Connecticut healthcare is at a crossroads

We are primed for a transparent discussion in our state about the pros and cons of a public option for healthcare insurance.

H. Andrew Selinger, MD

Anything that will serve to decrease the inequity perpetuated by our current healthcare climate is long overdue. Over the past 15 years, Connecticut saw the cost of healthcare rise by 77% while median wages only rose by 21%.

Additionally, in January Gov. Ned Lamont issued an executive order which will hold insurers, hospitals and other healthcare providers to a fixed rate of cost growth. The order also calls for increasing the state’s investment in primary care services from the current 5% of healthcare dollars to 10% by 2025.

We cannot deliver equitable, high value and comprehensive primary care without the platforms afforded by universal access and cultural commitment.

For 34 years I have practiced family medicine in the Bristol community. Our specialty stresses the value of comprehensive, continuous, coordinated, and above all else patient-centered and compassionate healthcare. To successfully achieve this requires a trusting relationship between the clinician and the patient. One cannot have a strong and enduring relationship in healthcare unless we are operating in a system that offers affordable and accessible primary care. Primary care is foundational, the linchpin that drives effective decision-making in an increasingly siloed and fractured medical care system.

I recognize the tremendous potential value of what is called “population health.” It is healthcare that emphasizes:

• Data-driven clinical decision making
• A primary care-led clinical workforce
• Patient engagement and community integration

What a wonderful opportunity to elevate the health status and health outcomes of entire populations of patients  – but not when it is subverted and distorted, by corporate healthcare systems throughout our state, to maximize their own revenue streams.

Population health efforts are meant to coincide with the ongoing emphasis on patient-centered and relationship focused care, not to replace it. Corporate medical practices are, in many situations, contributing to the “burnout” of their clinicians by emphasizing both maximal volume, or throughput, of patients seen and maximizing the medical coding of those patients to capture every dollar.

Focusing only on data entry and data driven care is a prelude to depersonalizing care. This is especially true for Medicare patients enrolled in “Medicare Advantage” plans –plans administrated through commercial insurance companies (i.e. Anthem, Cigna, United healthcare etc.) where the “sicker” the individual patient, the higher the allocated payment from the Center for Medicare Services (CMS). We need complete transparency to assure that increased reimbursement is indeed devoted to resource expansion.

Sicker patients do require more resources. But increasingly alarming is the increased time and emphasis placed on these efforts. Yet there is no administrative and clinical leadership effort devoted to the proven value of enhancing clinical skills to strengthen relationship and trust building with patients.

As chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine, Quinnipiac University, I work very hard to teach our medical students how to engender trust with patients using skills that include “shared decision-making,” “motivational interviewing,” “active listening” and “patient validation” etc. These efforts vanish in the corporate practice of medicine environment.

The very important goal of increasing successful chronic care management (diabetes, hypertension, heart disease etc.) by increasing clinician ordering of evidence-based testing and treatment-quality metrics universally accepted is meant to achieve overall better health outcomes, not to crowd out the humanity in delivering patient care. But when achieving these quality metrics is linked to enhanced revenue, the pressure is on to prioritize achieving these benchmarks over meeting other important patient care needs.

Not-so-subtle practices like prioritizing patient scheduling to achieve these goals does exist, unfortunately, in our healthcare organizations. There are only so many hours in the workday to accomplish what we as healthcare workers need to do on behalf of our patients.

Patients are not and never should be reduced to “units of care” — calculations in a balance sheet of corporate profit and loss and shareholder value. This is where we are now and why we must change direction! This is why I hope and pray that our state will follow through on the stated goal of increasing the resources devoted to delivering effective primary medical care –including a recognition that good health begins at home and in the community and requires a commitment to addressing social determinants of health; housing, education, nutrition and transportation, to name but a few.

It is well known that one’s zip code is a more powerful determinant than one’s genetic code for a hopeful long and healthy life. On Jan. 1 , 2021, Medicare will deploy an increased reimbursement structure designed to acknowledge the complexity involved in outpatient non-procedural patient care. The payment structure will be based only on the complexity of medical decision-making and the total time spent by the clinician, with the patient and independently, reviewing material provided by all caregivers involved (nursing, social work, behavioral health etc.) in the patient’s care. It is a  strong federal statement supporting the value of thoughtful and coordinated patient care.

Our state legislators must be part of a national movement to reverse our current course and move us in the direction of true health equity where all citizens, regardless of means, deserve a basic right to quality healthcare.

Howard A. Selinger M.D. is Chair of the Department of Family Medicine, Frank H. Netter MD School of Medicine at Quinnipiac University.

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