The Antidote Interview #2: Robert Doherty, American College of Physicians

A couple of weeks ago I alerted readers to a health care reform proposal from the American College of Physicians, which went a bit beyond the mix of health reform proposals from states, insurance groups, etc., in its focus on prevention and wholistic care in addition to advocacy of coverage for all Americans. Robert Doherty, Senior Vice President for Government Affairs and Public Policy, was kind enough to answer my questions by email, and I've included the interview below.

A notable thing about the current political climate in the U.S. is that the time really does seem to be ripe to reopen the debate on how to reform health care, and it's important that all voices be heard. I'm happy to host some of that debate right here, so here's one perspective, and please bring on your comments!

The timing of this proposal is interesting, given that, in the past couple of weeks, we've seen health care reform proposals from states, presidential candidates, the insurance industry, and even the White House. How does the ACP proposal fit in?

I think we are seeing an congruence of interest in expanding HI coverage that is being driven by several factors: the upcoming Presidential election, where health care reform is expected to be a major issue; the Democratic take-over of Congress, which will result in a greater emphasis on health coverage (although most of the recent joint statements from different stakeholders were the result of discussions that had started long before the mid-term elections), and very significantly, the positive press that Romney and other governors have received on their respective states' proposals to expand coverage. At the same time, the number of the uninsured keeps rising, there has been a slow erosion of employer-based coverage, and more cost-shifting to individuals. All of this suggests an opening for groups to get attention to proposals that until recently may not have been considered to be politically realistic. Notwithstanding all of this, I don't think we will see major reforms at the federal level until after the 2008 elections.

ACP was part of a coalition of physician organizations that recently came out with joint principles on expanding access but was not directly involved in the other coalition activities. We've been struck though that many of the ideas being proposed--expanding Medicaid to all people up to the poverty level, providing advance refundable tax credits to low income persons to buy into the Federal Employees Health Benefit Program, and providing federal funding support for states that wish to develop their own plans--are very consistent with a proposal that ACP released in 2002, and that was introduced as bipartisan bill, The HealthCARE Act, in both the 108th and 109th Congresses.

The proposal that ACP released on Monday, though, is different in one key respect: we go beyond proposing how to extend health insurance coverage to redesigning how medical care is organized, reimbursed and financed in the United States. We think the U.S needs to do both: make sure all residents have affordable coverage, but also create a higher quality and more efficient model of delivery called patient-centered care. Otherwise, more people will have coverage, but they'll get their care under a system that is fragmented, expensive, and provides inconsistent and inadequate quality. Other countries with more successful systems provide universal coverage AND have redesigned their health system around patient centered primary care.


How can the proposed plan address health care costs? You're proposing extending health care to all Americans; would that not increase costs still further? Will the plan address overuse of health services?

Our plan is based on strong evidence that a health system organized around patient-centered primary care will achieve better quality at lower cost. The materials we provided to the press on Monday cite numerous studies that show that the availability of well-supported primary care, both within the US and in other countries, is positively associated with fewer hospital admissions, lower utilization, reduced mortality, longer life spans, fewer ICU admissions, few ICU deaths, a better overall composite quality score--and lower per capita health care expenses. Our plan directly addresses over-use of services by rewarding reward physicians for managing care and providing preventive services rather than ordering more tests or procedures.

We also provide evidence that helping primary care physicians acquire the tools and systems to help them manage care effectively--things like tracking patients based on disease condition (patient registries), secure email consultations, evidence-based guidelines at the point of care--will result in better care and lower overall costs.

In our view, it makes sense to combine expansion of health insurance coverage with patient-centered care to help reduce the costs of insuring more people.

Also, Health Affairs published an article about a year ago that found that the US already spends approximately $100 billion annually on the uninsured (cost shifting, lost productivity, uncompensated care, and federal, state, and local spending) but we spend it very ineffectively and inefficiently. Redirecting these expenditures to provide everyone with affordable coverage would be a far wiser use of these resources.

We also support creating a process for identifying services that are overpriced by Medicare and other payers. There is evidence that services that are overpriced also tend to be overutilized.


How does the primary care-centered plan differ from the HMO gatekeeper model, which some research has shown does not improve cost or health outcomes?

Our proposal is not a gatekeeper. Patients would not have to get permission from a primary care doctor to see a specialist. They would have an ongoing and trusted relationship with a primary care physician who will advise them if and when specialty care is needed, and who would be best qualified to provide that specialty care, but it would be the patient's decision. Physicians in the patient centered medical home would help arrange for specialty care when needed. And they would make sure that when a patient is seeing multiple clinicians, there is one clinician--the personal physician in the patient-centered medical home--that is integrating all of the information from the other clinicians to make sure it results in a consistent and integrated plan of treatment. This is unlike the current fragmented system when there is no one accountable for the patient's whole health and information often is not shared among clinicians or shared incompletely.

How will procedure-focused care settings, such as diagnostic and screening radiology facilities, be addressed? more broadly, what happens to the rest of the non-primary care health system, from ambulatory care to hospitals?

Our proposal is based on the idea that patients need to have a single site, and a single physician (their personal doctor in a patient centered medical home) who is responsible for their whole health. But that physician is responsible for assuring that they have access to a team of health professionals to provide them with the full spectrum of services needed, including imaging, hospitals, etc as needed. We do believe though that effective management by a personal physician will reduce duplicate and unnecessary testing (for instance, it is not uncommon today for tests to be repeated just because one clinician does not know what tests another clinician had previously ordered) and hospital admissions by helping patients avoid complications that can lead to hospitalization.

We also believe that there will need to be a re-allocation of dollars to support patient-centered primary care.

How does prevention fit in with this proposal? Will it reduce the perverse incentives we have seen, for example, with diabetes care?

Prevention is an integral element. Patient-centered primary care is designed to assure that patients have access, through the patient-centered medical home or by referral, to all preventive and screening services that are supported by evidence-based guidelines. Physicians will develop self-management plans in partnership with patients to help them maintain healthy lifestyles and prevent complications

What is ACP's strategy for working with Congress to promote this program?

We developed a legislative roadmap that identifies different options for Congrses to move the program forward: Medicare legislation that addresses physician payment cuts and pay for performance, reauthorization of the S-CHIP program to encourage states to make the medical home available to all S-CHIP recipients, legislation to promote health information technology, and legislation to provide federal funding for states that develop their own programs to expand access and improve quality. We will also ask Congress to work with us to assure that CMS moves forward in a timely manner on a demonstration of this model that was mandated by the 109th Congress. In all of our contacts with Congress, we will emphasize that this model has the potential to substantially improve quality and lower costs and should be advanced through a variety of legislative approaches.

Who is likely to disagree with this approach?

I can anticipate that there will be concern among some providers that this model will redistribute dollars and resources toward primary care, and give more control to the primary care physician, at their expense. We will need to persuade Congress and the Congressional Budget Office that it will save money. Providers who benefit from procedures that are overpriced will likely object to a process that could result in reductions in those fees.