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]

Obama: "We're not producing enough primary care physicians"

A New York Times story this week suggests that the Obama administration understands that a shortage of primary care physicians could undermine health care reform. Family physicians, particularly those in rural and urban areas, know this all too well. Others need look no farther than Massachusetts, where a plan for near-universal coverage has been unfolding over the last three years, to see that without significantly greater numbers of primary care doctors, the expansion of coverage that Obama has championed is likely to drive costs higher.

A study last year predicted a shortage of 35,000 to 44,000 adult care generalists by 2025, and that was before expanded coverage was the realistic possibility it seems today.

Federal officials are considering several proposals for dealing with the growing shortage, according to the New York Times article: increasing enrollment in medical schools and residency training programs, encouraging greater use of nurse practitioners and physician assistants, expanding the National Health Service Corps, and increasing Medicare payments to primary care physicians. If the latter has to be done in a budget-neutral way, at the expense of payment to specialists, look for dysfunction in the house of medicine, or worse. “A civil war among physicians seems inevitable,” blogger KevinMD predicts.

Posted at 10:03AM Apr 30, 2009 by Leigh Ann Backer  |  Comments[1]

Anti-primary-care editorial borders on comical

A recent op-ed piece published in Emergency Medicine News is being described in the blogosphere as "an adolescent tirade," "cringe-inducing," "destructive ranting at its worst" and even "bordering on comical" were it not so full of contempt for the nation's primary care doctors.

The author, Jonathan Glauser, MD, who works at Case Western Reserve University and the Cleveland Clinic, attacks current initiatives aimed at improving the funding and the delivery of primary care on these grounds:

"If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Apparently, neither Glauser nor the editors at EM News are aware of the more than 100 peer-reviewed studies demonstrating that a strong primary care base is critical to a cost-effective, functional health care system. They must also be unaware of the payment inequities that have hamstrung primary care physicians for more than a decade and are now catching up to us in the form of a primary care shortage.

Glauser's diatribe, rich in anecdote, continues:

"I have my own ideas about what primary care should accomplish, but foremost among them is to see patients in a timely way when they get sick as opposed to the dermatologist who schedules an appointment three weeks later, by which time the rash has disappeared. Or how about having the diagnostic and therapeutic skills to intervene in some way when the acutely ill patient does show up? Or caring for patients regardless of their ability to pay. After all, the people who sustain strokes, MIs, and aortic dissections because of untreated conditions of some sort (hypertension, diabetes, hyperlipidemia) are the ones most likely to benefit from preventive services."

Yes, it's true that the primary care specialties need to do better (so do the non-primary-care specialties, by the way, especially the ones who practice in hospitals, according to the IOM). What the writer fails to realize is that family physicians, under immense time and cost pressures, have led the way in advancing concepts such as same-day appointments and effective chronic disease care. They have also continued to provide charity care out of their own pockets – not their hospital's deep pockets. 

Primary care physicians may be tempted to lash back at those hurling insults at them, but instead they should be heartened. As talk of increased primary care funding makes its way into budget-neutral health care reform proposals, such as the proposal by Sen. Max Baucus, the attacks are sure to get uglier. They signal that disruption is under way in our health care system. And isn't it about time?

Note: The AAFP has issued a response to the editorial. Read it here.

Posted at 09:23AM Dec 31, 2008 by Brandi White  |  Comments[0]

Reforming health care insurance isn't enough

Liberals and conservatives alike seem to agree on one thing when it comes to President-elect Obama's health care reform proposal: It would succeed at reducing the ranks of the uninsured – by 26.6 million, according to one estimate.

Expanding health insurance coverage is a good thing, but make no mistake: It won’t fix our health care system. As blogger KevinMD noted in an open letter to Obama (and McCain), “Implementing your plan without a solid primary care foundation will doom your proposal to failure.”

After all, what good is it to insure more people if a) you don't have enough primary care doctors to care for them and b) the primary care doctors you do have are underpaid and overburdened? A recent ACP white paper explains the seriousness of the problem, citing a predicted shortage of 35,000 to 44,000 primary care physicians by 2025 unless immediate steps are taken to make primary care more attractive to medical students and more sustainable for practicing physicians. The white paper goes on to summarize 20 years of research demonstrating that primary care produces better outcomes at lower costs. (The AAFP also has an online summary of the literature.) The inescapable conclusion is that primary care is the key to a functional health care system and strengthening it should be the starting place for meaningful health care reform.

So how do we create a strong primary care foundation? For starters, we need to “pay more for what we want more of, and less for what we want less of,” to quote Newt Gingrich. In other words, pay more for primary care, particularly prevention and care coordination. FPM recently published a simple proposal from one family physician for moving the physician payment system in this direction. And the AAFP and other primary care organizations are working to bring about a medical home care management fee, among other ideas.

Of course, despite the evidence cited above, policymakers may not recognize the value of primary care until they have to – when the Boomers swarm Medicare and we really feel the sting of the primary care crisis. As blogger Dr. Bobbs warns, "When the tipping point is reached and the health care system finally cries 'Uncle!' and agrees to start properly reimbursing primary care docs, there isn’t going to be some vast repository of FP and IM docs who have been sitting around waiting to be called up. It’ll take quite a number of years to 're-primary care doctorize' American medicine."

Posted at 10:19AM Nov 26, 2008 by Brandi White  |  Comments[1]