Five issues to watch out for in 2013
If you think the health care system has changed a lot over the last couple of years, just wait until 2013. It will be "a watershed year for the U.S. health care system," said Lou Goodman, PhD, president of The Physicians Foundation and chief executive officer of the Texas Medical Association, in a statement announcing the Foundation's "Physician Watch List for 2013." Based on research studies and policy papers issued by the Foundation, the list identifies five issues that are likely to have a major impact on patients and physicians in the coming year.
1. Ongoing uncertainty about health care reform. Although the Supreme Court upheld the Affordable Care Act (ACA) in June, key parts of the act have yet to be fully defined or fully implemented, including accountable care organizations, health insurance exchanges, and the Independent Payment Advisory Board for reducing Medicare spending. According to the Foundation's "2012 Biennial Physician Survey," uncertainty about health reform was a key reason that 77 percent of physicians reported pessimism about the future of medicine.
2. Ongoing consolidation. Hospitals and large groups are acquiring small private practices at a steady rate by offering physicians income security and relief from administrative burdens, according to the Foundation report "The Future of Medical Practice: Creating Options for Practicing Physicians to Control Their Professional Destiny." While consolidation can yield benefits, such as improved communication between providers, it can also create monopolistic behavior, raise the cost of care, and reduce the viability and competitiveness of solo or small private practices, cautions the Foundation.
3. Patient access challenges. More than 30 million individuals are expected to gain health insurance in 2014 under the ACA. This will likely create challenges for patients trying to access care because the current physician supply is not adequate to meet this demand. In fact, according to the "2012 Biennial Physician Survey," physicians are working fewer hours, and if this trend continues, the health care system could lose the equivalent of more than 47,000 full-time-physicians in the next four years.
4. Eroding physician autonomy. Doctors' ability to exercise independent medical judgment is markedly deteriorating, says the Foundation, because of threats to their reimbursements, liability pressures, and an increasingly burdensome regulatory environment. Increased consolidation may also play a part.
5. Growing administrative burden. One of the chief contributors to physician discontentment, according to the "2012 Biennial Physician Survey," is the increased burden physicians carry because of administrative and regulatory tasks. "The Future of Medical Practice" report calls for the creation of a new federal commission for administrative simplification to evaluate cumbersome physician reporting requirements and eliminate those that do not save money or improve quality.
The Foundation hopes this watch list will serve as "a pragmatic resource that will help policy makers, physicians, and health care providers formulate smart policy decisions that are beneficial to America's patients and doctors," said Walker Ray, MD, vice president of The Physicians Foundation and chair of the Research Committee.
Flat-rate medicine: The future of health care?
A new model of health care, called flat-rate medicine, is popping up around the country in primary care offices. In these practices, which are similar to concierge practices but generally more affordable, patients pay a monthly fee -- usually ranging from $50 to $150 -- for unlimited, 24/7 primary care that includes everything from preventive care to chronic disease management.
This model is said to save money because the patients have fewer emergency department (ED) visits and hospitalizations, and it cuts the middle men -- insurance companies -- out of the equation, letting doctors spend more time with fewer patients with less overhead.
One practice example is Qliance, a Seattle-based primary care practice that compares its setup to a health club membership, but for health care. According to NPR's health blog, the setup is working. In 2010, Qliance patients had 65 percent fewer ED visits and 35 percent fewer hospitalizations, when compared to benchmarks for its region.
To learn more, watch this video on NBC Nightly News with Brian Williams.
Are high-utilizers the key to lower health care costs?
In the latest issue of The New Yorker, Atul Gawande tells the story of Jeffrey Brenner, MD, a family physician in Camden, N.J., whose passion for the last decade has been to identify the people in his community who use the most medical care and do something to help them. In May of 2009 Brenner closed his regular practice to focus full time on this effort, which some refer to as “health care hot-spotting.” In seeking out these individuals and helping them to improve their health, one patient at a time, Brenner has come face to face with what Gawande describes as the critical flaw in our health care system, “that it was never designed for the kind of patients who incur the highest costs.”
Brenner is currently trying to clear all the hurdles necessary to open a practice in the low-income housing project that is source of the highest health care spending in Camden and where the residents understand that Brenner would be “involved in their lives” and “after them about their smoking, drinking, diet, medications.” They accept this because they know him and believe he cares about them, Gawande writes. It remains to be seen whether it's possible to both improve health care services and lower health care costs beyond the local level, but Brenner’s story and those of other health care providers described in the article are a testament to the values of primary care and family medicine – and to the morass that threatens their efforts.
After House votes to repeal health care reform, what's next?
With a vote of 245 to 189, the House of Representatives passed legislation (HR 2) Wednesday night to repeal the federal health care reform law (HR 3590). Three Democrats joined all 242 Republicans in voting for the repeal.
Because the legislation has little chance of progressing in the Democrat-controlled Senate (Majority Leader Harry Reid has said he will block it), the vote is considered by some to be mostly symbolic. However, House members of the GOP are preparing to take additional steps toward repeal, reports Politico. Republicans plan to draft smaller bills that would essentially dismantle the health care reform law piece by piece and plan to hold committee hearings that would require Obama administration officials to publicly answer their questions about the health care reform law. They could even withhold funding for certain provisions.
President Obama has said he is willing and eager to improve the law, according to The Hill, but he added, "we can’t go backward. Americans deserve the freedom and security of knowing that insurance companies can’t deny, cap or drop their coverage when they need it the most, while taking meaningful steps to curb runaway health care costs."
AAFP President Roland Goertz, MD, issued a statement saying that the AAFP will continue to work with Congress and the Administration to implement health care reform provisions "that expand coverage, that emphasize access to primary medical care and that support a healthy primary care physician workforce. These are issues that have had bipartisan support in the past and should continue to have that support in the future."
New Affordable Care Act provisions take effect
The much-anticipated reform provisions known as the Patient's Bill of Rights took effect last week. These revisions are part of the Affordable Care Act -- the health care reform law that was enacted in March 2010.
The new provisions bring many insurance industry exploitations to an end and give
Americans new health benefits, including helping more children get
health coverage, ending lifetime and most annual limits on care, and
giving patients access to recommended preventive services like screenings, check-ups and patient counseling. The new provisions include:
- A ban on discriminating against kids with pre-existing conditions,
- A ban on insurance companies dropping coverage,
- A ban on insurance companies limiting coverage,
- A ban on insurance companies limiting choice of doctors,
- A ban on insurance companies restricting emergency room care,
- A guaranteed right of appeal,
Coverage of young adults on parent’s plan and
- Coverage of preventive care with no cost.
For more on each of these provisions see The White House fact sheet.
While most Americans probably consider the provisions of the Patients Bill of Rights desirable in themselves, health care reform remains controversial, with Republicans arguing that it costs more than the nation can afford and will result in government control of health care and insurers blaming their recent premium increases on the requirements of the law. Consequently, the administration’s efforts to sell America on the benefits of the law continue, most recently in the form of President Obama’s back-yard discussions of health care reform.
Primary care physicians sound off in Epocrates survey
In a survey conducted this summer by the medical software company Epocrates, 1,060 primary care physicians gave their opinions about the state of the industry, health care reform and practicing medicine.
- The majority of primary care physicians are concerned about the primary care shortage, and 92 percent of respondents recommend increasing reimbursement to help fix the problem. More than two-thirds recommend using incentives to draw medical students to primary care.
- If they had to give the health care reform bill a letter grade, only 2 percent of respondents said they would give it an A; 43 percent said they would give it a D or F.
- Seventy percent of respondents would still choose a career in primary care if they had it to do over again. This is an increase from 28 percent in 2007 and 60 percent in 2009. Yet, primary care physicians continue to be the least satisfied with their career choice when compared with other specialties.
- Sixty-nine percent of respondents would recommend a career in primary care to a medical student. This gives primary care the smallest discrepancy (1 percent) between career satisfaction and recommendation.
- Fifty-five percent of respondents reported spending an average of 15 minutes or less with their patients during office visits.
- More than half of respondents said they worry about low reimbursement rates, work-life balance and the increasing costs of practicing medicine.
What patient-centeredness looks like
Depending on who you believe, Donald Berwick, MD, the Harvard professor, Institute for Healthcare Improvement president, and pediatrician appointed by President Obama to head the Centers for Medicare & Medicaid Services (CMS), is a radical bent on transforming the U.S. health care system in the image of Great Britian’s or a genius capable of reinventing health care and saving the U.S. economy in the process. (Just search for “Donald Berwick” on Google to see what I mean.) Of course the truth lies somewhere in between, and time will reveal the extent to which he can effect real change in his latest role.
Back in May, Berwick was a proud father delivering the commencement address at his daughter’s Yale Medical School graduation, the prepared text of which is making the rounds via e-mail. In describing the first history and physical he performed as a medical student and also in telling the story of a woman who was prohibited from seeing her ailing husband in the intensive care unit during most of the last hours of his life, he touches on themes that should be familiar to any family physician – the biopsychosocial model, patient-centered care and family:
“Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity – of the dignity in each and every soul.”
Download the entire speech from the Institute for Healthcare Improvement web site.
Health care reform: Reader poll results
Half of respondents to a recent FPM online poll said the health care reform bill that Congress passed in March will make things worse for medical practices. Another 44 percent said it will make things better, and nearly 6 percent said it will not change practice.
The poll was conducted between March 31 and July 12, 2010, and had 1,415 respondents. Poll results are not scientific and reflect only the opinions of those who chose to participate.
Health care reform and the future of primary care
The recent health care reform law is likely to promote the use of health care organizations that emphasize primary care, such as accountable care organizations and patient-centered medical homes, says a recent article from The Washington Post, and this could be a positive change for patients and family physicians.
"It appears that when a doctor happens to be in a place that moves to a 'medical home' model, they can turn their frustration into excitement again. That is huge," said J. Fred Ralston Jr., president of the American College of Physicians. "We are getting reports that patients are happy, physicians are happy and that, in at least some cases, [these new sorts of practices] are saving money."
The results of a national demonstration project designed to test a medical home model, launched by the AAFP and TransforMed in 2006, will be published later this month in a supplement to the Annals of Family Medicine.
In a recent interview with FPM, Kevin Burke, director of government relations for the AAFP, shared his perspective on what the new reform law means for family physicians. Read the article, and let us know what you think.
Donald Berwick, MD, faces his biggest challenge yet
President Obama’s impending nomination of Donald Berwick, MD, MPP, to head the Centers for Medicare & Medicaid Services (CMS) is welcome news. Berwick, a pediatrician and professor at Harvard Medical School and Harvard School of Public Health, is president and CEO of the Institute for Health Care Improvement (IHI), a think tank whose impressive and ambitious work we at FPM have been following since it launched the Idealized Design of Clinical Office Practices (IDCOP) initiative in 1998 (read more about IDCOP in FPM). Our only beef with Berwick is that, following IDCOP, IHI hasn’t devoted more focused attention to office-based practice.
Washington Post blogger Ezra Klein calls Berwick "the most important health-care reformer you’ve (probably) never heard of” and Maggie Mahar’s two-part profile of Berwick introduces him (don’t miss the video clip that, near the end, features Berwick’s thoughts on primary care payment). Having heard several of Berwick’s rousing keynote addresses at IHI’s Annual National Forums, it’s hard to imagine him not making the most of the new tools and authority of the CMS position to improve health care for patients and providers. If only we will let him. Let’s hope his confirmation isn’t a casualty of the resentment bred by the passage of health care reform legislation. May it be quick and painless. This man has work to do.
And it's done
Last night, with a vote of 220 to 207, the House of Representatives approved the
budget reconciliation bill containing a package of fixes to the recently passed health care reform bill. The reconciliation bill now awaits President Obama's signature, making health care reform legislation complete.
The health care reform bill: What's in it for doctors?
Last night, the House of Representatives voted 219 to 212 to approve the health care reform legislation passed by the Senate in late December. Thirty-four Democrats joined Republicans, who were unanimous in voting against the bill. The President is expected to sign the bill into law tomorrow. The House also adopted a package of “fixes” to the bill, which will now go to the Senate.
To obtain the last few votes needed to pass the bill, the White House promised anti-abortion Democratics that it would issue an executive order ensuring that federal funds will not be used for abortions.
The bill is expected to provide coverage to 32 million uninsured Americans, leaving 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.
The bill is estimated to cost $940 billion over 10 years but would reduce the deficit by $143 billion during that same time frame, according to the Congressional Budget Office. The savings are projected to come from Medicare reforms and from new taxes and fees, including a tax on high-cost (or “Cadillac”) health plans and increased taxes on individuals making more than $200,000 per year or couples making more than $250,000.
Although “Washington may live and die by the pronouncements of the Congressional Budget Office,” wrote pollsters Doug Schoen and Scott Rasmussen in The Wall Street Journal, “81 percent of voters say it’s likely the plan will end up costing more than projected.” The Cato Institute estimates that the bill will cost nearly $3 trillion.
How will the bill affect doctors?
The bill establishes a 10-percent Medicare bonus for many primary care physicians (those whose Medicare charges for office, nursing
facility and home visits comprise at least 60 percent of their total
Medicare charges) for the next five years; increases Medicaid
payments for primary care physicians to 100 percent of Medicare payment
levels for 2013 and 2014; and increases funding for primary care scholarships, loan repayment programs, residency programs, the
National Health Service Corps and community health
centers. Whether these measures will succeed in reversing the shortage of primary care physicians, which will become increasingly critical as newly
insured patients seek care, remains to be seen.
The bill also establishes multiple pilot projects to test payment reform in federal health programs such as moving from payment based on quantity of services to payment based on quality of services, financially rewarding physicians who make their offices “medical homes” for high-need beneficiaries, and establishing “accountable care organizations” that allow providers who voluntarily meet quality standards to share in the cost savings they achieve for the Medicare program.
The bill does not repeal the Medicare sustainable growth rate (SGR) formula or provide comprehensive tort reform.
How will the bill affect patients?
The bill would almost immediately provide the following:
- Patients who become ill cannot be dropped by their health insurer.
- Insurers must provide free preventive care.
- Lifetime benefits cannot be capped.
- For children under age 18, insurance companies cannot deny coverage for pre-existing conditions.
- Young adults can remain covered on their parents’ insurance until age 26.
- Small businesses can claim tax credits to help purchase health insurance for their employees.
Other changes won’t go into effect for several years, such as the following:
- Americans will be required to have health insurance or pay a fine.
- Insurance companies will not be able to deny coverage for pre-existing conditions for adults.
- Medicaid will be expanded to cover an estimated 16 million people.
- Low- and middle-income Americans will be eligible for subsidies to purchase private health insurance – a cost of $938 billion over 10 years.
- Employers with more than 50 employees will be required to offer health care coverage or pay a fine.
- States would establish health insurance exchanges to help consumers without health care coverage and small businesses shop for insurance meeting federal standards.
For a timeline of key changes, see this Washington Post article.
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.
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.
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.