"Values" based care: Public Health, Primary Care, and Medicare for All

Recently, a class of undergraduate freshmen I teach debated the issue “Health Care is a Human Right”. Although we later determined that most of them personally supported that statement, the “no” team did a good job marshalling the arguments of opponents, often citing those of libertarian think tanks such as the CATO Institute (originally founded as the Charles Koch Institute, in case that helps), which identifies itself as promoting "free markets and individual liberty”. This includes identifying health care as a “commodity” and opposition to health care as a right (and thus to universal health coverage) as an infringement upon individual liberty. Essentially these two concepts boil down to the idea that the individual is free to decide what kind of health care they want, or don’t want, and what kind of insurance coverage they want, or don’t want, and can use their money (or not) to purchase this commodity (health care) as opposed to another (I don’t know, say a bass boat).

The hole in this argument is wide enough, though, to drive a bass boat through. It is that not everyone has such a large amount of disposable income that they have the financial options to make such decisions. An old point about commodities having to do with cars, when most Americans bought American brand cars, is that some folks can buy Cadillacs and others Chevrolets. But of course, even if we update this to Beemers and Kias, there are a huge number of people who are buying used cars – often old “junkers” – to try to get to work and shopping. And there are those who can’t afford to buy, insure, and run any car at all and are reliant on public transportation. If there is any public transportation where they live. People without a lot of money (often despite working multiple jobs, even those making quite a bit more than the federal minimum wage of $7.25/hour -- last raised in 2009 when $7.25 was equivalent to about $9 today) make regular trade-offs on what they will spend their money on. Rent? Food? Clothes for the kids? Heat? Electric bill? Gas for the car to get to work, if they have a car? Health and medical care are rarely right up there at the top unless they are actively ill. Indeed, often even chronic diseases don’t get adequately managed, with medications for common conditions such as diabetes and hypertension stretched out. This family – and to a greater or lesser extent, this is probably true of the majority of families – is trying to figure out how to juggle absolute necessities, not luxury goods. The students arguing the “anti” position gamely tried to respond to such concerns, but learned that, outside the walls of conservative think tanks, Congress, state legislatures, and country clubs, there is a limit to the effectiveness of continually repeating “individual liberty” and “commodities”.

Paying for the cost of health care is a real juggling act for the government, although for a different reason from the one the families above are doing. It is balance between wanting to spend less money and continuing to support the profits of health care corporations such as insurance companies, hospital systems, and drug makers. The rational solution to this problem is to decide that it is not the government’s business to guarantee the often obscene profits of such private corporations, but rather to spend the money on whatever maximally increases the level of health of the American people.

This should include at least two major changes: first, a national health insurance plan (such as “Medicare for All”, recently reintroduced with major improvements by Reps. Pramila Jayapal and Debbie DIngell) that ensures that everyone is covered – everyone, all in one plan, no exceptions by age, disease, etc.), and second, a massive and continuing re-investment in public health, the need for which should have been made clear by the COVID pandemic. Historically in the US, in Democratic and Republican administrations, funding for public health is about 1% of the health budget, with the rest going to individual medical care. When we have a crisis, we bemoan the lack of public health infrastructure for a while, but then it recedes. Yet this is the most important component of keeping us healthy. Fighting an active enemy (like COVID) can garner support, while maintaining programs of prevention absent an obvious crisis gets less. How often do we wake up and say “I’m glad I don’t have cholera today because we have clean water and sewage”? And, yet, recently folks in Mississippi and Texas can count themselves lucky that their lack of water did not come with cholera or another infectious disease.

Instead of such wholesale reimagining we have had programs like “value-based care” for Medicare, adopted with the ACA (“Obamacare) in 2010. When this was first rolled out, I was enthusiastic because I misunderstood it – I thought it was about providing care based upon values, presumably decent human values. Sadly, I was wrong. It was about spending less money. Did it work? To do what? If the goal was spend less, yes, to some degree (see Austin Frakt in the NY Times Upshot Oct 9, 2019, “more singles than home runs”). One of the big goals was to substitute “value” for “volume”. Paying for volume, the number of patients seen, was the accepted way to pay doctors. But what does paying for value mean? This whole issue is reviewed by Dr. Don McCanne in his “Quote of the Day” for March 17, 2021 “Policy community hung up on ‘volume to value’”. Dr. McCanne reviews the recent article “The Future of Value-Based Payment: A Roadmap to 2030” from the University of Pennsylvania on the topic, but in his comments he notes that

“All health care has “volume” – time, effort and resources devoted to health care. Volume varies tremendously depending on the clinical situation. Think of management of a common cold as opposed to management of severe multiple injuries in an accident. Can payment schemes ignore volume? Of course not. Volume is built into the problem.”

Here is a volume/value solution that I have discussed before but will now say clearly: Revise the way that physicians (and other providers) are paid so that family physicians and other primary care doctors make at least as much as those providing subspecialty care. This is the third step to add to universal health coverage and investment in public health. When I go to a shoulder orthopedist for the pain in my shoulder, that is the ONLY PROBLEM they deal with. Not BP, not abdominal pain, not my cold -- not even the arthritis in my knees.  My PCP would deal with every problem on my – and all their patients’ -- problem list (to greater or less extent, depending upon severity and acuity), and thus rarely has enough time for any on person. If you go to the cardiologist, and mention that you have knee pain, they say "I don't do knees; here is a referral to the orthopedist". And you go to the orthopedist, they make a recommendation, you come back to the cardiologist who says "I don't do knees; whatever they said". So, for the subspecialist, referral is a time saver.

But if you come to a PC doc and say your knee hurts, they make some diagnostic and treatment suggestions. After examining your knee, maybe ordering imaging and lab, and thinking about it, if they think it might need surgery, they might refer you to the orthopedist. Then you go and the ortho says "maybe surgery", so you come back and ask your PC doc’s opinion, so they read the whole consult and review the films and think about it and discuss it with you. Result: referral for a PC doc makes MORE work.

And they get paid less.

PC docs need more time with everyone, and thus fewer patients each day/week/year. How much money should they make? I don't care, pick a number, but it should be able to be earned by seeing no more than half the number of visits that they currently do. People's complaint is ALWAYS about not having enough time with the doctor.  

So, increase funding for public health, develop a universal single-payer health insurance system, and pay PC docs at least as much per hour or patient as the highest-paid subspecialist in the outpatient setting. 

Now we begin to have “value”!

The denominator matters: we only have a quality health care system if everyone can access it!

Denominators.

Even if you are not a regular user of statistics, you probably remember that word from arithmetic. You know, the “4” in ¼, as opposed to the “1”, the numerator. Why is this important in the current policy debate? Well, if you know, for example, that a majority of, say, Republicans (or Democrats) like a policy, it would be a mistake to assume that a majority of all people like it. In health care policy, in particular, denominators, and how they are chosen, are important, because by choosing an inappropriate one you can “prove” a point that is wrong.

I recently was present for a debate on the issue of “health care is a human right” in an undergraduate class. The students did well, and although almost all personally supported the “pro” side, the “anti” side was able to find arguments in the literature, often from organizations like the CATO Institute. To a significant degree, however, they were either philosophical objections (“what is a human right?”) or, conversely, pragmatic irrelevancies to the issue (“a lot of doctors don’t take Medicaid”). Many of the assertions are belied by the facts. For example, the Northwestern economist Craig Garthwaite, interviewed in VOX, notes that if drug companies can’t make huge profits, innovation will go down, and most of the world depends upon the innovations discovered in the US. In fact, of all New Molecular Entities (NMEs) discovered, a little over 1/3 are in the US. But even this ignores another important point – many or most of these were not originally discovered by pharmaceutical companies using their hard-earned profits on Research and Development (R&D), on which they spend much less than on marketing, but by government (National Institutes of Health, NIH) supported university research, which the drug companies skim for the most promising ones. So what is the denominator there? All NMEs, or only those funded by drug companies?

The students also cited these opponents of healthcare-as-a-right or Medicare for All who also assert that, in a similar manner, it would cause quality to decrease. If everyone has access, and hospitals and doctors can’t make more money on some, they opine, then those people will not get all the best, most modern and effective care. This is where denominators come back in. Even if it were true that there might be decreased quality for those who currently have unfettered access (very questionable), it is obvious that the quality of care would increase for those who now get little or none! Overall, when the whole population is considered as the denominator, the quality of care would absolutely go up. Denial of care, as asserted long ago by Schiff, Brennan and Bindman, is “the gravest of all quality defects”.[1] If a hospital, for example, reports excellent outcomes for people treated there for heart attack, but only those with good insurance were admitted for treatment and the overall rate of death from heart attack in the community rose, it would be painting a very skewed picture. If what you mean is “I have real privileges, and I am afraid that by spreading access out to everyone I might lose that privilege”, then say that; don’t dress it up by pretending quality would decrease!

A common assertion we hear, particularly from “moderates”, or at least from the politicians, pundits, and media who assert that they speak for moderates, is that “Most people obtain health insurance through their employers and are generally satisfied with their choice of providers, coverages and the amount they contribute to their family’s healthcare.” This may be true, or it may not be. The majority of people current have health insurance coverage through their employer, but whether they are generally satisfied is another question. The main thing is that they are much more likely to be satisfied when they are healthy and do not have to utilize health care very much or at all. Even then, the copays and other surprise costs can prove burdensome, but it is only when something happens that causes them to need to use a lot of healthcare that it becomes critical, bankrupting them and often even making that care inaccessible. When you and the members of your family are not sick, costs can be low (and you can be satisfied) but when you are sick is when all the hidden costs kick in. In this case, the important denominator might be a smaller group, those who used healthcare, rather than everyone.

These excess costs include the various legal scams described by Elisabeth Rosenthal “Where the frauds are all legal” on December 7, 2019 in the NY Times (discussed by me in Scamming Medicare: It's the providers and insurers, not the patients!, December 19, 2019), when her husband had a serious accident. They also include the “surprise bills” that come because, even though you went to a hospital that was in your insurance network and saw a surgeon who was in your network, it turns out that the ER group or the anesthesiology group contracted by the hospital, or the assistant surgeon your surgeon picked, is not in network. Boom! $10,000, $100,000 bills! No one is “satisfied” by this.

Such problems are most often faced by those with multiple chronic diseases, often older people, who have to see the doctor, be hospitalized or be operated on more often. Most people, in most years, are not in need of major or expensive care, so they are the “satisfied well”. But something bad and expensive could happen to any of us any day: Your doctor surprises you by telling you that you have cancer! You are in a car (or bicycle) accident and need big surgeries! Your baby was premature and needs to be in neonatal intensive care! We are all at risk in a system where only some people are covered, and only some of the time, and for some things, and for certain providers.

Recently, there was big news when the large Culinary Workers of America union came out to oppose Sen. Sanders’ Medicare for All plan, which the union suggests would void the excellent health care coverage that they have won for their members. The union deserves tremendous credit for having negotiated this coverage in the current and recent negative environment for unions, especially for a membership that is largely relatively low-paid, minority, female, and often non-English speaking. However, to suggest that it would be a loss for their members is deceiving. For one thing, the coverage of a Medicare for All plan would be at least equal to this excellent plan; it would cover everyone for everything. Health coverage is a great benefit, but the money that employers pay for their contribution (which unlike workers’ contributions is tax-deductible) is money that they don’t pay in wages. The benefits of M4All compared to the CWA plan are well-described in this Quote of the Day by Dr. Don McCanne. And the CWA contract is a relative outlier and not guaranteed to be as good next time; remember the many General Motors workers who were the exemplars of having “Cadillac coverage” during prior healthcare insurance debates, but who lost most of those benefits when GM “restructured” after bankruptcy – if they were not laid off altogether?

At least as important are the relatives, friends, and neighbors of those covered workers who work for small companies without good – or any – health insurance plans, or are disabled, or unemployed for longer or shorter periods. This is the “community”, the “population” that needs to be considered as the denominator. Many CWA (and other union) members realize this; while the union leadership may rightly be proud of their accomplishments in negotiating, this does not bring excellent health coverage or care to all of the people. The denominator needs to be all of us.

Only a universal single payer system, an improved and expanded Medicare for All, will do that.

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[1] Schiff GS, Brennan AB, Bindman TA, A Better-Quality Alternative Single-Payer National Health System Reform, JAMA 272(10):803-808, September 14, 1994.