Tomorrow's Healtcare Reform, Today
Submitted by Dr. JG Kaplan on Thu, 2009-06-04 09:26
In the NY Times piece, "Shortage of Doctors an Obstacle to Obama Goals," we learn there are "shortages of primary care providers.... the main source of health care for most Americans." What gets me is the payment system has caused this; for years, the way insurers and the entitlement programs have been paying doctors is the proximate cause of this disparity and now the same nonsense is undermining true health care reform.
It's nothing but politics—While "Family doctors and internists are pressing Congress for an increase in their Medicare payments.... medical specialists are lobbying against any change that would cut their reimbursements. Congress, the specialists say, should find additional money to pay for primary care and should not redistribute dollars among doctors — a difficult argument at a time of huge budget deficits." End result? The specialists win (again) and the front line, the first venue, is left bereft of doctors.
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Let's think of health care reform using the analogy of new construction with primary care is its cornerstone. The translation of data, especially the longitudinal picture of "who" does "what, "where," "when" and "how well" into information is its foundation. It's windows are the critical and oftentimes missing, point-of-contact feedback by organizations and consortiums who represent health care professionals (as opposed to insurance companies) and whose focus is on managing the care better. Comparative and normative statistics, clinical and administrative, guidelines and observations about evidence-based medicine are its floors, and so forth).
Clearly, we need greater transparency in communication and in improving accessibility, in reaching out to patients in case management, in preventing errors, and in making certain that critical tests are completed and that there is follow-up and follow through.
Is there anything else we need in terms of interior design? We will need ways to limit unexplained variation; we must also improve cost effectiveness, curb discrimination (e.g., of preexisting conditions) and curtail cream skimming by insurance companies (e.g., selective marketing; in fact, this practice alone should reduce the role of insurance companies to health care facilitators and conduits for money exchange, even across state lines. There's absolutely no footing in insurance companies making huge profits off the backs of patients and doctors). We need more measurement and management, the crown being to get the right care at the right time and place.
However, to build this model of health care, we must be prepared to think differently. To overuse a worn-out expression, how health care will be funded (or closer, "reimbursed") involves a paradigm shift. We can no longer afford accessibility problems and 50 million uninsured; more relevantly, financial barriers to necessary, non-discretionary care should not be tolerated. We can no longer be complacent about the lack of a medical home. Unexplained variation is a sign that quality can be improved. Cost-effectiveness, errors, waste and duplication—all represent an opportunity to effect change. Closing the feedback loop about getting the right care at the right time and place and aligning the incentives vis a vis practitioners and patients are the ergonomics that will restore this house to order
Note: readiness for change is the Presidential election, itself; it is the door opener and healthcare information technology is the key.
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According to a report on health information technology, "Remaking Primary Care: From Crisis to Opportunity" by the New England Healthcare Institute (NEHI), "Properly implemented, HIT frees up physician time during visits, provides all members of the primary care team with timely access to patient information and aids in the overall coordination of care." The information technologies it lists includes: electronic health records, clinical decision support systems, computerized physician order entry (CPOE), facilitated appointment scheduling, and secure reporting of test and consultation results. It also "urges reimbursement for phone and e-mail encounters," especially since many "clinicians already provide these contacts without compensation, believing that they improve care and enhance patient experiences."
Among the drivers of the crisis, according to the report are:
- Demand: the aging population and longer survival of those with chronic illness ("The percentage of individuals aged 65 and older in the United States is expected to increase from 12.7% in 2008 to more than 20% in 2050").
- Supply: primary care practitioners are in short supply and unevenly distributed caused by disparities in pay (PCP v. specialist for mundane tasks.
The report recommends changes in service delivery, site of care, workforce, reimbursement and medical education. It also calls for aligned incentives, improved pay-for-performance approaches that "would reward providers for helping their patients achieve positive health outcomes and move the system away from paying for episodic care. The reality of this new generation of pay-for-performance is complex; any system would need to fairly and transparently adjust payment according to case mix to prevent cherry-picking of healthy patients, and reward physicians who succeed with those patients in greatest need."
"IT key component to curing ailing primary care system, report concludes." From the New England Healthcare Institute – NEHI, published by Healthcare IT News May 27, 2009 | Bernie Monegain, Editor
I support the idea that a more competent and comprehensive view of healthcare costs should include the less easily measured issues of "quality of life" outcome measurement and management as well as "opportunity cost." The former is usually defined as quality-adjusted life-years (QALYs); the latter, for the purposes of this discussion, is the excess in time and money spent because the insurance company, through parsimony as opposed to genuine quality of care concerns, interfered with reasonable and timely medical care. E.G., Mom having to miss work, Sally suffering longer and possibly needing to miss school for a longer period of time.
The above has been my position and I find it completely consistent with Michael E. Porter, Ph.D.'s comments, of July 9, 2009: "A Strategy for Health Care Reform — Toward a Value-Based System."
"[We] must change the nature of health insurance competition. Insurers, whether private or public, should prosper only if they improve their subscribers' health. Today, health plans compete by selecting healthier subscribers, denying services, negotiating deeper discounts, and shifting more costs to subscribers. This zero-sum approach has given competition — and health insurers — a bad name. Instead, health plans must completion value. We must introduce regulations to end coverage and price discrimination based on health risks or existing health problems. In addition, health plans should be required to measure and report their subscribers' health outcomes, starting with a group of important medical conditions. Such reporting will help consumers choose health plans on the basis of value and discourage insurers from skimping on high-value services, such as preventive care. Health insurers that compete this way will drive value in the system far more effectively than government monopolies can."
"The current delivery system is not organized around value for patients, which is why incremental reforms have not lived up to expectations. Our system rewards those who shift costs, bargain away or capture someone else's revenues, and bill for more services, not those who deliver the most value. The focus is on minimizing the cost of each intervention and limiting services rather than on maximizing value over the entire care cycle. Moreover, without comprehensive outcome measurement, it is hard to know what improves value and what does not."
