One Thing I Can Do for Health Reform

On Saturday, I tried to contribute to my local chapter by hosting a letter-writing party. No one else showed up, but I still thought I could pass on what I've written to use as inspiration or as one of many example letters out there. We may disagree on details of legislation, but we cannot abide the status quo any longer. Please get active in your advocacy, folks!

Dear Congressperson:

First of all, I do want to express my gratitude for your service to our community and your concern for responsible government. I am writing today on the topic of health care reform.

Health care is complex, yet as a Family Physician in Lexington KY, I have seen that to most of my patients, the issue is simply that they cannot afford care through no fault of their own. As the most recent hire in our practice, I have seen many new patients. These patients are disproportionately without insurance; they have been laid off or cannot find work and there is absolutely no way for them to get affordable individual insurance plans. Most of them would not even qualify due to pre-existing conditions. They have put off visits for six months or more, hoping to find work or waiting to qualify for Medicare or Medicaid. One woman, having turned 65 last month, came in with an entire notebook page listing the medical conditions for which she needed attention. Every single uninsured patient who comes to our clinic must pay a $20 co-pay to be seen; they then meet with a financial counselor to discount the approximately $130-190 visit fee a bit and arrange how they will pay it in installments. There is, of course, no point in suggesting a costly colonoscopy or mammogram. Most patients agree to some important labs or a Pap test even though there are extra fees for those.

For the most part, these folks are hard working people who simply can’t get a job or insurance right now. Times like these also engender an increase in people seeking disability or worker’s compensation for questionable reasons, seeing those avenues as their only hope of getting any care. All of these things put a burden on health care providers and weaken our fragile relationship with our patients. (Our clinic’s financial situation is worse than it has been in years. Our patient “no-show” rate has skyrocketed as patients decide they can’t afford those fees after all; in the meantime we can’t see enough walk-in and chronic care patients due to the long visits and extraordinary paperwork burden imposed by the ones who have put off care for months.)

I know you are committed to finding a solution to the health care crisis that is financially responsible, but I want to point out that no change is the least responsible of all. Costs have escalated despite years of “band-aid” measures, and yet quality has barely improved at all. I firmly believe that if we change the way physicians are paid, including incentives for model delivery systems, we could, in fact, give better care at reduced costs. Every reputable study (see the attached examples from Barbara Starfield and the Dartmouth Atlas team) confirms that a strong primary care base delivers this type of care and saves money over a tertiary-care based system. I do not advocate “taking” money away from specialists, just paying more for care that truly benefits patients. All of us doctors should be judged on our outcomes and quality for the population that we serve.

With quality and value in mind, I want to especially emphasize these elements of reform:
- elimination of the sustainable growth formula over the next 5-10 years as we investigate more equitable options
- paying for coordination of care through bonus payments to providers who fit a standard definition of giving primary care
- paying for services that provide value to patients by allowing them to maintain their health without the undue burden of navigating the health care system unnecessarily. These services include communications via email, phone, and/or internet, group visits, and community health conducted by nurses or lay health workers. All of these things can promote prevention behavior, reduce waiting times for care and unnecessary visits to emergency rooms, and are much cheaper for Medicare and Medicaid than having these people visiting the doctor every few weeks.
- Reducing the over-payment for reimbursement of imaging modalities whose profit/overhead has ballooned over the last 10-15 years, as well as elimination of Medicare Advantage Plans. MedPac has overwhelmingly endorsed these cuts as fair and of value for patients.
- Encouragement of research and demonstration of novel modes of delivery such as primary care medical homes. We physicians desperately want to improve care for our patients through teamwork and quality improvement measures, but can’t afford to make major changes under the current reimbursement system that simply encourages large volumes of simple (often unnecessary) visits
- Support for graduate medical education funding being directed to the source of training, rather than always to the hospital. Hospitals have essentially no accountability for where this enormous amount of money goes. In the meantime, keeping the money tied up in tertiary care centers stunts experiences in community health centers, private offices, and rural sites that primary care trainees desperately need
- Fund comparative effectiveness research aggressively. It is not designed to force decisions on doctors, but rather help them make decisions. The tragedy isn’t that a child might not get a tonsillectomy, it’s that in 2009, we still don’t know if they actually benefit anyone, and if so, whom. We’re still guessing at many tests and treatments, and that is bad patient care.

Figuring out how to judge quality and structure this system of delivery will be difficult, but that doesn’t mean that patients can wait. They are desperate for change, and so are providers. Many people are frightened of change, but the truth is that we are in a burning building here, and we cannot let those who would stand still out of fear keep us from saving it.

Competition in service delivery is good. Efficiency and value are good. But health does not operate as a free-market good. You cannot choose your body. Nor can you choose your parents, whether you grew up in poverty, were abused, were exposed to environmental toxins, or got a decent early education. You can shape your health if you have enough education and resources to buy good food, exercise safely, and take care of your mental health, but many people do not have this luxury. Nor do they have the expertise to “shop around” for the best health care, especially when the situation is an emergency. It is ethically and morally wrong to keep punishing our brothers and sisters who are in this situation while we try to protect the business interests of a few or make a perfect health system.

In the name of competition and accountability, I highly support transparency in procedures and outcomes (especially medical errors), and a public plan to put pressure on insurers. But by far the most important part of the legislation in question is guaranteeing basic coverage – at least for primary and catastrophic care without exceptions for pre-existing conditions. In a society that actively promotes unhealthy lifestyles and still leaves poor children at terrible disadvantage, we owe ourselves and our neighbors this much – to be free of fear of being ruined by their own health and health care system. We can always change the details of this legislation in the future if we find that there are better ways to deliver this care, but it may be years before we have another chance to avoid the unsustainable dismal future of the status quo.

Please do not let this opportunity pass to protect equity in health care.

http://pcpcc.net/content/primary-care-video-presentation-dr-barbara-starfield

http://www.dartmouthatlas.org/index.shtm

http://finance.senate.gov/hearings/testimony/2009test/031209dgtest.pdf

To the Editor:

I am a native of Murray who is now a Family Physician in Lexington. As the most recent hire in our practice, I have seen many new patients. These patients are disproportionately without insurance; they have been laid off or cannot find work and there is absolutely no way for them to get affordable individual insurance plans. Most of them would not even qualify due to pre-existing conditions. They have put off visits for six months or more, hoping to find work or waiting to qualify for Medicare or Medicaid. There is, of course, no point in suggesting a costly colonoscopy or mammogram. Most patients agree to some important labs or a Pap test even though there are extra fees for those.

Competition in service delivery is good. Efficiency and value are good. But health does not operate as a free-market good. You cannot choose your body. Nor can you choose your parents, whether you grew up in poverty, were abused, were exposed to environmental toxins, or got a decent early education. You can shape your health if you have enough education and resources to buy good food, exercise safely, and take care of your mental health, but many people do not have this luxury. Nor do they have the expertise to “shop around” for the best health care, especially when the situation is an emergency. It is ethically and morally wrong to keep punishing our brothers and sisters who are in this situation while we try to protect the business interests of a few or make a perfect health system. Please write and call your Senators and Representatives and tell them how important health care reform is to you.