By Albert Gibosse | Global Initiative To Fix Healthcare Delivery | Website |
With health being a basic human right, universal access to timely, acceptable and
affordable health care of decent quality is imperative. Moreover, ensuring health care coverage for everyone entails creating a foundation of comprehensive and longitudinal primary care to arm all providers with the necessary advocacy flexibility toward considering all options that might come before the central and local governments as well as the stakeholders in working to achieve the goal of health care coverage for all.
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Health care costs and rate of Quality
One of the major obstacles to reaching the level of universal health care is the uncoordinated and fragmented nature of the disparate systems that focus rather on intervention in lieu of prevention and comprehensive health management.
American policies implemented through the Children’s Health Insurance Program (CHIP) and the Patient Protection and Affordable Care Act (ACA) extended access to affordable health care coverage to millions of previously uninsured, non-Medicare eligible adults and children pushing the uninsured population to a historic low of 8.8% under the implementation of these policies.
Ensuring a healthier and more productive society Also requires that all people have affordable health care coverage that provides a comprehensive and defined set of essential primary health benefits. Such health care system must account for and address social determinants, such as socioeconomic status, housing and occupational conditions, food security, and the environment that have a profound impact on individual and population health outcomes and costs. Likewise, such a system will have a deep impact and will enable sustainable and systematic improvements in access to care, equity, quality of care, efficiency, and cost control.
All successful healthcare systems or reforms must be effectively designed to achieve
health care coverage for all while making primary care a pivotal role and redesigning the manner of primary care delivery and payment system(s). Increased focus on resources on specialty care only creates fragmentation, decreased quality, and increased cost. Health care quality improves along with the cost efficiency, when primary care practices redesign their process(es) so that they are more accessible, promote prevention, proactively support patients who have chronic illnesses, and engage patients in self-management and decision-making.
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Family medicine and comprehensive primary care are the best entities that can reliably ensure longitudinal continuity of care for the whole patient. In this relationship, the patient and primary care physician rapport and its comprehensiveness have the greatest effect on health care outcomes and costs over the long term. Healthcare systems that rely more on primary care have lower overall medical cost, lower resource inputs (hospital beds, intensive care unit [ICU] beds, total physician labor, primary care labor, and medical specialist labor); lower utilization rates (physician visits, days in the ICU, days in the hospital, and patients seeing 10 or more physicians); better quality of care that includes fewer ICU deaths and a higher composite quality score.
An approach to providing comprehensive advanced primary care (APC) for children, youth, adults, and the elderly is the patient-centered medical home (PCMH). This approach facilitates a partnership between the patient, the patient’s personal physician, and, when appropriate, the patient’s family or caregiver, and ensures that each patient receives a comprehensive care. The primary physician leads a team of individuals at the practice level and beyond who collectively take responsibility for the ongoing care of patients.
The direction of the existing healthcare system must be shifted fundamentally toward ensuring healthcare for all as well as an emphasis on comprehensive and coordinated primary care. Likewise, appropriate resources must be allocated adequately, and new resources must be deployed to achieve effective and efficient results. Payment policies by all payers must change to reflect a greater investment in primary care to fully support and sustain primary care transformation and delivery.
Workforce policies must be addressed to ensure a strong cadre of the family physicians and other primary care physicians who are so integral to a high-functioning health care team. Congress and/or state legislatures must enact comprehensive legislation to achieve this change. If such legislation only addresses the uninsured and fails to fundamentally restructure the system to promote and pay differently and better for family medicine and primary care, any solution will not reach its full potential to achieve the Quadruple Aim of better care, better health, smarter spending, and a more efficient and satisfied physician workforce.
Five fundamental areas each of us needs to understand and use to help fix healthcare delivery
Key Elements of the Framework
Affordable health care coverage providing equal access to all will have a primary care physician and a medical home.
Insurance reforms that have established consumer protections and nondiscriminatory policies will remain and will be required of any proposal or option being considered to achieve health care coverage for all. Those reforms and protections include, but are not limited to, continuation of guaranteed issue; prohibitions on insurance underwriting that uses health status, age, gender, or socioeconomic criteria; prohibitions on annual and/or lifetime caps on benefits and coverage; required coverage of defined EHB; and required coverage of designated preventive services and vaccines without patient cost sharing.
Any proposal must reflect at least a doubling of the percentage of healthcare spending invested in primary care. This investment will result in a payment model for primary care that supports and sustains primary care medical home transformation and reduces the current income disparity between primary care and subspecialty care to ensure an adequate primary care physician workforce.
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Appropriate medical education must be established to create a national physician workforce policy that produces a primary care physician workforce adequate enough to meet the nation’s urgent health care needs. Likewise, medical schools will be held to a higher standard in regard to producing the nation’s needed primary care physician workforce.
A defined set of visits and services to a primary care physician will not be subject to cost-sharing.
In any system of universal coverage, the ability of patients and physicians to voluntarily enter into direct contracts for a defined or negotiated set of services (e.g., direct primary care [DPC]) will be preserved. Additionally, individuals will always be allowed to purchase additional or supplemental private health insurance.
Five fundamental areas each of us needs to understand and use to help fix healthcare delivery
Achieving health care coverage for all should involve one or more of the following approaches, with the understanding that each of these have their strengths and challenges:
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A mixed health care system approach to the financing, organization, and delivery of health care that is designed to achieve affordable health care coverage and that involves competition based on quality, cost, and service. This approach includes multiple for-profit and not-for-profit private organizations and government entities in providing health insurance coverage. Such an approach to universal health insurance coverage must include a guarantee that all individuals will have access to affordable health care coverage.
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A Bismarck model approach that involves multiple nonprofit payers that are required to cover a government-defined benefits package and to cover all legal residents. Physicians and other providers operate independently in a mix of public and private arrangements.
A clearly-defined single-payer model that is organized, adequately financed, with a sound delivery model that is adequately administered. This model must incorporate a plan that competes directly for customers with private insurance plans that allows physicians and other providers to continue to operate independently.
Likewise, payment parity for the services provided to the patients of primary care physicians must be ensured.
Worth noting, though, for achieving coverage for all, each of these options has its strengths and challenges, which need and deserve to be debated by the people and their elected officials and representatives. These include, but are not limited to, the following important issues:
The current form of administrative and regulatory burden for physicians, clinicians and other health care providers, and patients/consumers
The effect on overall health care costs to government, employers, and individuals
Level of patient, consumer, physician, and clinician satisfaction
Level of tax burden
Impact on the timely delivery of health care services (wait times) and delays in scheduling elective health care services
Simplification of the financing model and levels of payment to physicians, clinicians, and other health care providers
Inclusion of family physicians on payment, delivery, and other health care decision-making boards
Elaborated set of essential health care benefits available to all, especially primary and preventive care, management of chronic illnesses, and protections from catastrophic health care expenses
Effect on the reasonable availability and delivery of health care services
Influence on quality and access
Comprehensive budgets and price/payment negotiations
Prerequisite of a clear and uniform definition of a single-payer health care system
Comprehensive Primary Care
Primary care embodies the principle that patient-centered primary care is comprehensive, longitudinal, continuous, coordinated, connected, and accessible for the patient’s first contact with the health system. Clinical quality must be improved through the delivery of coordinated, longitudinal care that improves patient outcomes and reduces health care spending. Medical practice that provides comprehensive care and a partnership between patients and their primary care physician and other members of the health care team, as well as a payment system that recognizes the comprehensive work of providing primary care. The key functions of a primary care medical home are:
At a minimum, essential benefits should include items in the following categories:
Ambulatory patient services
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Rehabilitative and habilitative services and devices
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
Moreover, independent of financial barriers (i.e., deductibles and co-pays), all proposals or options must ensure that primary care is provided through the patient’s primary care medical home and must include the following service:
- Medical evaluation and management services
- Transportation to and from medical appointments
- Evidence-based preventive services
- Health Education
- Population-based management
- Hygiene Education
- Well-child care
- Disease Prevention
- Basic mental health care
Achieving the proposed goal entails ensuring that health care coverage for everyone must also be aimed at identifying and reducing the costs of health care services including the administrative costs of delivering those services.
A health care system that is comprehensive and prioritizes primary care must also emphasize the cost and affordability of care. This is important not only for consumers, but also for the decision-making of physicians, clinicians, payers, and government agencies. Affordability is a critical component in efforts to create or reform any health care system.
Prevention & Public Health
Investment in preventive care, specifically those preventive services that have been proven to reduce the prevalence of preventable diseases (e.g., access to free vaccines and screening programs). A focus on reducing preventable diseases likely would reduce or, at minimum defer, future high-cost spending for preventable diseases. In addition, there should be an increased focus on identifying societal and environmental factors that contribute to increased health care spending.
Fees and Transparency
Increased investment in primary care and the medical home, generally, allows health plans to not only reduce the costs of treating high-risk patients but improve the quality of health services. However, this increased investment must be supported with aggressive efforts to establish fee transparency for all health care services. Such transparency likely will contribute to reducing excessively high health care costs by informing the public about their costs of care and creating more competition in the health care industry.
Consolidation creates a less competitive market which leads to higher health care costs and insurance premiums.
Site-Neutral Payment Policies
Site-neutral payment policies and the elimination of some facility fees can address the discrepancy in payments for some services, which are higher for the same services performed in a hospital ambulatory surgery center versus a physician’s office, despite no significant differences in quality or outcomes of care. These are part of policies that typically incentivize consolidation, decrease competition between providers of care, and facilitate over-utilization of high-cost health care services.
Administrative costs are due to complexities in billing which is exasperated by multiple payers. Countries with lump-sum budgets and fewer health care payers have seen lower costs in administrative spending. Whereas 25%, nearly $200 billion, of all hospital costs is dedicated to administrative costs in the US, Canada dedicates only 12% of hospital spending to administrative costs, which does not guarantee care quality.
Pharmaceutical & Biologics
Advances in pharmaceuticals and biologics have improved the health of millions of people, decreased the prevalence of preventable diseases, and allowed for chronic diseases to be maintained over a prolonged period of time. However, the escalating costs of pharmaceuticals and biologics places these interventions and treatments out of reach for far too many people. Policies should be established that allow purchasers of health care, including Medicare, to negotiate the costs of prescription drugs. Additionally, there should be greater flexibility in the design of formularies that allow for increased use of generic and bio-similar products.
It is primordial that all primary care physicians be compensated in a manner that is consistent with a comprehensive payment model for family medicine and primary care, as that is essential to a better system of care. This model, however, will be best if built on the population-based care, which supports small and independent practices and reduces administrative burden in the health care system.
Key Components of Successful model
For any health care system to achieve its goals, there must be greater investment in the primary care component. Increased investment in comprehensive primary care as well as family physicians is primordial, as they serve two distinct functions: direct patient care and non-face-to-face care.
Equally crucial is a payment model built on the realization that high-quality primary care is delivered through both direct patient care and the population-based services that are provided by the primary care team, which must move to a prospective payment model with an appropriate evaluation that strongly emphasizes performance and quality. This model must also emphasize prospective payments for a direct patient care global payment, a population-based global payment, and a performance-based incentive payment.
Building on our belief that primary care should remain comprehensive at the primary care level. The presence of this FFS component recognizes that a comprehensive primary care practice will provide episodes of care that are beyond the scope of the direct patient care global payment.
Adequate investment in primary care is more likely to ensure sustaining success through the simplified payment structure and a dramatic reduction in administrative burden. More importantly, we believe patients will achieve better outcomes and have a more favorable experience through this model.
KEY COMPONENTS OF THE FRAMEWORK
This framework offers important policy options to move healthcare toward a primary care-based system in which all people have appropriate and affordable health care coverage, are provided a medical home, and have primary care-oriented benefits. However, this is achievable only if legislatures act to ensure the implementation of the policy objectives.
Moving toward a primary care-based system that can secure improvements in access, quality, and cost, requires a fundamental change in the health care system. A primary care-based health care system ensures coverage for everybody.
The primary care framework must be predicated upon the premise that achieving better health outcomes from primary care, reaching higher patient satisfaction, and getting more efficient use of resources are essential requisites. We will only achieve the type of health care system that the population needs through this sound framework of health care coverage for all that is foundationally built on primary care.