Health Care Reform and the Future of Family Medicine What Does Health Care Reform Mean for Me As a Medical Student? You are training at a pivotal time You will be the change-agents for a system that will deliver better care Your patients, friends, and community leaders will look to you as a guide
You already have the expertise needed to advocate for a better system The Current U.S. System at a Glance U.S. health care spending per capita: $9,541 What other wealthy countries spend: $4,908 What we get: 28.2 million uninsured (as of 2017) Life expectancy worsening
Poor access to primary care U.S. system ranks last when compared with similar countries How Are Patients Covered? Employer Non-Group Medicaid
Medicare Other public Uninsured Total 49%
7% 20% 14% 2% 9%
100% Coverage + access to a usual source of care = better health Health Care Disparities Which would save more lives: Medical advances or eliminating the impact of negative social determinants of health?
Family physicians identify and address social determinants of health. Health Care Disparities Real-world impact: On 40% of measures, blacks and American Indians and Alaska Natives receive worse care than whites Poor persons nearly always receive worse care than high-income persons Patients with diabetes in lower-income zip codes have higher rates
of limb amputations Sources: AHRQ, 2010 and Health Affairs, 2014. Eight Ways the Affordable Care Act Changed Coverage Allowed children up to age 26 to remain on parents plan Pre-existing conditions no longer denied Premiums vary by no more than 3:1 (e.g., depending on age) Elimination of lifetime caps Waiting period for coverage limited to 90 days
Deductibles limited ($2000 for one person, $4000 for a family) USPSTF A/B-rated services must be covered All ACIP/CDC immunizations covered Why Should Reform Prioritize Primary Care? Number of potentially preventable deaths among the five leading
causes of death, for persons aged <80 years United States, 2010 and 2014 Primary Care Saves Lives Review of longitudinal patient-level data shows access to primary care reduces mortality
Primary Care Saves Money An adult with a primary care physician spends about 33% less on health care costs. Comprehensive Care: It Makes a Difference Physician comprehensiveness Cost and
hospitalizations Source: Bazemore A, Petterson S, Peterson LE, Phillips RL Jr. More comprehensive care among family physicians is associated with lower costs and fewer hospitalizations. Ann Family Med. 2015;13(3):206-2013. Not Enough Primary Care Physicians CDC, 2014. Not Enough Primary Care Physicians
Current System Specialty Primary Care Ideal System Specialty
Primary Care AHRQ, 2014. Not Enough Primary Care Physicians The ideal workforce: There is significant evidence that optimal health care outcomes and optimal health system efficiency are demonstrated when at least 40-50% of the physician
workforce is composed of primary care physicians U.S. Department of Health and Human Services, 2010 Patients Arent Getting the Right Care from Our Current System 1976: Congressional report estimates 2.4 million unnecessary operations performed 1997-2005: Study shows more spending on back and neck pain leads to no measurable benefit
2006: One-third of Medicare spending for chronic illness unnecessary 2016: 700,000 arthroscopic partial meniscectomies performed 2016: Medical-related deaths estimated at 250,000 annually What Will It Take To Get It Right? We need at least: 44,000 more Primary care physicians by 2035.
Case Study: Primary Care is the Answer Setting: Texas Practice: Primary care-based accountable care organization Finding: Adjusted mortality rate for the practices population of older patients is 50% that of the rest of the state More Findings from National Research States with more primary care physicians involved in managing
chronic illness tend to have: Lower Medicare spending and use of hospital beds Less physician labor Fewer referrals to multiple specialists Better quality scores Less patient time in intensive care Fewer physician visits Fixing the System: Improvements Happen In 2012, number of persons uninsured was as high as 47.3
million The system is making a turn toward addressing social determinants of health Affordable Care Act elevated the role of prevention and primary care Fee-for-service model that rewards procedure-based specialties is being replaced Another improvement that has been well
documented: the continued decline in personal bankruptcies since implementation of the ACA. Continued Progress on Payment Reform Remains a Priority Repeal of Sustained Growth Rate, implementation of value-based system (MACRA)
Medicare temporarily paying up to 20% bonuses to primary care physicians in the years after ACA signed Medicaid reimbursement for primary care services increased to Medicare levels in 2014 Additional primary care seat added to national physician payment decision making body (RUC) Continued Progress on Payment Reform Remains a Priority In 2015, the Centers for Medicare and Medicaid Services began
paying separately for non-face-to-face chronic disease management and care coordination In 2017, payment codes were created for complex care management Latest Major Shift: MACRA Whats the aim? Reward value, not volume. Key takeaways:
Previous system threatened up to 21% cut in reimbursement rates. MACRA is a multi-track model for paying for high-quality care. Main track, MIPS, scores physicians on four areas. AAFP watching closely and monitoring impact on family physicians. The AAFPs Top Issues in 2017 Promote physician payment reforms that value primary care. Defend Affordable Care Act coverage gains. Improve physician well-being. Reduce administrative and regulatory burdens.
Increase family physician workforce. Support population health improvement. Family Medicines Advocacy Power Family medicine is the largest single specialty One of the largest specialty organizations (AAFP; 129,000-plus members) Family physicians are on the frontlines of communities With our patients, we have stories to amplify Start now: as a student you already know enough to
speak out Presenter: Find more slide sets with information about primary care and family medicine in the AAFPs Presentation Resource Center at www.aafp.org/medical-school-residency/fmi g/presentations.html
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