Wednesday, June 3, 2009

Guess which "cost driver" was overlooked by Obama's economic team?

Yesterday, President Obama's top economists released a report on how health care reform will improve the economic health of the country.

The President's Council of Economic Advisers estimate that "expanding health insurance coverage to the uninsured would increase net economic well-being by roughly $100 billion a year, which is roughly two-thirds of a percent of GDP" and that "[With health care reform] the real income of the typical family of four could be $2,600 higher in 2020 than it otherwise would have been and $10,000 higher in 2030." The report makes the case that, "slowing the growth rate of health care costs will prevent disastrous increases in the Federal budget deficit" because, absent reform, "Medicare and Medicaid expenditures are projected to rise from the current 6 percent of GDP to 15 percent in 2040..."

The report identifies seven "drivers" of inefficiency that need to be addressed in health care reform:

1. Provider incentives that reward providers for volume of services rather than quality, cost and efficiency.
2. Limited financial incentives for consumer to consider price, quality and choice of health care setting.
3. Pricing of medical treatments that are slow to adjust for productivity improvements and decreasing marginal costs of production.
4. Fragmentation caused by patients receiving care from independent and competing organizations instead of vertically integrated groups like Geisinger and the Mayo health systems.
5. Lack of information for providers on the clinical risks and potential health benefits of alternative treatments.
6. Lack of comprehensive performance measurement and feedback to providers on how well or poorly they are doing on providing recommended care.
7. Lack of information to consumers on the effectiveness of different treatments.

What's missing? That the growing lack of internists and other primary care physicians in the U.S. is a principal driver of higher costs and a major reason why we lag behind other countries.

Oh, to be fair, they did mention primary care in passing:

"Though we describe them separately, it is important to note that there may be interactions between expanding access to coverage and slowing cost growth. For example, wider access to primary care, with an emphasis on prevention, is likely to help restrain cost growth."

That's it. No other mention of physician workforce issues. No mention of medical home. No mention of internal medicine, family medicine, or pediatrics. No mention of "patient-centered" care except for once in the introduction. No statement about the urgency of reversing the imminent collapse of primary care medicine.

This, despite the evidence that primary care is consistently associated with better outcomes and lower costs of care.

That such bright people overlooked the importance of having an adequate primary care physician workforce suggests several possibilities. One is that they are unpersuaded by the evidence. Another is that they simply overlooked it. A third is that they are aware of the evidence, but have decided for political reasons not to make it a priority. Or maybe they just forgot.

No matter the explanation, the Obama administration needs to make physician workforce issues, and especially the need to avert a collapse of primary care medicine, a higher priority. The urgency of the issue deserves a lot more attention than 17 words out of a 51 page report that was supposed to make the definitive economic case for health care reform.

Today's question: What else do you think should be done to get White House policymakers to make primary care a priority that matches the urgency?


PCP said...

Obama is a pragmatist. He will respond to any idea that frames the issue as one of value in health care.
We need to demonstrate how this has been systematically undermined by the payment system and how an over specialised system of care is just as detrimental as a system with no specialists.
I think once he and his team hear that, they will come to include our interests in their policies.
Additionally I want to state that another reason they may not have included generalists in their policy is they feel that ANPs are up to the task of primary care entirely. That would be astonishingly foolish and myopic, but nonetheless possible, since politicians are not always known for their visionary brilliance.
Finally much of the advocacy of the ACP should focus on increasing the attractiveness of General IM as a career, not on just merely increasing the numbers as happened in the 90s. If General IM is attractive as a career, our younger professionals are not stupid, they will choose wisely.
That is why we need to draw attention to the RUC and its failure to appropriately assign value in health care. The AMA will surely fight this, however sadly the RUC has failed Generalism miserably and needs to be replaced/reconstituted.
Obama needs to be made to understand the value of each patient having a competent General Internist as the person overseeing their care, whether it is delivered by a ANP/PA or by a Sub-Specialist. I feel if he understands that role he will support it.

DrJHO7 said...


If you're a soldier in George Washington's army, half frozen in the snowy winter encampment in Valley Forge of 1777 (with cloth wrappings of your feet and ankles for shoes...), which of the two statements by the lookout sentry is more effective in causing you to scramble to action and grab your musket?

1. The British are coming, the British are coming!

2. The British are here!

Unfortunately, and for way too long, our government has been crisis oriented with regard to springing into action on important issues, and usually (almost always, unless political gain is involved) waits for scenario #2.

So, how do we convince the government that there is a primary care medicine manpower crisis NOW, rather than "looming, impending, coming soon to a community near you...etc"?

Well, in some parts of our country there is a crisis NOW, but I'm not sure we have a good handle on just where these communities are, how many, how bad and what their stories are. The government has data on health care manpower shortage areas, but it may not have a sense of the collage of communities across our country where access to primary care physicians is CURRENTLY a crisis. If the medical profession could access this data and present it to the Gov't in such a fashion that a current crisis was more appreciable, we might have something. (By the way, I'm sure that such a study would be a very expensive, man-hour heavy undertaking)

The University of DE studies this issue and publishes a report every 2 years re: conditions in the primary care sector in the State, and a report of the study is available online. I wonder if other States/Universities study this and publish results: it might be a good thing for perhaps HPPC of ACP to study and report on, as part of the health care reform push.

In Washington the motivators are: a. big stories on TV news channels: "constituents [voters] in trouble",
b. captivating anecdotal stories from physicians/organizations with specifics, by any media, re: "constituents [voters] in trouble",
c. congressman's family member a victim of deficiencies or toxicities in the health care system
d. any situation that improves one's chances of getting re-elected, including financial support for one's campaign (I know, I should have put this one first)

We have to find a way to magnify the CURRENT primary care physician access crisis and its implications so that it fits a-d. God knows, we've done a first rate job of magnifying and detailing the impending crisis.

Jay Larson MD said...

Every time I hear someone say that they want a health care system with lower costs and improved quality I think to myself that the only way to accomplish this is through primary care. Rarely do I find that someone has made the obvious connection.

Perhaps the executive branch will learn from the history of primary care in the VA system. In the early 1990’s many veterans were unhappy with the care that they received in the VA system. A mandate to transition to a primary care system in 1994 resulted in a shift from specialty care to primary care. In 1993 38% of VA’s had primary care emphasis; this increased to 95% in 1999. Initially specialists provided 70% of care and primary care only provided 30% of care. Now most care in the VA system is provided by primary care. VA medical care quality improved during the 1990’s.

Perhaps the executive branch will understand the meaning of the GAO report on overcrowded ER’s . Government Accountability Office (GAO) released new findings that overcrowding in hospital emergency rooms continues, resulting in longer, sometimes dangerous wait times for patients and forcing ambulances to divert patients to other facilities. How many patients were in the ER because they had no other place to go due to lack of access to a primary care doc?

The urgency of the matter will probably have to play out. We can talk about this until we are blue in the face. Many just don't get it. The primary care crisis is snowballing. It should not take too much longer for primary care to go splat. Then they will get it.

Toni Brayer, MD said...

The lack of primary care drives up costs but until Medicare beneficiaries have trouble finding a doctor, I am not sure Washington really believes there is a "shortage". I agree with PCP that exposing the failed RUC is needed. But I think that is too complicated for most lawmakers and what will grab their attention most is patients who can't access service.

Anonymous said...

Well Bob, I fear that ACP has reaped what it has sowed. I am sorry but these words are harsh. Three and one-half years ago the ACP Board of Regents approved the Patient Centered Medical Home. The PCMH is not supported by the 80% of Internists who work in small practices. I don't have scientific proof, but neither do you because you never canvassed the membership. The membership doesn't support it and the politicians certainly don't understand it. Three and one-half years have been wasted while Primary Care is dying. The only thing these politicians will understand is when they and their family can't find a doctor. The ACP should drop the PCMH advocacy. We need immediate increase in our Medicare and commercial re-imbursement. It is time to take off the gloves and we may need to literally march in the streets of Washington.

K McCabe MD said...

Until the politicians in our local communities actually hear what their constituents have to say about the lack of general internists nothing will be done. Twenty years ago I chose a primary care residency program and was proud of my training. I worked in a general medicine clinic and enterd Pvt practice 14 years ago. Since that time the hours have gotten longer, the constant interference of non=medical personal in everyday treatment decisions has increased astronomically and the payments for services rendered are slower to come in to the bank. The problem is right now so that any plan to increase residency slots and loan forgiveness programs are great ideas but they put off what to do about the problem now. My practice invested in an EMR system which will eventually pay us back in cost savings but the loan for that, the initial slowdown while one trains on the EMR, and slow payments especially by medicare has wreaked havoc on the practice's bank account. Then there are the malpractice costs! No physician will cut down on tests unless patients agree to have a hand in cost savings...any system that mandates less tests without protection for the physician will be doomed to failure and we will be back where we started. As Dr Larson stated, we all know that primary care cuts costs but as a "specialty" it cannot cover it's overhead unless we see more and more pts in the current payment situation. Many of us are so inundated with forms to complete, preauthorizations for services and drugs and pts not complying with a treatment plan that has 10 people interfering in. It's a wonder that pts leave the office understanding anything at all despite having explained it to them! As pts are living longer they have many more problems and diseases to coordinate and generalists do this well. My practice participated in PQRI from the outset and never saw a dime! When we called to see why we didn't get paid for this we were told that we would have to apply to CMS for them to tell us why we did not receive a bonus. I do not know of any physician who was paid in this program.
Again this problem can be fixed by an infusion of money to primary care soon and upfront and this will be enough for med students to see its effects and believe that primary care can be a rewarding specialty for them to choose! The future generalists will see that the govt as well as pvt plans put their money where their mouth is.