Report from the White House Conference Call Briefing for Physicians, August 25, 2009

The White House Office of Health Reform hosted a conference call for physicians last evening. 2,700 physicians joined in the conference call, and 400 submitted questions in advance, evidence of how serious physicians are about trying to make sure this is done right. It was not open to the press, and the idea was that doctors could speak freely, though there wasn't much time for open questions.

Much of the conference was a general overview of the goals of reform as well as addressing the most common questions that had been submitted. They wanted to reassure physicians that they "get it:" Doctors are spending too much time on paperwork and bureaucracy, and that hurts patients by reducing the time we can spend with them. It's not what we went to medical school for. Keeping the current system isn't an option anymore, as the costs are spiraling out of control. Malpractice costs have to be reduced, although a simple cap on non-economic awards has had unintended consequences in some jurisdictions. The payment system is broken, and it's insane that we have to endure the annual handwringing ritual while we wait for congress to come up with another band-aid fix for the automatic pay cuts created by the "sustainable growth rate" formula (SGR).

Some of the features of the new system they wanted to highlight:

-- Insurance companies will no longer be able to exclude pre-existing conditions, nor can they limit coverage or terminate policies once people are sick.

-- There will be limits on out-of-pocket expenses, so that high deductibles and co-pays don't prevent patients from being able to obtain services that are otherwise supposed to be covered by their plans

-- Annual and lifetime caps on coverage will be prohibited, so catastrophically ill people won't suddenly find themselves with no coverage because they've passed some arbitrary maximum amount of expenses

-- Preventive services that can be shown to save money for taxpayers will be completely free to patients, with no copays or deductibles. The assessment of cost effectiveness will include not only what such preventive services save in future medical costs -- the impact that insurers already look at, although their focus may be on short term cost-effectiveness only -- but will also include the overall cost to society in non-medical costs and lost productivity. It's a big shift from Medicare's current policy of not paying for preventive care except in a very limited number of procedures.

-- There will be more emphasis on "global payment formulas" rather than paying per procedure. If you find that spending more time on one visit keeps your patients healthier than five short visits, go for it. Under the current system, Medicare and most other insurers significantly underpay for long visits, but short ones tend to be paperwork-intense and unsatisfying for doctors and patients. The idea is to reward quality rather than quantity of service.

-- There will be money to increase the numbers of primary care physicians, both through loan forgiveness with programs like the National Health Service Corps and through medical school scholarships

-- The planning already includes an "SGR fix" -- no more pretending that expenditure won't exist and acting surprised when it has to be added to the budget.


Obviously, whether these lovely promises will work will depend on the details of implementation. For those of us working with managed care in the 80's and 90's, we know that a well-run capitated health plan can reduce paperwork overhead, provide superior results in patient care, and allow physicians the choice of how best to budget their time to keep their patients healthy. We also know that in recent years capitation has been used by commercial insurers as a means to dump more of the insurer's costly bureaucratic tasks on physicians and their staff while keeping reimbursements stagnant, making a government-run option actually look like a better alternative.

It will be important to have flexibility to reward mini-centers of excellence, so physicians who become particularly competent in managing a particular illness aren't penalized by having large numbers of sicker, more time-consuming patients without being compensated for it. (Currently, insurers usually have programs for a small number of common, costly diseases like asthma, heart failure, and diabetes, but they have nothing for less common conditions like deafness or paraplegia that could be better managed if a few primary care doctors had a significant number of similar patients and could justify special equipment and services for them.)

It will be important to resist the urge to micromanage quality control, creating a whole new mountain of paperwork to suck up time and money. Whenever possible, quality control should flow from patients being educated about how to recognize quality, and then letting them make choices for themselves and their family members that reflect their personal experience with health care providers.