Beverly Jordan is a partner at a family-medicine clinic in Enterprise, Alabama. Enterprise is situated in “wiregrass country”—a largely rural region, encompassing southeastern Alabama and parts of Georgia and Florida, named for the ubiquitous vegetation that takes root in its sandy soil. Her clinic is one of a few offering primary care in the area; like many independent medical practices across the U.S., it has been gutted by the coronavirus pandemic. Even though her practice received a lifeline from the federal government’s Paycheck Protection Program (P.P.P.), Jordan had to take a pay cut, reduce staff hours, and lay off two new physicians who were about to start work. “For the first time in my career, we’re really just planning short-term,” she told me recently. “We’ve never had this level of insecurity.”
For decades, health care was America’s indomitable industry. While employment in other sectors—retail, manufacturing, construction—rose and fell with the business cycle, clinics, hospitals, and medical practices steadily added jobs. But the pandemic has changed health care’s trajectory. Hospitals now find themselves in dire financial straits as they forgo revenue from elective procedures, and a surge in unemployment is shifting patients from private insurance plans to Medicaid, which is less remunerative for doctors. Some rural hospitals, whose financial footing was already tenuous, are facing the prospect of closure.
Among the most vulnerable parts of the nation’s health-care system are family-medicine, internal-medicine, pediatric, and obstetrics-and-gynecology clinics. With COVID-19 precautions in place, in-person appointments have dropped precipitously. In May, a survey of primary-care doctors found that nearly a fifth had temporarily closed their practices, owing to the pandemic, and two in five had laid off or furloughed staff. Primary-care clinics are tasked with keeping people healthy, and decades of research have shown that the care they provide is associated with better outcomes and lower costs. As my colleague Dhruv Khullar has written, the health consequences of these clinics’ closures could be significant. Vaccination rates for children have already begun to fall; patients are missing screenings proven to save lives; prescriptions are going unfilled. Chronic conditions could worsen; life expectancies could drop.
Even before the pandemic, primary care was in crisis. Primary-care doctors were already among the most poorly compensated physicians in the country; for medical students burdened with debt, those smaller salaries lessened the specialty’s allure. Experts have long warned of a shortage of doctors providing foundational forms of outpatient care, especially in rural areas. Last year, the Kaiser Family Foundation estimated that more than fourteen thousand primary-care physicians were needed to eliminate existing shortages.
For this article, I spoke with more than twenty primary-care physicians, from New York City to rural Nebraska and suburban Colorado. They work in single-physician practices, in multi-specialty groups, or as part of hospital systems. Nearly all of them described dramatic declines in revenue. Many benefitted from the P.P.P.; without it, some of their clinics might not have survived. All of the physicians expressed concern about how they would navigate the uncertainty ahead. “This is taking us down,” Jacqueline Fincher, an internist and the president of the American College of Physicians, told me. “We’re not going to have a vaccine and herd immunity for probably a year—so, is this sustainable for a year? The reality is, it’s probably not, certainly not for most small practices.” If many of them go out of business, the consequences for Americans’ health could be profound and enduring. What’s at stake is not just a pattern of health outcomes but the shape of the health-care system as a whole. The way that patients interact with their doctors and the path that American health care takes in the future may be about to shift.
The challenges facing primary care are rooted in the structure of the American health-care system. This system wasn’t designed at any one moment; instead, it has accreted over time, with each new layer seeking to compensate for the deficiencies of what came before. One of the most consequential layers is fee-for-service payment, which was codified as part of the Social Security Amendments of 1965—the law that created Medicare and Medicaid. In a fee-for-service setup, the payer, usually a health insurer or government agency, pays the health-care provider a set fee for any given service. Break your arm, and your insurance company might pay one fee for an X-ray, another for a splint, and a third for a follow-up visit. Though conceptually simple, the system has obvious flaws. It encourages health-care providers to offer more services, in order to earn more revenue, without necessarily controlling for quality. If one surgeon’s hip-replacement operation is successful, with no complications, but a second’s is complicated by infection, leading to a series of follow-up visits, their fees are still the same; in fact, the second hospital may make more money. “In a fee-for-service payment system,” Atul Gawande has written, “we are actually penalized for making the effort to organize and deliver care with the best service, quality, and efficiency we can.”
To address this problem, government programs and insurers have come up with alternative payment schemes—but, at a fundamental, almost philosophical, level, many of them still operate on a fee-for-service principle. In the nineteen-eighties, Medicare changed its approach to inpatient hospitalizations so that a single global fee covered a particular admission; in this system, a hospital is reimbursed at one payment level for a broken leg, at another for pneumonia, and at a third for sepsis. More recently, the Medicare Access and CHIP Reauthorization Act of 2015 pushed Medicare reimbursements away from a pure fee-for-service model and toward others that pay based on the quality of health care provided. Still, for the most part, it’s the provision of services that indicates that care has happened. Ultimately, when physicians are paid, it’s the number of office visits, lab tests, and surgeries that matters.
The fee-for-service principle reverberates through the whole health-care system, but it has especially dire consequences for primary care, because it favors discrete medical episodes over ongoing and preventative treatment. Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time.
Primary-care groups and health-care policy experts have long contended that the R.U.C.’s choices favor procedures over the counselling, education, and chronic-disease management that form the basis of primary care. Twenty years ago, Don Berwick, the co-founder of the Institute for Healthcare Improvement and a mentor of mine, called for a total reimagining of health-care reimbursement in a speech that has since become famous in industry circles. Addressing an audience at the institute’s annual meeting, Berwick told the story of a Montana forest fire, from 1949, that killed most members of a team of firefighters. When the firefighters finally realized the imminent danger posed by the blaze, they tried to outrun it—but they did so while shouldering heavy equipment, including their Pulaskis, special firefighting axes that combine an axe head with an adze. The firefighters did not recognize that, in this new scenario, their old tools no longer served them; many died carrying them.
The health-care system, Berwick said, was falling into the same trap: clinging to a sometimes burdensome tool, no matter the circumstances. “Our Pulaski,” he argued, “is the encounter—the visit.” A better health-care system could only be built if “scientists, professionals, patients, payers, and the health-care workforce” agreed “that the product we choose to make is not visits. Our product is healing relationships.” In 2010, President Barack Obama, in a recess appointment, made Berwick the acting administrator of C.M.S.; he resigned, in 2011, when he concluded that he would be unable to win confirmation from Republicans in the Senate.
from Hacker News https://ift.tt/3jEoLju
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.