Medicaid reform, health transparency and a sick dog

Happy New Year, fellow family physicians, and welcome to the opening of a new legislative session. The gavel has come down in Austin to begin what should be a very important session for family medicine.

We’ve been quite busy over the past several months in preparation. Since the publication of our policy report, “Fractured: The State of Health Care in Texas,” we’ve sent representatives from the Primary Care Coalition to meet with the editorial boards of the state’s major daily newspapers. Those meetings have resulted in editorials, opinion columns and news stories that outline the major problems threatening Texans’ access to quality, affordable health care and some possible solutions that depend on fostering a healthy, patient-centered primary care environment.

The fact is the public is listening. Now it’s time to take advantage of that attention and do what’s right for the patients of Texas. This Legislature started with a surplus of about $14 billion, partly because previous Legislatures have starved down our health care safety net programs.

It’s time to reinvest in those programs so that for families in need, finding a doctor who takes Medicaid doesn’t take all week and for physicians, participating in Medicaid isn’t bad business. With the margins in many family doctors’ offices, seeing new Medicaid patients is a losing proposition. With increased reimbursement, we can see these patients in our offices and keep them out of the emergency room, giving them better continuity of care and saving us all money in the long run.

While we’ve been gearing up for the Legislature, I’ve had some opportunities to represent family medicine on a few panels at meetings hosted by the Texas Hospital Association, the Texas Association of Health Plans and the Texas Association of Business. The topic: health care transparency, the latest buzzword from the policy folks. Employers hope that publishing price and quality information about providers and services will encourage consumers (or as I like to call them, patients) to make better choices about their care, thereby bringing down the cost of care overall. Whether it will work or not, time will tell, but business groups and health plans list transparency at or near the top of their legislative priorities.

There are some pitfalls we’ll have to watch out for, which you can read about in detail in this issue’s cover story, but for the most part I think transparency can be a good thing for family medicine. Publishing price and quality information will show patients and employers alike what researchers like Barbara Starfield, M.D., M.P.H., have been saying for years: Family medicine is the best deal in town. If you haven’t read any of Starfield’s work or any of the Health Affairs articles on the value of primary care, AAFP has put together a repository of articles on its Web site, www.aafp.org. Look under “Policy and Advocacy” and click the link named “Value of Family Medicine.”

As I’ve sat on these transparency panels amid all the talk of premiums, quality measurements, efficiency ratings and hospital chargemasters, I’ve tried to bring the discussion back to the most important party in health care­—who’s never represented on these panels, by the way—the patient. Every patient is unique and so is every patient encounter. Measuring quality is important so we can all get better at what we do, but physicians have to be able to make judgment calls. In some ways, medicine is a science that can be measured but in some ways it’s an art that can’t.

I’ve also brought the message that transparency ought to be applied across the board, so that accurate information about coverage benefits, co-pays and deductibles is easy to access at the point of service. Then patients and physicians can have meaningful discussions about the best treatment options and the cost of their care.

Where price is concerned, I think it’s important for patients and employers to understand that what I charge and what I’m paid are not the same. My payment is determined by the health plans, which already have all the price information anyone could want.

I like to tell the audiences at these meetings a story about my son and his dog. He’s got a big black Labrador retriever named Gus. Last summer, Gus came down with a bad case of diarrhea, and when you’ve got a 100-pound dog with a bad case of diarrhea, brother you’ve got a problem. After a failed attempt with Pepto-Bismol, my son took the dog down to the local veterinarian who promptly prescribed some medication that cleared up the trouble in a couple of days. Out of curiosity, I asked my son what he paid for that service. Eighty-five bucks. Now folks, I can charge 85 bucks to cure a case of diarrhea but I won’t get paid 85 bucks by anybody. The most any health plan will pay me is $64, and I’m taking care of somebody’s kid, not somebody’s dog!

Of course that story gets a laugh out of audiences, but it’s absolutely true and it’s only one of a million. We’ve got to tell those stories to anyone who’ll listen. This is an important time for us. Climbing health costs and state budgetary constraints have employers and policymakers looking for new solutions. Family medicine and primary care are in the spotlight like never before. Now is our chance to make something happen, to do what’s right for our patients. I hope that as you list your New Year’s resolutions, you’ll make one with me to be involved in improving our state’s health care system. Together, we can make a difference.