We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us

Every day it gets more difficult to write about the new “American Health Care Act” (AHCA) that has been introduced in the House of Representatives by Speaker Paul Ryan because every day there is so much more news about it, and so much more criticism of it that appears in the press. Even before its introduction, the bill was attacked for being likely to significantly increase the number of uninsured Americans while providing windfall tax cuts for the wealthiest.

It did not disappoint. Consistent with predictions, the nonpartisan Congressional Budget Office (CBO) estimates that initially 14 million people will lose coverage, with the number rising to 24 million in 10 years. These estimates are discussed in detail, and clarified, in “Deciphering CBO estimates” at the Kaiser Health News site. The largest number of people who will lose coverage will do so because of the changes – but let’s call them what they are, “cuts” – to federal funding of Medicaid (discussed by the Health Affairs blog), which would shift costs to the states, most of which will be unable or unwilling to absorb these costs. The 31 states that have expanded Medicaid to all those under 138% of the federal poverty level  under the Affordable Care Act (ACA) will be faced with having to fund a lot more from their own coffers; poor people in the states that have not expanded Medicaid eligibility will continue uncovered. The other group that will lose coverage will be those who have bought subsidized insurance on the ACA-created marketplaces and who will no longer be able to afford the premiums. Yes, the new GOP plan calls for tax credits to help pay premiums, but they will be far less than under the ACA and far from enough to cover the actual cost.

This change will have the biggest impact on the older, sicker poor who are not yet eligible for Medicare (and, while I we will not address it here, the GOP leadership certainly has plans for cutting Medicare!), whose premiums will go up because of two important changes the AHCA will make. It will end the “individual mandate” of ACA, so that those who feel that they do not need health insurance can pass on buying it, which means the pool of insured will lose those healthier people and have a pool more skewed to those who are sicker and will actually use health care. This will tend to drive premiums up for them, and the AHCA also allows insurers to charge 5 times as much to older people as younger. As reported by Thomas Kaplan and Robert Pear in the NY Times on March 13, 2017

Under current law, in 2026, a single 21-year-old earning $26,500 with an insurance policy that costs $5,100 a year would get a tax credit of $3,400 and would have to pay $1,700 of the premium. Under the Republican bill, that person’s share of the cost would drop to $1,450.

By contrast, a 64-year-old earning the same amount would fare much worse. That person’s $15,300 health plan would be offset by a $13,600 tax credit under current law, leaving the consumer responsible for $1,700. Under the Republican plan, health insurers would be free to charge older people more, raising that person’s premium to $19,500. But the tax credit would be only $4,900, and that person’s share of the premium would then be $14,600.

That’s a bite! And, ironically, as pointed out by Noam Levey in the Los Angeles Times (March 12, 2017), it will hurt Trump/GOP voters more than Democratic voters, because those Trump voters – and the counties and states which went for Trump in which they live -- are more likely to be in this older, sicker, group. This group of Republican voters did not like Obamacare because the premiums, co-pays, and deductibles were going too high and the coverage was not always great, especially for the plans they could afford. Trump, and the GOP, promised them high-quality, affordable coverage. These folks believed them. They voted for them. And they are not going to get it, certainly not from the AHCA. Levey notes that “…In nearly 1,500 counties nationwide, such a person stands to lose more than $6,000 a year in federal insurance subsidies. Ninety percent of those counties backed Trump…[a]nd 68 of the 70 counties where these consumers would suffer the largest losses supported Trump in November.” What can you do. Politicians lie. This one was a whopper.

What is the reason for this? Many of Congress’ and Washington’s leading “conservatives” say that they believe that the role of government should be as close to zero as possible, and certainly think that the government has no business being involved in the insurance marketplace to ensure that people without resources have health coverage; to them, the AHCA is too much like the ACA in that it actually makes some effort to help some people, if weakly. There are a few of these “conservatives”, in and out of Congress, who really believe this and act on such beliefs. Uniformly, they are not poor, are not close to poor, and are not likely to be negatively affected. There is a much larger contingent that only believe government should not help most people. They support legislation that benefits rich people, like the AHCA, which uses the money it will save (and the CBO says that it will reduce the deficit over 10 years by $337 billion) to give tax cuts, not evenly distributed, but very much skewed to the highest incomes. This is where the [mean] rich people come in; they fund the Congresspersons, and this is what they want. Rep. Michael Burgess (R, TX), Chairman of the Energy and Commerce subcommittee on health, is quoted in the Times on March 11 (“The GOP’s high-risk strategy for health law repeal”) as saying “If you ask someone to give up something, there will be resentment,” and he is correct. That it is regular people who are being asked to give up something by Mr. Burgess and his colleagues, so that his rich patrons can save even more on their taxes, is something he doesn’t focus on.

One of the most iconic differences between ACA and AHCA focuses on equity: the subsidies (and tax credits for those who paid taxes) under ACA were tiered to income. The tax credits that replace subsidies under AHCA are tiered to age. Of course, as I have noted, older people are more likely to be sick, but they are not all of the same need; some older people have lots of money, and some have none. The same is true for younger people, including those with medical need. In any case, the tax credits in AHCA will not, as demonstrated above, be sufficient for those without significant other resources to buy health coverage, even if they are in the more-highly-subsidized older group. The Times’ Alan Rappeport reports on March 16, “One certainty in health bill: tax cuts for the wealthy”, with 40% of the cuts going to the top 1%, and the bill providing the necessary basis for further tax cuts for the rich. Rappeport quotes Mike Mulvaney, the White House budget director: “We promised at the outset that we were going to repeal all of the taxes. Who cares if someone else benefits?” Well, maybe the people who will suffer for their benefit? The same issue of the Times contains a brief and informative piece by Mr. Pear, “Putting Republicans’ plan on the Obamacare scale”, examining the criticisms of ACA and how the AHCA solves them (or not).

President Trump apparently feels conflicted; he promised the repeal of ACA, and the Congress wants to do that. He also knows that any plan that comes out that does this will be called “Trumpcare”, just as the ACA was called “Obamacare”. Enough Republican senators are concerned that the House’s AHCA will make it too hard for too many people to afford insurance that they might vote against it, so “Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress,” (”G.O.P. Senators Suggest Changes for Health Care Bill Offered by House” NY Times, March 14).

For the rest of us, it is an impending disaster.

Medicare Advantage plans, CMS, and providing high-quality care to -- and care for -- all people

Medicare Advantage plans, also known as Medicare HMOs, or officially as Medicare Part C, are an alternative to traditional Medicare. By enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient gets additional benefits that are characteristic of HMOs. This may include smaller (or no) copayments or deductibles, coverage for things not covered by traditional Medicare like dental care, eyeglasses, and hearing aids, and other “advantages”. There are disadvantages, also, of course, just as in other HMOs. Beyond cost, the main one is that there is a limited panel of providers – doctors and hospitals – that the person can use. This is particularly an issue for retired people who travel a lot, or may spend the winter in a warmer climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other providers employed by the HMO itself. There are fewer of these than there once were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”, where any doctor can be “approved” to be part of their provider group, but many doctors may choose not to be for reasons such as lower reimbursement or onerous regulation. Thus, it is at least theoretically possible that a Medicare Advantage enrollee could receive lower quality care from the doctors and hospitals that were part of the HMO’s network than from another doctor or hospital that might not be, but would be available to traditional Medicare patients. In addition, some Medicare Advantage plans are open to “dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying the additional premium. That such programs might provide worse care than others isnot an unreasonable concern based upon other services targeted Medicaid patients (e.g., nursing homes) and other programs targeted specifically to low income people.

Thus, Medicare has developed a rating system for Medicare Advantage plans, which assigns from 1 to 5 stars based, presumably, on carefully considered and assessed quality measures. If you want a good plan, it would behoove you to choose one with a “5 star” rating. Provided, of course, one is available in your area, and provided you can afford the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will pay for. Unsurprisingly, many plans that have enrolled Medicaid or other lower-income patients have had lower ratings, based on the outcomes of those patients. The plans argue that this is because these low-income patients are higher-risk, have more co-existing medical, mental health, and social conditions outside of the plan’s control. Others, including the Center for Medicare and Medicaid Services (CMS), which administers Medicare, have argued that considering these characteristics might “give a pass” to plans that provide lower-quality care to poor people. A similar rating system exists for hospitals, and similar arguments have been made. As I discussed in a blog from November 10, 2013, “Does quality of care vary by insurance status? Even Medicare? Is that OK?”, there are legitimate arguments to be made on both sides.

Now, however, according to a report in “Modern Healthcare” on October 21, 2015, CMS interim administrator Andy Slavitt and his deputy administrator who runs the Center for Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for Medicare Advantage plans based upon the pre-existing risk of the patients enrolled. This is important to the plans, since Medicare can drop them if they have several years of lower-than-3-star ratings. And they don’t want to be dropped, because these plans are moneymakers, in no small part because CMS treats them, financially, better than traditional Medicare plans (a result of purposeful federal policy to try experiments to “privatize” Medicare). While new criteria have not been officially announced, and would not take effect until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising because the CMS has previously downplayed the effects of socio-economic status on the ratings. The agency described the effect as ‘small in most cases and not consistently negative’ in a summary of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the (possible) change of heart is happening, it is difficult to not consider the financial and political clout of the insurance industry that sponsors these programs, and the political support that such “private” Medicare-replacement programs have.  It is worth noting that CMS has not indicated that it will consider revising the ratings for hospitals, despite the fact that hospitals that care a higher proportion of poor and socially disadvantaged people face the same issues. The financial penalty for hospitals is very direct, as Medicare is not paying for readmissions which occur within 30 days. If this seems, on its face, reasonable, consider that sometimes even when the care provided in the hospital is of high quality, people go back to their homes (or long-term care facilities) where it may not be. This is sometimes a result of lack of money, lack of social support, and other stressors, but the result is that they are more likely to be readmitted. Again, CMS has argued that it would not want to encourage hospitals providing lower-quality care for poor people (which certainly would be a bad thing). But if CMS penalizes hospitals for readmissions that are outside their control, it simply encourages hospitals to not care for low-income people, or, if they are sole providers in their community, possibly even close their doors, and that would be a very bad thing. Studies that have been done indeed show that readmissions are higher when hospitals care for lower income and Medicaid patients, and that this is not the result of poorer quality care provided when those people are inpatients. (See “Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program” from the Kaiser Family Foundation and “Socioeconomic status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to all Medicare recipients (indeed all people) by a hospital is not discriminatory or inequitable and that all patients have access to the care they need at the highest possible quality level. But unadjusted readmission rates are a very crude measure of quality, and it is unreasonable for CMS to expect that hospitals will be able to compensate for the impacts of poverty and lack of access to preventive care and early diagnosis and treatment. It is not unreasonable, however, for us, the American people, to expect that our government develop and help pay for programs that ensure that people’s basic needs for shelter, food, clothing, warmth and other social determinants of health, as well as post-hospital care (access to primary care, home health, and high-quality long-term care).

A single-payer health system is insufficient to address all of these needs. But it is a good start for some of them.

Integrating health systems must be to improve quality, not increase cost

The February 13, 2014 article in the New York Times by Elisabeth Rosenthal, “Apprehensive, many doctors shift to jobs with salaries”, more or less just presents the facts. It notes that the medical placement firm, Merritt Hawkins, says that 64% of jobs this year are salaried as opposed to 11% in 2004, and that it expects it to go up to 75% in the next two years. She cites AMA figures that “…about 60 percent of family doctors and pediatricians, 50 percent of surgeons and 25 percent of surgical subspecialists — such as ophthalmologists and ear, nose and throat surgeons — are employees rather than independent.” In some places it is more dramatic; in Kansas City, there are no longer any cardiologists (a type of internal medicine subspecialist) who are not employed by hospital systems, and oncologists (cancer specialists) are not far behind.

So, is this a good thing? The article suggests yes, but maybe not entirely. It states that “Health economists are nearly unanimous that the United States should move away from fee-for-service payments to doctors, the traditional system where private physicians are paid for each procedure and test,” and I agree, and that “When hospitals gather the right mix of salaried front-line doctors and specialists under one roof, it can yield cost-efficient and coordinated patient care. The Kaiser system in California and Intermountain Healthcare in Utah are considered models for how this can work,” with which I also agree. However, not all health systems are Kaiser or Intermountain Healthcare. The article continues: “But many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect. For example, when doctors’ practices are bought by a hospital, a colonoscopy or stress test performed in the office can suddenly cost far more because a hospital ‘facility fee’ is tacked on.”

Rosenthal has written about facility fees before, as has Alan Bavley of the Kansas City Star in his “Doctors, Inc.” series (“’Facility fees’ add billions to medical bills”, Dec 29, 2013), and I have commented on it in Changing the structure of health care delivery systems: to benefit the patient, the providers, or the insurers?, January 14, 2014. The new arrangements promise more money, or at least stable incomes, to physicians, and continue to pay the currently-most-highly-paid specialists the most money, with primary care doctors getting less. This is not because hospital systems have anything against primary care, but rather that they are following the money, and these acquisitions have occurred precisely while we are still under fee-for-service reimbursement in most locations. If cardiology or orthopedic or radiologic or neurosurgical procedures bring in great amounts of money to the hospital (“technical fees”) the hospitals like this, and are willing to share some of that money with the doctors to ensure that they keep their patients in their hospital or health system. Primary care does not generate such largesse. Relatively intelligent systems recognize that they need a locked-in “primary care base” to create referrals to their subspecialists, but will pay as little as they can, and demand “high productivity” (which could be seen as “patient churning”), and it is not just primary care: “many doctors on salary are offered bonuses tied to how much billing they generate, which could encourage physicians to order more X-rays and tests.”

Bloomberg News has a more direct take on this phenomenon, stating firmly in an article by Shannon Brownlee and Vikas Saini that “Bigger hospitals mean higher prices, not better care”, February 18, 2014. They cite data from sources such as the Dartmouth Atlas of Health Care, a recent article in Health Affairs[1] which demonstrated that “On average, higher-priced hospitals are bigger, but offer no better quality of care,” and a variety of lawsuits by public agencies (such as the Massachusetts Attorney General) to demonstrate that hospital acquisitions are about market share and control of practices and, ultimately, about money, not quality. “If you think of value as some combination of needed services delivered for the right price, large hospitals are no better than small hospitals on both counts.” As I have written about before, doctors control a lot of costs in the health system, by choosing the tests that they order, deciding whether to admit to the hospital or not, and where they refer. By employing the physicians, hospitals can not only control the latter, but can set criteria requiring physicians to abide by hospital policies on the others. The doctors then become, in the words of this article,  “…another cog in the corporate machine, and many physicians have told us they feel they must skew their medical judgment to keep their jobs.”

This is the nonsense that occurs when things are done piecemeal. Intermountain Health Care and Kaiser are not perfect, but they have used their status as integrated health systems to control costs and increase efficiencies. To the extent that they are also the insurer, it is in their interest to do so. Efforts by the federal government to have others emulate these models through the creation of Accountable Care Organizations (ACOs), without changing the manner of reimbursement, are bound to fail. As Paul Baladian is credited with saying “every system is perfectly designed to get the results that it gets.” If we are getting a system in which hospitals are buying up physician practices so that they can charge insurers, from Medicare to Blue Cross, more; if we are getting a system in which medical decisions are being made in the best financial interests of hospitals rather than the best health interests of patients; if we are getting a system in which we continue to favor some patient over others based upon their income, insurance status, or their type of disease (middle-aged well-insured person who needs a single joint replacement = “good”, older person with multiple chronic medical conditions and “just” Medicare or worse yet uninsured because they are under 65 or undocumented = “bad”), it is because we have perfectly designed it to be so.

Brownlee and Saini offer some suggestions for solutions. They suggest that Medicare expand its “Advance Payment Model,” a program that provides capital to small or rural physician groups, and also particularly about forming multispecialty Accountable Care Organizations driven by primary care.

“Until we give primary-care groups control over what happens to patients, large hospital systems and specialist-dominated groups -- those with greatest access to capital -- will be able to keep raising prices, even as they issue press releases about their plans to control costs and improve care.”

Sounds like a good idea to me. Combine that with a single-payer system that covers everyone, “everybody in, nobody out!” and we may be able to reverse the trend toward higher profit at the expense of lower quality.

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[1] White C, Rechovsky JD, Bond AM, “Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs”, Health Affairs, January 2014 10.1377/hlthaff.2013.0747.

Does quality of care vary by insurance status? Even Medicare? Is that OK?

While the Affordable Care Act will not lead to health insurance coverage for everyone in the US (notably poor people in the states that do not expand Medicaid, as well as those who are undocumented), it will significantly improve the situation for many of those who are uninsured (see What can we really expect from ObamaCare? A lot, actually, September 29, 2013). The hope, of course, is that health insurance will lead to increased access to medical care and that this access will improve people’s health, both through prevention and early detection of disease, and through increased access to treatment when it is needed, including treatment that requires hospitalization. Implicit in this expectation is the assumption that the quality of care received by people will be adequate, and that the source of their insurance will not affect that care.

This may not be true. I spent a large portion of my career working in public hospitals. I absolutely do not think that the care provided by physicians and other staff in those hospitals was different for people with different types of insurance coverage (many or most patients were uninsured), and indeed for many conditions the care was better. But the facilities were often substandard since they depended upon the vagaries of public funding rather than the profit generated from caring for insured patients. The physical plants were older and not as well maintained, staffing levels were lower, and availability of high-tech procedures often less. There are changes; the Cook County Hospital I worked in through the late 1990s, with antiquated facilities including open wards and no air-conditioning, has been replaced by the very nice (if overcrowded) John P. Stroger, Jr. Hospital of Cook County. University Hospital in San Antonio, where I worked in the late 1990s, may have been seen by the more well-to-do as a poor people’s hospital, but in many areas, including nurse turnover and state of the art imaging facilities, it outdid other hospitals in town. Still, the existence of public hospitals suggests two classes of care, and as we know separate is usually unequal.

But what about the quality of care given to people with different insurance status in the same hospital? Surely, we would expect there not to be differences; differences based on age, yes; on illness, yes; on patient preference, yes. But who their insurer is? Sadly, Spencer and colleagues, in the October issue of Health Affairs, call this assumption into question. In “The quality of care delivered to patients within the same hospital varies by insurance type”[1], they demonstrate that the quality of care measures for a variety of medical and surgical conditions are lower for patients covered by Medicare than for those with private insurance. Because Medicare patients are obviously older, and thus probably at higher risk, the authors controlled for a variety of factors including disease severity. The most blatant finding was that “risk adjusted” mortality rate was significantly higher in Medicare than in privately insured patients.

This is Medicare. Not Medicaid, the insurance for poor people, famous for low reimbursement rates. It is Medicare, the insurance for older people, for our parents, for us as we age. For everyone. Medicare, the single-payer system that works so well at covering everyone (at least those over 65). (One of the reasons the authors did this study was the existing perception -- and some evidence -- that Medicaid and uninsured patients, as a whole, received lower quality care, but that was related to their care often being delivered at different hospitals.) The increase in mortality rates for Medicare patients compared to others with the same diagnosis was often substantial. But why?

Our hospital clearly has demonstrated that, essentially, Medicare is its poorest payer, and that, on the whole, it loses money on Medicare patient. This may well be true at other hospitals, but in itself should not account for lower quality of care, just lower profit. I would strongly doubt that either our hospital or the physicians caring for them believe that they deliver lower quality care to Medicare patients or that they are more reluctant to do expensive tests or provide expensive treatments when they are indicated. And yet, at the group of hospitals studied (if not mine, perhaps), it is true. The authors speculate as to what reasons might be. One thought is that Medicare (and other less-well-insured patients) might have worse physicians (“slower, less competent surgeons”); in some teaching hospitals, perhaps they are more likely to be cared for by residents than attending physicians. However, I do not believe, and have not seen good evidence, that this is the case. Another possibility is that newer, more expensive, technologies are provided for those with better insurance. Not good evidence for this, either, nor for another theory, that more diagnoses (“co-morbidities”) are listed on patient bills to justify higher reimbursements. I think that there is an increasing trend to do this (not necessarily inappropriately), and that, as the authors indicate, the trend is greater among for-profit than teaching hospitals, but in itself this does not suggest a significant difference for privately insured patients compared to those covered by Medicare.

What, then, is the reason? Frankly, I don’t know. It could be simply a coding issue; that is, in order to get greater reimbursement, hospitals list more intercurrent (co-morbid) conditions for private patients in hopes of greater reimbursement, which makes them appear sicker compared to Medicare patients when the latter are actually sicker. Or it may be that less experienced physicians and surgeons care for them. Or it may be that, despite the willingness of physicians, hospitals are less likely to provide expensive care for patients who, like those covered by Medicare, are reimbursed by diagnosis, not by the cost of treatment. Indeed, there may be other patient characteristics that lead to inequities in care that confound this study, but the idea that it may be because they are insured by Medicare is pretty disturbing.

Actually, in any case it is disturbing. It is already disturbing enough that a large portion of the US population is uninsured or underinsured, and that even with full implementation of the ACA there will still be many, if fewer, of us in that boat. It is disturbing to think that those who are poor and uninsured or poorly insured receive lower quality of care, possibly from less-skilled or less-experienced physicians, than those with private insurance. It is understandable (if not acceptable) that hospitals, physicians, and rehabilitation facilities might prefer to care for relatively young, straightforward patients with a single diagnosis, low likelihood of complications, and clean reimbursement. But if people are receiving poorer-quality care because they are our seniors, that is neither understandable nor acceptable.

It is another strong argument for everyone being covered by the same insurance, by a single-payer plan. Then, whatever differences in quality might be discovered, it would not be by insurance status.

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[1] Spencer CS, Gaskin DJ, Roberts ET, “The quality of care delivered to patients within the same hospital varies by insurance type”, Health Affairs Oct2013;32(10):1731-39.

Why poor people choose ERs: we need a system designed to meet everyone’s needs

“Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care”[1], by Shreya Kangovi and her colleagues in the July, 2013 issue of Health Affairs, tries to help us answer that question in order, presumably, to help re-design ambulatory care in order to change that preference. A general assumption of health policy is that use of hospital emergency rooms for “routine care” is expensive, inappropriate, provides worse patient outcomes, distracts emergency room staff from caring for the true emergencies that they are presumably there for, and is a significant cause of the overall high health care spending in the US. Although the whole article is available on-line only to Health Affairs subscribers, a summary is presented on the Robert Wood Johnson Foundation (RJWF) website, because Dr. Kangovi was an RJWF Clinical Scholar.

The authors conducted a qualitative study interviewing 64 people who frequently used the emergency room as their source of medical care, using trained community members to engender greater trust on the part of the patients, mostly lower income African-Americans, to conduct the interviews, in two hospitals in the Philadelphia area.  “Study respondents (both the insured and uninsured) explained that they consciously chose the ER because the care was cheaper, the quality of care was seemingly better, transportation options were more readily accessible, and, in some cases, the hospital offered more respite than a physician’s office.”

These findings should be surprising to many students of public policy, but they were the legitimate perspectives of the people who were using these services, those Kangovi correctly notes, whose “…voices are seldom heard in policy discussions.”  Understanding their concerns is critical, not because they are always “right”, or represent everyone, but because those concerns reflect their experiences, and the degree to which our current strategies are not working, and the degree to which our future strategies are unlikely to work if they do not take into consideration these issues. Three themes generated by the researchers, with supporting quotes from the folks who were interviewed:

• Convenience. “You must call on the same day to set up a [primary] care appointment … whenever they can fit you in.” This open-access scheduling resulted in people taking days off from work and still being unable to see a doctor. It also made it impossible for many to access transportation covered by Medicaid because the transport arrangements had to made 72 hours in advance. Late hospital hours also made care more available.  
• Cost. “I don’t have a co-pay in the ER, but my primary [physician] may send me to two or three specialists and sometimes there is a co-pay for them. Plus there’s time off from work to go to several appointments.”
• Quality. “The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years.”

Any health care provider who has worked in an ER or in ambulatory care can validate these concerns, and also respond to them. The most obvious is Cost. Obviously care in an ER is not free; indeed the cost is a major driver of efforts to get people to not use it. But the patient, at the time of service, doesn’t have to put down cash, put down a co-payment, put down real money now. There will be a bill, but that will be something that goes on their (likely existing and mounting) debt burden.

Convenience is, perhaps, a poor choice of words; it suggests something purely volitional, as if people were choosing to have their hair done during the day rather than go to the doctor. Convenience in the way that a middle class person understands it is not what these folks are talking about. They may not have a car or a family member with one (or perhaps it is being used by a family member to get to work), public transportation may be unavailable, unreliable or inaccessible to them given their medical problems, and if they have jobs, they are often not those that just allow you to take a sick day to go to the doctor, but mean they lose pay. Despite efforts to have “extended hours”, most ambulatory care offices are open mainly during regular business hours, during the day weekdays, when the folks who work there want to work, not when it is necessarily most “convenient” for patients. Let’s get this straight, it is not “convenient” to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!

Quality is another issue, and the quotation chosen is very open to criticism. The hospital had 4 days of complete control of the person’s life, giving them their medicines and minimizing any external issues, while the doctor had 3 years in which the person was responsible for taking their medicine, choosing their diet, and deciding where to rank health among the many competing priorities in their lives. As any of us who have worked in medicine know, the control that was achieved in the hospital may well evaporate once someone is back in their regular environment.

Really, this is largely an issue of money, of resources. The authors emphasize that not all the patients were uninsured, but those who had insurance almost all had Medicaid. Not only is Medicaid not equivalent to private insurance (it pays less and lots of doctors do not take it) but it is only available to really poor people. People who are poor enough to have Medicaid have all those issues listed above under “Convenience” and “Cost” that go beyond the direct cost of medical care, but inform every decision that they make in their lives.

Policy is made, in almost every area, by the “haves”, those with money and political power. At the rawest, it is a blatant example of “let’s do for us, and screw those without power”, as for example the farm bill that cuts food stamps for the neediest while continuing support for giant agribusiness (well discussed by Paul Krugman in  “Hunger Games, USA”, NY Times July , 2013[2]). More subtly, and with much less intentionality, not to mention hostility, it is made from the perspective of people who have a lot, who cannot even imagine the lives, decisions, and trade-offs made every day by “have-nots”. The “haves” may identify a lot that is wrong with the health care system, but they do not even think of things like not having transportation, or not being able to take off from work to go to clinics open during working hours, or not having childcare. They are not mean people, but they do not see.

In her comments, Kangovi looks at plans to develop Accountable Care Organizations (ACOs). “Our findings suggest that these efforts could backfire by making hospitals even more attractive to these patients. We also debunk the notion that people from these groups abuse the emergency room for no reason and need to be taught how to use it properly.”  The real issue is that there are not the financial incentives to provide high-quality care that is accessible in terms of both cost and the other obstacles people face (e.g., transportation, childcare, office hours). The financial incentives are to try to avoid these patients all together, keep them out of the ER, keep them out of your office; to develop “Patient-Centered Medical Homes” that are centered around the kinds of patients you want to have, and not those you would rather not have show up (and go to the ER!).

We need a system that, first of all, ensures that taking care of everyone is (at least financially) desirable. That means a system in which everyone has the same insurance coverage (a single-payer system), and one that is designed to pay more when providing care for people with greater needs, both medical and social. We need a wrap-around system that enables the most needy to have access to the transportation, childcare and other issues that they need to be able to utilize their medical coverage, and to the education, jobs, food, and housing that they need to be able to have a reasonable chance at health. We don’t need a patchwork system of “good ideas” that do not, in themselves or together, create a real safety net for people.

If we have one that is so full of holes that gaming it for profit is the main activity of hospitals, doctors, and other providers, we have no reason to be critical of the least powerful finding the ways around it that work best for them.

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[1] Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

[2] Krugman indicates the logic “…goes something like this: ‘You’re personally free to help the poor. But the government has no right to take people’s money’ — frequently, at this point, they add the words ‘at the point of a gun” — “and force them to give it to the poor.’  It is, however, apparently perfectly O.K. to take people’s money at the point of a gun and force them to give it to agribusinesses and the wealthy.”

Reinventing Primary Care: Themes and Challenges

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My May 27 entry, Universal Coverage and Primary Care: The US needs both, focused on one article from the May 2010 issue of the journal Health Affairs. That article, by Barbara Starfield, (“Reinventing Primary Care: Lessons from Canada for the United States”) was just one of 65 articles in this issue that addressed the topic of “reinventing primary care”. The articles cover the gamut of the history of primary care, the problem of undersupply of primary care providers, proposals for increasing the number of primary care providers, analyses (such as Dr. Starfield’s) of the health systems of other nations’ that are based on primary care, proposals for how the organization and structure of primary care practices need to be changed, and case studies of models of practices and demonstration projects that have implicated innovative approaches to primary care delivery. Many of these practice changes are contained under the rubric of the Primary Care Medical Home (PCMH), which is also the abbreviation for the related Patient Centered Medical Home. Indeed, the Patient Centered Primary Care Collaborative (PCPCC), a coalition of major employers, insurers, providers, pharmaceutical and device makers, and consumers, uses both “PC”s in its name (one hesitates to say that it is thus very PC!)

One of the articles is in fact “The multistakeholder movement for primary care renewal and reform”, by Paul Grundy, et. al., specifically addresses and discusses this collaborative, as well as its proposals for change in the entire structure of the primary care delivery system. Grundy, who is vice-president for global health reform of IBM, is president of the collaborative. It has brought together these various stakeholders in recognition not only of the overwhelming data that shows systems that are built upon primary care are more efficient, more cost-effective, and lead to better health outcomes, but on the actual experience of IBM and other multinational companies. These companies find that their health costs, and the health (and thus lack of time off for illness) of their workers is dramatically lower in countries in which the health system is built upon a primary care base. It is actively involved in educating, advocating, and demonstrating the importance of developing such a base in the US.

Many of the other articles in the journal address changes that need to happen to allow the small (and, as I have pointed out, likely to stay too small even if there is a significant increase in production from our current paltry 16%) number of primary care providers to care for larger panels of patients, while maintaining or increasing quality of care, patient satisfaction, and efficiency. Two of these are co-written by Thomas Bodenheimer, MD, ‘Primary Care: Current Problems And Proposed Solutions”, by Bodenheimer and H.H. Pham, and “Transforming Primary Care: From Past Practice To The Practice Of The Future”, by D. Margolius and Bodenheimer. Another perspective, more from that of the individual physician than the overall health system, is Lawrence P. Casalino’s contribution, “A Martian’s Prescription For Primary Care: Overhaul The Physician’s Workday”

What is striking about these articles in the similarity of their recommendations. The recurrent themes include the need for multi-disciplinary teams of health professionals who all play roles in caring for patients, and panels of patients. This goes beyond the simple “nurses doing callbacks” to patients before, or instead of, the physician. It means that nurses provide the care that they can, that pharmacists and psychologists and social workers all are part of the team, communicating with each other but often operating independently. Group visits are another theme; often people with the same (or, in fact, different) conditions can benefit from being seen in a group. This can be for a more formal didactic session of patient education about their condition by a nurse, or pharmacist, or health educator, or physical therapist, or physician, or medications, or other treatments, often combined with a great deal of person-to-person interaction. There is more to this than efficiency; people actually benefit from the fact of being in a group, of sharing experiences, and ideas, and successes and failures.

Another important and recurrent theme is that of physician-patient interactions that do not involve face-to-face contact, but rather phone calls or emails. Again, this is not just a matter of efficiency for the physician; patients often have concerns that can be successfully addressed by one of these other methods that do not involve them having to take off work, drive a long distance, look for parking, and wait in the waiting room. A physician can be far more effective, and interact with a much larger number of people, if an afternoon consists of seeing a few in person, a much larger number by telephone, and an even larger number by email; a number of products exist that provide not only secure email communication, but provide a structure for the patient to supply information that will help the doctor (or NP, or nurse, or whoever on the team is most appropriate) provide the greatest help.

In his article, Casalino lists five reasons why a physician should see someone in person:
“(1) for a first visit; (2) when it may be necessary to engage in some physical maneuver for diagnostic purposes—such as palpating the abdomen, listening to the heart, or performing a skin biopsy; (3) for specific therapeutic purposes, such as injecting a joint; (4) when the patient has problems for which lengthy discussion would be helpful; (5) when for psychological or emotional reasons it seems better to see the patient face-to-face; and (6) when face-to-face visits are necessary to build trust.”
These are very good, but I would simplify it even more: the physician should see the patient face-to-face when either the patient or the physician think it is important.

The effectiveness and satisfaction from increased phone calls substituting for visits was clear in the late 1990s when capitation, rather than fee-for-service, was a dominant mode of payment (of course, at that time the internet was not yet developed enough for most people to be using email). To reprise, and to improve upon that process will, obviously, require a reimbursement system that does not pay only for face-to-face physician visits. This is another common theme to many of the articles in this issue. It is also not happening in most places. It is, however, a sine qua non for such practice reorganization. And increasing the primary care supply.

Which of these themes is the most important: increasing the supply of primary care physicians, reorganizing practices to become true Patient Centered Medical homes, utilizing all of the strategies above and more, or restructuring the way health care is paid for? They are all important, all related, and all dependent upon each other for success. What is not addressed in most of the articles in this issue of Health Affairs, however, is arguably the most important: ensuring health coverage for everyone. The work of the Patient Centered Primary Care Collaborative may go a long way to having a more rational delivery system for those with access, but as long as the same old hands, in particular the insurance companies but also the drug and device makers, are part of the decision-making process, they are unlikely to come up with a plan that truly covers everyone, single-payer, “Medicare for All”, or any other rational system. And without that, all the primary care reform is not going to really work. It is not only a moral issue (although that should be enough!); it is that the cost, in terms of work hours lost, unnecessary suffering, direct dollars spent on diseases that have advanced too far because people have delayed care, and ultimately worse outcomes, is unsupportable and unsustainable.

We’ve passed PPACA. Now it’s time for real health reform.
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