Medicare Needs to Emphasize Prevention and Quality of Care

July 7, 2013
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(Editor’s Note: Stephen Schimpff has been a member of our Advisory Board since the very beginning. He has given us numerous exclusive posts; here is his latest!)

(Editor’s Note: Stephen Schimpff has been a member of our Advisory Board since the very beginning. He has given us numerous exclusive posts; here is his latest!)

medicare prevention and quality of careMy last post discussed how Medicare has marginalized primary care physicians with low reimbursements over a long time frame. The result is PCPs carrying very large patient loads, seeing 24-25 or more patients per day and giving each about 10-12 minutes of actual interaction time per visit. This means that there is no time for listening, no time for prevention, no time for care coordination and no time to just think. Meanwhile, with a rapidly aging population beset with numerous chronic illnesses resulting from adverse behaviors, the costs of care are rising rapidly. And at the same time new graduates are shunning primary care due to the long hours, the work load, the inability to give really quality care and the frustrations of dealing with the insurance industry, including Medicare.

Medicare needs to greatly increase reliance on “front end” care, meaning primary care and wellness/preventive care. This must include addressing lifestyle issues (diet/nutrition, exercise, stress and smoking) as part of a wellness, disease prevention and health promotion action. And concurrently it needs to assure that those with chronic illnesses get the type of care coordination that they desperately need.

One step in this direction came with passage of the ACA. There is now an annual preventive care session with the PCP paid by Medicare with no deductions or co-pays and, as noted, PCP reimbursement rates are scheduled to rise by about 10% over time. But one session per year is not enough to give really adequate preventive care and the 10% increase will not reduce the 15 minute visit time. Whatever increases in reimbursement occur they need to recognize the importance of the PCP in maintaining wellness and health, providing enough time to listen and think so as to assure quality care and time for coordination of care for those with chronic illnesses.

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Changing the payment paradigm from fee for service to a capitated or salaried approach will only improve care and reduce costs if the PCP is granted the needed time to listen, to prevent, to coordinate and to think. Absent this, costs will continue to rise and care will be less than satisfactory. Many PCPs are leaving their private practice to work for the local hospital. This saves administrative work but the hospital’s productivity standards still demand seeing too many patients per day. The concept of the medical home and the accountable care organization have real value but only if the PCP is granted the time and in return the PCP agrees to limit his or her practice to a smaller number so that indeed the patient gets the time needed.

To summarize, improving care quality through appropriate reimbursement by Medicare to allot the time truly needed for 1) visits with a complex issue, for 2) extensive preventive care activities and for 3) chronic illness care coordination would all lead to better care quality, more satisfied patients and substantially reduced costs. Medicare would benefit greatly and medical school graduates would once again enter primary. A good bargain for patient, doctor and Medicare.

Stephen C Schimpff, MD is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center. He chairs the advisory committee for Sanovas, Inc. and is a senior advisor to Sage Growth Partners. He is the author of The Future of Health Care Delivery – Why It Must Change and How It Will Affect You from which this post is partially adapted.

(Medicare / shutterstock)