Health Care Stakeholder Discussion: Primary Care

Health Care Stakeholder Discussion: Primary Care


(Cross Talk) Nancy-Ann DeParle:
Thank you for coming in. Getting toward a holiday
weekend, I appreciate it. I’m Nancy-Ann DeParle, and I
met some of you before, and for those of you I haven’t met, look
forward to a good discussion. We’re today going to be talking
about the critical role that primary care providers play in
our healthcare system, and it’s something that the President
talks about — well, if you haven’t been listening recently,
he’s talking about healthcare every day, and he always talks
about the importance of primary care and how he wants to make
sure that we aren’t just covering people and offering
people affordable healthcare in the old system, he wants to make
sure that it’s in a new system that has a renewed emphasis on
lowering costs and on getting people the right care at the
right time, and that means primary care and prevention. So you all play a critical role
in helping us to figure that out, and we appreciate it. I would like to say hello also
to everybody watching this discussion on www.whitehouse.gov and
www.healthreform.gov, so this is a new — one of the innovations
here at the White House, and you all are going to have
to help me do this. So in addition to streaming this
meeting on the Internet, as we always do, there’s a live chat
going on about the meeting on Facebook right now, and people
are also submitting their questions and comments through
the White House website. There’s a lot going on. Jenn Cannistra from our office
is being kept up to date on everybody’s reactions, and
during our discussion, we’re going to ask her to let us know
what everyone is thinking. And Jenn is right over
there with the laptop. We know that health reform
has to improve primary care
in this country. We know that we need to increase
the number of primary care clinicians, and we want your
suggestion on that, including how to keep more primary care
clinicians satisfied with their work and continuing to do it,
because that’s part of the solution, too. We know there are a
lot of people retiring. We know that we can cut costs
and help Americans to live longer, happier and healthier
lives if we invest in prevention and wellness programs that keep
Americans out of the doctor’s office in the first place. And that’s why President Obama
is committed to reform that emphasizes patient involvement
and promotes prevention, wellness and primary care. To put it another way, without
reform that improves primary care and strengthens primary
care and what you do every day, we won’t be able to meet our
goal of giving every American high quality and affordable
healthcare coverage, so today we’re really eager
to hear your ideas. And I want to introduce my
colleague, Dr. Kavita Patel, who is working here at the White
House with us and helped to organize this meeting. So with that, I’ll open it
up and I guess — am I first supposed to do a
video; is that right? A Speaker:
We do, in fact, have a
YouTube question that was submitted yesterday for the
President’s online town hall, and so we can certainly start
with that, and then, you know, open up for people
to make comments. Nancy-Ann DeParle:
Okay, great. It’s going to be back here. A Speaker:
(inaudible) starting my own
business, I found that I can only afford health insurance
with a high deductible, I found myself motivated not to
go out for care until things
get really bad. How could the health reforms
you and Congress are working on change the system so it would
encourage prevention and treating healthcare problems
before we worsen and
get more costly? Nancy-Ann DeParle:
Well, there’s an example of a
policy that doesn’t make sense, a high deductible
for preventive care. So a young man who I assume is
healthy, and hope he is, but should not be discouraged, I bet
everyone here would agree, from coming in and getting
preventive care. See, that’s a good way to
start off the discussion. I guess I’ll just open it up by
asking you how we can change the system so we encourage
prevention and treating healthcare problems before they
get worse and lead to something a lot more expensive. Keith, do you want to start? Keith:
Sure. I’m an independent community pharmacist. And pharmacists, from a pharmacy
perspective, pharmacists for years have only be paid for a
final drug product, that’s it. We’re the purveyor
of a commodity. Outcomes is what we need to
show, and pharmacists see more and more — more patients, more
individuals on a daily basis than any other
healthcare provider. We’re well positioned to show
outcomes, it’s been proven, and it has been shown medication
therapy management, which is under Medicare Part D,
face-to-face contact with the community pharmacist saved
twice of what just the phone conversation would be, twice
what a phone conversation
would be. Insulin injection technique. Compliance, compliance
is a huge issue. One-third of all hospital visits
could be avoided, could be prevented if patients were
compliant and adhered to medication therapy. It’s very simple and a — A Speaker:
And how. Keith:
— a small price to pay. A Speaker:
How widespread is — you
know, medication therapy management, it’s a fancy word,
but really you’re just talking about your pharmacist consulting
with you and understanding what you’re taking and making
sure that you’re doing it
properly, right? Keith:
Doing it properly,
working with the patient to make sure they are taking it
properly, changing them possibly to a cheaper alternative,
working with the physician on the best therapy possible for
that patient and one they can afford. Nancy-Ann DeParle:
How many different kinds of
drugs are there out there these days? (laughter) Keith:
I can’t count that high. I know in my pharmacy, I roughly
have probably around 1400 on the shelf, 14 different
SKU’s just on the shelf. Nancy-Ann DeParle:
That’s a lot for a patient to
understand that, you know, if they are taking four or five
things, they may not understand what they should be doing. Keith:
Sure. I know about 200 of those is roughly about 54 percent of what I fill, but yet I carry, you know, that inventory on a day-to-day basis. Nancy-Ann DeParle:
And how many insurance
plans right now cover medication therapy management? Keith:
Right now, Medicare
Part D mandates, but there are very, very few individual plans
that actually cover medication therapy management, and that’s
where we’re losing our patients. You know, private employers
don’t benefit from this. Individuals like this young
gentleman don’t benefit
from that. And, you know, my employees
don’t benefit from that being a small business person. And small business employs more
people across this country than the large businesses, but yet
we’re losing all of those folks, and those are the ones that
can’t afford healthcare right now and they are being lost
because they can’t afford the premiums, they can’t afford to
go to the doctor when they don’t have the insurance. Nancy-Ann DeParle:
So you see both sides
of it as — Keith:
See both sides of it. Nancy-Ann DeParle:
— you’re a small
business owner. Keith:
Yes, ma’am. Nancy-Ann DeParle:
Interesting. Who else wants to get in here? Fred? Fred:
We really need to
change our — Nancy-Ann DeParle:
You’re the American College of Physicians. Thank you. Fred:
Right. I practice general internal
medicine in a small town in Tennessee. Nancy-Ann DeParle:
I was going to
say, do I know you? I think I do. Okay. And, Bob, I know you, too, so. Fred:
We actually —
we’re celebrating our 100th anniversary this year. It’s a primary care practice,
eight physicians and a nurse practitioner. And never in our history have we
been more challenged than we are in the current environment. And I would just throw out, and
this is an element that I think everyone, including our
questioner shares, we need to align the incentives for a
system that truly works. We need to have providers
who are able to provide cost effective evidence-based care,
and we need to have people have an easy way to get
into that system. And in that case, I might use
the term system without quotes, because we clearly don’t
have a system right now. It seems almost like any time I
see a patient, there may be an unnecessary burden or way
in providing them care. I may not know what medication
is covered under their formulary, even though it’s
appropriate, I may not know whether a screening test for
colon cancer is covered under their insurance, even though I
get dinged if we don’t do it. The same website that dings me
won’t provide me an answer to the question of whether
it’s covered or not. So anything that allows us, when
we see individuals, to provide the best quality care in the
most efficient way possible is something that we
need to move toward. And there are a lot of
different elements to that.
But — Nancy-Ann DeParle:
So you waste a lot of
time, then, trying to figure out if preventive care
is even covered. Fred:
Right. Right. Absolutely. Fred:
And individuals like
this have been shown by studies, if deductibles are high,
they don’t seek care. And, you know, high deductibles
are wonderful for something that isn’t based on the evidence. I would endorse that heartily. But if someone is not taking
medication that is going to keep them out of the hospital, then
that clearly is penny wise and pound foolish. Nancy-Ann DeParle:
Fred, does your practice
have an electronic health record or how — Fred:
I’m glad you asked
that question. Five years — Nancy-Ann DeParle:
We didn’t practice this, so. Fred:
Five years ago, we
invested our money in an electronic health record system,
and, you know, I think the general estimates are that
physicians gain about 15 percent of the economic benefit
of those systems. And we did it because we knew
it was the right thing to do. And we know that it — I mean, I
was managing Coumadin from my — from the ACP office this
morning, which, by the way, also is a service not
covered under Medicare. I would love to have
that discussion later. Telling people whose blood was
too thin what dose, and they call me on the 4th of July to
have a follow-up study and to let me adjust the dose. But that is something that
we know has been helpful. We’re able to track things,
although it’s, you know, sometimes hard to — you know,
to learn all of the techniques, and we would love some help from
the Administration on that. But we endorse what the
Administration has been doing to try to simplify things and try
to enhance technology, but we also need sort of a go-to
person to help have a two-way conversation with people
who are in practice. I could give you suggestions
that could probably cut that health affairs estimate of
$65,000 worth of administrative costs, I could probably cut that
in half if you would help us or you would foster a common
website where I could take your insurance card, get that
information, it would automatically tell me which
angio — which ARB was covered if a certain generic medication
was contraindicated, and have that only take 15 seconds in an
office visit as opposed to 30 minutes, 29 minutes of which is
going through the 1-800 mommy may I, and only one minute
is clinical information. But there are plenty of
opportunities for us
to enhance care. Nancy-Ann DeParle:
That’s a great idea. That’s a great idea. Mona. Mona:
I’d like to speak to
Fred, I’m a nurse practitioner, I practice in rural Appalachia. Nancy-Ann DeParle:
You heard the President
talking about nurse practitioners the
other night, I hope. Mona:
Yes, I heard that. (laughter) Mona:
We are an independent
nurse practitioner practice, and we’re out in the
Appalachian hills, and there are no other providers. And who we work the most with is
our community pharmacists, which we’ve been discussing. But I — we’ve been all
electronic medical records for ten years. The problem that we find is the
cost of the support and the upkeep of the good programs
is overwhelming to us. That’s number 1 issue. And addressing what you asked
earlier about how you get the primary care providers into
prevention, we’ve got a mobile unit that we’ve just put on the
road about four months ago, and we’ve gone out to the churches
and the schools and do free screenings while we had grant
funds, we don’t — we’re going to run out of grant funds, but
doing free screenings, so we got really early identification. Then went after the
grandmothers, because we’re in a matriarchal kind of society, and
started educating them on how can we keep the grandchild
healthier as they grow. And we’re trying to track
some of the lifestyle changes
because of it. But you really got to go after
them at the beginning and get early identification. And it’s not payable. So I can’t bill for it, so
without grant funds, it’s not something you can sustain. Nancy-Ann DeParle:
Diana. Diana:
I’m a family nurse
practitioner, I also work in a family practice. But I’d like to go back to the
original question of I’m young, I’m healthy, I have a high
deductible, I can’t afford to pay for preventive care. In Indiana, the governor and the
legislature developed a program for people who don’t have health
insurance, it’s kind of a public/private coverage program,
and in that program, all of the recipients of that insurance
plan are required to
get health — their preventive healthcare
every year, and they are given something called a power
account, which is $1,000 that they can use to pay for
preventive things that don’t get covered otherwise. And, you know, I don’t know why
that couldn’t be something that if we’re looking at an employer
plan, an employer contribute to that power plan. In fact, the hospital that owns
my practice is recruiting people for this program, because it
also saves the hospital money, and they are funding
the power account. And these people are called —
in fact, I just talked to one of my patients yesterday, I said
it looks like you are ready for your annual exam, when was your
last PAP, mammogram, et cetera, and she said, oh, I don’t know,
and I said, well, you have the healthy Indiana plan and they
are going to call you in about two months to tell you you’d
better get in here to have that done or they’ll take
the power account away. So, you know, you could have
some kind of a deductible for certain types of things, but
then you have this medical savings account or power account
that you can use for those healthy things. It might also help, you know,
for insurers to maybe go in a partnership with patients on a
combination of a medical savings plan and a contribution for
those kinds of preventive care things. Nancy-Ann DeParle:
That’s great, so we —
We have a question. A Speaker:
We have a question.
From the Internet. We have — well, we have a
couple of Facebook comments that I’ll just throw out there, and
then when you all speak, you can certainly incorporate
some of your thoughts. Bob is asking about the nurses’
shortage in the country and that relationship to primary care. Mike talks about how we need to
deal with chronic conditions and how good primary care
can help us do that. Nathan thinks we need to invest
more in preventive care. And Amanda supports universal
care because she treats too many people who don’t have access
to primary care and who are bankrupt from their
medical bills. So those are a couple of the
comments that we’ve been hearing so far. A Speaker:
Just to pick up on the
comment regarding access. Thank you, Ms. DeParle,
for inviting us. And (inaudible) we’re with the
Academy of Physician Assistants and we’re thrilled with the
President’s focus on primary care, and along with physicians
and nurse practitioners, PA’s, are also among the core
providers of primary care
in the country. And one of the challenges I
think we have an opportunity to address with the reform efforts
of the Administration is clearly prevention and incentives and
the financing and in bringing all of those things together are
key, but at the end of the day, there needs to be a healthcare
provider workforce in place and ready to provide primary care. And today there’s not. We have certainly a shortage of
primary care physicians, we need more physician assistants, we
need more nurse practitioners, and certainly would encourage
and would look forward to working with the Administration
in terms of how do we go about building the pipeline of
both physicians and other nonphysician practitioners,
such as PA’s and NP’s. PA’s are produced in, you know,
a third of the cost and half of the time of physicians,
certainly nurse practitioners are more quickly
trained as well. We work very closely in a
physician-led team, and we’re visible and vocal advocates
of a physician-led team, but recognize the shortages that are
out there, and would love to work with the Administration so
that we can incentivize people to go into primary care, stay in
primary care, and likewise build the pipeline going into primary
care by making sure there are faculties, not only for nursing
schools, but for physician assistant schools that would
encourage primary care professions. Nancy-Ann DeParle:
Great. And we are working on this, and
we recognize there are areas of the country where there are
shortages, and we are going to need more primary care
clinicians, including PA’s
going forward. We did make — I’m proud that
the President did make a big investment in this in the
beginning of the Administration in the Recovery Act, investing
in the national health service corps, that will produce
thousands more, but not enough. We know that that’s just a
building block, and they’ll have to do more going forward. And Congress is focused
on that as well. So we look forward to
working with you on that. Katherine. Katherine Nordal:
Yes, I’m Katherine Nordal,
and I’m the executive director for
professional practice at the American Psychological
Association. I’m not here primarily as a
practitioner, but I came to Washington last year in my
current position after 30 years of practice in rural and
suburban Mississippi. I was a small business owner,
I was a Medicare and Medicaid provider, and have treated some
generations actually of families now with both mental and
behavioral health issues. And I would like to bring
another perspective to the clinicity problem and to
just some observations
about the system. We have the greatest healthcare
in the world here in America, but the problem I think
is the delivery system. And we have a number of
different provider groups represented here today. And I think one thing that is
really missing in the reform discussion is how we
deliver that care. It’s like the blind man feeling
the elephant, you know, you are not sure what the animal is
because you’re only feeling one part of it. So I would like to make the
case for fully integrated care. We made some tremendous inroads
last year with the Mental Health Parity Act, and hopefully that
will set the floor so that mental health and substance
abuse disorders will be treated like other physical
disorders, as they should be. If we look, even though just
within the realm of physical medicine, we know that probably
70 percent of all mental health problems show up first in the
primary care doc’s office. I worked with family
practitioners, pediatricians, nurse practitioners, PA’s and
other primary care docs, and they were just absolutely
overwhelmed with the complexity of mental health problems that
they saw in their practice. And people went there because
they wouldn’t go to like the community mental health center
in my community where I started out and then left to do my own
practice, because the mental health center system is in
such shambles that most of the treatment that’s provided there
now really is tertiary and treatment of chronic care for
conditions that had we had good preventive care may not
have gotten to that point. Insofar as physical healthcare
is concerned, 75 percent of our healthcare dollars are
spent on chronic illness. And what is the biggest problem,
you mentioned when you were talking about with the pharmacy,
it’s motivational, motivational issues, lifestyle issues
and lack of adherence
and compliance. So I would make the argument
that if we want to deliver healthcare in a way that really
treats the whole person as a whole person, that we have
healthcare teams that treat the whole person, and that we
address the mental health issues as well as the behavioral issues
that create and maintain chronic illness at the same time that
we’re deciding, you know, do we want to give that person a
beta-blocker or do we want to have a mental health person see
them and teach them how to deal with their anxiety. Do we want to have to wait to
put somebody on Lipitor, when maybe if they’ve had appropriate
preventive care in regard to nutrition, exercise and other
kinds of lifestyle choices that made them and keep them sick,
we can send them all to the pharmacist, and then they take
half of what is prescribed or they don’t take it correctly. But I think we have to deliver
care differently and we really have to put that emphasis on
prevention, and incent programs, employers, and payers to pay for
that care on the front end so we don’t continue with these
horrible problems we have with chronic physical and
mental health conditions. Nancy-Ann DeParle:
Lorrie. Lorrie Kaplan:
Yes, I’d like to just
follow along with what Katherine is saying. And I’m Lorrie Kaplan, I’m
the Executive Director of the American College
of Nurse Midwives. And you might wonder why
midwives are here at the table talking about primary care. Nancy-Ann DeParle:
That’s where it starts. Lorrie Kaplan:
Exactly. Thank you. Because we — nurse midwives
attend childbirth, but we also provide primary care to
women across the life span. But there were two really
wonderful reports in
the last year. We look at people who are
responsible for delivering care, integrated care to
indigent populations. They are really talking about
this integrated workforce strategy as being really the
most economical way, and really showing how that is improving
health outcomes when we have nurse practitioners, PA’s,
certified nurse midwives in these team environments, such
as academic health centers or national — community health
centers, we really are lowering the cost of care, we’re
improving access. And I think you’d find in some
of the disciplines, you have a heavy focus on health education,
promotion and wellness, so investing in a workforce that
really focuses on those skills and really having an integrated
workforce strategy, I love a quote from the Academic Health
Centers saying enabling all healthcare professionals to
function fully within their defined scope of practice
would contribute to leveraging workforce capacity and
increase access to care. So this is where I think the
Administration has really
shown leadership. I think for the first time in
that we’re looking at workforce issues, we’re looking at payment
incentives, we’re looking at all of these areas, not just access,
but if — not just coverage, but once we have the coverage, how
do we make sure that those patients are actually going to
have access to care and not just coverage without access. So I really encourage us to look
at workforce and payment reform, and a really integrated team
approach that is really going to meet the needs of consumers. Nancy-Ann DeParle:
Cheryl and then Bill. Cheryle Garvin:
I’m Sherry Garvin,
I’m a licensed pharmacist and pharmacy owner
in Leesburg, Virginia, and I appreciate the chance to come
and talk about healthcare
reform today. It’s funny sitting here hearing
everyone speak, the same words keep cropping up, and
I’m like yes, yes. I mean, those are the issues. Integrated care is huge. We began really seeing the need
for that, or at least I did, my eyes were open to it when
pharmacists started doing medication therapy management
for the Medicare Part D patients. We get those patients in and
they see their cardiologist and they see their orthopedic doctor
and their primary care, and before they know it, they are on
24 different medications, many of them are duplicates or
unnecessary, many of them are causing adverse effects for
which they are getting another medication for. So integrated care is huge. The pharmacists have to be a
part of that team in order to, you know, effect good
overall healthcare. There’s a lot of dollars being
wasted because of those
things happening. The other thing that really
struck me was aligned interests. We have to have aligned
interests, and that takes care of a whole slew of issues. Nancy-Ann DeParle:
What do you mean
when you say that? Sherry Garvin:
Everyone involved in
the process of providing healthcare, the
interests have to be aligned. In other words, if the insurance
company is only looking at what they are going to spend this
year to provide care for that patient, they are going to want
to try to make it be the least amount of money possible, when
the reality is if you can spend some money on preventive care,
that saves a lot of healthcare dollars farther down the road. And speaking — Diana mentioned
preventive care being provided. We have a lot of employers,
private employers who have realized this, that their health
insurance for their employees, and I see that, too, with my own
employs, does not cover certain things, but they have learned
that if they put out a few dollars at the beginning for
some preventive care,
they save a lot. One great example is in the
fall, we do flu clinics all around our area, we go to local
businesses and provide flu shots for their employees, the
business pays for those, but if you think about how much money
that saves the business because they are not out sick for two
weeks in the winter or, you know, a host of their employees
aren’t out all at the same time, so there are, you know,
employers beginning to realize that a small amount of money up
front for preventive care pays great dividends in the end. Nancy-Ann DeParle:
Thanks. Bill and then Tom. Bill Ellis:
Bill Ellis with the
American Pharmacists Association Foundation. I wanted to build on the
comments earlier about integrated teams and
how important that is. And a lot of times in a
discussion about healthcare reform, sometimes we almost talk
about it like we have to create something that’s never been
there before, and I think that community health centers in
particular are there and serve as great examples. I’ll mention specifically the El
Rio Community Health Center in Tucson, Arizona, providing
tremendous care to an underserved population where
physicians, pharmacists and nurses are working very closely. It’s a real model, it’s not
theoretical, it’s there, so I’d encourage the Administration
to continue to work with us to identify some of those sites
that are there that aren’t in theory, they are real practices,
and I think can health illuminate what a reformed
healthcare system should look like. Nancy-Ann DeParle:
Great. That’s great. Bill Ellis:
It’s really then
about scaling those models, not necessarily creating
something that’s that new. Nancy-Ann DeParle:
You’re right, we do talk
about it as though it’s something that doesn’t exist. It’s really more just focusing
on what we already have learned can work, medication therapy
management, you know, community health centers. Nancy-Ann DeParle:
How about the primary care
medical home, because that’s been another kind of model that
— and I know that — I think of the pediatricians, because that
was when the term first — when I was training in school, that
was — I remember pediatricians would talk about the medical
home, and how does that realize the success of integrated
care, which is a common theme. Mark Minier:
So thank you very much
for segueing — Nancy-Ann DeParle:
I’ll put you in a second time. Mark Minier:
My name is Mark Minier, and
I’m a practicing pediatrician here in Washington. And there’s been a million
things that have been talked about that personally affect
me and the children that I
take care of. First of one, as I am a member
of the National Health Service Corps, so I am working as a
clinician in an underserved community in exchange for
getting my loans paid off for medical school by the
government, which is fantastic. And I will say that is a
wonderful program that the Administration is putting money
into to encourage more people to take those positions. So one thing I do caution is
that it’s great to get people there, and you mentioned at the
beginning keeping people in primary care is
a huge challenge. It is a very hard job to be a
primary care practitioner every day all day long. I was thinking about it, I got
the call yesterday to come from the AAP, thank you very much. And I had to cancel 15 patients
this afternoon to be here, but to me, that was really important
to get down here to say, you know what, those 15 people, I’ll
have to fit them in another time, because I need to
represent the 75 million kids here in the United States and
the 9 million kids who don’t have insurance, because this
is something that’s really important. But as a primary care doc, I’m
making it a priority to be here. And we are a community health
center that is doing integrated care, as you mentioned, the AAP
created, I believe, the word the medical home, or at least has
really kind of defined that in a way that talks about
comprehensive coordinated culturally appropriate care in a
home where everybody serves that patient. So in our center, we have
pharmacists, we have OB services, we have social work,
we have nutrition, we have all of those things that we need
to help provide these kids the services that they need. I think that the most important
thing that we’re talking about here, if we’re talking about
early intervention, we’re talking about primary
prevention, we have to talk about children. If the healthcare reform program
does not specifically mention children as a different entity
within the program, then we’ve lost everything. I think if we focus on adults,
yes, I understand adults have medical concerns, I am an adult
and — (laughter) Mark Minier:
But if we really want to look at how to prevent problems in the future, then we
need to look at children. Medicaid is something that I
think is often forgotten about. We talk a lot about Medicare
and how we’re going to increase funding for Medicare and how
we’re going to do all of these programs, and then there’s
Medicaid over here, it’s kind of, oh, we’ll deal with that
later or we’ll figure out what we’re going to do for children,
but I think we really need to spend close attention treating
children as children and not just little adults, who have
very different problems and very different needs. A Speaker:
Could I respond
to that as well? Nancy-Ann DeParle:
You know what, before you do,
it do you mind if I — because I called on Tom and I haven’t let
him talk, so just let him go and then I’ll get you. Thomas Menighan:
Thank you. And I resonate with mostly
everything that’s been said around the table thus far. You know, I’m Tom Menighan
with the American Pharmacists Association. I practiced community practice
for many years, and I still own a pharmacy. Pharmacists really can play a
major role, to go back to the first individual who you had
on the webcast, many of those people who wonder what’s
wrong with me walk into a
pharmacy first. And they look on the OTC shelves
to see if there’s something that can fix their problem. And pharmacists are too doggone
busy in the back to come out and spend the time helping that
person because of a system that doesn’t put incentives
in place to do that. Now, if that individual was part
of an integrated group that allowed us to work with him to
get him to the right doctor, to get him into the system in
such a way that we’re going to prevent issues, maybe it’s
something that could be treated easily with an OTC, maybe it’s
something that requires care by a nurse practitioner or
physician or PA, that’s what we’re all about, we triage all
day every day, it’s a big part of what we do, but we’re not in
a system that incentivizes that. If you shoot ahead of the duck a
little bit here and you look at healthcare technology, you’ll
see that the big push now is in diagnostics, and diagnostics are
getting closer and closer to the patient all the time. As that happens, they are going
to find their way to pharmacies and they are going to be asking
questions in pharmacies. So a system that prevents people
from trying to fix a problem with the wrong things is just as
important as one that helps us send them to the right places,
and we would love to work with you to build that
kind of system. Those systems don’t have to
be in four walls, they can be virtual. There are a lot of things we can
do with wires, and there are people in this room that have
done a lot of work in that regard. Nancy-Ann DeParle:
That’s great. Thomas Menighan:
You know, I guess just
to point out, sometimes we get the question,
can what we’re professing with regard to MTM scale. I can tell you that the model
that we built with immunization has truly scaled. Today we have over 80,000
pharmacists trained to do immunizations. In this coming flu season, we’ll
do over 5 million immunizations. We can scale. Nancy-Ann DeParle:
That’s great. Jan. Jan:
I’m going to combine my comment now with a couple of things that have been said and
one of the questions that’s been asked, but I’m with the American
Academy of Nurse Practitioners and I’m the director of health
policy, and one of the things we can tell you is that we have
125,000 nurse practitioners out there that are very interested
and willing to put their shoulder to all of this. We are the fastest growing group
of primary care providers at the present time, so. Nancy Ann DeParle:
How long does it take to
become a nurse practitioner? Jan:
Well, it takes — in the long
haul, it takes six years to become a nurse practitioner,
because you have to become a professional nurse first, and
then you go back to get your graduate work in order to become
an advanced practice nurse and to be a nurse practitioner,
so we’re talking about a significant period
of time, it’s true. The thing that nurse
practitioners have done through the years is incorporated
prevention in everything
they do. They are very hot on disease
prevention and heath promotion, so this has been something that
has been incorporated in the medical home model that
we’ve been talking about. The coordinated primary care
model that is holistic, et cetera, has been our mantra for — forever, that’s the way we do things, and we feel it is very
much couched in our nursing background, to which we
add the medical expertise. And that’s one of the things
when you’re looking at this, we certainly need more nurse
practitioners and we certainly would like to have some help in
producing more of them as well. But we also know that some of
the models that are out there that would be really useful that
we need to have people look at relate to the question that
was related to chronic care. The nursing models that are
out there that have been so significant aren’t being picked
up and looked at in terms of what can be done in relation to
dealing with chronic care, and yet they are the most
successful models. And so I think looking at some
of the nurse practitioner literature and the nursing
literature and the group of studies that have been done and
trying to see how we can plug that into the system I think
would be a very good thing, and we’re willing to try
whenever you’re ready. Nancy-Ann DeParle:
Please help us. Sort of like transitional care. A Speaker:
We have a question
from the Internet again. Yeah, we actually have
had a couple of comments. There are a lot of different
discussions going on online in response to what you’re saying. One talks about, you know,
people who don’t have insurance or people who know folks who
don’t have insurance and just have primary care can’t be a
priority then, but there’s a woman who has cancer and two
young kids and just talks about, you know, now she needs to try
to treat her cancer without insurance, but the importance of
if she had had primary care from the beginning. There was a discussion about
incentives and how, you know, people at work or trying to just
incentivize people to focus on prevention, wellness and really
prioritize primary care. And then there was a
conversation about ER use and primary care, and how because
a lot of people don’t have insurance or delay care, they
often wind up going to the ER where the care is much more
expensive, the condition is much worse, and that contributes
to longer waits at the ER. So thank you to Bob and Erica
and Amanda, Lynn and Tim for those comments. Nancy-Ann DeParle:
And it contributes to higher costs for everybody who is insured, so it’s just a vicious
cycle going the wrong way. Maggie? Maggie Mitchell:
I’m Maggie Mitchell here
on behalf of American Dental
Hygienists Association. I just wanted to jump in quickly
and say, as long as we’ve had all of the talk about
prevention, that as you all know, because we all have a
mouth — (laughter) We’ve all been children,
we’re all now adults, but we all have a mouth, and
dental hygienists are the preventive professional in the
oral healthcare team, and there is no workforce shortage right
now of dental hygienists. There are 150,000 currently
licensed in the United States, and so — Nancy-Ann DeParle:
Why is there no workforce shortage with dental hygienists? Maggie Mitchell:
Well, they just —
there was, there was. Nancy-Ann DeParle:
There was, yeah. And they addressed it. Maggie Mitchell:
That’s been one of ADHA priorities is to encourage — it’s mostly women,
I was going to say women, it’s women and men, but
it’s a lot — Nancy-Ann DeParle:
But when you look at the other shortages, you have to be
honest and say in some cases, it’s reimbursement or
it’s working conditions. I mean, when I threw out that
question at the beginning, I was serious about how can we prevent
— like Dr. Roston, you know, the people that you practice
with, I bet there’s people in your community who are saying
I’m done with this, I’m tired of it, how do we — A Speaker:
Well, as a matter of fact, that’s actually happening as we speak. Nancy-ann DeParle:
Yeah. So how do we keep
them doing it? Anyway, I interrupted
you, Maggie. Maggie Mitchell:
So, but I was just going
to say we strongly urge that oral
healthcare be included in this whole overall healthcare
reform debate. A Speaker:
You know, you
can’t gum an apple. (laughter) Nancy-Ann DeParle:
Bob and then — Bob:
Yeah, just a few comments. I work for the American College
of Physicians, but I’m not a clinician, I’m a policy guy, and
so my world is focused on what’s going with Congress right now. And I think here in the
discussion today, it strikes me how important that we have
a comprehensive approach. If we deal with workforce by
itself but don’t deal with coverage, we’re going to fail. If we deal with coverage without
dealing with workforce, we’re going to fail. So we have to start with the
premise everybody has to have affordable coverage. Everybody has to have affordable
coverage that covers primary care and preventive services. We need a workforce of
physicians, nurses, PA’s and others to provide care to these
people that hopefully will have insurance coverage. And I think a very big part that
we haven’t really talked about too much is payment reform. Right now in our system, we
overvalue procedures, we pay physicians, nurses and others on
an a la carte fee-for-service basis, we pay for fragmented
care and uncoordinated care. You know, we all talk about
teams, why don’t we have high functioning teams, because
that’s what we pay for in the United States. In part, I think the answer to
keep people in practice is to start by reforming the
current payment systems. And yesterday Medicare had a big
announcement that it proposed a bill to raise payments to
primary care clinicians very substantially, which is the very
first step, but then we need to move to other payment models
that are aligned with value, because we believe that primary
care will be shown to be the best value in the
healthcare system. Nancy-Ann DeParle:
Great. Daniel? Daniel Tippett:
My name is Dan Tippett,
I’m a practicing physician assistant in Virginia,
and I’m also an educator as well, so I speak very strongly
about workforce issues. Two comments I wanted to
make, but first, I certainly appreciate all that all of you
do for the health of all of our patients that we take care of. But one, we’re very supportive
of the idea of the medical home and I want to emphasize that
PA’s are part of the medical home concept. The notion that we offer an
insurance plan for someone with a very high deductible is very
counter-intuitive to prevention and wellness, and then we wait
for something to happen for the disease so we can treat it. And so certainly we’re going to
have to shift the philosophy of how we look at the patient
as a whole and the idea
of prevention. When it comes to workforce
issues, I cannot emphasize enough the need for
more clinical sites. I had a conversation with
Congressman Glenn Nye who is in our — is representing our
district, and it’s not just about providing more seats in
a classroom, it’s the clinical side when we have to go out and
get preceptors to actually want to teach students in the
clinical setting, and I think that’s going to be the real
issue, not just for physician assistants, but for physicians,
nurse practitioners and — Nancy-Ann DeParle:
How do we do that? Daniel Tippett:
Well, he asked me the
same thing, and the honest answer is I — quite
honestly I think we’re going to have to incentivize
physicians to want to teach. My wife is an obstetrician, she
has medical assistants, LPN’s, nurses, nurse practitioners,
physician assistants and physicians all wanting to get
into her practice on top of taking care of her patients. So there has to be an emphasis
of prioritizing your patients first, but then having the
altruism there, but that’s clearly an overload on the
system, and we’re going to have to find more individuals that
are going to be willing to take on the education of more
providers if we’re talking about increasing the workforce. A Speaker:
You probably all see — those
of you in education, this was certainly when I was a
first-year med student, there was a ton of us that wanted to
do primary care, we couldn’t find preceptor sites. And that’s not the only reason
we didn’t all go into primary care, I did, but I was — by the
time I got to my fourth year, I was one of a handful
out of 200 who did. And that’s repeated itself, I
would imagine, in every area, that we just couldn’t find a
role model, and the role models we did have were not happy. And why would you want to go
into something like that, that was — that was everybody,
my friends who were nurses, dentists, all of it. A Speaker:
Well, we have programs that
are having to turn students away because they can’t find
enough clinical sites. We’ve had programs that have
closed because they can’t find enough clinical sites. So this is absolutely
the key issue. A Speaker:
Another part of the problem
is also that not enough of the providers are
reimbursed in any way. We have a system in which, for
example, physician residents can come in and, you know, the
hospital is reimbursed for training those physicians,
but we as an institution, my hospital is not reimbursed for
training nurse practitioners or nurse midwives, and so as a
certified nurse midwife in the inner city, I work with a
largely uninsured population, all on Medicaid, these women
come in with no dental care, they need behavioral health
resources, they need preventive care of all types, and they are
not able to access that care until they are pregnant. So once they are pregnant, we
have a window of opportunity then, you know, a nine-month
period in which we are their medical home, they come to me
for everything, they are — we develop a relationship with them
and we refer them for those much needed services. But then again, while I would
love to train more nurse midwives to, you know, fill this
void, we can’t do it because there’s no — there’s no funds
for it or it really drains our resources, so it’s
really a big problem. Nancy-Ann DeParle:
Yeah. Carolyn. Carolyn:
I’m director of
nurse-midwifery and women’s health nurse practitioner
program at Georgetown University, and I’ve actually
spent the greatest part of my career as a practitioner, and
we always had students, and the lineup was as you speak, I mean,
the demand was far more than we could possibly take, at a time
when reimbursement was dwindling for the practice, and, you know,
we’re getting fewer and fewer cents back on the dollar while
we’re trying to train more and more students. Now I’ve — I jumped the fence
and now I’m in education, and I’m begging, I mean, literally
begging my friends in practice to please take my students,
because I — the limitation on the number of students that we
can take is literally based on clinical sites. And we’re sitting in the middle
of Washington, DC, where there are healthcare providers, as you
all know, that we’re falling over, but trying to get those
sites is incredibly difficult. A Speaker:
And in my — Carolyn:
There’s no incentive. A Speaker:
Exactly. And in my situation, we — at the nurse midwives, we already train family practice residents for, you know, in obstetric care. Carolyn:
Yeah, she turned me down. (laughter) A Speaker:
And I have to turn her —
but it’s because my hospital administration will not
allow me to take a nurse midwife student because they feel that,
you know, they are not getting anything out of the deal. Where, you know, we’re already
training the family practice docs, so it’s
really a big issue. Nancy-Ann DeParle:
Yeah, it’s very difficult. Keith and then Michelle. Keith:
Thank you. We do have the greatest
healthcare system in the world, but unfortunately we’re
paying the price for it. And go to answer the young lady
back to the lady that has cancer and can’t afford her treatment,
she can’t afford the much needed medications, because in this
country, we’re paying more than any other country in the world. The largest purchaser in this
country, the federal government, is paying more for
medications than anyone else. The largest group paying more
for those medications than anyone in the world. And to go back to Medicaid, Mark
mentioned Medicaid is often forgotten, the high price
of those medications when pharmacies are reimbursed on
average manufacturer’s price below what we actually pay for
that medication, what are we going to do? We’re going to drop
those contracts. I ran a spreadsheet when average
manufacturer’s price first came out, ran the numbers, and I
actually lost money on every prescription for Medicaid,
every generic prescription
that I filled. So there’s no incentive to use a
much cost-effective alternative with generic medication,
so what are we going to do? We’re going to change that
patient to a brand name medication and end
up paying more. Now, the folks — if I took that
Medicaid contract, and I don’t mind giving the numbers, my net
profit below what I actually paid for that medication was
minus $20,000, at 2 percent,
2.4 percent Medicaid. I’m very low
Medicaid in my area. The average in Virginia
is about 16 percent. Now, when you get out to the
valley, in the rural areas, you’re looking at 50, 60
percent or even higher. And that is access, people are
going to — pharmacies are going to drop those contracts, and
folks and our patients are not going to have access to their
much needed medications. So we’re paying the highest
price in the world. A Speaker:
We have questions at
this end of the table. Nancy-Ann DeParle:
Okay. I’m doing the best I can. Michelle, and then
I’ll come on this end. Okay? Michelle Herbert Thomas
Thanks. I’m Michelle Herbert Thomas,
and I’m a pharmacist down in Richmond, and my family
owns three pharmacies. And my job within our company is
— well, I love what I do and I work with patients every
day, it’s a little bit less traditional when it comes to
pharmacy practice, but I wanted to comment on access to care. With my two main responsibility
areas are medication therapy management, and there are
definitely access issues. There’s not — there’s not a
problem accessing a prescription drug, you know, if you have
your coverage, but beyond that, medication therapy management
access is very low. We have thousands of patients,
and many of those patients have Medicare who should get
medication therapy management coverage, but of all of those,
each — twice each year, I get the opportunity to provide
medication therapy management to a handful of patients through
the Medicare services, and that’s because the insurers are
offering service — medication therapy management services that
aren’t directly offered by the individual pharmacist who
takes care of the patient. The patient doesn’t
know the person. And whether or not they are
contacting and doing anything with those patients, I do not
know, but I know that the problems that exist with those
patients, it appears to me that it’s not being done. A Speaker:
Letters don’t work. Michelle Herbert Thomas:
Letters and calls from an
outside person who is not aware of what’s going on with that
patient is not really the most effective way to help improve
their care using medication therapy management. So the access is very, very low
to a service that I think we all agree is — is a needed service. It’s just not getting to
the patients that need it. So that was the first thing I
wanted to comment on, and really very much appreciate that
Medicare coverage is there for that service, but we just
really need to expand it. The second area of
responsibility I have
is I run a diabetes education program that
is an integrated program, I have a nurse and a dietitian and
myself, the pharmacist, we receive referrals from
physicians to provide diabetes education services. In most cases in our program,
it’s people with newly diagnosed diabetes, so they are very much
out of control, they are very scared, they don’t know what to
do, they need help with, you know, from — my role is to help
with, you know, what medications are doing to help them and what
they need to do to work with lifestyle issues and how
medication works in with that. But again, as a program that is
nontraditional, that’s not in a hospital system, in the Richmond
area, there are three ADA recognized diabetes education
programs that are available for patients to select from, two
of those three are based
in hospitals. So there’s — there are
several insurers who refuse to compensate us for our
services because we are not hospital-based. So — Nancy-Ann DeParle:
Why would that matter? Michelle Herbert Thomas:
we have to turn down all patients who are State of
Virginia employees and all patients who have Aetna, then
physicians say, well, I can’t refer patients to them, I don’t
remember who I can’t refer there, so, you know, that means
we have less opportunity to help patients. And really with three diabetes
education programs in all of the Richmond area, that’s not enough
as it is, and for us to not be able to have access to those
patients, I think there’s a lot more people we could help. Nancy-Ann DeParle:
Why would the fact that it’s
hospital-based make a difference from — clinically
why would that matter? Michelle Herbert Thomas:
I wish I understood that. I think that, you know, having
called multiple times and asked and gotten the same answer, it
sounds to me like, you know, they get national contracts, so
if it’s a hospital system, you know, they can — they can
contract with, you know, diabetes treatment centers of
America across the country, and they can’t let anyone else in. So, but that really does
limit access to diabetes
education programs. Nancy-Ann DeParle:
Bruce, okay. Bruce Roberts:
Nancy, I really appreciate this opportunity to be with
you today, and I think
it’s really — I commend you for bringing
together practitioners. The other forums I’ve
participated in, we’ve had health systems and physicians
and, you know, all sorts of folks, and bringing this focused
under primary care I think makes an awful lot of sense. I think primary care really
is going to hold a lot of the answers to healthcare reform. From — I’m Bruce Roberts
from the National Community Pharmacists Association,
I’m a community pharmacist. And I think that a lot of what’s
been said, whether it be aligned interests, a fully integrated
system, we all I think would agree that that is
where we need to go. With pharmacy specifically
related to those areas, I think that there’s some — I would
just highlight some real problems out there
in healthcare. With pharmacy, you know, said
for every dollar spent on prescription drugs, there’s a
dollar’s worth of problems. There’s studies
that back that up. And so the realty of how do we
pay for healthcare reform if we can just get the pharmacist
integrated into the healthcare system and begin to really make
sure prescription drugs are used correctly, we can save an awful
lot of healthcare dollars. I mean, there’s great examples
of where, you know, pharmacists and physicians and the rest of
the healthcare team have worked together to make sure that
patients adhere to their medications with models that
align the incentives between, you know, all the different
players, and healthcare costs go down. I mean, it’s amazing the
money that can be spent. And so one of the things that I
would really recommend that you give serious consideration to,
and some of the bills
that are — the language is coming out or
beginning to talk about it, and the President has talked about
it an awful lot, and that is the whole interoperability of
healthcare, the technology that is going to be required. Because we can talk about all of
these wonderful things about an integrated system, but if we
don’t have the systems in place, we don’t have the technology to
embrace that, you know, whether it’s from electronic medical
record from a prescriber to, you know, the pharmacist, and we’re
all integrated in a way that drives maximum value to those
patients, we’ll never get there. So I think it’s really,
really important. And from pharmacies’
perspective, too, we have in instances been
siloed in healthcare. Medicare Part D is an absolute
tremendous example of not — of how not to do it. Because you have the
prescription drug benefit and a siloed, all it’s about is
driving down the cost of the drug, and there’s no incentive,
I mean actually there is — there’s a disincentive for
prescription drugs to be used correctly, because the reality
is if you don’t take them, the insurer, whomever the Medicare
Part D provider is, does better. And so we really need to make
sure that we, you know, we’re aligning those interests, we’re
making sure that we have a fully integrated system, and pharmacy
can — I think pharmacy can play a real significant role in
helping control those costs as long as they are considered. And we appreciate in the medical
home that, you know, it says nontradition providers can —
are going to be part of that, but I think we need to get more
specific to say, you know, what practitioners are going to be
involved in the medical home. A Speaker:
We’ve got another set of
comments I think from the Internet, and then Mary had her
hand up right before Jenn had her comments. A Speaker:
So there was a discussion
about (inaudible) primary care which we had just been talking
about, and Michael from
St. Paul, Minnesota, talked about how
support for training is really important, so it touched on what
we were talking about here. Brian from Washington, DC,
talked about shortages in all professions, physicians,
nurses, pharmacists. And Julie from Reno, Nevada,
said that the number of students at her college taking classes in
nursing is tied to the number of faculty they have for nursing. And so she talked about
the need for more faculty. And then there was a long
discussion on costs and
primary care. Angela and Justin and Diane
talked about the high
cost of COBRA. There was a comment from Florida
about the high cost for small businesses for all types of
care, the highority (phonetic), primary. And then there was a discussion
as well about liability premiums and making it financially
reasonable for people to stay in primary care by trying
to lower premiums. And Julie and Mary also talked
about premiums as well. Nancy-Ann DeParle:
Who is next? Mary.
Mary and then Jean. Mary Alvord:
I’m Mary Alvord,
I’m a full-time psychologist practitioner, as well as
a business owner, small. We have two offices in suburban
Maryland, so I manage the practice as well. So a lot of these issues that
are being brought up resonate both from various hats. But I wanted to talk
about a couple of things. I guess the stigma of mental
health and making sure that psychologists are truly viewed
as health providers, and that parity really becomes
implemented in a way that psychologists are on the table,
because so many people file complaints about physicians or
others, but they don’t want to go and file any complaints to
insurance regarding their mental health issues, and I think
it’s because it’s so much
of a stigma. But in addition, I work
primarily with children adolescents, so I want to make
sure, like Mark, that they really are not just little
adults, it takes
specialized training. Psychologists are doctorly
trained to, beyond sort of the adult, to work with children
adolescents, and so many parents are reluctant to have — to even
use insurance when they do. So that’s another issue that
needs to be addressed, I think that’s partly the stigma. We need prevention for children. We create all of these — just
as we all have mouths, we were all children, and create
habitual patterns. You know, the obesity epidemic
now is created to — is related very much in part to lifestyle
choices, and we’re trying to educate, but there isn’t the
incentive for people to do a lot of work in that. So I’d like for parents to be
able to get some preventive services and not wait until
the children’s problems
are so great. We work collaboratively with
schools, with pediatricians, and many psychologists, I know many
providers are less reluctant — more reluctant to work with
children because of all of the time, the extra time that is
spent collaborating that’s not reimbursed at all. Nancy-Ann DeParle:
Thank you. Jean. Jean Carter:
Thank you. I’m Jean Carter, I’m also a
psychologist, and I have a practice here in Washington, DC. And I wanted to actually to pick
up on one of the things that Mary just said, or she stole it
out of my mouth, around stigma. That’s a very significant issue
around — around mental health. And people think of mental
health as over here and separated off from the notions
of behavioral health, and so all of what we’ve been talking about
about prevention is really about changing behavior. We often think about it as, you
know, we get these tests with these numbers, and that’s
part of prevention. And it is part of it. But then what do you do with
those and how do we help people change their behavior so that
the prevention actually becomes a lifestyle change, actually
becomes the kinds of activities that people need to engage in
for better health and for
health promotion. So incidentally, sort of on the
side of that, I would love to see us talk about healthcare
homes rather than medical homes so that we expand the notion
to a broader perspective that includes things like
behavior change. One of the issues that we face
in expanding this notion of mental health to behavioral
health is that the mental health coverage, which is what pays
psychologists, is often in a carve out, which means that it’s
limited, it’s separate, it can’t really be integrated in the same
way into healthcare more broadly as long as it’s kept carved out. And in addition to that, the
limits that we end up facing is that the CPT codes, the
procedure codes and the diagnostic codes that
psychologists can use and other mental health providers are
limited to only certain kinds of services, so we’re limited to
things like psychotherapy, which doesn’t translate well to
helping with issues of compliance around meds. So expanding the notion of how
psychologists can be paid, how mental health can be paid for
and how we can move it to notions of behavioral health
I think would be a tremendous thing for us to be able to do. Nancy Ann DeParle:
I think Randolph is next. Randy Brooks:
Thank you, Ms. DeParle,
we appreciate the invitation, and applaud what
the President is doing on healthcare, it’s a
tremendously difficult topic. I’m Randy Brooks, I’m an
optometrist practicing in New Jersey, and I’m the Presidentof the American Optometric Association. Like Mark, I’m a practitioner
and changed all of my office hours today for patients,
because this is an important thing to do. Nancy-Ann DeParle:
Thank you, we apologize
to your patients. Randy Brooks:
Not at all. Optometrists render about 70
percent of the primary eye care in this country. We are in 7,000 communities, and
in 3,000 of those communities, we are the only eye
care practitioner. And we render care from a
perspective that is both preventive as well
as medical care. Our practitioners are in rural
settings and urban settings and we do see shortages. We encourage increased
involvement in community
health centers. Prevention and early
intervention is a tremendous key, as we’ve heard
it here today. Bill and I served on an NCQA
committee and we found that you could achieve a lot more bang
for the buck in terms of early intervention and care, because
not only is there less spent on disease management when
intervention occurs early, whether it’s a diabetic patient
or a glaucoma patient, but it also is a contribution to
less lost time at work. Every day in our office, we
counsel patients, whether it’s on their A1C, smoking cessation,
control of their hypertension, or a nutritional therapy
on macular degeneration. We see cost of medicines as a
huge issue in this country. Many patients come in and afford
their copay, but they can’t afford their medicine. And when I prescribe the
medication, I have to look toward the affordability and
whether the patient will be adherent and compliant
with the therapy. Our primary focus and our
primary concern is on everything that’s being — generally being
patient centered, patient is the important person here, not the
practitioner, and the patient needs a choice, the
patient needs access. The patient needs access for
whatever the covered service is, whether it’s routine eye care
which may be covered under a routine vision plan, or medical
care that we render and be seeing like glaucoma patients or
removing a metallic foreign body from someone’s eye. To me, it’s critical that the
patients have their choice
of practitioner. If a practitioner is able to
and licensed to provide that particular service, provides
quality care, there shouldn’t be any artificial restrictions or
boundaries on who provides
that care. So we feel that’s an important
piece to the healthcare picture. Thank you. Nancy-Ann DeParle:
Has everybody had a chance
to speak once at least? Okay. As we’re
repeating some people now.
Okay, Mona. Mona:
I’ll defer to Jan,
she’s going to have — she really wants to talk. Nancy-Ann Deparle:
Okay. (laughter) Jan:
I just wanted to
bring up the health IT thing. There was a mention of small
business issues, which kind of triggered my thinking a little
bit, because that’s one of the big frustrations I think
everybody in this room has, is that, you know, money was put in
the stimulus package for health IT, and I don’t imagine anybody
that’s sitting in this room, well, maybe a few, but most of
us had — you know, weren’t able to see any of that money, and
yet these are the practices, our practices are the small
practices that really need shoring up, and those of us who
are dealing with vulnerable populations, we need help with
— with being able to establish medical records as well, but
it’s very hard to kind of get that over the top, and it’s
something that parity in a lot of these things would
be really helpful. Nancy-Ann DeParle:
Thanks. Mona, go ahead. Mona:
Thank you. One of the things — I go back
to my pediatrician colleague over there, is the CHIP program
and the Medicaid program and that kind of thing, you have a
lot of practices that are not 330 grantees, like the FQHC
look-alikes, like all of the nurse managed centers, like the
small — but they are serving the vulnerable population and
they have no access to any of the stimulus monies. Nancy-Ann DeParle:
Mark, I guess. Mark:
I just want to pick up
on what Mona said as well, and also kind of going way back to
what Keith said about Medicaid contracts. And I’m very fortunate, I work
for an FQHC who I’m salaried, so I don’t have to worry about my
reimbursement from Medicaid. I have 100 percent Medicaid
population or uninsured or Medicaid eligible, but I
don’t worry about what my reimbursement rate is because we
are contained within an FQHC, but that practitioner who works
in a rural community or in a small community that needs to
decide will I take a Medicaid child where I’m not going to be
reimbursed for what I actually do, I think the business person
in you at some point has to say I can’t do it, even if
your heart says I want to. They may for a while do as much
as they can to see that kid and do what they can for them, but
at some point the bottom line I think ends up becoming so
important that they have to deny care to those kids. So I think that, again, going
back to Medicaid and making sure that all FQHC’s are protected,
I’m kind of happy about that, that the individual
practitioners and smaller practices as well are also
looked at far as their Medicaid reimbursement rate. A Speaker:
The electric company
won’t accept zucchini. Yes. (laughter) Nancy-Ann DeParle:
No, they won’t. Just doesn’t work. Michelle. Michelle:
Thank you. I just really wanted to add on
to the pediatric, the issue with pediatrics as it relates to
diabetes, and I think one of the most difficult family issues
to deal with is a child who develops a chronic illness. And when it’s diabetes, the
child ends up in the hospital and everything changes for that
child, everything changes for that family. Medicaid, at least in the State
of Virginia, does not cover diabetes education
services at all. So a child of a family who is
without the privileged life does not get any training on how to
live past that diagnosis, and they are in and out of the
hospital and they don’t know what to do and it’s a very scary
way to live, and it takes a long time for them to figure out how
to manage that disease without that, you know, without that
background of education on management, so I think that’s
another way that system is kind of failing the children. Nancy-Ann DeParle:
Keith. Keith:
We’ve talked about
a number of ways to save healthcare dollars long-term. We talked about outcomes, paying
providers incentives to increase outcomes, we talked about
medication therapy management, but what else can we do
to lower healthcare costs. If the federal government is
going to be a stakeholder in this, they need to know
what they’re paying for. We need to have a transparent
system, no hidden fees, no hidden costs, no hidden rebates. They need to know what they’re
paying for, and it needs to be a transparent system. I’m not saying that companies
can’t make a profit. If they’re aligned with the
private insurance or whoever, companies need to make a profit. You know, they have stockholders, you
know, I’m a business person as well and I need to make a profit
and meet payroll and pay
myself hopefully. But we need to have a
transparent system to know what we’re paying for, and that’s one
huge way to lower healthcare dollars in the long run and it
makes it more affordable in healthcare premiums, it lowers
drug costs, it lowers costs across the board. Nancy-Ann DeParle:
Thank you. Tina. Tina:
We also have to pay for the right care at the right time. Going to the question about the
ER problem, you know, the use of especially — you know, in
my population in inner city Baltimore where, you know,
nobody has insurance and the average community patient in my
practice for midwifery is maybe 19 years old, possibly Hispanic,
African-American, high rates of major socioeconomic problems and
behavioral problems, substance abuse, HIV rates are very high
in the city, and these people don’t have primary care, and the
only care they get, like I said before, is when
they are pregnant. And so they come in and because
we’re able to have a practice in which we can reach out to them,
we’ve encouraged them to call
us at any time. We always have a midwife and a
doctor on staff at the hospital, and they are encouraged to call
so that we can eliminate some of the walk-in problems that are
seen, especially in OB, and amongst the uninsured and the
uncovered, but also this is a problem in everybody’s ER,
people don’t have a place where they can go and a place — a
relationship with a provider at all of any kind. And so you end up spending so
much money just trying to cover the problems that you could
have possibly paid for had you established a person for
that patient to contact. So I think that’s one of the
ways in which we can really improve care, is to just get in
there, get people the care that they need at the right time so
that they are not going back. You know, if we can get to a
woman in early part of pregnancy and talk to her about her
lifestyle, her behavior, prevent the diabetes from happening,
prevent the preeclampsia from happening which costs
us so much money. You know, childbirth is the
number one reason for admission to the hospital in this country,
and we throw so much money at it, but we don’t have the
best outcomes in the world. And there are practices — in my
practice, for example, we have a 14 percent C-section rate and a
very, very high-risk population because of the way that we —
the integrated practice they we have and the fact that these
people are managed in a women’s medical home type model by nurse
midwives in collaboration with the physicians and the rest of
the healthcare team, and we’re saving the system an incredible
amount of money, but it’s just one little practice. If you could expand these types
of practice settings that have proven to make a difference that
people don’t really know about that are out there, I think we
can really save the system a lot of money and also prevent all of
this ER admission that happens that really bogs
down our system. A Speaker:
Yeah. Fred. Fred:
Well, moving back a little to 30,000 feet to sort of incorporate a lot of what
different people were saying today, I think most of us
here would agree that the patient-centered medical home,
although the name nobody likes, I mean, a lot of people think
they are being sent to the “home,” but for lack of a better
term, that’s where we really want to be in the future. And evidence will guide us
toward the best way to deliver that care, the best mix of
professionals to do it. But in the meantime, there are a
number of the chess pieces that we do know we need
to get in alignment. We need — we desperately need
workforce stability among those already there. And I just look back in my 25
years in practice, when I first went into practice, I did the
little exhibit where I helped them start the RBRVS system, I
had my little clipboard with the timer, my life was totally
different then than it is now. Most of what I was — did for a
patient was in the exam room and dictating immediately
following the visit. Now that’s perhaps
half of my time. I had time to teach med
students, residents, nurse practitioner students. I don’t have time, even before
my public policy hobby,
to do that. And I think what we have to
do is we have to have some transitional issues. Granted, the current payment
system is imperfect, but we need to stabilize those who are
currently in practice and have happy practitioners who can be
role models, who can teach and who provide an opportunity to
bridge that toward where we all know that we need
to be eventually. Nancy-Ann DeParle:
Amen. (laughter) Nancy Ann DeParle:
That’s right. That’s great. All right,
yes, Diana. Diana:
I would like to back
up a little bit to some things I’ve heard around the table
today, and that is certainly that we need all hands on deck,
we need all people to be able to do what they are capable of
doing without artificial barriers, and I think that
that’s the 800-pound elephant in a lot of rooms, is allowing
people to do what they know how to do, which they have been
educated to do, and, you know, evidence is out there,
there is evidence. And, you know, we have — we
have to address those
artificial barriers. Some people are unhappy in
primary care because they are limited to certain things that
they wouldn’t be if we didn’t have these artificial barriers. I also wanted to comment on the
Medicare — I mean the
Medicaid issue. In my state of Indiana, because
nurse practitioners can’t be primary medical providers, we
have — we have practices where you have these available
excellent providers, but they can’t see the patients because
the physician panel is full. So they drive past your clinic
30 miles down the road in their rickety old car at $4 a gallon
of gas or $3, whatever it is now, when there are two
perfectly willing, educated, ready to work primary care
providers who are underutilized, and that happens all the time. I work in a rural area that’s
between a bunch of different towns, and my practice is the
safety net for a large town where no one takes
Medicaid anymore. They just don’t want
to deal with it. And — Nancy-Ann DeParle:
So what’s
the solution to that? Diana:
What’s the
solution to that? Use all the people you have. Nancy-Ann DeParle:
Yeah, remove the barriers. Remove the barriers. Diana:
Use the people you have. Get rid of the barriers. You know, how do you do that? You X these things off the
books, because they are old-time, old-fashioned,
old-thinking, fossilized ways of thinking. Nancy-Ann DeParle:
Are you talking about
state scope of practice laws? Diana:
Well, just — there’s federal
barriers, there are federal barriers.
I can’t order home care. I’ve taken care of Ms. B for 15
years and she now needs home care before she goes to the
nursing home or wherever else she goes. I can’t do that. I’ve taken care of her, I’ve
managed all of her chronic medical problems, but when she
has to be at home and she’s on Medicare, I can’t order that. I have to find someone, I have
to find someone who doesn’t know this patient at all, who trusts
me because they know me, that will say, oh, yeah, sure, okay,
okay, and, you know, and they — Nancy-Ann DeParle:
Charge you to sign it. Diana:
Well, or charge
you, you know, you do pay collaboration fees, I do. And the same with hospice, you
know, you’ve taken care of this person, they’ve developed
cancer, you know, they’ve been through all of their treatments,
they are at the end of their life, we want them to have a
comfortable way of leaving this world, and I can’t
order hospice. I can be an attending in
hospice, but I can’t order it. We have to go find somebody who
doesn’t know this patient at all, who has to then step in and
order this hospice that I can then carry on with. I mean, those are things
that are just so stupid and frustrating for us in the field. I just, you know, it just is
a very, very difficult thing. And I’ve done this for 18 years,
you know, I was a nurse for many years before that, and that
would be one of the things that would make me just want to throw
in the towel and walk away. A Speaker:
And it’s the same
thing at pharmacy. I mean, pharmacy — pharmacists
are not recognized as practitioners, they have
no recognition under
Medicare Part B. I mean, it’s the same thing. I mean, to the extent that
you can get all of these practitioners working together
to make sure that the patient is taken care of, get rid of these
artificial barriers so that the entire team can work together,
ultimately we can drive much better outcomes at much less
cost than the system we
have today. Nancy-Ann DeParle:
I have to ask Dr. Roston, do
you agree — well, go ahead. Dr. Roston:
I would love for us to evolve
toward a constantly changing practice environment. And I understand that the
Administration has taken some great strides toward improving
the rather flawed PQRI program, but to me, I would love to have
the data that shows exactly what the right mix of providers is
in our practice, adding certain types of either physicians, PA’s
or nurse practitioners, whether that improves quality, lowers
costs, and that will .
evolve over time. But I think importantly for all
of us, we need to be the first one to get the feedback on the
quality of care that we provide. It can be spun off to as many
other entities that want it, but it shouldn’t be claims kind of
data being thrown at us and just interfering with our work cycle. We need to have sort of a
dimming kind of continuous quality improvement approach,
and I think a lot of these issues, I mean, Mona and I were
talking earlier, one-on-one, we could handle an awful lot of the
things that — you know, that we talk about in theory
being difficult. I mean, when we first met, the
ACP and nurse practitioners have been talking with each other, we
gave examples of particular kind of patients, and once we talked
about real world examples, we found out we had a lot more in
common and we understood that we face common challenges. In theory, you know, in the past
we maybe talked past each other, but we need to have more
communication and we desperately need help from an
Administration, because we have more in common in our daily
frustrations than we do in opposition. A Speaker:
So we’re getting close to our
time, and we have some comments from the Internet, and, Nancy,
I could spend all day here, but part of Jenn and I, our job is
to make sure she can get to her next thing that she has to solve
the healthcare crisis on, so. I do want to mention, though,
that we will be — there’s an opportunity to kind of continue
to contribute your ideas on healthreform.gov. So I want to say that to not cut
off anyone in the audience or on the Internet that didn’t get a
chance, but would like to keep this dialogue going. So, Jenn, did you have more? Jennifer Cannistra:
Yeah. I guess I’ll just do some larger summary comments. There have been a bunch
of discussions going on. But Jeanette mentioned, you
know, we need to remember that preventive care will keep costs
down and reduce the number of visits to hospitals and give
people more time who really
need attention. And Crystal goes down how
so many people are dying of diseases that are preventable,
and so, you know, focusing on primary care from the
get-go is really important. And then Deb talked about how we
need to teach preventive care and really focus on healthy
education, childhood nutrition and also lowering
childhood obesity. But everyone very much agreed
with what you were saying, so, you know, they appreciate
the discussion. A Speaker:
So there were a couple of
themes, I know Nancy-Ann gets the last word, but it’s — we’ve
done a number of these in the White House and just listening
kind of outside from the town halls that we’re doing across
the country, but then a lot of the dialogues that have been
going on that some of you have hosted in your homes, and a lot
of it centers back to kind of a mutual respect, and especially
in the world of primary care, I think that’s something that’s
constantly reverberating, and it’s not just mutual respect
of what our titles or our identities are, but it’s the
mutual respect with transparency and with the industry complex,
whether it’s pharmaceuticals, insurance, doctors, hospitals
— we didn’t really talk about hospitals here, but when I was
in practice, that was a constant tension for our community
practice was our main hospitals and kind of we always felt like
we were in opposition to each other instead of
working hand in hand. So the mutual respect aspect,
I’ve been taking a lot of notes, which I’ll get to Nancy and then
the rest of the team, but really realigning incentives and making
sure that what we’re paying for is really high quality and the
right care at the right time, and also understanding that
we don’t necessarily have the answers to what the right care
or the right mix is, but that we’ve got to be open to evolving
as a system so that we can make room for that. And then the health IT issues, I
think there are a number of us that have been very supportive
of the President’s, thankfully to all of you, who has really
championed getting health IT and really taking this to the
forefront of the public conversation, but that’s
certainly not the end. And so keeping working on that
and making sure it’s truly accessible. And then workforce issues all
around, I don’t think anyone — maybe the dental hygienists
are in good shape. (laughter) Nancy-Ann DeParle:
That was a bit of good news. A Speaker:
That’s like so we can take
that back and say check, we finished that up. Everything else is still —
They haven’t gotten — A Maybe you should teach us what it is you’re doing that’s working. So I don’t know with that, Nancy, if you want — Nancy-Ann DeParle:
I found this very inspiring, and in thinking about it, we have done a number of these discussions. And one thing that really
struck me about this one is how constantly the patient was
at the center of this whole conversation with each of you
and the comments that
you’ve made. And I find that
really inspiring. And you’ve expressed some
frustration with the way things work right now and your
inability to really treat the whole patient and make sure that
they are getting the preventive care and primary
care that they need. But also thank you for
highlighting some of the models that are working out there. And the community health centers
and some of the things that you are doing around the country
that are working and that we can build upon as we look toward
hopefully a healthier future for America’s families. And so I just want to thank you
for the work that you are doing and for continuing to go help us
to try to craft a better — a better system going forward. So thank you very much
for taking the time. Panel:
Thank you. Apologize to your patients
again — (laughter) for missing the afternoon. Thank you.

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