Insurers Expand Primary Care: an Argument for Obama’s Plan
Imagine appointments with your primary care doctor that last 30 minutes, or longer. What if you could e-mail her when you need a prescription refill? If you have a two-minute question, she encourages you to call; she or a nurse practitioner will come to the phone. If they are busy, they will return your call within a few hours.
A recent story in the Seattle Post-Intelligencer offers hope for primary care by focusing on an innovative program at Group Health Cooperative, a nonprofit health care system headquartered in the state of Washington. Under the new program, patients see their doctors less often, but when they do, it is a meaningful encounter. And in between appointments, doctors are paid to communicate with patients in other ways.
A multi-specialty integrated health care system, Group Health, like Kaiser Permanente, provides both healthcare and insurance. Group Health’s doctors work on salary, so there are no financial incentives to “do more.” And because Group Health is both the insurer and the caregiver, the payer and the health care provider are not adversaries: they are on the same team.
By creating its own small revolution in primary care, GroupHealth is demonstrating that private sector insurers can be part of the solution to our healthcare crisis. In this case, the key is paying doctors for the time they spend e-mailing patients, returning phone calls, and doing research on their behalf. Because doctors are on salary, they are paid for everything they do - not just for the number of patients they manage to “see” in a given day.
In a two-year experiment, Group Health is encouraging doctors to spend more time in face-to face appointments with patients. Given the finite number of hours on a physicians’ calendar, this means seeing patients less frequently. But doctors also keep in touch with patients by phone and e-mail.
As a result, a doctor like Dr. Patricia Boika can spend a half hour, or more, with the patient she sees. Before she became part of this program, “The practice had become a dismal treadmill, with too many patients and not enough time, double-bookings and harried visits, and paperwork lugged home every night,” Boika, who has been a family doctor for 28 years, told the Post-Intelligencer.
"’It was an assembly line of people she recalls. ‘You were just slammed. You had to tell yourself, “It's really OK to take one minute to go to the bathroom.”
“But, these days,” the paper observes, “Boiko, who practices at Group Health Cooperative's Factoria center, does medicine the way she intended.”
Group Health has found its medical home pilot project in Factoria so successful that it is rolling the idea out to all 26 of its medical centers.
“A similar concept will guide a new family-medicine residency clinic that Swedish Medical Center is opening next year in Ballard,” the Intelligencer reports. “Like Group Health, it will allot 30 to 60 minutes for a visit, instead of 15 minutes.
“And while some family doctors oversee 2,000 to 2,500 patients, doctors at the new clinic will have a panel of only 1,700 to 1,800 patients.”
"’It almost sounds impossible,’” Carol Cordy, Swedish's medical and residency-site director of the new clinic told the newspaper. “‘How can you see 10 patients a day instead of 25, and still make ends meet?’"
“That is the question,” the paper adds. “The challenge for medical-home advocates is the country's fee-for-service system, which pays doctors for visits and procedures, but not for phone calls, e-mails or time to research a condition.
“There's this motivation to see more patients so you make more money,” Cordy confides.
But Swedish Medical Center, which uses outside insurers, has found a group willing to pay a monthly fee for each patient rather than fee-for-service. Again, payers and providers are collaborating.
Maybe this can happen only in what some healthcare reformers describe as “Canada South”: the Northwest (running from Washington and Oregon across to Iowa) and Northern New England (Maine, Vermont and New Hampshire.) But I like to think that the rest of the country can catch on to the idea that healthcare is not a competitive sport. It should be a team effort.
What the Best Private Insurers Bring to the Party
Many single-payer advocates believe that private insurers should not be included in national health reform: a government program that some call “Medicare –for- All” should provide all coverage. This, they say, is the only way to deliver effective, affordable care.
But I am impressed by the “hybrid” plans that both president-elect Barack Obama and Senate Finance Chairman Max Baucus have proposed—plans that include both a public sector option and private insurers. Here it is worth noting that the hybrid model is the norm in most of Europe, where the cost of healthcare is much lower, and outcomes are generally better than in the U.S. Only the U.K. and Canada offer a pure “single-payer” system and there is no evidence that their health care systems are superior.
As the Seattle Post-Intelligencer piece suggests, the best private sector insurers can bring innovative solutions to the table. Of course there is no reason why the government cannot run equally imaginative pilot projects. In fact, Medicare already is investigating alternative ways to pay providers. But keeping honest insurers in the mix should ensure greater variety.
Moreover, a system that includes both private sector and public sector insurers guards against the danger that, with a changing of the guard in Washington, a single-payer system could become something quite different from the program that today’s healthcare reformers envision.
Lessons Learned From PBS
Here I think of PBS. In theory, PBS was supposed to be “the people’s television.” And in many ways, for many years, it was—and sometimes still is. But compare PBS’ programming to the best of HBO. PBS has been captured by conservative forces that would never air programs like Deadwood or The Wire–television dramas that have taken the norm to a level of acting, writing and political thinking that rivals the best films. Ultimately HBO became the network which offered programming that you won’t see on commercial television.
For news, compare PBS to BBC. Frontline still does some excellent programming and Bill Moyers remains the Ted Kennedy of PBS. But you only have to look at the folks raising funds on televisoin during the network’s membership drives to realize that these are not disruptive innovators.
Just as PBS was co-opted by politics, a single-payer healthcare system could become a political football. Imagine that, in a backlash against the Obama administration, Jeb Bush is elected president in 2016. Clinging to his coattails, a horde of conservative Congressmen come to Washington. (If you think this couldn’t happen, remember how surprised you were when [name your least favorite politician] was re-elected.)
If we had a single-payer system, today’s health care reformers might be astonished by just how quickly its priorities could be re-aligned. Conservatives in Congress might well slash subsidies while creating a “consumer-driven” single-payer system that leaves Americans free to choose (or forced to choose) the healthcare they can afford from a menu of policies. This could mean unlimited end-of-life care for those who can afford gilt-edged insurance—and Medicaid -for-all for the rest of us. Some conservatives might even call for a vote on whether abortion should still be covered.
At that point, many Americans would be grateful to have alternatives to government insurance. No doubt, insurers such as Kaiser and Group Health would step up the plate. Let me be clear: I deeply believe that healthcare is a public good—and that government should be the guardian of the public good. But this is true only when we have good government. As recent experience demonstrates, this is not something we can count on.
National Health Reform—No Single Solution
In addition, the more I think about it, the more I realize that unrolling national health reform will be a process that will require many experiments. Some will succeed; some will fail. Disruptive innovation calls for a variety of players thinking outside of the box.
After all, this is a big country and I’m becoming convinced that what works in one region may not work in another. The basics of universal coverage should be uniform. Everywhere, we must have patient-centered healthcare based on medical evidence. Coverage should be equitable, and providers should be paid for value, not the volume of what they do. That said, healthcare for all could take many forms, just as it does in Europe.
While large, integrated, multi-specialty centers work well in Western states, fully- funded, well-staffed community clinics might prove better suited to densely populated cities on the East Coast. Ideally, these clinics would offer services eighteen hours a day, seven days a week. In addition to primary care they would offer specialty care ranging from cardiology to obstetrics, ophthalmology, gynecology, pediatrics and physical therapy—as well as counseling services for those addicted to tobacco, alcohol or drugs.
Today, both affluent and low-income patients find themselves in the ER when they can’t get an appointment with a doctor. A neighborhood clinic that is staffed with M.D.s and nurse-practitioners could keep patients out of ERs, while providing the disease management and preventive services that we associate with a “medical home.” Insurers could experiment with different payment models. Some might offer salaries that let doctors follow the Group Cooperative model; others might make monthly per- patient payments, bundling bonuses for good outcomes to be shared by everyone who saw that patient. Some private practice specialists might work part-time in the clinic; others might be paid to collaborate with the clinic’s primary care physicians, making room in their schedules to take the clinic’s referrals in a timely fashion while consulting with the clinic’s doctors to co-ordinate patient care. Finally, clinics might offer flex schedules and part-time salaries for the many physicians and RNs who do not want to work full-time. In this way, they could bring some nurses out of early retirement.
This is just one model. Imaginative insurers would find different ways of delivering care and paying for value. And this is one reason why I find the “hybrid” insurance system proposed by the new administration so appealing. As both Obama and Baucus envision it, private sector insurers would compete, on a level playing field, with a public sector “Medicare-for-All” alternative.
Fair Competition between Public and Private Insurers
Make no mistake, leveling the playing field means regulating insurers. Private insurers should be required to insure anyone who applies, without regard to pre-existing conditions. And insurers must charge everyone in a given community—young or old, healthy or sick—the same price for a policy. Insurers have agreed on the first point, not on the second.
This is one reason why the insurance industry is pushing for reform Now. If we forge ahead, Congress won’t have time to work out the details of regulating the industry and requiring fair pricing.
But Congress must pause and fight this battle. If insurers are allowed to charge sicker, older customers more, many sick patients will find their premiums unaffordable. At that point, either we follow Massachusetts’ example, and “exempt” some of our oldest and sickest citizens from universal coverage—or taxpayers pick up the tab in the form of exorbitant subsidies. This is not how insurance is supposed to work. Insurance is about spreading risk. In this case, rather than letting insurers set prices for sicker patients we should insist that they charge everyone in a community the same premium, spreading the cost of caring for the old and the sick through the insurance pool, just as we do with Medicare. (Meanwhile, the government would provide subsidies for those who cannot afford the community rate.)
Fair competition between the private sector and the public sector also means that all insurers must offer coverage that meets the high standard set by the Medicare-for- alternative. No more surprises in the fine print. Policies would cover surgery and rehab after surgery, pregnancy and all complications during pregnancy.
Alternatively, Congress could give everyone a voucher which entitles them to the same high quality, comprehensive insurance. Individuals would pay nothing for the voucher; the cost would be financed collectively, through our taxes. I have written about this plan on HealthBeat here and, here).
Again, it will take time to consider the alternatives. Congress must not let the insurance lobby hi-jack the process. Insurers are hungry for 45 million new customers, many coming to the market with a government subsidy in hand. But we need to ensure that they receive equitable, effective care at a reasonable price.
If Congress sets strict rules, some insurers may decide that they do not want to play the game. Those who rely on “cherry-picking” healthy patients to stay in business—while selling many of them skimpy policies filled with holes—won’t be able to survive in a market where they have to compete on a level field. But others, that are able to compete on quality, will stick around and add value to the system.
The Rules of the New Administration’s Proposals
Many voters still seem hazy on the details of the president-elect Obama’s proposal for healthcare reform. Somehow the campaign never managed to spell out how his plan works—presumably because strategists who are more interested in politics than policy believed that voters wouldn’t be interested in the wonky details.
But now that various group are proposing their own quick fix, “magic bullet” solutions, it is imperative that the public understand the president-elect’s hybrid plan.
Here are the rules of the game:
* Employees who have employer-based private-sector insurance can keep the insurance that they know. (It would be a shame to force anyone to give up Group Health.)
* Meanwhile, the self-employed, the unemployed, and those working for an employer who does not offer insurance will be able to buy insurance through a National Health Insurance Exchange ) where they can choose between private sector and public sector options. Small employers also will be able to go to the Exchange to buy subsidized insurance for their employees. Some small employers will be exempt, but their employees will have access to the Exchange.
* Large and medium-sized employers will be asked to either “play” or “pay.” They can choose between offering insurance to their employees (playing), or contributing a percentage of payroll into a common pool that helps fund universal coverage (paying)
* If the “Medicare-for-All” public sector insurance is able to offer better coverage for less—as many hope—some employers may well decide that, rather than “playing” (and continuing to try to oversee private health insurance for their employees) they would rather “pay.” In that case, their employees would be free to go the Exchange where they can choose between private and public plans. If the public sector plan proves popular, no doubt many employees will lobby their employers for this alternative.
In this way, the nation might well move from employer-based insurance to a system where employees choose their own insurance. But under the administration’s plan, this would happen only if employers and employees choose to give up employer-sponsored insurance, not as the result of a government edict.
In the end, National Health Reform cannot be imposed on the nation, deus ex machina. Considering the options, experimenting with alternatives, battling the lobbyists—all of this will be part of a lengthy, sometimes bloody, often difficult political process. As the latest Congressional Budget Office report makes clear, there will be many trade-offs. “Cost-containment lite proposals will not be enough.”
No doubt more than one piece of legislation will be required. Those who want to move quickly would like to side-step the hard decisions. Lobbyists, in particular, would like to skip over discussions about cost-cutting and regulation.
But as David Mechanic points out in The Truth About Health Care: “At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit from it or to protect the health and welfare of all Americans.”
That time has come.
Reprinted from http://www.healthbeatblog.org/ and written by Maggie Mahar