Debating the pros and cons of Medicare for All

Although neither of the major party nominees for U.S. President in November support a "Medicare for All" style single-payer health insurance program, this issue emerged during the Democratic primary debates as one option for extending coverage to the uninsured and reducing health care administrative costs. Our recent Georgetown Health Policy Journal Club discussed two editorials in the October 1 issue of American Family Physician that offered contrasting answers to the question: "Would Medicare for All Be the Most Beneficial Health Care System for Family Physicians and Patients?"

In "Yes: Improved Medicare for All Would Rescue an American Health Care System in Crisis," Dr. Ed Weisbart argued that the COVID-19 pandemic exposed the shortcomings in an employer-based health insurance system with an patchwork public insurance safety net. He pointed out that 93% of U.S. primary care physicians accept Medicare, and Medicare enrollment has been associated with improvements in age-specific mortality relative to peer nations. In addition, Dr. Weisbart suggested that implementing an expanded version of Medicare with more comprehensive coverage for the entire population would lead to large administrative cost savings, reduce documentation burden, and potentially increase primary care physician satisfaction by eliminating the moral injury associated with being unable to help patients who cannot afford care.

In "No: Medicare for All Would Cause Chaos and Fail to Control Health Care Costs," Dr. Richard Young countered that "expansion of Medicare ... would not address the deeper problems in our health care system." At current payment rates, implementation of Medicare for All could cause substantial financial difficulties for hospitals. Absent new legislation to allow the Centers for Medicare and Medicaid Services (CMS) to negotiate drug prices and consider costs in coverage determinations, he pointed out, expanding Medicare would further inflate the already staggering U.S. health care bill. Dr. Young argued that regardless of their financing mechanisms, other countries with universal coverage have lower costs primarily because their citizens are willing to sacrifice - whether that means practicing within strict budget limits (e.g., fewer cancer screenings, more conservative prescribing of statins) or declining to cover some beneficial but very expensive therapies. Finally, he observed that

many of the things that frustrate family physicians about the current [U.S. health care] system originated with Medicare: the devaluation of primary care services; the relative overpayment for specialist care; the inability to bill for helping patients with more than two or three concerns in one visit; the requirement for face-to-face services (before the coronavirus disease 2019 exceptions took effect); the refusal to pay family physicians for clinic and hospital work on the same day; and the lack of incentives for full-scope family medicine.

A 2019 RAND study estimated that total national health expenditures under a Medicare for All plan would increase by only 1.8%, from $3.82 to $3.89 trillion annually. However, the federal government's direct share of health care spending would rise by 220%, from $1.1 to $3.5 trillion, an increase that would have represented more than half of 2019 federal expenditures and exceeded the $2 trillion plus CARES Act economic relief package passed earlier this year.

We also discussed less ambitious (and, possibly, more politically palatable) proposals for extending coverage that build on the framework of the Affordable Care Act, such as adding a publicly administered insurance option to increase competition (and lower premium costs) in the state health marketplaces. Former Vice President Biden has expressed support for "Medicare for More," extending Medicare eligibility to persons age 55 to 64 and possibly allowing younger adults without affordable insurance options to "buy in" to the program. The upcoming Presidential and Congressional elections will clearly play a critical role in determining if our country moves in that direction.

Maryland's Primary Care Program: incremental progress or breakthrough?

 - Kenny Lin, MD, MPH

Much has changed in the past six years since our last Health Policy Journal Club at Georgetown. Our residency, formerly a collaboration with Providence Hospital, is now known as the Medstar Health/Georgetown-Washington Hospital Center Family Medicine Residency Program. I stepped down as director of the Robert L. Phillips, Jr. Health Policy Fellowship three years ago, though I still enjoy working alongside these talented family physicians in clinic, such as Dr. Brian Antono, who recently blogged about his fellowship experiences for Harvard Medical School's Center for Primary Care. And this academic year I am not only working remotely due to COVID-19, I am more than 2,000 miles off campus as a visiting professor at the University of Utah in Salt Lake City.

What hasn't changed is that our family medicine residents remain excited about health policy and advocacy. Since their continuity clinic continues to be located in Maryland, we decided that a great topic to revive this series of seminars was the Maryland Primary Care Program (MDPCP), which was recently featured in a Milbank Memorial Fund Issue Brief.

MDPCP is a multi-payer "advanced primary care" program modeled after previous patient-centered medical home projects such as the Center for Medicare and Medicaid Innovation's (CMMI) Comprehensive Primary Care initiative. CMMI partnered with Maryland's Department of Health to launch MDPCP last year with Medicare as the first participating payer. (CareFirst Blue Cross Blue Shield joined the program in 2020.) With 476 participating primary care practices, MDPCP provides prospective, non-visit based payments known as "care management fees" and operational support from a program management office and Care Transformation Organizations (CTO). According to MedChi, the average practice received $176,000 in care management fees in 2019.

Interestingly, Medstar not only participates through its network of Medstar Medical Group practices, but is also a CTO serving Medstar and non-Medstar practices throughout the state. MDPCP practices must implement "data-driven, risk-stratified care management," integrate behavioral health services, screen patients for social needs, convene a patient advisory council, and use health information technology for continuous quality improvement.

We spent some time discussing one unique aspect of MDPCP, a tool to reduce avoidable health services developed by the University of Maryland's Hilltop Institute. This electronic tool uses artificial intelligence to sift through patients' demographics, claims, and other data to produce a list of those with the greatest likelihood of an emergency department visit or hospitalization, theoretically allowing primary care physicians to intervene to prevent the event and its associated medical expenses. However, it wasn't clear to us how easy it would be to apply this information, given that we usually need to prioritize patients on the schedule for that day.

Another feature of the program allows MDPCP practices to identify "high-volume, high-cost specialists" in order to "focus attention on the relative costs between specialists and to have providers engage specialists in conversations and cooperative agreements about creating value." First, though it may be helpful to know which subspecialists are more likely to prescribe (possibly inappropriate) expensive tests or procedures, the tool does not measure excellence in other areas, such as patient satisfaction and quality of communication with primary care physicians. Also, patients may not have a choice of specialists, depending on the insurer's network. Finally, it seems awkward and unrealistic for a family doctor to tell a specialist that his or her practice style is too aggressive, even if there's good data to back it up.

MDPCP promises to narrow the primary care-subspecialist reimbursement gap and provide opportunities to improve patient care in the short term. However, expecting primary care practices to bend the health care cost curve on their own, even with additional funding and support, may backfire in the long run. Whether MDPCP represents incremental progress in primary care, or a genuine breakthrough, remains to be seen.