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Is it society’s duty to ensure equitable access in healthcare?

Question posed to my students in a health policy course

In his book “The Healing of America,” T.R. Reid identifies four distinct methods of (paying people who are) providing healthcare to the citizens of a country. Some countries follow the model of England and collect money form all citizens, mostly via taxes, and use that money to pay for needed care. It is also referred to as  the Beveridge model, after Lord Beveridge, who wrote a report in the war years identifying disease as one of the five “Giant Evils” and recommended state action to combat this and other evils. In this model everyone is entitled. The second was the German model which mandates participation in private insurance. This is also referred to as the Bismark model, after Otto von Bismark, the Prussian chancellor who determined that universal healthcare could be a force in the fight for a unified Germany.  In this model, everyone is mandated to participate. The third is the Canadian model, which taxes citizens to pay for care but allows health care entities to be private contractors. In this model, budgets are set at a regional level and as a consequence some artificial shortages are created. In this model, everyone is treated equitably within the system.  Lastly is the “out-of-pocket” model. In this model, prevalent in developing countries, care is rationed based on ability to pay. In this model, no money=no access.

As T.R. Reid explained in his book and my class identified as America’s unifying model, we use an “all of the above” approach. For those over 65, active duty military, eligible veterans, and native Americans we apply the Beveridge model. Once Americans are in one of these groups, it IS society’s responsibility to provide equitable access in healthcare (well, sort of. Physicians can “opt-out” but for the most part, this is true). For those who work at jobs in larger businesses, we tend to apply the Bismark model (and Obamacare reinforces this). The employers are given a significant subsidy to provide health insurance and most Americans (before 2010, 66%) pay through healthcare via this mechanism. For some of the poor (mostly children and pregnant women but some with chronic illness) and military dependents we apply the Canadian model (how Medicaid and Tricare work, for the most part). For everyone else, we apply the pay- out-of-pocket-or-die-or-go-to-jail model. Obamacare attempted to move the last three groups into an amalgam of Beveridge (poor) and Bismark (everyone else) model.

Turns out the sticking point is the question I asked my students. Unlike my students, who had about a 70-30 split that it was a society and thus government problem, the American public thinks differently. Only 42% of Americans feel a responsibility for their fellow American’s access to healthcare. This increases as people get older peaking with of those who are 65 and older. 53% of these  believe that government should not be providing their health care. The majority of folks opposing the law, in all fairness, despite this believe it is the responsibility of our elected officials to make the existing law (be it via Bismark, Beveridge, Canada, or other) work.

The New England Journal of Medicine has published two essays on this topic this week. The first, out of Kentucky, discusses the benefits to patients living in a poor state that has elected to avail itself of the improvements in access offered by the Affordable Care Act. The author, who had previously written of access problems, says it this way:

But during the past year, many of my lowest-income patients have, for the first time as adults, been able to seek nonurgent medical attention. I recently evaluated a 54-year-old man with hyperlipidemia and a systolic blood pressure of 190 mm Hg whose last physician visit had been with a pediatrician. Before he enrolled in Medicaid, he would have been unable to pay for his appointment and laboratory work, and I wouldn’t have considered offering him a screening colonoscopy since he would surely have been billed for it. Newly insured, however, he was able to afford the tests and medications that most Americans would expect to receive, and he told me he felt proud to have witnessed a sea change in health care delivery in Kentucky and that recent reforms seemed “just.”

On the other side of the discussion is South Carolina, an equally poor state that has elected not to avail itself of the benefits afforded via implementation of  Obama-care. The author speaks of the many attempts to influence policy makers into accepting access for South Carolina’s poorest citizens. This culminated in a series of arrests following peaceful protests on the capitol steps. In his words, he had to act because

When I graduated from medical school in 1979, we did not take an oath, but I have since striven to adopt the words of Moses Maimonides as my guiding philosophy: “The eternal providence has appointed me to watch over the life and health of Thy creatures” and “Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.” My interpretation of this prayer is that I need not only be a good clinician in the hospital or clinic but also attend to the effects on my patients’ lives of the wider world, whether my own hospital or the state government. [W]e must pay attention to the whole patient. Similarly, I now believe that our concern for our patients should encompass the effects of public policies that result in direct harm.

I do believe it is society’s responsibility to provide equitable access and believe Obamacare is the mechanism through which to accomplish this. Living in Alabama, a state that has not accepted the Medicaid expansion, how do we as educators look those we teach in the eye and say “We did all we could” to ensure access for those who are poor, who have mental illness, who are unable to speak for themselves? Anyone else ready to march on Montgomery?

'When did you first notice your timbers were shivering?'I get the New England Journal of Medicine (NEJM) delivered to my home. I know, I know, it is so 1980s to read a journal in paper form (ok, even to read a journal) but I enjoy browsing the most current science and sometimes retain a factoid that later might be useful. I still remember the time I read the Clinical Pathological Conference about a person with confusion and thrombocytopenia (low platelets) where the diagnosis turned out to be thrombotic thrombocytopenic purpura (very rare) and darn if a person with that exact same presentation didn’t call me about a month later. I, the junior resident,  called the hematologist who was at a party and he said something to the effect of “Yeah, right, what do you know…” I elected not to say “I read the New England Journal of Medicine, sir.” Instead I cited all the evidence without mentioning the NEJM article and he agreed with my diagnosis and came in. The patient survived without knowing that her life was saved (or at least the diagnosis was made in a timely fashion) because I got a journal and actually read it.

Many of the diagnoses for those complex cases in the NEJM hinge on an unusual piece of history. Typically, that history is not in the story of the illness (in doctor lingo, the HPI). A fever that starts a week ago is pretty much the same whether it is the flu or malaria. Instead, the clue is in the family or social history. “The patient reports swimming in a waterfall pool in Hawaii” would make me think “leptospirosis” (an infection carried by rats and spread through their urine, typically in large concentrations in the stream above the waterfall…kind of makes you think twice about those movie love scenes, doesn’t it). Part of the job of the health care team is to gather the correct information and synthesize it, keeping the valuable information (swimming in a waterfall pool) and discarding the red herrings (wearing a blue bathing suit). Part of the fun of medicine is to put things together and make a diagnosis so as not to miss a NEJM moment.

Although the details are sketchy, apparently someone in Dallas missed their NEJM moment and is blaming the computer. If you have not heard, Thomas Eric Duncan, a Liberian national, got on an airplane feeling well in Monrovia. He then flew to Brussels, Washington DC, and ended up with family in Dallas. When he started to feel ill, he want to the Emergency Room. At the time (5 days before he got really sick) he had some fever, body aches, and in general wasn’t feeling well. This is where the facts become murky but clearly the moment was missed. Even a doctor, half paying attention (“Ok, so any travel? New pets?”) should raised an eyebrow when a person with an accent says “Well, I did just get in from Liberia.” Reading between the lines of the Slate article, the hospital apparently assigned someone to take a history and enter it into the electronic medical record (perhaps to save the clinician time). Thus, “travel to Liberia” was buried in the record.

Doctoring is very expensive and interpreting symptoms is often unrewarding. Of 1000 people with fever, 999 will have something self-limited. This is especially true in America, where many infectious diseases have been eliminated. There is something, however, to be said for inefficiency. Every now and again, what one person thinks is a red herring (just where is Liberia, anyway) another puts into a pattern and prevents an epidemic. Doctors have got to want a NEJM moment enough, though, to pay attention.

I said in my last entry that I was not going to write about immigration policy. My friend Josh Freeman has done a good job of writing about it for me today so I will refer you to his blog if you still crave HB 56 information.  I have spent a good bit of effort trying to get my arms around the extent of the problem and do have some information to share that will challenge the statement that reducing health care costs justifies HB 56 style “immigration reform.”

There is a belief among proponents of “immigration reform” that folks are coming like moths attracted to a flame to take advantage of our exceptional health care delivery system at no cost to them. The Federation for American Immigration Reform (the “hate group” that was the driving force behand HB 56) has put together a list of diseases spread by “those people” (tuberculosis, trichinosis, and typhoid, mostly culled from case reports related to a single index case). Although they could use these diseases to make a case for the development system of care for undocumented workers, instead they suggest that the fact that these folks are “uninsured” is costing America a bunch of money. From their information: “A California study put the number of these anchor baby deliveries in the state in 1994 at 74,987, at a cost of $215 million.” Contrast this with data from a RAND report:

The report – which appears in the November edition of the journal Health Affairs – estimates that in the United States about $1.1 billion in federal, state and local government funds are spent annually on health care for undocumented immigrants aged 18 to 64. That amounts to an average of $11 in taxes for each U.S. household. In contrast, a total of $88 billion in government funds were spent on health care for all non-elderly adults in 2000.

Is $11 in taxes too high a price to pay for inexpensive catsup? The New England Journal of Medicine article “cited” by FAIR offers a much different perspective as well.

The reason most immigrants come here is to work and earn money; on average, they are younger and healthier than native-born Americans, and they tend to avoid going to the doctor. Many work for employers who don’t offer health insurance, and they can’t afford insurance premiums or medical care. They face language and cultural barriers, and many illegal immigrants fear that visiting a hospital or clinic may draw the attention of immigration officials. Although anti-immigrant sentiment is fueled by the belief that immigrants can obtain federal benefits, 1996 welfare-reform legislation greatly restricted immigrants’ access to programs such as Medicaid, shifting most health care responsibility to state and local governments. The law requires that immigrants wait 5 years after obtaining lawful permanent residency (a “green card”) to apply for federal benefits.

Regarding costs,most data suggests the costs are much less than the taxes paid.

In a study from the RAND Corporation, researchers estimated that undocumented adult immigrants, who make up about 3.2% of the population, account for only about 1.5% of U.S. medical costs

When costs do get high in these young, mostly healthy people it commonly is associated with barriers to care:

Although U.S. hospitals must provide emergency care without first asking about income, insurance, or citizenship, early diagnosis and treatment in a primary care setting are both medically preferable and a better use of resources. “If people keep postponing medical care because they’re so concerned about being sent back over the border,” noted Elizabeth Benson Forer, executive director of the Venice Family Clinic, a venerable free clinic in Los Angeles that serves many immigrants, “then you can end up with some pretty horrendous health situations.”

While there are other costs associated with an influx of undocumented workers (primarily education), to use health care costs as an excuse to encourage the spreading of intolerance is disingenuous at best. Health care costs are high in this country for some very well documented reasons, not including this one. Groups concerned about the future of this country, given our obligation to our “citizens,” should support the Affordable Care Act’s proven cost savings. If they are worried about infectious disease transmission as well as desire to reduce the cost of emergency care delivered to undocumented workers, they should support eliminating barriers to primary care access for these folks through specialized programs.

Mardi Gras has once again hit Mobile and I am taking some time to enjoy the festivities although today it is raining more rain than beads. I did spend some time while running today discussing the relative merits of staying fit, staying skinny, and the effect on health (as opposed to the negative effect on the medico-industrial complex’s bottom line). I have a couple of evidence based observations that I would like to share before I go to collect moon-pies for future consumption thrown to me by perfect strangers.

1) If you want to live a longer and healthier life, it is better to be skinny than fat. From the New England Journal of Medicine:

…overweight and obesity (and possibly underweight) are associated with increased all-cause mortality. All-cause mortality is generally lowest with a BMI of 20.0 to 24.9.

2) If you are overweight, it is better to be in shape than not in shape. From the journal Obesity:

Low Cardiorespiratory Fitness (CRF) in women was an important predictor of all-cause mortality. Body Mass Index, as a predictor of all-cause mortality risk in women, may be misleading unless CRF is also considered.

This remains true even if you look within groups. So, fit people who are very overweight outlive those very overweight people who are unfit, and so on.

3) The real problem for America, in addition to folks dying prematurely,  is that those who are not in shape will consume a lot more health care dollars in their old age. Those dollars are all federal tax dollars. From AHRQ:

Currently, almost one-third of total U.S. health care expenditures is for older adults (over age 65). Health care expenditures for people aged 65 years or older are four times that for 40-year-olds. By 2030, health care spending will increase by 25 percent, simply because the population will be older, before inflation or new technologies are taken into account. Estimates from a study by Harvard researchers calculated that the direct medical costs attributable to inactivity and obesity accounted for nearly 10 percent of all health care expenditures in the United States (Colditz, 1999). Being inactive results in loss of muscle strength and balance and increases the risk of falls. Every year, fall-related injuries among older people cost the nation more than $20.2 billion. By 2020, the total annual cost of these injuries is expected to reach $32.4 billion.

So whose problem is it? As many like to point out, folks need to take “individual responsibility.” Here are some things we all should do from the AHRQ website:

  • Make activity a daily part of your life. Find activities that you enjoy that can become a regular part of your routine, and find others to join you. Partners can make it more fun, can provide encouragement, and help overcome problems of transportation or safety.
  • Consult your clinician about what level of activity is safe and appropriate for you. Discuss any medical issues that might be interfering with more regular activity and review any symptoms and problems that might affect what activities are safe for you.
  • Set specific activity goals. Start slowly and build up to increasing levels of activity. Try to be active for 30 minutes a day on a regular basis.

However, as I like to point out, we need to change how we spend “health care dollars” as well. If, as I pointed out previously, we were to redirect funds into wellness instead of illness, here are some things that have been proven to work that we could do (again from AHRQ):

  • Conduct community-wide campaigns that combine highly visible messages to the public, community events, support groups for active persons, and creation of walking trails.
  • Establish community-based programs, such as those that take place at community centers and senior centers, that can provide individually tailored programs for seniors to become more active. Such groups help members set individual goals; teach participants how to incorporate physical activity into daily routines; provide encouragement, reinforcement, and problem solving; and help sustain progress.
  • Establish community programs that help build social support (at work or in the community) for physical activity.
  • Improve access to places that people can be active, such as walking or bike trails, classes at gyms or senior centers, athletic fields, etc. A review of 12 studies that created or enhanced access to places for physical activity found, on average, a 25 percent increase in the number of persons exercising at least 3 days per week (Kahn, Ramsey, Brownson et al., 2002).

I went to look a some commercial property in downtown Mobile yesterday and was reminded of the Roger Miller song, “King of the Road.” The building, clearly built in the 1920s had gone through a tragedy of some sort. The second story was apparently removed and added onto the structure in the 1940s were about 20 8×8 rooms, each with a sink. There was a door labelled “Office.” There was a common bath for all of the rooms. The word was that it was a “hotel” although I suspect that was being euphemistic. The whole area had been sealed in the 1960s (judging from the papers on the floor) and had not been maintained since. The roof had many leaks, the boards were suffering from dry rot, and even the rats seem to have abandoned the space for fear of disease.

We were looking for potential investment property and this would certainly allow us to invest quite a bit of money (sort of like a sailboat). The truth is that with enough money, the building could be made into a showplace. An article in the New England Journal reminds us that the body does not work that way. In this article people’s blood pressure, cholesterol level, smoking status, and diabetes status looked at in various ways. The investigators found that of the people who were 55 and had everything well controlled, 85% were very likely to live beyond 80 years of age regardless of race or sex. Of people who had two or more of their risk factors uncontrolled or who smoked, 50% were likely to be dead of heart disease or a stroke before age 80.

To fix this building, we would likely have to tear out the entire interior and retrofit it with a modern building. We would end up with a 1920s facade in a 1920s neighborhood but would functionally have a 2010s building. Many of my patients would like to believe that if they let their insides go, I can retrofit them as well. A better approach for the building would have been ongoing maintenance over the past 90 years. It turns out that it is the only approach for the human body.

Victor Fuchs, the health economist, has an essay in a recent New England Journal of Medicine regarding health care rationing. Dr Fuchs has been writing and thinking about health care for a long time. If you are unfamiliar with his work, here are some quotes from an interview in 2000:

When asked how Americans will respond to health reform –

Two-thirds of the American people say they favor universal coverage, but the minute you start to spell out what that means — subsidization for the people who are poor and who are sick, and that the plan has to be compulsory — they are less supportive

When asked what is driving up the cost of health care –

The principle factor by far is medical innovations like new drugs, new surgical procedures and new diagnostic techniques. This is [confirmed by other] health economists in the country.

When asked if more medical care would make us more healthy –

I’m saying that almost everyone is getting the medical care that matters to health. Adding more care does not make much difference. The stuff that’s really effective, the antibiotics, the appendectomies and so forth — people get them. Health depends much more on the things we do to and for ourselves or that we don’t do. It depends on cigarette smoking, it depends on obesity, it depends on certain environmental conditions.

When asked what should we do to improve our health –

Improved health will come about through changes in the physical and psychosocial environments and in individual behavior and in medical advances, not in increasing the quantity of medical care at a given point in time.

In the recent New England Journal essay, Dr Fuchs identifies the payment structure as a significant barrier to reducing health care costs

The context… will affect the physician’s choice. If the physician is paid on a fee-for-service basis and the patient has open-ended insurance, the scales are tipped in favor of doing as much as possible and against limiting interventions to those that are cost-effective. In that setting, who would benefit from the resources that are saved by practicing cost-effective medicine is not obvious to the physician.

He believes that changing the payment structure to create an environment where the physician is responsible for the totality of care of a defined population will cause the physician to make better decisions based on a different frame of reference. He also believes that the patient will more readily accept physicians decisions not to recommend marginally effective care based on a “group good” in this context. Being in it together will help us to reduce both supply (from the doctors side) and demand (from the patients). There are several components of the Affordable Care Act including the Accountable Care Organization vehicle that use this strategy to reduce health care costs.

There is one other problem…who picks which group of people are in the health care lifeboat together? In doing some research on another topic, I came across this quote taken from a 1968 interview with a Mobile landlord regarding his plan to move his rental housing to an unincorporated area rather than offer city services (garbage pick up, sewerage and running water) to his (African-American) tenants:

“These people don’t mind,” he said. “You know, that’s the way with niggers. They’ll be happy in a community–everybody together. They try and go back to African tribal life. He don’t need garbage service–a darkie will feed it to his pigs. He don’t need a bathtub–he’d probably store food in it. Wouldn’t know how to use it.”

Granted, it was a different time. In conversations I have had with people both in and out of healthcare, though, I am concerned that we are still not certain that our neighbors are all striving for the same healthcare goals that we are. In the last 60 years we have come to realize that everyone likes to feel clean, regardless of skin color. How long will it take for us to believe that everyone wants to be healthy.

New England Journal of Medicine published an article this week entitled “The Four Habits of High Value Health Care Organizations. The habits were described as follows:

  • Specification and planning. To an unusual extent, these organizations specify decisions and activities in advance. Whenever possible, both operational decisions, such as those related to patient flow (admission, discharge, and transfer criteria), and core clinical decisions, such as diagnosis, tests, or treatment selection, are based on explicit criteria.
  • Infrastructure design. High-value health care organizations deliberately design microsystems — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways.
  • Measurement and oversight. For many, measurement of clinical operations is driven by external audiences: payers, regulators, and rating agencies. Although high-value organizations share this reporting obligation, they primarily use measurement for internal process control and performance management. They collect more (and more detailed) measurements than those required for external reporting, selecting those that inform staff about clinical performance.
  • Self-study. Beyond ensuring that their clinical practices are consistent with the most recent science, these organizations also examine positive and negative deviance in their own care and outcomes, seeking new insights and better outcomes for their patients. By contrast, most health care organizations treat clinical knowledge as a property of the individual clinician, “managing” knowledge only by hiring and credentialing competent professional staff.

The Commonwealth Fund published a report 3 years ago on this very same topic. Their main recommendation is as follows:

Payment reform. • Provider payment reform offers the opportunity to stimulate greater organization as well as higher performance. The predominant fee-for-service payment system fuels the fragmentation of our delivery system. We recommend that payers move away from fee-for-service toward bundled payment systems that reward coordinated, high-value care.

What the high value delivery systems have in common is that they are paid to delivery care “better.”  Why do Alabamians not have better care here? In the words of Deep Throat, “Follow the Money.”

Family medicine lost a great friend on June 10th when Barbara Starfield died. A pediatrician by training, she entered into services research and spent her career describing the American Health Care system. She became convinced around 2004 that the system that she was describing was not only dysfunctional but directly led to the bad outcomes that she had been describing, detailed here in this interview.  She then spent the last 6 years of her life as a voice in the wilderness, trying to let people know how important family medicine was to the health of our fellow Americans.

She died at 78, much too young and with much left to do. In his June 24 newsletter (worth signing up for), Fitzhugh Mullins of Medical Education Futures has given us a sample of 5 of her most important articles. The one that made the biggest impression on me was published in 2005 in Health affairs and as abstracted in Medical Education Futures:

The effects of specialists supply on populations’ health: Assessing the evidence
Starfield B, Shi L, Grover A, Macinko J.
March 2005 – Health Affairs
“Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States’ position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.”

Wow. I was sitting next to a colleague at a meeting this weekend, and upon hearing this study cited, he said to me “That can’t be true. Congress would have done something if it were to protect the American people.” As I told him, I am willing to vouch for the consistency and thoroughness of Dr. Starfield’s analysis. I also continue to be amazed by the way the entrenched medical industrial complex, first described by Arnold Relman in the 1980s,  has managed to protect the self-interest of the non-primary care infrastructure.

Requiem aeternam dona eis, Domine, et lux perpetua luceat eis.

The New England Journal of Medicine has a very good series on the implementation of the ACA (Affordable Care Act) or imminent arrival  of socialism as ushered in by  PPACA (Affordable Care Act)  depending on your politics. In the  article this week, John Kastor details the potential impact (or lack thereof) of Accountable Care Organizations (ACO)  on the Academic Health Center (AHC). As a physician who has spent almost his entire career in academics, I have seen how change happens (slowly) and how difficult the transition is for some. As the new law is being implemented despite some controversy, it is important that we in academics prepare for the changes as best we can.

Dr Kastor points out that the concept of the ACO is completely contrary to the way medicine is practiced in the AHC. AHCs tend to be rather top heavy with sub-sub specialists. In contrast

The ACO concept is predicated on the primacy of primary care, with doctors, nurse practitioners, nurses, and other health care providers working together to supply the most efficient, successful, and economical care for their patients.

He also points out that the AHC administrative structure may not be conducive to an ACO infrastructure. The tradition is for colleges of medicine to be a part of a larger university. The university is typically composed of many colleges, each of which is headed by a Dean. While this works for arts and sciences, it can be problematic if the college is expected to generate excess revenue in some manner such as patient care:

…the dean, who is often responsible for the practice plan, reports to a senior university official, whereas the hospital’s chief executive officer (CEO) reports to an independent board of trustees, as is the case at the University of Maryland, where I work. Conflict among deans, among chairs of clinical departments, and between directors of practices and directors of hospitals, particularly over the distribution of resources, can be endemic in institutions structured in this manner.

The organization of the AHC will be challenged in another way as well. The structure of the clinical department is based on the university model developed in the 16th century. In this model faculty members who share a common knowledge are gathered in a department. This department is headed by a Chairperson. These departments are tasked with offering instruction in the unique content that the department faculty represent.

Chairs tend to be jealous of their prerogatives and are not naturally inclined to transfer the administration of their clinical services to a central authority whose aims may not coincide with their own. The effectiveness of ACOs will depend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model. At least currently, department chairs have few incentives to change from their traditional method of operating. Without such coordination, it will be difficult for academic medical centers to reduce the costs of practicing medicine — one of the principal aims of ACOs.

Another potential problem is the use of faculty physicians to supervise and deliver care. Faculty members in academic departments see their role, at least in part, as furthering global knowledge. The way this is traditionally assessed is  when the faculty members receive grant funding and publish papers in peer reviewed journals. For faculty who teach history, this means going to the library and researching in the stacks then perhaps going out into the field. To some medical school faculty, this means treating patients in a unique manner. Unfortunately, for ACOs to work, the care, where possible, must be standardized.

Such standardization is not characteristic of the work of many clinical faculty members, who may have their own ways of diagnosing and treating patients who have similar diseases. Furthermore, doctors must accustom themselves to working with teams of auxiliary personnel to optimize their patients’ care, particularly for chronic conditions.

The traditional mission of AHC—teaching learners the nuts and bolts of clinical medicine—doesn’t pay very well. As ACOs proliferate, the anticipated efficiencies will eliminate some of the fee-for-service excess revenue that was being used by AHCs to accomplish this mission. Unfortunately, there doesn’t seem to be any obvious replacement for this revenue at this time. Additionally, the ACO is intended to change the balance in the health care world. As opposed to other industrialized countries, America has a health care system that is specialist dominated.  Many have speculated that this is a contributor to the well documented high cost and poor quality of care. This will be a problem for AHCs.

It is the specialists, not the primary care providers, who dominate academic medical centers and order the expensive tests that increase hospital charges. Moreover, many patients are referred to academic centers for single-encounter diagnosis and treatment of one particular medical problem and not for long-term care, which is a key focus of ACOs. The requirement for robust primary care programs will present a problem for many, perhaps most, academic medical centers that propose to become ACOs. Centers that do not have large primary care programs staffed by full-time faculty or that decide not to develop such units will need to form alliances with off-campus groups of primary care providers, many of whom may be self-employed — an undertaking with which many centers will be unfamiliar.

Ultimately, AHCs may find that they have a niche that doesn’t require affiliation with an ACO to take advantage of the ACA (PPACA). Their hyperspecialization may be useful to patients on a contracted basis for care such as transplants or treatment of rare illnesses. However, if AHCs remain tasked with training physicians-to-be with learning bread and butter medicine, they had better find a way to bring learners and these types of patients together. ACOs are potentially one such way to do that but it will require the AHC to change, not the other way around.

Should the Mayans have been wrong and we survive 2012, 2014 is approaching rapidly. Despite the belief among newspaper letter writers that providing healthcare is a form of communist income redistribution, the Affordable Care Act (or PPACA) is the law of the land, most of the provisions occur in 2014, and implementation will need to be planned. Unfortunately, suddenly providing health care to 30,000,000 Americans previously denied is not a simple as giving them an insurance card. The New England Journal of Medicine published an article that looks at America’s state of readiness for the impending increase in people who suddenly have access to healthcare. Not surprisingly, they found that America is not ready, southern states are less ready than most (Alabama is 41st out of 50 as it relates to readiness) and we have no plan for increasing readiness. They conclude:
Addressing the goals of health care reform will take a combined federal, state, and local strategy involving resource deployment and actions designed to expand the available short-term and long-term supply of well-trained primary care professionals who are ready and willing to serve the newly insured. Ensuring access to care will depend on our ability to achieve smart growth in both insurance coverage and primary care capacity.
There is one group that has looked beyond 2012. The Council on Graduate Medical Education has published a report entitled Advancing Primary Care, focusing on how physician training should be redeveloped given the new realities. The recommendations are as follows but I encourage you to read the report in its entirety:
1. The Number of Primary Care Physicians
Recommendation: Policies supporting physicians providing primary care should be implemented that raise the percentage of primary care physicians (general internists, general pediatricians, and family physicians) among all physicians to at least 40 percent from the current level of 32 percent, a percentage that is actively declining at the present time. The achievement of this goal should be measured by assessing physician specialty once in practice, rather than at the start of postgraduate medical training.
2. Mechanisms of Physician Payment and Practice Transformation for Primary Care
Recommendation: To achieve the desired ratio of practicing primary care physicians, the average incomes of these physicians must achieve at least 70 percent of median incomes of all other physicians (According to data from the Medical Group Management Association cited in the report, primary care physicians’ median annual compensation was $186,044 in 2008 versus $339,738 for physicians practicing in other specialties). Investment in primary care office practice infrastructure will also be needed to cope with the increasing burdens of chronic care and to provide comprehensive, coordinated care. Payment policies should be modified to support both of these goals.
3. The Premedical and Medical School Environment
Recommendation: Medical schools and academic health centers should develop an accountable mission statement and measures of social responsibility to improve the health of all Americans. This includes strategically focusing and changing the processes of medical student and resident selection and altering the design of educational environments to foster a physician workforce of at least 40 percent primary care physicians and a health system that meets societal needs.
4. Graduate Medical Education
Recommendation: Graduate Medical Education (GME) payment and accreditation policies and a significantly expanded Title VII program should support the goal of producing a physician workforce that is at least 40 percent primary care. This goal should be measured by assessing physician specialty in practice rather than at the start of postgraduate medical training. Achieving this goal will require a significant increase in current primary care production from residency training and major changes in resident physician training for the practice environment of the future.
5. The Geographic and Socioeconomic Maldistribution of Physicians
Recommendation: So long as inequities exist, policies should support, expand, and allow creative innovation in programs that have proven effective in improving the geographic distribution of physicians serving medically vulnerable populations in all areas of the country. This should be done through mechanisms such as the National Health Service Corps and Area Health Education Centers.
The Future of Family Medicine blog, found here, is created and maintained by medical students to support students who remain interested in Family Medicine despite all of the obstacles and hardships. They are excited. In the words of mdstudent31, these are exciting times
I do not know about you, but these are pretty bold recommendations and very exciting for the future of our great specialty.  Will these recommendations gain traction anywhere within the government?  While it is true that more primary care used appropriately and effectively decreases the amount spent on healthcare, will there actually be an increase in salary?  Or would we go as far as entering into the blasphemous territories of decreasing the median specialty salary?  ::GASP:: My guess is it would probably be a little bit of both.
I will concede that if we make it past 2012 we are in for exciting times.