In 2011, the United States faced staggering unemployment and soaring national debt while changes in health policy strived to deflect the cost curve downward. Here we present some of the best evidence produced in the past year.
- As there exists no consensus on immigration reform in 2011, undocumented immigrants will gradually become a larger share of the uninsured population due to exclusion from programs of the Affordable Care Act that expand access to care
- Under the direction of the Affordable Care Act, individuals and small businesses will soon receive a certain package of diagnostic, preventive, and therapeutic services and products defined as “essential” by the Department of Health and Human Services (HHS)
- Primary care is principally provided by physicians (74 percent), nurse practitioners (19 percent), and physician assistants (7 percent). The numbers of primary care providers have grown in recent years relative to the general population. State laws regarding the practice authority of nurse practitioners and physician assistants vary and may limit the access to care in underserved areas. Nurse practitioners as a group are more likely to practice primary care, with over 60 percent focused on family care; by contrast, physician assistants are more likely to practice in specialty care settings (over 60 percent).
The Delivery System
- Physicians who work as employees, receive productivity based compensation, and are in high capitation settings were found to spend the least of all other physicians
- United States physicians in both primary care and orthopedics are the best compensated in the world despite accounting for the cost for US physicians of medical education
- The total estimated cost for interacting with insurance payers for US practices was four times higher than Canadian practices after adjustments for salary, payment rates, exchange rates, and specialty mix
- The US General Accountability Office created an annual report on federal programs & agencies that have duplicative goals or activities, showing overlapping health care goals of the Departments of Defense (DOD) and Veterans Affairs (VA)
- The Affordable Care Act promotes the Accountable Care Organization (ACO) model in Medicare and Medicaid even though roughly half of the US health system consists of the private commercial market. Adaptation by the private sector is essential for the widespread success of ACOs. One ACO example, Advocate Physician Partners, is perceived by private payers as a way to reduce medical costs and improve care by reducing the resources used across episodes of care, standardizing performance measures, and adapting quality measures in response to market needs.
- Beginning in 2015, the Affordable Care Act (Section 3007) directs the Secretary of HHS to develop a value-based payment modifier for physicians. Although touched upon in the Affordable Care Act, physician payment reform is not substantially altered as a result of the health reform law.
- The leading trend among health care payers is to pay for quality instead of quantity
- In Canada’s universal health care system, patients of lower socioeconomic status made greater use of health services compared to patients of higher socioeconomic status, but it was secondary to disease progression (i.e. patients of lower socioeconomic status are likely to seek health care for disease-reactive services instead of preventive services)
- Combined, EHR technology and mobile health provide tremendous opportunities to improve quality of care due to their ability to measure and monitor
- The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 provides incentive payments through Medicare and Medicaid to clinicians and hospitals to move beyond health information technology implementation barriers to meet standards of “meaningful use” for EHRs by delivering specified improvements in care delivery
- Personal health records allow the patient to access and interact with their own medical information electronically; however, few physicians incorporate these records into daily practice and many fear that PHRs might threaten patient care
- An evaluation of MassHealth’s Medicaid Pay-for-Performance plan failed to show a significant effect on quality improvement measures despite spending $2.6 million for incentives
As 2011 concludes, uncertainty about physician salaries and political leadership linger. Ever since the passage of the Balanced Budget Act of 1997, Congress has repeatedly delayed mandated cuts to Medicare’s physician fees. That statutory reduction has slowly accumulated and until last week would have resulted in a 27 percent cut. Most physicians care for a sizable number of Medicare beneficiaries. A pay cut of this magnitude seriously threatens the ability of some physicians to keep their practices open to Medicare patients. Even though Congress agreed to a 2 month “doc fix,” the intense debate on this seemingly annual issue will resume shortly.
As the sun rises on a new year, the challenge to contain health care costs while ensuring access is destined to grow larger. Providers will be challenged to care for more patients, deliver higher quality care, focus on chronic illnesses, and yet receive potentially shrinking compensation. Low-cost, high-technology solutions such as tele-health and mobile health can assist providers and payers to succeed in this challenge.
Jennifer Dyer, MD, MPH and Tyree Winters, DO