Monday, August 24, 2009

A Modest Health Care Reform Proposal

Most of me thinks that two health care reform options are most worthy:
1. Consumer-paid fee-for service with a spartan government-provided safety net for the poor. OR
2. A single-payer system.

But I met a primary care physician involved in health care reform planning whose views represent a more middle-of-the-road approach that seems a good balance between concern with quality and cost. So I invited him to summarize his key recommendations in 500 words and that if I thought the document was worth your reading, I'd post it.

Here it is. As always, comments are welcome.

Health Care Reform: Viewpoint from a Primary Care Perspective
by Michael Rosenblum, M.D.

There are three essential issues for health care reform in the United States

1) We need a uniform national digital health record--Many errors are made due to illegible handwritten entries in patient records.A majority of prescriptions are still written by hand, and a majority of outpatient medical records are written by hand. We could greatly improve the quality of care, and save a considerable amount of money, by having national standards for digital data entry and making all health care records accessible from any point of care in the nation. There are political barriers to instituting this policy. Proprietary electronic systems would have to yield to uniform national standards. There are concerns about the privacy of patient records. We need to overcome such obstacles and get health care into the digital age.

2) We need to re-emphasize primary care—In the United States we are culturally addicted to the latest technological advances. We spend a disproportionate amount of the health care dollar on the latest laser surgery and the latest high-tech drugs. To provide health care to all citizens, we need to train more primary care doctors like pediatricians and internists and family doctors. The importance of the primary care doctor in providing preventative care, and coordinating the patient’s journey through a complex system, cannot be overemphasized. Insurance reimbursement needs to be increased for primary care, and decreased for specialists if we are to achieve this goal.

3) We need to fix Medicare and Medicaid before establishing costly new federal programs—The Medicare “trust fund” is on the verge of insolvency. Medicaid (MediCal in California) reimburses doctors and hospitals typically at 20-30% of the current market rate, resulting in poor access for patients. Both of these programs need to repaired and reinvigorated. Fortunately, this can be achieved without creating vast new federal agencies and hiring hundreds of thousands of new federal employees, as would be needed for the new programs proposed by the administration and Congress. The infrastructure for these programs has been in place since the 1960s. We merely need to fund them and they can reach their full potential. For example, Medicaid could be made available to uninsured adults up with incomes up to 400% of the Federal Poverty Level, rather than the current 125%, to make a large proportion of currently uninsured adults eligible. There are huge political barriers to reforming Medicaid. For example, Medicaid uses a formulary of generic drugs, and there would be strong opposition from the pharmaceutical industry to increasing funding for this program. Funding for Medicaid is partly from the states, and they are pushing back on any increase in the program that would require them to fund more health care. Clearly, the federal government will have to shoulder the fiscal burden of Medicaid expansion, but this is cheap by comparison to setting up a whole new program.


Anonymous said...

This is essentially single (or at worst, dual if Medicaid is used) coverage for many people. I don't know that all jobs paying 400% of the federal poverty line include health coverage, but I suspect many do.

Add a pharmacy benefits manager to this (and it's implicit in the formulary) and implementing something along these lines would be great.

Getting providers to accept Medicaid patients, and getting enough primary care facilities into play, would be the challenge.

As it is now in Massachussets, something I think is interesting is that apparently there is a shortage of primary care docs now that many more people are trying to see them.

It's also time to revisit the role of the AMA in capping the number of doctors in the US. They've been keeping medical school enrollment low, and the costs of medical education high (having a medical school at a university is essentially a cartel-controlled operation, not at all unlike having a major league sporting team in prestige and getting sign-off from all the others in the club; unis can charge what they like, absent competition) for many years.

One solution here would be to expand the program which forgives or reduces med school costs if the graduates agree to do primary care as their specialty for the first X years after residency. This also eliminates the problem that current med school graduates really do need big incomes to service their big debts.

Marty Nemko said...

Thank you, Anonymous, for your solid contribution. I didn't realize that the AMA was involved in capping med school enrollment. I would go further and argue that training should be shortened--much that is required isn't necessary, often a sop to the canard of "high standards," which really is a smokescreen for academicians wanting to legitimize their arcana.

Bill said...

Interesting ideas.

There is a big problem with #2 -- from my family's experience (relatively health family of 4, living in Seattle with access to good doctors), we have been though several primary care physicians in the past few years. They're useless if you have anything beyond having a cold.

My wife had a very common skin condition. It was mis-diagnosed by 2 primary care physician, and both of them told us that she didn't need to see specialists.

We had to switch to PPO so that I could go directly to see the specialist. The ironic part is that my wife got pregnant, and had a OB check-up. Her OB doctor spoted the skin condition and immediately gave the right diagnosis.

Similar issues happened to me as well. I grew up in Asia. One thing I don't understand is that for some reasons, people in this country think that American medical schools is the best in the worlds. They're good, have most cutting-edge technology. But, they're not as good as people think.

In summary, I cannot trust primary physicians. The quality of primary physicians in this country is poor. I thought this was my own experience. But, when I talked to my coworkers, almost everyone agreed with me!

Marty Nemko said...

Thank you, Bill, for a fine contribution.

Anonymous said...

I've had good luck with Kaiser PCPs my whole life (I'm a Kaiser baby.) My PCP diagnosed a benign but fairly uncommon tumor using a tuning fork. Yes there were MRIs before a definitive diagnosis, but they knew what test to order based on the tuning fork.

I'm very proactive when approaching my docs during a visit; I make an effort to engage them and be memorable.

I'm not sure if folks have looked at a typical medical school curriculum or not. I thought these sounded like things you'd probably want docs to know. At most schools med students are interacting with patients after two years of coursework. is a decent overview of the curriculum. Looking at that list (and having seen the textbooks for a couple of these courses, gross anatomy and pharmacology) I see stuff I know doctors hate taking, but it seems like a fairly serviceable set of courses. And there's a lot of anatomy to learn, a lot of stuff about medication to learn, etc.

Marty Nemko said...

Thank you, most recent Anonymous, for yet another good comment. I do wonder if much of those facts and drug info we require of medical (and other health care) students to memorize couldn't be simply gotten online, thereby shortening training and increasing the supply of health care providers. Also, info on diagnoses and treatment are constantly changing, so why make them memorize a status quo that will quickly change. I'd be teaching prospective health care providers how to quickly obtain the best current info re diagnoses, treatments, etc.

Michael Rosenblum, M.D. said...

Author Comments: Primary care has been so poorly reimbursed in the United States in the last two decades that the brightest and best young doctors gravitate toward the higher paying, procedure-oriented subspecialities. To encourage the training of more and better qualified primary care M.D.s, reimbursement rates need to be raised relative to those of the subspecialties. Few people realize that physician fees are fixed by contract with insurers, and M.D.s have no ability to set or negotiate fees for the majority of their patients. The result is sometimes the type of care that Bill's family received. The primary care doctor cannot afford the time to think or look things up, but simply makes a referral to a subspecialist.


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