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Access to Care and Health System Reform

Michael Kulczycki, CAE, Linda Lambert, CAE, John Jordan, CAE, Jon Sutton, MBA

The issue of access to care and health system reform has taken center stage among policymakers and Congress throughout the 2008 U.S. election. With the change in administration, there is strong momentum for health reform initiatives such as system reform, a focus on public health, tax credits for small business, reductions in overall cost of care (fiscal responsibility), improvements in patient safety and quality, and implementation of health information technology. In addition, many members of Congress with a traditional interest in health care have released their own plans, promising a vigorous debate for the next few years. Various groups including business, labor, health care, consumers, and others are also driving the debate and have developed their own reform plans. These often focus on quality and cost, and represent a variety of financing proposals for single and pluralistic payment plans.

System reform and access to care are complex issues with a multitude of factors. While some of these are addressed in greater detail in other parts of this report; the following trends should be mentioned:

Trends:

• There are 45 million uninsured and 25 million underinsured Americans1 , with a real interest to find some way to make health coverage available to them all. Both the president and Congress are serious about making sure that everyone has some type of coverage, which will be a major part of any health system reform plan enacted. It is likely that until a plan is passed, the numbers of uninsured will increase as the economic recession continues to result in millions of lost jobs and employee-sponsored health plans.

• There are not enough physicians available to provide medical care to everyone, and training programs will not be able to keep up with the increasing demand for services -- particularly as the US population ages. Shortages exist in both primary and specialty care, with rural areas the first to be impacted especially with regard to trauma and emergency care. As primary care physicians, general surgeons, and other specialists move into retirement, it will be increasingly difficult for rural hospitals to adequately staff their facilities, potentially resulting in the closure of small community hospitals in areas where they are critically needed.

• Pressure will be put on Congress to substantially increase funding for medical education and residency training to address the primary care and specialist shortages.
  
  
• The patient-centered medical home (PCMH) is an approach to provide comprehensive, coordinated healthcare for patients. It facilitates a partnership between the individual patient, their personal physician, and when appropriate, the patient’s family (Joint Principles of the Patient-Centered Medical Home, Feb 2007). Since numerous demonstration projects have just gotten started, it will be a year or two before data is available to determine the overall feasibility/viability of the concept. Questions also remain about the details of the PCMH, particularly related to physician payment mechanisms, availability (or not) of new funding, how systems of care will work, who is eligible to be the medical home provider, and so on.

• The serious shortage of primary care physicians and other physician specialties is well documented(2) . Studies and solutions will be tested in an effort to create an adequate physician workforce.

• Quality and patient safety will continue to be a cornerstone of health system reform proposals. The adoption of evidence-based guidelines and pathways, as well as promotion of those guidelines and pathways into clinical practice, will accelerate implementation of standards of care and cost efficiencies.
  

• More patients (whether insured, uninsured, or underinsured) will take advantage of the basic care provided in retail clinics or urgent care centers, driving expansion of these facilities into various settings. Large corporations may consider opening similar clinics within their own buildings in order to reduce health insurance costs, provide basic lab testing, and implement well-care/preventive care programs.

• Particularly for the uninsured or underinsured, the number of people participating in medical tourism will expand. More overseas hospitals will become accredited by The Joint Commission and other accrediting agencies, drawing highly-trained medical professionals to their facilities. Insurance companies and self-insured employers will take advantage of cross-border care providers to save money.
  

1U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2007, August 2008

2Asletine, Robert H., Jr., PhD and Katz, Matthew C., MS and Geragosian, Audrey Honig, Connecticut Physician Workforce Survey 2008: Final Report on Physician Perceptions and Potential Impact on Access to Medical Care, September 2008