The effect of healthcare reform on pulmonary, critical care and sleep medicine was addressed May 18 by seven speakers who focused on topics that included the effect of insurance, pay-for performance, measuring quality, allocation of resources, the patient-centered medical home, universal coverage and future challenges.
The three main aims of reform are better health for the population, better care for individuals and lower costs through improvement, Ivor Douglas, MD, co-chair of the session, said in his opening remarks.
Health Insurance & the Critically Ill
A study of the influence of the insurance state on access and outcomes for the critically ill led to the conclusion that the uninsured are less likely to receive critical care services, but more likely to have greater care needs at the end of life, said Robert Fowler, MDCM, MS. Dr. Flower is associate professor of medicine in the Interdepartmental Division of Critical Care Medicine at Sunnybrook Hospital at the University of Toronto.
Dr. Fowler looked at the U.S. and Canadian healthcare systems to compare cost differences. The insurance-based system of the United States consumes 17 percent of the U.S. gross domestic product (GDP) while Canada’s single-payer system is 11 percent of the country’s GDP, he said.
Dr. Flower looked at 29 studies of healthcare costs, 27 of which focused on the United States and examined areas that included the treatment of the insured versus the uninsured, and managed care versus traditional insurance.
Although the uninsured are less likely to receive critical care services, Dr. Fowler’s study found that they are more likely to be admitted to intensive care units after hospitalizations. His study also found that they are less likely to receive certain life-supporting procedures and have life support removed, but more likely to die in the hospital, Dr. Fowler concluded.
Pay-for-Performance
The effect of pay-for-performance (P4P) on healthcare in the United States is expected to be generally positive and is a necessary change that has been implemented around the world, said Jeremy M. Kahn, MD. MS, associate professor of critical care, medicine and health policy at the University of Pittsburgh School of Medicine and Graduate School of Public Health.
“We’re spending way too much,” said Dr. Kahn, adding that financially, the United States spends far more on healthcare than other nations. “Not only do we pay too much, we don’t get enough.”
Most healthcare systems around the world incentivize for either quantity or efficiency. The United States is attempting to balance costs and quality by eliminating disincentives for quality, but it faces challenges in measuring quality, he said.
In looking at 128 studies of financial incentives for quality, the studies had many different conclusions, ranging from “substantial improvement” to “no impact” to “substantial worsening,” Dr. Kahn said.
Keys in designing a P4P program are to have varied measures, reward successes and improvements, target at-risk populations and reward performance over longer times, he said.
“P4P is an innovative and likely necessary approach to improving quality. It is more of an opportunity than a threat,” Dr. Kahn concluded.
Measuring & Improving Quality of Care
Public reporting on the performance of physicians and institutions is a necessary part of the attempts to measure healthcare quality, said Dr. Douglas, associate professor at the University of Colorado at Denver School of Medicine and chief of pulmonary sciences and critical care at Denver Health Medical Center.
Driving this public review of healthcare services is an increase in healthcare consumerism and local healthcare market competition, he said. In addition, the healthcare reform law calls for the development of Web sites to assess performance not only in terms of outcomes, efficiency and safety, but also patient experience.
A key in the process will be translating guidelines into measures for public reporting that could be reflected on Web portals for public reporting. These portals could play a key role in regulation and public accountability, consumer choice, purchasing decisions, provider behavior, quality of care and impact on costs, Dr. Douglas said.
“If systematically developed and integrated, if rigorously validated and reported, if carefully and consistently implemented, and if effectively and robustly championed, funded and managed, public reporting can improve care,” he said.
Implications of Healthcare Reform
The good news about that healthcare reform is that if it is truly enacted, it would make healthcare accessible to more people, but that is also the bad news because the United States does not have the infrastructure to treat the increased number of patients, said Bruce Siegel, MD, MPH, CEO of the National Association of Public Hospitals and Health Systems.
The Affordable Care Act will have three effects: It will drive the expansion of medical coverage for more low-income Americans, encourage insurance market reform and be used to rein in Medicare costs, he said.
With these changes, it is expected that by 2014 Medicaid could cover 76 million Americans—one-fourth of the population, making it the largest source of coverage for Americans, Dr. Siegel said.
“It would be similar to what we’ve seen in Massachusetts, where hundreds of thousands of people had coverage after its healthcare law took effect, but people could not get in,” he said. “This is the best example of what will happen to resources. There is not the capacity in America today to take care of these newly insured.”
In this environment, Medicare could become a platform for experimentation in healthcare to improve quality and value, Dr. Siegel said. This would also lead to the writing of many more regulations for healthcare professionals.
“Those of us in Washington look at those things, and I urge you to watch that and engage in the debate, he said.
Patient-Centered Medical Home
The birth of patient-centerness came about in 1998, when the Institute of Medicine established the Quality of Health Care in America (QHCA) program. That year, an IOM Roundtable on Health Care Quality identified the need to reduce overuse, underuse and misuse. In 2000, the QHCA refined its aims to improve safety, effectiveness, patient control, timeliness, efficiency and equity.
“Thus, patient-centerness was born. A patient-centered medical home is that very unique relationship between the patient and the personal care physician. That is the hallmark of patient-centered care,” said Cynthia J. Gries, MD, MSC, assistant professor in the Division of Pulmonary, Allergy and Critical Care Medicine at the University of Pittsburgh.
Beyond involving a personal relationship with one physician, the PCMH’s one physician the care and takes the whole person into account, involves coordinated and/or integrated care, includes quality and safety components, and provides enhanced access.
Her talk on specialists and subspecialists and the patient-centered medical home (PCMH) also examined PCMH neighborhoods and accountable care organizations (ACO). A PCMH neighborhood allows pulmonary, critical care and sleep consultants to communicate through a primary care physician who relates the information to the patient, she said.
Such neighborhoods ensure communication/integration; guarantee appropriate and timely consults; ensure efficient, appropriate and effective flow of patient and care information; guide responsibility of co-management; and enhance access with quality and safety.
In 2010, the Patient Protection and Affordable Care Act (PPACA) authorized CMS to create ACOs by Jan. 1, 2012. Dr. Gries noted that the PPACA states that providers will form ACOs and submit lists of their ACO PCPs to CMS. Then CMS will assign groups of patients to the ACOs based on plurality of primary care, but much work on defining the structure is needed, she added.
A Global Perspective
The immediate past president of the American College of Physicians, Fred Ralston Jr., MD, MCAP, looked at how achieving a high-performance healthcare system with universal access in the United States could be guided by what other countries have achieved.
In 2007, the ACP Health and Public Policy Committee, for which he was chair, compared the United States with 11 other industrialized countries. When working on the research, the group sought to learn from best practices abroad, but also took into account what is good about U.S. healthcare.
The ACP updated its report in January 2011 with “How Can Our Nation Conserve and Distribute Health Care Resources Effectively and Efficiently.” Recent events in several countries—Canada, France, Germany, Japan, the Netherlands, Switzerland, Taiwan, the United Kingdom—could provide an opportunity to remember that health reform is a dynamic process, he said.
The ramifications are far-reaching. In America, 120 million people have at least one chronic condition, and 60 million have multiple chronic conditions. By 2015, 150 million will have at least one chronic condition.
Pointing to a June 2003 IOM report, he said, “It’s clear that there is a significant cost in terms of at least $100 billion year in 2003 dollars to us as a society for having such a large proportion of our citizens uninsured. It’s important for us to put our political considerations aside and remember that any particular healthcare system involves a variety of elements.”
While ACP thinks politicians should decide if the model should be single payer or pluralistic, the ability for primary care to interact with “the great specialty care that we have in the country” is key, said Dr. Ralston, adding that other elements included the patient-centered medical home and a focus on care coordination and quality instead of volume.
“We feel the solution will be uniquely American,” he said. “Universal coverage has been achieved elsewhere and in an affordable way, and we think that high-value, cost-conscious care with the information tools and right professionals to deliver it is the future of American medicine.”
Missed Opportunities & Challenges Ahead
Attendees got a sense of the American Thoracic Society’s position on healthcare reform, when Gary Ewart, MHS, director of government relations with the ATS, discussed some of the missed opportunities and remaining challenges from an ATS perspective.
In 1996, the ATS formed a position statement. From that followed the formation of the ATS Healthcare Reform Rapid Response Team, which included the Health Policy Committee, Clinical Practice Committee, Education Committee and the ATS leadership.
The ATS position involves several components, including that healthcare is a right and the Society supports universal coverage. During debate of the Patient Protection and Affordable Care Act, the ATS favored private market reforms, engaged in the issue of physician supply, sought more attention on prevention and public health funding, and addressed a permanent solution to the sustainable growth rate and malpractice reform.
“As we know, healthcare reform was ultimately passed in March 2010, but how did we do? I think we did pretty good,” Ewart said, noting that the law allowed for near universal coverage, included private market reforms, involves initiatives that will look at physician supply and created a Public Health Trust Fund.
“We failed miserably on the sustainable growth rate factor,” he added. “We’d call malpractice reform pretty close to abject failure, but there is some language in the Affordable Care Act that gives clearance to states to try to be a model of state-based malpractice reform.”
While its not certain if healthcare reform will survive, he said it would have to withstand three major threats—political, judicial and budgetary.
With the political support of healthcare reform “soft,” he said the ultimate fate of the healthcare reform act would not be known until after the next presidential election. To date, 33 states have filed court challenges, and 13 states have passed legislation making it illegal to require people to purchase private health insurance in their states.
Along with sustainable growth rate and cost containment concerns, budgetary threats, including the federal debt limit and Medicare and Medicaid deficits, could all undermine the affordable care act.
Still yet to be unresolved are questions regarding implementation, capacity and the uninsured. “While the Affordable Care Act is successful at reaching 95 percent of all U.S. residents, there are a number of people who are still left out,” Ewart said. “Who is going to provide their care, and who is going to pay for their care? That’s something that’s largely been unaddressed.”