Care, Cost, Access, and Health Reform

November 27 – This morning my good friend, Brian Klepper, an imminent health care analyst, sent me an email that said, in part,

“Later this week on Wednesday, 12/1, David Kibbe and I will launch a new health care professional forum called Care and Cost, which we hope will aggregate and showcase great HC writers of all persuasions and from all disciplines.

We’ve put some energy into designing the site and its characteristics. Among the things we’ll do:

• Categorize each post into major interest areas, so readers can easily find articles germane to their own work.

• Incorporate an area called “Urgent Science” that will run peer-reviewed, highly documented scientific review articles, aimed at giving practicing clinicians the basis for using new approaches.

• Run daily charts that say something interesting about what’s going on in health care.

• Provide occasional image galleries, by topic, suitable for presentations.”

David Kibbe, MD. MBA, and Brian Klepper, PhD, are long-time, trenchant commentators on health reform, innovation, new practice models, and medical homes. Their major concern. as I see it, is how to rationalize the system to bring costs into line while maintaining quality. They would like to do this before costs bring the system to its knees, and chaos ensues.

I do not always agree with their point of view – that practicing doctors, especially specialists, are the major drivers of cost, loose cannons that need to be reined in and that strict adherence to “best practices” will bring costs down dramatically – but I understand their logic.

I recommend readers visit their C&C site for their insights.

The big things that concern me about health reform are the cost implications of reform for physician supply, demand, and patient access. Reform will immediately add 16 million more people to Medicaid rolls (now 47 million or 19% of U.S. citizens) and potentially millions more as employers drop coverage, premiums escalate for existing plans, and word gets around that a massive new entitlement program is there to be had.

To me, the biggest question is: what will be the effect of reform on Medicare/Medicaid access? No one knows for sure. But a 2008 survey by The Physicians Foundation of 300,000 primary care physicians may hold some clues.
Here is how primary care physicians responded to three key survey questions.

1) Which, if any, of the following payers provide reimbursement that is less than your cost of providing care?

• Medicaid 65%
• Some HMO/PPO 43%
• Medicare 36%
• CHAMPUS 21%
• Some indemnity plans 14%
• SCHIP14%

2) Have cost/reimbursement or time issues in your practice compelled you to close your practice to any category of patient?

• Yes, 47%
• No, 53%

3) If yes, which types?

• Medicaid patients 34%
• Some HMO/managed care patients 30%
• Certain managed care companies 26%
• Indigent patients 16%
• Medicare patients 12%
• New patients 5%
• Other 4%
• Self pay patients, 4%

These figures were before the health reform bill passed in March 2010. In a 2010 Physician Foundation survey of 2600 randomly selected physicians of all specialties, 51% said they would close their practices to new Medicaid patients, and 30% indicated they would not accept new Medicare patients.

Low government reimbursements for Medicare and Medicaid do not bode well for expanded access, the primary purpose of health reform. Instead, limited access may be an unintended and paradoxical consequence of the health reform law.