May 27, 2014
Last Wednesday, President Obama called the much-publicized problems in the Veterans Affairs health system “disgraceful” as delays in care in at least 26 facilities grabbed media attention. In testimony before Senate and House Congressional committees, VA officials disclosed systemic misrepresentations about the timeliness of treatments in VA primary care clinics: rather than getting care within 14 days of request, many veterans appear to have waited 6-12 months to see a doctor, and some are alleged to have died while waiting.
In referencing a special report due this week that assesses the scope of the problem in the Department of Veterans Affairs, the President’s commitment to fix the problem was unequivocal: “I want to see what the results of these reports are and there is going to be accountability.”
As I have watched the VA storyline play out over the course of the past few weeks, I found myself asking questions the reporters weren’t:
Why do we need to operate a separate system of 820 clinics and 151 hospitals for Veterans? Might the system of care for the 21 million it currently serves not be better coordinated through the 5200 public and private hospitals, 820,000 physicians, 1200 federally qualified health centers, 2000 community mental health clinics, 56,000 pharmacies and 1700 retail clinics? In most communities, there’s a surplus of beds. In most communities, those with insurance can get doctors’ appointments and receive treatment. Veterans who lack private coverage, like those who are uninsured, have fewer choices. It is not a capacity issue: it is an economic issue. And common sense suggests we might redeploy some the VA health administration’s $60.3B budget for better coordination with the private systems that already operate in our communities while reducing duplication of services and their associated costs.
Why don’t we get serious and fix the problem of access to primary care shortage once and for all? It’s not just a veterans’ problem. Those who live in poorer neighborhoods lack access. Those on Medicaid face long waits to see a primary care doctor for the first time. And those lacking coverage altogether use emergency rooms and public health clinics as their primary care providers. The Federal Trade Commission says expanding scope of practice responsibilities for nurse practitioners solves it. The Affordable Care Act proposes expanding the supply of primary care residencies and increased pay (though nowhere near compensation paid specialists). Academic medicine says it’s a matter of better recruitment and improved training. The key primary care medical societies say it’s a matter or money and role: paying general internists, family physicians and pediatricians more and giving them responsibility as gatekeepers to the rest of our specialty-heavy system. These are important but not enough.
And why does it take the media spotlight to prompt righteous indignation over access issues in our system? We all know access is an issue for the uninsured and underinsured. It is widely documented, but solutions are reported rarely. It goes beyond primary care, but it’s an issue nonetheless.
What’s the solution?
Paying primary care physicians more might encourage a few more smart kids in undergraduate school to consider the career, and innovation in the medical school curriculum around team-based care and accelerated competency-based training might encourage a few more to enter the profession, but that’s not enough. There are three keys to the solution in my view:
Employer activism: employers have enormous untapped influence on how primary care is used in the U.S. beyond benefits design for their 141 million employees and dependents. They sit on boards of hospitals. They contribute to political campaigns. They run trade associations and exert influence in statehouses and DC. Every employer that provides health insurance pays a hidden tax to fund primary care delivered through hospital emergency rooms for the uninsured and redundant clinics operated by the VA and other government agencies. Employers are the difference. Employers can accelerate their own primary care gatekeeper system via in-house primary care clinics. Employers can meld the skillsets of pharmacists, dentists, mental health professionals, optometrists and nutritionists into newer, more comprehensive patient-centered medical homes that can manage population health better while lowering costs. Employers are community leaders and access to effective, efficient primary care is a community problem. Employer activism, focused on fixing access to primary care, would turbo-charge the solution.
State legislative leadership: federal policy about fixing the shortage of primary care physicians is cumbersome. It deduces that primary care is delivered primarily by physicians, only dispensed via visits, and only accommodated by expanding access to medical residencies and financial inducements for PCPs who agree to practice in underserved communities. These help but take a decade to implement. Meanwhile waiting times for primary care get longer and fewer physicians-in-training are pursuing primary care as a career. States have the authority to expand scope of practice for pharmacists and nurses to diagnose and treat. States have the capacity to pass tort reforms that would enable primary care teams to manage populations more effectively without fear of plaintiff’s bar. States have the ability to incentivize hospitals to create well-run integrated primary care networks that offer a full compliment of physical and mental health services cost effectively. And states can encourage spending changes from bricks to clicks to enhance care coordination and population health. Ground zero for primary care solutions is the statehouse, not the White House.
Unbridled consumerism: Technologies and online services that equip individuals to diagnose and treat themselves for uncomplicated conditions are readily available. Access to personal health records that integrate the individual’s hospital, lab, physician and health history into a personalized care path are accessible. Consumers want to control their own health. They want to know what over-the-counter therapies do and how alternative treatments might work. They want useful information about the efficacy of drugs, the accuracy of diagnostic tests, the appropriateness of surgical procedures and whether cheaper options with the same or better outcome is available and where. They embrace group visits, personalized online tools and electronic authorization for script fulfillment. They want to know how other consumers rate the services and products they use. They want to know how their doctors are paid and how much. And they want to know the total costs and their out of pocket portions for their drugs, hospital and clinic visits, insurance premiums and more. The power of unbridled consumerism in healthcare toward a new, national vision for primary care is virtually untapped.
Fixing the primary care access issue is as important as the Kennedy era race to space, and more important to the economic recovery than arguably any other endeavor. The VA system’s flaws are an embarrassment to the Department of Veterans’ Affairs, but the bigger story is uneven access and inadequate momentum toward fixing the primary care system in the U.S. That’s the story that’s not being told.
P.S. Lost perhaps in the media buzz about the Ukraine and the VA is the 50th anniversary of Lyndon Johnson’s Great Society legislation signed into law May 22, 1964. It brought us Medicaid and Medicare along with food stamps and other programs-- arguably the most far-reaching changes in the health care system then and perhaps now. Per the Pew Research Center, when Americans were asked how often they trusted the federal government to do what is right, nearly 80% said “just about always” or “most of the time”.
Sources: US Department of Veterans Affairs (VA.gov); “2014 Survey of Patient Appointment Wait Times” Merritt Hawkins (MerrittHawkins.com); “Projecting the Supply and Demand for Primary Care Practitioners Through 2020” National Center for Workforce Analysis (HRSA.gov); CMS (CMS.gov); National Council for Behavioral Health (thenaitonalcouncil.org)