Expanding Health Insurance Coverage Should Reduce Costs

(This post was initially published at on the National Physicians Alliance blog, February 26 2012)

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Without significant changes, healthcare spending in the United States (already one of the highest rates in the world per capita) will continue to increase at an unsustainable rate (PDF).  One of the most important goals of the Patient Protection and Affordable Care Act (PPACA) is to control the costs of medical care.  Various analyses have discussed the PPACA's potential to reduce healthcare utilization and costs, including this analysis of the law's cost containment features (PDF) and this review of how the PPACA could bend the healthcare cost curve.

However, it can be argued that the key cost savings feature of the PPACA is also the law's defining reform: the PPACA is expected to extend health insurance coverage to nearly 32 million currently uninsured Americans.  It can be argued that this expansion of coverage was the underlying crisis that drove the passage of this law, but whether or not expanding healthcare insurance access would reduce costs was unclear. 


Now, a new study looks at the impact of extending healthcare access to individuals who previously lacked this access.    In November 2000, Virginia Commonwealth University (VCU) Medical Center launched a community-based coordinate care program in response to the health center's role as a principle safety net provider in Richmond, Virginia.  Individuals under 200% of the federal poverty level who lacked any other coverage options were eligible for this program.  Once enrolled in the program, patients were assigned to a community-based primary care office and these primary care providers received a management fee and fee-for-service reimbursement that were equal to roughly 110% of Virginia's Medicaid fee schedule.  This structure would be comparable to enrolling patients in programs that enhance primary care access through either private insurance or public insurance programs such as Medicaid--the two major approaches that the PPACA will take to expanding coverage.


Since this program was implemented, VCU Medical Center has seen a significant change in their system's usage of high-cost services.  Primary care visits increased over the period when patients were enrolled in the program, while emergency department visits and inpatient admissions decreased during the same period.  This suggests that increased access to primary care services reduces the need for higher-cost emergency department and inpatient interventions.  The program also saw inpatient costs fall each year, and total average costs per year per employee fell nearly 50% (from $8,899 to $4,569).

The study's authors conclude that "previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage, but that it may take several years of coverage for substantive health care savings to occur."  The authors also noted that there were larger cost savings were achieved in patients with more chronic conditions.  This conclusion aligns with prior research including this study, this study, and this article from Dr. Barbara Starfield (PDF). 
This new article highlights two important considerations.  First: in the program this article describes, increasing individuals' access to health care reduces the overall costs of care.  This has significant implications for national healthcare spending trends.  Second: as the US population increases its theoretical access to healthcare services, there will need to be primary care physicians available to care for them.  The PPACA includes plans to address this workforce need, but other healthcare system reforms (including payment reforms and graduate medical education training) will need to be enacted to meet its full potential. 

As the PPACA approaches its second anniversary, and as it moves closer to full implementation in 2014, there is increasing evidence that the reforms embodied in the law will begin bending the cost curve of medical care.  This is of critical importance, especially as the political debate in Washington, DC focuses on budgets and deficits.  We must support and fully implement the PPACA to help address the nation's fiscal security, as well as providing better and more effective care for our patients.

Interdisciplinary Service Learning: Una Vida Sana! and Richmond's Hispanic Community

In 2009, I helped start a new interdisciplinary service learning program named "Una Vida Sana!" (A Healthy Life).  This program targets cardio-metabolic disease screenings (diabetes, high blood pressure, and high cholesterol) within Richmond's Hispanic Community.

We have now started analyzing some of the data from student participation and our patient data.  We reported on the early data analysis at the recent Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education two weeks ago.  Below is the presentation from that conference (apologies that the formatting is a little off after the upload):

Una Vida Sana! STFM Pre-Doc

View more PowerPoint from RichmondDoc

Where I'm Coming From

(This article originally appeared on Progress Notes on February 9, 2012.)

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When I entered medical school in Richmond, Virginia, I was certain I wanted to be in primary care but I was not yet sure what specialty.  Once I had decided to work in a medically underserved community I chose family medicine because in a rural site, where resources are limited, there is added value in the breadth and scope of family medicine training. I would be able to see all patients, regardless of age, gender, or initial symptoms. This training served me well when I took my first job after residency, in the small town of Keysville, Virginia.  In Keysville, I worked for four years providing care to patients in town and in the surrounding counties.

While in Keysville, I helped launch an international medical service and community development in the Dominican Republic in partnership with the College of William and Mary in Williamsburg, Virginia.  Working with this project in close partnership with the community of Paraíso, just outside the capital city of Santo Domingo, I have become more aware of the concept of community-oriented primary care. At its heart is the idea that primary care is most effective and most responsive when it is provided in the context of the community.  Interventions and care should take into account—and make use of—community resources in order to have the greatest effect. There is little value in a doctor’s recommendation that a patient does not have the resources to follow.

After four years in Keysville, I returned to Richmond to provide care to the Hispanic community and to work more with medical students.  Through our department’s International/Inner City/Rural Preceptorship (I₂CRP) program, I further developed my understanding of community-oriented primary care and of the importance of social determinants of health – the wide-ranging community and environmental factors that affect health, such as local schools and education, environment and pollution, access to affordable and nutritious foods, and safe public space for exercise.  Robust evidence supports social determinants and the need to address them if we wish to improve health (and, perhaps, reduce costs).

Knowing this, I have noticed my perspective changing both on my specialty and on my medical practice.  It is increasingly clear that social determinants wield tremendous influence on individual health and that to be effective in primary care we must advocate for change that targets social determinants, but change that is focused on communities’ needs as the community itself identifies them. For example, diet might be difficult to address in a community where the cheapest food is calorie-dense fast food. Exercise might be impractical if patients work late hours and lack safe places to exercise.  I believe that we must both keep social determinants in mind as we work with patients and push for reforms that will address (and improve) them. 

One-on-one primary care provides notable benefits for the individual, but there is great value in advocating for socially responsible change that will benefit the community at large and, as a result, benefit the individuals we care for.  It is not appropriate or sufficient for those outside a community to define what a community’s priorities should be.  These priorities should be mutually agreed-upon with the community and should target its key needs.

It is with this combination of motivations and interests that I practice and teach day-to-day.  At the heart of all medical care is the one-on-one care provided for the individual patient.  This is the core of what we do and what we believe as clinicians, and this relationship and responsibility still carry critical importance.  However, we must provide this care with an understanding of the social determinants of health.  We must recognize the limits of some of our standard recommendations. Finally, we must begin to connect with our communities.  Much of medical education occurs in the sheltered and protected environment of tertiary care centers and classrooms.  Students must begin to learn how to look outside of that environment, work with and understand communities, and help build coalitions and partnerships that stand to improve conditions within the communities we serve but to do so on the communities’ own terms.

This is an exciting and challenging time to be in primary care.  With our national workforce shortage in primary care, we are both in high demand and heavily worked.  For these reasons, we need to train medical students with broad vision, individual focus, and community orientation to provide the medical care that our community and our nation need.  I hope to be a part of this solution.  It is an important step in making our medical care more efficient and more effective.

On The Shoulders Of Giants

(This was originally posted on the Occupy Healthcare blog, February 2, 2012)

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Dr. Barbara Starfield died in 2011.  For many people, her name will not stand out.  For those of us looking to improve our healthcare system, however, her work is of critical importance.

Dr. Starfield is best known for her work emphasizing the importance and the value of primary care.  Primary care (usually focused on family medicine, but including general pediatrics and internal medicine) is the segment of our health care system that focuses on long-term relationships, addressing medical problems from a whole-person perspective, and addressing undifferentiated problems and illnesses.  Dr. Starfield wrote in the New England Journal of Medicine that "[i]mportant functions of primary care include serving as the first point of contact for all new health needs and problems; delivering long-term, person-focused care; comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them; and coordinating care that must be received elsewhere."  This as a concise definition as I have seen for the role of primary care.

In the same article, Dr. Starfield notes that "[r]obust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, there are fewer disparities in health across population subgroups in primary care–oriented health systems"

The article noted above goes on to summarize the evidence that backs up her claim, and I will not post all that evidence here.  Similarly, Dr. Starfield authored many, many other articles that provide additional insight on the key roles of primary care in an efficient and effective health care system.  I encourage you to review some: if you have taken the time to find this site and read this post, then I presume you have an interest in these ideas.  Dr. Starfield's work is a good place to start.

I would like to make myself look smart, and recite all the ways in which our healthcare system fails us on a daily basis.  And I would like to pretend that I came up with these ideas on how to fix the system on my own.  But, as with so much of life, these ideas are not mine.  I try to contribute what I can, but I am building on the work of those who came before--physicians and scholars such as Dr. Starfield.  So I would like to present her suggestions (from this interview) as to how we can reform our healthcare system to make it stronger and to improve our nation's health:

"For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples' needs, professionals define the needs -- usually in terms of having a specific disease -- and then forget about the people while dealing with the disease. We know from evidence that if you don't deal with people's problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for -- the less common and complicated things -- and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don't do it."

Accessible care, person-focused care, comprehensive care and coordinated care.  Simple concepts, and core ideas, that have been lost in our hospital-focused and specialist-heavy system.  This is how we change healthcare: identify the beliefs and practices that matter and that work...and then start finding ways to make our system honor and be accountable to them.  We don't do it, but we should...and we must.