As the U.S. healthcare system moves forward in its shift from a volume-based to a value-based payment system, where does primary care fit into the picture? In particular, how does primary care fit into the emerging financial ecosystem in healthcare? These questions were posited to two healthcare industry thought leaders at a recent panel discussion in New York City on primary care policy and health care reform, hosted by NYC-based Primary Care Development Corporation.
During the afternoon Primary Care Summit on Feb. 26, Mitchell Katz, M.D., the new president and CEO of NYC Health + Hospitals, New York's 11-hospital municipal health system, provided his perspectives on health care reform issues as both a seasoned primary care doctor and a public healthcare executive. Prior to his post as CEO of New York’s safety net health system, which he began in January, Katz led the Los Angeles County Health Agency, an agency that combines the Departments of Health Services, Public Health and Mental Health into a single entity with a $7 billion budget. Previous to that, Katz served as the director of the second-largest public safety net system in the nation, the Los Angeles County Department of Health Services (DHS), where he created the ambulatory care network. Katz also served as the director and health officer of the San Francisco Department of Health for 13 years.
Now leading the nation’s largest municipal health system, which is facing a $1.8 billion budget gap in 2020, Katz has said in previous media interviews that he is focused on continuing to push NYC Health + Hospitals’ focus from hospital care to primary care.
The panel discussion was moderated by Louise Cohen, CEO of Primary Care Development Corp., and joining Katz on the panel was Elisabeth Rosenthal, M.D., editor-in-chief of Kaiser Health News and a former emergency department physician. Rosenthal was also a reporter at The New York Times for 22 years, covering health and health policy issues, and recently authored a book, An American Sickness, about the U.S. healthcare system. Katz and Rosenthal shared their perspectives on the challenges facing primary care in the ongoing health care reform debate, and touched on the use of health IT as both a barrier and an opportunity to improve care.
Discussing the rising cost of healthcare for patients, Rosenthal noted that she was working in New York City ERs in the 1990s when Former U.S. President Bill Clinton’s proposed healthcare reform bills failed to pass. “Here we are, 25 years later, still talking about many of the same problems,” she said, adding, “Back then, healthcare wasn’t working for the poor and uninsured. Now, we’re in a different and more critical situation. We’re talking about the same issues, but on steroids. The crisis of healthcare affects all of us, and, politically, it’s an opportunity for change. My colleagues can’t afford healthcare, so not only is healthcare inaccessible, but with rising costs, it’s expensive.”
Sharing her thoughts on what could be done to improve primary care to the benefit of patients, Rosenthal said price transparency and patient education are both critical. “Part of it is getting patients to know what is value in care and what is necessary. Patients need to change too, we need to change to a culture of what it means to be a patient and what we expect to be the norm. The patient expectation now in our culture is that patients expect doctors to ‘do something.’ The key to primary care is talking, listening, watchful waiting, but there’s no money to be made in watchful waiting. The doctor training also is to ‘do something,’ order a test, do a procedure, we have to shift that,” she said.
Katz, who referred to himself as an “unapologetic primary care doctor,” agreed, saying that he views primary care as foundational to shifting the U.S. healthcare system to provide better outcomes at lower cost. “The special sauce is the longitudinal relationship with patients, and that can’t be replaced by technology or the smartest diagnostician. People want different things from their healthcare and only by knowing what they want, then you can steer them in ways that will not further inflame healthcare expenses.”
Katz also said that addressing social determinants of health was imperative to bending the healthcare cost curve, and an area that primary care physicians are well-suited to address. “Making sure that people have a place to live, food to eat, a safe environment to live. I’m hoping as primary care doctors are naturally focused on what patients need, that’s how we can address their housing, their food, whether they are living with a violent spouse, whether they are drug addicted, have serious mental health issues; primary care doctors are comfortable thinking about those issues, and I think that would make a huge difference in the cost curve.”
Rosenthal also said, “I tell doctors to get away from what I call the ‘why don’t we just…’ culture in medicine—why don’t we just get a CT scan or a MRI? Think about why you’re getting it. We have to reach medical students and move away from the ‘do something’ culture to think about chronic care and prevention and that’s hard right now given the current payment system.”
Rosenthal also noted that technology can be leveraged to enable more face-to-face time between physicians and patients. “There is tremendous potential in things like the digitization of records, online interactions, telemedicine. I think all of these technologies can be used to give physicians and patients more face time, which is what we want and need.”
She added, “When technology is applied well, and some health systems are doing a great job, then it’s a great adjunct to primary care, but it shouldn’t replace the doctor-patient relationship.”
What’s more, on the issue of technology and IT systems, Rosenthal noted that while many clinicians complain about their electronic health record (EHR) systems and health IT, she argued that physicians aren’t advocating for the functionalities and usability changes that they need. “People complain about EHRs and Epic. They say, ‘It’s not our fault, it’s Epic.’ Well, Epic also built EHRs for Denmark. If they ask Epic that the EHRs be interactive, then they build things that are interactive,” she said, adding, “I am incredibly encouraged by younger doctors coming into the field, and at a time of uncertainty, they are coming in despite whatever the business model is, because they want to take care of patients.”
When Cohen asked the panelists about the ability of startups, entrepreneurs and venture capital to bring new investments to healthcare, whether for new drugs or new technology, Katz responded that while healthcare is becoming more technological, the cost of healthcare is not dropping. “If you look at iPhones, technology keeps getting better and cheaper. The argument for price control is that the economists will tell you that you use price controls in capitalism when the market isn’t working; healthcare is an example of when the market isn’t working.”
Rosenthal said, “I’m a little skeptical of the narrative of money will guide us in the right direction. We have demonstrated time and again that the market is broken.” And, she noted, “The Japanese take an interesting approach. With a new machine, such as a new MRI, they price it high, but every two years, the price has to come down; it’s a regulated price.”
And, asked about whether they support the idea of free primary care, essentially “Federally Qualified Health Centers for all,” Rosenthal noted that primary care is too integral to all of medicine to be separated out.
Drilling down into the economics of healthcare, and primary care in particular, Katz said, “I prefer value-based payment to fee-for-service, but in primary care, the things we do are not easy to put into value. Spending more time with people, making them feel cared for, that’s hard to quantitate. There are some things that clearly lend themselves to value-based payment and other things, not so much, but it is an improvement. Getting people to a salaried model would do more than anything else.”
Rosenthal said the operationalization of value-based care is very problematic, as “the last 30 years of medicine, every time we set up a metric to evaluate something, somebody can abuse it."
"It’s like studying for the test," she continued, "you can know the value measure, but you ignore the essence of medicine. People go into healthcare because they like it, and tinkering with the financial incentives is not a bad idea, but if you put everybody on a salary, then you don’t have to play this game.”
To wrap up the panel discussion, Cohen asked the panelists if they had an optimistic or pessimistic outlook on the U.S. healthcare system for the next five, 10 and 25 years. “I’m optimistic, only because people need healthcare,” Rosenthal said. “I do think over time this is now no longer a rich versus poor issue, this is a national problem now, and so, it will have a solution. I’m seeing a lot of action, not in D.C., but at the state level on how to tackle this problem. States are starting to pass their own laws on drug pricing and individual mandates.” She pointed out that in some states, when insurers have all dropped out of the insurance exchanges in certain counties, state government leaders moved to opt everyone in those counties into Medicaid or Medicare.
“I’m hopelessly optimistic,” Katz responded. “I love being a primary care doctor. Health + Hospitals is filled with mission-driven doctors, nurses, and pharmacists, and part of the solution is to empower clinicians and patients. The system is too heavily driven by consultants and administrators, people who don’t know what goes on in a hospital room. I think that if there is a solution, it’s going to come from front line staff people who can say, ‘This is what patients need and we need a system that fits those needs’.”