Last Updated on April 16, 2022 by Lee Burnett, DO, FAAFP
We gratefully acknowledge the sponsorship of the Kaiser Permanente Los Angeles Family Medicine Residency Program for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:
Mark Clasen, MD, Ph.D., Wright State University, Dayton, Ohio (Moderator): Our third Thought Provocateur of the morning is Doctor John Zweifler, formerly of the University of California, San Francisco, now the California Prison Healthcare Services.
John Zweifler, MD, MPH, California Prison Healthcare Services, Fresno: Thanks Mark. Today, my presentation is “Beyond the Affordable Care Act: What Should We Be Looking at in the Future”. I’m now at California Prison Healthcare Services, which is a single-payer system, and a universal system, so it’s a very interesting in that regard. There’s been some jokes already about prisons, but our in and out privileges are just a little bit more stringent than what we see for parking here at the Hyatt Regency.
It’s a pleasure to be here again. It’s been a few years since I’ve been here. I kind of miss working with the residency program at UCSF Fresno, but I have enjoyed being in a place where there are opportunities to look more globally at how we provide healthcare services.
What I’m going to talk about today is based on an article that was published in the Journal of Health Care of the Poor and Underserved a couple months ago. Since it’s published it must be real! The title of the article is “Creating an Effective and Efficient Publicly Sponsored Healthcare Delivery System”.
During the first part of the morning, we talked about the Affordable Care Act. I think that David Sundwall hit the nail on the head when he said what PPACA is really about is expanding coverage to the currently uninsured. There are a lot of elements to the legislation, but is the essential component. I know there’s some angst about PPACA from the Physicians for a National Health Program (PNHP) supporters, including myself, but I fundamentally support it.
I think that PPACA basically makes it clear that “we’re all in this together” Because we’re all paying for this, we’re all responsible for each other’s healthcare costs. All of our healthcare costs will increase together.
Eventually, I think this legislation will force us to make decisions more rationally by pulling out the distortions that are created by having some patients uninsured and some not. I think that was a necessary, although not a sufficient step. I support what the Affordable Care Act did in that regard.
I think it does offer us a chance at meetings like this to say,”O.k., assume we have significantly expanded coverage. What else can we do to assure that we do the best job in providing healthcare services for all?”. Implementing PPACA means that we no longer have to focus on how we can provide healthcare coverage, but instead on how we actually deliver healthcare services.
I’d like to focus not so much the insurance side but to look at elements that are already receiving large federal subsidies. If we look at programs such the community health centers, our safety net hospitals, and our training programs, particularly the specialty training programs and the faculty that work with them, we have the elements of creating an integrated delivery system.
The primary care base would be in community health centers. Specialty and inpatient care would be concentrated in our safety net hospitals, where a lot of graduate medical education occurs, although there are certainly other safety net institutions and hospitals, such as rural hospitals, that would have to be incorporated.
Creating a Publicly Sponsored Healthcare Delivery System
Why would we want to do this? I think there are a number of good reasons for creating a publicly sponsored healthcare delivery system. First of all, it gives us a chance to increase our access to care by making it easier to refer patients in and out for primary care and for specialty care. It can improve healthcare outcomes in the same way by providing access across the continuum.
There are opportunities to reduce spending in terms of making sure we’re not providing people duplicate tests; also, I think, by incentivizing to provide the appropriate level of services. If somebody is in the hospital we want to get them out quickly. There’s an incentive to do that, as opposed to the way our system’s structured now.
A publicly sponsored healthcare delivery system that included a community health center base woven into safety net hospitals and including specialty services through physician residency training programs and the faculty that work with them, would have the elements to become an accountable care organization. This system could work in various payment systems. It could function as the individual elements do now in a pay for service system. It could work in a capitated system. It would be well positioned in the type of value-based system that’s envisioned by the Affordable Care Act.
It would also be a safety net for the uninsured. It already is to some degree, because individual elements are provided, but by incentivizing integrated services we could do a better job in that regard.
The role of the community health centers
Let’s talk a little bit about the individual elements, beginning with the federally sponsored delivery systems – first the community health centers. This audience is very sophisticated about community health centers, so I’m not going to spend a lot of time on this.
One of the aspects of community health centers is they use salaried primary care providers. I’m working in the prison system now and you know there’s always a balance between trying to encourage and incentivize salaried civil service type folks to work harder and do more needed services, while not doing extra unnecessary things. But I think working with salary positions puts you in a good position to establish incentives that reward both the quality aspects and the cost containment aspects that are most important. Because your providers are salaried, you can structure their reimbursement in a way that rewards those whose work results in high value for the care that they provide.
Earlier this morning, Doctor Hector Flores expressed concern that we may lose the ability to do case management, because there’s just not the money there for it. Community health centers – because they are cost-based reimbursed – have a little better shot at supporting medical homes and multidisciplinary teams. At least, within community health centers, their cost-based reimbursement structure provides some ability to hire staff that can best meet their needs.
If we focus on extending our use of our primary care providers in the most effective way – using the medical and multidisciplinary teams to enable our providers to focus on the aspects that they only can provide and using others to help augment that care – we should be able to develop an integrated system that better supports our primary care providers and at the same time provides more individualized services to our patients.
These types of innovations are supported by the Affordable Care Act, but I don’t think they’re funded to an extent that will result in a massive shift in how care is delivered. Again, I think the main dollars in PPACA are really for that expansion in health care coverage.
The Safety Net Hospitals
Safety net hospitals currently provide the bulk of care to the uninsured and for indigent populations. I think there’s a lot of angst out there, and concern about what’s going to happen with our safety net hospitals if Disproportionate Share Funding (DSH) goes away. If safety net hospitals were part of a network of care, that could benefit us by their providing care in the most efficient matter. Then they can be incentivized to move people out of the hospital quickly, and perhaps expand some nursing home or skilled nursing care types of step down facilities that best meet the needs of the organization as a whole. Rather than being totally dependent on providing high cost services, if they’re part of a system that’s integrated, they can perhaps share as we redesign our system.
Specialty services is a trickier concept. Community health centers are well-defined entities and the physicians that work in them, as I’ve said, are salaried for the most part. Our specialist colleagues are reimbursed in a number of ways and, for those in academic settings, the faculty plans vary across the country.
There are other issues with specialty services. It’s hard to get a handle on exactly how much specialty services that we need. We have an aging society, so that will increase demand. I think as a society we always want the best for ourselves and our family. I think people tend to think they should see the specialist even if it is for things that a primary care provider should handle.
At the same time, there are some interesting studies that look at the amount of time that specialists spend on things like prevention and more primary care aspects and it makes up to 50% of the time that they spend. So exactly how much time would we need from our specialists? I think that’s something that we could push a little bit.
Also, if you could change reimbursement models for specialists it could dramatically change utilization. If you capitate a cardiologist, you’re likely to see a dramatic decrease in the number of angiograms that they do. I think there are opportunities to look at different kinds of mechanisms and structures for reimbursing specialists.
I think there are also a lot of opportunities to improve efficiency within specialty care by expanding use of warm lines, telephone consultations, and by doing more with e-mails. There are a lot of opportunities to significantly impact on specialty services costs in an integrated system, such as hiring specialists for second opinions and consultation. There are a lot of things that we as primary care providers would be comfortable handling, if we just got a few words of advice from a consultant.
The Fit with Accountable Care Organizations
Earlier this morning, there was a little bit of talk about accountable care organizations (ACOs), that are created by PPACA. Exactly how that will look is still up in the air, but I think it’s basically a move in the right direction. It looks at both quality and cost aspects and it requires that you do have a primary care base and a more integrated approach to care. I think the basic elements are all very positive. A publicly sponsored healthcare delivery system that combines community health centers, safety net hospitals, specialty training programs and the faculty that serve them, would be very well positioned to act as an ACO.
What are some of the keys to success? First of all, focusing not so much on how we insure everybody because PPACA, assuming it makes it through the Supreme Court, does that for us. Now let’s focus on how we actually deliver healthcare services. Let’s look at how we can reduce redundancy within our system. Information Technology (IT) is critical. It’s been a tough nut to crack, but unless we have strong IT systems, we’re all going to be in trouble. I think healthcare is far behind the curve on this compared to other industries. We need to get that fixed.
We need to provide appropriate care in appropriate settings by appropriate personnel. If we have community health centers backed up by specialists and by safety net hospitals, we would be in a strong position to do that. If we look at our reimbursement system so that we reward both quality and cost containment, I think we can see a publicly sponsored healthcare delivery system that is in a strong position to compete for patients and is financially viable. That’s my pitch!
Dr Clasen (moderator): Dr Babitz has a question of Dr Zweifler:
Marc E. Babitz, MD, Utah Department of Health, Salt Lake City: John, this is in your response to your remarks about the public system of care. I agree with you that there are some great opportunities in the public system to have those integrated systems, but those are still very small systems and they wouldn’t even begin to care for the mass of people.
I’m wondering what you think about the role of the private systems, because there are the Kaiser Health Plans and, in Utah, the Intermountain Healthcare system, and there are other private not for profit systems that try to do the same kind of thing. How do you see their role in having integrated systems to cover people better?
Dr Zweifler: Well, such a system would have difficulty handling everybody. But right now, if someone gets sick they end up being cared for someplace and generally it’s in a public entity. So I think that if we build upon the public components, we would be off to a very strong start.
We could create organizations dedicated to providing comprehensive, cost effective care as a public good, as opposed to a for profit motivation. Even though we don’t have have a public option [in PPACA], we could point to these entities helping to meet the needs of our underserved populations.
I would start with that. Certainly the Kaisers of the world could go a long way towards fulfilling this goal. We could just have “Medicaid for all”, or we could just have “Kaiser for all”. That’s certainly a solution. But as an intermediate step it would be beneficial to have an entity that’s more specifically dedicated to providing quality, cost effective, comprehensive care as a public good, as opposed to an entity that has a profit motive. I think that that is the important principle.
Dr Clasen (moderator): Thank you, John.