Posts Tagged ‘health care costs’

Wal-Mart: The future leader of low-cost care?

Save money. Live better. It’s Wal-Mart’s corporate motto, but put it in the context of health care and add a third line targeted at improving care for individuals and you’ve got something awfully close to Don Berwick’s triple aim for health care reform. If cost is the real cancer in the U.S. health care delivery system—and we think it is—why not look to America’s low-cost leader for the cure?

When reports started hitting the news this week about a request for information Wal-Mart sent out to its vendors in late October announcing the mega-retailer’s intent to “build a national, integrated, low-cost primary care health care platform that will provide preventative and chronic care services that are currently out of reach for millions of Americans,” alarms went off in health policy circles across the country.

The company has since backpedaled on the statement of intent. John Agwunobi, M.D., M.P.H., M.B.A., head of Wal-Mart’s health and wellness division, released a statement on Nov. 9, 2011, saying, “We are not building a national, integrated, low-cost primary care health care platform.”

Well, that’s a relief.

What struck me about the RFI wasn’t just the ambitious statement of intent, now characterized by the company as “overwritten and incorrect,” it was the list of services Wal-Mart plans to offer: chronic disease management of everything from diabetes, asthma, and hypertension to sleep apnea, osteoporosis, HIV, and clinical depression.

A few years back, Wal-Mart announced plans to open more than 400 retail health clinics in its stores from coast to coast. As of now, it operates about 140 clinics. The company exerted its massive purchasing power and brought us $4 generic pharmaceuticals. And now it wants to bring its cost-cutting strategies to the chronic disease management market.

The trouble is the price points of primary care services and chronic disease management services aren’t the cause of our health care cost crisis. The real problem is the effect on system-wide health expenditures when chronic diseases aren’t managed properly. So maybe Wal-Mart’s idea of enhanced retail clinics could improve access to those services thereby improving population health and lowering overall health care costs, but I doubt it.

I tend to agree with AAFP President Glen Stream, M.D., M.B.I., who told National Public Radio that Wal-Mart’s proposal takes health care in the wrong direction. “I would still be gravely concerned that this is going to fragment care at a time when we now clearly understand that people having a usual source of comprehensive and continuous care in a single location is one of the main features that drives high-quality care, good patient health outcomes, and drives down costs.”

Today, family physicians across the country are transforming their practices to make them more accessible to their patients, and to evolve our delivery system into one that coordinates patient care in an efficient manner to make sure patients receive the right care at the right time and in the right setting. The 2010 AAFP Practice Profile survey shows that significant percentages of our members offer many of the same conveniences that retail health clinics offer. More than 73 percent offer same-day or open-access scheduling. More than 48 percent have extended office hours, and more than 31 percent offer weekend appointments.

Wal-Mart’s interest in expanding its line of health care services is a big indication that primary care is on the rise. Here’s yet another indication. The Baltimore Sun reported this week that Maryland state officials plan “to increase the number of primary care health professionals by as much as 25 percent in the next decade through a wide range of goals that include increased educational opportunities, financial incentives, and tort reform.”

Competition for primary care services is about to get fierce, folks. Wal-Mart knows where the money is and where the demand is. Seems to me family medicine is in a great position for strong market growth.

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The super charge

Texas House Speaker Joe Straus, R-San Antonio, released the interim charges for the standing committees of the House of Representatives. As he said in the accompanying letter, these charges will set the stage for legislation considered during the 83rd Texas Legislature, which convenes in January 2013.

Of those that may affect family medicine, one assigned to the House Committee on Public Health stands out for its sheer immensity. It directs the committee to:

  • Examine the adequacy of the primary care workforce in Texas, especially considering: the projected increase in need (from an aging population and expanded coverage through federal health care reform), and cuts to workforce-building programs such as graduate medical education and physician loan repayment programs.
  • Study the potential impact of medical school innovations, new practice models, alternative reimbursement strategies, expanded roles for physician extenders, and greater utilization of telemedicine.
  • Make recommendations to increase patient access to primary care and address geographic disparities.

That about says it all, right?

Fortunately, TAFP is in a good position to positively influence the state health care reform discussion thanks to our members’ grassroots involvement through the TAFP Political Action Committee and the wise direction of big-picture strategists.

Because we’ve cultivated relationships with lawmakers, their staffs, and other capitol playmakers, they know the many benefits of primary care, family physicians’ concerns with the current system, and I’m convinced they even recognize the fonts and imagery on TAFP’s issue briefs. That means that we can actively work through the interim and the 2012 election cycle to proactively advance family medicine, and when the opening bell rings in January 2013, we’ll have laid the foundation to make substantial gains.

I invite you to use the comment section to give us your thoughts on any of the objectives above to give us direction as we move forward.

To the educators, what changes would you make to medical school curriculum that would provide the greatest benefit to the next generation of physicians?

To the innovators, actively experimenting with new practice models, what have you seen as the biggest barriers to controlling costs and providing the best care for patients?

To the rural physicians, what incentives are needed to draw more doctors to your area?

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The unintended, but not surprising, negative consequences of hospitalism

By Richard Young, M.D.

A recent study in Annals of Internal Medicine looked at what happened when patients were cared for in the hospital by private physicians (presumably often their personal physicians) compared to hospitalists.

For a little background, hospitalists are doctors whose job is limited to taking care of patients in the hospital. They pick up new patients in shifts or cycles and almost always have no previous relationship with the patients. They rarely see patients in clinics and have no long-term outpatient relationships with patients.

This study found that hospitalist patients stayed in the hospital 0.64 days fewer than the private physician patients. This finding is consistent with previous studies. However, hospitalist patients were 18% less likely to be discharged home (more likely to a nursing facility), 18% more likely to make an ER visit in the 30 days after discharge, and 8% more likely to be readmitted to the hospital. This study was important because it measured real world performance across the U.S. after previous controlled studies showed the hospitalist approach had merit.

The hospitalist movement was born from many factors. One was the assumption that a doctor who is at the hospital can be more efficient because he can, for example, check on a patient later in the day and discharge the patient if a test performed in the middle of the day came back normal in the afternoon (while the private practice physician won’t come back to the hospital until the next morning). The private physician is paid nothing for any work past the first patient encounter each day. The hospitalist isn’t either, at least as a payable charge to Medicare or most insurance companies, but he’s at the hospital anyway so it’s not nearly as inconvenient for him to see the patient again.

To my knowledge, no study or private initiative has ever tried to preserve the personal physician-patient relationship in the hospital by paying the physician for the time it takes to do further work in one calendar day beyond the initial trip to the hospital–neither face-to-face work nor work performed electronically.

The best summary on the research of the impact of hospitalism to me is exactly what this study found — the length of stay decreases a little and is associated with a few problems down the road. Whether a patient spends three days or 10 days in the hospital has a lot more to do with how sick she is, not the kind of doctor providing the care. My biases about family medicine are transparent, but I can’t help wondering: if there is no significant improvement for a patient so sick she needs to be in the hospital to see a hospitalist, then why not create incentives and processes to encourage the pre-existing relationship with her family physician to continue in the hospital, especially when is she is the most ill, vulnerable, and scared?

The hospitalism movement is not a hindrance to improving our health care system, but it’s no solution either.

This post originally appeared on American Health Scare blog on Sept. 4, 2011. It has been reprinted with permission from Richard Young, M.D.

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