Wednesday, December 3, 2008

The Hidden Barrier to U.S. Health Care Reform

We know that because of the priorities of the incoming Obama/Biden administration, there is a great possibility that health care reform in the U.S. may be designed and (hopefully) implemented in the next several years. We also know that the major barrier that any potential reform will face is the cost and who will pay.

There is no doubt that this is a key question which must be answered. But because of the overuse of medical services, the duplication of many health care product lines and expense associated with the reworking of procedures that were not done correctly the first time, there are dollars that could be significantly saved and redirected to care for the large number of under- or uninsured. These issues must be addressed if we are to provide basic health care for all.

This undoubtedly will take a strong collaborative effort between all constituencies--including health care providers, the government and insurance companies--in order to develop an equitable source of funds for this expanded coverage.

We do know that both president-elect Obama is aware of the Massachusetts plan which, although unique, has successfully put together a multi-tiered and multi-participant funding program which is creating the dollars necessary to deliver care for all in that state. However, closer inspection of the Massachusetts plan and its results over the last 6 months uncovers a significant issue which I call “the hidden barrier” in making health care reform possible.

Although Massachusetts has enough money to provide the care, their issue now is the lack of primary care providers to see the patients who now have insurance coverage. This issue is present throughout the U.S. and will clearly come into focus to everyone who has the ability to pay for care that they either think they want or clearly need, regardless of their method of payment.

At the present time, less than 2 percent of all medical school graduates are entering family practice or internal medicine, which serve as the primary caregivers for adults in this country. For years these residency programs have been challenged to fill their open slots with American-trained medical students; therefore, the majority of those training slots in these specialties have been filled with foreign medical graduates.

We find ourselves in this situation primarily because primary care is not seen by the reimbursement bodies as significantly important in the health care continuum, and therefore these physicians have been the lowest on the reimbursement scale for many years. Their low payment rates for services provided are not only causing fewer people to enter the field, but most recently are causing family practitioners and internists who have been practicing for many years to decide that they can no longer continue as independent practitioners. This exodus from primary care is prevalent everywhere, but is mostly exaggerated in rural communities, where--in fact, if reform occurs--the needs will be greatest.

In addition, American health care has not rapidly embraced non-physician health care providers such as nurse practitioners, midwives and physicians’ assistants. This lack of support for these important professions has also been exaggerated recently because of declining reimbursement. Therefore these professionals have become very threatening to primary care physicians, who see any decline in volume as the result of treatment by others as a significant blow to their ability to survive.

I believe that our ability to increase the quantity of primary care providers to care for all of the uninsured in America might be more critical than finding ways to financially support this important undertaking.

So what are some of the possible answers to this dilemma?
1. Both federal and state governments must restructure their payment scales through the Medicare and Medicaid programs so that primary care reimbursements move closer to the payments that some specialists are receiving.
2. Medical school faculties must encourage their students to consider primary care residencies as valuable and exciting as those for surgery.
3. Incentive programs must be developed to entice medical students to enter primary care residencies. This could be done through loan forgiveness programs or providing perks and benefits which might be different than those offered to residents who will eventually go into high-paying specialties.
4. The American Medical Association must do a strong marketing/public awareness campaign to educate the public on what an important role primary care specialist play in maintaining the health of communities throughout the U.S.
5. Health systems should undertake similar awareness programs to make sure primary care physicians know that there are opportunities to enter medical groups. This would provide guaranteed salaries and opportunities to serve in multiple positions (including acting as hospitalists), which would give them the ability to not only make an adequate living, but have a better balance of their personal and professional lives.
6. Health systems, hospital associations and physician societies should understand the appropriate use for well-trained ancillary providers and create opportunities where they can be utilized appropriately to fill in the voids that are created by this low number of primary care providers. There is adequate proof, based on sound research, that midwives, physicians’ assistants and nurse practitioners can work in independent duty stations with clear guidelines that are formulated and overseen with physicians’’ input. These groups of people must be seen as adding value to rather than competing with physicians.

If health care reform is to be successful, not only will the question of affordability have to be answered, but perhaps even more importantly, the question that will need much more deliberation will be, “Who will be providing this care once we make it affordable?” The sooner we address the latter question, the greater chance we will have of being successful in creating some meaningful health care reform that will have permanent sustainability.

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