Are we the bestFrom my perspective (and remember, if your only tool’s a hammer, all the world’s a nail) here are aspects of health care reform that are important to Alabama:
1) Access for acute, preventive, and chronic disease services for all Americans (which does not include a pre-exist clause) in places other than the ER. While EMTALA provides coverage for “heroic” care in the ER, it does not allow for the prevention of these very expensive and often preventible episodes. Also, many feel that without universal access any healthcare reform will fail due to “cherry picking” by the commercial carriers such as has historically occurred. This access can occur through commercial plans or a government “Medicare for all” model. If commercial plans are utilized, it is very important to create minimum standards based on quality because (as you are no doubt aware), if these are not created then competition is based on price alone which is why the HMO movement failed. Creating access would allow us to work on the entrenched health problems that dominate Alabama health statistics such as a premature birth (access for family planning), care for diseases such as diabetes (primary care access), and early detection and treatment of cancers such as breast cancer (primary care and specialty care). A lack of a “public option” would leave Alabama an effective single payor system as 95% of people not covered by Medicare or Medicais are covered by Blue Cross/Blue Shield
2) Strengthen the primary care infrastructure and reward coordinated, collaborative care DIRECTED by the primary care physician. We now have enough data to know that people do better and care is cheaper if they have a medical home, if that medical home has the electronic capability to allow prospective recommendations regarding preventive and chronic disease care, and the specialty care is coordinated through the primary medical home. Although many people believe they can coordinate their own care, the evidence is that this is expensive and leads to poor patient outcomes. Additionally, the reimbursement system needs to be restructured away from rewarding episodic “procedural” care towards this type of care management. Lastly, the vast cost of care for a given person is incurred in their last months of life. A medical home can allow patients to have access to an “honest broker” who might be able to reduce these costs through timely hospice referral and effective palliation. The proposals that pay for this through management fees seem to make the most sense to me. Creating this type of payment system would encourage practices to move from an urgent care model (many providers have left private practice in rural Alabama and moved into urgent care type practices) to a model where primary care in rural areas is adequately rewarded. These practices could offer urgent care as a part of the “basket of services” but would not necessarily need the full and costly infrastructure of the hospital.
3) Training of primary care physicians (family physicians, internists, pediatricians) needs to be revamped and adequately funded. Current funding mechanism through Medicare is based on a model of care from the 1960s when training was based on an apprentice model and the poor were the substrate upon which physicians trained. Primary care training should not be primarily hospital based. Additionally, trying to teach learners (premed students, medical students, and residents) primary care is difficult work. Training programs need funding for instructors above what the supervised learners can generate through supervised patient care. HRSA Title VII has been an historic mechanism through which to do this and it is up for reauthorization this year but it may be that the entire method of paying for medical education should be revamped. In Alabama the problem is even more acute as we are a net exporter of physicians and our primary care workforce is rapidly nearing retirement age. Physician assistants and nurse practitioners are important providers of healthcare as well but people want physician directed care.
4) Transformational change must occur which includes universal coverage and movement towards a primary care based system. Attempts at incremental change will lead to failure. Funding concerns, while important, should take into account the current situation and anticipated savings. Paul Grundy, Vice President for Healthcare at IBM is going around the country with a slide show demonstrating how poor the cost/quality ratio is in this country as opposed to other countries as well as how IBM is not creating jobs in this country as a consequence. Up until very recently, healthcare was seen as “an important part of the American economic engine”. I think now we see it is more of a support service which helps us to have a productive economy and that wasteful healthcare spending hurts us all. In Alabama, Medicaid and Blue Cross (included the Medicare plans they administer) cover over 80% of the population. If they can be convinced to embrace such change, it will happen.