Symposium on Health Reform.....

[physasst]

So, just got back a couple of days ago from a health policy/health reform summit in DC..

All the major players were there, including Rohack from the AMA, Ignagni from AHIP, Clancy from AHRQ, Kirch from the AAMC, etc.etc.etc. Along with a bunch of Congressional folks and others, inlcuding several presidents of consumer watch groups, and others. My highlight was getting to have a long discussion with Tim Johnson from ABC News, Gilifillan, and the editor in chief of Health Affairs about the fact the ACA was actually a conservative, republican plan advanced by Stuart of the Heritage Foundation in 2003.

Great meeting, similar to most that I have been too. Most of us in the health policy arena are all on the same page with the primary objectives...

The number one objective coming out of this meeting was: CHANGE the way medicine is paid for, and eliminate the archaic fee for service payment model. All other changes will be driven by money. We discussed ACO's, although, as I pointed out at one point, there is not a single ACO in existence yet, so although they look promising on paper, we have not a single shred of quantitative data on which to base any decisions.

Still the number one objective voted on by the attendees was changing the payment structure.

Whether this means adopting a model like Prometheus, which I support, or a different model is yet to be seen.

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[facetguy]

Is there hope that with a change in reimbursement structure (e.g., ACO) we will finally see more emphasis on preventive care? Is the topic of 'what medicine', in addition to just 'how to pay for it', discussed at symposia like the one you attended?

 

[physasst]

Is there hope that with a change in reimbursement structure (e.g., ACO) we will finally see more emphasis on preventive care? Is the topic of 'what medicine', in addition to just 'how to pay for it', discussed at symposia like the one you attended?

Yes, but not as much. There is a lot of discussion about returning the focus to primary care, but the specifics get a little murky after that. I practice as a PA in EM, but am finishing my doctoral, and have an undergraduate degree in economics, so policy kind of lends itself to me, which is the reason for me being there.

I usually get a little more disappointed by the lack of discussion about workforce specifics, as my career is evolving into one of a medical/physician workforce researcher. There is a lot of vague discussion about letting non physician providers practice to the "top of their licensure", but these symposia generally stop at that point, and other workforce discussions are really more subtle. The Annual AAMC Physician Workforce Research Meeting is much better for my interests.

This meeting was primarily about value in healthcare, and how do we define it, and how do we obtain it. All participants would listen to various panel discussions, ask questions, and then work in a small workgroup on a particular broad question. The answers were collated, and then later, using electronic voting pads, all participants rated items by their importance. These were narrowed down, finalized, and then voted on again. The output is then a consensus of attendees there, and not the host.

FWIW, there was a contigent of medical students there as well, and they got to vote too.

 

[JaggerPlate]

ACOs, pushing the ACA, and expanding midlevel practices to fill a 'primary care gap.' It sounds awesome.

 

[facetguy]

Yes, but not as much. There is a lot of discussion about returning the focus to primary care, but the specifics get a little murky after that. I practice as a PA in EM, but am finishing my doctoral, and have an undergraduate degree in economics, so policy kind of lends itself to me, which is the reason for me being there.

I usually get a little more disappointed by the lack of discussion about workforce specifics, as my career is evolving into one of a medical/physician workforce researcher. There is a lot of vague discussion about letting non physician providers practice to the "top of their licensure", but these symposia generally stop at that point, and other workforce discussions are really more subtle. The Annual AAMC Physician Workforce Research Meeting is much better for my interests.

This meeting was primarily about value in healthcare, and how do we define it, and how do we obtain it. All participants would listen to various panel discussions, ask questions, and then work in a small workgroup on a particular broad question. The answers were collated, and then later, using electronic voting pads, all participants rated items by their importance. These were narrowed down, finalized, and then voted on again. The output is then a consensus of attendees there, and not the host.

FWIW, there was a contigent of medical students there as well, and they got to vote too.

But you see what I'm getting at. What's the use in trying to figure out different ways to pay for the same healthcare that is failing miserably at making us healthier? I'm primarily referring to the chronic diseases that do the most damage to our system (and to us!). Nobody will argue that our medical system is the best at acute/crisis care and highly complicated cases. But using an acute care model to deal with chronic diseases doesn't work. I just hope that there are discussions happening that consider how we can change for the better. Navigating through financial conflicts of interest will prove challenging.

 

[physasst]

But you see what I'm getting at. What's the use in trying to figure out different ways to pay for the same healthcare that is failing miserably at making us healthier? I'm primarily referring to the chronic diseases that do the most damage to our system (and to us!). Nobody will argue that our medical system is the best at acute/crisis care and highly complicated cases. But using an acute care model to deal with chronic diseases doesn't work. I just hope that there are discussions happening that consider how we can change for the better. Navigating through financial conflicts of interest will prove challenging.

True, and we have to find a way to manage the 5% responsible for 47% of the spending better. This is where the concept of an ACO is useful. Primary care needs to drive the ship.

One of my other initiatives that I have proposed is not very popular with some, but could help with both workforce and chronic care management. That is to reduce reimbursements to specialists and proceduralists by 20%, and institute a concomitant rise in pay of 15-18% to primary care. You can imagine that that has not made me very popular with some groups. It won't happen, for primarily political reasons, but it should.

 

[JaggerPlate]

That is to reduce reimbursements to specialists and proceduralists by 20%, and institute a concomitant rise in pay of 15-18% to primary care. You can imagine that that has not made me very popular with some groups. It won't happen, for primarily political reasons, but it should.

"Robbing Peter to pay Paul?" When has this solved anything, ever?

 

[physasst]

"Robbing Peter to pay Paul?" When has this solved anything, ever?

Nothing to do with that. It's quite simple. Primary care makes way too little. FP average salary as of 2007 was 148,000, while the same year, Neurosurgery was 476,000. That's over a 300% difference in pay.

I have never stated, not once, that specialists, due to longer residencies, and, at least theoretically, more complex risk exposure and management, should not get paid more than primary care. But the question is, HOW much more?

I think 300% is obscene. I would suggest that no specialty should make more than 75-100% of primary care. Not ever. There would of course be a scalar effect depending on specialty, and demand, but the current differential or gap, is simply unacceptable.

 

[JaggerPlate]

Nothing to do with that. It's quite simple. Primary care makes way too little. FP average salary as of 2007 was 148,000, while the same year, Neurosurgery was 476,000. That's over a 300% difference in pay.

I have never stated, not once, that specialists, due to longer residencies, and, at least theoretically, more complex risk exposure and management, should not get paid more than primary care. But the question is, HOW much more?

I think 300% is obscene. I would suggest that no specialty should make more than 75-100% of primary care. Not ever. There would of course be a scalar effect depending on specialty, and demand, but the current differential or gap, is simply unacceptable.

Nothing to do with that? You directly said that you'd like to take away 20% of specialist reimbursements (which is a hard generalization to make by the way) and add 20% to PCP reimbursements. How is this not a textbook definition of 'robbing Peter to pay Paul.'

Furthermore, your ideas are starting to get a bit extreme. It sounds like you're definitely in favor of an increased amount of authoritative control over practicing clinicians. Maybe it's my ideology, but I don't think this anti-competition (if there is such thing in the health service industry) mentality of some over riding body saying 'you make too much, I will take X% from you and give it to him' is effective. Granted, in a way, the current reimbursement model from insurance companies does resemble this basic structure, but it isn't so centralized. You're starting to tread on thin ice when you begin decreeing how much certain practitioners should or should not make.

 

[physasst]

Nothing to do with that? You directly said that you'd like to take away 20% of specialist reimbursements (which is a hard generalization to make by the way) and add 20% to PCP reimbursements. How is this not a textbook definition of 'robbing Peter to pay Paul.'

Furthermore, your ideas are starting to get a bit extreme. It sounds like you're definitely in favor of an increased amount of authoritative control over practicing clinicians. Maybe it's my ideology, but I don't think this anti-competition (if there is such thing in the health service industry) mentality of some over riding body saying 'you make too much, I will take X% from you and give it to him' is effective. Granted, in a way, the current reimbursement model from insurance companies does resemble this basic structure, but it isn't so centralized. You're starting to tread on thin ice when you begin decreeing how much certain practitioners should or should not make.

Well, I won't lie. I'm in favor of centralized workforce planning for the medical workforce, ala the UK, however, as I cannot achieve that in the current construct, I will advocate whatever other means (primarily economic) to mobilize providers into specialties and areas where needed.

Don't worry however, as much as I do have a small voice in this process, the specialist lobby groups have a greater voice, as they have the only real voice of reason in Congress.....money.

 

[JaggerPlate]

Well, I won't lie. I'm in favor of centralized workforce planning for the medical workforce, ala the UK, however, as I cannot achieve that in the current construct, I will advocate whatever other means (primarily economic) to mobilize providers into specialties and areas where needed.

Don't worry however, as much as I do have a small voice in this process, the specialist lobby groups have a greater voice, as they have the only real voice of reason in Congress.....money.

Umm, are you aware that England is looking to decentralize their model and essentially move away from a non-clinician run, bureaucratic, centralized model and toward a 'local-level,' physician focused model?

http://www.nytimes.com/2010/07/25/world/europe/25britain.html

 

[physasst]

Umm, are you aware that England is looking to decentralize their model and essentially move away from a non-clinician run, bureaucratic, centralized model and toward a 'local-level,' physician focused model?

http://www.nytimes.com/2010/07/25/world/europe/25britain.html

That's a decentralization of the healthcare delivery mechanism, not the workforce planning mechanism, which is different.

But, it does raise some questions. I will email my friend and colleague, Andy Knapton, who is one of the primary UK workforce researchers, and administrators of the UK centralized program. I will let you know what his response was.

 

[JaggerPlate]

That's a decentralization of the healthcare delivery mechanism, not the workforce planning mechanism, which is different.

But, it does raise some questions. I will email my friend and colleague, Andy Knapton, who is one of the primary UK workforce researchers, and administrators of the UK centralized program. I will let you know what his response was.

Not only do I see both as different modes of 'top-down' control (mediated by non-clinicians), but I also think differentiating two different models (one centralized for planning, one decentralized for delivery) seems to simply add more bureaucracy to the process. Never a good thing in my book. Personally, I think the system needs reform (everyone does). However, like JackaDeli said before, I see no reason why this shift needs to be toward more centralization.

 

[Lokhtar]

Because I'd rather have more consistency in delivery of care, availability of services, and uniform standards. That's my opinion, of course. But then, I am happily counting the days until a single payer system, so I am probably to the left of many on here .

 

[shopsteward]

Umm, are you aware that England is looking to decentralize their model and essentially move away from a non-clinician run, bureaucratic, centralized model and toward a 'local-level,' physician focused model?

http://www.nytimes.com/2010/07/25/world/europe/25britain.html

I strongly suspect that while this is the retoric about the proposed changes in England, it is not going to be the reality. In practice, what happens at the moment is that health services are "commissioned" by primary care trusts, which are public bodies with members mainly drawn from local health care professionals and serviced by administrators who are public employees. In future, health services will be commissioned by a group of general practitioners, who will need to be supported by administrators. Because of employment rules governing the transfer of a public function from one body to another, the existing employees will have to be transferred over from the existing primary care trusts to the new GP groups.

In other words, this is yet another case of rearranging the deckchairs on the NHS Titanic, just three years after the last rearrangement of primary care trusts.

I still happen to think the UK system is better than the US lack of system. But in healthcare no system is perfect and no system ever will be.

 

[MOHS_01]

****ing philosopher kings have been the bane of the self sovereign and vandal of the lot of the ordinary man since the time of Antiquity. It does not matter what manner of resource allocation we are referring to -- toilet paper or healthcare delivery -- the record of history is perfectly clear and remarkably consistent: IT DOES NOT WORK.

 

[Lokhtar]

Hmm, serious question to you MOHS. If we moved to zero public funding for (for example) police department, would it result in superior outcomes?

 

[MOHS_01]

Hmm, serious question to you MOHS. If we moved to zero public funding for (for example) police department, would it result in superior outcomes?

I believe that you are conflating two fundamentally different arenas, but to answer your question: a total privatization of policing may prove to be problematic for a variety of reasons. For some it would undeniably be "better", but for others it would not. A key point that needs to be understood is that the enforcement of law and contract constitutes a legitimate purpose of government; trimming grandma's toenails does not.

 

[OffPiste]

I would like to hear some explanation why specialists do not deserve to have higher reimbursement than primary care. Please provide some rationale why a neurosurgeon or cardiac anesthesiologist should not be reimbursed more than Marcus Welby, MD. Go ahead enact gross reductions in vital subspecialty care and see what happens. It is a cheap argument to propose 20% reduction in specialist income and increase in PCP income will solve the problems associated with management of chronic conditions, most of which are related to lifestyle modification. Nonsense.

 

[lee9786]

Sorry guys. It looks like government is going to be running the show not too far down the line. who knows. From what I've heard. Money might not be an issue.

 

[bronx43]

I would like to hear some explanation why specialists do not deserve to have higher reimbursement than primary care. Please provide some rationale why a neurosurgeon or cardiac anesthesiologist should not be reimbursed more than Marcus Welby, MD. Go ahead enact gross reductions in vital subspecialty care and see what happens. It is a cheap argument to propose 20% reduction in specialist income and increase in PCP income will solve the problems associated with management of chronic conditions, most of which are related to lifestyle modification. Nonsense.

I don't know how this issue can be argued in the current system of third party reimbursement and governmental limitation on supply of providers. The mere fact that you're asking why specialists don't deserve to have higher reimbursement demonstrates that you carry the inherent assumption that specialists deserve higher reimbursement. Furthermore, you use the word "deserve," as if there was some external basis of entitlement. If your next argument involves length of training, then you'll have to explain how such a parameter can be used as a pricing mechanism. Why does additional training necessitate increased reimbursement? Even if you can demonstrate that point, how would you price it specifically? How much is one additional year worth? And how do you know that?

 

[bronx43]

Sorry guys. It looks like government is going to be running the show not too far down the line. who knows. From what I've heard. Money might not be an issue.

Barring another financial crisis of far larger amplitude, I don't foresee any single payer systems. Special interest groups are far too ingrained in American politics that the demise of corporate lobbying will necessitate the demise of the nation as we know it.

 

[lee9786]

Barring another financial crisis of far larger amplitude, I don't foresee any single payer systems. Special interest groups are far too ingrained in American politics that the demise of corporate lobbying will necessitate the demise of the nation as we know it.

What if the currency crashes? Things will either centralize or decentralize. All systems are pointing toward centralization. If you look deep enough, you'll see how governments been growing. The false assumption is that it's the government. In fact the people that make all these stimulus plans possible is the man behind the scene- The Federal Reserve. When people realize it's really their Federal Reserve they have to be worrying about, and not the government it will be too late.

The bankers/Corporatists have a global agenda, and it's working quite nice them. They want one currency they can control. Just look at how Medicine in this country is going. Everything is merging and consolidating. There are less docs working in private practice and working for corporations. Look at the mergers in the health insurance industry. At some point it will be past the point of no return, and people will be begging for the government to run their healthcare. They don't want private ownership, and we've seen corporations gobble them up.

There's my case for single payer. People might claim conspiracy theory, but if you actually looked -which is rare in this country- than you would find out there's evidence pointing to this happening. The people in this country are completely clueless, as they think Democrat/Republican really means anything. You have people out there like Alex Jones and Jesse Ventura who are actually damaging any real progress for a real solution. The people in this country by and large aren't capable of critical thinking and will follow as directed to where they need to go.

The solution is simple. Re-establish a currency based on what we have, get rid of the central bank, get rid of Corporatist political influence, re-establish our political system (aka kick them all out, add new parties, establish citizen checks and balances), decentralize the government back to the the local, county, and state level with minimal federal government power. None of this will happen though. The only politician really talking about this is Ron Paul, which people have written off as some quack. In reality they aren't paying attention. One man wouldn't do much anyway. We'd need the entire populace to wake up, which won't happen. We won't respond until we're really feeling the pain. By then we will be begging big brother to come save the day. Really sad actually.

 

[bronx43]

What if the currency crashes? Things will either centralize or decentralize. All systems are pointing toward centralization. If you look deep enough, you'll see how governments been growing. The false assumption is that it's the government. In fact the people that make all these stimulus plans possible is the man behind the scene- The Federal Reserve. When people realize it's really their Federal Reserve they have to be worrying about, and not the government it will be too late.

The bankers/Corporatists have a global agenda, and it's working quite nice them. They want one currency they can control. Just look at how Medicine in this country is going. Everything is merging and consolidating. There are less docs working in private practice and working for corporations. Look at the mergers in the health insurance industry. At some point it will be past the point of no return, and people will be begging for the government to run their healthcare. They don't want private ownership, and we've seen corporations gobble them up.

There's my case for single payer. People might claim conspiracy theory, but if you actually looked -which is rare in this country- than you would find out there's evidence pointing to this happening. The people in this country are completely clueless, as they think Democrat/Republican really means anything. You have people out there like Alex Jones and Jesse Ventura who are actually damaging any real progress for a real solution. The people in this country by and large aren't capable of critical thinking and will follow as directed to where they need to go.

The solution is simple. Re-establish a currency based on what we have, get rid of the central bank, get rid of Corporatist political influence, re-establish our political system (aka kick them all out, add new parties, establish citizen checks and balances), decentralize the government back to the the local, county, and state level with minimal federal government power. None of this will happen though. The only politician really talking about this is Ron Paul, which people have written off as some quack. In reality they aren't paying attention. One man wouldn't do much anyway. We'd need the entire populace to wake up, which won't happen. We won't respond until we're really feeling the pain. By then we will be begging big brother to come save the day. Really sad actually.

A hyperinflationary event would certainly count as a crisis that is needed to get the country out of status quo, though I would say the likelihood of that happening in the near future is slim. You're probably right about centralization, but that'll depend on the sentiment of the nation right before and after the crash. But, the bottom line that we agree on is that the general populace is clueless, which makes it impossible for any change to rise about organically without the help of disaster.