The 21st National Conference on Primary Health Care Access met in six breakout sessions on Monday, April 12, 2010. The following question was posed to each of six teams:
The enactment of 2010’s health reform legislation was the consequence of a contentious political whose result left many dissatisfied. As the legislation moves to the implementation phase, what should we look for, over the next few years, to judge whether the health reform act’s consequence will be a substantial improvement over the present system?
The following responses were developed by each team
Team 1. Clover (Lead), Baird, Coleman, Fort, Hansen, Hines:
[Below: Team One discusses health care reform legislation at a meeting at Dondero's Restaurant; from left, clockwise, Thomas Hansen, MD; Macaran Baird, MD; Richard Clover, MD; Mary T. Coleman, MD; Thomas Hines, MD and Arthur Fort, MD.]
1. The worry exists that the “new” system could repeat the problems experienced with capitation in the health care reform initiatives of the 1990s.
2. In Massachusetts, its state reform has improved access to care, but costs have increased and now they face rising state budget deficits.
3. We know that public health measures must be implemented to really improve population-based health measures.
4. Individual care makes a difference, but will payment reform help support the time and effort needed to help people adapt?
5, We have hope that this new legislation will be a good first step in the “long and winding road” to sensible health care/prevention nationwide.
6. the current “winners” in the health system will do everything possible to block meaningful change.
Macaran Baird, MD, session scribe.
Team 2. Bejinez-Eastman (Lead), Babitz, Herman, Osborn, Webster
- Receiving lots of questions from patients on impact of legislation
- Most patients don’t appreciate the fact that their health insurance is tied to employment and that when that is lost, their health insurance is lost.
- This insurance reform has been designed to serve insurance companies.
- Revisited question of whether health care in the U.S. is a right or privilege.
- One view is that health care coverage is one’s reward for working hard and earning this benefit – which should not be the case.
- Good points of the reform include not losing benefits because of job loss and eliminating coverage denial for pre-existing conditions.
- Concerns raised about health manpower being inadequate to support successful reform.
- Motivation for expanding residency slots examined. Deans run hospitals and medical centers to be profitable which means utilizing lots of sub-specialty fellowships.
- Don’t expect changes in manpower distribution (by specialty) without meaningful reimbursement reform. Medical students are smart (can figure out if it’s better to earn $150K vs. $350K per year over their career, especially when faced with $200+K in debt.
- How to judge the consequences of reform? Standard measures: Cost (overall), Quality, and Access.
- Glad that something was passed. Hopefully a first step.
- This legislation will be tested in Fall 2010 by the elections. Many congressional candidates will try to focus on opposing reform, after all, polls show majority of Americans opposed this legislation.
- Workforce discussion: medical students remain idealistic upon admission but much changes during their 3rd year during specialty rotations taught by sub-specialists.
- Student exposure to poverty care and global care and rural care tends to reinforce interest in primary care careers.
- Again, student debt vs. potential earnings a major issue in specialty choice.
- Students may see FPs in negative settings (overworked, frustrated, unhappy).
- Ultimate change will follow the money.
- Reform as recently passed is unlikely to be successful without workforce reform and reimbursement reform.
- Transformation of Family Medicine suggests practices that see fewer patients, have better outcomes and offer higher reimbursement. But, how is that possible under current system? This reform will serve to increase the demand for services of family physicians with no better reimbursement (at least, initially).
- Ontario, Canada, did some comprehensive reform that included better reimbursement for primary care and community-based training. This has resulted in increased interest in primary care.
Marc Babitz, MD, scribe.
Team 3. Fowkes (Lead), Erickson, Freeman, Lee, North
We would like to see the residents trained in sites side by side with mid level providers and others that will be part of PCMH teams. One of the barriers to training now is the lack of coordination and integration of mid level curriculum and practice experience. We need to model what we expect learners to actually do in practice.
Health equity is the main issue to address access to care, not having access to health care payBabitments.
Register patients to vote at clinics.
Charles North, MD, session scribe.
Team 4. Hara (Lead), Kimball, Pugno, Vega, Wilke
[Below: Team four discusses the health reform legislation at a meeting at Dondero's Restaurant; from left, clockwise, Perry Pugno, MD; Charles Vega, MD; Allan Wilke, MD; Jimmy Hara, MD; Betsy Kimball.]
1. The legislation is not revolutionary. Like affirmative action, it will be a five to ten year process.
2. The second steps in the legislation are the bills to follow.
3. There shoulod be an increase in interest in primary care, in the improvement of primary care compensation, and in progress towards the medical home and team concept.
4. The following should be seen in the market: 3 year medical schools, and increase in medical schools and primary care interest. Changes towards non-profits like Kaiser-Permenente where 3% of revenues go towards graduate medical education.
5. Attacks (on the legislation) will follow dollars – on costs, abuses, the focus will shift from quality to insurance and pharmacy charges. All of this will require more legislation.
6. We will be talking about all this next year.
Jimmy Hara, MD, session scribe.
Team 5. Maudlin (Lead) L. Burnett, Casey, Flinders, Kasovac
1. Will parts of the bill be repealed? Who knows?
2. Can a workforce commission make a difference, and, if so, how? Is the Utah model relevant?
3. If primary care docs can convince insurance companies that family medicine cast save companies money, it might decrease the likelihood that the current opponents of the legislation might try to repeal it. Data must be collected and used.
4. It might lead to a shift in graduate medical education dollars from hospitals to primary care residency programs.
Donald Frey, MD, session scribe.
Team 6. Ross (Lead), W. H. Burnett, Fernandez, Frey, Peck, Troy
Did the process actually satisfy anyone? It doesn’t seem so. Despite this it may turn out to be transformable.
Indices that should be Measured:
- Increase in raw numbers of people who have access to insurance, are insured, and/or have health care
- Increase in absolute number and percentages of real PCP’s
- Increase in the number of people say in medical homes and/or managed care
- Reduction in the rate of inflation of costs of health care in the long term (not short term) maybe 9 or more years hence (2020)
- Decreased ED visits for manageable chronic diseases and non-emergent care
- Decrease in so-called “covered” people who cannot get access
- Increase in the number of people in the country who with one phone call can name their care provider/family doctor
- Is there a powerful Office of Health Care Effectiveness that can actually make and enforce policy?
- Very difficult for a for-profit managed care plan to do good work and survive.
- Possible that there should be a shake-out and some for-profits may figure out how to do good work and survive in a changed environment.
- Most of US population IS covered, but due to a large set of perverse incentives.
- Are the proposed policies and enacted legislation actually going to be followed?
- Federal government also pays now for many futile treatments and some things which we probably don’t even know about, vis-à-vis specialties. For example, Hyperbaric O2 for chronic wounds, which is not proven evidence-based medicine
“ Adding rights to risk pools (an insurance mechanism) distorts the original intent of insurance” W. H. Burnett
Bill, Really enjoyed the conference. Bright people full of ideas. Thanks for including our department once again in the proceedings. All the best, Chip
Allen L. Hixon, MD, University of Hawai’i