By ED PULLEN, MD

Starting in 2011 with the regulations required by the PPACA Medicare will mandate copay and deductible free preventative services for our older Americans.  This is great news for primary care physicians.  I’m a family physician, and have struggled for years with the fact that just about every private insurance plan covers an annual physical exam, but Medicare did not.  What this anti-intuitive dichotomy accomplished was bringing in my relatively healthy 30-something patients for a physical exam each year, while for my 70 year old for whom far more preventative services were recommended by the United States Preventative Services Task Force was not covered for a preventative exam ever.  Not annually, not every 3 years, just once at age 65 to last their lifetime.

As primary care physicians we tried to our best to squeeze preventative care into visits primarily for other complaints.  At a visit of my diabetes patients every 3 months I’d try to focus on the diabetes and save enough time to review immunization status, assure breast and colon cancer screening was up to date, help med decide if they wanted prostate cancer screening, ….   I’m looking forward to being able to ask my seniors to schedule a preventative care visit annually now and being able to focus on these issues without having to eke out time in a problem oriented visit.

Still I have to say if the goal is to provide incentive to older Americans to go to their physicians for services that will really make a difference in the health of the Medicare population problems I think congress has it wrong.  If we want to prevent unnecessary hospitalizations and expensive complications from neglected medical problems, and have the biggest impact to reduce the burden of expensive medical complications and I believe the most efficacious preventative services we can offer in health care are secondary prevention and disease management.  I’d love to think that by primary prevention, education, and physical exams I can help patients improve their health and subsequently reduce costs and get better outcomes.  The problem is that there is little evidence that this is the case. This new regulation, offering a free once annual preventative care visit may find some early cancers, improve immunization rates and make us feel like we are being proactive.

Finding a way to give incentive to our poorly controlled diabetics to control their blood sugars, blood pressure, and LDL cholesterol would save a lot more lives and prevent a lot more hospitalizations.  Getting our post MI patients in for LDL management, BP control, and smoking cessation help would have a much bigger impact.

Maybe Medicare should offer reduced copay or deductible on quarterly visits for everyone with a diagnosis of diabetes.  Maybe add a benefit for no copay for diabetics who take an ACE or an ARB, have a HemoglobinA1C under 8% and have an LDL under 130.  How about no copay or deductible for select services or on medications for certain diagnoses?  Maybe diabetic eye exams annually, free generic BP medications from a list of drugs with JNC recommended options, and free generic statins for patients who meet risk profile cutoffs.  I’m not a population modeling actuary with sophisticated algorithms to help know just which of this type of interventions would be most effective.  I can’t help but believe that this type of objective modeling could provide a data based framework on which to set up a plan to improve health at the best possible cost.

With the health information systems we have today, we need to start putting the financial incentives to receive highest priority services where they belong, with patients.  There are new physician directed incentives in the upcoming government plans.  In 2011 physicians will be given financial incentive to make meaningful use of digital health records.  This is fine.  Why not give patients incentive to get care that can improve health reduce morbidity.  Physicians are bright enough to figure out how to work with their patients to make this type of program mutually beneficial.  Reduced copays and lowered deductibles would allow physicians more predictable and quicker pay that they now get for these services.  Patients would be more likely to respond to physician recalls if they knew their costs for the care was reduced.

It is unlikely to be politically correct to punish patients for poor choices.  Higher copays and deductibles for smokers is not going to happen.  Insurance surcharges for obesity, alcoholism, or dangerous hobbies seems unthinkable.  So let’s think about taking a positive frame of mind.  Let’s set up studies to see if financial incentive to get targeted disease management and secondary prevention works to save lives, money or both.

Ed Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news and policy from a primary care physician’s perspective at his blog, DrPullen.com.