that saw benefit to their bottom line by restricting care. The efficiencies of consumer cooperative HMOs had benefited their members; these new entities denied care to benefit their stockholders. It was the corporate for-profit control, not the management of care, that led to consumer dissatisfaction with restrictions on access to care.
The second big problem is related to one that I have discussed before (Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), the fact that most people are not sick. In an effort to control costs, everyone was made to jump through hoops, such as gatekeepers and prior authorization, which made them angry but did not do much for the cost, since most people do not use much medical care. Indeed, for at least half the population, you could let them do whatever they want, and they wouldn’t use any significant number of health care dollars. To illustrate this, I am reproducing the graphs from the previous blog.

While there are some things we can do to reduce the risk of unexpected crises –cancer, multiple trauma from car accidents, infants in NICUs – and control the costs of caring for those who have them, the most obvious benefit will be achieved by pre-emptively working with people whose chronic diseases have gotten so bad that they are frequently admitted, often to Intensive Care Units. These are the people who should be targeted for intensive intervention, not only medical but in terms of the social determinants of health, such as in the programs highlighted by Atul Gawande in his February 2011 New Yorker piece, “The Hot Spotters”. Needless to say, such interventions are being funded on a shoestring, while the high-tech interventions get all the money.

 It doesn’t have to be this way. We could have a rational, cost-effective health care system if we start with coverage for all through a single-payer mechanism. We might be able to back into quality despite not having one, but it will be much harder.
<!--[if !supportFootnotes]-->[1]<!--[endif]--> Festschrift: “A volume of learned articles or essays by colleagues and admirers, serving as a tribute or memorial especially to a scholar

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