Last Wednesday, President Obama called the much-publicized problems in the Veterans Affairs health system “disgraceful” as delays in care in at least 26 facilities grabbed media attention. In testimony before Senate and House Congressional committees, VA officials disclosed systemic misrepresentations about the timeliness of treatments in VA primary care clinics: rather than getting care within 14 days of request, many veterans appear to have waited 6-12 months to see a doctor, and some are alleged to have died while waiting.
In referencing a special report due this week that assesses the scope of the problem in the Department of Veterans Affairs, the President’s commitment to fix the problem was unequivocal: “I want to see what the results of these reports are and there is going to be accountability.”
As I have watched the VA storyline play out over the course of the past few weeks, I found myself asking questions the reporters weren’t:
Why do we need to operate a separate system of 820 clinics and 151 hospitals for Veterans?
Might the system of care for the 21 million it currently serves not be better coordinated through the U.S. health care system of 5200 public and private hospitals, 820,000 physicians, 1200 federally qualified health centers, 2000 community mental health clinics, 56,000 pharmacies and 1700 retail clinics? In most communities, there’s a surplus of beds.
In most communities, those with insurance can get doctors’ appointments and receive treatment. Veterans who lack private coverage, like those who are uninsured, have fewer choices. It is not a capacity issue: it is an economic issue.
And common sense suggests we might redeploy some the VA health administration’s $60.3B budget for better coordination with the private systems that already operate in our communities while reducing duplication of services and their associated costs.
Why don’t we get serious and fix the problem of access to primary care shortage once and for all? It’s not just a veterans’ problem. Those who live in poorer neighborhoods lack access.
In my last post on California and Texas’s imminent expansion of their scope of practice regulations, I didn’t cover one important question: what do patients actually want?
Fortunately, a study just released in Health Affairs looked into it, and the results are clear: many patients want to be seen by nurse practitioners (NPs) and physician’s assistants (PAs) – especially if it allows them to be seen sooner.
To be clear: generally, Americans still prefer being seen by a physician. But preferring a NP/PA – or “not having a preference” between a NP/PA and a physician – is a big deal; it insinuates that, for certain ailments, the public views a NP/PA as just as effective a clinician. That has significant repercussions for how care is delivered, particularly for young people and underserved populations.
The researchers conducted a survey that focused on three different scenarios to judge patient preferences: a straight-up comparison of preference for physicians vs. NPs/PAs; a scenario where a patient could see a NP/PA today vs. a physician tomorrow for a minor ailment; and a scenario where a patient could see a NP/PA today vs. a physician in three days for a minor ailment. Continue reading…
A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
In November 2008, the New England Journal of Medicine convened a small roundtable to discuss “Redesigning Primary Care.”
U.S. primary care is in crisis, the roundtable’s description reads. As a result … [the] ranks are thinning, with practicing physicians burning out and trainees shunning primary care fields.
Nearly five years out — and dozens of reforms and pilots later — the primary care system’s condition may still be acute. But policymakers, health care leaders and other innovators are more determined than ever: After decades where primary care’s problems were largely ignored, they’re not letting this crisis go to waste.
Ongoing Shortage Forcing Decisions
The NEJM roundtable summarized the primary care problem thusly: Too few primary care doctors are trying to care for too many patients, who have a rising number of chronic conditions, and receive relatively little compensation for their efforts.
On January 7, a federal appeals court rejected six Georgia primary care physicians’ (PCPs) challenge to the Centers for Medicare and Medicaid Services’ (CMS) 20-year, sole-source relationship with the secretive, specialist-dominated federal advisory committee that determines the relative value of medical services. The American Medical Association’s (AMA) Relative Value Scale Update Committee (RUC) is, in the court’s view, not subject to the public interest rules that govern other federal advisory groups. Like the district court ruling before it, the decision dismissed the plaintiffs’ claims out of hand and on procedural grounds, with almost no discussion of content or merit.
Thus ends the latest attempt to dislodge what is perhaps the most blatantly corrosive mechanism of US health care finance, a star-chamber of powerful interests that, complicit with federal regulators, spins Medicare reimbursement to the industry’s advantage and facilitates payment levels that are followed by much of health care’s commercial sector. Most important, this new legal opinion affirms that the health industry’s grip on US health care policy and practice is all but unshakable and unaccountable, and it appears to have co-opted the reach of law.
The RUC exerts its influence by rolling up the collective interests of the nation’s most powerful medical specialty societies and, indirectly, the drug and device firms that support and benefit from their activity. The RUC uses questionable “methodologies,” closed to public scrutiny, to value medical services. CMS has historically accepted nearly 90 percent of the RUC’s recommendations without further due diligence. In a damning October 2010 Wall Street Journal expose, former CMS Administrator Tom Scully described the RUC’s processes as “indefensible.”