Sunday, March 30, 2008

Pennsylvania's Health Care Reform Proposal Includes Primary Care

In a prior post, the Disease Management Care Blog had a brief report on Massachusetts’ health care reforms. If you are interested in learning even more about what’s going on in the Bay State, check out this well written article (subscription may be required) in the March 18 Annals of Internal Medicine.

Your trusty DMCB has the bottom line however. It was the description of that all important thing called "funding" that caught the DMCB’s eye. A pre-existing ‘free care pool,’ used to compensate hospitals for uninsured patients, was combined with matching Medicaid funds, additional state monies and employer (‘free rider’) and tax payer (kiss the deduction good bye) mandated penalty assessments. The DMCB agrees this multi-pronged approach aided the reform’s passage, along with three other factors. There was a manageable uninsured prevalence rate of 10% (versus 16% nationally). There was familiarity with the complicated issues at stake thanks to multiple prior attempts at reform. Finally, there was an appetite for bipartisan compromise.

As noted in that prior post, Massachusetts’ reform has been criticized from both the right and the left. According to the Annals, some physicians have also weighed in, pointing out that economically disadvantaged patients are now responsible for practically unaffordable insurance premiums and co-payments for care that had been previously covered by the free care pool. However, there is some consensus that many more health care consumers have been aided by access to health insurance than have been hurt.

Why is the DMCB thinking about this? Well, it believes the States and ERISA protected health insurers, in contrast to what's happening inside the beltway, may ultimately be the twin leaders in health care reform. It also believes any meaningful reform will need to include primary care.

The Annals article pointed out that Massachusetts’ reform is being hampered by the lack of any measures to meet a predictable increase in demand for primary care services. For example, in the year it was passed, the percent of internists not accepting new patients jumped 13% to 49%. Fewer are accepting Medicaid and wait times for new appointments have increased significantly. It seems there is some truth to the adage that providing health insurance doesn’t necessarily guarantee access to health care.

While all eyes are on Massachusetts, the DMCB points out that there is an instructive attempt at health care reform underway in Pennsylvania. Like Massachusetts, there is a separate pool of dollars that advocates of reform would like to tap. In addition, the State’s numbers of uninsured, as a percentage of the population, is not high. On the other hand, there is a distinct lack of bipartisanship. It remains to be seen if meaningful reform is ultimately achieved, or if the outcome is merely some increased familiarity for another try at some later date.

While its prognosis is uncertain, the Pennsylvania plan is worth close examination because its plans for primary care contrasts with Massachusetts'. Elements include increased use of non-physician health care providers, expansion of federally qualified health centers, more nurse-managed care centers, providing funding for better evening and weekend coverage, expanding the primary care workforce, providing financial incentives, addressing the need for greater diversity and promoting the Chronic Care Model . Pennsylvania fee for service Medicaid also relies on a disease management company.


Vince Kuraitis said...

I really wonder how much leverage a state has to promote the Chronic Care Model (CCM). While Pennsylvania's efforts sound good, can they be translated into effective policy?

While the CCM is an excellent model, at it's core it is a bottom up effort at health system reform -- it starts at redesigning the physician office and community delivery components. It's not easy.

How can a state create the right financial incentives and business model to make this work?

I'm curious how the DMCB and others see this.

Jaan Sidorov said...

Learning cooperatives will be formed. The organized primary care groups in Pennsylvania are supportive and several physician practices have signed up. This is still in the pilot phase, so stay tuned.