24th National Conference on Primary Health Care Access
Monday, April 8, 2013 Breakout Group One
Boltri, Lead; Babitz, Scribe; Bejinez-Eastman, Flinders, Levitt, and Schwartz
FACING CAMERA, LEFT TO RIGHT, ANA BEJINEZ-EASTMAN, MD; RICK FLINDERS, MD; FREDERIC SCHWARTZ DO; FACING OTHER DIRECTION, LEFT TO RIGHT, CAROL LEVITT, MD; JOHN BOLTRI, MD; MARC BABITZ, MD
Doctors Marc E. Babitz and Ana Bejinez-Eastman are Senior Fellows of the Coastal Research Group.
Doctors John Boltri and Rick Flinders are Fellows of the Coastal Research Group.
Dr Frederic Schwartz was the 2012 J. Jerry Rodos National Conference Scholar
Dr Carol Levitt is the 2013 Ana Bejinez-Eastman National Conference Scholar.
“Rick Flinders, MD, reminded everyone that summary comments of the Group’s discussion would be posted on coastalresearch.org.
Potential Beneficial and Adverse Impacts of PPACA
Marc Babitz, MD, expressed concern that a lack of support for primary care (increasing the number of primary care providers and increasing primary care reimbursement) may bankrupt ACA by forcing newly insured to use ERs and sub-specialists since they cannot find a primary care provider.
Frederic Schwartz, DO, noted that ACA eliminated additional funds for CHCs and THCs after a five-year period, hoping that THC program will receive long-term support from elsewhere.
Dr Flinders asked if ACA better than nothing? He noted that there are some good things: no exclusion on pre-existing conditions, no lifetime cap, the ability to keep dependents on parent’s insurance until age 26. He expressed his belief that Ted Kennedy’s death had a negative impact on the resulting legislation. He believes that major players (pharmaceuticals, hospitals, equipment manufacturers) have a stranglehold on the American health care system. He also noted that states have options under ACA.
Ana Bejinez-Eastman, MD agreed that the politics of ACA was affected by strange events; ACA is better than nothing, but we can’t rely on the goodness of people to pick up the pieces that are left unfunded.
Dr Schwartz asked if we can judge Medicare in the same way as we look at ACA?
Carol Levitt, MD suggested that from the standpoint of patient care, Medicare has proven to be very valuable.
Dr Schwartz asked how long it was, before we could state that Medicare is valuable? Will some wish to give up some of their income for the benefit of others?
Dr Flinders remarked that the general public’s view now is to “keep government out of my Medicare!”
Dr Levitt expressed her belief that if everyone would give up a little bit, it would help others.
Dr Babitz suggested that the movement of “Tea Party” conservatives to reduce the size of government, has the power to prevent expansion of social programs.
Dr Boltri asked whether the resistance to ACA is about fear of change, loss of wealth, loss of choice?
Dr Flinders asked how much does a person need to make? The answer is always More! He said that he recently started a chapter of Physicians for a National Health Plan, but for the first time in years, there is no proposed legislation in California for a single-payer system. The health care systems problems are a financial issue. Time magazine’s analysis “A Bitter Pill” is important.
Community health centers (CHCs) and federally-qualified health centers (FQHCs)
Dr Schwartz suggested that nobody advocates for the poor,, but that ACA [the Patient Protection and Accountable Care Act] helps the poor with something besides rhetoric. It has funding for teaching health centers [THCs].
Dr Boltri noted that FQHCs are comprehensive systems of care (medical, dental, etc.) that were expanded under President George W. Bush. These could be expanded to provide more service.
Dr Bejinez-Eastman asked why FQHC’s are limited to underserved areas? This system could serve all.
Dr Schwartz observed that the last burst of funding for CHCs went for capital improvements, not expansion of service. CHC’s are hoping to survive until 2014. The problem is that they serve “those people.” That is why some “private” patients won’t go to CHCs, but he expressed his belief that only community health centers among United States providers still had reasonable costs.
Current issues in primary care: costs and patient dissatisfaction
Dr Bejinez-Eastman observed that in the managed care world, a patient comes to an appointment with a “WebMD” note stating that they need a MRI, but, if the doctor doesn’t agree, then the patient is unhappy and reports that they waited for an appointment, couldn’t get what they wanted, and had to “buy” an Over the Counter med).
Dr Boltri remarked that medical bills are very confusing to patients.
Dr Schwartz put forward the case of a patient who has a relatively minor operation, and looks at unbundled bill. The patient calls the insurance company about the costs, to which the insurance company responds “what do you care?, the bill has been paid.”
Dr Bejinez-Eastman recalled a story from Dr Rob Ross about Canadian charges to treat his daughter’s serious injuries in a skiing accident in Canada. The total for all services, was $5,000, including $200 for a plastic surgeon and EMS helicopter transport!) She recounted a recent experience with a routine appendectomy, which cost $25,000 without including the surgeon’s fee.
Dr Boltri raised the issue that insurance companies take a monetary approach to health care, The “medical loss” ratio is their term for paying for health care
Dr Babitz noted that insurance companies don’t have an incentive to pay for anti-smoking efforts, since those patients’ diseases will be covered later (under Medicare, usually)
Dr Schwartz stated that the health cares system in the United States does a lousy job delivering care compared to other countries. He gave the example from Germany of medical care that included a public health intervention.
Dr Boltri noted that a patient living in Germany, who discovered testicular cancer was treated, and his bills were under $5,000. The costs in Germany are affordable for the average person.
Dr Bejinez-Eastman remarked that the emergency room costs $275/half hour, even when the patient is just waiting for a doctor. Other countries have sensible approach. They pay more attention to public health and all other parts of the health care system. In Ireland during flu season there were ads and commercials everywhere with public health messages.
Dr Flinders said that consumers think our higher costs are because of higher quality, but, he noted that Dr John Saultz [of Oregon Health Sciences University] said that we have passed the point of diminishing returns on health – i.e., the more money we spend on health, the worse our health outcomes, because we take money away from “social determinant” factors like education, healthy environments, etc. We lay off teachers and close state parks to save money for health care costs. He noted that family physicians still have those special moments with patients in the room. He expressed his belief that the EHR is a huge invasion into that personal encounter.
Dr Bejinez-Eastman suggested that residency programs need to teach residents how to prevent the computer from taking over the visit.
Issues with the medical school training and specialty choices of physicians
Dr Levitt raised the problems caused by the lack of primary care providers. Many years ago most medical school grads were primary care, but often waited for fellowship positions to open up.
Dr Schwartz suggested that an historical analysis should be made of the consequences of adoption of the RB/RVS scale which created disparity in compensation between sub-specialists and primary care. Blue Shield was organized by surgeons.
Dr Boltri stated that our health care system is a like a broken down Gremlin. We need to replace the system rather than keep trying to repair it. Detroit has been pioneering ACOs. There are four hospital-based ACOs that are in competition with each other. But working together would decrease their individual revenue.
Dr Schwartz suggested that we need to recognize the undersupply of primary care providers, and change the methods of training physicians.
Dr Babitz noted that medical schools train students to be like the medical school’s sub-specialty faculty. Those that cannot be like the faculty end up trying to do primary care, but these are not appropriate primary care physicians (failed ortho surgeons, etc.)
Dr Flinders noted that MD schools only have 8% going into primary care. DO schools graduate many more. There needs to be more loan forgiveness for primary care.
Dr Bejinez-Eastman suggested that if you want something that is in short supply, pay more for it.
Dr Babitz asked whether that isn’t the idea behind boutique/concierge medicine?
Dr Flinders suggested that there was a need to determine what would be funded by which sources.
Dr Babitz suggested that boutique medicine aggravates the shortage of primary care providers because they see so few patients.
Dr Bejinez-Eastman suggested that students need to figure out how to pay off debt.
Dr Babitz said that there is a “debt payoff” study showing that you could be a family physician and pay off debt, although he believes it would be a bad idea for the nation to rely on that possibility to obtain an adequate supply of primary care physicians.
Dr Boltri asked whether the financing of health care has affected physician behavior?
Dr Babitz reported that at a 25 year medical school reunion, the medical sub-specialists were the most “unhappy” and many found their professional lives were boring and repetitive.
Dr Flinders said that the most satisfied physicians are family doctors.
Dr Schwartz asked whether the changes that are coming in health care will continue to provide satisfaction for FPs?
Dr Bejinez-Eastman noted that here have been past times when family physicians had lots of pressures to see large numbers of patients. The move ove to team-based care helps. She said she is looking forward to having more time with patients.