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Saturday, April 16, 2011

Access to Health Care

Yusuf (JP) M. Saleeby, MD
Access to healthcare in South Carolina is in need of a large band-aid.  South Carolina happens to be one of the unhealthiest states in theUnion by reports with a ranking of 46 out of 50 in the nation.  This low ranking may be in part to the lifestyle and genetics of the population, but very likely the resident's poor access to quality healthcare is a determining factor.  Poor dietary habits, a diet traditionally rich in fatty and fried foods along with the general lack of exercise by the vast majority contribute to this but can be overcome with proper preventive medicine interventions.  Syndrome X (Metabolic Syndrome) is rampant in the southeast, hitting SC very hard with large populations of those suffering from hypertension (HTN) and diabetes mellitus (DM).  Lack of access to basic healthcare mean hypertension, diabetes and other disorders go unrecognized and thus untreated.  Ramifications of untreated HTN and DM alone can account for great morbidity among the population, leading to heart disease, renal failure, stroke, and blindness to name a few outcomes.  This population of under-treated will eventually consume a greater healthcare dollar as their disease process worsens and sequelae materialize.
Statistics show some 19.4% of those living in South Carolina are uninsured, having no type of health insurance at all.  From a 2002 report, the uninsured residents cost the healthcare system upwards of $1,936 per individual per year.  While 60% of the uninsured are hard working citizens, the vast majority (74%) when asked list "affordability" as the reason for not obtaining or purchasing health insurance.  About half the eligible individuals without health insurance do not enroll in public programs for two chief reasons; firstly, they don’t want to receive government support and secondly, they don’t want government to provide health coverage.
 
The problem goes beyond the individual residents of the state.  Almost 80% of businesses in SC, excluding self-employed and government workers have fewer than 10 employees and 53% of these “small employers” with a work force less than 10 employees do not offer group-sponsored health insurance to their employees because of cost issues.  Now that the problem has been identified, what is the solution?  Well it is a complex and multi factorial problem to solve.  Should the government step in and cover the cost of supplying healthcare to all individuals at great expense to the taxpayer?  I say no.  A resounding no!  For the most part we see the failures in the system of government sponsored or supplied healthcare with what is currently going on with Medicare and Medicaid.  Another example of mediocre healthcare delivery is with our nation's veterans.  The Veteran Administration (VA) system of healthcare is increasingly slow, impersonal and cumbersome.  Private sector delivery systems can provide an answer as long as they are regulated to eliminate unfair business practices and unscrupulous profiteering.  To allow a system to become successful as a business model, it must keep overhead down, allow current advances in communication technologies to be at its disposal and become free from the blood letting of insurance companies and a legal system with no reforms to place a ceiling on monetary awards for malpractice claims.  One way to solve issues of cost containment for delivery models that will allow savings to be past to consumers is the use of telehealth with self insurance and the passing of legislation for tort reform.  For a mere fraction of the cost of operating a brick-and-mortar typical family practice, telehealth can accomplish almost 70% of what can be conducted in an office setting without the cost prohibitive costs.  End result is the savings passed along to the patient (consumer).  Making routine and basic healthcare one again affordable.  

Exploring this model is the AtroGene Telemedicine group.  This group of clinicians have departed from the typical means of conducting business via a traditional office based practice and is exploring new ways of healthcare delivery via telephone and video-consulting.  The Internet savvy end consumer will most likely embrace this new technology with offers great promise and practicality.  Older patients who are used to office based practice may find the task of trusting the Internet and telemedicine a daunting task.  The younger patient, typically will have minor acute illnesses that have lower acuity and can be managed comfortably by practitioners well versed in telemedicine, knowing the abilities and limitations of the system.  Thousands of healthcare dollars can be saved if this new model is embraced.  This will divert non-emergent or non-urgent patients from burdening our already overcrowded emergency departments and allow for better and more efficient management of higher acuity patients in true need of the ED.

Likewise access to direct access testing (DAT) will allow astute consumers/patients direct access to lab and blood testing.  By passing the traditional avenues to obtaining routine annual labs, they can once again drastically reduce their expenditures on the basic routine aspects of health and wellness.  With only minor interventions and guidance by healthcare providers the vast majority of the public can obtain affordable healthcare tests they would have otherwise ignored or put off for lack of ability to pay a higher price tag.  Affordable and easily accessible telehealth may very well be the panacea to save the majority of uninsured clients in our state.
 
Source: some statistical information gained from www.covertheuninsuredsc.org
 
 
Other interesting facts:

A 2010 Press Ganey Pulse Report (survey) demonstrated the national average emergency room wait time was 4-hours and 7-minutes long.
There are 123-million emergency room visits in America each year.  The vast majority are considered non-emergent.
There are an estimated 312,000 Primary Care Physicians (PCP) today, but the current need requires about 13,000 more.
65-million Americans live in areas without enough Primary Care Physician coverage.
Wait times of about 2-months are routinely being reported for patients to see their physicians (PCPs).
http://www.nejm.org/doi/full/10.1056/NEJMp0902909  (Another article crying out for help, proposes some solutions)
 
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Health Care 2009

A Lifeline for Primary Care

Thomas Bodenheimer, M.D., Kevin Grumbach, M.D., and Robert A. Berenson, M.D.
N Engl J Med 2009; 360:2693-2696June 25, 2009
Article
Primary care in the United States needs a lifeline. In 2009, for the 12th straight year, the number of graduating U.S. medical students choosing primary care residencies reached dismally low levels.1 Overloaded primary care practices, whose doctors are aptly compared to hamsters on a treadmill, struggle to provide prompt access and high-quality care. Three major factors contribute to this crisis. First, primary care physicians earn far lower incomes than procedural specialists, reducing career attractiveness for medical students with high debt burdens. Second, the work-related stresses felt by primary care physicians tags primary care as the career with more work at less pay. Third, medical education favors training in non–primary care fields. Rescuing primary care requires national policies that address all three issues.
Growing clamor that primary care's plight may undermine important goals of health care reform has Washington policymakers concerned. Primary care has featured prominently in recent hearings held by Senate and House committees, and the New York Times has quoted President Barack Obama as saying that “we're not producing enough primary care physicians.” The administration and Congress understand that after Massachusetts expanded health insurance in 2006, many newly insured adults were unable to find a primary care physician, raising the specter of theoretically universal access to care but no primary care to which to have access. Policymakers are also familiar with studies showing that health systems anchored in primary care have lower costs and better quality.2
A bold federal initiative to revitalize primary care is urgently needed as part of health care reform legislation. This initiative must be comprehensive, simultaneously addressing three interrelated issues: physician payment, practice infrastructure and organization, and the training pipeline (see tableRevitalizing Primary Care.).
For the first of these, physician payment, Medicare and most private insurers currently use the resource-based relative value scale, which was purportedly designed to reduce the payment gap between primary care physicians and procedural specialists. That gap, however, continues to widen. Under Medicare's sustainable-growth-rate approach to containing expenditures, spending on physicians' services remains a zero-sum game: if expenditures for all physicians' services exceed a congressionally set target, physicians' fees are supposed to decline. Because of disproportionately large increases in spending growth for advanced imaging, tests, and minor procedures, physicians whose income depends on evaluation and management (cognitive) services, especially primary care physicians, have seen a relative reduction in Medicare revenues.3 And commercial health plans frequently amplify this gap between primary care and specialty payment.
Congress is considering options for reducing the Medicare payment gap. For the short term, the Medicare Payment Advisory Commission (MedPAC) has recommended that Medicare primary care evaluation and management services receive an increase of 5 to 10% next year.4 Congress is exploring such an increase, perhaps also for additional years. To close the income gap, annual increases of this magnitude would need to compound for several years, and private payers would have to follow suit. Medicare would also have to split physicians' services into separate buckets so that primary care payments would not be reduced as a result of rapid growth in expenditures for procedures and imaging.
An additional strategy to make primary care financially attractive would be providing more relief from medical education debt for clinicians entering primary care. The stimulus package — the American Recovery and Reinvestment Act of 2009 (ARRA) — included expanded funding for the National Health Service Corps, which provides debt-relief opportunities for primary care physicians. Congress is considering further growth of the corps.
For the longer term, Congress is weighing alternatives to fee-for-service compensation of physicians. Currently, reimbursement for office visits does not capture many activities that primary care practices must perform for their patients, especially those with chronic conditions. Under the Medicare Patient-Centered Medical Home demonstration, additional payments would be made to qualifying practices for care-coordination activities, including communication with patients and families by telephone and secure e-mail. Even more ambitiously, Congress may expand the modestly successful Physician Group Practice Demonstration for primary care–oriented integrated care systems, such as the Geisinger Health System and Kaiser Permanente. Under this approach, groups would be rewarded for improved performance on quality measures and assessments of patients' experience by being allowed to share in the savings if costs for their Medicare patients were lower than projected. Under both of these approaches, primary care physicians should receive higher incomes. Moreover, these models provide resources and incentives for enhanced practice capabilities and team orientation to make primary care practice more satisfying and manageable.
Payment reform is a necessary but not sufficient measure for revitalizing primary care, which also requires a modernization program for the second piece of the puzzle — practice infrastructure and organization — akin to federal infrastructure investments to shore up aging bridges and outmoded electrical grids. Most primary care physicians practice in small offices and clinics and cannot afford major capital improvements.
The most pressing infrastructure need is health information technology (HIT). Governments in several European countries equip all primary care practices with interoperable, ambulatory care–focused electronic health records that allow information to flow across settings to enhance the continuity and coordination of care. The ARRA included $19 billion for HIT but did not specify how these funds should be apportioned; it is essential that a substantial share be channeled toward primary care electronic health records.
Yet primary care needs more than computer chips and keyboards. Primary care clinicians require technical assistance to reorganize their practices into modernized medical homes, which will entail the formation of teams to assist physicians in providing proactive preventive and chronic care, the institution of same-day appointment scheduling, the substitution of e-mail and telephone encounters for face-to-face visits when clinically appropriate, and improvement of the coordination of care with specialists, hospitals, and other service providers. Recognizing these needs, Congress included a section in the ARRA calling for the creation of HIT regional extension centers to assist practices and hospitals in implementing HIT. This model draws from the Department of Agriculture's Cooperative Extension Service, a collaboration among federal and state governments, agricultural experts at land-grant universities, and farmers. Extension field agents in every county provide technical assistance to local farmers, spreading agricultural innovations. Believing that what worked for family farmers may also work for family doctors, Congress is considering broadening the scope of a health-oriented extension program beyond HIT to facilitate more profound reorganization of primary care.
The final area requiring action is federal funding of medical education. Medicare spends $8.8 billion annually on graduate medical education (GME), almost all of which flows to hospitals rather than directly to residency programs. Appreciating that this payment mechanism inhibits training in nonhospital ambulatory care settings, which is critical for the development of primary care skills, MedPAC and the Council on Graduate Medical Education are calling for more flexible approaches to Medicare GME payment.5 Advocacy groups for family medicine have gone further and proposed that Medicare GME funding for primary care residency training be wrested from hospital control and paid directly to residency programs, raising the politically charged question of whether GME funding should fundamentally be payment for medical education or a subsidy to hospitals.
The federal government also administers smaller but strategically important programs supporting primary care education under the Public Health Service Act: Title VII (for physicians, physician assistants, and dentists) and Title VIII (for nurses). Despite research documenting these programs' effectiveness, Title VII training funds were reduced from $88.8 million in 2005 to $41.3 million in 2006. The ARRA provided $200 million in one-time funding for Title VII and Title VIII programs, and Congress may increase the base level of funding in the 2010 appropriations bill. Far-reaching medical-education reform would redirect a substantial portion of Medicare's GME billions to strengthening primary care residencies and preparing residents to lead the implementation of innovative models of primary care.
This triad of reforms to primary care policy would result in a comprehensive and interlocking solution to the causes of distress in primary care. Reducing the payment gap would help to refill the pipeline of physicians going into primary care, as would reform of training programs. Changes in reimbursement would pave the way for practice reorganization and be symbiotic with a technical-assistance program. Practice reorganization, in turn, would improve the satisfaction, performance, and productivity of the primary care workforce.
As it writes health care reform legislation, Congress is deliberating over measures that would offer a three-stranded lifeline to rescue primary care. Successfully weaving these strands together is a political challenge, particularly if shifting resources to primary care is viewed by specialists and teaching hospitals as coming at their expense. But for health care reform to succeed in improving access, quality, and affordability, Congress and the Obama administration must make the primary care lifeline strong; otherwise, they risk watching primary care go under.
No potential conflict of interest relevant to this article was reported.
Dr. Bodenheimer is a professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine, and Dr. Grumbach a professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, School of Medicine, San Francisco. Dr. Berenson is an institute fellow at the Urban Institute, Washington, DC.
References
  1. 1
    National Resident Matching Program. Advance data tables: 2009 main residency match. (Accessed June 4, 2009, at http://www.nrmp.org/data/advancedatatables2009.pdf.)
  2. 2
    Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health.Milbank Q 2005;83:457-502
    CrossRef | Web of Science | Medline
  3. 3
    Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007;146:301-306
    Web of Science | Medline
  4. 4
    Report to the Congress. Medicare payment policy. Section 2B. Washington DC: Medicare Payment Advisory Commission, March, 2009:77-128. (Accessed June 4, 2009, athttp://www.medpac.gov/documents/Mar09_EntireReport.pdf.)
  5. 5
    Nineteenth report: enhancing flexibility in graduate medical education. Rockville, MD: Council on Graduate Medical Education, September 2007. (Accessed June 4, 2009, athttp://www.cogme.gov/19thReport/default.htm.)

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