By Janet Hurley, MD
There was once a time when I believed that organized medicine would play a major role in creating a sustainable health care product for our nation. Admittedly our organized medicine leaders have a lot of great ideas, many excellent skills, good relationships with lawmakers, and brilliant expertise. However I learned with sadness as time progressed that the dysfunctions in Washington, D.C., and Austin are unlikely to lead to substantive health care changes. While our organized medical societies give wise advice, our lawmakers are not always listening.
I then turned my energies to the private sector and focused my leadership on a large integrated health care system that emphasized and respected high-value primary care. I had hoped that these kinds of systems could leverage their medical homes, medical neighborhoods, and IT systems to more optimally coordinate care and reduce waste. Yet once I entered that world, I became aware of the massive regulatory burden facing our hospitals today. The relentless push to become a Joint Commission-accredited, “high reliability organization” with “zero harm” is commendable, yet requires the hiring of multiple levels of safety officers, nursing leaders, and administrative leaders, and the development of many more “clicks” in the electronic medical record that leads to massive nurse burnout rates in our country.
I also learned about the army of IT analysts that are required to make our behemoth electronic health record work. When we decide to add a new EHR module to do something cool for our clinicians, we spend a ton of money yet our hired IT analysts still have to work huge numbers of hours to “build it” in our system.
And it is not the hospital’s fault! Hospitals did not design EHRs to be unwieldy beasts and hospitals did not ask for countless regulations to be heaped on their shoulders. When you couple this with the legal requirement to treat unfunded patients without any hope of payment, they naturally look for new ways to get paid such as facility fees, DSRIP, URIP, intergovernmental transfers, 340 B Drug Pricing, and other modalities. Watching this tap dance for money and seeing the vast number of people needed to choreograph the routines is disheartening.
So then I focused my energy on value-based contracting. I have read about organizations that are effectively controlling costs by leveraging the power of the premium dollar to do unique things for patients such as care coordination, nurse navigation, transition of care processes, home visits, hospital at home, social work support, transportation assistance, and sometimes even housing and food assistance. These examples of Medicaid, Medicare, commercial, and FQHC pilots have truly bent the cost curve for their populations, yet sadly we have had sparse penetration of these plans in Texas. Some hospital systems are trying to lead these initiatives, yet struggle because the total dollars of value-based payments are a tiny fraction of what they get paid with fee-for-service, and they must consistently balance the desire to lower costs with the desire for steerage to their brick-and-mortar assets which may or may not be the lowest cost and highest value location for care.
I did not start my medical leadership experience as an advocate of a single payer system and I certainly do not feel that model is perfect. Yet wouldn’t it be easier if nearly everyone had some sort of coverage, so hospitals would not have to waste so much energy on the tap dance of getting paid? Wouldn’t it be easier and likely less expensive to simply pay doctors more to see Medicaid patients, rather than diverting them to federally qualified health centers? Wouldn’t it be better to mandate that EHR vendors play an active role in ensuring their upgrades work across their entire product and not have to be “built” into each client’s platform at the expense of the client? Wouldn’t it be better for our nation and our state to invest more money on social services like housing and subsistence income subsidies rather than to spend so much on the health outcomes of poor health behaviors? Sadly, I don’t think the political climate is anywhere close to adopting any of these principles and the alternatives do not bode well for our nation.
So what advice should I give to practicing family physicians to prepare for the possible health care apocalypse? Simply this — keep doing what family medicine does best! Regardless of what disaster awaits, family physicians will continue to be the most valuable asset to our health care system providing the most benefit to the highest number of patients at the lowest cost. As patients cannot afford their deductibles, they can still see us to manage 90% of their problems. As patients lose insurance altogether, they can find some of their best health care advice in our exam rooms. As patients face health care crises they can’t afford, we can provide comfort in their suffering.
Regardless of what the future brings, family medicine is part of the solution.