Economic Crisis Will Change The Health Care Delivery System: Why Family Physicians Should Take The Lead!

Every business in America is buckling under the increasing costs of healthcare expenses. Year after year, health care costs grow faster than the rest of the economy, straining families, businesses, and government budgets. Americans will spend $2.4 trillion on health care in 2008, which is equal to $7,900 a person! No industrialized nation in the world comes even close to what America spends on healthcare! Focusing on cost containment measures most politicians consider health insurance reform as the primary goal. But what we need is not ONLY health insurance reform BUT healthcare access and delivery reform!

The Massachusetts healthcare reform model has demonstrated that expanding coverage without improving access to quality healthcare is a recipe for failure! The success of universal health coverage depends on an adequate supply of primary care physicians, especially family physicians. But current physician workforce models are already forecasting a shortage of 46,000 primary care physicians by 2025.

The access problem will be compounded by the fact that within a few years, the first wave of the 76 million Baby Boomers will become eligible for Medicare. Patients older than 85, who are in the most need of chronic care, will rise by 50% by the end of this decade! Lets not forget that chronic disease care already consumes 75% of all healthcare costs but our healthcare delivery system is ill equipped to coordinate chronic disease management.

According to a study published in the prestigious New England Journal of Medicine the average Medicare patient visits a total of seven doctors — two primary care physicians and five specialists — in a given year. This leads to an increased fragmentation of care resulting in duplication of medical tests, the increase in medical errors and exponential rise in healthcare costs. Furthermore, the shortage of primary care physicians forces many patients to seek basic medical care in crowded and expensive emergency rooms.

Since the beginning of this recession in 2007 over 5.7 Million Americans lost their job and the growing unemployment rate will further decrease the number of patients with health insurance. These patients are also unable to pay the high COBRA premiums to maintain their insurance coverage. Already, the seven largest commercial health insurers in Florida representing about two-third of the total commercial health plan enrollment report a loss of 190,000 enrollees during 2008.This trend will continue and accelerate. Furthermore, small businesses lack the negotiating clout needed to obtain favorable rates from insurance companies, and their inability to spread risk across a large group of employees’ means that the health problems of a single employee can drive premiums up to unaffordable levels. As a result, fewer and fewer Americans receive health coverage from work. The percentage of Americans covered by employers dropped from 62 percent in 2003 to 59 percent in 2008, the equivalent of 8 million people losing coverage. And for tens of millions of Americans ineligible for Medicare, Medicaid, or another public program, no viable alternative exists to employer-sponsored insurance. This insurance conundrum combined with the economic downturn adversely affects the physicians practice too, decreasing cash flow and reducing operating margins.

Furthermore, financial institutions tighten credit requirements and limit collateral loan facilities. So what can physicians do to maintain our professional autonomy and the financial viability of their practices? There are few options left. Some do still believe that the storm may pass and that they will be able to continue practicing the way they are used to. This is an illusion and will lead to financial disaster! Lets not forget one simple truth: crisis breed’s opportunity, and success favors the prepared mind. Therefore, physicians have to move forward to meet those challenges. To secure access to quality health care we need to promote the expansion of primary care services. But primary care delivery should be organized along the line of practice integration ranging from collaborative practice models to fully integrated group practices. Such models will allow us to respond to complex reimbursement changes that will focus on value versus volume. This will require the skilled utilization of medical information technology tools, including Electronic Health Records, to measure the cost, quality and outcome of the services rendered.

The emergence of pay-for -performance and quality reporting initiatives will also require sophisticated care delivery, data collection and reporting systems. The necessary technology investments required to meet the increasing standards can be shared within an integrated practice models. In addition, centralized billing, supply management and human resource administration will create efficiencies and reduce the overhead of individual practices. Such integrated practices will not jeopardize but maintain professional autonomy. Depending on the framework of integration, most physicians will be able to remain in their own practice setting, oversee many day-to day practice operations and be financially rewarded based on individual productivity while still achieving a high level of practice integration. The application of proven business management principles in medical offices can help doctors to work smarter and NOT harder Above all, such integrated practices can assess and evaluate the performance of medical services rendered, can negotiate for higher reimbursement, and directly contract with employer groups offering discounted medical care.

But coordinated and integrated healthcare delivery should not stop here. All healthcare reform efforts focus on establishing centers of excellence in medical care administered by family physicians! These centers are intended to provide access to high quality primary care emphasizing coordinated healthcare delivery in collaboration with a team of specialists and allied healthcare professionals. Family physicians should coordinate and deliver such care within the context of Patient Centered Medical Home (PCMH) which will lead to higher value care (enhanced quality and lower resource use) for patients with chronic illness or preventative service needs. The key principles of the PCMH statement stipulate that PCMH practices will provide:

1. Access to care based on an ongoing relationship with a personal physician who is able to provide first contact, continuous and comprehensive care,
2. Care provided by a physician led team of individuals within the practice, who collectively take responsibility for the ongoing needs of patients,
3. Care based on a whole person orientation in which the practice team takes responsibility for either providing care that encompasses all patient needs or arranges for the care to be done by other qualified professionals,
4. Care coordinated and/or integrated across all elements of the complex health care system and the patient’s community,
5. Care facilitated by the use of office practice systems such as disease registries, information technology, health information exchange and other systems to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

But without financial incentives and value-based reimbursement all such business models will fail. Financial viability depends on sustained cash flow. Therefore, we must support fundamental payment reform that will reward family doctors to spend time with their patients and to focus on the core values of patient care. We must demand that physicians are being paid for the quality and value of care provided and not the quantity and volume of services. Otherwise, stagnating reimbursement based on flawed payment models will deprive us of an entire generation of urgently needed primary care physicians.

Finally, we need to restructure the medical education system, which is currently focused on training specialists but not primary care physicians. Student loan forgiveness programs and other financial incentives must be utilized to entice medical students to consider primary care as a career option.

These are just a few ideas that should be assessed and evaluated. As primary care physicians we must take a proactive position and start reshaping our practices. Many of us are stuck in the daily routine and are afraid to change. We need to collaborate and act as a collective group to leverage the financial risks and, through mutual support, assist the individual doctors along the process of change.

If we do not adjust to the rapidly changing healthcare environment, third parties will enforce painful solutions. We need to change our direction, otherwise we end up where we’re headed today.