• Quote: Medicaid reform

    Start by paying a primary-care physician $80 a month to see each [Medicaid] patient, whether he is healthy or sick. That’s what so-called concierge doctors charge, and it would give Medicaid patients what they really need: first-class primary-care physicians to manage their chronic cardiovascular and metabolic conditions. […]

    Then throw on top of that a $2,500-a-year catastrophic plan to protect the poor against financial ruin. The total annual cost of such a program would be $3,460 per person, 42 percent less than what Obamacare’s Medicaid expansion costs.

    Reihan Salam, National Review Online quoting Avik Roy


    • Do we really need MD’s to do this? Could we hire and train (in 6 months) some social workers to help manage their chronic cardiovascular and metabolic conditions.

      • And maybe we could bring down the cost of air travel by training some flight attendants, or legal costs by training some clerks or police officers?

    • As many others have pointed out, that’s an extraordinarily low price for concierge medicine, but for the sake of argument, let’s ignore that for now. Boiling down Avik’s proposal, he’s saying the government will give a fixed amount of money per beneficiary to practices, as well as backstopping catastrophic health insurance in the case of major health issues. What I’m hearing is “narrow-network (i.e. one practice) capitated HMO, plus your major hospital costs.” ~75% of Medicaid beneficiaries are already in a managed-care plan. How, exactly, does this save money? Well, it doesn’t pay for intermediate care (lab tests, minor procedures) — the exact things that the poor can’t pay for out of pocket, and thus account for the difference in cost between Avik’s plan and current Medicaid.

      Long story short, I don’t get it. Once you take out the unrealistically low concierge price, there’s nothing new about this proposal.

    • Avik’s argument is about freeing primary care to care for patients in the best and most efficient way possible. Insurers and cms have devalued primary care and we are all living with the effects – docs seeing patients every 10 minutes, long waits, high ED use, and spiraling costs. 75% of healthcare costs are due to chronic disease- largely preventable or manageable. Primary care is the only part of our system that can effectively treat these conditions at a low cost/high touch manner. Contrary to Allan’s assertion, $80 is not an extraordinarily low price. Look at Qliance, iora Health, AtlasMD, MedLion and our own BlueSky Health, all of our prices are at or below $80/month. Furthermore, our outcomes are far and away better than any MCO has been able to produce. Also, we cover many procedures for that price and provide labs and imaging at cost. Our CBC study cost to a patient is less than $3. According to the AAFP, if done correctly, primary care can cover 80-90% of an individual’s needs. MCOs could do similar, but the paperwork, mandates, and inability to find specialists that will coordinate with primary care under the MCO capitation causes too many barriers to providing optimal care to Medicaid patients. Lastly, if these direct primary care practices do not provide good service to patients, those patients can take their $80 to a DPC provider who will. That’s tremendous power we can give to the most vulnerable among us. I’m happy to keep discussing this. You can reach me at @tjvalenti

      • I’m more concerned about the cost of imaging than the costs of something like a CBC. I agree that primary care is far undervalued (and the blame spreads far and wide for that) but I don’t think this proposal gets at that — changing things for Medicaid recipients only makes it hard on Medicaid recipients, because this won’t change how primary care is published at large.

        As an aside, could you point me to the research on your outcomes? I’d be very interested to see the type of patient population you serve.

        • Makes it hard on Medicaid recipients???? Are you aware of how hard they have it right now? Only about half of the primary care physicians in Michigan accept Medicaid. And those that do, the wait to see them is over 2 weeks! Put yourself in the shoes of a Medicaid patient. Are you going to try to find a doc and wait around for 2 weeks when you do? NO! Not when the ER down the street is advertising ER waits of less than 30 minutes. Therefore we have to change the payment model for primary care and we can’t emphasize FFS – that only leads to seeing patients every 10 minutes and doesn’t fix anything.

          Now imagine that Medicaid patient in a Direct Primary Care or concierge practice. The physicians would be charged to keep them well, not generate charges every time they are sick. Furthermore, they would have access to a provider 24/7 by whatever way is most convenient – phone, online, house call.

          BlueSky Health’s patient population is suburban to rural. Low income to middle class income. We’re far from “creaming the top”. BCBSM risk-adjusts our outcomes and we are one of the top practices in the state according to their measurement. Iora Health has done a lot with very poor communities. Do a search on Dr. Rushika Fernandopulle.

          • I’m of course aware of the difficulties in Medicaid. I’m saying, relative to the status quo, that only changing Medicaid makes life even harder for Medicaid patients.

            What I’m hearing you say is that “the incentives for treatment are broken and we need to fix them.” That’s absolutely true. But we need to do that across the system, not just for Medicaid patients. ACOs are a positive, though unproven, step in that direction. (Insert requisite caveat about issues of provider consolidation here.) We need to reform incentives around the system, but as this proposal stands, it’s not a very good way to do so.

            • I appreciate the debate, Allen. We share the same values, we just have different opinions on how to achieve them. I agree, the entire system must be changed. It’s not going to change through our current 3rd party payment system and hospital monopolies. I view healthcare as a product, no different than any other product that we purchase based on needs and wants (yes, there’s an inelastic demand issue, but I don’t think it’s that big, or rather, I think that’s rare). Unfortunately our system has purposely created complexity around those purchasing decisions in order to justify a lack of transparency and ridiculous pricing. The only way to break that is by going direct – direct from consumer/employer/payer to provider. Avik’s plan allows for that to occur. It needs to happen not only at the primary care level, but at the specialist level as well. The Surgery Center of Oklahoma is one example of that. Another is how Walmart is contracting directly with providers for certain procedures. Intel’s contract with Presbyterian in New Mexico is another great example.

    • What people who have chronic diseases need is teams who’ve figured out how to manage them with a mix of doctors, nurses and skilled lay people doing everything from diagnosis and high level care to running weekly/monthly clinics, calling with encouragement, and hand-holding.

      Unless the provider is huge, they might not get the volume to make running a clinic cost-effective. Worse yet, under the capitation model, if they run a successful diabetes clinic, they might attract diabetics and end up with a sicker, more expensive patient mix.