Op-ed by Kenneth Dolkart, MD
Have you ever heard people talk nonsense about something you know about? Perhaps you’ve had a laugh when you hear people talking through their hat about a machine you work on, a technique you know, or the computer coding of the software you design. Primacy Care docs found it less amusing this past week to hear politicians misapply the concept of “patient-centered care” to promote their poorly designed replacement. The idea of “Patient-Centered Care” dates back at least half a century, and was later widely disseminated in the article “Beyond the Healthcare Chasm” published by the Institute of Medicine in 2001. “Patient Centered” care was defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. ” In the context of safe, effective, equitable, efficient and timely care, “patient centered” means the moral obligation to respect the values, wishes and unique needs of the person before them, and promotes communication and care systems to help honor those values as possible.
In an era of increasing complexity of care and care delivery, this goal has sometimes be undermined by healthcare systems. For instance, fee for service billing might incent the doctor to do more procedures for more reimbursement, but not necessarily the right overall care. With capitated HMO systems there exists a potential to incent withholding of valuable services to limit insurance pay-outs or physician penalties. Such perverse incentives can interfere with the fiduciary responsibilities of some all-too-human clinicians. But none of this has anything to do with Obamacare! The ACA is certainly not perfect, but it does NOT prescribe which insurance types are offered in a particular state marketplace, nor the choice of which medical practices to attend, such as hospital-owned practices or solo practice, nor what tests, procedures or hospitals a clinician can use.
However, the ACA does increase the income level above previous poverty benchmarks at which Medicaid can be provided. The ACA does encourage states to develop their own unique experiments in care delivery, such as the Hoosier Indiana Plan in Mike Pence’s home state of Indiana or that in Vermont. The ACA does mandate that insurances sold in the government-subsidized marketplace provide a minimum of 10 essential services, not just profit for the seller. Preventive services, outpatient and inpatient care, mental health and substance abuse services are among them. The GOP argues that this restricts “patient choice.” Why not allow underinsurance to be sold, as in the bad old days? Why not circumvent state consumer protection law by selling near valueless insurances across state lines? Perhaps because it is immoral. Primary Care clinicians have watched their patients go bankrupt by illness by coverage not worth the paper they were printed on. It is not “patient-centered” nor “patient choice” when the person needs to delay or forego lifesaving tests or therapy not affordable under such flimsy coverage.Primary Care clinicians have watched their patients go bankrupt by illness... Click To Tweet
The “patient centered medical home” arose in the 1960s when pediatricians encountered complex, very sick kids requiring multiple specialists. There was natural confusion over who was responsible for care issues. Ultimately, a Pediatric Patient-Centered “medical home” was designed to enable the primary care provider to respond to acute and chronic problems, and coordinate the complex care provided among specialists. This care team concept was applied thereafter to the adults and the elderly, who often have complex, multiply competing medical issues, and receive numerous, potentially interacting medicines provided by various subspecialists. The Patient-Centered Medical Home is often comprised of nurses, medical assistants, clinicians (physicians, nurse practitioners and physician assistants and social workers), often working with pharmacists. There is certification by the Agency for Healthcare Research and Quality (AHRQ) in this designation. There is a defining necessity to provide comprehensive, patient-centered and coordinated care which is easily accessible and provides expertise. Many doctors believe this type of practice provides the best, patient-centered care for the complex patient.
Obamacare has made insurance attainable for 20 million lower income Americans, provides patient protections by ending preexisting condition and lifetime caps, and expands parent’s health coverage to young adults up to age 26. The reader may not be aware that many programs recommended by the Institute of Medicine were incorporated by the Agency for Healthcare Research and Quality (AHRQ) into Obamacare. These have resulted in at least 50,000 lives saved yearly from improved hospital safety incentives, 150,000 fewer avoidable hospital readmissions due to incentives for coordination of care, and reforms to provide reimbursement for overall quality rather than quantity in our national Medicare health system.
Perhaps it is simply ignorance when “patient centered care” is invoked by politicians to promote the withdrawal of expanded Medicaid and other critical measures. However, Tom Price, the former Senator-Orthopedist, and Secretary of Health and Human Services, is not so ignorant of terminology or health policy. One of the earliest stated goals of Price and conservatives was to defund the Agency for Healthcare Quality and Research, which sponsors research and accreditation for the Patient -Centered Medical Home and the U.S. Preventive Services Task Force. Is it ironic or just cynical for Price to roll out and erase the meaning of the word “patient centered” as they decimate AHRQ?
There is consensus that there are workable ways to improve the ACA. These might include the addition of Health Saving Accounts, creative use of tax credits or adding Medicare-type public options. The major sticking point for conservatives in remains the mandate to purchase insurance. However, for any private insurance to accomplish the eliminating preexisting condition clauses, cover the costs of prevention and also treat illness, there has to be enough steady premiums coming in from healthy people to keep the system solvent. The healthiest 50% of an insured population accounts for less than 3% of health care expenditures, while the sickest 10% account for nearly two-thirds of such spending. The costs of private health premiums started rising independent of the ACA years ago, largely related to drug and technology costs. Lack of competition in any state’s marketplace can certainly contribute. Still, the Right’s wild claims about economic catastrophe and “death spirals” of the ACA are about as factual as Sarah Palin’s claims that “death panels” would soon be mandated. Simply allowing Medicaid (and Medicare) to negotiate prices with pharmaceutical producers, or allowing the import of medication from responsible foreign sources, would rein in medical costs enormously. All other national health programs, as well as the Veterans Administration, use large scale negotiating strategies for controlling the cost of prescription drugs.
New Hampshire is now covering 50,000 citizens via expanded Medicaid. 10,000 New Hampshire residents are having their treatment for opioid addiction covered under these services. As to what to do about the working poor who will lose their coverage under expanded Medicaid, Paul Ryan states “We’re going to have to find solutions that accommodate (those) concerns.” Stay tuned for the return of the “high risk pool”, unused and unobtainable, which died a deserved death with the ACA. It will likely return as a zombie to pretend to exist as coverage for various unsolved problems under Trumpcare.
A randomized, bipartisan survey of 1000 Primary Care physicians was performed this year by the American Medical Association, and published in The New England Journal of Medicine. Only 15% of PCPs (all Republicans) supported outright repeal of the ACA, and 74% favored minor changes that maintained the key components.
Since 1965, Medicare was gradually developed into the popular national system which serves those Americans with the greatest intensity of medical need, and is widely accepted by patients and care providers. 70% of New Hampshire primary care clinicians support a single payer, universal health care program, as do 60% of all Americans. Even 2/5ths of all Republicans would opt for expanded Medicare for All. Since Secretary Price and the Right is intent on repealling Obamacare and Medicare thereafter, know that this is not “patient centered”, and that Americans and their doctors would prefer Medicare for All instead.
Dr. Kenneth Dolkart is an Assistant Professor of Medicine at Geisel School of Medicine and a Geriatrician and Primary care Internist having practiced in New Hampshire for 34 years. He lives in Grantham, NH.