Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?

Brian Klepper and David Kibbe offer a post today on the issue of primary care and the role they believe health plans should be taking to encourage greater involvement with PCPs. They ask why health plans are not being more proactive in partnering with PCPs to control costs.

Can Health Plans Explain Why They Aren't Re-Empowering Primary Care?
By Brian Klepper & David Kibbe



Sometimes a whisper is more powerful than a shout. Here's a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Over decades we allowed the combined actions of the AMA, Medicare and the nation's commercial health plans to marginalize primary care, so that now the typical cardiologist makes up to 4 times more than a PCP, and only 7 percent of medical school graduates now enter office-based primary care - not nearly enough to care for the aging boomer population that's growing by leaps and bounds.

Worse, as the most recent Dartmouth Atlas report made clear, the greatest concentration of "unwarranted variation" - waste - is concentrated in the specialties and inpatient arenas. This explosion in services and cost has largely resulted from tying the hands of America's PCPs, preventing their involvement in downstream decision-making. Equally corrosive culprits have been a fee-for-service reimbursement system that financially incents specialists to conduct unnecessary procedures, and a lack of transparency that would allow us to more easily identify the excesses when they occur.

There's hardly any question whether empowering primary care would dramatically improve the system. As Sepulveda, Bodenheimer and Grundy pointed out in a March Health Affairs article, literally dozens of studies show that more primary care in a community is associated with lower costs and better outcomes. More specialists lead to higher costs. In the US, the ratio of PCPs to specialists runs about 30/70, while in other developed countries its typically around 70/30. Their costs are generally about half ours and their outcomes better. Can anyone really argue with a straight face that empowering primary care is an iffy proposition, and that it demands more study before acting?

The entire premise of the Medical Home movement, seen most vividly through the efforts of the Patient Centered Primary Care Collaborative (PCPCC), is based, first, on empowering PCPs to do the things they were trained to do, and second, giving them the tools, programs and authority to optimize their roles. The PCPCC has been built around the power of Fortune firms and business health coalitions, each with considerable stroke, as well as several primary care associations. The health plans are at the table too, busily showing their support through pilot projects that test what happens when PCPs are paid a pittance more.

Even that is critically important, though, because the commercial health plans are the linchpins of change for this aspect of American health care. Unlike public health plans, who must adhere to policy that is dictated by the health care industry's lobby, the commercials can respond to market forces. Health plans also are the only ones who can reach and transform the practices of the 250,000 or so community-based PCPs faltering under the lash of our current reimbursement paradigm. Their salvation is absolutely vital to re-establishing American health care's stability and sustainability.

But so far as I'm aware, not one national health plan has yet decided to move beyond a pilot and unilaterally improve their medical management performance by paying PCPs significantly more. So far, there are no broad-based efforts to empower PCPs to have a say in what happens to their patients once they're referred downstream to specialists. Nor are health plans systematically helping PCPs acquire the sophisticated patient management information technologies that can result in better outcomes at lower costs.

What are they waiting for? Why aren't health plans making this obvious and straightforward adjustment to their medical management models? Skeptics might argue that, despite their protests that they're in business to hold down costs, health plans make a percentage of total claims, so they certainly don't want total claims to be less.

The plans might respond that they don't want greater PCP involvement to antagonize the specialists, who they rely on. After all, it's clear that, interference notwithstanding, collaborative decision making at the specialist level drives down specialty utilization and, with it, specialist incomes.

Or they might argue that they run enormous, complex operations, and big course changes are difficult and take time. Whatever.

Hence the inherent truth of the cartoon.

Still, there's no question that we're at a tipping point and that the time for action has come. Health plans have reported weaker enrollment figures, with reductions in the sales of even their much skinnier High Deductible Health Plans (HDHPs), as more employers and families are priced out of insurance. The coverage market is eroding as health costs continue to spiral upward, exacerbated by a credit crisis that is freezing liquidity. These economic trends are abetted, of course, by a primary care structure that is unable to exert control over the unbridled provision of specialty and inpatient services.

All this would be academic if there weren't a very visible alternative model that performs MUCH more efficiently. Employers with strength and foresight are actively moving around the health plans by establishing worksite clinics, effectively staff model primary care practices that are fully realized medical homes. In general, these enterprises pay PCPs far better than they make in private practices, giving them access to excellent tools, and letting them loose to provide the care they know how is appropriate. The results are dramatic. Clinic companies routinely report significant savings, both on group health costs and occupational health and productivity costs, which are corroborated by their clients.

If the reports from the big benefits firms are right, more than half of all jumbo Fortune firms will have put up worksite clinics by 2010. Because these clinics are scalable, the trend is now catching like wildfire with large and even midsized (down to about 250 employees) firms as well. Several clinic firms are also working to bundle commercial insurance products with clinics in ways that allow smaller businesses and individuals to come together, collaboratively using the clinics to enhance access and drive down cost.

But the core problem remains. We won't have real change in the delivery of care until the health plans either voluntarily change their relationship with primary care, or are forced to do so. As the cartoon suggests, they're not inclined.

So here's a sincere request. If you're a reader of this blog associated with the health plan sector, how about providing us with a lucid explanation of your hesitancy to change. What EXACTLY are you waiting for? Tell us.

If you're a primary care physician and you agree with us on this, then please send this post to your regional health plans and pointedly ask why they're dragging their feet. Pass this along to business leaders you know as well, and ask them to contact their health plans too.

Brian Klepper PhD is a healthcare market analyst. David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on healthcare professional and consumer technologies.

Health Wonk Review is UP!

David Harlow hosts this week's edition of Health Wonk Review over at his, "HealthBlawg."

It is a very comprehensive sample of some of the best recent posts from the world of health blogs.

The McCain Health Plan's Good Idea for Health Care Reform--Likely Going Down With the Candidate

John McCain would reform the American health care system by providing big tax incentives for it to transition from being employer-based to one built on a system of individual responsibility. He would do this by eliminating the longtime personal tax exemption on employer-provided health insurance and replacing it with a $2,500 individual, and $5,000 family, tax credit for those who have health insurance.

It's too bad this idea will likely recede from the national health policy debate whether John McCain wins or loses the presidency. Even if he wins, the Democratic majorities in Congress will be so large there is little chance we will be able to move away from the traditional employer health insurance base in the next few years. All you have to do is look at the way Obama and all of the Democratic candidates for the Senate and House have railed against McCain's plans to "tax your health benefits" to see how Democrats have willingly painted themselves into a political corner that makes this idea a non-starter in the new Congress.

As I have said on this blog before, I have been largely disappointed in the McCain health plan. He started out with a bold new approach but never closed the loop on so many key elements in his plan. For example, he leaves those with pre-existing conditions to the fate of state-based risk pools--a place no one would ever vote themselves into. See: John McCain's Health Care Plan and the Uninsurable--There Are Better Fixes Than the Ones He's Proposed

It never made sense to me for McCain to ask voters to take a bold leap with him to reform the health care system but do little to make voters comfortable with the consequences of all that he was proposing. As a political proposal, the McCain health plan was a disaster. Who would ever vote themselves into such a system with less health care security than they have today?

It is no surprise that a big part of Obama's advertising budget has been spent zeroing in on the McCain health care plan's tax changes. I am surprised they didn't zero in on even more of it.

McCain's failure to make such a big leap away from our current system of third-party pay something voters could look forward to also makes it harder for more serious proposals to fundamentally redo our health care system on a platform of individual responsibility--the Wyden-Bennett plan for example.

The employer community themselves have amazingly added fuel to the arguments we need to stay with the employer-based system. The U.S. Chamber, the Business Roundtable, The National Business Group on Health, the American Benefits Council, and the NFIB have all had at least cool things to say about McCain's tax credit idea (New York Times, October 7th). The health insurers have gone along with this opposition--most certainly afraid to call for their benefit manager clients' layoffs!

Why are employers so against taking this big benefit cost off their books? They continue to see benefits as an effective way to compete for workers. They are also worried that they are going to get the bill anyway but won't have any control over what it costs in a new system.

As I have also said many times on this blog, I believe that either the employer-based or individual-based approach to health care reform could work. However, my guess is that if most health policy experts could create a clean sheet health care system in America, putting it on an individual platform would be one of the things most--liberal and conservative--would agree to do.

McCain has made such a mess of selling his health plan--and Obama has done such a good job of taking advantage of it--that I fear we have boxed ourselves into the third-party pay employer-based system, that has proven to be so expensive, for a longtime to come.

The only hope for this idea is that, in the face of daunting federal and state budget deficits, a restructuring of the system on an individual platform may be the only way we can achieve health care reform on a pay-as you-go basis--Wyden-Bennett for example, pays for itself in the third year.

But the well has been poisoned over an individual-based system in the face of big Democratic majorities that have so opposed the idea in this election.

The Democrats, in trashing the idea of a tax change for health benefits, and the Republicans in so fumbling the argument, may have taken the one way we could have done pay-as-you-go health care reform off the table.

Or, both sides can take a second look at it--this time complete with the appropriate arguments and policies that give voters the health care security they require.

Update: Speaking of fumbling the arguments for the conservative approach to health care reform, a few hours after I posted this, a leading McCain spokesman was quoted at CNN regarding the McCain health tax credit:

Younger, healthier workers likely wouldn't abandon their company-sponsored plans, said Douglas Holtz-Eakin, McCain's senior economic policy adviser.

"Why would they leave?" said Holtz-Eakin. "What they are getting from their employer is way better than what they could get with the credit."

So just why would Holtz-Eakin expect anyone to vote for the end to the employer tax exemption on health benefits in favor of the McCain tax credits?

Coventry Health Care Stock Down 48%--"Sort of" No Surprise

Readers of this blog will not be surprised to see Coventry Health Care's stock down 48% this afternoon after its earnings call this morning.

That is a 77% drop from their 52-week high.

Last July I commented on their earnings call where senior management used the precise financial term "sort of" 63 times to explain their then earnings and operations situation: Required Reading for Health Care Analysts and Coventry Health's "Sort of" Informative Conference Call

Well, three months later they're "sort of" in the crapper.

Joe Paduda, over at Managed Care Matters, has been following the Coventry problems more closely than I and has a number of recent posts on their problems.

What Impact Do Medical Costs Have on Home Mortgage Foreclosures?

That is the subject of a recent paper by Christopher T. Robertson, Richard Egelhof, & Michael Hoke.

The authors studied homeowners going through foreclosure in four states and found a big impact on their being able to stay in their house because of the health care cost issues these families had to deal with.

Here is an excerpt from their work:

"This preliminary study reveals that the standard account is, at best, an inadequate understanding of the causes of mortgage defaults. We found homeowners that tended to have significant equity in their homes and reasonable ratios between their income and their mortgage debt burdens. Few reported that their loans were unaffordable and only about a third said increasing mortgage payments were a factor in their defaults. From the surface, these respondents appear to be able to afford their homes and have no reason to walk away from them. So why are they in default?

"Our evidence suggests that medical disruptions are a major contributor to mortgage default, often striking in combination with other factors. Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem, including illness or injuries (32%), unmanageable medical bills (23%), lost work due to a medical problem (27%), or caring for sick family members (14%). We also examined objective indicia of medical disruptions in the previous two years, including those respondents paying more than $2,000 of medical bills out of pocket (37%), those losing two or more weeks of work because of injury or illness (30%), those currently disabled and unable to work (8%), and those who used their home equity to pay medical bills (13%). Altogether, we found that about 7 in 10 of our respondents either self-reported a medical cause of foreclosure, or experienced one of these indicia of medical disruptions in the years before foreclosure. In many cases, homeowners were hit with a perfect storm of factors – a few thousand dollars of medical bills, a few weeks of missed work, and perhaps a divorce or rising interest rate – all combined to push them over the edge into foreclosure."

The survey studied homeowners going through the early part of the mortgage meltdown--focusing on families in the first stage of the foreclosure process in November 2006.

The full report: Christopher T. Robertson, Richard Egelhof, & Michael Hoke, "Get Sick, Get Out: The Medical Causes of Home Foreclosures" Health Matrix 18 (2008): 65-105. You can access the entire report here.

Demystifying U.S. Health Care Spending--Some Surprising Information

Paul Ginsburg, of the Center for Studying Health System Change, has just authored a new report, "High and Rising Health Care Costs: Demystifying U.S. Health Care Spending." The report is part of the Robert Wood Johnson Foundation's Synthesis Project.

This paper reviews existing literature in search of a more clear understanding of U.S. health care costs, the drivers, and the trends.

It is an encyclopedia of the research on U.S health care costs and required reading for any health policy wonk!

I found the following notable:

• Technology is the key driver in health care spending accounting for an estimated 38% to 65% of spending growth.
• "Obesity is a significant factor driving health spending, accounting for an estimated 12% of the growth in recent years." However, any gains from reducing obesity would be concentrated in the short and intermediate period "because some of the savings will be offset by increased longevity and the cost of disease that are most prevalent during old age." The irony is that obese people die sooner thereby avoiding the high medical costs associated with living longer.
• If we insure more people our health care system will cost more not less. "The increase in the percentage of people with health insurance accounted for approximately 10% to 13% of the historical growth in spending." The uninsured has not contributed to the recent growth in health spending in the aggregate and will not be a driver in the future unless we find a way to insure more people.
• Aging will not be a major factor in driving health care spending, and will not become one, despite aging baby boomers.
• Medical malpractice is not a major driver of spending trends. Medmal does contribute to health spending at any moment in time, but is not a large factor nor a significant factor in overall growth of health care spending.
  
• "Productivity gains in the health care sector have probably been lower than in other industries."
• U.S. health care cost increases continue to outstrip those in other industrialized nations by a large margin. Excess health care growth in the OECD nations was 0.6% between 1985 and 2002 compared to 2% in the U.S. for that period.
• When compared to the health systems of other industrialized nations, "prices, efficiency, and insurance administration are the most important differences."
• Drug prices are 70% higher in the U.S., physician compensation is 6.6 times per capita GDP for specialists and 4.2 times for primary care compared to 4 and 3.2 in OECD nations, the U.S spends 54% more for the top five inpatient medical devices, and the U.S. spends six times more for administration than the OECD nations.
  
• "Overall our understanding of high and rising costs is fairly solid. Our most pressing needs are not as much on the research side as on the development side, that is, all of the technical work needed to pursue many of the reforms..."

Aging and medical malpractice costs are not major contributors to the cost of health care in America? If we solve our obesity epidemic we will just increase longevity, more people will make it to old age, and we'll have all sorts of other high costs? Covering everyone will cost us more in the aggregate not less--getting them all in the system won't be a money saver?

Are these the "inconvenient truths" in health care reform?

The data would seem to say they are.

So does this mean we should back off on tackling obesity, forget medical malpractice reform, and scrap plans to reduce the uninsured?

No. I'd respond it's fair to say that is not what the author has in mind.

There is a moral imperative to deal with the uninsured. Being obese may save the system some money in the long-term because the person dies a lot earlier--hardly a desirable policy objective. That obese person still costs us a lot more in the near term and typically suffers from chronic disease in the meantime. Our medical liability system needs reform if only to reduce the rate of medial errors and the human toll those take.

But when it comes to health care costs, the real target needs to be productivity--or said another way cost containment.

One finding from this report really struck me: "If the efficiency of the delivery of services could by increased by 20% over 10 years, this would roughly close the gap between health care spending and GDP over that period." The bottom line is that if we want to contain our health care costs we need to find productivity improvement in things like technology use, treatment patterns, and administrative overhead.

Today, most health care reform plans focus on things like expanding the number of the insured and wellness initiatives. Those are good objectives.

But covering more people will cost more not less. Improvements in lifestyle--particularly obesity--can help.

But we cannot afford to stop there. Literally.

The big-ticket play is in productivity--the more discriminate use of medical technology, consistently practicing outcomes-based medicine, and reductions in system overhead particularly in the insurance system.

The problem with the health care productivity issues is that you have to step on some very powerful toes amongst the stakeholders to make any big gains--it's a lot easier to talk about insuring everyone and promoting wellness.

If we only increase access and don't hit the health care productivity issues head-on we will simply craft a system we will never be able to sustain.

HIGH AND RISING COSTS: DEMYSTIFYING U.S. HEALTH CARE SPENDING

I have seen an advance copy of this very comprehensive report on the growth in health care spending. If you are in DC next week, I highly recommend this event to you:

HIGH AND RISING COSTS: DEMYSTIFYING U.S. HEALTH CARE SPENDING

New Report Synthesizes the Literature on the Growth of Health Care Spending

Concern about high and rising health care costs in the United States has increased sharply in recent years. With the increase in costs and the lack of affordability of health insurance for many Americans, health policy experts are discussing whether steps can be taken to expand insurance coverage while keeping costs down.

A new report from the Robert Wood Johnson Foundation’s Synthesis Project sheds light on the driving forces behind health care spending and examines the reasons why health care costs continue to rise.

An October 15 briefing with the report’s author and other leading voices in health care will address:

• What are the historical data on health care spending?
• How does U.S. spending on health care compare with other developed nations?
• What are the primary drivers of the growth in health care spending?
• What options do policy-makers have for restraining health care spending?

SPEAKERS
• Paul B. Ginsburg, Ph.D., President – Center for Studying Health System Change (Synthesis Report Author)
• Robert Galvin, M.D., Director of Global Healthcare – General Electric
• Robert Laszewski, President – Health Policy and Strategy Associates, LLC
• John R. Lumpkin, M.D., M.P.H., Senior Vice President & Director of the Health Care Group – Robert Wood
Johnson Foundation
• David Nexon, Senior Executive Vice President – Advanced Medical Technology Association (AdvaMed)

WHEN/WHERE:
Wednesday, October 15, 2008
9:30 a.m. – 11:00 a.m. (Breakfast available at 9:00 a.m.)
National Press Club
First Amendment Lounge, 13th Floor
529 14th Street, N.W. – Washington, D.C. 20045

TO RESERVE A SEAT:
To reserve a seat, please R.S.V.P. to Erica Garland at egarland@gymr.com or 202-745-5119.

Time to Get Real--On the Economy and Health Care Reform

I just got a call from a reporter at one of the major news organizations to talk about the chances for health care reform.

We both commented on the almost surreal environment we are all in. I'm not sure if my friends and neighbors are in denial or just numbed by the recent cascade of events in the financial world. Up on the Hill and in the presidential campaigns it's business as usual when it comes to extending the Bush tax cuts, spending on alternative energy, or the imperative to do health care reform.

The reality is we are now headed down an unavoidable slope into a recession. The only question is how bad. Today, Dr. Phil told his audience to stop spending money, get their credit card debt paid off, and hold cash--"Cash is king." They are and they will.

General Motors' stock hit a price today not seen since the 1950s because no one is buying cars--and won't be for quite awhile.

A slowed economy means less tax revenue at a time we were already headed for a $500 billion budget deficit in 2009--and that was before we would spend as much as $200 billion to extend all (McCain) or most (Obama) of the Bush tax cuts. (Anybody want to give odds on that?)

The next Congress and the next President are facing unprecedented fiscal challenges presuming the credit crisis starts to work itself out.

Someone recently told me an economic crisis doesn't necessarily mean we won't have important social legislation. After all, Social Security came from the depths of the Great Depression. It did. But it was pay-as-you go--there was no big upfront cost as there is in health care.

This denial--or numbness--in the face of a harsh reality reminds me of the times I have called the airlines in the face of a blizzard looking to get them to rebook my flight without penalty. The usual answer is, "The computer says its on time so far." Of course you know it isn't going to take off in the midst of the terrible storm outside.

Health care reform isn't going to take off in the midst of this huge financial storm either and McCain, Obama, all those offices on the Hill saying it will aren't going to make it so.

The sooner we get real--on health care and everything else--the sooner we can start talking about what is really possible.

Recent post: What I'm Telling the Health Care Business About the Future

The Big Elephant in the Room During the Presidential Debate

Last night Tom Brokaw asked Barack Obama and John McCain to prioritize health care, Medicare/Social Security, and energy. Neither of them backed down from their promises to deal with all of them.

When Jim Lehrer tried to challenge them at the last debate on their ability to do all of the expensive things they want to do he got pretty much the same answer.

About the only two people in America that think we can do all of these things--or maybe any of them--would appear to be the two candidates.

So, why do we let them get away with the notion there isn't any reason why we can't have it all on top of their expensive plans for extending some or all of the Bush tax cuts and all of the bailout costs?

A couple of weeks ago I posted about, The Pretend Presidential Debate on Health Care--The Health Care Press Needs to Force the Presidential Candidates to Get Real on Health Care "Change".

Two debates later the press is still letting the candidates get away with their pretend campaign promises as if none of this were happening.

The real issue at hand is just what would each of the candidates be able to do on health care? What's the real health care strategy that each of them have in the face of the greatest financial crisis since the Great Depression.

In all likelihood the most we will see next year is a Medicare bill necessary to deal with the upcoming 21% Medicare physician fee cut. There is money for that in the extra private Medicare payments thereby satisfying the pay-go rules.

If there is any other money the Congress might try some modest expansion of SCHIP and maybe something to stem the enrollment bleeding in the small employer health insurance market. But even those things look like a long shot in the wake of the crisis.

Business as usual isn't an alternative.

Getting these guys to talk about the real world would be helpful!

Rrecent related posts:
What I'm Telling the Health Care Business About the Future

The Chance for Major Health Care Reform in Either 2009 or 2010 Is Now Zero