Improving access key to reform, says Commonwealth Fund VP

Health care access has become a top issue in 2008. Presidential candidates are discussing the matter seriously for the first time in more than a decade. Many health care organizations, ACP included, are offering serious and thoughtful analysis of how to offer primary care to every American regardless of time, cost or geography.

But despite a growing consensus that the federal government must devise a way to improve access and provide health insurance for the approximately 47 million Americans who lack it, politicians, medical societies and nonprofit research groups do not necessarily agree on the path to wider coverage.

Art 1 One source of information about health policy is the Commonwealth Fund. The Fund is a private foundation that conducts research and offers grants to improve health care access, quality and efficiency, particularly for society's most vulnerable citizens. For a better understanding of why inequities in health care access persist and how policy-makers might improve health care for the underserved while also reversing the trend of escalating costs, ACP Internist talked to Stephen C. Schoenbaum, FACP, executive vice president for programs at the Commonwealth Fund and executive director of the Fund's Commission on a High Performance Health System.

Q: Why do disparities in health care access and treatment based on race and income persist in the U.S.?

A: There are undoubtedly several reasons for this problem. One of the most important is that people who are poor are less likely to have health insurance coverage: The Commonwealth Fund conducts a biannual health insurance survey. The most recent, reported in 2006, breaks down the 47 million Americans who lack health insurance by income level. Only 7% of adults in the highest income group lack health insurance. Among middle income families, 9% are uninsured and 9% are underinsured. In moderate income families, 28% of individuals are uninsured, and in the lowest income group, 37% were uninsured in 2005. Another 16% were insured, but they had had gaps in insurance during the past year, so that over half were either currently uninsured or had been uninsured.

On average, minorities—at least blacks, Hispanics and Native Americans—are likely to have a lower income status than white Americans, and they are less likely to have health insurance. 48% of Hispanics are uninsured and 33% of African-Americans are uninsured. Illegal immigration is not a major factor. Hispanics, both legal and illegal, tend to have jobs in industries that do not offer health insurance.

And, there are other problems besides coverage disparities. Minorities and low income persons are more likely to get their care through hospitals and other health care delivery organizations that on average don't perform as well as where higher income and white Americans get their care. In short, it matters not just who you are but also where you get your care. There are probably several reasons why people get their care in several places. One of those may be transportation or convenience. Others could include things that are non-specific but important, such as the degree to which people feel “comfortable” in various settings.

Another issue contributing to the continued existence of disparities in care is that measurement of care by race, ethnicity and income is relatively recent and still developing. You need to see a problem before you can fix it. It is only with that recent measurement that it has been possible to tease out how much of the problem of disparities is occurring within an institution vs. between institutions.

When it comes to racial and ethnic disparities, language is also a big issue. It requires effort and expense to provide accurate translation services. Translation errors can lead to clinical errors and poorer outcomes.

Q: What kinds of problems do disparities lead to?

A: In Commonwealth Fund surveys, people who are uninsured currently or were uninsured at some time during the year report they are likely not to fill a prescription, likely not to see a specialist, likely to skip a test, and likely not to go to a physician. There's a strong relationship between income, coverage and care disparities. People who don't have insurance are three times as likely to skip drug doses for a chronic condition. They are one to two times as likely to visit an emergency department for a chronic condition than to see a primary care physician.

Q: Health care reform is a major issue in the presidential campaign. Which proposals are likely to be the most successful?

A: All three candidates, Senators Clinton, McCain and Obama, want to see more prevention. There is certainly a party difference on universal coverage. The two Democratic proposals for universal or much broader coverage are related to a proposal in a 2003 paper by Karen Davis, PhD, president of the Commonwealth Fund, and Cathy Schoen, which outlines a mixed public-private approach that combines an individual mandate with an employer mandate and enhances existing government programs. [Health Affairs Web Exclusive, April 23, 2003] This type of approach is similar to the health reform that is underway in Massachusetts, but has been running into some funding problems. It seems clear to me that it takes bipartisan agreement to pass this type of plan.

Q: Do you think we will see some national reforms in the near future?

A: I would hope so. We have candidates in both parties who are talking about a variety of ways to reform the health care system. It's a positive step that health care reform is on the national agenda. We think it is imperative to act and to act soon.

[The U.S. is] spending 16% of its GDP [gross domestic product] on health care. By 2016, we will be spending 20%. Nevertheless, we're not performing close to what we think we could perform. As a nation, across a set of 37 indicators, we score only about 66 out of 100 against achievable benchmarks. The benchmarks reflect the performances of top-performing hospitals, health plans, other providers or U.S. states. The set of 37 indicators is broad and includes subjects as diverse as access to mental health care, infant mortality and adult immunization rates. We've got to improve performance as the same time as we moderate cost trends.

Q: Will measuring physician performance and health outcomes lead to higher quality care for the underserved?

A: We're very early into developing and implementing new incentives such as pay-for-performance. In general, we're interested in payment reforms that provide incentives to improve care to higher levels. Pay-for-performance is one way of doing that. Dr. Davis was a co-author of a recent article (N Engl J Med 2007;356:1166-1168) that said that pay-for-performance is a transitional step to coming up with other payment reforms. It's not the be-all and end-all of payment reform. Some are concerned that persons who care for the underserved will be disadvantaged under pay-for-performance and other types of payment reform. I do not believe that has to be the case, but the details of the payment incentive will make a big difference in whether providers are rewarded or not for caring for the underserved and for improving care for the underserved.

Q: Why does the U.S. far outspend other developed countries on health care but fail to achieve comparable outcomes?

A: Uwe Reinhardt, PhD, and Gerry Anderson, PhD, experts in this area, argue it is not our utilization rates per se, especially since they are often the same or less than in other countries, but the prices attached to various health care services are higher in the U.S., and hence the earnings of people and institutions involved in health care. [Health Aff. 2007;26:1481-9.]

The other issue is why we fail to achieve comparable outcomes to those in other countries. We know that uninsurance is a major contributor to that problem. We've already mentioned that the uninsured have poorer access to all types of care and are less likely to get preventive care and care for chronic conditions. An Institute of Medicine report from about five years ago attributed about 18,000 deaths a year to the effects of being uninsured, which would include deaths due to later detection of illnesses due to poorer screening and deaths due to less adequate treatment of diseases.

In addition, we also do not have national goals for improvement of care; whereas, some other developed countries do.

Q: What is The Commonwealth Fund's reaction to the ACP's recent high-performance health care proposal?

A: The Commonwealth Fund does not have official reactions to proposals such as ACP's. That said, I personally am an ACP Fellow, and I personally like the proposal. It is consistent with several of the five strategies that the Commonwealth Fund Commission on a High Performance Health System has offered for improving the performance of the U.S. health care system. Those are:

• extending affordable health insurance to all,
• aligning financial incentives to enhance value and achieve savings,
• organizing the health care system around the patient to ensure that care is accessible and coordinated,
• meeting and raising benchmarks for high-quality, efficient care, and
• ensuring accountable national leadership and public/private collaboration.

Q: Fewer medical students are choosing careers as primary care physicians, only worsening the current shortage of internists and other primary care physicians. How does the Commonwealth Fund propose to address this trend?

A: Our Patient-Centered Primary Care Program has been making grants related to evaluating medical home demonstrations and other activities related to stimulating the medical home model of care. One of those grants involves ACP. I also have been involved in a proposal to change compensation for physicians in primary care. The principal author of that proposal is Allan Goroll, MACP, at Massachusetts General Hospital, who is a former ACP Governor.

Q: Can individual internists improve access to care and reduce health care disparities?

A: Absolutely, or at least those who can provide a medical home to their patients can. The 2006 Commonwealth Fund Survey on Quality of Care has led to a report entitled “Closing the Divide.” That report shows that minorities who have a medical home report fewer disparities in care and in some instances no disparity. That said, it is hard for individual internists to provide a medical home. It is much easier for a team of practitioners, supported by robust after-hours/weekend care services and a health information technology infrastructure, to do this.