The ACA has created significant payment reform. Instead of paying a fee for each service performed, there will be a fixed payment amount allowed for each disease entity per year, no matter how many times the patient needs to be seen. This is known as “bundled” payment.

Under the “fee for service” system, providers are paid for every “event” of sickness. The more sickness a patient has, the more money health care providers make. Finances are aligned with sickness; therefore, the “fee for service” payment system in a subtle way encourages sickness.

Under fee for service, the government has been giving the healthcare industry a blank check. Whatever tests or treatments that are needed, the government covers. Those days are over! The “blank check” has been ripped up.

The new guidelines establish a cap per disease entity. A simplistic explanation is that each disease entity will be allotted a specified amount of money per year and once the limit is reached, providers will not be reimbursed beyond it. What is happening here is a shift of incentives – from sickness to wellness. Providers will make more by creating health, rather than sickness.

This payment reform is radically different; a restructuring of our entire health care system will result. Since there will now be a “cap” (a limited amount of money available for each patient’s disease level), patients will be routed to primary care and wellness to ensure that the money is spent more wisely. This movement to primary care and wellness, by aligning finances to wellness, will not only create better care; it will re-establish primary care as the backbone of our health care system instead of specialists and hospitals, as it is today.

In yesterday’s blog post I introduced Triple Aim, an approach designed by the Institute of Healthcare Improvement to fix healthcare in America. I want to spend the next couple of days focusing on each of the Triple Aim’s main goals, in order for us to develop a clearer understanding of what they truly encompass. What does our healthcare system look like today? In the past couple years, the United States ranked has ranked 31st among the nations for life expectancy, 36th for infant mortality, 28th for male healthy life expectancy and 29th for female healthy life expectancy.

In 2008, 40% of patients with congestive heart failure were readmitted to the hospital within 90 day. We had access to treatments that reduced and controlled this condition more than 80% of the time! These patients were not getting appropriate follow-up and coordinated care. A Health Affairs article stated that our healthcare system lacks memory and this has led us to significant spending in the midst of poor care.

We pay twice as much per individual, than any other industrialized country, yet our healthcare system received a 66% by the Commonwealth Fund Commission. It’s unfortunate that while we pay this much for healthcare, it is much worse than many other countries in the world by comparison. We are the only industrialized country that does not guarantee universal health insurance. We claim that we cannot afford it, yet we spend an exorbitant amount of money on healthcare that doesn’t achieve the quality that it should.

How will Triple Aim help our healthcare system? The first goal of the Triple Aim is better care for individuals. In other words, the care experience will produce better outcomes. One way is through payment reform. We will discuss more about payment reform on Monday.

Currently, if a patient goes to the emergency room for pneumonia, they will receive the appropriate treatment and medication during that visit. Once the patient leaves, they are on their own.

Improved care must have improved coordination. The new experience of care that the Triple Aim is offering will extend beyond the initial visit for an acute or chronic symptom. Not only will a patient receive the appropriate treatment and medication at the time of their visit, a primary care physician will follow-up with them a few days later.

By operating this way, patients will avoid repeat emergency room visits and hospital admissions because they have a primary care physician managing their health and treating them if their conditions worsen. This new experience of care happens over time involving different locations, hence better coordinated care leads to better care.

Did you know that if other prices had increased as quickly as healthcare costs, since 1945, a dozen eggs would cost $55 and a gallon of milk would cost $48?! It is no question that the cost of healthcare is crushing.

The Institute for Healthcare Improvement proposed a challenging systematic approach for changing healthcare, in 2008, entitled “The Triple Aim”. This new, bold, and encompassing goal was embraced by the Affordable Care Act to be its ultimate outcome.

An article published by Health Affairs, as well as Don Berwick, Administrator of the Centers for Medicare and Medicaid Services, describes the Triple Aim’s three overarching goals:

• Better care for individuals – a 2011 report, “Crossing the Quality Chasm”, by the Institute of Medicine describes six dimensions of healthcare performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity

• Better health for populations – focus will be on factors that cause our ill health, such as poor nutrition, physical inactivity, and substance abuse

• Reduce per-capita cost

All three goals have to be accomplished simultaneously in order to fix our healthcare crisis.

Berwick is devoting most of his time to the Triple Aim. He believes this is the key to transforming America’s healthcare system.

I agree with Berwick that all three have to be fixed simultaneously, if we are to reverse this crisis. 45% of adults who have a chronic disease are not getting adequate care and 50% of all adults are not getting recommended care. The staggering costs we pay in America are not hitting the mark and this should no longer be acceptable.

If you are a primary care provider, or aspire to be, there is no better time to be in primary care than now. Primary care is the only discipline in medicine with the training to look at the whole person, not just discrete parts of the person. Also, it looks at all areas of a person’s health – preventive, genetic conditions, lifestyle issues, early detection, acute illnesses, chronic disease management and end of life issues.

As it once was, primary care must become the backbone of medicine again. Patients must have and deserve to have a continuous relationship with a known provider, who will use specialists, hospitals and emergency rooms when it’s appropriate. This is the best way to maintain health, create health, and decrease costs.

Since the ACA is to accomplish all three goals concurrently, I would say that this is why the ACA is a mandate for primary care.

It’s more than demoralizing; it’s distressing that healthcare has been accused of a crime. Much to my dismay, the NY Times has a credible argument. Where do reasonable healthcare costs end and outrageous ones begin?

Time magazine and many other publications have been reporting the shocking numbers individuals are paying for their healthcare. The Affordable Care Act addresses those ever-increasing figures through the Triple Aim:

1. Improve the culture of healthcare

2. Improve the quality of healthcare

3. Decrease the costs of healthcare

I am not arguing whether or not the ACA can accomplish these goals; however, I agree that the cost of healthcare is unsettling when compared to other industrialized nations across the world.

Presently, we are paying close to 18% of our GDP for healthcare and it’s broken. Additionally, it is paralyzing businesses and threatening personal household incomes significantly.

When you look at countries like Denmark, whose population is very satisfied with their available healthcare and only paying 5% of their GDP toward it, you realize something definitely needs to change.

How did we get into this trouble?

I think “fee for service” has been a major offender. The government gives a blank check to the healthcare system to perform an unlimited amount of medical activities. In other words, the healthcare community can look to find sickness and get paid, as much or as little, as they want for trying to fix it based off of how many medical activities they perform.

This reminds me of an article that was published by the NY Times in 2009. Dr. Paul Grundy, the former Medical Director of International Business Machines, Corp. (IBM) shared that IBM paid $1.4 billion in 2008 for garbage. He was referring to the fact that we pay for sickness, rather than health.

After many years of operating this way, our culture has been trained to accept this standard. It is extremely important to understand that the ACA is striving to bring cost control to healthcare, while simultaneously improving the quality of healthcare.

The ACA did not break healthcare as this NY Times article argues. The question we need to be asking is if the ACA can help fix our already broken healthcare system or create more problems?

Through payment reform, we will be noticing a change from the “fee for service” payment system to a “bundled” payment system.

Rather, the government will establish an amount they will pay for specific medical activities. Healthcare professionals will make every effort to provide their very best care below these set amounts.

This holds healthcare professionals accountable for the care that they are providing patients and mutually invests all parties in the healthcare delivery process because everyone’s goal is health, not sickness, which our culture has come to accept.

Increasing coordination and integration of care, as well as decreasing fragmentation, are several ways to help eliminate unnecessary hospital readmissions. But how does this look practically speaking?

It is all too common that physicians are forced to readmit their patients because the alternative, sending them home to an inadequate environment with little social support, would cause their condition to deteriorate further.

Researchers from two universities in New York have developed a program where medical professionals and social workers collaborate on patient’s discharge, home planning and observation post-discharge. This may be a credible solution to help decrease costs from unnecessary hospital readmissions due to improved communication and quality care.

After a patient is discharged from the hospital, a social worker will call to set up a home visit to determine how they feel, if they are taking their medications properly and if they are experiencing any uncomfortable side effects, assess the healthiness of their living environment and more. Another key factor, I can’t help from mentioning, is that the social worker emphasizes the importance of following up with their primary care provider.

This study took into account 100 patients living independently, but who were at high risk for hospital readmission. After the two-year study concluded, the data revealed that having a social worker involved cut hospital readmissions by half.

“A social worker can create savings equal to his own salary and benefits just by preventing seven readmissions a year – and the patient’s quality of life is improved significantly in the process,” says Dr. Shawn Bertowitz, the medical director of the study.

It seems to me that including other skilled individuals, like social workers, in the delivery of healthcare for patients is essential. It may be a good indicator that Affordable Care Organizations (ACO) will decrease hospital admissions effectively as team coordination is further developed.

The last 50 years have made the biggest impact on where our healthcare system stands today. In our previous blog post, we covered the history of healthcare from the late 1880s to the mid-1900s.

Brief history of healthcare continued…

• 1965: President Lyndon Johnson moved a bill through Congress that created Medicare and Medicaid. The government expanded proposed legislation to include physician services for the aged.

• Early 1990s: Unsuccessful attempt to overhaul the U.S. Healthcare system. Hillary Clinton guided a project aimed to convince Congress to move towards a universal health insurance system.

• 2008: The rise of support in the universal health insurance bill. Barack Obama, Hillary Clinton and John Edwards, three of the most successful Democratic presidential primary challengers, agree to support a universal health insurance bill.

• Early 2009: President Barack Obama asked Congress to develop a universal health insurance proposal. “My plan begins by covering every American. If you already have health insurance, the only thing that will change for you under this plan is that the amount of money you will spend on premiums will be less,” Obama said. “If you are one of 45 million Americans who don’t have health insurance, you will after this plan becomes a law.”

• Late 2009: Final version of ACA – H.R. 3590 – debated by Senate. The final vote was 60-39 to give final approval to the bill.

• Early 2010: Congress sent President Barack Obama an ACA “fixer bill” – H.R. 4872. This bill makes several changes to the H.R. 3590 bill, including changes to health-related financing and revenues. It also modifies higher education assistance provisions. The two bills (H.R. 3590 and H.R. 4872) combined are referred to as the ACA.

• Early 2012: U.S. Supreme Court heard oral arguments on legal challenges to ACA. One of the challenges was concerning a provision to the ACA that would require most individuals to own health coverage or else pay a penalty. Another challenge concerns the individual mandate provision.

• Late 2012: President Barack Obama’s re-election confirmed that the ACA will remain a law.

• Today: Government producing materials to help public understand the law. Federal agencies, state regulatory agencies and other various groups have been developing rule-making notices, white papers, regulations and more to help the public interpret regulations, procedures, forms, processes and programs needed to implement the law.

We aim to give our readers the facts. We hope that this information has been helpful and will encourage you to make decisions and form opinions, about our healthcare system, based on facts and not political rhetoric.

The White House has decided to delay the ACA’s employer-coverage mandate, for businesses with 51 employees or more, by one year and does not think it’s a big deal. Over 90% of businesses with 51 or more employees already do offer health insurance. Basically, employers have an additional year to comply with the regulations of the ACA.

Businesses are relieved because they have been experiencing trouble setting up the proper technology and infrastructure to comply with the new law, in such a short period of time.

However, it is important to note that while businesses have been granted a year-long grace period, the individual mandate remains unchanged.

Employees, whose companies are affected by the recent delay, can obtain subsidized coverage through the individual insurance exchange in the meantime.

If an individual does not purchase insurance for 2014, they will be fined and that amount will escalate fairly rapidly over the next three years.

That’s the big news for today concerning the ACA. Let’s take a brief look at some of the major events that have occurred over the past 100 years between the government and healthcare.

• 1880s: Germany’s Universal Health Insurance Program influenced United States policy makers. On January 1, 1891, the U.S. implemented a sickness-related income protection program that paid for people to obtain healthcare through local “clubs”. Sick insurance was not compulsory at this point.

 C.D. Babcock, Secretary of the Insurance Economy Society argued that sickness insurance programs did not reduce poverty, mortality, or duration of sickness. Medical practices, where these programs were already implemented, were experiencing a demoralized system.

• Late 1800s/Early 1900s: Reformers were interested in improving social conditions of the working class. President Theodore Roosevelt and progressive groups campaigned for compulsory health insurance.

• 1920: James Lynch of the New York State Industrial Commission proposed a “universal health insurance” program that would pay for medical and maternity care. His proposal included that worker’s would pay half the cost of their health insurance, while their employers would pay the other half.

• 1930s-1940s: Call to bolster national preventive care programs and support state and local health departments. President Franklin Roosevelt was not interested in a large federal health insurance program.

• 1946: President Truman argued that the U.S. needed a prepaid health insurance system for the entire population. The country was already using taxpayer money to provide free medical care for low income or no income families.

“This is not socialized medicine,” Truman said. “Everyone who carries fire insurance knows how the law of averages is made to work so as to spread the risk, and to benefit the insured who actually suffers the loss. If instead of the costs of sickness being paid only by those who get sick, all the people—sick and well—were required to pay premiums into an insurance fund, the pool of funds thus created would enable all who do fall sick to be adequately served without overburdening anyone.”

Tomorrow we will bring you up to speed on where our healthcare system stands presently. Please check back!

Click here to continue reading about our government’s involvement in healthcare.

Reality dictates that there is a definite difference between physicians and nurse practitioners, due to their levels of education. As a whole, I think everyone would agree that we value a physician’s extensive education. However, if the physician is not accessible when the patient is sick or needs medical assistance, that education is meaningless.

In order for physicians to have a legitimate argument that keeps nurse practitioners from seeing patients independently, they have to become more easily accessible to patients. To paralyze our competition, so we don’t have to change, is really not what we nor the culture needs.

As primary care physicians, our challenge is to improve primary care by making it more robust and built around access to physicians. Furthermore, in order to achieve the quality of care that our culture deserves, we will need to include nurse practitioners.

A physician and nurse practitioner’s training is meant to complement one another. Nurse practitioners are trained to manage preventive care, straight-forward acute illnesses and previously diagnosed chronic conditions. Physicians are trained to manage all of these, as well as patients with complex problems, multiple diagnoses and complex acute problems. This difference is exactly why the playing field should not be leveled.

I battled with this very concept when I was practicing medicine. I saw patients that had experienced heart attacks and heart failures, all the time. I had to come to grips with the fact that I was not a cardiologist.

My residency training lasted for three years. Typically a cardiologist’s residency training lasts for 5-7 years. While I treat patients with heart problems frequently, I had to acknowledge that this doesn’t make me a cardiologist. It’s not ridiculous for a heart patient to prefer to see a cardiologist over me because of their more extensive and heart-specific training.

Along this same thinking, nurse practitioners cannot expect to be considered equal to a physician when their education and training is much less. However, I do not say this to undermine nurse practitioners.

According to the American Academy of Family Physicians, nurse practitioners spend between 5 and 7 years completing 5,350 clinical hours of study, whereas physicians spend 11 years completing 21,700 clinical hours of study.

To say that they are equal would be completely disregarding our education system, which is built upon the fact that the more educated a person is in their profession, the more qualified they are to do that profession.

Most of the time, nurse practitioners may give the same diagnosis and/or treatment plan as physicians. The problem lies with those remaining patients that may be more complicated and require different medical insight than the nurse practitioner has been trained to handle.

While the difference in education and training between a physician and a nurse practitioner is dramatic, it should not be the main point of focus. Physicians need to be discovering ways to solve their shortage crisis in order for accessibility to be improved.

There are two things our culture demands of healthcare – access and comprehensive care if needed. Currently, emergency rooms and primary care offices alike have been struggling to meet these demands, but often come up short. Emergency rooms provide around the clock access to patients, however they lack continuity; emergency room physicians make the most appropriate decision for patients based off the short amount of time they have been in the exam room. On the other hand, primary care offices are backlogged, but physicians have a long-standing relationship with their patients and are able to provide better quality care based on this relationship.

Several years ago, one of my patients, Daniel, came into the office for an infected hand. It was pretty bad off and in one sense I wanted to immediately hospitalize him.

Daniel was 60 years old and had been hanging drywall for much of his adult life. He didn’t have insurance and worked very hard to make a living.

I hesitated to hospitalize him because I knew he would easily walk away with a bill for $15,000-20,000.

After evaluating his hand and his situation, I recommended that he come into the office every day for the next 3-4 days. In order to have any chance of healing the infection, it had to be closely monitored, elevated continuously and treated with antibiotics.

It wasn’t an easy task, but I knew he could handle it. Daniel was motivated to stick to my medical recommendations because he knew I didn’t want him to have to pay an unnecessary bill from being hospitalized. I felt confident in my recommendations because he would return to the office.

This is exactly why hospitalization has become such a hot topic. Since primary care physicians are hard to reach, patients default to the emergency room. Emergency room physicians do not know the patient; therefore, if there is any question, the patient will be admitted for monitoring.

Our culture desperately needs primary care offices to extend operating hours, during the week, and offer weekend hours, in order to pull patients out of the emergency rooms. It is completely reasonable to expect primary care offices to be available 7 days a week and up to 12 hours per day on any given week day, as a minimum. This can be accomplished without overworking the support staff.

Some may argue to make emergency rooms more capable of being used for primary care. This is absolutely the wrong answer for our culture. The key is to re-establish primary care as the central hub of healthcare and redefine emergency rooms as a place for patients to receive emergent care.

Several days had passed and Daniel’s hand was almost completely healed; the decision to treat him outside of the hospital, though time consuming, literally saved him thousands of dollars.

If I had sent him to the emergency room or if Daniel had gone to the emergency room without seeing his primary care doctor first, there would have been no other choice than to be hospitalized. This is something that happens all day long in primary care.

Relationships can help to create pleasure for everyone. Within a healthcare relationship, interactions between patients and physicians become more than just pleasure, they become an integral part of practicing quality medicine, by helping to motivate and engage patients.

Patient motivation

Several years ago, I heard Dr. Paul Grundy, the former Medical Director of International Business Machines, Corp. (IBM), tell a story about a fellow IBM employee, Jane, who was forced to see a different doctor because hers was not approved by their company’s insurance.

Jane was extremely disappointed because she had been seeing her previous doctor for quite some time and had already established a meaningful relationship with him. He knew her medical history, lifestyle and most importantly, they mutually trusted one another.

After several regular visits to her new doctor, Jane was not convinced that he was trying to get to know her or her needs. She couldn’t trust him and was not motivated to turn for her follow-up visits as a result.

Jane decided to monitor her own health conditions, diabetes being one of them, and promised herself she would only see her new doctor only if something went severely wrong. Over the course of three years, the Jane’s diabetes gradually worsened to the point where she needed on-going medical care. Her diabetes complications required countless labs, testing and more. In the end, IBM was charged $1M in medical expenses.

This is just one example, of countless others, substantiating that an on-going and consistent relationship between patients and physicians can prevent controllable health conditions, like Jane’s diabetes, from potentially worsening into life-threatening illnesses. In order for this to be successful, physicians must motivate their patients to continue their care by scheduling routine appointments and engage them in decision-making.

Patient engagement

Patients are pleased when they know that their doctors are putting their medical needs first. Moreover, when patients are given the opportunity to become active participants in their care process, they will immediately embrace it.

In late 2011, the California Healthcare Foundation conducted a study about Californian’s attitudes and experiences with death and dying. One finding was that almost 80% of Californians would like to talk to a doctor about end-of-life care, but only 7% had a doctor whom they could engage in conversation about it.

End-of-life care is a sensitive area of medicine in which to involve patients and their families. However, engaging the patient every step of the way with this type of care, as well as all others, has proven to be a great source of motivation. In sharing ownership of their own health and well-being, patients are more likely to manage their health closely and thus, have better health outcomes.

Due to time constraints and the pressures that physicians face in primary care medicine today, patients have often been the recipients of mediocre care by their primary care doctor. However, if we can focus on building relationships with our patients, listening to them and understanding their needs, we have the chance to provide the quality care that they deserve. Just think what a revolution this could make in primary care medicine!