Friday, February 28, 2014

Dead Men Talking and Revival of Primary Care

We have been relentless advocates for universal health coverage and the Affordable Care Act (ACA).

Molly Cooke, MD, president, American College of Physicians, “Dead Men Walking,” Correspondence,  New England Journal of Medicine, February 27, 2014

I’ve been a puppet, a pauper, a pirate, a poet, a pawn, and a king, in and out, and I know one thing. Each time I find myself flat on my face, I pick myself up and get back in the race.

Lyrics to Frank Sinatra song, “That’s Life”

Primary care doctors have been called a lot of things  -  puppets of the AMA,   paupers by  the SGR formula,  pirates by critics,  poets (see William Carlos Williams, MD),  and keys to the greater health care kingdom, but never as “Dead Men Walking,” as highlighted in a letter to the editor in the  February  27 New England Journal of Medicine.

Much of this talk is unfair.   Compared to specialists, primary care physicians have less income and less respect, and their morale, as evidenced by multiple surveys is low.   

But through it all, their professional associations – The American College of Physicians, the American Academy of Family Physicians,  the American College of Pediatrics, the American College of Osteopathic Physicians – have steadfastly supported the Affordable Care Act.    

For the most part, this support has not filtered down to the membership of these organizations, who,  by majorities of 60% or more,  are advising their children not to choose medicine as a career.   Furthermore,  only a minority of medical students,   25% or less,  are entering primary care residencies. 

In his annual budget,  just released,  President Obama , has stepped forward  to  support primary care with:

  • ·         $5.23 billion over the next 10 years to train 13,000 primary care residents in high need communities, and in team-based care, as in accountable care organizations.

  • ·         $5.24 billion for higher payments to Medicaid primary care providers, including physician assistants and nurse practitioners.

  • ·         $3.95  billion over the next 6 years to expand   the current 8,900 primary care physicians in the National Health Service Corps, which provides care in under-served and under-doctored areas, to  15,000 in 2015.

This “booster shot” for primary care, as described by Mary Wakefield, HHS administrator,  is  not necessarily  a good thing in the eyes of primary care physicians  now in practice.    

It is tailored to smacks of  government programs – accountable care organizations,  team-based care, and nurse practitioner care -  not to the needs of private primary care physicians.   It does not help with  government regulatory burdens,  the complicated new ICD-10 coding system,  or the expenses of installing and maintaining dysfunctional electronic  health record systems.    

Furthermore,  many of these physicians are not fans of accountable care organizations,  nurse practitioners  in independent practice,  and team-care.

Still, federal financial support for primary care is welcomed, and President Obama  deserves credit for offering that support.    Government aid is start towards  revitalizing primary care and reducing the primary care physician shortage of roughly 50, 000.

Tweet:   In his budget,  President Obama  has proposed spending $14.4 billion to train more primary care doctors, pay  more for PA and NP Medicaid providers, add doctors to the National Service Corps.

Thursday, February 27, 2014

Affordable  Care Horror Stories

"There’s plenty of horror stories being told.  All of them are untrue, but are being told all over America."

Harry Reid,  Democratic Leader of Senate

Now, really,  Senator Reid,  all of them?

Some of them, maybe, but not all of them.

It’s probable that some of them are untrue.

That some of them came straight out of the blue.

But not all of them, six million lost plans,

When so many faced health policy bans.

Some of them, perhaps, but not all of them.

Get real, you can fool some, some of the time,

But certainly not all, all of the time.

There is such a thing as hyperbole.

Sometimes it morphs into hypocrisy.

There's no fool like an old fool,

When he becomes a political tool.

Tweet:   Some Americans are being hurt by cancelled health plans, not all, but an unequivocal few.

Boston: Home of the Longest Waiting Times in America and the Highest Acceptance Rates of Medicare and Medicaid 

This is good old Boston.
The home of the bean and the cod,
Where the Lowells talk to the Cabots,
And the Cabots only to God.

John Collins Bossidy (1860-1928), On the Aristocracy of Harvard

And here’s more on good old Boston.

The home of the architects of the Affordable Care Act.

The home of RomneyCare,   the model for the Affordable Care Act.

The home of David Cutler,  PhD, a Harvard economist and the President’s  chief medical advisor in his 2008 campaign.

The home of David Blumenthal,  MD,  the president’s first health information czar and one of the fathers of electronic health records.

The home of Donald Berwick, MD,  the first CMS administrator appointed by the President, and now Democratic candidate for governor in that state.

The home of the highest concentration of primary care physicians in the U.S. per square mile if one excludes Washington, D.C,  the distal  end of the Washington-Boston intellectual axis.

And the  home of the longest physician waiting times for appoointments  among major metropolitan areas,  in  Merritt Hawkins periodic surveys (2004,2009, and 2013).

Here are the key findings of Merritt Hawkins 2013 survey of waiting times and Medicaid and Medicare acceptance rates among 15 major metropolitan areas.

·         At 45.4 days, Boston had the highest cumulative wait time for a physician appointment, a distinction it also had in 2004 and 2009.

·         The average appointment waits to see a family physician ranged from a high of 66 days in Boston to a low of 5 days, in Dallas.

·         The average wait time to see an obstetrician-gynecologist ranged from a high of 46 days in Boston to a low of 10 days in Seattle.

·         The average wait time to see a dermatologist ranged from a high of 72 days in Boston to a low of 16 days in Miami.

·         The average cumulative wait time to see a family physician in all 15 markets was 19.5 days.

·         The average cumulative wait time to see physicians for all 5 specialties (cardiology, family practice, dermatology, Ob-Gyn, orthopedics) was 18.5 days.

·         Boston had the highest cumulative average rate of Medicaid acceptance by physicians in 15 markets surveyed at 73% while the average was 45.7%, down from 55.7% in 2009 and 49.9% in 2004.

·         Of the 15 markets surveyed, Boston had the highest rate of Medicare acceptance at 98% while Minneapolis had the lowest 38.2% while the cumulative average was 76%.

·         The markets surveyed included Atlanta, Boston, Dallas, Denver, Detroit, Houston, Los Angeles, Miami, Minneapolis, New York, Philadelphia, Portland, San Diego, Seattle,  Washington, D.C.: 1399 medical offices were surveyed. 


Here is Merritt Hawkins conclusion (for details you can find the entire survey results on the web),
“At 45.4 days, Boston has the highest cumulative average wait time for a physician appointment of the 15 metropolitan markets surveyed. Boston also had the highest average waits times when the survey was conducted in 2009 and 2004. The average appointment wait time to see a family physician ranged from a high of 66 days in Boston to a low of 5 days in Dallas. However, as the example of Boston illustrates, access to health insurance does not always guarantee access to a physician. In addition, the survey demonstrates that many if not most physicians in the 15 markets examined are not accepting Medicaid as a form of payment. It is our intention to bring the physician supply discussion into practical focus and to determine how health reform and related trends are affecting access to physician services.”

Boston is a city of health care extremes.  It has the highest premiums in the land, the lowest number of uninsured, the longest waiting times,  the highest acceptance rate of Medicare and Medicaid.  It is an example of rationing by waiting.  It is probably not representative of America as a whole, but what American health care might look like if progressives win the day and have their way.

Tweet:  Of 15 major metropolitan areas,  Boston has the highest average wait times for a physician appointment, the highest Medicare acceptance rate (98%), and the highest rate of Medicaid acceptance (73%),

Wednesday, February 26, 2014

February 26, 2014

A Vision of the Future for Primary Care

For I dipp’d into the future, as far as the

 the eye could see,

Saw the Vision of the world, and 

All the wonder that would be.

Lord Alfred Tennyson (1809-1892), Locksley Hall

Grace Marie Turner,  founder and president of the Galen Institute, sent me this message today,
Fresh ideas and a new vision for health reform
Vision, policy, and politics

“Please plan to join us virtually via webcast or in person tomorrow for a conversation over the vision, policy, and politics of health reform that relies on incentives, genuine competition, and consumer choice.”

In person: Thursday (Feb. 27) National Press Club Ballroom, Washington, DC, beginning at 8:30 a.m. EST

“The stage is being set right now for a pivotal debate over ObamaCare in the 2014 elections – whether it will ultimately get “fixed” or replaced by credible free-market policies.  Join us tomorrow (Thursday) as top political and policy leaders discuss “Fresh ideas and a new vision for health reform.”

 "Vision: Panel I will feature a discussion with leading members of Congress talking about their vision of a true market-based health reform. Six leaders will describe a health sector where incentives are properly aligned and consumers have more control over choices in a truly competitive market."

Sen. Richard Burr, NC
Rep. Diane Black, TN
Rep. Michael Burgess, TX
Rep. Tom Price, GA 
Rep. Phil Roe, TN
Rep. Steve Scalise, LA

*Moderated by Douglas Holtz-Eakin, American Action Forum
Policy:  On Panel II, 10 policy experts from the major market-oriented think tanks will translate the vision into policy solutions for real insurance with real examples of portability and tax fairness, protections for those with pre-existing conditions, and a strong safety net.

Jeffrey H. Anderson, Ph.D., 2017 Project
Joseph R. Antos, Ph.D., American Enterprise Institute
James C. Capretta, Ethics and Public Policy Center
John C. Goodman, Ph.D., National Center for Policy Analysis
Hadley A. Heath, Independent Women's Forum
Paul Howard, Ph.D., Manhattan Institute
Merrill Matthews, Ph.D., Institute for Policy Innovation
Thomas P. Miller, J.D., American Enterprise Institute
Nina Owcharenko, The Heritage Foundation
*Moderated by: Grace-Marie Turner, Galen Institute

Politics: Journalist Ezra Klein and Avik Roy, opinion editor of Forbes and Manhattan Institute senior fellow, will give a lively Left/Right preview of the health policy debate in the 2014 and 2016 elections.

Co-sponsoring organizations:  American Action Forum, the American Enterprise Institute, the Ethics and Public Policy Center, the Galen Institute, The Heritage Foundation, the Independent Women’s Forum, the Institute for Policy Innovation, the Manhattan Institute, the National Center for Policy Analysis, the Pacific Research Institute, and the 2017 Project."
My Response to Invitation

Dear Grace-Marie:

I will be there, virtually.  

Unfortunately,  I cannot personally  attend.

But I do have this vision.

I foresee a  resurgence of decentralized personal health care  in the wings.
Five  developments will promote its resurgence:    

One, the desire for consumers for more personal one-on-one care with  personal physicians as an escape from narrowing  physician networks.

Two,  an escape from the long waiting lines occasioned by the shortage of primary care physicians and from the impersonal nature of consolidated integrated health systems,

Three,  the emergence of smartphone and other information technologies that simultaneously empower consumers and physicians.

Four,  the increasing prevalence of high deductible plans that promote shopping for full-service,  quickly accessible care  on a direct pay basis.

Five,  the rapid emergence of direct pay, private physicians, with  on demand services characterized by the innovative use of software with more accurate diagnostic, prognostic, and wellness information with the patient leaving the office with their complete medical record in hand or on their smartphone.

Tweet:  One new vision of health reform is that of personal decentralized personal service rather than impersonal consolidated services by depersonalized teams in integrated health systems.

High Deductibles Help Retailers Compete with Primary Care Doctors

Data! Data! Data!  How dangerous it is to reason with insufficient data.

Yes, I have a turn both for observation and for deduction. The theories which I have expressed there, and which appear to you to be so chimerical are really extremely practical—so practical that I depend upon them for my bread and cheese.

It’s elementary,  My  Dear Watson!

Sir Arthur Conan Doyle, MD (1859-1930),  creator of Sherlock Holmes

Sir Arthur Conan Doyle  was a physician.   He created Sherlock Holmes, the master of observation, reasoning, and logical deductions, and his sidekick,  Dr. John Watson.   If Doctor Doyle were alive today,  he might well accept the logic that retailers will be formidable competitors of primary care physicians.

I have just finished reading John Commins two part series in Health Leaders Media: One, “Retail Medicine Syncs with High Deductible Health Plans" (February25) ; and Two, "Behind Retailers Health Care Strategy"( February 26).    

Both pieces feature an interview with Vaughn Kauffman and Ceci Connolly of PriceWaterHouseCoopers’ Health Advisory Service on how retail services plan to carve out larger roles for themselves from traditional  primary care doctors.

What retailers have to say and what they plan to do,  I think Sir Arthur Conan Doyle and his fictional characters would agree is logical .

One, high deductibles, in essence, switch risk to  health consumers for routine health problems and certain routine treatments for chronic disease.

Two, high deductibles make competitive prices important for consumers, and prices for retailers tend to be lower than prices found in primary care settings.

Three,  high deductibles make price transparency important, and health consumes want to know in advance what they are paying for.

Four,  high deductibles make convenience in shopping more important.

Five ,  high deductibles renders important  familiarity with the provider, be it a primary care physician, a nurse practitioner, a physician assistant,  or a store where one shops and for whom one has established brand name recognition.

Six ,   high deductibles gives chain grocers, big pharmas,  and big box retail story advantages with their  marketing strategies, data, and the ability to reach thousands of customers at the click of a mouse.

Seven ,   high deductibles have one great failing – they lack the expertise,  equipment, and knowledge needed to deal with serious disease and catastrophic care.

Look at it this way.   The average consumer may visit a  retail outlet (national pharmacy chain, grocer, or big box retailer)  60 or 70 times a year,  a pharmacist 30 times, and a primary care doctor 3 times.  Familiarity breeds comfort and convenience, and higher volumes breed lower prices. These are formidable advantages in a consumer-driven stagnant economy in which consumers have little time and little cash to spare. 

What can primary care doctors do to combat these trends?   

One, they can hook up with retail outlets as back-ups for problems requiring greater knowledge.    

Two, they can offer high level services in concierge-type or direct cash practices with a higher level of personal attention.   

Three, they can consolidate services with hospitals and other physicians with one-stop shopping for medical services.

In summary,

Retailer  health services are here to stay.

Deductibles up retailer appeal right away.

Trouble is they can’t deal with catastrophe,

They don’t have sufficient mentality.

For real  problems answers aren’t  in big boxes,

Real  solutions reside in minds of real docs.

Tweet:   Retailers, using knowledge and data on consumers,  are carving out health care services to compete with primary care physicians.