Improving Healthcare Access, Quality, and Efficiency: An Expert Interview With Public Policy Analyst Robert Doherty

Barbara Boughton

May 03, 2009

May 3, 2009 — Editor’s note: A presentation highlighting new ideas for reforming the healthcare system was featured at the American College of Physicians (ACP) 2009 Annual Meeting, held from April 23 to 25 in Philadelphia, Pennsylvania. As well as improving access to healthcare, the seminar focused on how to improve quality and efficiency of healthcare in the United States.

To learn more about the newest ideas for reforming healthcare, Medscape Internal Medicine interviewed moderator Robert Doherty, senior vice president of governmental affairs and public policy for ACP. He has worked in the area of health policy for 30 years, and is coauthor of the recent ACP position paper, Achieving a High Performance Health Care System With Universal Access: What the United States Can Learn from Other Countries, which was published in the January 1, 2008, issue of the Annals of Internal Medicine.

Medscape: What ideas do you view as important for improving healthcare access, quality, and efficiency?

Mr. Doherty: Getting universal health coverage is critical, but we also need to look at how to make the healthcare system work better for patients and physicians, so that the care provided is more effective and efficient. What we’re talking about is redesigning healthcare in this country from a system where people are treated when they get sick to one that works on preventing illness. In this system, it’s vital that primary care doctors get the support they need to manage their patients’ conditions for the best possible outcomes. In fact, the cost for the care of chronic diseases is one reason why the cost of healthcare is climbing in this country. Yet there is evidence that you can keep people out of the hospital and keep them healthier by helping primary care physician provide good follow-up. So we need to fund support systems for patients and physicians that prevent disease whenever possible. That’s a very different notion from just looking at improving access, and getting people insurance cards, as important as that is.

Medscape: What are the important components for reforming the healthcare system in a comprehensive way?

Mr. Doherty: We need to invest in primary care as well as prevention and wellness. We also need to reform the insurance markets so that insurance companies can no longer turn down people because they get sick. Everyone needs to get affordable health insurance, but real reform means reforming the way insurance is provided so people don’t get charged more because they’re sick. It also involves changing healthcare benefit structures so that insurers pay for wellness programs rather than just treatment of patients when they get sick. If you do all these things, the evidence shows that you could cover everyone in this country at less cost than we have now.

Medscape: What might a reformed healthcare system look like in this country?

Mr. Doherty: There’s a developing consensus that we need to get everyone covered by insurance in the US. To do that, we would build upon the current system and use a combination of private insurance and public plans like Medicare. But those who can’t afford to buy private insurance would receive federal subsidies. However, insurance would cover everyone whether they have a preexisting condition or not.

Yet access to insurance is just part of the equation. You would also need to improve healthcare delivery. So you would design health insurance benefits to pay primary doctors more if they can effectively manage their patients’ health. There would also be support to primary care physicians for providing preventive care.

Medscape: What can we learn from other countries about how healthcare and health insurance might be improved in the United States?

Mr. Doherty: In our paper for the Annals of Internal Medicine, we looked at a dozen countries around the world, and most of them outperformed the US in terms of keeping down healthcare costs and providing quality outcomes. The best systems support primary care, and make it attractive for physicians to go into primary care. In the US, by contrast, there’s a heavy emphasis on the subspecialties.

Many countries that had better outcomes than the US, with lower costs, paid their doctors differently than we do in the US. Physicians were paid not on how many visits they get from patients or how many procedures they do but on the value of the care they’re providing. Access was also guaranteed by law, whether that was through the government or through a combination of public and private insurance. Although it’s not feasible for us to import models from other countries, because we have a uniquely American way of doing things, there are certainly things we can learn from other countries.

Medscape: How could we encourage more physicians to go into primary care?

Mr. Doherty: One of the ways is to change the payment system. Right now we undervalue care by primary physicians and overvalue care by specialists. The average physician has $140,000 in debt when they get out of medical school, and most physicians see that the earnings potential is so much greater in the specialties. So we should try to commensurate primary care because it provides the best value in terms of healthcare quality and outcomes.

It’s also important for medical school students to be exposed to good primary care training so that they can see how exciting it is to have a relationship with a patient over a lifetime. Many physicians today are trained in hospital settings where they don’t ever see that continuity of care. Another idea is to use government funding to eliminate debt for people who go into primary care, particularly in underserved areas. More funding is also needed to grow primary care residency programs.