The following are my prepared remarks at Health Care Reform: Putting Patients First, held at the National Press Club in Washington, DC, on July 17th, 2009.
President Obama recently declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.” And indeed, finding a way to provide universal health coverage to every American is one of the focal points in today’s health care debate. There are a variety of ways we can achieve this, ranging from a Medicare for all, single payer system to requiring everyone to purchase health insurance. But no solution can work unless we first deal with the shortage of primary care doctors.
After all, what good is having health insurance if you can’t find a doctor to see you?
As a primary care physician in Nashua, New Hampshire, a city that borders the state of Massachusetts, I have had the luxury of closely observing that state’s health reform efforts. And to their credit, Massachusetts currently enjoys near-universal health coverage, in part because of the mandate requiring every resident to obtain health insurance. Many policy experts are predicting that a national plan will closely emulate the Massachusetts model, so it’s worth noting any potential consequences.
Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits. In fact, since the universal coverage law was passed, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that treating simple conditions in the ER can be exponentially more expensive than an office visit. It’s no wonder that the plan has placed significant fiscal strain on the state’s budget, which is struggling to contain soaring health spending.
This affects hospitals like Boston Medical Center, which primarily serves the city’s poor. The state’s mandatory health insurance law is causing the medical center, according to a front page story in last Sunday’s Boston Globe, to brace “for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families.”
Furthermore, consider the words of family physician Kate Atkinson, who practices in Amherst, Massachusetts. She had decided to temporarily accept new patients, as 18 doctors in her area had recently closed their practices or moved away.
“There were so many people waiting to get in, it was like opening the floodgates,” she says. “Most of these patients hadn’t seen the doctor in a long time so they had a lot of complicated problems. We literally have 10 calls a day from patients crying and begging.”
She closed her practice to new patients 6 weeks later.
I witness this phenomenon myself every day, with patients from Massachusetts routinely crossing the border to New Hampshire looking for a new primary care doctor. These are people with chronic conditions like heart disease, diabetes, depression, and high blood pressure – all who need a regular physician to follow them.
And keep in mind that Massachusetts has the highest density of doctors per capita in the country. What do you think will happen to states that do not have a comparable supply of physicians?
Moving away from Massachusetts, let’s look at two other examples where universal coverage was promised before ensuring adequate primary care access. One would be our military veterans, who are guaranteed health care through the Department of Veterans Affairs, also known as the VA. Earlier this decade, the wait to see a primary care doctor in the VA routinely exceeded 50 days in various parts of the country. Although that number has improved, a recent report by the Office of the Inspector General concluded that more than a third of veterans still waited a month or more to see a doctor. And with tens of thousands returning home from Iraq and Afghanistan straining an already overburdened VA health system, it’s no wonder that my practice in Nashua, New Hampshire sees a fair amount of veterans who are unable to obtain timely care from their local VA clinic up north in Manchester, or from down in Boston.
Next, consider the care Native Americans receive via the Indian Health Service. Despite having guaranteed health care coverage, President Obama himself cites Indian reservations in South Dakota that have some of the lowest life expectancies in the Western Hemisphere. American Indians are twice as likely to die from diabetes when compared to whites, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease. Although each of these conditions can be treated or prevented with timely primary care, according to a 2005 Government Accountability Office report, patient waits within the Indian Health Service for routine women’s care and general physicals lasted anywhere between two and six months.
It is encouraging that the President and members of Congress recognize the threat that the primary care shortage poses to their health reform efforts. But some of the solutions being discussed, such as reducing medical school debt, increasing funding to the National Health Service Corps, and training more mid-level providers like nurse practitioners and physician assistants, fall woefully short. None will have any immediate impact, which will be especially critical if there’s a distinct possibility that already overwhelmed primary care doctors will be responsible for almost 50 million additional, newly insured, patients overnight.
Instead, we need to value primary care, and make it central to our health system. Rather than being encouraged to squeeze in appointments and rush through office visits, doctors need to be incentivized to practice patient-focused primary care, including, managing chronic diseases, providing preventive medicine guidance, and taking the time to counsel patients.
There’s no question that we need to find a way to provide health coverage for every American. But we must do so in a responsible manner, and that starts with ensuring that we have a strong primary care system first.
Related posts:
- Universal coverage without primary care access is useless
- Primary care incomes and universal health coverage
- Discussing health care reform at the National Press Club, Friday, July 17th at 9am
- Universal coverage without primary care
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- Universal coverage and primary care
- Will the lack of primary care doctors make universal coverage useless?
{ 29 comments }
President Obama is the master of misdirection. He talks about preventive care yet smokes cigarettes. He extols the virtues of the cost savings of prevention yet nominates an obese doctor for surgeon general. What are we to believe – the president or our collective lying eyes?
Two months’ wait? I waited that long as a new patient for a primary physician in the 1990s (two different ones). Interestingly enough, the wait times have gone down recently if you are willing to go with any primary physician who is available to new patients (but you may not have much of a choice, as there are few available).
Excellent speech BTW. Great information that people/legislatures need to know that I have been touting for awhile.
I have a question and a solution. My question is why BMC is having financial difficulties. My hypothesis is that if 97% of people are insured, then hospitals like BMC which used to see approx 30% insured would have a dramatic increase in insured patients and thus would be getting paid more, not less. The more utilization by more patients with insurance, the more money they should make. So why are they losing money? What am I missing?
Solution to getting a long-term increase and short term increase in PMDs:
Long term: This means we need more money for physical infrastructure in medical schools to accommodate such a large increase in students. Also, more money for residency spots (it takes approximately $100,000/year to train a physician). Finally, I highly support government subsidization of medical school tuition to minimize student debt as students with large amounts of debt tend to pick higher paying specialties (in other words, NOT primary care).
Short term: I have a few suggestions:
1) Increase physician productivity by elimination of non-patient duties:
a) Documentation (have government subsidies for scribes)
b) Pre-approvals (Patients in the health markets or Medicare will not need pre-approvals – this costs tons of money in physician productivity and unnecessary administrative costs)
2) Improved physician reimbursement for primary care (It will lure back current primary care physicians that have shifted away to become medi-spas/hospitalist/concierge medicine etc…Also it will encourage more medical students to go into primary care)
3) Encourage US-Trained foreign residents to stay in the US.
4) Create a pathway for foreign-trained primary care residents who speak good English (particularly Australia/U.K/Canadian trained) to do a one year primary care apprenticeship under a board-certified IM or FP MD, followed by an exam to allow them to obtain a license to practice.
One other thing that seems odd: people are irrational about caring for their health. Primary physician visits are not that expensive in the context of overall medical costs. In a rational population, people would get catastrophic cost (high deductible) insurance for the big uncommon expenses and pay the smaller stuff themselves. And they would actually go to their primary physicians for minor stuff (paying their own way) before it becomes serious and expensive (and thus extending insurance to more of the population would not change primary care use much in a rational population). But the real world is that people would delay medical care until it is serious and expensive because they don’t want to pay the small (compared to what medical care could cost) fee for a primary physician visit. So insurance schemes cover the minor stuff to encourage use of that, even though that is economically inefficient from an insurance standpoint. And then extending insurance to more people increases use of primary care.
Kudos, well said! And if medical school was less costly and was subsidized as well I am sure many more terrific candidates would emerge and offer their hearts and minds to the medical profession.
Ah, geez Kevin .. stop making sense .. you’re just wasting your time .. and Mr. Obama (Harvard Law ‘91) would n’t understand, anyway.
You are just making his job of ruining a great country, even harder.
/SARCASM — OF COURSE/
The next available appointment in my town for a new patient at the federally subsidized sliding scale clinic (or Medicaid, it pays essentially the same) in my city is……..
October.
You get what you pay for.
As pointed out by Happy Hospitalist, there are already federally backed Medicaid clinics that provide primary care, and they are a massive failure–largely because the same conservative politicians you were hob-knobbing with today keep funding to this clinics anemic at best.
You want to improve access to primary care without guaranteeing universal health care? How exactly are you going to do that when a standard primary care visit costs between $75 and $125 for an uninsured person who is making $10 an hour?
And what exactly happens when somebody who visits those clinics–which are designed to treat routine problems–develops a serious illness like cancer, Crohn’s Disease, HIV, Lupus, MS, or other diseases with high management costs. How do you propose the person who is making $10 an hour pay for their expensive medications, or are you arguing that the guarantee of humane treatment implicit in the medical profession should only be extended to wealthy people who can afford insurance?
How do your propose to fix the problem that the chronically ill cannot find insurance in the current system? What do you think should happen to them? And how would you address the problem the current system has–which is patients with chronic illnesses can’t afford proper treatment because insurers drop them at every opportunity and make it so they can’t afford proper treatment; then patients end up in ERs and hospitals at a huge financial drain to the system?
Not that you’ll answer my question. You never did answer my question–which I posted on Duncan’s blog. It was did the drug/insurance company outfit paid for your appearance at the National Press Club, or compensated you for your travel? It’s more relevant than ever now that you used the platform to spout this nonsense.
And PS–The current wait for seeing a primary care doctor without insurance? For some, eternity, and for others until you can pay the $250 new patient fee. For people working paycheck to paycheck, that can be 7 or 8 months!
I’ve been a family doc for 20 years.Obama is fumbling in the dark on health care, so your diagnosis is right on, but your prescription is vague. Value primary care? OK, I’ll buy that. ” Incentivizing practicing pt-focused primary care”. That’s gobbledygook. Please stop writing like that. Taking time to counsel pts?Often that is not the best use of our limited time–RNs can counsel.
The primary care collapse in already baked in the cake most of (America just doesn’t know it yet) and things will get worse before they get better. America will lose it’s primary care infrastructure over the next decade and then, slowly and painfully, will probably see reason and then build a new one. Strap yourselves in for a rough 10-20 years.
The National Health Service Corps is being pushed again as a way to beef up Primary Care. But as a former NHSC scholar and present day rural PCP, I urge caution and careful review before dumping money into this poorly run program.
The first issue is how NHSC entices providers into primary care during the early years of med school by offering payback of medical school with scholarships which incur years of obligation after training . While this sounds like a good way to get docs into primary care, it is not nearly effective in retaining physicians in underserved locations as using Loan Repayment. A study by Pathman et.al. in June 2004 Medical Care gives data showing this. Having worked in rural health care for nearly two decades, I can also personally attest that working with physicians who are forced to work in an underserved location is much more difficult than having willing PCP’s coming out with the guarantee of Loan Repayment.
The next issue is that NHSC scholarship obligations only perpetuated many of the problems with serving in a health shortage area. Many of the rural areas are poorly managed, dysfunctional and poor. Forcing doctors to work there for 2-3 years only allows badly run health clinics to continue treating providers poorly and underpaying them. This was especially true in the Indian Health Service. Only with the drying up of the steady stream of NHSC scholars did IHS partially improve their their treatment of physicians and improve retention. Again, if we force docs to rural, underserved areas, we will never address the underlying problems causing rapid provider turnover.
Finally is the problem of how NHSC is run. Right now the red tape to get Loan Repayment is ridiculous. If you were finished your FP residency last month and wanted loan repayment in an underseved town in rural america on the HRSA list, you probably would not get loan repayment for a year. No one can promise you anything except paperwork and waiting. The program scares off many applicants with threats of indentured servitude and huge penalties.
Although I am against the NHSC scholarship program, I am in principle, a fan of Loan Repayment – if run better than it presently is. But in the end those who would force docs to work in underserved areas for stints will prevail over those who would improve the pay, conditions, and health administration to better attract and retain long term providers.
I agree with the sentiment, but I think you have your sequencing backwards.
We can do universal insurance coverage today. It will not be easy, but it is possible, whereas previous attempts have failed over the last 60 years.
Fixing primary care is something we can start today, but even the best efforts won’t show dividends for several years at the very best. That’s optimistically assuming that primary care reforms would even work.
By you thinking, we should allow the 50 million uninsured to languish without any access to health care for another decade until we see if primary care improves?
Both universal coverage and primary care reforms are necessary, but it is not an either-or proposition. Both must proceed on parallel tracks.
The top 15 socialized European countries spend about $2,800 per capita to cover everyone in their country.
Our current government spends 1 trillion dollars to cover 100 million Americans. That’s $10,000 per capita.
For our government to come in line with the next 15 expensive socialized health care systems of Europe would require us to spend only 840 billion dollars a year to cover all 300 million Americans.
That means our country would have to cut $160 billion dollars a year in government spending AND provide access to an additional 200 million Americans at the same time.
Now I ask you, how do we do that? How do we become like all the other Utopias?
There is only one way we can afford to. By inducing the largest health care recession this world has ever seen.
If you want America to be like every other country, be prepared for the consequences of cutting one trillion dollars a year from our GDP.
Nobody in America is ready for this. Instead, we simply spend more and more and more…
Happy Hospitalist,
Man, you are right on target. It is about the money. And right now all that health care wasteful spending is keeping more jobs than any other economic stimulus package our government has ever had. There is no way our economy could tolerate an efficient health care system.
Happy Hospitalist, it won’t be a health care induced recession. GDP doesn’t decline when you cut health are spending–it increases. If you free up money which currently goes to exorbitant premiums and for medical procedures which wouldn’t be needed if care could be given before things spin out of control, you put money in people’s pockets.
It’s demand side economics. You can have all the supplies in the world, but if no one can afford to buy it, then what good is it? If you reduce high out of pocket costs, you free up cash and that can be put towards buying things like cars, and the other stuff which drives our economy.
We do need to reduce end of life care. That will curtail growth in the nursing home industry. But frankly, the nursing home industry will collapse of its own weight if nothing is done. Because there will be an increase in the elderly population, it’s unlikely that there will be mass layoffs in the nursing home industry.
Sorry Kevin, but no one in the current Washington regime is going to listen to a single eloquent word you say.
And what makes you think these phonys are interested to authentic availability of care, any way? RESTRICTING access to care is critical as a back door cowardly cost control tool.
And what better way to restrict access than to make it impossible to see a PCP.
“The top 15 socialized European countries spend about $2,800 per capita to cover everyone in their country.
“Our current government spends 1 trillion dollars to cover 100 million Americans. That’s $10,000 per capita.
—
Why? You (and Obama) should read (and understand) these books –
http://www.hbs.edu/rhc/
http://search.barnesandnoble.com/Who-Killed-HealthCare/Regina-E-Herzlinger/e/9780071487801
Why is the USA so FUBAR on health care?
1. PARASITE MED-MAL LAWYERS and defensive medicine
2. Insurance companies and providers arguing who owes what — BIGGEST ELEMENT
3. high costs that often accompany large numbers of very small, dispersed providers
4. very high level of bureaucracy and organizational conflict
5. few, if any, patient options on provider choice
6. uneven quality, including national programs such as Veterans Administration; and uneven distribution, as was the case of over-serviced urban U.S. cities versus under-serviced rural U.S. areas.
THAT IS WHY.
Kevin I think your positions would be more useful if you would more clearly define your goals. You are advocating for “improvement” yet you never define exactly what you are asking for. How many primary care physicians should there be? What constitutes adequate access to them? Without information like that you sound like you’re just giving a campaign speech which carefully avoids actually committing you to a position.
Thanks, Kevin. Our medical students understand the need for primary care docs when they start school and half end up matching in primary specialties (IM, Peds, OB/Gyn, FP). Sub-specialization is a siren’s call for a lot of reasons. Creating incentives for students and residents to pursue and then remain in primary care is critical for any reform plan to be successful.
Kevin great perspective. I feel strongly we need to address the inefficiencies in primary care so these dollars can be used to reduce cost for physician groups and patients. The average personnel ratio is 4 staff to 1 physician. The one question I can’t seem to get answered is:
Why do we have Insurance claims at the primary care level? If approximately 95% of claims are approved at a 30% cost to process please explain economics. Seems like these claim costs do not benefit physicians or patients or for that matter insurance companies.
What am I missing?
The really sad thing about Obama “fumbling around in the dark” is that he doesn’t have to.
Instead of pandering to all of the lowest common denominators, he could start chatting up doctors & nurses in primary care – doctors who, over the last 10-15 years (about the time the businessmen really took over medicine), have been marginalized, devalued, and largely ignored by all of the people he’s working with now (lawyers, politicians, special-interest groups, and pitiful “advocacy” organizations like the AMA) to “reform” care – which really translates into buying votes.
Listening to the President of the United States pander and fear-monger this week, I wanted to channel me some disgruntled liberal Hollywood celebrities, thow up my hands and move to Canada.
Of course, if Obama has his way, I can stay here a few more years and pretty much be there.
Good speech, and thanks for representing. A fortified system of primary care is essential as you’ve mentioned. Comprehensive reforms (including a retooling of the medical malpractice system so that doctors who practice evidence-based, lower cost, less defensive medicine) would go a long way towards restoring rational decision making. Health care courts still seem like a fair alternative:
http://commongood.org/healthcare.html
Barbara Starfield, MD, has written some excellent pieces on the importance of primary care. Your additions are much appreciated. Her citing of evidence showing primary care outcomes might add even more power to your arguments:
http://bostonreview.net/BR30.6/starfield.html
Keep up the good fight.
I’m sure you mean well Kevin, but to simply state that the primary care system needs to be revamped doesn’t help root out the solution.
You (very appropriately) touch upon the the miserable failings of Native American and VA systems. These are SINGLE-PAYER and perfect examples as to why we should run like hell from single payer options. Couple this with Medicares bankruptcy, Medicares propensity for screwing doctors and cutting payments, the governments proven track record of poor management, and the governments unwillingness to afford tort reform (they are lawyers after all), and I could tell you that only the most ignorant of physicians (or socialist) would want a single payer option.
The AMA (traitors that they are) support HR3200. On page 15-16 of the bill it is laid out how the government plans to lead EVERYONE into a single payer system. This bill will destroy this country as the 80+ insureds who like their insurance will be FORCED into government “APPROVED” plans within 5 yrs.
Tort reform must be at the center of any meaningful reform.
Tax credits would help legal individuals and families purchase policies, as well as removing barriers to purchasing out of state policies.
Mandatory insurance is not reasonable. Some 18 million of the 47 million number bandied about CAN afford insurance, but they CHOOSE not to. For these people, insurers could craft low price “emergency” policies and such. Otherwise, when they are put into collection/bankruptcy, these people deserve it for not taking the proper precautions. Many of my patients have had the means to purchase some of these policies but CHOSE not too. I cared for the MRSA infection that ate off half of one persons thigh, but regarding her financial situation, I had little compassion as she CHOSE to go rock climbing, instead of buying a plan.
Personal responsibility has left the room. Nanny state is here. The single payers shills around here (can’t quite figure out if you are one of them) are gonna get screwed by our government.
No doubt we need more doctors. The best way to get more PCP would be to pay more money, this is obvious. Additionally, many med students I have spoken with fear medicine because of the governments role in regulating it, where it is heading (single payer-rationed health care) and malpractice.
Make medicine a profession in which you don’t have to watch your back (tort reform)
A noble profession where the doctor makes the choices and not some advisory board from the government culture of death. (Eliminate the possibility of single payer)
You WILL get more PCPs.
I agree with you Kevin and Chicagotrauma. When did personal responsibility become such a horrible thing? It should be the basis of our society. The Bag of Health and Politics does not believe in personal responsibility and neither do Dems as a whole. They believe that government, everyone else in other words, should support those who don’t take of themselves.
Why should I pay more taxes because some people prefer to spend money on luxuries instead of health care. I am constantly amazed at how many Medicaid patients have nicer cell phones than mine, and drive nicer cars. Many also find themselves with enough money to buy lottery tickets and go to the casinos.
I have also been asked to discount my services by people who have the means to pay full price, but have no desire to sacrifice luxuries. even some who have ski boats, camping trailers, and can afford to go out to eat most nights of the week.
Why should I provide healthcare to individuals at break even or a loss when they value a cell phone, or even sometimes a fast food meal to be of greater worth than the services I provide.
There are some people who are not currently insured and who truly can’t afford it, but I would say that it is less than 1/2 of the uninsured in this country. More than 1/2 could afford health insurance if they wanted to, without sacrificing necessities. The problem is getting individuals to not live beyond their means and to understand health insurance is their responsibility first and foremost.
Like Chicagotrauma, I feel no sorrow for those who decided to not buy health insurance when they could have afforded it, but now find themselves burdened by medical bills. Again, they need to take responsibility for their actions. I do feel sorry for those who thought they had insurance to cover any major illness or condition that might occur, only to find they were misled by the insurance company.
It comes down to this plain and simple fact: Health care is not a right. Look at the Constitution. The only way it can become a right is to enslave physicians and forcing them to provide care to whomever the government tells them to. This will also require people being forced to attend medical school against their will as well.
This is the real reality of healthcare! You have stated it so well. Primary care access is being rationed, and will need a miraculous overhaul to provide health care to all. Thank you for sharing your personal accounts from the front line. Hope to hear more.
The silence on HSAs is deafening.
Individual American patients would go for a ‘Medicalocity.com’ type website to price-compare medical services, right?
Why not open up cash-only med centers on Indian reservations? Or on offshore decommissioned aircraft carriers? Different civil jurisdictions,NO medmal threats—share the savings with patients.
Why not train retired women, who are looking for meaningful ways to contribute time, to be nursing-educators of their fellow aging population?
Why not write special legislation granting civil immunity for volunteer or charity-pay medical workers?
What about letting patients create home-hospitals if they can, and save lots of money?
We are Americans! Come on!
“neither do Dems as a whole. ”
Do you see Republicans fighting this? No, they’re just trying to nibble around the edges. Their constituency, corporate America, wants free of its healthcare obligations.
“Tort reform must be at the center of any meaningful reform.”
It’s this kind of foolishness that has led you astray. Tort reform is a miniscule issue compared to the way physicians have allowed the government and insurers get between them and their patients financially. According to CMS, malpractice premiums account for an average of 5% of a physician’s overhead, and 2% of the total cost of healthcare. And it’s not like “reform” will totally eliminate those costs. Same with defensive medicine, where despite 30 years worth of “reform”, health care is not appreciably cheaper in those states that have it.
The AMA is doing what is best for the AMA. They see which way the winds are blowing, and like all organizations are going to preserve their positions. They fear being left behind by taking a strong position toward a free market solution. Instead, they’re nibbling at the edges of the same system and calling it “meaningful”, and then mentioning that they’re after those sneaky lawyers just to keep your blood boiling.
The fact is that as long as you rely on the government to pay your salaries, you will never be in control of your own destinies. And as more and more of the cost of healthcare gets paid by the government, your bargaining position only weakens. It will not get stronger as long as that is your primary payor.
Oh well, maybe you guys can join the federal employees’ union.
I read with interest (who doesn’t?) the summaries of how the new reform plan will impose on those without insurance. Apparently, the new law will “require” one to have insurance. I only wonder, “or what?” Supposedly there will be “penalties” if you are required to purchase insurance but do not.
Since when has this ever forced people inclined to be scofflaws into compliant behavior? People are “required” to have a valid drivers license and insurance to drive their cars, but unless you get stopped and arrested, what is really keeping you from driving without those things? If you believe you will be treated anyway if you go to the ED, insured or not (thanks, EMTALA), do you really think being required to purchase insurance is going to make you behave one bit differently? I doubt it. If this law is going to have any teeth, it is going to have to repeal EMTALA completely. Because then, why would you need EMTALA? Everyone will have insurance; they will be required to.
If only medical school was heavily subsized and family physicians/general physicians were paid more.
Even something where the government pays a doctor’s way through school and the government gives them a clinic/practice to operate. They would be paid a general salary and would have to see x amount of patients and have to spend at least x amount of time with each other their patients.
It feels like such a rip off when I see my general doctor. 10 minutes and I can’t even tell them everything that’s wrong so I have to call and make yet another appointment.
I know they’re swamped with paperwork and have other patients to see. I sympathize, I really do.
If only the private sector could step in and try to pay off some student loans’ of doctors willing to be physicians for their employees or whatever.
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