One of the goals of the Affordable Care Act (aka Obamacare) was to increase access to primary care physicians. The notion is that if people have insurance it would be easier for them to get appointments with primary care physicians. This is because many physicians are unwilling to accept new patients who are uninsured. Further, a key component of the ACA was to increase physician reimbursement for Medicaid because this program was a major mechanism for expanding insurance coverage. Medicaid reimbursement has always been low — significantly lower than Medicare pays for the same encounter — so many physicians would not take it. The ACA drafters hoped higher reimbursement would entice these physicians to accept Medicaid. We don’t know if any of these assumptions are correct, but a recent study published in The New England Journal of Medicine suggests a positive impact.
The authors’ method was a bit sneaky, I suppose. They had trained field staff call physicians’ offices posing as potential patients asking for new appointments. They were divided into two groups; one group said they had private insurance, the other said they had Medicaid. The authors compared two time periods — before and after the early implementation of the ACA. A sample of states were compared to see if the rates of acceptance of new Medicaid patients was associated with a particular state increasing physician Medicaid reimbursement.
The results were not striking, but they suggest a significant positive trend. This is what the results showed, in the authors’ words:
The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group.
Again, these are data from the early days of ACA implementation. But they are encouraging. One of the most important components of slowing the seemingly inexorable rise in healthcare costs is getting people good primary and preventative care. This keeps people with a chronic, manageable condition out of the emergency room and, one hopes, out of the hospital. This is particularly the case with common conditions like diabetes and asthma. For both of those disorders regular care by a primary care physician can spare patients much suffering and save many thousands of dollars.
I hope this kind of research continues as the ACA matures. It’s a good way to see if the overall goals are being met. Of course it raises a new challenge: making sure we have enough primary care physicians. Right now we don’t.
In all the noise of our current debate over government funding of healthcare, most people seem unaware that the government — federal and state — already pay half of our nation’s healthcare bills. Although some of this funding comes through the Veteran’s Administration system, the bulk of it is in the form of two government programs — Medicare and Medicaid. Again, most people lump them together in their minds. Physicians and hospitals, however, realize that, although the two programs were begun at the same time in the mid-1960s, they are very, very different.
Medicare is the federally funded program that cares for the elderly. We pay into the program with a payroll tax and are generally eligible for coverage under it when we reach age 65. Everybody is eligible, regardless of income. In contrast, Medicaid is a program jointly funded by the federal government and the states. It is for children of low-income families, pregnant women, and the disabled. (This is slated to change with implementation of the Affordable Care Act, aka Obamacare, with low-income adults also eligible.) The ratio of federal money to state money in Medicaid varies — the federal contribution is higher for poorer states — but for most states the number is about fifty-fifty.
That’s the funding side. Looking at the payment side, the money paid out to hospitals and doctors shows a huge disparity between Medicare and Medicaid that few people outside healthcare know about. Medicare typically pays much more to the provider than Medicaid does FOR THE EXACT SAME SERVICE. You can read more about the details of this disparity, which the Affordable Care Act also aims to change, here. As with all things about Medicaid, it does vary from state to state. But it is not unusual for a physician to be paid ten times as much by Medicare for the same thing. Why is this?
The fundamental reason is that, when Medicaid was established, the Congress needed to compromise to get it passed. That compromise needed to accommodate Congressmen who were frank racists, mostly Southern Democrats. As Timothy Jost wrote:
The fact that Medicaid is a federal-state cooperative program, rather than a national program like Medicare, is an artifact of a history of which we should not be proud. It is in part the history of trying to keep poor people on relief under the thumb of local government, where their lives could be managed more closely. It is also in part the history of racism, with which President Roosevelt had to come to terms to get his New Deal programs past Southern Democratics in Congress who insisted on control over who got welfare and how much.
A huge proportion of poor people in the South during the 1960s were black. And Congress wanted to make sure of two things: not as much money would be spent on them; and the individual states could keep the medical care the poor received worse than that of more affluent people by the simple expedient of paying doctors and hospitals less money to deliver it.
The effects of this huge disparity in reimbursement has had predictable effects on physicians, who frequently lose money with every Medicaid patient they see. Not surprisingly, six times as many physicians refuse to see Medicaid patients as refuse to see Medicare patients.
It’s all a sorry legacy, and its correction is a key component of the Affordable Care Act.
We badly need effectiveness research — which medical treatments work and which ones don’t. After all, some reasonable estimates are that a third or so what we spend on medical treatments is for things that aren’t known to work, or worse, don’t work. Effectiveness research means comparing two competing therapies to see which works better; if both work the same, our preference should be for the less expensive one. We have very little of that now.
There is another way to think of effectiveness research, a more global one. This approach looks at the bottom line — does a treatment make people’s lives better and/or make them live longer? A key metric for this kind of research is the quality-adjusted life year, or QALY. The idea is simple: to what extent does the treatment add meaningful years of life to people? This notion has been around for decades. It’s particularly useful because it crosses all disease categories, simply comparing life outcomes.
The idea of the QALY, however, can create fears that it will somehow be used to judge lives, one against the other, regarding which has a higher “qualtiy.” Could QALY measurement be a stalking horse for rationing, of allocating heathcare resources to those some committee deems more deserving. The political traction that Sarah Palin’s nonexistent “death panels” received shows the depth of this distrust.
This fear is, in fact, embedded in the recent healthcare reform bill, the Affordable Care Act. The Act established an outcomes research center, called the Patient-Centered Outcomes Research Institute. But, as a recent editorial in the New Journal England of Medicine notes, the Act specifically forbids the use of QALY measurement “as a threshold.” It is not clear at all what that means, but, like the authors of the editorial, I think it reflects a fear that some lives will be judged more worthy than others, leading to unfair (or unethical) rationing of care.
But here’s the problem: QALY analysis is one of the most powerful tools of effectiveness research, and it’s absurd to pretend is should not or will not be used. From the article:
“The antagonism toward cost-per-QALY comparisons also suggests a bit of magical thinking — the notion that the country can avoid the difficult trade-offs that cost-utility analysis helps to illuminate. It pretends that we can avert our eyes from such choices, and it kicks the can of cost-consciousness further down the road. It represents another example of our country’s avoidance of unpleasant truths about our resource constraints.”
I suppose the fear-of-QALY clause made into the bill because the legislative sausage-making machine contains many pet items of the various legislators. But this particular one is absurd.
Sachin on 