Dr. Kevin Haughton, Director of the Providence St. Peter Family Medicine Residency Program, offers some perspectives about areas of the delivery system that health reform has potential to address–along with some areas where the law may overreach…and fall short.
Q: What is your perspective about healthcare reform at this point?
A: If you’re speaking of the bill that has been passed, my feeling is that it’s really more about insurance reform than healthcare reform. We have problems with people not having access to primary care and they’re trying to address this with the Affordable Care Act. It’s got a lot of nobility in it that it has laudable goals. I think that people who raise a fuss about whether this is exactly a perfect way to approach it or not frequently have good points because there are likely going to be unintended consequences that we have to live with but meanwhile I don’t see us doing much else, and I would certainly be in favor of us trying to change something. The way we’ve been doing it for the last 50 years is clearly not working and so I think trying something new is a great idea.
Part of the problem with the system is that there’s legislated coverage for people as it is: If I walk out here and don’t have any health insurance and I get hit by a car, I go to the emergency room, they’ll put me in the ICU for a couple of months and I’ll get just fine care whether I have insurance or not. Well that’s a problem, because there’s a whole group of people who don’t think that’s going to happen to them, they don’t have health insurance. It’s a rational choice, because health insurance is so expensive. So they’re not putting any money into the system and then when they have these $50,000 misadventures the rest of the system has to absorb those costs. So this is an effort to address that problem with the system. There’s also the case that, for instance, if I were to have a stroke it would be likely that I would lose my job and therefore lose my health insurance and then I would be completely out of luck in no time. And this is an effort to try to address that problem with the system. So if we try to limit the preexisting condition problems, if we try and eliminate insurer’s ability to not take care of people once they actually need insurance I think that will helpful.
Whether this particular bill, when it actually gets entirely fleshed out, is the be-all and end-all is unlikely. But it think there are probably some really good things in there, I think there are probably some things that need to go. For example, I don’t want to see legislation that implies what you need to do when you’re actually providing care to patients, and I believe that there’s some of that in there. So you just can’t pass a law that ‘this is how you’re supposed to take care of patients’ and ‘this is what’s supposed to be covered’ because that’s science, and science is a moving target and we need to be able to move with the science and not just work with special interest groups who squawked loud and got the legislation fixed.
Q. What are some of the most promising aspects of reform?
A. Well I think that the way we have been operating for the past 50 years is to pay for volume and this is an effort to try and direct us more to paying for quality, to paying for outcomes. So I get paid to see patients; I don’t get paid to keep people healthy or to cure patients who are ill. So what you get out of that is a lot of people seeing patients–in whatever your specialty is, whether it’s in a lab or in an imaging center or with a scope of some kind–and getting paid various amounts of money to do that. Instead, we need to focus on how we keep people healthy and minimize the disruption to their life and their suffering. And I think this moves us in that direction and it’s a huge opportunity and it’s very exciting. The push to have Accountable Care Organizations may lead to more collaboration between various types of providers, which would be extremely helpful. I am particularly excited about interactions with public health for example, or being able to play a role with mental health. These are all pieces that are usually operating relatively independently compared to primary care.
Q. You mention greater access to primary care; are there enough physicians for people to access primary care physicians?
A. Well that’s a potential problem with the bill is that a lot more people will now have insurance and as we say, ‘we’re giving away tickets to a bus that’s already filled.’ So they may have trouble finding out where they can go to get primary care. Even though I’m in the business of helping to produce more primary care clinicians, there’s no way we’re going come up with the amount of primary care clinicians that we need in the short order that we will need them.
One of the exciting things about medical homes is that maybe we can find some new ways of doing things that will actually allow us to get more primary care out of the workforce that we have. And in particular I’m thinking, allowing other people who are working in primary care besides physicians to play a larger role in what we do. So for example, perhaps I should have more nurses in my office than I currently do, also they could use more computers, and I could have pharmacists coming to my office and helping manage the medications and teaching patients about how they can take their medications. Typically if you set up a well-defined system or protocol with people who are not physicians, they can follow that just as well, perhaps even better, than the physicians can. So I am optimistic that this will lead to better care and that will keep people out of the cath lab, out of dialysis, out of the transplant team longer and save us a little bit of money in the long run.