Three years ago I wrote – An opinion on the Massachusetts plan
My personal position is that Massachusetts is undertaking an interesting experiment. This experiment will have some successes and some failures – all experiments have such possibilities.
In any field, the greatest progress occurs when champions take risks. We should not overanalyze this experiment prematurely. Hopefully, Massachusetts will have both successes and failures, and correct the failures.
Those who argue strong against this plan must either desire a single payor system, or are satisfied with our current system. I find both of these options unsatisfactory.
The Massachusetts plan is showing us the problems we would have if we introduce universal health and do not fix the primary care crisis. The NY Times addresses this issue in an important way today – Massachusetts, Model for Universal Health Care, Sees Ups and Downs in Policy
“Although major expansions in coverage can be achieved without addressing health care costs, cost pressures have the potential to undermine the gains,” wrote the researchers, Sharon K. Long and Paul B. Masi of the Urban Institute.
The difficulties in receiving care were severest among low-income residents, who have gained the most from expanded access under the state’s law, passed in 2006. It requires most residents to have health insurance and provides state-subsidized plans for the poor. Massachusetts now has the country’s lowest percentage of the uninsured — 2.6 percent, compared with a national average of 15 percent.
But the study, which was scheduled for publication Thursday in the journal Health Affairs, found that increased demand for care from the newly insured was confronting an insufficient supply of willing physicians. One in five adults said they had been told in the last 12 months that a doctor or clinic was not accepting new patients or would not see patients with their type of insurance. The rejection rates for low-income adults and those with public insurance were double the rates for higher-income residents and those with private coverage.
The authors concluded that the high rejection rates helped explain another important finding: that there has been little change in the use of emergency rooms for non-emergency treatment. Among low-income residents — defined as those with incomes of less than three times the federal poverty level, or $66,150 for a family of four — 23 percent said their last trip to an emergency room had been for a non-emergency, the same as in 2006.
Universal coverage means little unless we change our distribution of physicians. We need more primary care, and we need it now. Some opponents think we cannot afford to invest in primary care. I argue that they do not understand the economics of medicine. Primary care saves money. We need more primary care and we need it now. It will only occur if we change our absurd payment system.
Support HR #2350!
{ 4 comments… read them below or add one }
These findings from Massachusetts would be an opportunity to show the value of physicians as opposed to other providers. What were the diagnoses established for those ED visits? Did those diagnoses occur in patients who had to have physician care only as opposed to care by other providers? That is, these diagnoses and these patients, absent an MD/DO capable of providing “complex comprehensive care”, would have faced unacceptable risks of morbidity and mortality that could have been dealt with ONLY by that MD/DO. Why didn’t those patients see their physicians during the day? Why didn’t they have physicians? The NY Times article doesn’t seem to establish the…well… primacy of the PCP.
Here is the reference to HR 2350′s kick-off by Representative Allyson Schwartz of PA’s 13th District: http://www.house.gov/apps/list/press/pa13_schwartz/PCA.html. In fact, the description of HR 2350 talks about “primary care providers”. For example:
“Primary care is at the core of America’s health care system, and without a sufficient number of doctors, nurses and others providing primary care, Americans face long wait times to see their doctors and health care providers, as well as other obstacles to quality care.” Nothing there about MD’s vs any other provider.
And here is the definition of “Primary Care” from HR 2350: “(4) PRIMARY CARE- The term ‘primary care’ means the provision of integrated, high-quality, accessible health care services by health care providers who are accountable for addressing a full range of personal health and health care needs, developing a sustained partnership with patients, practicing in the context of family and community, and working to minimize disparities across population subgroups.” Now, HR 2350 defines “Physicians” based on the Social Security Act (1861(r)(1)), and so we have MDs and DO’s, but also DPM’s, DDS’s, DC’s, and OD’s. Maybe we shouldn’t assume a priori that Rep. Schwartz means what we mean when we say “primary care” and “primary care provider.” For there is nothing in that definition of “primary care” in HR 2350 that an RNP or PA would say he or she could NOT do. And they might be right.
For that is the question that will be asked by asked by Ways and Means, and answered by the President. The debacle in MA does not show we need more university-trained physicians. It shows we need more people who are willing to work for less and who are willing to work longer hours. It shows that we need worker-bees who are not bound by the same culture of Osler and the Academy.
You need to be careful what you wish for.
Dr Block makes a good point. There seems to be some cognitive dissonance on the part of those trying to bolster primary care, while at the same time accepting a much broader role for midlevels delivering it.
Either the comprehensive care is complex, difficult, and best provided by an extensively trained (and expensive) physician, or it’s usually straightforward, algorithm driven, not particularly complex, and best provided by a less expensive midlevel (with much less training).
Arguing those providing comprehensive care should be paid more, then arguing that we should have midlevels delivering a lot more comprehensive care seems schizophrenic. And it’s not convincing.
Why do you think they care ? I mean, the politicians, why do you think they care ? They just want to be reelected.
Where and how does primary care save money?
Whether provided by MDs, DOs, PAs, or NPs, more people being evaluated means more follow-up visits, more imaging, more referrals to specialists. It’s likely true that a visit to an office based primologist (just made that one up) is less expensive than the same complaint being evaluated in an ER, but that’s a false comparison. A lot of people with headaches, back pain, hyperglycemia/DM2, htn, DJD, bellyaches, ad nauseam, put up with symptoms rather than get help because accessing help is difficult/expensive/time consuming. With more and better-insured access to the primologist, stuff that gets tolerated now would get (appropriately but sometime expensively) evaluated and treated. More screening leads to more biopsies, more discovery of asymptomatic disease such as htn that will require treatment. I’m all for all of the above- barriers to care being removed, symptoms being relieved, advanced disease being prevented- but selling it as a cheaper way to run a society is likely to not work out, and lead to disappointment, to say the least. With a better run medical system, including easy access to primary care, people will live longer, increasing costs of SS and Medicare. Again, a better situation overall, but not a cost reducer. You might point to France or Japan as an example, but 85% Americans have certain expectations of quality and quantity of service that they will not willingly give up for the 15% who do not.