A simple request from the front lines of healthcare

I know that there is going to be another scuffle over the Sustainable Growth Rate (SGR). I know that we have already paid $150 billion on “doc fixes” since 1997, and I know that everyone in healthcare is trying to make sure that their ox will not be gored. I also know that nobody is looking forward to the tectonic disruption that a 24 percent pay cut will have on innocent Medicare patients and the physicians struggling to care for them. Given all that, wouldn’t it be nice if we could do something that might dramatically reduce the cost of healthcare while also improving access, quality and patient satisfaction? What if this were something over which there is virtually no controversy?

There are simpler steps Congress should consider to cure Medicare's ills.  

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I am a primary care physician.  This week a 90-year old patient of mine with arthritis went to the ER with severe back pain – without talking with me first.  He had a full exam by an ER doc, a panel of 30 lab tests, 2 sets of X-rays, an MRI, ECG, and a neurosurgical consultation.  He was given morphine to dull his pain, which made it impossible for him to walk or move his bowels.  The steroids they gave him raised his blood sugar to 3 times normal.  He was admitted to the hospital, given insulin, evaluated by more physicians, nurses and a physical therapist while he recovered from his ER visit. 

If I had been able to see him before the ER, he would have received reassurance, a carefully calibrated dose of pain medication and instructions on how to minimize the constipation and gradually mobilize himself from bed so as not to reinjure himself.

These two approaches are worlds apart – one high tech, high risk and high price - the other personal, simple, and inexpensive. One system costs $2.8 trillion per year without evidence that patients are any healthier or safer. The other can reduce that cost by roughly a third while providing a more responsive, humane and rewarding care experience for patients and doctors alike. The primary care that is at the heart of this approach has been undervalued and badly damaged by our public and private health systems for decades.

As goliaths fight to preserve their piece of the SGR, wouldn’t it make sense to ensure that Medicare patients have 24/7 access to high functioning primary care so that they won’t be forced into ERs and hospitals unnecessarily? The need for better, more accessible primary care has been dire enough that large numbers of doctors and patients have banded together to produce their own personal care systems called direct primary care (DPC).  Removing fee-for-service incentives that drive massive costs and unnecessary care, and replacing it with DPC at an adequate monthly fee, will preserve effective primary care and allow physicians to spend real time with patients in an unhurried environment.

Early data suggests that an extra dollar spent on high performance primary care is likely to return at least three dollars in savings. Not to mention better access and patient satisfaction. Medicaid patients in Seattle have access to DPC.  Truck drivers and grocery clerks have it in West Virginia. Longshoremen in New York, and ski instructors in Colorado have it.  Medicare patients do not. This can and should change.

S. 2000 / H.R. 4015 would repeal SGR and allow Medicare to use this simple and innovative payment reform. The Affordable Care Act allows DPC medical homes in combination with qualified health plans to offer coverage in healthcare exchanges. This provision, like similar provisions in state law, defines DPC practices appropriately as outside of insurance regulation.   But the IRS defines DPC practices as “health plans,” keeping it from millions of Americans with Health Savings Accounts.

These two changes alone could ensure that millions of American patients have full access to a primary care physician who is paid appropriately to take the time needed to care for them.  And it would save billions of dollars.

Bliss is  chairman of the Direct Primary Care Coalition, an advocacy organization dedicated to bringing patients access to a personal primary care physician of their choice.  Like many other physicians, he is in Washington this week to lobby Congress on Medicare and other healthcare reforms.