Thousands of low-income Massachusetts residents may be getting a new health insurance option under a proposed venture by the Caritas Christi Health Care network and St. Louis-based Centene Corp. Massachusetts regulators unveiled the proposal as they reviewed bids to provide state-subsidized health insurance to 163,600 adults in the Commonwealth Care program.
A recent debate in healthcare reform has centered on the $1.1 billion set aside in the economic stimulus bill to compare the effectiveness of different treatments for the same illness. Supporters believe that such "comparative effectiveness" research will help to identify ineffective therapy, improve quality of care and ultimately decrease the time, effort, and money spent on treatments that don't work well. But critics say that such research could ultimately lead to a one-treatment-fits-all approach and that it would allow the government to dictate "appropriate" decisions in the doctor-patient relationship.
The New York Times provides a series of articles from healthcare experts responding to Barack Obama’s calls for fixing healthcare. Contributors include Elliott S. Fisher from Dartmouth Medical School, blogger Kevin Pho, MD, Daniel Callahan, co-founder of the Hastings Center, Karen Ignagni from America’s Health Insurance Plans, and Steven Findlay, analyst with Consumers Union.
What if physicians could make decisions about which drugs, devices, and treatments to use based on objective research into which options were most effective?
The concept is called comparative effectiveness research, and many physicians believe it could improve quality and loosen the stranglehold the device and drug industries have on healthcare. The American Medical Association has endorsed the idea, as have several other physician organizations. In fact, it's difficult to find many doctors who consider it, in concept, a bad idea.
Here's how one physician blogger explains its value: "As a physician I really want unbiased comparative data. I love new drugs, when they provide a significant advance over older drugs. Without [comparative effectiveness research] we can only guess about the relative benefit of a new drug, or a new diagnostic technique, or a new operation."
Yet the $1.1 billion allocated to comparative effectiveness research in the economic stimulus package sparked one of the most vitriolic political debates over healthcare reform in a while. Why?
The controversy began when Betsy McCaughey—the same Betsy McCaughey who laid the groundwork for the rally against Bill Clinton's healthcare reform efforts in 1993—wrote an op-ed implying that the comparative effectiveness research provision would lead to healthcare rationing, and it reached fever pitch when the Washington Times ran an editorial, complete with an accompanying photo of Adolf Hitler, suggesting that it might lead to Nazi-style euthanasia.
Consider that a taste of what's to come when Washington undertakes larger healthcare reform efforts.
Some of the disagreement is ideological, and as we've seen in recent weeks, those divides are difficult to bridge. But the lobbying effort against comparative effectiveness research seems to be coming from the drug and device industries (McCaughey has even been forced to defend her own ties to the industry recently, including her board membership at Cantel Medical Corp.).
And that gets at what's really at stake here: Money. Lots of it.
Let's say, for instance, that researchers conclusively find that physical therapy combined with medication is a more effective treatment for neck and back pain than surgery. Or that the latest heart failure medication isn't as effective as previous options combined with careful home monitoring. That's not news an implant or drug manufacturer wants to hear.
Without third-party research, physicians have to rely on pitches from drug industry representatives or journals that have lost some credibility due to recent medical ghost-writing scandals. The Food and Drug Administration only tests new drugs and products on their individual merits, not in comparison to existing treatments. So without some sort of objective evaluation, it's difficult for doctors to distinguish between the effective and the favored.
"Clearly, the pharmaceutical and device industry would like both the public and physicians to continue to assume that "newer means better." Not asking these questions allows them to continue promoting profit-making, brand-name treatments," says Kevin Pho, MD.
To be clear, I'm not suggesting there aren't valid reasons to oppose comparative effectiveness research. Well-intentioned concepts often become mangled in the machine of bureaucracy, and a debate about how to keep research neutral and avoid mandated care protocols is needed. And, as McCaughey pointed out, this should have been discussed as part of a broader healthcare reform effort, rather than included in the stimulus package.
But this debate is too important for more comparisons to Nazi Germany and fear mongering about government-run healthcare.
During his address to Congress this week, President Obama promised to bring together "businesses and workers, doctors and health care providers, Democrats and Republicans" next week to begin work on what may be one of the biggest public health initiatives in U.S. history. What happens in the next year—maybe the next few months or even weeks—could cement the structure of the healthcare system for decades.
Physicians have an important seat at the table. And as respected members of their communities with a front-line perspective of the healthcare system, they can't afford to let partisan hacks and special interests drown out their voices and derail legitimate healthcare improvements.
People listen to and respect physicians. I hope more doctors in the coming weeks will challenge inaccuracies in the media (from both sides), give policy makers feedback, and discuss these topics with colleagues—anything that contributes to the conversation.
Because this will likely be the last chance for this type of change for a long time.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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The nation's physician leaders, legislators, and healthcare advocates are wringing their hands over a spate of articles highlighting the ever-decreasing number of primary care physicians (PCP).
It's an issue worthy of concern. According to a recent article in JAMA, "the United States faces a shortage of primary care physicians that could exceed 40,000 by 2025." Many areas of the country already face a severe shortage of PCPs.
It is commendable that the nation's healthcare leaders are aware and concerned about the problem, but it is time to do more than just talk about what can be done. It's time for an honest dialogue about realistic and viable options. While many solutions are being discussed, most agree that what we need is a system that promotes quality care while creating a realistic option for physicians and providing affordable and accessible choices for healthcare consumers.
As with any complex problem, there is no one answer and no single solution that will address all of the challenges related to the current primary care physician shortage. However, many physicians now believe that a small but growing practice model—hybrid concierge—should be added to the discussion.
Hybrid concierge models give patients the choice of the model within a practice—concierge or traditional insurance coverage—that best meets their needs. In addition, it gives physicians the opportunity to practice medicine the way they were taught and to be fairly compensated for their commitment and service to patients.
Options for Physicians and Patients
While the concept of concierge medicine holds much promise, the current model, also known as boutique or retainer medicine, has gained its share of detractors. Primarily they that claim it:
Costs too much for the "average" healthcare consumer
Creates multiple tiers of care
Exacerbates the shortage of primary care physicians
However, a hybrid practice directly addresses all these points and more. For example, in terms of cost, the average price of a hybrid option within a primary practice is $100-$150 per month for a patient. While the price will not fit all budgets, it will fit many, particularly those who value a more personal relationship with their physician.
In addition, the hybrid model includes a Comprehensive Wellness Exam. This evaluation and a series of screening tests are the cornerstone of a preventive program designed to achieve long-term health goals. Combined with other services, the actual yearly cost of a hybrid practice option is less than what most patients would pay for a standard executive physical.
As to the argument of a multi-tiered system, the majority of medicine practiced today is already multi-tiered. Patients have many healthcare needs, as well as many personal preferences. As Americans, we don't want anything single-sized; we want choices. The hybrid model provides a reasonable, accessible product that allows the consumer to select the option that makes the best sense for him or her.
However, the aspect of the hybrid model that most intrigues physicians and consumer advocates is that it enables physicians to continue to see their traditionally insured patients and to remain in government and private plans.
Under a full concierge practice, many physicians simply stop seeing patients that don't opt to join and pay the monthly fee, leaving patients to find new healthcare providers (and causing some insurers to drop those providers). In addition, they often are dismissed from plans or elect to leave government plans like Medicare.
Under the hybrid model, physicians do not have to "fire" their patients. In fact, the additional economic support enables physicians to remain in plans that they otherwise might have to leave. Physicians can move to a hybrid model when as few as 5% of their patients opt to participate.
This level allows physicians to have a more meaningful office visit with their concierge patients. In medical school, physicians learn that 80-90% of a patient's diagnosis is tied to family and social history. Yet with an average office visit of 7.5 minutes, it's difficult, if not impossible, to fully gather all of this important information.
Because physicians can see fewer patients in a day and have more time for office visits with all scheduled patients, concierge models allow physicians to return to the way they were taught to practice medicine. They can take the time to thoroughly discuss family and personal histories. There is more time to be an advisor and advocate and to help insure a complete understanding of the medical, physical, and perhaps emotional situation that a patient is dealing with.
In short, it enables an element of advocacy and education as the ability to focus on preventive measures and plans for long-term health. No matter how dedicated or committed, those are simply services most primary care physicians can no longer provide during the average routine office visit of today.
Rewarded for Excellence
In fact, it is the opportunity to get to know patients and provide more meaningful counsel and care that has many physicians so invigorated by a concierge option. Indeed, physicians that now practice a hybrid model frequently comment that they had forgotten how much they missed talking with patients and that they are much better physicians when they have the appropriate amount of time to spend with each patient.
Physicians also appreciate the fact that with a hybrid model, not only can they continue to see patients, but the compensation mechanism of a concierge model allows them to be rewarded for excellence. Quality physicians, who are committed to providing outstanding personalized care, will see their practices thrive. Those that provide sub-par service will be unable to keep and attract the patients necessary to offer a viable practice.
In essence, that is with the hybrid model is about: a combination of socially responsible medicine and a private pay system that rewards excellence and strong patient relationships.
Let the Debate Continue
The debate on both how to "fix" the nation's current healthcare system and how to attract and retain primary care physicians is far from over. As discussions continue, we need to focus on the solutions that are viable, possible, and preferable. We would all like to have the prototypical Norman Rockwell style of medicine. However, realistically no one—not government, business nor individuals—is prepared to increase payment to a level that will achieve this level of care.
The hybrid concierge model represents a viable solution—one worthy of discussion in an honest debate. It accomplishes the following:
Introduces a private source of revenue that can help to supplement a physician's practice
Gives patients real choices in the type of care they receive
Enables physicians the opportunity to practice
Strengthens the physician/patient bond
This model provides the value that both patients and physicians want. It is one that can help to attract quality and caring physicians to the practice of primary care.
Is the hybrid model the only answer? Will it solve all the problems facing the primary care system today? No. But a growing number of players in the system believe that in order to maintain a healthcare model where physicians and patients are at the center of the care paradigm, the hybrid option must be included in the discussion of solutions.
Wayne Lipton is a managing partner with Concierge Choice Physicians, a private company developing hybrid model concierge practices for physicians in 11 states—California, Arizona, New York, New Jersey, Nevada, Delaware, Virginia, Massachusetts, Texas, Maryland and Florida. For additional information, contact Lipton at wlipton@choice.md or visit www.choice.md.
In today's ailing economy, financial troubles have affected professionals in myriad sectors of the marketplace. Job recruiters—namely those in healthcare—have been no exception. And a looming physician shortage doesn't help.
Working to address a rising physician shortage, many hospitals and physician practices are in the midst of recruiting doctors from various regions nationwide. Innovation in the recruitment process has become almost a necessity.
Examples of creative practices include:
Alternative bonuses. Traditionally, hospitals and physician practices will offer a recruitment bonus when courting potential candidates. But as the housing market continues to be unkind to sellers, some are opting to forego the bonus and use this money to help candidates with relocation, particularly in the way of a down payment on a new home.
Loan forgiveness. Some are offering to provide the candidate money toward a new home. Per this option, candidates must agree to stay in the position for a specified period of time—typically several years, says Trelles. If they do not agree to this or fail to live up to the obligation, the money must be repaid.
Rental. Some physician recruits having trouble selling their homes are opting for the rental market. They're making their homes long-term rentals as they wait for the housing market to turn around.
This article was adapted from one that originally ran in the February issue ofHealth Governance Report, a HealthLeaders Media publication.
President Obama is proposing to begin a vast expansion of the U.S. healthcare system by creating a $634 billion reserve fund over the next decade. The move will launch an overhaul that most experts project will ultimately cost at least $1 trillion. The "reserve fund" in the proposal is Obama's attempt to demonstrate how the country could extend health insurance to millions more Americans and at the same time begin to control escalating medical bills that threaten the solvency of families, businesses, and the government.
Medicare spending continues to vary widely across the country, with some cities experiencing much faster growth in costs than others, according to an analysis by Dartmouth researchers. In the analysis, the researchers say that addressing the wide variations in the cost of care for the elderly will be critical to any overhaul of the nation's healthcare system envisioned by the Congress and the Obama administration.
As the state Legislature prepares to meet, a group backed by the for-profit HCA hospital chain and Associated Industries of Florida is using fliers and a TV commercial to hammer public hospitals, which are accused of spending "$1.2 billion of our tax money . . . on themselves." The targets of the ads are members of the little-known Lower Income Pool Council, which advises the Legislature on how to distribute state-federal money to hospitals and clinics that provide the most care for the poor and uninsured.
Home visits died when medical insurance replaced pay-as-you-go, and administrative costs and malpractice insurance fees forced doctors to abandon individual practices and join together in groups. By the early 1970s, fewer than 1% of doctors made house calls.
But now, doctors visiting the sick in their homes seems to be in vogue again.
