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.

Nutrition and dietary guidelines: stirring the (policy) pot

At first glance, federal nutrition policy seemed to be an unusual topic for our Georgetown Health Policy Seminar for family physicians. As described in a recent JAMA Internal Medicine editorial, future doctors receive little formal instruction about healthy dietary habits. An accompanying commentary noted that to promote effective change, nutritional education in medical school should encompass much more than memorizing facts about biochemistry and metabolism:

Medical students and residents must also develop competence in the interpersonal and communication skills needed to counsel patients about behavior change and to perform motivational interviewing. ... They must learn to work in interprofessional teams with dietitians and other skilled health professionals to help patients make needed dietary changes. ... Just as medical students and residents must be taught to become antismoking advocates, they need to be taught how to advocate for healthier food environments as part of their role as future physician-citizens.

The USDA Food Pyramid, circa 1990.

Every five years beginning in 1980, the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) have jointly issued the Dietary Guidelines for Americans, which serve not only to help citizens make healthy dietary choices but also to guide federal programs that support school lunches and supplemental nutrition assistance for low-income individuals and families. However, a recent analysis suggested that adhering to recommendations of the 2010 Dietary Guidelines to consume more potassium, dietary fiber, vitamin D, and calcium would add hundreds of dollars to an average person's annual food budget; potassium alone would add $380. In contrast, increasing intakes of saturated fat and added sugar are associated with lower food costs.

Current (2010) U.S. Dietary Guidelines.

Last year, former U.S. Secretaries of Agriculture Dan Glickman and Ann Veneman argued in Health Affairs that there is a "disconnect" between federal food and farm policies and evidence-based dietary recommendations:

On one hand, with obesity-related health costs rapidly rising, the federal government has encouraged people to make healthy dietary choices through efforts such as Let's Move! and MyPlate. On the other hand, the federal government spends billions of dollars on traditional agricultural commodity programs that fail to reinforce the kind of healthy dietary choices outlined in federal dietary guidelines.

Providing greater access to nutritious food options at affordable prices doesn't mean that people will purchase them, but is a necessary first step in realizing the potential of nutrition policy to reduce obesity and improve population health.

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

Forecasting and adapting to the family medicine workforce shortage

Projecting future physician workforce needs is a challenging calculation that must take multiple variables into account to avoid missing its mark. In the mid-1990s, the American Medical Association confidently predicted that the penetration of managed care would lead to a large "physician surplus" and convinced Congress to cap the number of graduate medical education (GME) positions subsidized by the Medicare program. Two decades later, there is a widespread consensus that the U.S. is actually experiencing a physician shortage that will worsen with population growth, the aging of the baby boomer generation, and an influx of newly insured from the Affordable Care Act.

Although medical schools have expanded to meet the anticipated demand for doctors, the AMA and others are still pushing for the GME cap to be lifted so that new medical graduates will have enough places to train. But how has the specialty of family medicine fared, and what else can be done to extend capacity of the existing primary care workforce? These questions were the subjects of two recent Georgetown University Health Policy seminars.

Image courtesy of the American Academy of Family Physicians

Modest gains in the numbers of U.S. and foreign medical graduates matching into family medicine residency programs over the past five years will fall well short of supplying an additional 52,000 primary care physicians by 2025, a shortage projected by the Robert Graham Center. A recent issue of Health Affairs examined potential strategies to extend primary care capacity in the absence of an (increasingly unlikely) surge in generalist trainees. For example, telehealth technologies could lighten the load on family physicians by promoting patient self-management of chronic conditions; improving medication adherence; and facilitating real-time specialist consultations. A more radical and controversial proposal aims to provide EMT-style training to a new profession of "primary care technicians" who could provide basic primary care services under the supervision of a physician, freeing physicians to "focus on patients with more complex conditions."

As our discussion pointed out, though, these proposals have serious disadvantages. By reducing face-to-face interactions, telehealth could easily make family medicine less rewarding. Family physicians who end up seeing only patients with multiple complicated chronic conditions could burn out faster, leaving even fewer in the workforce. As a broad cognitive rather than a narrow, procedure-focused specialty, family medicine is less likely to be suited to care by technicians than, say, anesthesiology or gastroenterology. Finally, given the persistent and growing income gap between family physicians and subspecialists, the real solution to the primary care shortage may still be staring us in the face.

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

Tapping the potential applications of mHealth

Mobile health, or "mHealth" for short, describes technology that allows clinicians or public health professionals to monitor and/or deliver health-related messages to patients via cellular phones, tablets, or other wireless devices. mHealth applications can complement and expand care provided at traditional face-to-face visits, and exploring their untapped potential to improve health in the U.S. and abroad was the topic of a recent Georgetown University Health Policy Seminar.

One popular mHealth initiative is the text4baby program, a public-private partnership launched in 2010 that sends free text messages to expectant and new mothers containing appointment reminders, safety alerts, and general prenatal and postpartum health advice. Smartphone apps now include a variety of self-management tools for weight loss, physical activity, and chronic diseases such as hypertension and diabetes. The U.S. Food and Drug Administration recently moved to regulate health apps that act as medical devices (e.g., electrocardiogram) and would pose safety risks to patients if they malfunctioned. However, the vast majority of health apps used by consumers will not require FDA approval.

In the developing world, "mHealth projects are launching at an exponential rate," declared a recent issue of Johns Hopkins Public Health Magazine. Cellular phones have made real-time communication with field workers routine and allowed teams of nurses and midwives to attend births in rural Bangladesh. However, the field of mHealth is hampered by a lack of evaluations of health outcomes and concerns about sustainability of successful interventions:

Using phones to advance public health isn’t as simple as it seems. Researchers are grappling with complex questions that have already doomed hundreds of mHealth projects: How do you know whether mHealth projects are really working and worth the investment? How do you conquer the phenomenon known as “pilotitis,” and scale effective strategies into health systems that have regional or national impacts? And how do you make sure these projects are long-lasting additions, instead of the public health equivalent of a dropped call?

We debated the types of policies that would be most likely to encourage innovations that make a positive difference for individuals and populations. How can we avoid creating "digital divides" that could worsen health disparities? Should state and local governments provide direct grants or tax relief to promising startups? Or should the central planners get out of the way and trust free market forces to produce the future of mHealth?

- Kenny Lin, MD, MPH

  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

Learning from primary care in Canada and Europe

What can family medicine in the U.S. learn from the organization of primary care in other Western countries? In this month's Georgetown University Health Policy Seminar, we explored two recent studies that shed light on successes and challenges of primary care reforms in Ontario, Canada and the European Union.

Starting in 2000, policymakers in Ontario implemented a primary care reform strategy based on five national objectives, which are strikingly similar to many proposed U.S. reforms: "1) increasing access to primary care organizations that would provide a defined set of services to a defined population; 2) increasing emphasis on health promotion, disease and injury prevention, and chronic disease management; 3) expanding all-day, every-day access to essential services; 4) establishing interdisciplinary primary care teams; and 5) facilitating coordination and integration with other health services." As a result, an almost entirely fee-for-service primary care system was gradually replaced with a mixture of salary-based, capitation-based, and blended fee-for-service payment models by 2012. Far from being demoralized by the rapid changes, Ontario primary care physicians actually reported increasing satisfaction during this transition period.

Another study in the same issue of Health Affairs analyzed associations between the strength of primary care systems in 31 European countries, national health expenditures, and measures of population health. The study found that countries with more robust primary care had lower hospitalization rates and less socioeconomic inequality in self-rated health, in addition to better chronic disease outcomes. However, these advantages came at the cost of higher baseline health care spending, though spending growth appeared to be slower in countries with a comprehensive primary care bedrock.

What lessons should U.S. policymakers take home from this research?

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine

The sense and nonsense of CT screening for lung cancer

Supporters of evidence-based preventive medicine cheered when the Affordable Care Act required Medicare and private health insurers to provide first-dollar coverage for all preventive services assigned an "A" or "B" recommendation grade by the U.S. Preventive Services Task Force. However, editorials published in JAMA and BMJ earlier this year expressed concerns that explicitly linking Task Force determinations with coverage decisions would politicize the guideline development process. Also, since the USPSTF is permitted to consider only clinical effectiveness, not cost effectiveness, it could potentially put taxpayers on the hook for cost-prohibitive screenings.

In this context, our August 2013 Georgetown University Health Policy Seminar debated the USPSTF's recent draft recommendation statement that endorsed annual low-dose CT screening for lung cancer in longtime smokers. This Grade "B" recommendation applies to "healthy persons with a 30 pack-year or more history of smoking who are ages 55 to 79 years and have smoked within the past 15 years," a population that includes up to 8 million persons in the U.S. Using data from the National Lung Screening Trial and five modeling studies, the Task Force estimated that implementation of their recommendation could prevent up to 20,000 lung cancer deaths each year. They downplayed the potential harms of false positive screens (which affected 1 in 4 participants in the NLST), overdiagnosis, and radiation-induced cancers.

Images from the Lung Cancer Foundation's Demand A CT Scan campaign.

Lung cancer screening advocacy groups, which had been pressing for years for patients at high risk of lung cancer to "demand a CT scan," were quick to praise the USPSTF's decision. Notably, the American Cancer Society's guideline for lung cancer screening, also released this year, advocates a more conservative approach: initiating a shared decision-making discussion about benefits and harms of lung cancer screening in high-risk persons in otherwise good health, rather than simply recommending screening. The USPSTF's approach is certain to be far more costly, and may discourage clinicians from explaining the many downsides of this screening test to their patients.

- Kenny Lin, MD, MPH
  Director, Robert L. Phillips, Jr. Health Policy Fellowship
  Department of Family Medicine
  Georgetown University School of Medicine