President Obama won the hearts and minds of independent and progressive voters with his message of "hope" and "change." Yet the Obama administration repackaged his rhetoric with conservative ideology and pragmatism.
This is certainly true in regards to the Affordable Care Act, conceived (and now disowned) by Mitt Romney. Obama rejected single payer activists from the negotiation table. Ironically, the current snapshot of the Obama administration is framed by "socialized medicine," "death panels," and "Obamacare."
Rays of hope for single payer financing shine on Vermont, where a new law creates Green Mountain Care Board, a public board that "can wield traditional tools such as fee-for-service rate setting, controls on the acquisition of technology, and reviews of both health insurers’ rates and hospitals’ budgets."
Anya Rader Wallack, Ph.D., special assistant to Vermont Governor Shumlin, further writes in the New England Journal of Medicine: "we must align incentives for payers, providers, and consumers so that the risks and rewards embedded in provider payment systems, benefit designs, and cost sharing all promote a higher-value health system and better health." Without elaborating upon the pitfalls of over-utilization, she explains "the project will expand to include 'anchor' specialists attached to advanced primary care medical homes, with bonus payments linked to both quality and total cost of care."
Like Harry Potter's peers who dare not utter Voldemort, she seems to go out of her way to avoid using "accountable care organization," "triple aim," "capitation," "managed care" and other policy lingo that drives shivers down the spines of health care crusaders.
The name she and other single payer activists also avoid: the RUC.
In the current issue of Health Affairs, Brian Klepper and Paul Fischer write:
"the Relative Value Scale Update Committee (RUC), a secretive, specialist-dominated panel within the American Medical Association (AMA) that, for the past two decades, has been the Centers for Medicare and Medicaid Services’ (CMS’) primary advisor on valuation of medical services... It has systematically under-valued primary care and operated without regard for financial conflicts of interest. Its influence has compromised care quality and facilitated the primary care labor shortage."
Unlike other developed countries, the United States does not control specialty growth. For decades, policy makers have worried about a "specialist glut." And yet, the Accreditation Council on Graduate Medical Education and the American Board of Medical Specialties enable medical schools to keep pumping them out and in many new flavors: Hospice and Palliative Medicine, Undersea and Hyperbaric Medicine, Female Pelvic Medicine and Reconstructive Surgery, Pediatric Transplant Hepatology, Medical Biochemical Genetics (to name a few).
Medical school debts compel idealistic medical students to follow the money down the specialty path. Consequently, our nation is glutted with well-paid specialists who are threatened that they might sink if they are "anchored" to a primary care physician with fee-for-service rate setting.
Current health plans don't afford the undervalued primary care doctor time to help individuals sort our risks and benefits for any care they receive. Accountable Care Organizations, with information technology to automate screening tests, will indiscriminately do that for them.
Consider this review of Overdiagnosed: Making People Sick in the Pursuit of Health by a family practitioner. "Recently I was told that I do not have enough time to explain risks and benefits of screening to my patients. I try to take the time, but many have been convinced by media and friends that 'good medicine' means 'early detection.' My risk and benefit speech is not what many want to hear. It's so much easier just to be told what to do."
If quality is measured solely by the tests done, we will surely see more false positive and false negative test results without improved health. That's because the Affordable Care Act promises free preventive care and punitive cost-sharing for the follow-up testing and treatment. After all, cost-sharing is the antidote to consumer appetite for too much care.
And if this happens, health care will surely go down the path of education reform as No Patient Left Behind.
I hope, as Anya Wallach does, that the less-than-perfect single payer financing in Vermont will create savings and improve outcomes through reforms that include fee-for-service rate setting.
Instead of a new frame, we need to create a new image of health care that puts the focus on primary care physicians as advocates for individual and societal health. Rudlolf Virchow, a mid-nineteenth century German doctor who is remembered for advancing public health wrote, "The physicians are the natural attorneys of the poor, and social problems fall to a large extend within their jurisdiction." Single payer activists and the Physicians for a National Health Program should demand we Replace the RUC!