The 52 Republican senators have been meeting several times a week behind closed doors to develop a bill to repeal and replace the Affordable Care Act. At least 50 of them must be on board for the bill to pass, and they could try as soon as next week.
In recent years, a small but growing number of practices embraced a buffet approach to primary care, offering patients unlimited services for a modest flat fee instead of billing them a la carte for every office visit and test. But after a pioneering practice shut its doors earlier this month, some question whether “direct primary care,” as it’s called, can succeed.
Many doctors and patients say they like the arrangement. Direct primary care practices typically don’t accept insurance, which frees physicians from treatment preapprovals and claims paperwork. They say that allows them more time and energy for their patients. Patients can consult with their doctor or a nurse practitioner as often they need to, typically for around $100 a month. (Some employers buy the service for their workers.) Patients need to carry a regular insurance plan for hospitalization, specialists and other services. In the long run, the result should be better patient health and lower health care costs overall.
But some health care experts are concerned that the set-up encourages the “worried well” to get more care than they need. They describe unlimited primary care as a blunt instrument that doesn’t necessarily improve the odds that patients will get evidence-based services that improve their health. Others argue it’s important to find a way to provide cost-effective primary care within the health insurance context, not outside it.
Although only a sliver of practices do direct primary care, the number is on the rise, said Shawn Martin, a senior vice president at the American Academy of Family Physicians. He puts the figure at about 3 percent.
Seattle-based Qliance, founded in 2007, was an early leader in this type of care. With startup funding from high-profile investors Jeff Bezos and Michael Dell, by 2015 the company was serving 35,000 patients at several clinics in the Seattle area, including individuals, workers at companies like Expedia and Comcast and Medicaid patients through a contract with the state’s Medicaid insurer. The company said medical claims for Qliance patients were 20 percent lower than those of other patients because Qliance members went to the emergency room less often, were hospitalized less frequently and saw fewer specialists, among other things.
By early 2017, though, Qliance was faltering. The company had lost some large employer clients, and its patient base had shrunk to 13,000. On June 15, it closed five of its clinics. Dr. Erika Bliss, the company’s CEO, said that in general the market is reluctant to pay what it takes for primary care to flourish, and in some cases payers were resistant to rewarding the company, even when Qliance exceeded targets on quality and savings. She will continue to operate one site that provides occupational health for Seattle firefighters.
“The bottom line is it’s not for free,” she said. “You can’t do this for $25 [per person] per month. If we start doing it for $50 to $100 per month then we can start doing serious primary care.”
The closure took January Gens by surprise. A Qliance patient for a couple of years, Gens, 45, had worked with her primary care doctor there to manage crippling pain from endometriosis. The $79 monthly fee was worth every penny, she thought. She had been able to reduce the dosage of some of her medications and was awaiting a referral to start physical therapy when she learned that Qliance was shutting down. Now she’s not sure what she’ll do.
“I had felt very lucky to have found Qliance, to know I had a doctor and could always be seen when needed without causing more damage to the family budget,” Gens said. “Now it’s just gone.”
But for people who are generally healthy and without symptoms that need to be diagnosed, “unlimited primary care is no guarantee that the services that are provided will improve the health of those people,” he said.Patients who have chronic conditions that need ongoing management may benefit from direct primary care, said Dr. A. Mark Fendrick, an internist who directs the University of Michigan’s Center for Value-Based Insurance Design.
As an example, Fendrick noted that the annual checkup, one of the most popular primary care services, isn’t clinically helpful for most people, according to the Choosing Wisely initiative, a program of the ABIM Foundation that identifies overused and unnecessary medical services.
An examination of research related to direct primary care practices found that they charged patients an average $77.38 per month. “Concierge” medical practices are similar to direct primary care, but their monthly fees are typically higher — averaging $182.76 — and they generally bill insurers for their services, the study found. However, the study, published in the November-December 2015 issue of the Journal of the American Board of Family Medicine, concluded that there was a paucity of data related to the quality of care provided by these practices.
Some analysts say that while they’re sympathetic to doctors’ frustration with large numbers of patients, insurance companies’ intrusion into patient care and billing hassles, the answer isn’t to turn their backs on insurance.
“I think absolutely this type of care could be done inside insurance, but it means we have to learn how to pay within the system for the things that doctors should be doing and are doing in direct primary care,” said Robert Berenson, a fellow at the Urban Institute.
As things stand now, the direct-care model can create difficulties for some patients. Take the situation where someone goes to his direct primary care provider for an earache, but antibiotics don’t work and he needs to be referred to an ear, nose and throat specialist. That patient, who likely has a high-deductible plan to provide non-primary care services, will probably be on the hook financially for the entire cost of care provided by the specialist rather than insurance paying a share.
Qliance’s Bliss scoffs at the idea that patients may get stuck paying more out-of-pocket if they have direct primary care. Most people these days have high-deductible health plans, she said. “The reality is that unless you have Medicaid, you are on the hook no matter what.”
Offering unlimited primary care inside the insurance system is no guarantee of success in any case. One such experiment, a subsidiary of UnitedHealthcare called Harken Health with clinics in the Chicago and Atlanta areas, announced it will shut down at the end of the year.
The company confirmed that it would phase out membership at the end of the year but didn’t respond to a request for further comment.
Healthcare Triage: Employer-Based Insurance Can Trap You at Work
Here’s another possible consequence of repealing the Affordable Care Act: It would be harder for many people to retire early. That’s the topic of this week’s Healthcare Triage.
Dawn Nagel, a nurse at St. Joseph Hospital in Orange, Calif., knew she was going to have a busy day, with more than a dozen patients showing signs of sepsis. They included a 61-year-old mechanic with diabetes. An elderly man recovering from pneumonia. A new mom whose white blood cell count had shot up after she gave birth.
Nagel is among a new breed of nurses devoted to caring for patients with sepsis, a life-threatening condition that occurs when the body’s attempt to fight an infection causes widespread inflammation. She has a clear mission: identify and treat those patients quickly to minimize their chance of death. Nagel administers antibiotics, draws blood for testing, gives fluids and closely monitors her charges — all on a very tight timetable.
“We are the last line of defense,” Nagel said. “We’re here to save lives. If we are not closely monitoring them, they might get sicker and go into organ failure before you know it.”
Sepsis is the leading cause of death in U.S. hospitals, according to Sepsis Alliance, a nationwide advocacy group based in San Diego. More than 1 million people get severe sepsis each year in the U.S, and up to 50 percent of them die from it. It is also one of the most expensive conditions for hospitals to treat, costing $24 billion annually.
Most hospitals in the U.S. have programs aimed at reducing sepsis, but few have designated sepsis nurses and coordinators like St. Joseph’s. That needs to change, said Tom Ahrens, who sits on the advisory board of Sepsis Alliance.
“From a clinical point of view, from a cost point of view, they make a huge impact,” said Ahrens, a research scientist at Barnes-Jewish Hospital in St. Louis.
Redistribution of wealth — one of the most radioactive subjects in American politics — has moved from being a subtext in the national debate over health care to being the core of it.
Politicians prefer to talk about health reform in terms of benefits — extending medical coverage to those who lack it, curbing increases in costs and improving quality.
They offer gauzy, have-it-all promises to make the system better, more efficient and more generous, as though it can all be done without anyone having to sacrifice anything.
House Republicans, led by Speaker Paul D. Ryan (R-Wis.), say that the measures they introduced Monday will increase competition and give consumers more choices.
What makes the latest health-care battle different from past ones is that it is not about building a new government program. This time, the question is whether to abolish one — and replace it with something else.
That means it is harder to gloss over a bedrock philosophical and ideological question that has always been in the background of any argument about the government’s role in health care: What is the minimum that society should provide for its poorest, most vulnerable citizens, and how much should be taken from the rich and powerful to do it?
“Even though it is a technical discussion, it’s a really big value discussion,” said Robert Blendon, a professor of health policy and political analysis at Harvard University.
Democrats, who had passed the seven-year-old system known as Obamacare without a single Republican vote, say that the GOP proposal to repeal more than 20 taxes enacted under the law amounts to a windfall for the rich and for corporate interests.
The Republican plan also probably would make Medicaid, the program that provides coverage to the poor, less generous.
Overall, it would be “a big transfer. This is a massive tax cut for unpopular industries and wealthy individuals,” said Andy Slavitt, who was acting administrator of the Centers for Medicare and Medicaid Services during the final years of the Obama administration. “It is about cutting care for lower-income people, seniors, people with disabilities and kids to pay for the tax cut.”
Meanwhile, conservative critics argue that the blueprint goes too far the other way. In their view, for instance, the individual tax credits included in the Ryan-backed plan to offset the cost of insurance are actually a new entitlement, not all that different from the subsidies provided under the Affordable Care Act.
“The House Republican proposal released last night not only accepts the flawed progressive premises of Obamacare but expands upon them,” said Michael Needham, the chief executive of Heritage Action for America.
However, economic historian Bruce Bartlett, who served in the administrations of Ronald Reagan and George H.W. Bush, said that argument ignores that health insurance itself is a means of spreading the cost of health-care around.
“Republicans argue that redistribution is inherently immoral without acknowledging that the very nature of insurance is per se redistributive,” Bartlett said. “You’re taking money from people whose houses don’t burn down to give it to the people whose houses do burn down.”
There were many ways that Obamacare also redistributed the burden of medical costs — from the sick to the healthy, with provisions such as the one denying insurers the ability to refuse coverage to people with preexisting conditions; from the old to the young, with a mandate that everyone have coverage or pay a penalty; from the rich to the poor, with an array of new taxes.
By contrast, “the Republican plan, as outlined right now, really is centrally about income redistribution, of the reverse Robin Hood variety,” said Austan Goolsbee, a University of Chicago economics professor who was chairman of Obama’s Council of Economic Advisers.
Democrats are framing their argument against the Republican approach in precisely that way.
“If Republicans have their way, working families, older Americans, and people with disabilities will face huge new health costs. Families across America are going to be pushed off their health coverage just so Republicans can hand a massive tax break to the wealthy,” House Democratic leader Nancy Pelosi (Calif.) said in a statement.
By producing their own proposal, Republicans are wandering into a familiar political thicket.
“The problem that the Republicans are going to have is anything they do makes them the inheritor of anger at the health system. That’s not a pleasant place to be, and now, they’re going to own it. All the Democrats know exactly how that feels,” Goolsbee said.
White House press secretary Sean Spicer insisted that widespread dissatisfaction is going to help the Republicans pass their plan to replace the Affordable Care Act. Health-care costs have continued to rise, and in many states, insurance companies are pulling out of the health-care exchanges that were set up under the law.
“What we’ve seen over the last few years with Obamacare is you can have an insurance card, but that doesn’t mean that someone’s going to take it, and it sure doesn’t mean that it’s going to be affordable,” Spicer said.
“When it comes to communication, I think, one of the things that’s really helpful is that part of the sell is done for us,” Spicer said. “We don’t have to explain the problem: People are living it.”
The question now is how to come to grips with the fact that it will not be painless to fix it.
https://www.healthnewsreview.org/2017/06/conflicts-of-interest-in-health-care-journalism-1-of-3/
Ben Harder, a journalist with US News & World Report, recently tweeted, “Pharma ads subsidize many health reporters’ salaries.”
Elisabeth Rosenthal, who now heads Kaiser Health News after a long career with the New York Times, tweeted in that same discussion, “Many of my articles in the NYT carried pop-up ads for pharma. Infuriating.”
Many journalists are aware of the drug industry’s attempts to gain positive attention by buying placement within the nation’s health care news. A few occasionally write or talk about it, as Harder and Rosenthal did publicly.
But I don’t think we talk often enough about why it matters if health care industry entities are allowed to advertise within, or sponsor, health care journalism content. Americans spend more than $3 trillion on health care. Conflicts of interest in health care and research are rampant. The Journal of the American Medical Association (JAMA) last month published a special edition all about health care conflicts of interest. JAMA included a Viewpoint article entitled, “Conflict of Interest: Why Does it Matter?” The first line: “Preservation of trust is the essential purpose of policies about conflict of interest.”
But who talks about conflicts of interest in health care journalism? In a Gallup poll, “Honesty/Ethics in Professions,” respondents rated journalists’ honesty and ethical standards below psychiatrists, chiropractors and bankers….and just above lawyers.
There is great potential harm in a further erosion of trust in journalism and in health care. There is a great potential harm in journalists – and the audience they serve – becoming numb to the presence of and influence of drug companies and other industry entities in the news and information disseminated to the public. There is, as we have begun to point out repeatedly in our review of news stories and PR news releases, advertising and marketing messages, often a polluted stream of contaminated information reaching the public. Often vested interests pollute that stream. (We will discuss these potential harms in more detail in part 3 of this series.)
That’s why I think that this issue demands and deserves a deeper dive. Why now? Because, as outlined in this series, there are a growing number of questionable alliances between a growing number of news organizations and health care industry sponsors. Money is exchanging hands and I ask “Why? Why do news organizations enter into these arrangements? Why do they feel they need to? Have they exhausted all other options?” I want to shine a light on a collection of news organization practices. I’m raising the same types of questions that journalists often raise as they report on various issues. But I’m asking them because I don’t see enough journalists talking about it when their own organizations accept industry money.
