"The health care problem no one's talking about"

As the U.S. Senate inches closer to passing its version of a health reform bill, general internist Thomas Bodenheimer and colleagues from the University of California, San Francisco argue convincingly in the December issue of the Journal of Family Practice that expanding health insurance coverage without expanding of primary care capacity will not lead to improved health outcomes. In addition to a shrinking supply of family physicians, they identify eight additional "barriers" to patients accessing primary care services that must be addressed if health reform is to achieve its potential:

1) Panel size - family physicians, especially those in rural locations, are caring for more patients than they can effectively manage.

2) Capacity - shorter visit times necessitated by large patient panels negatively affect care quality.

3) Distance - many patients live too far from the nearest family physician to access regular primary care.

4) Medicaid/Medicare issues - Medicaid and Medicare fees are often considerably lower than those of private insurers, in some cases, paying physicians less than the actual cost of providing services. Consequently, many practices limit the number of patients with these types of insurances that they accept.

5) After-hours care - is often unavailable.

6) Scheduling - most practices are unable to schedule timely (same day or next day) appointments for non-acute issues.

7) Virtual visits - insurers do not pay for patient encounters via telephone or e-mail, leading to missed opportunities or unnecessary office visits for equivalent services.

8) Troubles with team care - although registered nurses, pharmacists, medical assistants, and other allied health workers that can be trained to perform routine medical tasks and free up physician time, most insurers do not acknowledge (or pay for) non-physician services.

There is no single solution to all of these issues, nor will every solution be right for every practice or every community. But the recent experience of Massachusetts in providing universal health insurance coverage tells us that making primary care more affordable will not make it more accessible; in fact, it is likely to do the opposite. As Dr. Bodenheimer and colleagues conclude, "Unless Americans have greater access to primary care, we fear, the U.S. health care system will undergo significant change without substantial improvement." Regardless of whether a health reform bill passes Congress before Christmas, policymakers must understand that they remain very far from the finish line.

Cultivating new models of health care

I'm a big fan of surgeon-author Atul Gawande, and I eagerly devour each of his new pieces on health and health care reform in the New Yorker. So it was somewhat surprising how difficult it was for me to digest his most recent essay, "Testing, Testing." In a nutshell, Gawande argues that it's okay for the Senate version of the health reform bill to have no "master plan" for controlling the skyrocketing cost of care because health care is to agriculture as family physicians are to family farmers. Huh? This sounds like a bad analogy-type question from the SAT, not a serious argument. But it would be a mistake to dismiss Gawande's suggestion that farming and health care have more in common than one would initially think:

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. ... Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county.

Other notable physicians have recently proposed that primary care practice could be revitalized with the help of a "primary care extension service" analogous to the successful U.S. Agricultural Extension Service. In a plenary address at the 2007 spring conference of the Society of Teachers of Family Medicine, family physician Kevin Grumbach noted:

Just as family farmers were once the nation’s major agricultural providers but are now an endangered species, we know that 75 years ago the majority of physicians in the US were general practitioners, but by the end of the 20th century, family physicians and other generalists had become a distinct minority of physicians. Just as family farmers find that few of their progeny are becoming farmers, we find half as many US medical school graduates are entering family medicine residency programs now as were a decade ago. The dominance of a reductionist paradigm in medicine has devalued the work of primary care and its integrating function for whole-person care.

So what's the solution? How can whole-person care survive in a specialist-dominated U.S. health system? By encouraging lots of experimentation, said Dr. Grumbach, and rethinking the essential functions of a family physician within a health care team. But most practices don't have the time, resources, or expertise to accomplish this practice transformation on their own. Financial incentives should help, but like Drs. Grumbach and Gawande, leaders from the Agency for Healthcare Research and Quality argued in a 2009 editorial that a government-supported extension service would speed the pace of innovation.

Admittedly, it's tough in these times to imagine that a government-sponsored anything could effectively control costs in health care or any other important sector of our failing economy. But regardless of the lack of political will on Capitol Hill, Dr. Gawande's latest article still provides food for thought about the best means of cultivating more effective models of health care in the U.S.

Ignore health reform scare stories

In a previous post, I argued that debates about the inclusion of a "public option" for health insurance in the reform bills taking shape in the U.S. Congress obscured the critical issue that elected officials have been reluctant to tackle: cost control. Extending insurance coverage to everyone is a moral imperative, but doing so will do little or nothing to hold down the rising price tag of health care, which is driven in large part by the proliferation of "care" that is unnecessary or harmful. In a New York Times editorial earlier this week, David Leonhardt observes that opponents of cost control use "scare stories" to falsely assert that cutting spending always means hurting patients:

Hospitals that practice more intensive medicine, to take one example, get no better results than more conservative hospitals, research shows. And while the insured receive better care and are healthier than the uninsured, the lavishly insured - those households with so-called Cadillac plans - are not better off than households with merely good insurance.

Yet every time Congress comes up with an idea for cuttting spending, the cry goes out: Patients will suffer! You're cutting bone, not fat!

How can this be? How can there be billions of dollars of general waste and no specific waste? There can't, of course. The only way to cut health care costs is to cut health care costs and, in the process, invite politically potent scare stories.

The trouble is, while disease advocacy groups such as the American Cancer Society can trot out endless legions of men whose lives have been "saved" by screening for prostate cancer, for example, you won't hear anything from the much larger numbers of men who have suffered permanent impotence or urinary incontinence due to surgery for prostate cancers that may never have affected their health. (A recent analysis in the Journal of the National Cancer Institute estimated that over 1 million additional men have been diagnosed and treated for prostate cancer in the U.S. since the introduction of PSA screening in 1986, and even under the most optimistic assumptions, only 1 in 20 of these men actually benefited from treatment.)

It's completely understandable that men who undergo treatment for cancer and suffer adverse effects from their treatment want very much to believe that their lives have been saved and that the harms they suffered were worth the cost. Doctors who detect and treat those cancers want to believe this too. In a phenomenon that has been called "a system without negative feedback," all of the incentives in U.S. health care conspire to encourage excessive testing and treatment for individual patients. Only by paying attention to health on the population level can we get a better perspective. Resources are limited, and given this fact, it makes no sense to squander resources on care that doesn't work, or care that hurts more people than it heals. Scare stories about cost control make for good headlines, but the story that scares me is what would happen if health reform passes without it.