Good Intentions, Universal Coverage, and NBC’s Manimal
You know how some things seem like a good idea at the time, but then afterwards, not so much? That notion pretty much defines my life. Eating five Egg McMuffins for dinner because Iâ€™m an adult and I make the rules. Wearing a white linen jacket over a pastel orange t-shirt and slip on shoes to my college graduation. Letting my kids see my college graduation picture, and then showing them an episode of Miami Vice because theyâ€™d think my linen jacket and orange shirt was cool. Buying a VHS just to tape episodes of Manimal.
Promising intentionsâ€¦unfortunate consequences.
Along these same lines, a lot of smart, talented health care policy experts who believed access to care is a right and not a privilege crafted the universal health insurance coverage provision in the Affordable Care Act, and that seemed like a good idea at the time. Intuitively, it makes sense. If more people have insurance coverage then more people will be able to get primary care doctors, and therefore get better care. It turns out things probably wonâ€™t work out that way.
Experience tells us that people with insurance are more likely to consume healthcare than those without. There is currently a shortage of primary care physicians across the country, somewhere between eight and sixteen thousand. So what seems more likely to happen is that universal insurance health coverage would, ironically, impede appropriate utilization of primary care and increase demand for emergency room care. And that outcome makes sense if you think about it this way: people with insurance have a higher expectation of access to health care, a larger pool of insured people are vying for the same supply of primary care physicians, emergency rooms are always open and can never turn away patients, so thatâ€™s where the newly insured will end up to have their expectations met.
Here in Oregon, we like to think weâ€™re ahead of the curve in population-based health care delivery. In 2008 we instituted a limited expansion of OHP, our stateâ€™s version of Medicaid. A study published in the journal Science last year showed a 40% increase in emergency department use among OHP patients over an 18-month period following the expansion. So it did, in fact, look like increased coverage drove up ER utilization.
But this is one of those times when youâ€™re glad to be wrong and, as an ER doctor, I felt like I already had more than enough business. So last month, when the Oregon Health Authority released its 2013 Performance Report on the stateâ€™s CCO model (a CCO, or coordinated care organization is a kind of statewide accountable care organization for Medicaid providers), I was thrilled to see them tout a 17% decrease in emergency department visits by CCO enrollees and an 11% increase in primary care visits. Admittedly, this was confusing, because the findings of the Science study were so contradictory to the CCO report and so aligned with my own biases. But the findings were great!
Or not so great as it turns out. Because the Oregonian recently reported that OHP added 360,000 new enrollees this year under the federal health care overhaul, and since that time ER visits for CCO enrollees has increased as much as 30% in some regions while thousands of new enrollees are unable to find primary care providers.
By 2020, the shortage of primary care physicians is projected to increase to between 20 and 45 thousand. The government has proposed increasing spending to train more primary care physicians. But it takes four years of medical school, three years of residency, and hundreds of thousands of dollars to train one primary care physician. Multiplied by 20 to 45 thousand, thatâ€™s a lot of time and a lot of dollars. Even training physician assistants and nurse practitioners takes years and is too costly to scale.
Providing sufficient providers to meet the swelling demand for primary care will take an evolutionary change in how we envision primary care delivery. We need a novel provider model that is scalable, one where training can be completed in a fraction of the time and at pennies on the dollar compared to traditional physician and midlevel provider training. We need a unique class of provider who would be happy to work in rural areas or inner cities, where shortages are and probably always will be the direst. Medical assistants, for example, or paramedics with specialized training in primary care and chronic disease management. And we need to utilize clinical decision support technology to augment their skill sets, to allow them to operate at the upper margins of their scopes of practice, and to alert them to outliers and unusual presentations of life threatening conditions.
This new class of practitioner canâ€™t replace physicians â€“ obviously thereâ€™s no substitute for education and experience. But as much as 75% of primary care can be delivered by these non-physician, non-midlevel providers if they are equipped with sophisticated decision support technology.
Until we can predict the future, there will always be things that seem like a good idea at the time, but turn out not to be. New Coke. Spinning off Joey from Friends. So much promise. So much disappointment. But we donâ€™t want to throw out the proverbial baby with the bathwater. A lot of those ideas have a lot of good in them, and we just need to figure out a way to make them work the way they were intended.
And at the end of the day, a show about a man who can change himself into any animal to fight crime still seems like a hell of an idea.
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