(This is the sixth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
As hospital systems become larger and employ more physicians, healthcare prices will continue to rise and independent doctors will find it harder to remain independent. Hospitals will never fully embrace value-based care as long as it threatens their primary business model, which is to fill beds and generate outpatient revenues. To create a viable, sustainable healthcare system, the market power of hospitals must be eliminated.
Federal antitrust policy is not adequate to handle this task. Even if the Federal Trade Commission had more latitude to deal with mergers among not-for-profit entities, the industry is already so consolidated that the FTC would have to break up health systems involving thousands of hospitals. Such a gargantuan effort would be practically and legally unfeasible.
The government could curtail health systems’ market power without breaking them up. For example, either states or the federal government could adopt “all-payer” models similar to those in Maryland and West Virginia. Under the Maryland model introduced 40 years ago, every insurer, including Medicare, Medicaid, and private health plans, pays uniform hospital rates negotiated between the state and the hospitals.
(This is the fifth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Real healthcare reform depends on an effective plan to reduce cost growth. To achieve this goal, it makes a whole lot more sense to cut waste than to limit access to necessary services or slash provider payments to the bone, noted Donald Berwick, MD, a former acting CMS administrator, and Andrew D. Hackbarth, a RAND Corp. researcher, in a 2012 JAMA article. In their telling, a significant reduction in waste would allow us to bend the cost curve without hurting healthcare quality or access.
Berwick shared with me that he doesn’t know how much unnecessary care physicians or hospitals could safely eliminate. “Some of it is marbled into the daily activities of healthcare organizations,” he said. “There would have to be systemic changes to get it done. But it’s a matter of will. With enough will, a lot of it could be eliminated. And when you’re talking about $1 trillion [worth of waste], even if you get 10% of it, that’s a tremendous amount that could be applied to other activities.”
Risk-based contracts, whether shared savings or capitation, can incentivize physicians to reduce waste. From the viewpoint of long-suffering primary care physicians, value-based-care agreements that let them share in the savings they generate are a godsend. Of course, not all primary care doctors are willing to take financial risk or change their practice patterns. But if maintaining their current income depends on it, most physicians will embrace change.
Specialists, too, can benefit by embracing the new paradigm. If they’re mainly being paid fee for service, they’ll have to forgo a lot of lucrative tests and procedures. But they can still keep their incomes up by delivering more-appropriate procedures and tests to a larger patient population.
(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.
The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.
Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.
One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.
(This is the third in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
The American Medical Association (AMA) last year announced that, for the first time, more physicians were employed than were independent. While many of these doctors were employed by private practices, the AMA said, about 35% of them worked directly for a hospital or for a hospital-owned practice.25
This estimate was lower than that of other surveys. According to research conducted by the Physicians Advocacy Institute (PAI) and Avalere Health, a consulting firm, 44% of physicians were employed by hospitals in January 2018, compared to 25% in July 2012. More than half of U.S. physicians now work for or contract with fewer than 700 healthcare systems across the country, according to a new study in Health Affairs.
Many of the physicians employed by hospitals and health systems formerly were in private practice. They sold their practices to hospitals because of increasing overhead, dwindling reimbursement, and the rising administrative burdens of ownership, according to Jackson Healthcare, a physician recruiting firm.
The many negative factors affecting primary care also have impelled a growing number of primary care physicians to seek employment in recent years. In 2018, 47% of general internists, 57% of family physicians and 56% of pediatricians were employed. There is evidence that this trend may be exacerbating the primary care shortage because employed doctors see fewer patients per day, on average, than do those in private practice.
(This is the second in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
In January 2015, then Health and Human Services Secretary Sylvia Burwell announced lofty goals for the government’s value-based payment program. By the end of 2016, she said, 85% of all payments in the traditional Medicare program would be tied to quality or value, and 90% would be value-based by the end of 2018.
The government planned to tie 30% of Medicare payments to alternative payment models by 2017, according to Burwell, and hoped to reach the 50% mark by 2018. In March 2016, HHS said it had reached the 30% goal a year ahead of schedule, mainly because of the Medicare Shared Savings Program (MSSP).
More recent data on the value-based-care movement comes from the Health Care Payment & Learning Action Network (LAN), a public-private partnership launched in 2015 by the Department of Health and Human Services. The LAN reported in October 2018 that public and private payers covering 226 million lives, or 77% of insured Americans, had tied 34% of their payments to value-based care. According to the organization, only 23% of total payments had been value-based in 2016.A deeper analysis of the LAN data, however, shows that the vast majority of value-based payments—both in Medicare and in the larger healthcare system—were still limited to pay for performance, upside-only shared savings, and care management fees paid to patient-centered medical homes.
(This is the first in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Even before COVID-19, healthcare reform seemed to be stuck between a rock and a hard place, but there is a rational way forward. This approach, which I call “physician-led healthcare reform,” would engage doctors in building a healthcare system that was safe, effective, patient-centered, timely, efficient, and equitable, to use the Institute of Medicine’s set of foundational goals in its landmark book, Crossing the Quality Chasm: a New Health System for the 21st Century.Primary care physicians, rather than hospitals, would be in charge of the system, and they’d work closely with specialists and other healthcare professionals to produce the best patient outcomes at the lowest cost.
It would take a decade or more to restructure the healthcare system so that this goal could be achieved. Similarly, the transition to a single-payer insurance system needs to be accomplished gradually—although the pandemic might accelerate that timetable. Most people are not yet ready to abandon employer-sponsored insurance, and there’s still a lot of distrust of the government. Providers are more likely to accept changes in how they’re paid over time than all of a sudden. Additional benefits can also be brought online slowly. Ideally, we could transform healthcare financing over a 10-year period while rebuilding the care delivery system at the same time.
That is why implementing Medicare for America—a reform plan devised by the Center for American Progress and embodied in a current House bill–makes more sense than going directly to Medicare for All: it changes the system incrementally while achieving universal coverage fairly quickly. Medicare for America would do this by enrolling the uninsured, people who purchase individual insurance, and those now in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). People would also be enrolled automatically at birth. Companies could enroll their employees in Medicare for America, and employees could opt out of employer-sponsored plans and enroll in the public plan.
In the strangest healthcare business story of 2020, the major health insurance companies are thriving despite—or because of—the pandemic. As the second quarter reports of United, Anthem, Cigna and other insurers reveal, their COVID-19-related costs were outweighed by the sharp drop in claims for other healthcare services.
As a result, the second quarter operating gain for Anthem, one of the largest national carriers, jumped 65% from the prior-year period, while the portion of its premiums spent on member benefits dropped to 78%. The earnings of UnitedHealth, similarly, vaulted 98% as the percentage of its premiums spent on health care fell to 70.3%. Such a low “medical loss ratio” has probably not been seen since the 1990s.
At the same time, the big insurers’ membership has been rising, but not among workers covered by employer-sponsored plans. Commercial insurance members served by United, for example, fell by 270,000 to 26.8 million, following a drop of 720,000 in Q1. In contrast, the number of people in United’s Medicaid managed care plans rose by 330,000.
These trends track with the short-time fallout of the pandemic. Families USA reported that 5.4 million workers who lost their jobs from February to May also lost their health insurance. Another study predicted that by the end of 2020, 10.1 million people will lose employer-based insurance tied to someone in their household.
As COVID-19 cases soar across the country, the federal government has lost control of the situation. Amid the Trump Administration’s happy talk and outright dismissal of the crisis, the U.S. is experiencing a forest fire of contagion and hospitalizations, and an upsurge in COVID-related deaths has already begun.
Other countries like Taiwan, South Korea, Germany, Australia and New Zealand have controlled their outbreaks, which is why their COVID-19 infections and deaths have been minimal or trending downward in recent months. To replicate those nations’ strategies of testing, contact tracing and quarantining, the U.S. Congress would have to appropriate about $43.5 billion, according to one estimate. But as we know, Senate Republicans won’t pass such a bill without Donald Trump’s prior approval—and that’s unlikely as long as his main focus is on reopening the economy.
We can hope that electoral victory by the Democrats in November will change this equation, but Joe Biden won’t take office until January if he wins. Meanwhile, the coronavirus is chewing up America. We can’t afford to wait six months to blunt the impact of this horrible disease. However, there is a solution that doesn’t depend on federal leadership: states can form compacts that would form the basis for collective action to get us out of the trap we’re in.
Interstate compacts are very common in the U.S. Various pacts cover everything from clean water and clean air to medical licensure, mental health and interstate transportation. For example, under the Middle-Atlantic Forest Fire Protection Compact, which includes Ohio, West Virginia, Virginia, Pennsylvania, New Jersey, Delaware, and Maryland, member states assist one another in fire prevention and suppression and firefighter training.
Telehealth has been a lifeline for many doctors and patients during the pandemic, and the decisions of CMS and many private payers to cover telehealth visits—in some cases, at full parity with in-person visits–has helped physician practices stave off bankruptcy. Assuming that these policies remain in effect after the pandemic, I agree with the commentators who assert that telemedicine will become a much larger part of healthcare.
Nevertheless, what that means is still far from clear. To begin with, telehealth visits may be adequate for some purposes but not for others. Historically, the technology has been used mostly for diagnosing and treating minor acute problems. Physicians were generally reluctant to take on more complex cases or treat chronic conditions without seeing patients in person.
Pre-pandemic, most telehealth encounters took place between patients and doctors who had never treated them before, using services such as Teladoc, American Well and Doctor on Demand that usually didn’t communicate with the patients’ personal doctors. Some larger physician groups had begun to use the technology with their own patients; but even in those groups, certain doctors were often assigned to conduct virtual visits with patients who were not necessarily their own.
Clearly, the latter barrier has been broken down, with nearly half of U.S. physicians in an April survey saying they were using telemedicine in patient care. While it’s unclear what kinds of cases these doctors are diagnosing and treating, it’s likely that the scope of practice for telehealth has been expanded to include some chronic disease care.
The main barrier to this expansion is that, in telehealth encounters, physicians don’t necessarily have the data they need to make sound medical decisions. To manage hypertension, for instance, the physician needs to be able to measure a patient’s blood pressure. If the patient has a digital blood pressure cuff at home, that data can be transmitted to a physician’s office; in fact, a smartphone app could show the trend of the patient’s hypertension over time. Right now, however, only a small fraction of patients have this kind of remote monitoring equipment.
The Smithsonian National Museum of Natural History has reported its biggest number of visitors in more than 2 ½ years. There’s a string of new Broadway musicals that are well-attended every night. It’s safe to shop in malls, eat out in restaurants and go to movie theaters again.
Of course, this has all been made possible by an effective vaccine against COVID-19 that was widely administered in the fall of 2021. Vaccinated citizens of the world are now confident that it’s safe to go out in public, albeit with appropriate precautions.
However, U.S. residents who have health problems are facing a new challenge. Five years ago, in 2017, the median wait time of new patients for doctor appointments was six days. In 2022, the wait time is six months or more.
The reason for this is no mystery. While life has started to return to what we think of as the new normal, the U.S. healthcare system has taken an enormous financial hit, and primary care practices have been especially affected. Many primary care physicians have closed their practices and have retired or gone on to other careers. Consequently, the shortage of primary care has been exacerbated, and access to doctors has plummeted. Urgent care centers, retail clinics and telehealth have not filled this gap.
Because of the long waiting times for primary care appointments, many more people now seek care in emergency departments (EDs). The waiting rooms of these EDs are overcrowded with people who have all types of complaints, including chronic and routine problems as well as emergencies. And this is not just a common sight in inner-city areas, as it once was; it’s now the same pretty much everywhere.