James Herman, MD, MSPH, the Dean of the Uiniversity of Oklahoma/Tulsa University School of Community Medicine, Tulsa, has been named the 27th G. Gayle Stephens Lecturer at the 28th National Conference on Primary Health Care Access. The Lecture is scheduled for Tuesday April 11, 2017 at the Hyatt Regency New Orleans.
Doctor Herman was previously Associate Dean for Primary Care and Department Chair of Family and Community Medicine at the Penn State University/Milton B. Hershey School of Medicine in Hershey, Pennsylvania, where he headed the Pennsylvania Area Health Education program.
The Tulsa School of Community Medicine, whose commitment to community-oriented primary care has been noted in previous sessions of the National Conferences, is in the process of expanding to a four-year medical school.
The Stephens Lectures are named after the late G. Gayle Stephens, MD, a noted author and pioneer of the resurgence of family medicine and primary care in the United States.
Later Stephens Lecturers have included many prominent figures in American medical education, including the late Charles E. Odegaard of the University of Washington, F. Marian Bishop of the University of Utah, and Lynn Carmichael of the University of Miami.
The Coastal Research Group has sought to honor major intellectual leaders in the Family and Community Medicine movements. Typically, each of the National Conferences on Primary Health Care Access has one of three named lectures associated with the conference. One honors G. Gayle Stephens, MD, one honors the late Charles E. Odegaard, Ph.D. and the third honors J. Jerry Rodos, DO. The lecturers in each series include many eminent figures in these movements.
On the first morning of the 28th National Conference on Primary Health Care Access, Creighton University’s Doctor Donald R, Frey will present a Thought Provocateur session entitled “Physician Workforce—An Issue of Medical Ethics as well as National Priority”.
At Creighton University, a Jesuit institution based in Omaha, Nebraska, Doctor Frey has held the Dr Roland L Kleeburger Endowed Chair since 1996.
As Creighton University’s Vice President for Health Sciences, Dr Frey is responsible for the oversight of Creighton’s schools of dentistry, medicine, nursing, and pharmacy and health professions. He has had long service at Creighton as Chair of the university’s Department of Family Medicine, preceded by the Directorship of the Family Medicine Residency Program.
Doctor Frey will discuss the American way of funding physician education. For the past half century, the major source of federal funding for medical education are the “direct” and “indirect” graduate medical education funds appropriated through the Medicare budget, currently administered by the Centers for Medicare and Medicaid Services.
These funds are distributed to eligible hospitals with physician residency positions by means of formulas that become increasingly complex over the decades, with major modifications of the program included within the Patient Protection and Affordable Care Act (ACA).
The provision of high quality health services throughout the nation requires a physician workforce sensitive to the needs to all the nation’s geographical areas and populations. The challenges, dangers and opportunities that face the nation’s postgraduate medical training (i.e., physician residency positions and fellowships) will be the subject of Dr Frey’s Thought Provocateur session.
Doctor Norman B. Kahn, Jr., the Executive Vice-President of the Council of Medical Specialty Societies, will present the 23rd J. Jerry Rodos Lecture on Monday April 10, 2017, the first morning of the 28th National Conference on Primary Health Care Access.
The academic and professional career of Doctor Kahn, a Senior Fellow of the National Conferences on Primary Health Care Access, brings him unparalleled insights into issues of access in the United States health system.
Dr Kahn was one of the residency classes for the new specialty of family medicine, training in the early 1970s at University of California San Francisco community-based public hospital, San Francisco General, thereby gaining professional experience in caring for San Francisco’s multicultural, diverse-lifestyle population.
Within a few years of his graduation, he was appointed family medicine residency director for Stanislaus County’s Scenic General Hospital, in the heart of California’s Central Valley, one of the nation’s major agricultural regions. Dr Kahn oversaw the Scenic residency program’s establishment of a community health center in the small, agricultural town of Hughson, one of the early experiments in teaching family medicine residents to provide care in a community health center setting.
Doctor Kahn subsequently replaced Doctor John Geyman (also a Senior Fellow of the National Conferences) in the role of administrator of the University of California Davis’ Network of Affiliated Residency Programs. From that position he was invited to join the executive staff of the American Academy of Family Physicians in Kansas City, Missouri, where he served Executive Vice President for education.
Dr Kahn was a strong advocate for cooperative activities between the primary care medical specialties, and, later, for cooperative activities for all of the medical specialties. These ideas were incorporated into the Council of Medical Specialty Societies, an institution which he has served as Executive Vice President.
On Monday, April 10, 2017, the first day of the 28th National Conference on Primary Health Care Access, the first plenary panel will follow individual presentations by Doctors David Sundwall and John Geyman, relating to the status of the Affordable Care Act.
The first plenary panel will be comprised of Charles Q. North, MD, MS of the University of New Mexico and Jeremy Fish, MD of the Contra Costa County Medical Services in Martinez, California.
Doctor North’s Presentation
Doctor North, a Senior Fellow of the National Conferences on Primary Health Care Access, served as a career officer in the United States Indian Health Service.
Dr North argues that the debate about how health care should be financed has obscured the debate about how the delivery system should be reformed to assure access to comprehensive, continuous health care that recognizes the importance of community-oriented medicine, and public health and its social determinants.
He has found that many of his patients, who previously had had access to most of the health services they needed through the Bernalillo County-financed health care system based in Albuquerque, have since the passage of ACA, found themselves assigned to prohibitively expensive insurance plans with narrow provider networks that do not meet their needs.
A fundamental error in Obamacare has been the imperative of enrolling patients in insurance plans that are basically designed as “risk pools” whose fees are priced to cover the expenditures required for the health care needs of all the persons covered in the plans.
Yet, when very sick people, whose care may previously have been subsidized by government funds, sign up for a given plan, the costs of care to the very sick are shifted from “taxpayers in general” to the specific persons enrolled in the plan. The increase in costs shouldered by the plan’s recipients, it can be argued, are not the fault of sick persons who were seeking ways to manage their health care costs coverage, but are the result in defects in the legislation.
Before enactment of the ACA, the health care costs of many “uninsured” persons were absorbed by various publically-financed programs, most of which continue to function, but, for some programs in some states and communities, are partly channeled through the health care plans.
Currently, the federal government re-insures the private insurance companies by paying for catastrophes through government insurance (Medicare, Medicaid, the Indian Health Service [IHS], the Veterans Administration [VA], the Department of Defense [DOD], End Stage Renal Disease [ESRD], Ryan White, etc.) and by subsidizing local hospitals through trauma care support and other disease specific schemes (Breast and Cervical Cancer screening program.) These are all “work arounds” that avoid the appearance of the taxpayer paying for re-insurance and to allow for a private for-profit insurance industry to survive.
Doctor Fish’s Presentation
Doctor Fish is the founding family medicine residency program director at a new residency program based John Muir Health, in Walnut Creek.
Previously, Dr Fish served as the residency director for the health system for California’s Contra Costa County, one of the early leaders in the creation of comprehensive county-financed health services. The Contra Costa County family residency program is part of a unique Registrar model for training traditional full-spectrum family physicians.
The new John Muir program will open in June 2017 and will focus on a clinic-first, new model full-spectrum family medicine, that will include the local population of all ages, genders and conditions (a feature of most family medicine programs, and all payer residency practice, which is planned to serve 50% Medicaid, with the goal of providing seamless care across the payer spectrum.
The residency program’s primary purpose is to develop graduates to “joyfully provide comprehensive Family Teamcare”, including common office procedures.
Dr Fish describes himself as passionate for the all-payer aspect. He argues that the multi-payer, single payment model should be the next step beyond ACA, since he believes that we are likely decades away from a single payer financing system
Dr Fish intends to highlight what is precious to primary care medicine in ACA that must be preserved, and what are the opportunities might exist for legislative improvements to strengthen primary care.
ACA’s commitment to assuring health care for all should continue as a national priority, whatever revisions might be made to its legislative format.
The ACA includes features that, fully implemented as originally envisioned, should improve the quality of the health care system.
Strategic Initiatives to Promote Access
The panel will introduce one of the themes that will continue through the plenary sessions of the three National Conference days – an examination and celebration of strategic initiatives that have proven successful models of entities that provide and enhance access to comprehensive primary health care.
These thematic presentations will include discussion of community-oriented health centers, community-based primary care physician residency programs, Area Health Education Centers, and teaching health centers.
Doctor John Geyman’s insightful analyses of what he believes are the fundamental errors in the Patient Protection and Accountable Care Act [ACA] have been highlights of the National Conference on Primary Health Care Access over the past half decade.
Dr Geyman returns as a featured speaker at the 28th National Conference on Primary Health Care Access, to be held April 10-12, 2017 at the Hyatt Regency New Orleans.
A prolific author on health care policy, Dr Geyman’s latest book, Crisis in U. S. Health Care: Corporate Power vs the Common Good is scheduled for release in early Spring. The book will incorporate (as will Dr Geyman’s presentation in New Orleans) Dr Geyman’s analysis on the new Administration’s proposals for revising ACA and other federal health priorities.
Dr Geyman’s presentation will take place on Monday morning April 10th.
Dr Geyman will be joined by a reactor panel enlisted from the permanent faculty of the National Conferences on Primary Health Care Access.
The National Conferences are invitational, and consist of approximately four to five dozen drawn from experts on health care policy, public health, community health centers and teaching health center projects, and academic health sciences center faculty. The National Conferences are conducted by the Coastal Research Group, a 501c-3 non-profit corporation devoted to healthcare workforce issues.
For information on the invitation process, contact William H. Burnett, Coordinator of the National Conferences at [email protected]
We gratefully acknowledge the sponsorship of Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference
Charles Q. North, MD, MS, University of New Mexico [Doctor North is a Senior Fellow of the National Conferences on Primary Health Care Access]: Thanks a lot, I’m following the same rules of disclosure as Mike Prislin is this morning, but instead of a cell phone to call the President, I have my experts – Doctors John Geyman and Don McCanne – on the front row of the audience here. Sometimes, it’s a long distance call and sometimes it’s local.
I want to be fair and balanced and talk about the alternatives to the Patient Protection and Affordable Care Act. I think that the “patient protection” part of the Act’s name was to make it slide down easier. It’s like the salsa on the burrito.
So what are the alternatives? Mike went through that subject very well; RomneyCare and ObamaCare are basically the same thing. The PPACA is a Republican plan. They were just too timid to bring it forward, except in Massachusetts.
There are other alternatives. There’s the British National Health Service as well as just about everybody else’s National Health Service. and there are some other kinds of universal health coverage plan.
The United States Veterans Administration, Indian Health Service, and Armed Services Health Care.
In this country, there is the Veteran’s Administration and the Indian Health Service.
The VA is trashed regularly, because it’s so doggone popular people have to wait to get in. That tells you something about their funding.
If you look at the Indian Health Service and compare its funding to what the rest of the country costs, then the Indian Health Service is funded at 50% of the level of need,
And then there is the United States Military Healthcare System. In our audience, we have an active duty officer in the United States Army who is a physician. He does not want to go to a private sector accountable care organization for his healthcare, which would not even available for him most of the time.
Having myself used the military system as a patient most of my career, I think that system ought to be supported and expanded, and provide the servicemen and servicewomen the healthcare they need, both locally and internationally.
Universal Health in Rwanda
We have the universal access systems in Europe that we hear a lot about when we’re talking about the ACA.
I’d like to point out that Rwanda – yes, Rwanda, where genocide was occurring ten years ago – has a universal access health coverage system. They have some of the most remarkable improvements in public health measures of anywhere in the world.
I refer you to the writings of Paul Farmer of Partners in Health. It is truly remarkable in a low-resource environment that such demonstrable progress has occurred.
Then there are the “single payer” plans. We know about the Canadian plan. But there is also a single payer plan in Taiwan that has celebrated its 20th anniversary. I refer you to this the recent article in Health Affairs, reflecting on that 20th anniversary; and how the single payer system is reducing health costs in Taiwan.
Mike Prislin talked about the triple aim or the quadruple aim of health care reform. This is a concept that Doctor Don Berwick, the former director of CMS (the Center for Medicare and Medicaid Services) came up with. Parenthetically, Don Berwick became a Democratic candidate for governor of Massachusetts. I’m not a betting man, but if I were I’d always lose. I bet on Don, but he only got third place and that just in the Democratic Party, after which a Republican won the Governorship of Massachusetts. Of Massachusetts!!
At the end of his campaign, Berwick came out for a single payer system in Massachusetts, which is where Romney Care was implemented, of course.
Although Massachusetts has the lowest percentage of uninsured, it’s not zero. It’s still substantial; it’s over five percent; Hawaii and Massachusetts have comparable percentages.
Access, Quality of Care, Reasonable Cost
The triple aim is, first, about access.
It is, second, about quality of care – measured by outcomes and by patient experience. From the viewpoint of patients, did they get what they wanted and what they needed that day? Do they have a measurable outcome – not a process, but an outcome? These are questions whose responses are not often included in quality measures.
It is, third, about cost, which gets to equity, social justice, and opportunity. Is it efficient, affordable, transparent, fair and sustainable financially? I put some ethical principles into the cost element of the triple aim – equity, social justice and opportunity. This should be an ethical measure.
What do healthcare systems, delivery systems and finance systems not do? I think it’s really important to talk about what this is not about. PPACA (or Obama Care if you prefer) is just a healthcare financing reform proposal, now a law.
I quote from the satirical medical journal Onion, published just recently, which pokes fun at medical studies. “The public health report is that the majority of Earth’s potable water is trapped in Coca Cola products. Experts estimate that the average can of Coke contains nearly 12 ounces of potable, but entirely inaccessible, fresh water.” Now if you have a problem in the desert, this is where to go. We know it’s there if you can just figure out how to extract it, maybe some form of fracking would work. I’m not sure. I know it’s illegal in Southern California, but people have to be doing research.
The Impact of Sugar on Obesity and Diabetes
Our food supply here and around the world is infused with sugar. The big change in the last 40 years is that processed food has more and more sugar. We talk about the salt a lot, but if you look at diabetes, obesity and processed food infused with sugar, they are very highly related. This is a public health problem that requires regulation at an appropriate level. The Affordable Care Act doesn’t address this,
The Impact of Public Campaings Against Smoking
Look at this graph of smoking, starting out in 1900. We didn’t smoke much in 1900, because there weren’t cigarettes. You had to make them. You had to roll your own back here.
About the time Medicare and Medicaid were started, we decided cigarettes were bad for your health and that they caused cancer. Who would have guessed back during World War II that they caused cancer? We thought it was a great way to win the war, fueled on nicotine.
The smoking rate has fallen since then, but it doesn’t really matter if you have an Affordable Care Act, a single payer system, or no healthcare financing system at all.
You can have a public campaign to regulate cigarette smoking and to counter advertising about cigarettes, whether or not you finance the healthcare system.
Child Poverty and Income Inequality as Social Determinants of Health
Completely separate from the ACA is child poverty in America. We’re right behind Turkey and ahead of Mexico in child poverty. 21.7% of children in this country are poor. That is one of the key social determinants of health.
The Affordable Care Act does not really address this. We’re talking about expanding the Medicaid child health program (CHIP) for another two or four years. But why aren’t all children eligible for healthcare in this country? Why isn’t it universal?
Why is it that if you have an undocumented child – who is probably the most needy child you’re going to see – that they can only be covered through their state health department where they might services without people asking about their immigration status. That’s the way we presently cover them.
Linked to childhood poverty is income inequality, which is a major determinant of health, and which has increased in this country. The Affordable Care Act really doesn’t address income inequality.
Actual Causes of Death in the United States
Most of what we do in healthcare financing delivery does not affect the health status of the population. Many of you will remember that Doctors J. Michael McGinnis and William Foege published the article “Actual Cause of Death in the United States” in 1993. That article showed that – when you look at the actual statistics (from death certificates) relating to premature death – healthcare delivery system and how that system is financed only accounts for about 10% of the health status of a population.
Your risk factors for the likes of heart disease and Alzheimer’s are little affected by health care delivery.
Most of the determinants of health status are the result of behavioral patterns, genetic predisposition and social circumstances. These determinants are related to addictions to cigarettes, sugar, obesity, alcohol, genetic predisposition and bad behavior (such as criminal activity).
Large Numbers of Uninsured Continue
In New Mexico we looked at our 2014 and 2015 Medicaid populations and our 2020 projections. We have a total Medicaid population of 741,000. It looks like it’s going to go up by another 90,000 in 2020. Our uninsured rates have decreased from 339,000 in 2014 to 235,000 in 2015 to a projected 167,996 in 2020.
There still will be a lot of uninsured people in 2020. That uninsured group is bigger than the population of many of the cities in the Los Angeles metropolitan area. They’re not just undocumented people. Most people who come here across the border from Mexico realize that there are jobs in Texas and California and skip comimg to New Mexico. The undocumented population is a small part of New Mexico.
The ACA reduction of the uninsured in this time period in 2014, and it’s not too much different in 2015. It still leaves New Mexico and California with 15% of the population uninsured. 15% is a lot of people, even in New Mexico, which is 1/14th the size of California, and 1/7th the size of Los Angeles county. There are about 2 million people in New Mexico and about 14 million in the LA basin here. 15% leaves a lot of people out in the cold.
Replacing the Uninsured with the Underinsured
Most of the newly insured are underinsured with health insurance exchange products or Medicaid. A team of us at University of New Mexico wrote a paper recently on underinsurance in our international district clinic in Albuquerque. Underinsurance really does prevent people from getting healthcare.
Medicaid is a form of underinsurance. Most of the health insurance exchange products are too. We’ll look at that in a minute and see why.
The undocumented, of course, aren’t covered under the ACA. Because of this, public hospitals and other safety net programs are being overwhelmed. Yes, they are getting paying customers now, but they’re being overwhelmed in terms of the delivery system because those vanguard ACOs don’t want Medicaid patients.
They don’t want them just like they didn’t want uninsured patients because they know those patients are underinsured and have complex medical problems that are based on the social determinants of their health – their poverty mostly, and, in many cases, their addictions.
This is why you don’t see people scrambling to get the Veteran’s Administration population. They can’t take care of veterans with TBI, PTSD, addiction to heroin, alcohol, and cigarettes. They don’t do that very well. It’s very expensive for them to do that. So they’re not going out there and recruiting those patients.
The private health system is narrowing their networks, and trying to get rid of their uninsured and Medicaid patients, and developing very narrow networks so that patients have to stay in that system if they get that insurance. That’s been an unintended consequence of the ACA. It’s a real problem if you’re working in a metropolitan area, but if you’re not in a metropolitan area it maybe even a larger problem depending on how many options rural communities have.
The expanded Medicaid program, of course, doesn’t even exist in many states and the benefits vary extremely widely between states. The confidence intervals around the average Medicaid benefit are huge.
It’s not the same program everywhere like Medicare is. Medicare is a much more standardized program. Medicaid will pay or not pay for a variety of different things. And expanded Medicaid has copays and deductibles in some cases.
Case Studies of My Patients: #1
I have a continuity practice, in which I see patients regularly.
One of them is a 53 year old, Hispanic woman who is a security guard. She was told that she is “self-pay”. These patient notes are from a conversation that I had with her, that I documented in our email system and in her electronic health record and shared with her social worker.
She works 12 hour shifts, makes $8.50 an hour, so it it looked to me like she’d meet poverty guidelines, especially if it’s 400% of the poverty level, which is where Medicaid is at. She’s been to the financial assistance office at our hospital three times.
We have an electronic health record. Any time one of my patients enters the system anywhere, I get a message and I look what is occurring. My patient, whom I hadn’t seen for awhile, was in the Emergency Department. I didn’t know what happened to her. I found out that she was actually enrolled in Medicaid family planning.
We have a lot of 53-year old males who are enrolled in Medicaid family planning too and we were wondering what kind of family they were planning. I found out that it was a gimmick to get people onto Medicaid, because we didn’t hire enough people in our state to enroll people on Medicaid. Because they couldn’t process all the claims, they put them in this “category 29” – family planning. It really confused people. It confused us. The patients would ask, what is that? We don’t need condoms, you know.
I learned that my patient made too much money for Food Stamps, but didn’t need family planning. She sounded unwell and overwhelmed. She was beyond frustrated. She previously had been on the Bernalillo County indigent program, which is sponsored by our hospital, before she was enrolled into Medicaid. She understood the indigent program. It worked very well for her. She had regular primary care visits and several specialty evaluations before that.
Case Studies of My Patients: #2
There’s another patient of mine, another Hispanic woman who’s in her 40s – hardworking, employed by a small business. She has fairly controlled Type 2 Diabetes. She’s got an insurance exchange product and had been on the county indigent program. She can’t see her primary care pharmacy clinician; who I defer to, to do Diabetes medication modifications and titrations. That is the pharmacy practitioner wasn’t on her plan, nor could we get the practitioner on her plan. I talked to our pharmacy faculty about this and they’re working on it, it but the practitioner is still not listed.
Because of this, my patient had disruption in her care. She wasn’t able to get into see the practitioner, so as to adjust her insulin, which she needed to do because the formulary was narrowed. The health insurance exchange plan had a very narrow formulary and instead of Lantus and Humalog, which I’ve used for the last ten or 15 years. She’s back on NPH and regular insulin, which I used back in the previous millennium, but I don’t have anybody else on NPH and regular insulin.
The patient’s sugars were all over the place, because she had to take her insulin – her regular insulin – much sooner than she would have Humalog, which you can take right before the meal. So she wouldn’t know how much she was going to be eating, and then she’d miss the mark. Her A1C rose substantially.
This lady is very adherent and very careful, very bright, very hardworking, and doesn’t expect a dime from anybody. She took this on as her responsibility to work her way through this unwieldy system.
So I spent a lot of time on this, just as I’ve spent another few minutes talking to you about. My time is valuable, so its seems a misallocation of resources that I spend it coordinating her care, trying to get her on the right medication, trying to figure out how to get her pharmacy clinician on the provider list.
This was a consequence of the Affordable Care Act. It was not affordable for her. It was very expensive. And it wasn’t affordable for me. It did not protect these two patients I just showed you.
The Bernalillo County/UNM (University of New Mexico) Health System
Let’s consider the UNM Health System’s county indigent program. It’s basically a single-payer system for the Bernalillo County for people that are below the poverty level. We had very small deductible and a reasonable maximum amount for out of pocket charges for, emergency room visits, the prescription formulary, etc. And we had a pretty broad formulary, including the new Hepatitis C drugs, because we did some of us at the university the research on them. No charge was over $75 and that $75 was for non-formulary prescription drug.
If you look at the silver plan for an individual and the silver plan for a family; they’ve got $2000 and $4,000 out of pocket maximums and deductibles of $400 and $800. How are people going to afford that? Then there are percentages, such as 15% of an outpatient surgery that cost $5,000. That’s a lot of money. People make decisions based on this, once they figure it out.
The county indigent program was much better and much more affordable; than the Affordable Care Act. I would claim that the Patient Protection and Affordable Care Act it doesn’t protect patients and is not affordable.
The Downside of PPACA to Lower Income Patients in New Mexico
If we summarize these patients’ experiences, they’re paying higher premiums. They can’t afford the family coverage. They pay higher deductibles. They pay higher co-pays. When they are billed for higher co-pays they miss visits once they find out what the co-pays are. Patients say “I can’t come in and see you. I’ve got to pay 50 bucks up front.” Before it was $5, $10, or nothing.
I worked in the Indian Health Service for 30 some years, with no co-pays, no deductibles, no premiums, no barriers to care. It made a huge difference. We’re seeing higher no show rates all the time. We have 14% average no show rates in our system. Some of our better clinics it’s about 7-8%. One of my jobs is to drive down those no show rates. Tell me that doesn’t waste the doctor’s time. It wastes a lot of time.
Higher drug costs, even the generic drugs are costing more because the Affordable Care Act isn’t affordable for individuals, but it makes money for Big Pharma. They were able to raise their prices.
We don’t have diabetes nutrition education covered under all of the plans in the Affordable Care Act. What happens is patients are uncertain about what is in their plan. They doubt that they really understand it. They’re confused about it, so what they do is to avoid care, basically.
They don’t know about the hidden costs and when they find out about them we get more complaints. Patient satisfaction goes down.
PPACA’s Chief Benefit is Expansion of Medicaid That Could Have Expanded Without PPACA
Most of the benefit of this program is from the expansion of Medicaid. When looking at PPACA as a whole I would say that in most cases states have benefited the most from expanded Medicaid. But expanding Medicaid didn’t require having a Patient Protection and Affordable Care Act. It just required changing the criteria for Medicaid.
So, who benefits?
Stephen Hemsley the CEO of United Healthcare’s salary is $106 million. That’s just a little bit more than the $100 million income in revenue that we got at the entire University of New Mexico Hospital system in one year. The University of New Mexico benefited. We can give raises to the staff and faculty. The positive impact on Big Pharma we’ve talked about. Medical device companies, physician executives and ACO owners I would say have benefited. A number of us are in physician executive positions that didn’t use to exist. And the Heritage Foundation who came up with this whole thing has benefited.
But let’s talk about value-based healthcare.
Americans aren’t getting a good value for the amount of money they put into healthcare compared to all these other countries in the world. You can’t have value-based healthcare if the whole system isn’t very valuable. Right? We don’t know how to measure quality so it comes out that value equals cost most of the time.
PPACA Fails on Access, Quality and Cost
I would submit that the PPACA fails on the criteria of the triple aim – access, quality and cost. It’s not a public health program. It doesn’t address public health for the most part, except for some prevention.
It’s not social progress, it doesn’t lead us to wealth equity. Instead I would recommend that we look at this quote from Senator Edward Kennedy’s 1972 book In Critical Condition: The Crisis in America’s Heath Care:
He talks about the triple aim, the entire nation, universal access, high quality, reasonable cost healthcare. I read it in medical school. And Senator Tom Dashell used it as the basis of his book that was published right before the Affordable Care Act was debated.
Here’s a better solution, How ObamaCare is Unsustainable by Doctor John Geyman. I would read this. You might recognize the guy on the right.
If you want the Cliff’s Notes version for Dummy’s, John published this in the International Journal of Health Services in 2015. You don’t have to read the whole book, but I’d recommend you buy it at least cause I’m sure some of the proceeds will go for a good cause.
What we want is high quality healthcare services at an affordable price for all. It’s not a very difficult concept. It doesn’t require a very difficult law. What it requires is an incredible amount of political will. I think it’s up to us, those of us who understand this, to advocate for a universal coverage program, preferably a single payer or national health program of some kind, of which there are many examples.
We’ll come up with our own, but everybody would benefit from that. American industry would much more competitive. So I think the people who pay for campaigns, pay for politicians will get on board and see the light and advocate for a system that makes more sense so they can be more competitive. Thank you.
We gratefully acknowledge the sponsorship of Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference
The following transcription is of the first plenary session of the 26th National Conference on Primary Health Care Access, held April 13, 2015 at the Hyatt Regency Orange County.
John Boltri, MD, Northeast Ohio Medical University, Rootstown, Ohio [Doctor Boltri is a Senior Fellow of the National Conferences on Primary Health Care Access]: Good morning. It’s a great pleasure to be here. I’m John Boltri, the Chair of the Department of Family and Community Medicine at Northeast Ohio Medical University.
I have the distinct honor of introducing the great debate: “Coast” versus “Heartland”. The question being debated is whether of not The Patient Protection and Affordable Act [PPACA, or ACA, or Obamacare] is a huge success.
Before introducing our debaters today, I will mention that we’ve been working on this for some time. After some heated email exchanges and meetings, we’ve agreed on a format: 20 minutes for each debater.
I will be sitting in the front row and I will hold up the time cards at five minutes and two minutes, and one minute. And if they go over you will see me stand up. (I use this same format in our department meetings. And then I will begin inching toward them and then if they go over too much. I will put my hand on their shoulder. In an extreme circumstance I might have to invoke the Dr. Gary LeRoy’s approach to ending the presentation of a speaker who has exceeded his time limit, applying a “wedgie”.
But both speakers have promised me that they will not go over 20 minutes, so I doubt I’ll even have to get up out of my seat.
Our first debater; will be Doctor Mike Prislin. He is a professor of family medicine and an associate dean at the University of California, Irvine. He will start off with one perspective. Then Doctor Charles North, who is a professor at University of New Mexico, Albuquerque for an alternate perspective.
Then each person will have an opportunity to ask the other a question; for which they will be given four minutes to respond. If they don’t use their entire amount of time they will be given more time to respond and provide additional back up material if they so choose. So without further ado, here’s Mike.
The Great Debate – For the Affirmative:
Michael D. Prislin, MD, University of California, Irvine. [Doctor Prislin is a Fellow of the National Conferences on Primary Health Care Access]: My fellow Americans – on behalf of the Left Coast, it’s my pleasure to welcome you to the great debate this morning.
My charge is to convince you that the healthcare overhaul that we’re all experiencing now is a resounding success. And I will do that I’m sure. Wait, wait a second, I’m getting a phone call. Yes Mr. President. Yes Mr. President. Yes Mr. President, yes sir. OK, thanks.
Let’s move on. First of all I’d like to provide you with this disclaimer, I have not injured any politicians in preparing this. Most of what I have to say will be somewhere near the truth. But I do reserve the right, I will shamelessly advocate my perspective at any opportunity that I have; so without further ado.
I think it’s important that we frame this debate in the appropriate context. I’d like to point out during the recent presidential election that President Obama did indeed let the candidate Mitt Romney know that we’re really not dealing with Obama’s healthcare act; we’re dealing with Romney’s healthcare act. So Mitt, could this really be true?
Well let’s examine it. We’ve got state-based health insurance exchanges, We’ve got subsidies for lower income households, We’ve got individual and business mandates, We’ve got cost sharing for preventive services. Loosely defined, we have expansion of government-supported healthcare: Romneycare.
So let’s really change what we’re going to talk about, we’re no longer going to talk about Obamacare. We’re going to spend the rest of this discussion talking about Romneycare. Now we’ll get back to PPACA. I don’t know where the Patient Protection part of it came from, so I’m just going to focus on the Affordable Care Act.
And this is a quote from a weekly Saturday radio address; I don’t know whether Barack still does these. I seem to be missing them on my Saturday morning radio station. But he said “This week I conveyed to Congress my belief that any healthcare reform must be built around fundamental reforms that lower costs, improve quality and coverage, we know that is the triple aim. And also protect consumer choice.” And so let’s frame that. I want to no longer think of this as the triple aim, but I want to think about it as the quadruple aim; because we’re also protecting consumer choice in this act.
Let’s take a look at it. As we know from our colleagues in the Republican Party, the Affordable Care Act is incredibly complex. In fact it goes on to thousands of pages. Somebody told me last week that the language in the act is intentionally designed to obfuscate what really is mentioned. Now I’m not really going to get into that, but I would say that we’re going to talk about three key pieces; expansion of coverage, improvement in quality of care, and reduction in cost.
Expansion of Coverage
So let’s look at expansion of coverage. What does the Act do? Well, we created a health insurance marketplace, we’ve expanded Medicaid coverage eligibility, we’ve extended dependent coverage for young adults, we’ve eliminated pre-existing conditions, exclusions from coverage, and annual and lifetime coverage limitations, and we’ve expanded the Medicare and Medicaid scope of coverage; particularly in the areas of preventive services and pharmacy coverage.
How have we done? The percent of uninsured Americans has dropped from 20.3% to 13.2%. That includes nearly two and a half million under age 26 who have gained insurance as dependents in their parents’ coverage. We have 14.1 million who have gained access through Medicaid expansion and increased access to private insurance. We have 36 states that have chosen not to create healthcare exchanges. We all know the decision regarding the federal marketplace is currently pending. We have 22 states who have elected not to participate in Medicaid coverage. That number seems to be declining. As resources get tight more states are signing up.
So if these policies were fully implemented we would probably have an additional 12 million more who could be covered. And I’d like to point out since we are on the coast in California, if we thought about our undocumented residents, and we provided access to coverage there, we could cover another 12 million.
We have a presidential election coming and I’d like to put forward that we do have a candidate who has spoken strongly in terms of immigration reform. It will sort of perpetuate a great American dynasty. And I present to you this morning Jeb Bush, the immigration president. Perhaps he will expand the Affordable Care Act to cover undocumented aliens.
Let’s talk a little bit about quality improvement. This is what the act proposes: expansion of preventive services primarily though Medicare, to a lesser degree through Medicaid. Those of us who are doing our annual well visits now know what the Medicare expansion is all about.
The act supports the creation of accountable care organizations. It established the Center for Medicare and Medicaid improvement. It established the Prevention and Public Health Fund. It established the Patient-Centered Outcomes Research Institute. It established the community care transitions program, increased support for community health centers, and it’s rebuilding the primary care workforce.
The vote is: The ACA innovation center has been established. There is a hospital injury program that has demonstrated improvement in outcomes and cost savings. We have 32 pioneer ACOs, 13 of which have saved money. We have a community based transitions program. We have the Patient Centered outcomes Research Institute, which I think you’ll all agree is a wonderful idea. Community health centers have received $11 billion to fund the support of improvement expansion over the next five years. This has increased the patients served in community health centers from 19 to 24 million since the implementation of the Affordable Care Act.
I think you’ll all agree that rebuilding the primary care workforce is another wonderful idea.
Reductions in Healthcare Costs
Let’s talk about reduction in cost. What does the Act do there? We’ve established the Accountable Care Organizations. We’re cracking down on healthcare fraud. We’ve addressed overpayments to large insurance companies and we’re reducing healthcare premiums. We’re linking payment to quality. We’ve reduced paperwork and administrative cost through the implementation of electronic health records. We’re improving individual and employer responsibility with the employer and individual mandates. And we’re paying physicians based on value, not volume.
So here’s the vote. Now admittedly you can’t really reduce healthcare costs. I mean nobody really thought that was going to happen, right? We can only hope to reduce the rate of increase in healthcare costs.
As you can see here – having a depression, or a recession – or whatever you want to call it, is fairly effective in reducing the rate in increase in healthcare cost. But we’ve also done pretty well.
You have to define when the recession ended, but if you assume that the recession ended in about 2010 or 2011, in the post-recession Affordable Care Act era we’ve also been fairly successful in reducing the rate of increase of healthcare costs.
Nobody really knows how much fraud is occurring in healthcare, there’s really no methodology to figure out how much fraud there might be. So it’s difficult to figure out exactly what’s happening there. But in terms of overpayment to insurance companies the estimate is, is that they’ve decreased by about $17 billion since the initiation of the act. Interestingly, health insurance premiums in the insurance marketplace are 16% lower than they would have been predicted by our own Congressional Budget Office.
Preservation of Choice
I want to get back to the fourth point of the quadruple aim because remember that was that we were going to preserve choice – which meant that we were going to continue to have private insurance cover the bulk of the expansion and access to care. I think that was – you have to be fair – an intention of the act.
It’s no surprise the insurance companies are doing well. Profits are up 10-17% for the Big Five, and the price per share has increased to twice the average for the Standard and Poors 500 index since the implementation of the act. If we’re talking about that as part of the quadruple aim, we clearly have had a success there.
Then there’s another winner, and that is our friends in the do nothing Congress. Most of the publications you’ll say that they’ve only voted, had motions to repeal 54 times, but I would point out to you that they voted again in February of this year so that makes it the 55th time. The number of times that the House has voted on a specific time to modify or replace Obamacare is zero.
I think I can stop here and turn the podium over to my most worthy adversary.
John Boltri, MD, Debate Moderator: Thank you very much. You’ve only used eleven minutes, so you’ve reserved nine minutes for future rebuttals. While we’re queuing up the next presentation I’ll let you know that we’ve debated previously about how to resolve the debate if there’s a tie. And we talked about using either height, or age, or another form to help decide and at the end I decided I would reserve the right as the moderator to make the final decision.
The 28th National Conference on Primary Health Care Access is scheduled for April 10-12, 2017 at the Hyatt Regency New Orleans. The conference theme for 2017, “Access”, will be incorporated into each of the National Conference plenary sessions.
Several presenters on the first day will continue to test how well this decade’s major health legislation – the Patient Protection and Affordable Care Act (ACA) – meets the goal of providing high quality, culturally sensitive primary health care to the nation’s population, regardless of socio-economic status, ethnicity or geographic location. [See 28th National Conference Keynote Sessions to be Dedicated to ACA Issues of “Access”.]
Regional Issues in Access
Other plenary sessions are grouped into specific perspectives on access. One will continues the National Conferences’ studies of the consequences of long-term strategic investment by medical schools, postgraduate physician residency programs, community health centers, public health departments and Area Health Education Centers in the creation of a community and family-oriented primary health care workforce and the institutions that workforce supports.
This year’s conference, among other regional studies, will examine such strategic interventions in the State of Louisiana and the Northwestern States, in the Central Valley and other agricultural regions of California and in various urban communities that appear to have sufficient numbers of physicians, but where significant access problems exist.
Another theme will be built on the National Conferences’ remembrance of the founders and early pioneers of family medicine and other strategic primary care interventions. We celebrate the work and mourn the losses of members the generation born before 1930 whose efforts resulted in the momentous mid-20th changes in federal, state, local and regional health care policies, of which Medicare and Medicaid are the most obvious examples.
We will also celebrate the generation born between 1930 and 1950, many of whom were the first physicians to enter the newly created family medicine residency programs and/or to staff the first group of federally-funded community health centers.
We will focus on two of the physicians we lost in the past year – Doctor Peter V. Lee, who was the first Chair of the Department of Family Medicine at the University of Southern California (born before 1930) and Doctor Mark E. Clasen of the Wright State University Boonshoft School of Medicine in Dayton, Ohio (a member of the second group).
Beyond the extraordinary influence that both physicians had on the careers of so many physicians who were inspired by their teaching and professionalism, both were emeritus board members of the Coastal Research Group, which conducts the National Conferences.
The composition and subject matter of individual panels will be announced in future weeks.
We gratefully acknowledge the sponsorship of the Charles Q. North, MD of the University of New Mexico Department of Family and Community Medicine for his support of the transcription and editing of this section of the Proceedings of the Twenty-Sixth National Conference
Stan Kozakowski, MD, American Academy of Family Physicians, Leawood, Kansas [Dr Kozakowski is the 2015 Norman B. Kahn, Jr, MD National Conference Scholar]: Good morning, I’m Stan Kozakowski and this, I’m a first time attendee here. I’m going to try and realize the challenge.
Bill Burnett asked me to touch on two topics during my ten minutes. One is the American Academy of Family Physicians (AAFP), response to the Institute of Medicine (IOM) report and then give you a brief update on the Family Medicine for American’s Health project. We’re going on a whirlwind tour here.
As a matter of disclosure, I’m speaking as an individual today, not as a member of the AAFP because some of the things I have to say may not totally align with the AAFP policies.
On September 15 of that year, the Academy presented a position paper on Capitol Hill. There were two campaign pieces that went with this. Essentially the Academy believes that the IOM got it mostly right.
1. Restrict GME Payments to “First Certificate” Programs
We as the AAFP put forth five policy recommendations. The first recommendation has to do with limiting payment for GME to “first certificate” programs.
Over the last decade, there have been a significant number and percentage of additional GME slots funded. If one agrees that we, as a nation, have a need to increase our primary care base and to address other potential specialty shortages, how GME funds are used should be considered.
If the funds for the 7700 existing fellowship positions were shifted to new first certificate programs, that could potentially fund another 7700 new first certificate programs. The AAFP recommendation is that half of those positions go to primary care specialties, and half of those allocated to primary care go to family medicine.
2. Require funding recipients to Meet Primary Care Physician Training Thresholds
The AAFP’s second recommendation is that there should be thresholds for receiving these government funds, that relate to production of primary care physicians.
Our recommendation is that a third of the positions that an institution receives are funding primary care positions. We define the primary care specialties as family medicine, general internal medicine and general pediatrics.
This recommendation addresses what has been referred to as the “Deans Lie”. I think about this as a systems issue and not as an intentional lie, but we do have a system designed to produce the results that we have. We know that five years out from a physician’s graduation from residency is a better measure of whether that physician is practicing primary care..
3. Require demonstrated Maintenance of “Primary Care” Training Efforts
The third AAFP recommendation is that for an institution to seek additional slots, there should be a demonstration that those positions going into primary care.
The institution should demonstrate that it is maintaining its primary care effort over the long haul.
4. Provide for for Innovation in Funding Formulas
The fourth AAFP recommendation endorses the IOM report’s recommendation that the funding formulas should allow a certain amount of innovation.
If there were an adjustment of the indirect medical education (IME) factor reducing it by a quarter percent, it would free up about $300 million that could be used to fund a workforce commission as well as innovation in community-based training.
5. Fund a National Workforce Commission
The fifth recommendation is to fund a national workforce commission. We know that politically that name may be problematic but the concept of an oversight body is important. Somebody has to do it. It’s not being done here in this country. That’s essentially the AAFP position on the IOM.
Now we shift directions!
Update on “Future of Family Medicine” Project
Over the past ten years, we’ve seen the development of the Future of Family Medicine efforts. The first iteration we call Future of Family Medicine 1.0.
In 2014 at the annual AAFP assembly we launched the Family Medicine for America’s Health effort.
I see that one of the challenges here, as compared to the first Future of Family Medicine project is that, if you will, we are building the airplane in the air. The Future of Family Medicine through tactic teams.
We launched this effort in September, 2014, to coincide with an AAFP Assembly was meeting in Washington, D.C., even though it was not fully fleshed out.
In our analysis of the first project a decade ago, we concluded that its communication strategy was ineffective. So an important component of this new project now is a communication strategy, whose theme is “Health is Primary”.
So here’s the report. I would recommend to you the article in Family Medicine, looking at the foundations.
The Seven Core Strategies
There are seven core strategies that are found in that report. Essentially, they articulate our need to connect our nation’s people with a trusted source of care. We need to achieve the Triple Aim; we need to demonstrate value, et cetera.
In order to have a well trained workforce to do that we have to have systems in place to support that, financially and otherwise.
The Six Tactic Teams
There are six tactic teams which began in January. 2015. They are looking at ways to set direction.
Each of these six tactics is important, and each team has been asked to develop a set of initial tactics. Today we will focus momentarily on the workforce, which is where medical education lies.
The Workforce Tactic Team
The workforce team here is looking at four initial tactics:
(1) incorporating EPAs (entrustable professional activities) into residency training;
(2) providing the skills needed for population health, (because that’s something new and evolving)
(3) increasing the number of students going into primary care and, particularly, into family medicine; and,
(4) addressing the national problem of inadequate numbers of preceptors.
The Public Relations Effort
Supporting this effort is a public relations campaign.
That campaign comprised of press events. Concurrently, a series of rallies are planned that convene people on a local level.
The goal is eventually to create tool kits that can be used in any community.
Workforce and Medical Education Issues
This is the strategy on which we have embarked. But the challenge we have before is to decide whether we asking the right questions?
Look at this list of initial activities around workforce and education. Are these the right ones that we should be focusing on right now? I’m not so sure. I hope we can talk about that as we get into our Q & A.
When considering workforce, do we know what we need and how we’re going to get there?
I would recommend to you Bazemore and Peterson’s article that was published in Family Medicine.
I draw your attention to what they see as a 33,000 primary care physician shortage by 2035.
With our current level of production we would need an additional 1700 primary care residency slots in order to produce that workforce.
If there is a reduction in the number of patients cared for by a physician, that number changes and, according to the authors, could be 3,000.
If we play with the retirement age and so on, the numbers shift again. So predicting the workforce needed is certainly a major challenge.
For family medicine, depending on how you slice the numbers and what assumptions you make, it could be as many as 1700 additional slots are needed, given current trends in terms of how general internal medicine is performing.
Have we really done very well? This graph shows the total number of residency slots, and the number of slots actually filled. It also shows the number of U.S. senior class medical students.
My answer to the question is maybe. We may be producing the numbers of residency graduates in terms of getting us to the increased production that we project we need.
It translates to about 65 additional positions per year. That is about 12 new family medicine residencies would need to come online every year over the next period of time here in order to ramp up to this level; or an increase in current positions at residency by perhaps two per residency program in the current configuration. But U.S. seniors are not finding this attractive, at least based on the last match. We had a net of six additional U.S. seniors select family medicine.
The Center for Interprofessional Education
Do we need to think about our delivery of the workforce differently?
I recommend consideration of Barbara Brandt’s work being done at the Center for Inter-professional Education.
She proposes creating new partnerships that bring together the education community with the practicing physician community.
Our ultimate goals are improved healthcare and educational outcomes. Should we not be thinking about inter-professional training and inter-professional care delivery in the future in new ways?