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Health Care

December 2009
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On December 15, 2009, Hope Street Group brought together an impressive group of major stakeholders in health care reform to continue discussing some of the most pressing issues in health care reform. Over the last 18 months, the Bipartisan Working Group has tackled some of the toughest and most important issues in health care reform such as cost, quality, and access. This last dinner shifted gears a bit and focused issues regarding current legislation and implementation as well as issues outside of legislation, such as revitalizing primary care.


You can find the full executive summary of the dinner here, however here are some key points from the primary care discussion for you all to ponder:


  • The notion that physicians are not going into primary care due to high levels of medical school debt is a fallacy. Since physicians training at military medical schools without any medical school debt still don’t go into primary care.


  • The primary care issue focuses on improving the supply of primary care physicians and does not place a strong enough focus on increasing quality care for patients. This needs to be turned around and thought in terms of how to best address the needs of primary care patients.


  • Primary care is not just about the physician shortage. We need to look at expanding the role of nurses, especially in chronic disease management. There is a real opportunity here to improve efficiency and quality.


  • Medical schools need to stop basing all of their residency training in tertiary centers (specialty hospitals) which biases students toward specialties over primary care since primary care seems less intellectually satisfying.


  • It is necessary to train physicians in underserved areas and to recruit from underserved areas through bridging programs. We can also train people in these communities by establishing more schools and programs in high-need areas.


  • Different geographic areas have different primary care needs and models need to reflect that. Our first mistake would be to ever talk about recreating the same primary care model   broadly. There is a remarkable opportunity for innovative model design for underserved areas, but this requires creative, out of the box thinking.


  • Making changes to the primary care practices/business models are an opportunity that payers have to innovate and pave the way toward delivering value and quality for patients.


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    Paul Krugman, from the New York Times thinks so, and he also thinks we can expand coverage AND still cut costs in health care. In the current haze of health care legislative pessimism, most people view these concepts as a dichotomy, rooted in the notion that an expansion of health care coverage would translate into a complete financial collapse of our health care system, but CMS projections don't support this assertion:

    "Take the CMS projection of total health care spending in 2018: it’s more than $4.5 trillion. So the direct cost of expanding coverage — the initial bump in the [cost curve} — is less than 4 percent of total health care spending. That’s the amount by which, on the current trajectory, health spending rises every 7 months.

     

    Against that you have to set the fact that this reform makes the first serious effort, ever, to rein in costs. It’s not at all hard to believe that after a few years this will lead to lower, not higher, spending."

     

    Ok, so really- how does providing everyone with health care curb costs? Here's one take on it:

     

    - Patients seeking care without medical insurance turn to the nation’s “Health Care Safety Net”, which is defined (not ironically) by the American College of Emergency Physicians as “providers who have a legal mandate/mission to offer medical care to all patients, regardless of their ability to pay.” This includes emergency departments, community health centers, public hospitals, and charitable clinics.

     

    - According to an ACEP survey released in March 2003, emergency physicians estimated that one out of every three patients they personally treated were uninsured.

     

    - Many of the nation's uninsured delay needed care and live with serious medical conditions because they do not have affordable access to health care when they need it and only turn to the "health care safety net" when their conditions turn dire, and unfortunately, expensive.

     

    - 55% of emergency care goes uncompensated and hospitals and physicians shoulder the financial burden by incurring billions in bad debt.

     

    - Outpatient care, including same-day hospital vists (aka, ER visits) is by far the largest and fastest growing part of the US health system, accounting for $436 billion or two-thirds of spending expected and 40% of health care spending.[i]

     

    In short, my point is that by extending coverage to the uninsured we'll be cutting some of the 40% of health care spending being used to provide them with care, which is one of the major causes for the cost problem.

     

    However, what happens if the CMS and CBO projections are wrong? Should there be a failsafe mechanism that requires the private industry to cut costs by a certain amount over the next ten years or an independent commission will intervene?

     

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    [i] McKinsey Global Institute, Accounting For The Cost of US Health Care: A New Look At Why Americans Spend More, November 2008

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    "Access to health care is more than giving someone an insurance card. It requires that patients also be able to find a primary care physician who can provide first contact, comprehensive, continuous, preventive and coordinated care for most of their health care needs." -- Snippet from letter written by AAFP and several other primary Care organizations to Congress.

     

    The American Academy of Family Practitioners and number of other primary care physician organizations sent a letter to Congressional leaders calling for more primary care provisions to be added to legislation. These groups have been saying for a long time that the pending primary care shortage is a major crisis that demands attention immediately, especially if coverage is extended through Medicaid to millions of the nation's poor. Low Medicaid payment rates make it nearly financially impossible for struggling primary care physicians to new Medicaid patients and will only exacerbate the shortage.

     

    Check out the AAFP press release to get an idea of what additions Primary Care Organizations are calling for.

     

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    Every couple of months, Hope Street Group hosts a dinner and invites some of the most influential stakeholders in health care reform to break bread, discuss the issues, and build consensus.  The dinners are intimate, closed-door, policy discussions focused on problem solving and finding common ground.

     

    Tomorrow we’ll be hosting our sixth Bipartisan Working Group Dinner on Health Care and we’re opening up an opportunity to all of our Policy 2.0 members to post a question that our Executive Director, Monique Nadeau will pose to the group. You can check back after the dinner to see which questions we picked and the corresponding responses (sorta like a high-tech version of Telephone).

     

    To get a taste of who your question will go to, heres a peek at our participant list:

     

    Byron Auguste | Director, McKinsey & Company; Chairman, Hope Street Group
    Dr. Sree Chaguturu | Attending Physician and Clinical Instructor, Harvard Medical School / Massachusetts General Hospital; Senior Associate, McKinsey & Company
    Dr. Jeff Harris | Former President, American College of Physicians
    Representative Jim Cooper | Tennessee (D)
    Doug Holtz-Eakin | President, DHE Consulting, LLC, Former Chief Economic Policy Adviser to Senator John McCain
    Karen Ignagni | President and CEO, American Health Insurance Plan
    Sr. Carol Keehan | President & CEO, Catholic Health Association
    Dr. Bob Kocher | Special Assistant to the President, National Economic Council
    Jeff Korsmo | Executive Director of Mayo Clinic Health Policy Center, Mayo Clinic
    Peter Lee | Executive Director, National Health Policy Pacific Business Group on Health
    Monique Nadeau | Executive Director, Hope Street Group
    Ralph Neas | CEO, National Coalition on Health Care
    Bill Novelli |Former CEO, AARP; Distinguished Professor, Georgetown University
    Andy Slavitt |CEO, Ingenix
    Simon Stevens | Executive Vice President, UnitedHealth Group
    Dr. Kate Tulenlko | Deputy Director, US Agency for International Development, Global Health Workforce 
    David Walker | President and CEO, Peter Peterson Foundation
    Dr. Len Nichols, Director of Health Policy Programs for the New America Foundation will moderate the discussion

     

    I’m sure you’re thinking, how do I get invited to one of these? Well, right now there isn’t much you can do, however we do invite top Policy 2.0 members to join these dinners from time to time, so get cracking on a question! Here are some examples to get you started:

     

    - Does current legislation do enough to cut costs?

    - What are important policy issues being left out of legislation that need to be addressed?

    - How do we attract more practitioners to primary care? Do you agree with the methods outlined in current legislation to do that?

     

    You can reference the Dinner Agenda and some of the pre-reading materials to help you brain storm.

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    There is a lot of chatter, especially on Policy 2.0, about possible solutions for the primary care shortage including business model changes as well as increasing incentives for medical school graduates to enter the field, however an option not getting much traction is the role nurse practitioners could potentially play.

     

    The Yakima Herald-Republic, Wash. posted a really interesting article on expanding the roles of nurse practitioners to allow them to practice on their own, outside the scope of a physician practice group where most are typically found. One of the things I found most compelling about the article was a citation of a study by the Congressional Office of Technology Assessment which estimated that "nurse practitioners can deliver as much as 80 percent of the health services provided by primary-care physicians."

     

    Given those numbers, expanding the roles of nurse practitioners should definitely be a potential solution to delve further into.

     

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