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Could a larger investment in primary care cure the health care system?

• 19

By Deron SchriverStethoscope

I’m going to go out on a big ol’ limb here by saying that 90 percent of our health care problems could be solved by rebuilding and refocusing our primary care delivery system.

It’s the issue most discussed issue in reform circles (aside from single-payer) and it makes perfect sense. Toyota has succeeded because it goes to great lengths to find the true source of quality issues. They have recognized that addressing root causes significantly limits efforts needed because you avoid treating secondary level problems that occur further down the line.

A highly trained, appropriately paid primary care physician with a focus on prevention, coordination and patient education could solve so many other problems. There are many preventable chronic illnesses out there driving up our costs.

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Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?

• 31

By Brian Klepper & David Kibbe

Mh_counseling

Sometimes a whisper is more powerful than a shout. Here’s a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

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Exploring and conquering new health care frontiers

By Scott Shreeve

The September/October issue of Health Affairs is dedicated to reviewing concepts of the medical home. It is most likely the most current, authoritative, and impressive review of this emerging idea. Health Affairs is an excellent resource for health policy wonks to gather, but in recent years has become more accessible to the general health care audience. I would recommend it as required reading for anyone interested in learning about this trend.

Simultaneously, there have been some recently updated “state of the industry” reports coming out of the retail health clinic world. As noted by Jane Sarasohn-Kahn, the fact that more and more retail clinics are being created has increased access, improved quality through an evidence based approach to a limited set of clinical conditions, but has not done nothing to address the cost issue. In fact, increasing the supply of retail clinics, has simultaneously increased the demand for these services. This is a common phenomenon within healthcare, and the supply driven demand has been well described particularly in the hospital setting.

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Patients lost in the maze

• 8

By Sarah Arnquist

Millions of patients are paying medical bills they don’t actually
owe after being confused about the practices of "balanced billing," according to a recent Business Week report.

The story goes onto discuss how it’s illegal for doctors, hospitals or labs to bill patients for the difference if they deem the insurance payment too low, but that it happens routinely to the tune of $1 billion each year.

Around the time that story first ran, THCB received this email from distraught reader, Paul Evans of Arizona:

I recently went into an emergency room at a local hospital in Scottsdale, Ariz. The doctor asked several questions and diagnosed kidney stones. To confirm this, he ordered a Cat scan and X-rays. While there I was given morphine for the pain. Two hours later, I was discharge with a prescription for pain pills and a strainer to examine my urine for the stone I would pass. I am insured by Aetna. Aetna received a bill for $6,000 and paid $4,000. I am now receiving bills for the remaining $2,000. All this for two hours in the emergency. Do I have to pay these bills? This is balance billing I think. What are my rights?  Help!!

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Hello Health open for business

• 13

By Matthew Holt

Hello Health, the clinic that Jay Parkinson has been promoting for a while, is open for business. If all the patients are as happy as the first patient, success is assured!

The deal is that they’ve gone with mid-range concierge fee ($35 a month—around the cost of a low cost cell phone plan or high-end Netflix?) for patients to get access/membership and then have fixed charges thereafter. That amount is about three times what I pay for very basic low-end concierge services (basically email) at Tom Lee’s Metropolitan Medical Group in San Francisco, but way less than the typical $150–200 a month fee for high-end concierge practices.Hellohealth

What remains to me the tricky factor in their vision is how they’ll make this work with the bureaucracy & accounting behind high deductible plans (without taking on a ton of staff). But however that piece works out, someone needs to shake up primary care. Jay and his 2 colleagues are young entrepreneurial docs giving it a shake.

Health 2.0 had a film crew there with David Kibbe acting as roving reporter at the launch party. Much more on both these topics to come, but remember that Hello Health is also working with MyCa on a very interesting new interface to the EMR and much more.

Yes, you’ll see much more about the Health 2.0 Across America video starring David Kibbe and the MyCa interface at the Health 2.0 Conference.

On Rural Doctoring: The Landscape

• 2

By Theresa Chan

This is the first part of a series that first appeared on the blog Rural Doctoring, where Theresa Chan writes about her experience working as a family physician and hospitalist in a rural Northern California community.

Ruralcare

I’ve been reading the blogs of medical students and residents with some interest lately. Their stories about the trials and tribulations of learning to stay awake night and day and how to deal with cranky attendings and even crankier patients take me back to the bad old days of my own residency.

I’ve also had a few glimpses of the osteopathic medical students (OMS) who are rotating in rural California as they assume their new roles as clinical learners. Hearing about and witnessing these experiences makes me reflect on my own training and the steps I took to become a doctor in a rural community. This post series will examine these steps in more detail, and I hope it will be helpful to trainees who are considering a career in rural health care.

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A Primary Care Paradigm Shift

• 8

By Dr. Richard Reece

Dick Reece is a retired pathologist and a prolific health care commentator with an active following, particularly among physicians. An astute, incisive observer, he is the author of 10 books; the latest is Innovation-Driven Health Care: 34 Key Concepts for Transformation. He is regular columnist on HealthLeaders, and writes his daily posts at MedInnovation Blog. THCB welcomes him. — Brian Klepper

RreeceSomething profound is happening in buyers’ and the public’s attitudes towards primary care and the health system. With inexorable rises in costs and corresponding decreases in access to primary care doctors, buyers and the public are mad as hell, and they’re deciding they’re not going to take it anymore. Something is badly and sadly wrong, and corrective measures are being put in place.

Signs of Paradigm Shift

Signs of a paradigm shift – a change in assumptions about the system’s basic structure – are everywhere. No longer do we accept the notion every patient should have a specialist for every disease, every life-improvement procedure, every orifice, and every organ. Care, it’s now assumed, must be coordinated to prevent people from falling through the cracks. We must stop wasting time and resources for patients and the system as a whole.

The U.S. system lacks timely access to primary doctors who oversee care. And specialty services are overused. Yet the U.S. has fewer primary care physicians per capita than any other country in the developed world. On the other hand, we have more specialists per square mile than other countries.

What’s Driving the Paradigm Shift?

•    Major corporate buyers, led by IBM, which spends $1.7 billion on health care, have created an activist organization, The Patient-Centered Primary Care Collaborative. Paul Grundy, MD, MPH, IBM’s Director of Health Transformation, chairs the Collaborative. It is based partly on IBM’s experience in Denmark, where it owns a company, and where patient satisfaction with care is 97% versus 50% in the U.S. Grundy believes every citizen should have a personal physician, and every physician should be rewarded for offering same day access, managing a patient panel, and be compensated for telephone and email consultations.

•    A vibrant movement is underway to “disintermediate” health plans. “Disintermediation” occurs when access to information or services is given directly to consumers. In the process, “middlemen” in the form of health plans may be ended, or their services transformed. That’s what consumer-driven health care is about, that’s why their existence in their present form is threatened, and that’s why health plans are moving rapidly to high deductible plans linked to health savings accounts.

•    The “medical home” concept is gaining traction. This concept hinges on two ideas: 1) placing the primary care physician at the center of care by having him/her coordinate overall care; 2) giving primary care doctors “ownership” control of specialty care referrals. America wants a health system in which the primary physician uses a secure computer platform to coordinate efforts of specialists, pharmacists, therapists, and others. Increasingly patients don’t appreciate why they must fill out a new form at each doctor’s office, why doctors don’t communicate with each other, and why doctors duplicate tests and don’t know what other doctors do. A number of medical home pilot studies are now being conducted. To make medical homes happen, doctors will need financial incentives and support to introduce technology, and coordinate care. Payers will need to step up the payment plate to help medical homes become real.

•    New business models to reduce cost and offer convenience are fast evolving. These include retail clinics, medical offices at the worksite, specialty clinics, urgent care clinics, elective surgical centers, and ambulatory facilities offering imaging, multiple specialty services, and one-stop care. Most of these are outside expensive hospital settings. Some are currently beyond the control of primary care physicians. At last count, there were over 1000 retail clinics, 500 worksite clinics, and roughly 3,000 urgent care facilities.

•    The physician empowerment movement is growing. The Physicians’ Foundation for Health System Excellence, which represents state and local medical societies, has completed a survey of 300,000 primary care physicians to highlight their problems, to educate the public, and to persuade policy makers to take steps to enhance the supply of primary care doctors, to pay them better, and to give them tools to offer comprehensive coordinated care. Sermo, a physician social networking site, has 75,000 members and will soon issue an “Open Letter to the American Public,” signed by 10,000 doctors to reflect physician grievances and to indicate how the system can be improved. These efforts, coupled with the Patient-Centered Primary Care Collaborative, are designed to improve the lot of primary care physicians.

Conclusion: A new primary care paradigm is upon us and will fundamentally change how the U.S. delivers care.

Healthy Howard coverage expansion could inform future reforms

• 4

By Sarah Arnquist

Howard County, Maryland is set to launch an ambitious universal health coverage, and the county’s top health officials says the effort will provide valuable lessons for future reformers.Fastfacts

Starting next month, 2,200 of Howard County’s 20,000
uninsured residents can enroll in the Healthy Howard Plan,
which will provide them access to primary, specialty and hospital care, and
prescriptions drugs for $85 or less a month.

Dr. Peter Beilenson, Howard County health commissioner and former Baltimore City health commissioner who ran for Congress in 2006, said this is the most ambitious local effort at universal coverage since San Francisco launched a universal coverage plan in April 2007.

Like Healthy San Francisco, Healthy Howard is not portable health insurance but rather health coverage for local treatment. Instead of levying a "pay or play" tax on businesses like San Francisco, however, Healthy Howard’s funding comes from individual premiums, county general fund dollars and substantial amounts of charity. (The Golden gate Restaurant Association is battling San Francisco in court over its tax.)

Beyond the grand ambition to provide universal health coverage, what Beilenson says  distinguishes Healthy Howard is its emphasis on personal responsibility, mandatory health coaching and a forthcoming rigorous evaluation.

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The result of the primary care crisis

• 11

By Matthew Holt

Over at Spot-on I’m writing about the primary care crisis in partial response to the great stuff from Bob Wachter last week on THCB and also from Maggie Mahar and Brian Klepper. Hopefully, it’s a primer for the politico types over there about the primary care crisis and also what the likely results of it are. Hint, no pay equality, but more retail clinics and online visits.

Meanwhile, my piece at Spot-on two weeks back about the Two Ted Kennedy’s appears rather smarter than it probably was given the long piece in the NY Times today about exactly how risky his surgery was and exactly the level of agreement (i.e. not much) that existed among the wide medical team he convened. Evidence based medicine? Well let’s just say that the oft heard rumors of Medicare’s impending bankruptcy may be truer than I tend to believe if every patient wants that level of service.

At any rate, please take a look at the new piece and the older piece and as ever come back here to comment.

Ask any health care wonk and they’ll tell you that within the larger
health care crisis is a primary care crisis. There is more and more
demand for primary care physicians – the person you probably call your
"family doctor" – but America’s medical schools are producing fewer of
them.


Why? Well in a word, money.

It’s not actually medical school that’s the problem. It’s what happens next. A newly graduated physician, looking a big chunk of debt used to pay for medical school tuition gets to chose their residency and, as such, decides what type of doctor to become.In the U.S. we let medical students choose what to do. Not being dummies, most of them notice that diagnostic radiologists and orthopedic surgeons make three times what primary care doctors make, and choose their career path accordingly. Why the vast difference in compensation? Doing something to a patient – fixing a broken hip, reading an x-ray – has always been better rewarded more than talking to them about their high blood pressure or their son’s excema.

Read the rest.

Rebuilding The Medical Home: What Walgreens Surely Sees

• 11

By Brian Klepper

Walgreens_logo Though it probably went mostly unnoticed in the cacophony of health care stories, last week’s news that Walgreen’s had bought the two largest and most well-established worksite clinic firms, iTrax and Whole Health Management, was a harbinger of very big changes in health care. Walgreens, the ubiquitous drugstore company that, with Wal-Mart and CVS, has already leveraged its pharmacy platform to establish a strong footprint in retail clinics, undoubtedly startled many health care observers with its announcement. After all, isn’t the company doctor a relic?

Actually, no. The worksite clinic – and by way of disclosure for the better part of the last year I have
worked closely with a small, very innovative, Orlando-based startup worksite clinic
firm, WeCare TLC  – has been
reinvented and refitted with 21st century tools, and offers the promise
of nothing less than a paradigm shift toward dramatically better care
at significantly lower cost. Understanding how these structures work and how they differ from both old-fashioned medical practices and retail clinics provides clues into what Walgreens likely sees and why that matters to American health care.

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