Primary care for the uninsured: A proposal for change

By Frank Lonergan, M.D.

As has been frequently stated, our health care system is in crisis. Unfortunately most trends suggest that this situation will continue to worsen. Health care costs continue to increase at a rate exceeding the rate of inflation. Most care in the United States is provided in emergency rooms or by specialists, and the number of uninsured citizens has grown by 6 million nation-wide over the past four years, according to the Journal of the American Medical Association.

No one cause is to blame for this systematic failure in our health care delivery system. However, it appears that the inadequate patchwork of care caused by our increased reliance on specialty care contributes greatly to the problem.

As has been shown repeatedly, care provided by primary care physicians equals the quality of specialty care, but at a lesser cost. Unfortunately our health care system has so reinforced the concept of specialization that we often refer patients now to meet their expectations for “quality care” rather than providing that care ourselves in a more efficient and patient-friendly environment.

This increasingly specialty-driven health care system along with the acceleration in technological advances has driven health care costs and insurance costs beyond the budgets of many companies and patients, leading to the large number of employed but uninsured patients in Texas. What would happen if care for the uninsured was provided entirely by primary care physicians?

AN OVERVIEW OF THE PROBLEM

Approximately 25 percent of the citizens of Texas have no health insurance. Of the approximately 5 million uninsured in the state, approximately 4 million are under the age of 40, according to “Profile of the Uninsured in Texas,” a report published by The Access Project. Nearly one-third have incomes between $25,000 and $50,000 per year, while one-half have household incomes of less than $25,000. The majority of the uninsured are employed, 80 percent full time and 10 percent part-time. In 29 percent of the households there are two full-time employees.

Studies indicate that the uninsured postpone care due to cost more often than the insured, tend not to fill prescriptions due to cost and do not get the care they need — especially preventive care. This is not surprising. What is surprising is that income does not affect these results. Even the uninsured with the highest household incomes received inadequate care.

To summarize, about 80 percent of the uninsured are younger than 40; the vast majority have jobs; and the majority are missing out on care that could prevent more serious health problems in the future.

HEALTH CARE UTILIZATION

Health care costs are driven by the intensity of care. This is intuitively obvious. In addition, excluding the newborn period, the intensity of care is related to the age of the population as is obvious when the Medicare population is compared to a typical commercial insurance population.

What is not so obvious is that the increase in intensity when plotted against the age of the population is not a linear graph. Instead there is a significant jump in utilization starting at age 40. For example, referral rates jump from about 60 per 1,000 encounters for patients ages 30 to 39, to 240 per 1,000 for ages 40 to 49. Similarly specialist visits per 1,000 jump from 55 to 299; emergency visits from 19 to 52; hospital admissions from 1.96 to 12; and inpatient days from 6 to 53, according to information provided by the North Texas Specialty Physicians. Removing obstetrics care from the figures would most likely make the numbers even more dramatic.

A PROPOSAL

The numbers listed above suggest that primary care providers could meet a large percentage of the health care needs of the uninsured. In addition, by providing adequate care to the 80 percent of the uninsured younger than 40, some of the more severe health issues of those in their 40s and 50s could be avoided, leading to a decrease in hospitalizations. My proposal would be to develop a statewide capitated primary care insurance plan for the uninsured.

Listed in Table 1 are the national averages for capitated care for 2005, according to the 2006 Capitation Survey published in Capitation Rates and Data. Based on these figures and using a figure of $15 per member per month for medication use, the cost would be between $38 and $70 per member per month with an average of $51, or about $612 per year. A statewide survey could be performed to see if this price level would be attractive to the majority of the uninsured.

Such a program would make health care costs completely predictable and should make health care increases more closely parallel the rate of inflation for the economy as a whole.

The inherent problems with this program are obvious. Patients with only primary care coverage would have no coverage for surgery, hospitalizations, chemotherapy, major injuries, obstetrics (although most of this would be picked up by Medicaid), transplants, etc. However, this is no different than the position these same patients are in now. The counter argument is that by providing good primary care, some of these hospitalizations could be avoided.

The other major problem would be the malpractice risk. Since all the care would fall upon the shoulders of the primary care physician, there could be claims of inadequate care or of a practitioner practicing beyond their area of expertise. There could also be claims of abandonment in the event that the patient develops a problem beyond the skills of the primary care provider with no referral network to back up the primary care provider. But again, this is a situation we are all facing already. It is especially problematic for practitioners in rural areas who do not have adequate back-up specialty care.

An obvious solution would be to add a specialty cap. However the cost to do this is significant. The average commercial specialty cap for 2005 was $41.19 with a range of $27 to $69, according to the survey. Adding this would nearly double the cost of the insurance and would most likely drive up the costs for outpatient and radiology services as well.

My hope is that this insurance vehicle will provide enough savings to hospitals in the form of decreased ER visits and charity care, that they may be willing to help provide some form of safety net for these patients.

WHERE TO GO FROM HERE

To make this plan work will require the backing of the TAFP and the American Hospital Association along with an insurance backer. In addition, primary care physicians, especially family physicians, will need to embrace the capitated plan. Keeping the plan capitated is crucial to keep the expenses totally predictable and the rates low. The ball is in our court.

Frank Lonergan, M.D., is a family physician in Azle, Texas, who also serves on the Board of North Texas Specialty Physicians, a multi-specialty IPA in Fort Worth.