Friday, September 5, 2008

Americans Who Have Insurance —But Still No Access To Care

Americans Who Have Insurance —But Still No Access To Care

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A friend who lives in Boston complained, not long ago, about not being able to find a physician. In Boston? “Come on,” I said. “This is like claiming you couldn’t find a liquor store.”

“They’re all oncologists and cardiologists,” he grumbled. “Last week I cut my hand badly enough that it needed stitches. I have good insurance. But I couldn’t get an appointment with my family doctor—or any of my friends’ doctors. I didn’t want to spend hours in the ER. So I wound up going to my sister’s house. She sewed it up at her kitchen table.”

His experience is not as unusual as it sounds. Some 56 million Americans do not have a regular source of care according to the National Association of Community Health Centers (NACHC) -- even though many of them do have insurance. The problem is a shortage of primary care physicians (PCPs) in many parts of the country, particularly, but not exclusively, in poorer communities.

Even Docs Have to Call In Favors

Not long ago, Bob Wachter, Professor and Associate Chairman of the Department of Medicine at the University of California, San Francisco (UCSF) , and author of Wachter’s World warned his readers: “The Long-Awaited Crisis in Primary Care: It’s Heeere.”

Indeed, if you try get an appointment at UCSF’s general medicine practice, you will find that it is “closed” –even if you are an UCSF physician. They just aren’t taking any new patients. “Turns out we’re not alone,” Wachter adds. “Mass General also is not accepting any new primary care patients.”

He calls attention to “to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare journalist Rachel Gotbaum called ‘The Doctor Can’t See You Now,’ is the best reporting on this looming disaster I’ve heard .

Wachter summarizes highlights: “Getting a ‘regular doctor’ (a PCP) at Mass General now takes the combination of cajoling, pleading, and knowing somebody generally referred to as ‘working the system.’ In other words, the process of finding a primary care doc is now like getting a great table in a trendy restaurant.

“The report also makes clear that providing more ‘access’ through expanded insurance coverage won’t do the trick,” Wachter explains. “Massachusetts, you’ll recall, markedly expanded its coverage a couple of years ago (in legislation proposed by that ex-liberal, Mitt Romney). Scott Jasbon, a 47 year-old contractor/bartender, thought he was all set when he enrolled in one of Massachusetts’ subsidized health plans. He was wrong.

“‘I received a card with my doctor's name on it and I was told that was my primary care physician,' Jasbon recalls. “’I called the office. They told me that they no longer took the insurance. So then I went through every list of doctors in Sandwich, in the book, called each doctor, and each doctor told me the new plan that I received, they, no one took the insurance… I knew that there was something wrong with me, and I was explaining to each doctor actually as I called them, "I'm having problems urinating." Hot flushes, I was hot all the time. I knew something was wrong, and I couldn't get anybody to take care of me.’”

“Jasbon ended up in an ED [emergency department ], where he was diagnosed with diabetes and hypertension. The ED staff helpfully suggested that he should think about getting a PCP. . .”

Readers commenting on Wachter’s post confirmed the story. One wrote: “I’m a physician and we moved to a new city a couple of years ago. I had to twist arms and call in favors to get myself and my wife PCPs--and we have ‘good’ insurance and no significant health problems (yet).”

At the Center of Healthcare Reform: A Medical Home for Every American

In the meantime, health care reformers talk about how, once we have national health insurance, we will create “medical homes” where primary care physicians will, at last, be rewarded for taking the time to co-ordinate patient care.

In a recent issue of the New England Journal of Medicine, for instance, a panel on “The Health of the Nation: Coverage for All Americans,” focused on the need for a “patient-centered home” that would be accountable for overseeing patient care.

The panel began by discussing the difficulties primary care physicians face today. Dr. Arthur Caplan, a professor of bioethics at the University of Pennsylvania, summed up the PCP’s lament: “I don’t have time to talk to anybody . . . . I don’t get reimbursed enough. I’m swamped by paperwork. I don’t have time for anything. And I answer to a bunch of— non-MD folks who are telling me what to do half the time. . . ..”

By contrast, in the brave new world of universal coverage, the panel members agreed, primary care doctors should be rewarded for talking to their patients, “making sure that patients are getting appropriate counseling” and that “they're up to date with their preventive care.” While specialists may see only a single body part, the PCP will have “the big picture.”

Commonwealth Fund president Karen Davis explained how physicians would be compensated: “in addition to fee for service [the practice would receive] a monthly . . . fee for being a medical home. It's a blended system of payment, which has worked very well in Denmark, where people have well-established relationships with primary care and compensation for primary care is on a par [with] or even higher than compensation for specialty care.

Former U.S. Senator Dr. Bill Frist then zeroed in on electronic medical records, describing them as key to helping the primary care doctor keep track of the specialists his patient is seeing, what those doctors are prescribing, and what they are recommending.

Davis agreed: When it comes to healthcare information technology, she noted, “we are way behind. One fourth of American primary care physicians have electronic systems. The Netherlands, New Zealand, Denmark, UK. . . ninety percent of physicians have totally electronic offices. . . What’s different in those countries? The government was willing to set standards on what is an acceptable system. . ..

And “in Denmark,” Davis added, “they found once they got this up and running, they were saving 50 minutes a day. Because it was so much easier to get the information they needed, to order a prescription or authorize a refill of a prescription. It really pays off. . . . But it needs leadership. National leadership...”

Others on the panel jumped into the conversation . . . . Until finally, Dr. Steven Schroeder a professor of health and health care at UCSF, interrupted:

“I think there is an elephant in the living room that we’re not talking about. All these comments presume the persistence of a vibrant primary care system.

“But,” Schroeder observed, “if [as we discussed earlier, doctors are] telling their sons and daughters and nephews not to go into medicine, those that [do] go into medicine know for sure they don’t want to go into primary care. . . . They want to go on what they call now the road to happiness. So this means they want to go into Radiology, Ophthalmology, Anesthesia, Dermatology . . . It’s an old-fashioned road. And why do they want to do that? They want to do that because they’re coming out with huge debts. Because unless we fix the payment system, they’re not gonna get the kind of income that they’d like.”

But the problem isn’t just the relatively low pay that primary care doctors receive. Students are also “more attracted to shift work, so they don’t have to worry about patients after they leave,” Schroeder added. “They want that eight-to-five job. And then finally, they don’t like all the hassles that we’ve been hearing about” in primary care.

“So the electronic medical record by itself isn’t gonna fix that,” Schroeder warned. “And unless we do more fundamental surgery on making primary care a more compelling field...in the future in primary care may will be practiced by [people] other than doctors. And maybe,” Schroeder allowed, “this isn’t a bad thing...”

The discussion swirled forward, as panel discussions do, without really facing up to the implications of Schroeder’s comment. But he was asking exactly the right question about the promise of “a medical home for every American.” Who, exactly, is going to be at home?

Once again, making sure that everyone has health insurance is not synonymous with ensuring that everyone has health care.

A Dearth of Doctors

Because the pay is low, the pace is hectic and the hours are long, fewer and fewer medical students are becoming family doctors or internists. Over the past decade, medical schools have witnessed a 22 percent drop in the share of graduates who choose to become “generalists” rather than specialists. A 2008 NACHC study estimates that to provide services to medically disenfranchised Americans who don’t have a regular source of care, we would need up to 60,000 more primary care professionals.

Instead, the pool is shrinking. Fed up with a broken system, older PCPs are retiring early. And younger PCPs are switching specialties. Wachter points to an “ABIM study [which] found that 10 years after initial board certification, approximately 21% of general internists were no longer in the practice of general medicine [vs. 5% of subspecialists leaving their field].

“The dwindling number of PCPs who remain in practice are being far more discriminating about the patients – and insurance payments – they will accept,” Wachter adds. “With Medicare reimbursement tightening . . . and Medicaid reimbursement near Starbucks barista levels . . . the result is primary care ‘access’ that sounds good in a press conference but is not real.

“You might ask, won’t the existing PCPs need to accept even these low insurance payments? After all, they need to see some patients to generate an income. Well, as it turns out, no,” writes Wachter, answering his own question. “The remaining PCPs are in such demand . . . that they can afford to limit their practice to patients with better paying commercial insurance.”

In the NEJM panel discussion Schroeder suggested that “someone other than doctors” may wind up doing the job. I’m assuming that he’s referring to nurse practitioners. And certainly, nurse-practitioners, working with primary care doctors, pediatricians or geriatricians could screen patients, take care of the least complicated cases, and give the doctor the 30 or 40 minute he needs to talk to—and listen to—patients with more difficult problems.

But as Niko’s post below reveals, we also face a serious shortage of nurses. Indeed, the same 2008 NACHC study says that, in order to staff medical homes, we would need up to 44,500 additional nurses.

Boosting the pay for physicians and nurses willing to co-ordinate patient seeing might draw more young professionals into primary care. But expanding the pool of primary care doctors and nurse is rather like drilling for oil. Even if we raised their fees tomorrow, it would still take many years for students to move through the pipeline, and into the workforce.

Moreover, it is important to keep in mind that it is not just the low salaries that med students find daunting. “Some primary care educators used to say that the problem was that students didn’t have opportunities to see the real practice of primary care docs – if they did, they’d recognize the subtle satisfactions and be more inclined to enter the field,” Wachter notes. “But an upcoming paper by UCSF’s Karen Hauer and others demonstrates that such exposure actually discourages trainees from choosing primary care. Primary care docs are frustrated and demoralized, and most of them are honest enough to share their angst with their students. In other words, It’s The Practice, Stupid.

The Lack of PCPs Creates Holes in the System

In the meantime, as Kevin M.D. pointed out not long ago, the lack of primary care physicians helps explain the number of hospital re-admissions.

Kevin began by pointing to an op-ed in the Boston Globe which urged Medicare to stop paying for patients who are rehospitalized within 30 days after leaving the hospital. “These readmissions are often avoidable,” the op-ed’s author wrote. “And if Congress focuses on reducing the need for rehospitalization in areas where the practice is most common, Medicare could save many billions of dollars.

Kevin took issue: “Not surprisingly, op-eds like these are written by non-physician policy makers, and further puts doctors in increasingly difficult situations. Physicians are pressured by hospitals to discharge patients and keep the turnover high, which increases revenue for the hospital. Now they're taking it from the other end, with this proposal not to pay for readmissions. It would be nice if someone advocated the proper support system be put in place first before acting on these ideas.

“The major reason for readmissions is inappropriate follow-up, which can be directly traced to a lack of primary care access. Solve the primary care shortage, and readmissions will go down.”

This makes sense. Granted, part of the problem is that some hospitals don’t take enough time explaining medications to patients—and making it clear what follow-up treatment they will need. But for proper follow-up, patients do need that “medical home”—a primary care physician who knows that his patient was in the hospital, and why, and what the instructions are for follow-up care. The primary care doctor should have the patient’s hospital records, a list of medications that he is supposed to take, the dosages, and recommendations for physical therapy or other treatments.

But if the patient does not have a primary care doctor, who is going to pick up the slack? The hospital can’t follow him home.

The lack of PCPs also is putting added stress on emergency care. Patients who cannot get an appointment with a primary care doctor are crowding ERS. From 1996 to 2006 Emergency room visits jumped more than 32 percent from 90.3 million according to the National Center for Health Statistics, a division of the Centers for Disease Control and Prevention. And this is not because more Americans lack insurance.

To the contrary, the study found the proportion of emergency visits by the uninsured had not changed substantially between 1992 and 2005, although the number of overall visits went up 28 percent. The survey found that people in the highest income bracket - in excess of 400 percent of the federal poverty level -- accounted for an increasing portion of emergency room visits, while the lowest income brackets remained virtually unchanged.

So much for the theory that illegal immigrants are responsible for the excruciatingly long waits in the nation’s ERs.

Who Suffers

“The state of primary care is not only sad, it is incredibly stupid,” Wachter concludes. “ Mountains of research have demonstrated that primary care-based care is less expensive – without access to primary care doctors, patients get their basic care in emergency rooms, or from subspecialists, or not at all. In any case, care is fragmented, technology over-intensive, and wickedly expensive.”

Yet, “the forces of inertia getting in the way of solving the primary care crisis are so strong that only a very powerful implosion will create the political wherewithal to overcome them. Specialists don’t want to forgo income, medical students will continue to vote with their feet, existing primary care docs have resigned themselves to more of the same and are hunkering down for retirement, and many patients are perfectly happy bypassing primary care docs to get their care from hordes of subspecialists. The patients who take the biggest hit, of course, are poor and middle class folks with chronic diseases – even those with insurance – who can’t find a PCP and can’t afford a VIP doctor, and who therefore live in perpetual fear of the next crisis.”

In Part II of this post, I’ll explore how specialists might become part of the solution. As Dartmouth researchers argue in "Tracking the Care of Patients with Severe Chronic Illnesses: Dartmouth Atlas of HealthCare 2008": “training more primary care physicians alone won’t solve the problem of . . ..the lack of co-ordination in our fragmented health care system.” If we want to contain costs while lifting quality, specialists, too, will need to begin thinking in terms of the “big picture.”

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