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A good read: http://healthpolicyandreform.nejm.org/?p=13628&query=TOC
Harnessing Our Opportunity to Make Primary Care Sustainable
NEJM | January 19, 2011 | Topics: Health Care Delivery, Reform Implementation
Jim McDermott, M.D.
Despite the heated rhetoric in Congress about repealing and replacing the Affordable Care Act (ACA), there is a dearth of productive ideas for improving on the legislation. As a Democratic U.S. representative from Washington State, I supported the ACA, but I believe that there remain essential areas of concern that must be addressed long before 2014, when 32 million newly insured Americans will join our health care system. Our foremost task this year must be to develop a strategy to ensure the sustainability of our primary care system.
We have long known that ready access to high-quality primary care permits timely and cost-effective intervention for many health conditions. But access is unreliable for many people in our disordered system. A recent poll conducted by the Kaiser Family Foundation revealed that more than half of Americans delay obtaining primary care because of its cost.1 Patients reported splitting or skipping doses of medications, delaying recommended tests, and neglecting mental health care. These practices contribute to our failure to control the world's most expensive yet inefficient health care system: since we lack a strong and accessible primary care infrastructure, people often enter our health care system disadvantaged by chronic disease or present to high-cost care sites, such as emergency rooms.
Sustainability requires that all patients in the system receive the right care, in the right place, at the right time, in the most effective manner possible. It therefore demands a robust primary care workforce and a system infrastructure that encourages coordination throughout the care spectrum and provides accountability. Any strategy for meeting the objective of primary care sustainability must address Medicare's sustainable growth rate (SGR) formula for determining physicians' reimbursement levels, and given Congress's tendency to address problems only when they reach crisis proportions, the SGR is ready for action.
December's last-minute vote to delay for a year the scheduled 25% reduction in the SGR marked the fifth time that Congress intervened in 2010 to forestall a critical problem related to Medicare access — this time at a cost of $19 billion. That is no way to run a health care system. Congress has given itself 1 year to find a permanent solution for the SGR. Possible solutions vary widely, from eliminating the SGR altogether with no replacement, while encouraging the development of payment reforms, such as those in the ACA (e.g., bundling of payments for episodes of care and the creation of accountable care organizations), to modest improvements, such as using the Medicare Economic Index minus certain productivity adjustments to more closely align reimbursement changes with medical inflation.2
Certainly, debate over the SGR will generate headlines; its effect on our primary care system cannot be overstated, because all physicians are at risk for reimbursement reductions. If Congress again merely delays a scheduled cut, then we will have lost a great opportunity. At the very least, Congress should consider separating and shielding preventive services from SGR cuts because primary care is not responsible for overutilization and because the economic effect on primary care practices could be devastating.
The SGR may currently be the mechanism of choice for Medicare to control spending, but Congress would be grossly negligent if it ignored the prices we pay for medical services in the first place. We can talk about utilization all day long, but if the value we get from our health care system is not aligned with reimbursement, then we will always have an incorrect estimate of what our target spending should be. Today, no group has as much influence in determining the value placed on U.S. medical services as the American Medical Association's Specialty Society Relative Value Scale Update Committee (RUC).3 Although primary care physicians provide about half of Medicare physician visits, they make up only one 6th to one 13th of the committee's membership (depending on how one categorizes internal medicine, osteopathy, and pediatrics). Given that the Centers for Medicare and Medicaid Services accepts the RUC's recommendations more than 94% of the time, this group of 29 private individuals exercises immense influence over Medicare's valuation of various medical procedures. Congress should consider enlarging or realigning the composition of the RUC, if not demoting it to an advisory function and requiring greater transparency of its deliberations. Another strategy could be to protect the reimbursement levels for evaluation-and-management activities from being reduced because of budget-neutrality requirements.
In addition to reimbursement issues, there has been much interest, mostly outside Congress, in reforming our medical education system to meet our primary care needs. We can best ensure an adequate supply of primary care physicians by taking action now to better prepare future physicians, nurses, and other health care professionals for primary care practice. Since medical school debt can easily exceed $200,000,4 physicians' choices of specialty are likely to be linked to financial considerations. The ACA strengthened the National Health Service Corps, which helps to repay medical school loans in exchange for service in medically underserved areas, but we should do much more to relieve medical school graduates of financial considerations when they make their career choices.
One approach might include federal scholarships that cover a significant amount of the cost of medical education if the candidate selects a primary care path. Such a program could be especially useful in conjunction with innovative curricula that defy the current pedagogical trend toward producing superspecialized physicians and researchers. One such curriculum is the Family Medicine Accelerated Track (F-MAT) at Texas Tech University School of Medicine, an accelerated 3-year M.D. program designed to increase the number of family medicine practitioners while imposing less debt and offering a focused and practical curriculum. Unfortunately, F-MAT is unique, and such programs are unlikely to proliferate widely without federal support.
Graduate medical education (GME) also presents an opportunity to improve the sustainability of the primary care system. Although academic medical centers are the hub for most clinical advances and breakthroughs, they are often very expensive or even inappropriate settings for physicians wishing to practice primary care. If the ultimate goal is for patients to avoid the highly specialized tertiary care inpatient setting, then it makes sense to have residency opportunities in less-intensive settings in which primary care physicians would actually practice. Although health policy experts are divided over whether the current allotment of GME slots that are funded by the federal government will be sufficient to meet future demand, one thing is clear: giving control of all GME slots to academic medical centers is probably not the best mechanism for recruiting, training, and dispersing a primary care workforce to meet the needs of the population, especially in rural and underserved areas.
Finally, the Center for Medicare and Medicaid Innovation (CMI) cannot be promoted enough. The CMI is probably the single most overlooked important advancement in the ACA. It is the nexus from which our delivery system may transform into an integrated and sustainable network that can harness and scale up many of the innovations that are already in place but are scattered around the country. If the CMI does its job correctly, Congress will have a creative playbook ready to use. Supporting and closely monitoring the CMI should be a top priority for anyone interested in transformational reform.
This is certainly not an all-encompassing game plan — it's simply the expression of one physician-politician's wish to engage our legislative body in matters that can make a major difference in Americans' lives. My greatest fear is that what may get lost amid the angry threats of "repeal and replace" and endless oversight hearings is our best chance to improve on the historic opportunities afforded us by the ACA.
This article (10.1056/NEJMp1014256) was published on January 19, 2011, at NEJM.org.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
Source Information
Dr. McDermott is a U.S. representative (D-WA).
