Sunday, July 05, 2009

Health Care's New Model: Don't Just Do Something, Stand There

Promoting High Quality Care will require organization around primary care.

In this great article in the New Yorker, Dr. Gawande shows how we need to come together and provide high quality care. This usually means less tests, consultants, and procedures.

Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker

The best idea I have heard on organizing physicians around quality care is from Brownlee and Fine (excerpted by Dr. Colin Kopes-Kerr, MD, JD:

"Primary Care for All will require new infrastructure at the regional, state, and federal levels to support universal access to primary care health centers... Each community or region will need a Primary Care Board, which can contract with primary care practices to provide effective, efficient care... Each state will also need a Primary Care Trust to plan and oversee the functions of primary care practices. The Federal Government will need an Assistant Secretary for Primary Care in the Department of Health and Human Services to bring focus and direction to the many agencies inside the Department that are concerned with primary care."

"Primary Care for All is not a proposal to change what most Americans have now. Instead, it brings together three existing systems that currently provide primary care, and out of them creates a primary health care infrastructure that cares for all citizens"--existing private primary care practices, community health centers, and vertically integrated accountable health care organizations like Kaiser Permanente. They see the continuation of a healthy tradition of private practice is "necessary for critical check and balance on the integrity of a more public system."

There are two possible methods that could be used to finance Primary Care for All. "The simplest method is for all payers (including Medicare and Medicaid) to put $400-500 per beneficiary per year into a Primary Care Trust--a state-based, non-profit, private public partnership, responsible for paying all primary care practices on a risk-adjusted, capitated basis. These funds would pay for the primary care of all Americans, not just the uninsured...People without health insurance would also be required to pay into the Primary Care Trust, but would receive tax credits for doing so. Those living in poverty would receive public subsidies for primary care, to be funded either by tobacco and alcohol taxes, or taxing employee health benefits."

The alternative payment mechanism would involve the use of Community Health Savings Accounts. "Like HSAs, Community health Savings Accounts are high deductible health insurance policies linked to tax advantaged savings accounts owned by the individual. Where they differ from HSAs is that policy holders would be required to make monthly payments out of their savings account to a certified primary care practice chosen by the individual."

"Why pay primary care practices through the Primary Care Trust? The Primary Care Trust approach is intended to produce an equitable and effective infrastructure, and reduce or eliminate regional disparities in the type and amount of care people receive." In addition there is a need for a single set of quality and service delivery measures, and population-based outcomes measures selected by the wisest among us. The important characteristic of this system is that physician reimbursement will no longer be on a fee-for-service basis. Like original sin, this single flaw at creation doomed us to the health care we have now.

As do most analysts of health reform, Brownlee and Fine expect to encounter work force issues--like a need for 25,000-50,000 more primary care physicians. They accurately comment, "The optimal supply of primary care physicians and practices for a given population, and the ideal composition of the primary are team is not known at present." They go on to speculate that "[S]ome of the immediate need for more primary care physicians will be relieved by improved organization or primary care practices, and by increased use of physicians assistants, nurse practitioners, case managers, and my favorite alternative, Community Health Workers.

Brownlee and Fine conclude, "Financing health care system reform can succeed best if it is accompanied by focused improvement in primary care delivery and organization. The development of Primary Care for All presents an essential and affordable first step toward an effective and efficient health care delivery system, and sustainable health care reform.
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