22nd National Conference Tuesday Breakout Questions
Breakout Group 1
Discuss and critique the following extract from the Consensus Statement of the Seventh National Conference on Primary Health Care Access:
Teaching Community Health Centers [TCHCs] are a model for community-based service, education, and research. These TCHCs are expected to improve the quality and outcomes of health professions education by integrating medical education within model community-oriented primary care practices operating in a reformed health care delivery system.
Changes should be made in federal and state statutes and regulations that accomplish the following:
a) TCHCs should be eligible to directly receive graduate medical education payments that reimburse these centers for their development and operational costs.
b) startup funds for planning and development of TCHCs should be identified and made available.
c) TCHCs will be recognized separately from non-teaching community health centers by taking into account the special needs of ambulatory-based teaching programa.
d) the National Institutes of Health, Agency for Health Care Policy Research, and other federal research agencies should increase their focus on primary care research by utilizing TCHCs.
e) faculty development, technical assisstance, and support programs for TCHCs should be developed and implemented.
f) loan repayment programs serving medically underserved communities should target residents and faculty of TCHCs.
McKennett, leader; Fernandez, Scribe; Babitz, Flores, Hines and Murray
For an introduction to the subject of teaching health centers, see: Darryl Leong, MD: Family Practice and the Future of Community Health Centers (October 17, 1993)
Breakout Group 2-7
It is now obvious that debate will continue over the costs or savings that will result from the particular federal health care legislation passed in 2010.
One of the potential consequences of that debate may be a more realistic discussion of the massive cost-shifts and hidden subsidies that occur in our current health care system.
What should be better understood about the costs, cost-shifts and subsidies in the present system? What potential savings that might be possible?
Breakfast Group 2 (See Discussion Question, above)
Freeman, Leader; Prislin, Scribe; Garcia-Shelton, Hansen, Haughton and Ross
Breakout Section 2 Scribe Notes:
For profit managed care really revenue shifting from health economy to share holders.
Medicare support of GME what is the logic? Increased costs of resident run patient care vs. Increased complexity of patients.
Administrative overhead of providers vs. Administrative overhead of insurers to wage combat over payment.
the self fulfilling prophecies of service economies – make work health care is a prime example.
Submitted by Michael Prislin, Scribe
Breakfast Group 3 (See Discussion Question, above)
Hara, Leader; Bejinez-Eastman, Scribe; Erickson, Flinders, Kimball and Smith
Breakfast Group 4 (See Discussion Question, above)
Henderson, Leader; Cobb, Scribe; Boltri, Jafri, North and Peck
1) we agree that there is massive cost shifting? Yes, 63% government funded now through a) tax subsidies, b) MA, MC, VAMC, HS etc., c) Medicare Advantage
2) cost of caring for underserved subsidized by a) private insurance, b) taxes
3) Americans want “everything done, no matter the cost” as long as they don’t bear the cost.
4) Palliative care unit
5) Strategies to reduce cost: a) decrease unnecessary admissions – duplicated (HIE’s functional), defensive (tort reform), not useful (comparative effectiveness), labor costs (practice to fullest extent of license, team-based care)
6) PPACA demonstration projects (will try to be generalizable even if successful)
Submitted by Stephen Cobb, scribe.
Breakfast Group 5 (See Discussion Question, above)
Maudlin, Leader; Clasen, Scribe; Christman, Fowkes, Frey and Lee
Breakout group 5 Scribe Notes:
1) Perverse financial incentives (more procedures; contracts)
2) Cost shifts (uninsured)
3) Dollars shifts WI/institutions
4) Insurance companies 20% profits
5) ____ in a variety of settings: a) companies, b) practitioners, c) charlatans
6) PCMH (management fees)
7) adversely ill population
8) Silos vs. integration
Submitted by Mark Clasen, scribe.
Breakfast Group 6 (See Discussion Question, above)
Sundwall, Leader; Troy, Scribe; Lee Burnett, Coleman and LeRoy
Breakout Group 6 Scribe Notes:
Foci: Discussion of nature, extent of cost-shifting
Systemic issues: challenge of funding entry points for exercising change
Insurance industry: essentially impenetrable. Marketing high cost, low benefit plans.
More foci: federal/state, shell-game characteristics (more lack of transparency) everywhere!
Hidden subsidies and cost shifting: sector leads to ______; huge burden on the plan member; prevention challenging.
. . .
Submitted by Warwick Troy, scribe.
Breakfast Group 7 (See Discussion Question, above)
Kahn, Leader, W. H. Burnett, Scribe; Clover, Kasovac and McCanne
Breakout Group 7 Scribe Notes:
Dr Kahn: The Accountable Care Organizations will be a replay of Community Care of North Carolina to the degree that University of North Carolina study showed that it was a success – with systems cost savings, measuring quality. Why shouldn’t Community Care of North Carolina be replicated in commercial ACOs?
Dr Clover: A study at the University of Louisville found a high degree of success in ”Passport Health Plan” – a 1517 Medicaid population of Kentucky Medicaid. Given 2015, whatever these will look like is unclear. What happens to the Disproportionate Share Hospital (DSH) subsides, safety net providers, GME funding?
In ACA there is some language to support GME, but not very much. One of the Republican plans would get rid of GME.
Theoretically, these costs would be applied. You woulnd’t need DSH, because everuyone would be covered.
Dr Kasovac: Is there any discussion for rewarding physicians for preventive care?
Dr Kahn: Only indirectly. The 10% bonus is supposed to address that because if you don’t cover everyone in the population, notably the poverty population, the services provided do not yield savings. Medicare now pays for.
In FFS, there is no motivation for specialists to do preventive services.
Dr Kahn: Medicare now pays for mammography and colonoscopy to the degree other preventive services are not funded, someone would have to make it possible.
How does evidence-based medicine play into this?
McCanne: There is the Center for Medicare and Medicaid innovation. It has two advantages. It’s budget has already been appropriated. Any program that CMMI can be incorporated immediately into these programs.
One of the areas of major cost-shifting is in the care of the indigent. The PPACA attempts to rein in costs, but the mechanism provided to do this will apply only to Medicare. PPACA requires the Independent Payment Advisory Board (IPAB) established by the law to make recommendations to Congress on how to modify payments to the various health care sectors. The law prevents them from making recommendations to ration care, restrict benefits, change eligibility requirements or raise costs to beneficiaries. However, IPAB is required to recommend ways to prevent health care costs from rising above defined percentages annually. If we try to squeeze costs out of the health care system through Medicare alone, this will exaggerate the cost shifts and we will be headed for disaster.
One of the advantages of ACA is that it increases Medicaid and Medicare population. Now you have 50% of the nation covered by one or both of these programs. Over a five year term, there will be health care budgets that balance, as opposed to previous “reforms” like Medicare Part D, with large, open-ended costs. Who could have designed Medicare Part D?
Dr Kahn: Author Jim Collins book Good to Great described what he calls the Stockdale Paradox (named after Admiral Stockdale, who spent eight years as a North Vietnamese prisoner of war). Those who are most optimistic that their situation will change for the better soon become the most disappionted. Those who accept the bleak reality of the current situation, yet have faith that eventually things will be better, have a better chance of prevailing.) Medicine is extremely fragmented politically. Cardiology and radiology have accepted that there are procedures that should not be done, but there are specialities that are so far out of the mainstream, it’s embarrasing.. Primary care can own the issue and the message.
Jack Lewin, the former Executive Director of CMA, from the perspective of a cardiologist, has endorsed models of universality and comprehensiveness. The Foundation for Health Coverage Education in San Jose, California, has produced a matrix that displays the wealth of public and private programs for covering health care that currently exist. You can look at the interactions between programs.
Dr McCanne: I was on the technical advisory committee for Senator Sheila Kuehl’s single payer bill in California, although she is no longer there.
The biggest cost shift is from our employer sponsored plans to the general public. We isolate these plans into a theoretically “low cost” sector that the insurance industry is anxious to serve. Because that’s the cheapest sector, it means that the other sectors are paying a lot more, some by a factor of five times. Now, 60% of the health care system is progressively funded through the public sector, if one includes public employees, tax credits and direct subsidies, such as Medicaid and Medicare.
The organization, Physicians for a National Health Plan, is often attacked. Yet economist Uwe Reinhardt believes it is a great facotr in the health care debate. The work our leaders produce is of the quality necessary to make the information credible.
Dr Kahn: How do you calculate the costs of the private and public sectors? How do you estimate the public sector costs?
Dr McCanne: All direct government subsidies equal 50% of expenditures on American health care. If you add the employer plans purchased by government for its own workers, it increases the expenditures up to to 60%.
Dr Kasovac: Explain the health exchanges.
Dr McCanne: The PPACA legislation includes the requirement that each state create a “health exchange”, a market place where small employers can go to find affordable health plans. The State of Massachusetts, through the legislation that then Governor Mitt Romney championed, already has such an exchange. Employers in Massachusetts are mandated have have health insurance for their employees.
Dr Kahn: It’s like a flea market for health plans!
Dr McCanne: I’ve heard of the possibility that several big employers are waiting to see how these will work, and might abandon more expensive plans if less costly alternatives can be found.
Dr Kahn: Would these be plans with low premiums that only cover catastrophic events?
Dr McCanne: For the most part, such plans are not permitted. They have to meet standards that take account of their medical loss ratio, and there will be a list of standard benefits. Many prople not eligible for Medicaid or Medicare will be forced into those plans. Once they are in a plan, they will help subsidize the health care expenditures. These plans will evolve, and teh grandfathered plans will get some relief.
Dr Kahn: Who develops the list of standard benefits?
Dr McCanne: The Institute of Medicine.
Dr Kasovac: Why don’t they use something like the Medicare standards?
Dr McCanne: Because Medicare has a more expensive population. We speak of an improved Medicare for all, which would put everyone in the risk pool, whereas now the least health people comprise it. The health exchanges should prove to be a somewhat more progressive way of financing health insurance.
Basically, how these plans will work will be determined by the United States Department of Health and Human Services. Thye have been quietly working behind the scenes. They have a good idea of the actuarial values. By the time you establish all of the medical benefits, you have to then figure out how to deal with mental health.
Dr Kahn: Why not adopt the Canadian approach to financing health care?
Dr McCanne: The conservative message has bashed the Canadian system, even though it worked better thanour system. However, it is not without problems. Yesterday, the Frazer Institute of Canada, a conservative think tank, showed that most of Canada’s health care finances are unsustainable.
Dr Kahn: Maybe we should talk about current cost-shifting from ambulatory care to the hospital sector. The North Carolina Community Care study assigned patients to medical homes, then studied the costs. It demonstrated that if you manage diabetes and ashtma in ambulatory settings, the savings in avoidng ER and hospitalization allows the subsdirzaiton of preventive services.
Dr McCanne: In fact the PNHP studied the North Carolina Health Foundation and found some tradeoffs. As rates go down, those participating lose access, as more providers drop out. Although the initial shift seemed positive, it didn’t look like the program created a beneficial steady state. The North Carolina study is being used to support the idea of commercial ACOs. The PNHP emphatically supports Medicare.
Submitted by William H. Burnett, Breakout Group 7 scribe.