Lawmakers consider health delivery system reform

Primary care physicians and specialists make their pitches on ways to improve care coordination and address doctor shortages.

By Chris Silva — Posted June 1, 2009

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As senators continued their work of drafting health system reform legislation, physicians and other health policy experts appeared before a key panel to stress the fact that true reform will involve not only payment revisions but also major changes in the way the system delivers care.

Testifying May 14 before the Senate Health, Education, Labor and Pensions Committee, experts expressed concerns about inadequate physician payments and work force shortages while promoting community health teams, medical homes and other care partnerships as some of the ways to improve health care delivery methods.

Sen. Sherrod Brown (D, Ohio) called the U.S. health industry a "patchwork system grounded in good intentions but derailed by unjustifiable variations." To build a better structure, leaders must address "lack of coordination, lack of information, lack of basic standards of care and standards of coverage," he said.

The lack of coordination issue could be addressed if Congress is able to encourage improved partnerships between primary care and specialties, said Steven Schlossberg, MD. He is chair of health policy at the American Urological Assn., which is a member of the Alliance of Specialty Medicine. A lack of coordinated care in the Medicare program leads to a high number of emergency department visits as well as preventable hospital admissions and readmissions, said Kenneth E. Thorpe, PhD, professor of health policy at Emory University in Atlanta and executive director of the Partnership to Fight Chronic Disease.

"Medicare spends nothing on care management, and so generates no savings from it," Thorpe said.

With certain chronic diseases on the rise, it is imperative that the health care industry embrace key design features from successful care management models used by such facilities as the Mayo Clinic in Rochester, Minn., and Geisinger Health System in Danville, Pa., Thorpe said. Using these models to launch community-based "health teams" would provide care coordination and prevention using the same tools and approaches employed successfully in larger practices, and it would allow Medicare quickly to replicate these efforts nationally.

Community health teams already are in place in Vermont, North Carolina and Rhode Island, he said. CHTs involve care coordinators; nutritionists; behavioral and mental health specialists; nurses and nurse practitioners; and social, public health and community health workers.

Medical homes and shortages

The medical home concept also is very much in play in the current health system reform debate.

In a medical home, care is delivered and directed by competent, well-trained physicians who provide primary care and also facilitate all aspects of specialty care, said Marsha Raulerson, MD, a primary care physician in Brewton, Ala., who testified at the HELP hearing on behalf of the American Academy of Pediatrics. She has been operating a medical home out of her office since the early 1980s, with a specific goal of providing a continuum of preventive and specialty medical services for every child.

When asked how Congress could promote medical homes, Dr. Raulerson said lawmakers must provide financial and structural assistance to help with implementing health information technology and e-prescribing.

The AAP believes that every child, regardless of health status, should have a medical home, she said. Such a goal would mean fewer chronic health problems later in life.

Still, properly coordinating care means that physicians must be available to cover all of the necessary treatment areas, said Richard A. Cooper, MD, a professor of medicine at the University of Pennsylvania. He said too few physicians are available now, and future shortages are unavoidable.

To address this crisis, residency programs must be expanded, Dr. Cooper said. Medicare also must lift its cap on residency positions and provide more support to existing training programs, he said.

When policymakers talk about medical homes, the discussion often centers on primary care physicians. But specialists should be able to play a larger role in medical home models by being allowed to function as principal care coordinators for beneficiaries, Dr. Schlossberg said.

Brown noted the argument that it might not make sense for a primary care physician always to serve as the medical home coordinator. "For example, many women view their obstetrician-gynecologist as their primary care provider and would want their medical home to be based out of their ob-gyn's office."

Physician shortages also are not strictly a primary care issue. Citing federal government data, Dr. Schlossberg testified that the number of practicing surgeons is expected to increase by only 3% between 2005 and 2020, and significant declines in a number of surgical specialties are anticipated. Dr. Cooper said cardiology and urology began to experience shortages seven to eight years ago.

Dr. Raulerson also reported that pediatricians are having trouble finding certain pediatric specialists. For example, the closest pediatric neurologist with whom she can coordinate if a child has a seizure is about 200 miles away in Birmingham, Ala.

Some payment reform issues highlight potential conflicts between the priorities of primary care doctors and specialists. A long-term solution is needed for the Medicare physician payment system, Dr. Schlossberg said. But Congress should not "rob Peter to pay Paul" by boosting primary care pay at the expense of specialists.

"Not everything can be prevented," he said. "People get sick. They need specialists. They need surgeons. They need hospitals and emergency rooms."

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Ideas for a new delivery system

The Patient-Centered Primary Care Collaborative is a coalition of more than 400 employers, consumer groups, health plans, hospitals and physicians that have worked to advance the patient-centered medical home concept. It states that the most effective way to re-align payment incentives to support the medical home concept would be to revise the traditional fee-for-service system according to a three-part model that involves:

  • Maintaining a visit-based fee-for-service component that provides an incentive for the physician to see the patient through an office visit when appropriate.
  • Introducing a monthly care coordination payment component to cover work that falls outside of the confines of a regular office visit.
  • Adding a performance-based payment component to recognize practices that meet quality and efficiency goals.

Source: American College of Physicians(link)

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