Uninsured population grows dramatically in California

You had to wonder about the prospects for health care reform last summer when it became clear that Republicans and Democrats couldn’t agree on the number of uninsured Americans. A study released today underscores the fact that while politicians were arguing about the size of the problem, it may have been growing much bigger: In California, the uninsured population increased by 25 percent between 2007 and 2009, from 6.4 million to 8.2 million, according to the UCLA Center for Health Policy Research study, which provides some of the first solid evidence of the effect of the recession and high unemployment rates on people’s health insurance status. Nearly one-quarter of adults in California now lack health insurance.  

"The number of Californians who lost their insurance simply because they lost their job is the clearest indicator yet that our current system of health insurance is broken and that urgent change is needed," said Dr. Robert K. Ross, MD, president and CEO of the California Endowment, which, along with the California Wellness Foundation, funded the study.

Posted at 04:52PM Mar 16, 2010 by Leigh Ann Backer  |  Comments[0]

Health care reform: What farming can teach us

Should health care reform really take its cues from American farming? Atul Gawande, MD, MPH, author of a thought-provoking New Yorker article, thinks so. In "Testing, Testing," Dr. Gawande explains how government-sponsored pilot programs such as those used to reform agriculture in the early 1900s could help us find answers to the health care problems we face today.

Read the article, and let us know what you think.

Posted at 02:41PM Feb 19, 2010 by Lynn Hofeldt  |  Comments[0]

The doctor will see you now -- or tonight or tomorrow or this weekend or online

Some interesting data about access to care in family medicine practices, according to a recent AAFP survey of active members (Practice Profile I, September 2009, 1,156 responses):

• 62 percent offer open access (same-day) scheduling
• 43 percent offer extended office hours
• 30 percent offer e-mail with patients
• 16 percent offer online scheduling of appointments
• 10 percent offer group visits
• 6 percent offer web-based consults or e-visits

The survey found statistically significant increases from 2008 in all but two of the areas listed above -- extended office hours and group visits. Look for the trend to continue as the demand for primary care continues to outpace the supply of primary care physicians, more so if health care reform succeeds in expanding coverage to 31 million Americans.

Posted at 03:43PM Jan 25, 2010 by Leigh Ann Backer  |  Comments[0]

"How will health care reform affect me?"

As health care reform legislation continues to make its way through Congress, many Americans are wondering how the proposals will affect them personally. According to an informative series of articles from ProPublica, here's what health care reform means for different groups:

For those already insured:
• They would not be required to change their health insurance plan.
• If their current plan fails to meet minimum coverage standards or is considered a "Cadillac" plan, they could be forced to pay a tax penalty if they want to keep it.
• Their health insurance costs probably wouldn’t change much. (Premiums could increase because of pressures to provide a comprehensive benefits package and caps on deductibles, or could decrease because reducing the number of uninsured people could reduce the costs borne by the system.)
• They may be concerned about their employers dropping health insurance coverage and instead choosing to pay the government fines, which may be cheaper.
• They could face a 5.4 percent surcharge if their adjusted gross income is more than $500,000 for singles and $1 million for joint filers.

For the uninsured:
• They may have expanded coverage options for their children under Medicaid if they meet income requirements.
• If they have sufficient income, they would be able to purchase private health insurance from the exchange.
• If they have low income, they would qualify for a subsidy to help buy insurance through the exchange.
• If they remain uninsured, they will have to pay a tax penalty (e.g., $750 per person per year).

For healthy 20-somethings:
• They will be required to purchase health insurance or pay a fine.
• They will be allowed to stay on their parents' insurance longer (until age 26 in the Senate bill or 27 in the House bill).
• If they meet certain income requirements, they will be eligible for Medicaid coverage, which currently ends at age 19 and is not available in most states for young adults without a child or a disability.
• They will be able to purchase health insurance through an exchange and, depending on their income level, may qualify for government subsidies.

To read how the proposals will affect other groups – Medicare beneficiaries, Medicaid recipients, the underinsured and small businesses – read ProPublica's series online.

Posted at 04:35PM Dec 23, 2009 by Brandi White  |  Comments[1]

Don't count on information technology to finance health care reform

“Predictions of cost-savings and effciency improvements from the widespread adoption of [health information technology] are premature at best,” says David Himmelstein, MD, lead author of a new study in the American Journal of Medicine (login required), which concludes that increased computerization in U.S. hospitals hasn’t saved money or improved efficiency. Himmelstein is associate professor at Harvard Medical School and former director of clinical computing at Cambridge Hospital in Massachusetts.

The study analyzed data from approximately 4,000 hospitals for the years 2003 to 2007. The data came from the Healthcare Information and Management Systems Society (HIMSS) Analytics annual survey of hospital computerization; Medicare cost reports that hospitals submit annually to the Centers for Medicare & Medicaid Services (CMS); and the 2008 Dartmouth Health Atlas.

Although the researchers found that U.S. hospitals increased their computerization between 2003 and 2007, they found no indication that health IT lowered costs or streamlined administration, even in the "most wired" institutions.

Posted at 04:40PM Nov 30, 2009 by Leigh Ann Backer  |  Comments[1]

China questions costs of U.S. health care reform

An interesting read from Reuters Blogs:

"It turns out the Chinese [America's largest creditor] are kind of curious about how President Barack Obama’s health care reform plans would impact America’s huge fiscal deficit. Government officials are using his Asian trip as an opportunity to ask the White House questions. Detailed questions. ..."

Posted at 11:58AM Nov 18, 2009 by Brandi White  |  Comments[0]

How to fix health care in one fell swoop

The House and Senate have drafted literally thousands of pages of legislation aimed at fixing the U.S. health care system, but the single most important reform according to renowned researcher Barbara Starfield, MD, is "to devolve unnecessary services provided by specialists back to primary care. This would, in one mechanism, reduce costs of care and improve quality of care."

(Note to skeptics: She has hundreds of research articles to back it up.)

In a recent editorial in FPM, Starfield warned the family medicine community not to waste this opportunity for meaningful reform by embracing proposals that do little to further the essentials of good primary care, which she describes as:

• "First contact care, which requires accessibility and responsibility for reducing unnecessary specialist care."

• "Person-focused care over time delivered by the patient's chosen physician, who assumes responsibility over long periods for all health care."

• "Comprehensiveness of care."

• "Coordination of care when people have to go elsewhere for problems outside the competence of the primary care practitioner."

Posted at 02:13PM Nov 13, 2009 by Brandi White  |  Comments[0]

What Baucus got right ... and wrong

Senate Finance Committee chairman Max Baucus (D-Mont.) released his committee's health care reform proposal last week to much criticism from his own party. But "despite all the vitriolic complaints from the left -- Howard Dean is becoming living proof that health care reform should offer a universal entitlement to Valium -- Baucus has advanced the historic Democratic cause of providing health security to all Americans by demonstrating that it can be compatible with fiscal responsibility and long-term cost control."

So writes Ronald Brownstein in The Atlantic.

In a Sept. 16 analysis of the proposal, the Congressional Budget Office concluded that the bill would reduce the federal deficit by $49 billion over 10 years and would produce savings equal to .5 percent of GDP after two decades. The bill does not include a public plan but would result in 94 percent of nonelderly people receiving coverage by 2019, excluding illegal immigrants. Notably, it would also provide a 10-percent bonus for primary care physicians on select E&M services under the Medicare fee schedule for five years.

The Baucus bill accomplishes all this by "creating a revenue stream [including a 35-percent excise tax on high-end health plans] that rises as fast as health care costs, and reshaping the incentives in the medical system in ways that should help 'bend the curve' on those long-term cost increases. Without those two elements any coverage expansion will prove unaffordable, and thus unsustainable, over time," writes Brownstein.

The bill's strategies for reshaping incentives include:

• Comparing the amount all physicians spend on patients with similar conditions and cutting Medicare reimbursements by five percent for those who generate the highest costs.

• Linking hospital reimbursement to their performance on quality measures.

• Allowing groups of providers to share in any savings for more effectively managing patients' care under Medicare.

• Creating an Innovation Center within the Health and Human Services Department that would fund experiments in coordinated care and payment reform.

• Creating an independent Medicare Commission that would be required to offer proposals for cost-savings whenever Medicare spending rises too fast and whose proposals would be fast-tracked for consideration by Congress.

The AMA has voiced several concerns, including the bill's use of payment penalties for physician outliers and the bill's failure to permanently repeal the sustainable growth rate (SGR) formula that would subject physicians to Medicare payment cuts of 40 percent over the next several years.

The bill is currently being amended in committee. Once approved, it will have to be merged with the Senate HELP committee's bill before going to the Senate floor.

Posted at 10:51AM Sep 23, 2009 by Brandi White  |  Comments[0]

What's behind the success of the most efficient medical community in the nation?

The Dartmouth Atlas of Health Care recently identified Grand Junction, Colo., as one of the most efficient medical communities in the nation (see our previous post on this topic). Its average Medicare spending per capita was $5,900 in 2006, about 30 percent lower than the national average of $8,300, while its quality ratings were much higher. A new report sheds light on why this medical community has been so successful and cites factors such as a local health plan that shares valid, individualized performance data with physicians and provides financial incentives for achieving quality and efficiency targets; cooperation between primary care physicians and specialist physicians; effective charity care and hospice programs; a community-wide EHR system paid for by the local IPA and HMO; fewer hospital beds and employees than the national average; and more primary care physicians than the national average. The report concludes with this:

"Primary care is the core of any high performance health system. Throughout a patient’s life, primary care physicians in Grand Junction are involved in all levels of treatment. Continuity and collaboration between primary care physicians, specialists, and other members of care teams leads to higher-quality care, better outcomes, and lower costs. Most importantly, team-based care refocuses the delivery system on the patient, not on the provider. Nevertheless, Grand Junction’s leaders are concerned by the extreme shortage of new primary care physicians entering the workforce. Primary care plays a central role in every collaborative, high-quality, and efficient health system. Thus, we must support primary care expansion within reform legislation, not as an afterthought. Without increased support for primary care, the miracle of Grand Junction’s health system could prove to be but an inspirational memory."

Posted at 10:30AM Sep 03, 2009 by Brandi White  |  Comments[0]

The more things change, the more they stay the same

Does this sound like your practice today? “[Family physicians] are depressed, discouraged and overwhelmed. They work two to three times as many hours as physicians in other specialties but get paid only half as much (family physicians always rank near the bottom of lists that compare average incomes of various medical specialties). They receive frequent nighttime calls that are devastating to their family and personal life. They practice in an uncertain atmosphere of liability and lack of trust that has led to defensive medicine, over-ordering and anxiety. ... This hellish type of life needs appropriate reimbursement if we expect to attract quality physicians and maintain quality care."

In fact, these words were written nearly 16 years ago, during the last push for health care reform, in an open letter from John Pfenninger, MD, to Hillary Clinton published in FPM. Of course we all know the outcome of the Clinton reform effort. In many respects, President Obama’s strategy for getting health care reform passed seems to be the opposite of the Clinton administration's. Still, as Ezra Klein argued in a recent Washington Post article, “The Ghosts of Clintoncare” are haunting the current debate. It’s hard to predict whether President Obama’s push for health care reform will meet a different fate. The bipartisan negotiations that preceded the August Congressional recess seem to have been replaced with ideological rancor. An article in Sunday’s New York Times breaks down the arguments on both sides.

A decade and a half after its writing, Dr. Pfenninger's letter reminds us that the stakes are high for family physicians and their patients – and have been for a very long time. Let’s hope that the next time we dust off his letter, the problems he describes won’t sound quite so familiar.

Posted at 04:23PM Aug 11, 2009 by Leigh Ann Backer  |  Comments[4]

President Obama discusses family medicine – and he gets it

Speaking at a town hall meeting on health care in Raleigh, N.C., yesterday, President Obama was asked by the wife of a family physician what he would do to address the hardships of family physicians and entice more students to enter the specialty. He replied by emphasizing the value of family medicine and primary care, and had this to say:

"When we pass health reform and more people have access to the system, it is going to be vital that we increase the number of primary care physicians. The best way for us to do it is two-fold. One is to change how we reimburse ... so that the incomes of primary care physicians are more comparable with specialists. The second thing is to provide scholarships and financial incentives for young medical students who are willing to go into primary care."

View a short video clip here or the entire video here. (The above quote appears at the 36:40 mark.)

Posted at 10:52AM Jul 30, 2009 by Brandi White  |  Comments[0]

Health care reform: a status report

As Congress' August recess approaches, it is becoming clear that passage of a health care reform bill that expands coverage and restrains costs is not going to happen this summer, as many had expected. In both the House and the Senate, bills are stuck in committee, but Congressional leaders vow they'll be ready for a vote this fall.

In the House, the 1,000-page America's Affordable Health Choices Act (HR 3200) has been approved by the Ways and Means Committee and the Education and Labor Committee but has stalled with the Energy and Commerce Committee. The fiscally conservative Blue Dog Democrats have refused to pass the bill until cost concerns have been resolved. An analysis by the Congressional Budget Office recently concluded that the plan would cost $1 trillion and increase the federal budget deficit by $239 billion over the next decade. Lawmakers' latest idea of establishing an independent panel to make cuts to Medicare would only save about $2 billion, according to the CBO.

Key features of the House plan as it now stands include the following:

• a new government-run health insurance plan that would compete with private insurers,
• penalties for employers who do not provide health insurance for their employees (with a small business exemption) and for individuals who do not purchase it,
• subsidies for lower- and middle-class families to pay for health insurance premiums,
• a prohibition on denying coverage because of health status or pre-existing conditions,
• a health insurance exchange that would help individuals and small businesses comparison shop among private and public options,
• caps on annual out-of-pocket expenses,
• an expanded and improved Medicaid program,
• a prohibition on cost-sharing for preventive services,
• elimination of the Medicare Part D “donut hole,”
• Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula,
• a 5-percent increase in Medicare payments for designated services provided by primary care physicians,
• a 1-percent surtax on households earning more than $350,000,
• a 5.4-percent surtax on households earning more than $1,000,000.

In the Senate, the Affordable Health Choices Act, sponsored by Sen. Edward Kennedy, has been approved by the Health, Education, Labor and Pensions Committee. Its coverage provisions are similar to those in the House bill. Meanwhile, the Finance Committee, led by Sen. Max Baucus, is working on its own bill, with debate focused primarily on the funding of health care reform. The two versions will need to be combined into a single bill before going to the full Senate for a vote.

While there's progress in Washington, the public may be having some misgivings. The latest USA Today/Gallup poll found that more Americans disapprove (50 percent) than approve (44 percent) of the way the President is handling health care policy. New York Times columnist David Brooks speculated as to why: "People have a legitimate question: How is it we're going to cut my costs by creating a new trillion-dollar entitlement? ... How are we going to control costs without anybody sacrificing anything?"

Obama's prime-time news conference last Wednesday was intended to build support for health care reform, but syndicated columnist Mark Shields observed that the speech may have fallen short: "All I could think of was, Adlai Stevenson once said when he was introducing John Kennedy -- remember in classical times, whenever Cicero spoke, the people reacted and said, 'He spoke so well.' But when Demosthenes spoke, the people said, 'Let us march.' And after the Wednesday presentation, there was nobody saying, 'Let us march.'"

Posted at 01:36PM Jul 29, 2009 by Brandi White  |  Comments[1]

"You're likely to hear a lot more about this idea"

Proponents of the patient-centered medical home gained a high-profile advocate this week – New York Times health columnist Jane Brody. Highlighting care provided by family physician Gloria Trujillo, MD, at Duke University Family Medicine Center, Brody's Monday column, "A Personal, Coordinated Approach to Care," highlights the medical home's potential to heal the U.S. health care system, both for patients and physicians: "As President Obama and Congress try to create a national system that provides better care for more people at lower cost, you are likely to hear a lot more about this idea."

Posted at 11:05AM Jun 25, 2009 by Lynn Hofeldt  |  Comments[0]

Solving the cost conundrum: Lessons from Grand Junction

An article in the June 1st New Yorker by physician and medical journalist Atul Gawande, MD, should be required reading for physicians concerned about the economics of medical practice. And what family physician isn’t? “The Cost Conundrum” presents the results of an investigation that began with the Dartmouth Atlas and led Gawande to one of the highest-cost health care communities in the U.S. – McAllen, Texas – and to one of the lowest – Grand Junction, Colo. – in search of an explanation for the three-fold difference in Medicare spending between these two cities. In exploring several hypotheses, Gawande contrasts the medical cultures in these communities and arrives at a conclusion sure to make many a physician squirm: The source of the difference in health care spending is “overuse of medicine” by hospitals and physicians alike. “Physicians in places like McAllen behave differently from others. The $2.4-trillion question is why. Unless we figure it out, health reform will fail,” Gawande writes.

The article captured the interest of President Obama, who cited the article in a meeting with two dozen Democratic senators earlier this week and said in effect, "This is what we've got to fix," according to one senator quoted in the New York Times.

Gawande suggests that cities like McAllen would be better served by “accountable-care organizations” like Grand Junction’s, “in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering.”

Roger Shenkel, MD, a physician leader in Grand Junction, Colo., was a member of the FPM Board of Editors for more than 10 years. During this time he wrote or co-authored a number of articles that reveal some of the health care strategies and tactics that underlie his community’s success. Dr. Shenkel also introduced us to his Grand Junction colleague Phil Mohler, MD, who wrote or co-authored several FPM articles that share the same themes of cost-effectiveness, quality and collaboration between physicians, medical groups, administrators and payers. We think you’ll find the articles as timely and useful now as when we first published them:

• New Drugs: How to Decide Which Ones to Prescribe
• Improving Chronic Illness Care: Lessons Learned in a Private Practice
• 1-800-Chronic Disease Management
• Weighing the Risks and Benefits of Clinical Interventions
• What Every Physician Should Know About Generic Drugs
• Creating a Successful After-Hours Clinic
• Building Rapport With Consultants: A Matter of Economics
• IPA Formation in Rural America: Nothing Like the City Slickers Do
• Medicaid Miracle in Mesa County
• Rural Managed Care: A 20-Year Road to Success

Posted at 04:09PM Jun 12, 2009 by Leigh Ann Backer  |  Comments[0]

Barbara Starfield on Family Medicine and the PCMH

The work of Barbara Starfield, MD, MPH, has been enormously effective in establishing the value of primary care in general and family medicine in particular. One testimony to this is the AAFP’s list of 100 articles demonstrating the value of family medicine; she wrote or coauthored 18 of the 100 articles.

Given her strong support of primary care, it’s reasonable to want to know her thoughts on the Patient-Centered Medical Home (PCMH), a concept that seems likely to shape the future of the specialty. In an opinion piece written for the July/August issue of Family Practice Management, she sounds somewhat dubious of the direction the PCMH is taking: “Proposals for the PCMH are not very patient-centered. They are justified on the basis of evidence regarding the benefits of primary care, but the criteria for assessment of PCMHs, such as those promulgated by the National Committee for Quality Assurance, concern organizational features such as electronic health records, computerized guidelines and amorphous 'teams,' none of which have been demonstrated to be pursuant to good primary care.”

To read more, see the prepublication version of her essay.

Posted at 11:59AM Jun 01, 2009 by Bob Edsall  |  Comments[1]