The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.
In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.
Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure. Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”
Yesterday I attended a meeting of Health Care for All Washington regarding single payer legislation in our state. The particular set of bills they are supporting are SB-5701 and HB-1026 which establish a trust fund (the Washington Health Security Trust or WHST) which would eventually act as a single payer for health care services in the state of Washington.
Specifically, this legislation creates the trust fund, establishes a board of trustees and guidance committees to run the Trust, and then lays out in very broad strokes what the Trust is meant to accomplish. As described in the legislation, the Trust is meant to pay for health care for Washington residents not otherwise covered by Medicaid, Medicare, or private insurance including dental and long term care (think nursing homes). Most likely the funds for the Trust would come from a combination of a payroll tax and a sliding-scale premium. Continue reading “Bringing Single Payer to Washington State”
In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here.
For the second meeting of the anti-racism reading group, we read part one of Ta-Nehisi Coates’ The Case For Reparations. In our first meeting, we discussed big-picture theory of race, so we followed that up by focusing in on particular racial project called redlining which had been a major contributor to both racial housing segregation and wealth inequality in America today. Continue reading “Anti-Racism Reading Group #2: Theft of Black Wealth”
In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion.
For the first meeting of the anti-racism reading group, we read a selection from Racial Formation In The United States by Michael Omi and Howard Winant. You can download a PDF of this selection here.
In this section, the authors describe race as existing in the interaction between 1) social structures which organize society by race and 2) the cultural representations and experiences of race. Racial projects is the term given to the mediators of this interaction. Continue reading “Anti-Racism Reading Group #1: Racial Projects”
This week, federal immigration agents in Texas stalked a 10 year old girl with cerebral palsy to the hospital where she was receiving emergency gall bladder surgery for a life-threatening condition. Taking advantage of this moment of vulnerability, they captured this girl at the hospital and have now imprisoned her at one of their loosely regulated detention facilities. Federal guidance lists health care settings as “sensitive locations” which are supposed to be protected from immigration raids because discouraging people from seeking needed medical care out of fear of predatory immigration agents is an attack on their health and safety.
As a doctor who believes that the value of a human being’s health and safety is not contingent on their documentation status but rather on their inherent human worth, I am appalled by the work of U.S. immigration agents who seems to be eternally at odds with my work to keep my fellow human beings safe and healthy.
Because of this, I want to take a moment to outline how I think medical professionals should interact with U.S. immigration agents in healthcare settings and to highlight the work of some amazing organizations in the Seattle area who are working to uphold the dignity of all people, regardless of documentation status.
Continue reading “Doctors Against Deportation”
As part of my family medicine residency training, I’m taking a month-long elective called Innovations in Primary Care. This month is an opportunity for primary care doctors from family medicine and internal medicine residency programs in Seattle to explore some of the different primary care models being trialed in the Seattle area and to use those experiences to fuel discussion about how primary care (and really, all medical care) can be improved in the United States.
Today was our first meeting, during which we gathered to collectively write an H&P for our current medical system. For those reading this who are not in medicine, the History and Physical or H&P is a semi-standardized note-writing structure that doctors use to describe the subjective and objective information about a patient’s health, assess why the patient is experiencing illness, and describe the next steps we need to take (diagnostic tests and/or treatments) going forward. It’s a structured way of thinking about a patient that helps us be rigorous and methodical.
It was a gratifying process because each of the doctors at the table shared a passion for making our health care system better, but brought a different set of experiences and priorities to the conversation.
Some of the take-aways I had from this conversation are as follows (in no particular order):
- The insurance framework for paying for health care, while originally conceived to improve access to surgical services which would otherwise be prohibitively expensive to most people, was quickly recognized by doctors as a way to extract larger fees for patient care. After all, when a third party (the insurance company) pays the bills, people tolerate much higher fees even if the end result is steady rise in out-of-pocket costs for everyone. Doctors, hospitals, and pharmaceutical companies have abused this system so greedily under the previous usual-and-customary payment system that increasingly rigid cost-containment measures have had to be implemented to control costs. We now live in a society where the average doctor makes $294,000 per year–more than 98.9% of Americans–while medical bills bankrupt patients and health insurance cost suppresses wage growth. Recognizing and holding ourselves accountable to how capitalism in medicine has brought out the worst in us is necessary before we can even begin to conceptualize a new system.
- The costs of most important and effective interventions to improve health, including primary care, are recurring and predictable costs that are best paid for through public health funding, NOT through health insurance. Access to clean water, nutritious food, safe housing, and preventive medical care is necessary for All People at All Times.
- America fails to invest in public welfare programs because of racism. The idea of the racialized-and-thus-undeserving Other benefiting from public welfare programs (e.g. the racist specter of the Welfare Queen that Reagan so infamously promoted) is fundamentally intolerable to White America. We are comfortable with 1 in 7 people in the United States facing food insecurity if it means we can prevent one person from buying steak with food stamps. There is no justice without racial justice.
- Many participants are needed to transform our medical care system into a true health care system. While there are only physicians in this particular group, the real work requires public health professionals, community health workers, housing experts, policy wonks, political activists, artists, chefs, personal trainers, behavioralists, and many others to both design an implement a better system.
I’m looking forward to the experiences and conversations this month will bring, and I hope to walk away with greater insight into how I can be a better advocate for effective and equitable health care in this country.
Inspired by this letter by Jennifer Tsai and Ann Crawford-Roberts, I’m working on putting together a reading list to jump start conversation about Critical Race Theory in medicine at my family medicine residency. The goal of such a conversation is to develop a more effective anti-racism praxis in our medical system and our lives more generally. I’ll update this list as I get more recommendations. Please let me know if you have recommendations to add.
Professor Adrienne Keene’s open-access course in Critical Race Theory at Brown: Introduction to Critical Race Theory 2017
If you are having trouble accessing any of these articles, let me know!