Health Care Stakeholder Discussion: Primary Care

Uploaded by whitehouse on 23.07.2009

(Cross Talk)
Nancy-Ann DeParle: Thank you for coming in.
Getting toward a holiday weekend, I appreciate it.
I'm Nancy-Ann DeParle, and I met some of you before, and for
those of you I haven't met, look forward to a good discussion.
We're today going to be talking about the critical role that
primary care providers play in our healthcare system, and it's
something that the President talks about -- well, if you
haven't been listening recently, he's talking about healthcare
every day, and he always talks about the importance of primary
care and how he wants to make sure that we aren't just
covering people and offering people affordable healthcare in
the old system, he wants to make sure that it's in a new system
that has a renewed emphasis on lowering costs and on getting
people the right care at the right time, and that means
primary care and prevention.
So you all play a critical role in helping us to figure that
out, and we appreciate it.
I would like to say hello also to everybody watching this discussion on and, so this is
a new -- one of the innovations here at the White House, and you
all are going to have to help me do this.
So in addition to streaming this meeting on the Internet, as we
always do, there's a live chat going on about the meeting on
Facebook right now, and people are also submitting their
questions and comments through the White House website.
There's a lot going on.
Jenn Cannistra from our office is being kept up to date on
everybody's reactions, and during our discussion, we're
going to ask her to let us know what everyone is thinking.
And Jenn is right over there with the laptop.
We know that health reform has to improve primary care in this country.
We know that we need to increase the number of primary care
clinicians, and we want your suggestion on that, including
how to keep more primary care clinicians satisfied with their
work and continuing to do it, because that's part of the solution, too.
We know there are a lot of people retiring.
We know that we can cut costs and help Americans to live
longer, happier and healthier lives if we invest in prevention
and wellness programs that keep Americans out of the doctor's
office in the first place.
And that's why President Obama is committed to reform that
emphasizes patient involvement and promotes prevention,
wellness and primary care.
To put it another way, without reform that improves primary
care and strengthens primary care and what you do every day,
we won't be able to meet our goal of giving every American
high quality and affordable healthcare coverage, so today
we're really eager to hear your ideas.
And I want to introduce my colleague, Dr. Kavita Patel, who
is working here at the White House with us and helped to
organize this meeting.
So with that, I'll open it up and I guess -- am I first
supposed to do a video; is that right?
A Speaker: We do, in fact, have a YouTube question that was
submitted yesterday for the President's online town hall,
and so we can certainly start with that, and then, you know,
open up for people to make comments.
Nancy-Ann DeParle: Okay, great.
It's going to be back here.
A Speaker: (inaudible) starting my own business, I found that I can
only afford health insurance with a high deductible, I found
myself motivated not to go out for care until things get really bad.
How could the health reforms you and Congress are working on
change the system so it would encourage prevention and
treating healthcare problems before we worsen and get more costly?
Nancy-Ann DeParle: Well, there's an example of a policy that doesn't make sense,
a high deductible for preventive care.
So a young man who I assume is healthy, and hope he is, but
should not be discouraged, I bet everyone here would agree, from
coming in and getting preventive care.
See, that's a good way to start off the discussion.
I guess I'll just open it up by asking you how we can change the
system so we encourage prevention and treating
healthcare problems before they get worse and lead to something
a lot more expensive.
Keith, do you want to start?
Keith: Sure. I'm an independent community pharmacist.
And pharmacists, from a pharmacy perspective, pharmacists for
years have only be paid for a final drug product, that's it.
We're the purveyor of a commodity.
Outcomes is what we need to show, and pharmacists see more
and more -- more patients, more individuals on a daily basis
than any other healthcare provider.
We're well positioned to show outcomes, it's been proven, and
it has been shown medication therapy management, which is
under Medicare Part D, face-to-face contact with the
community pharmacist saved twice of what just the phone
conversation would be, twice what a phone conversation would be.
Insulin injection technique.
Compliance, compliance is a huge issue.
One-third of all hospital visits could be avoided, could be
prevented if patients were compliant and adhered to medication therapy.
It's very simple and a --
A Speaker: And how.
Keith: -- a small price to pay.
A Speaker: How widespread is -- you know, medication therapy
management, it's a fancy word, but really you're just talking
about your pharmacist consulting with you and understanding what
you're taking and making sure that you're doing it properly, right?
Keith: Doing it properly, working with the patient to make
sure they are taking it properly, changing them possibly
to a cheaper alternative, working with the physician on
the best therapy possible for that patient and one they can afford.
Nancy-Ann DeParle: How many different kinds of drugs are there out
there these days?
Keith: I can't count that high.
I know in my pharmacy, I roughly have probably around 1400 on the
shelf, 14 different SKU's just on the shelf.
Nancy-Ann DeParle: That's a lot for a patient to understand that, you know, if
they are taking four or five things, they may not understand
what they should be doing.
Keith: Sure. I know about 200 of those is roughly about 54 percent of
what I fill, but yet I carry, you know, that inventory on a
day-to-day basis.
Nancy-Ann DeParle: And how many insurance plans right now cover
medication therapy management?
Keith: Right now, Medicare Part D mandates, but there are
very, very few individual plans that actually cover medication
therapy management, and that's where we're losing our patients.
You know, private employers don't benefit from this.
Individuals like this young gentleman don't benefit from that.
And, you know, my employees don't benefit from that being a
small business person.
And small business employs more people across this country than
the large businesses, but yet we're losing all of those folks,
and those are the ones that can't afford healthcare right
now and they are being lost because they can't afford the
premiums, they can't afford to go to the doctor when they don't have the insurance.
Nancy-Ann DeParle: So you see both sides of it as --
Keith: See both sides of it.
Nancy-Ann DeParle: -- you're a small business owner.
Keith: Yes, ma'am.
Nancy-Ann DeParle: Interesting. Who else wants to get in here? Fred?
Fred: We really need to change our --
Nancy-Ann DeParle: You're the American College of Physicians. Thank you.
Fred: Right.
I practice general internal medicine in a small town in Tennessee.
Nancy-Ann DeParle: I was going to say, do I know you?
I think I do. Okay.
And, Bob, I know you, too, so.
Fred: We actually -- we're celebrating our 100th
anniversary this year.
It's a primary care practice, eight physicians and a nurse practitioner.
And never in our history have we been more challenged than we are
in the current environment.
And I would just throw out, and this is an element that I think
everyone, including our questioner shares, we need to
align the incentives for a system that truly works.
We need to have providers who are able to provide cost
effective evidence-based care, and we need to have people have
an easy way to get into that system.
And in that case, I might use the term system without quotes,
because we clearly don't have a system right now.
It seems almost like any time I see a patient, there may be an
unnecessary burden or way in providing them care.
I may not know what medication is covered under their
formulary, even though it's appropriate, I may not know
whether a screening test for colon cancer is covered under
their insurance, even though I get dinged if we don't do it.
The same website that dings me won't provide me an answer to
the question of whether it's covered or not.
So anything that allows us, when we see individuals, to provide
the best quality care in the most efficient way possible is
something that we need to move toward.
And there are a lot of different elements to that. But --
Nancy-Ann DeParle: So you waste a lot of time, then, trying to figure out
if preventive care is even covered.
Fred: Right.
Right. Absolutely.
Fred: And individuals like this have been shown by studies,
if deductibles are high, they don't seek care.
And, you know, high deductibles are wonderful for something that
isn't based on the evidence.
I would endorse that heartily.
But if someone is not taking medication that is going to keep
them out of the hospital, then that clearly is penny wise and pound foolish.
Nancy-Ann DeParle: Fred, does your practice have an electronic health
record or how --
Fred: I'm glad you asked that question. Five years --
Nancy-Ann DeParle: We didn't practice this, so.
Fred: Five years ago, we invested our money in an
electronic health record system, and, you know, I think the
general estimates are that physicians gain about 15 percent
of the economic benefit of those systems.
And we did it because we knew it was the right thing to do.
And we know that it -- I mean, I was managing Coumadin from my --
from the ACP office this morning, which, by the way, also
is a service not covered under Medicare.
I would love to have that discussion later.
Telling people whose blood was too thin what dose, and they
call me on the 4th of July to have a follow-up study and to
let me adjust the dose.
But that is something that we know has been helpful.
We're able to track things, although it's, you know,
sometimes hard to -- you know, to learn all of the techniques,
and we would love some help from the Administration on that.
But we endorse what the Administration has been doing to
try to simplify things and try to enhance technology, but we
also need sort of a go-to person to help have a two-way
conversation with people who are in practice.
I could give you suggestions that could probably cut that
health affairs estimate of $65,000 worth of administrative
costs, I could probably cut that in half if you would help us or
you would foster a common website where I could take your
insurance card, get that information, it would
automatically tell me which angio -- which ARB was covered
if a certain generic medication was contraindicated, and have
that only take 15 seconds in an office visit as opposed to 30
minutes, 29 minutes of which is going through the 1-800 mommy
may I, and only one minute is clinical information.
But there are plenty of opportunities for us to enhance care.
Nancy-Ann DeParle: That's a great idea.
That's a great idea. Mona.
Mona: I'd like to speak to Fred, I'm a nurse practitioner,
I practice in rural Appalachia.
Nancy-Ann DeParle: You heard the President talking about nurse
practitioners the other night, I hope.
Mona: Yes, I heard that.
Mona: We are an independent nurse practitioner
practice, and we're out in the Appalachian hills, and there are
no other providers.
And who we work the most with is our community pharmacists, which
we've been discussing.
But I -- we've been all electronic medical records for ten years.
The problem that we find is the cost of the support and the
upkeep of the good programs is overwhelming to us.
That's number 1 issue.
And addressing what you asked earlier about how you get the
primary care providers into prevention, we've got a mobile
unit that we've just put on the road about four months ago, and
we've gone out to the churches and the schools and do free
screenings while we had grant funds, we don't -- we're going
to run out of grant funds, but doing free screenings, so we got
really early identification.
Then went after the grandmothers, because we're in a
matriarchal kind of society, and started educating them on how
can we keep the grandchild healthier as they grow.
And we're trying to track some of the lifestyle changes because of it.
But you really got to go after them at the beginning and get
early identification.
And it's not payable.
So I can't bill for it, so without grant funds, it's not
something you can sustain.
Nancy-Ann DeParle: Diana.
Diana: I'm a family nurse practitioner, I also work
in a family practice.
But I'd like to go back to the original question of I'm young,
I'm healthy, I have a high deductible, I can't afford to
pay for preventive care.
In Indiana, the governor and the legislature developed a program
for people who don't have health insurance, it's kind of a
public/private coverage program, and in that program, all of the
recipients of that insurance plan are required to get health --
their preventive healthcare every year, and they are given
something called a power account, which is $1,000 that
they can use to pay for preventive things that don't
get covered otherwise.
And, you know, I don't know why that couldn't be something that
if we're looking at an employer plan, an employer contribute to
that power plan.
In fact, the hospital that owns my practice is recruiting people
for this program, because it also saves the hospital money,
and they are funding the power account.
And these people are called -- in fact, I just talked to one of
my patients yesterday, I said it looks like you are ready for
your annual exam, when was your last PAP, mammogram, et cetera,
and she said, oh, I don't know, and I said, well, you have the
healthy Indiana plan and they are going to call you in about
two months to tell you you'd better get in here to have that
done or they'll take the power account away.
So, you know, you could have some kind of a deductible for
certain types of things, but then you have this medical
savings account or power account that you can use for
those healthy things.
It might also help, you know, for insurers to maybe go in a
partnership with patients on a combination of a medical savings
plan and a contribution for those kinds of preventive care things.
Nancy-Ann DeParle: That's great, so we -- We have a question.
A Speaker: We have a question. From the Internet.
We have -- well, we have a couple of Facebook comments that
I'll just throw out there, and then when you all speak, you can
certainly incorporate some of your thoughts.
Bob is asking about the nurses' shortage in the country and that
relationship to primary care.
Mike talks about how we need to deal with chronic conditions and
how good primary care can help us do that.
Nathan thinks we need to invest more in preventive care.
And Amanda supports universal care because she treats too many
people who don't have access to primary care and who are
bankrupt from their medical bills.
So those are a couple of the comments that we've been hearing so far.
A Speaker: Just to pick up on the comment regarding access.
Thank you, Ms. DeParle, for inviting us.
And (inaudible) we're with the Academy of Physician Assistants
and we're thrilled with the President's focus on primary
care, and along with physicians and nurse practitioners, PA's,
are also among the core providers of primary care in the country.
And one of the challenges I think we have an opportunity to
address with the reform efforts of the Administration is clearly
prevention and incentives and the financing and in bringing
all of those things together are key, but at the end of the day,
there needs to be a healthcare provider workforce in place and
ready to provide primary care.
And today there's not.
We have certainly a shortage of primary care physicians, we need
more physician assistants, we need more nurse practitioners,
and certainly would encourage and would look forward to
working with the Administration in terms of how do we go about
building the pipeline of both physicians and other
nonphysician practitioners, such as PA's and NP's.
PA's are produced in, you know, a third of the cost and half of
the time of physicians, certainly nurse practitioners
are more quickly trained as well.
We work very closely in a physician-led team, and we're
visible and vocal advocates of a physician-led team, but
recognize the shortages that are out there, and would love to
work with the Administration so that we can incentivize people
to go into primary care, stay in primary care, and likewise build
the pipeline going into primary care by making sure there are
faculties, not only for nursing schools, but for physician
assistant schools that would encourage primary care professions.
Nancy-Ann DeParle: Great.
And we are working on this, and we recognize there are areas of
the country where there are shortages, and we are going to
need more primary care clinicians, including PA's going forward.
We did make -- I'm proud that the President did make a big
investment in this in the beginning of the Administration
in the Recovery Act, investing in the national health service
corps, that will produce thousands more, but not enough.
We know that that's just a building block, and they'll have
to do more going forward.
And Congress is focused on that as well.
So we look forward to working with you on that. Katherine.
Katherine Nordal: Yes, I'm Katherine Nordal, and I'm the
executive director for professional practice at the
American Psychological Association.
I'm not here primarily as a practitioner, but I came to
Washington last year in my current position after 30 years
of practice in rural and suburban Mississippi.
I was a small business owner, I was a Medicare and Medicaid
provider, and have treated some generations actually of families
now with both mental and behavioral health issues.
And I would like to bring another perspective to the
clinicity problem and to just some observations about the system.
We have the greatest healthcare in the world here in America,
but the problem I think is the delivery system.
And we have a number of different provider groups
represented here today.
And I think one thing that is really missing in the reform
discussion is how we deliver that care.
It's like the blind man feeling the elephant, you know, you are
not sure what the animal is because you're only feeling one part of it.
So I would like to make the case for fully integrated care.
We made some tremendous inroads last year with the Mental Health
Parity Act, and hopefully that will set the floor so that
mental health and substance abuse disorders will be treated
like other physical disorders, as they should be.
If we look, even though just within the realm of physical
medicine, we know that probably 70 percent of all mental health
problems show up first in the primary care doc's office.
I worked with family practitioners, pediatricians,
nurse practitioners, PA's and other primary care docs, and
they were just absolutely overwhelmed with the complexity
of mental health problems that they saw in their practice.
And people went there because they wouldn't go to like the
community mental health center in my community where I started
out and then left to do my own practice, because the mental
health center system is in such shambles that most of the
treatment that's provided there now really is tertiary and
treatment of chronic care for conditions that had we had good
preventive care may not have gotten to that point.
Insofar as physical healthcare is concerned, 75 percent of our
healthcare dollars are spent on chronic illness.
And what is the biggest problem, you mentioned when you were
talking about with the pharmacy, it's motivational, motivational
issues, lifestyle issues and lack of adherence and compliance.
So I would make the argument that if we want to deliver
healthcare in a way that really treats the whole person as a
whole person, that we have healthcare teams that treat the
whole person, and that we address the mental health issues
as well as the behavioral issues that create and maintain chronic
illness at the same time that we're deciding, you know, do we
want to give that person a beta-blocker or do we want to
have a mental health person see them and teach them how to deal
with their anxiety.
Do we want to have to wait to put somebody on Lipitor, when
maybe if they've had appropriate preventive care in regard to
nutrition, exercise and other kinds of lifestyle choices that
made them and keep them sick, we can send them all to the
pharmacist, and then they take half of what is prescribed or
they don't take it correctly.
But I think we have to deliver care differently and we really
have to put that emphasis on prevention, and incent programs,
employers, and payers to pay for that care on the front end so we
don't continue with these horrible problems we have with
chronic physical and mental health conditions.
Nancy-Ann DeParle: Lorrie.
Lorrie Kaplan: Yes, I'd like to just follow along with what
Katherine is saying.
And I'm Lorrie Kaplan, I'm the Executive Director of the
American College of Nurse Midwives.
And you might wonder why midwives are here at the table
talking about primary care.
Nancy-Ann DeParle: That's where it starts.
Lorrie Kaplan: Exactly. Thank you.
Because we -- nurse midwives attend childbirth, but we also
provide primary care to women across the life span.
But there were two really wonderful reports in the last year.
We look at people who are responsible for delivering care,
integrated care to indigent populations.
They are really talking about this integrated workforce
strategy as being really the most economical way, and really
showing how that is improving health outcomes when we have
nurse practitioners, PA's, certified nurse midwives in
these team environments, such as academic health centers or
national -- community health centers, we really are lowering
the cost of care, we're improving access.
And I think you'd find in some of the disciplines, you have a
heavy focus on health education, promotion and wellness, so
investing in a workforce that really focuses on those skills
and really having an integrated workforce strategy, I love a
quote from the Academic Health Centers saying enabling all
healthcare professionals to function fully within their
defined scope of practice would contribute to leveraging
workforce capacity and increase access to care.
So this is where I think the Administration has really shown leadership.
I think for the first time in that we're looking at workforce
issues, we're looking at payment incentives, we're looking at all
of these areas, not just access, but if -- not just coverage, but
once we have the coverage, how do we make sure that those
patients are actually going to have access to care and not just
coverage without access.
So I really encourage us to look at workforce and payment reform,
and a really integrated team approach that is really going to
meet the needs of consumers.
Nancy-Ann DeParle: Cheryl and then Bill.
Cheryle Garvin: I'm Sherry Garvin, I'm a licensed
pharmacist and pharmacy owner in Leesburg, Virginia, and I
appreciate the chance to come and talk about healthcare reform today.
It's funny sitting here hearing everyone speak, the same words
keep cropping up, and I'm like yes, yes.
I mean, those are the issues.
Integrated care is huge.
We began really seeing the need for that, or at least I did, my
eyes were open to it when pharmacists started doing
medication therapy management for the Medicare Part D patients.
We get those patients in and they see their cardiologist and
they see their orthopedic doctor and their primary care, and
before they know it, they are on 24 different medications, many
of them are duplicates or unnecessary, many of them are
causing adverse effects for which they are getting another medication for.
So integrated care is huge.
The pharmacists have to be a part of that team in order to,
you know, effect good overall healthcare.
There's a lot of dollars being wasted because of those things happening.
The other thing that really struck me was aligned interests.
We have to have aligned interests, and that takes care
of a whole slew of issues.
Nancy-Ann DeParle: What do you mean when you say that?
Sherry Garvin: Everyone involved in the process of
providing healthcare, the interests have to be aligned.
In other words, if the insurance company is only looking at what
they are going to spend this year to provide care for that
patient, they are going to want to try to make it be the least
amount of money possible, when the reality is if you can spend
some money on preventive care, that saves a lot of healthcare
dollars farther down the road.
And speaking -- Diana mentioned preventive care being provided.
We have a lot of employers, private employers who have
realized this, that their health insurance for their employees,
and I see that, too, with my own employs, does not cover certain
things, but they have learned that if they put out a few
dollars at the beginning for some preventive care, they save a lot.
One great example is in the fall, we do flu clinics all
around our area, we go to local businesses and provide flu shots
for their employees, the business pays for those, but if
you think about how much money that saves the business because
they are not out sick for two weeks in the winter or, you
know, a host of their employees aren't out all at the same time,
so there are, you know, employers beginning to realize
that a small amount of money up front for preventive care pays
great dividends in the end.
Nancy-Ann DeParle: Thanks. Bill and then Tom.
Bill Ellis: Bill Ellis with the American Pharmacists
Association Foundation.
I wanted to build on the comments earlier about
integrated teams and how important that is.
And a lot of times in a discussion about healthcare
reform, sometimes we almost talk about it like we have to create
something that's never been there before, and I think that
community health centers in particular are there and serve
as great examples.
I'll mention specifically the El Rio Community Health Center in
Tucson, Arizona, providing tremendous care to an
underserved population where physicians, pharmacists and
nurses are working very closely.
It's a real model, it's not theoretical, it's there, so I'd
encourage the Administration to continue to work with us to
identify some of those sites that are there that aren't in
theory, they are real practices, and I think can health
illuminate what a reformed healthcare system should look like.
Nancy-Ann DeParle: Great.
That's great.
Bill Ellis: It's really then about scaling those models, not
necessarily creating something that's that new.
Nancy-Ann DeParle: You're right, we do talk about it as though it's
something that doesn't exist.
It's really more just focusing on what we already have learned
can work, medication therapy management, you know, community health centers.
Nancy-Ann DeParle: How about the primary care medical home, because that's
been another kind of model that -- and I know that -- I think of
the pediatricians, because that was when the term first -- when
I was training in school, that was -- I remember pediatricians
would talk about the medical home, and how does that realize
the success of integrated care, which is a common theme.
Mark Minier: So thank you very much for segueing --
Nancy-Ann DeParle: I'll put you in a second time.
Mark Minier: My name is Mark Minier, and I'm a practicing
pediatrician here in Washington.
And there's been a million things that have been talked
about that personally affect me and the children that I take care of.
First of one, as I am a member of the National Health Service
Corps, so I am working as a clinician in an underserved
community in exchange for getting my loans paid off for
medical school by the government, which is fantastic.
And I will say that is a wonderful program that the
Administration is putting money into to encourage more people to
take those positions.
So one thing I do caution is that it's great to get people
there, and you mentioned at the beginning keeping people in
primary care is a huge challenge.
It is a very hard job to be a primary care practitioner every
day all day long.
I was thinking about it, I got the call yesterday to come from
the AAP, thank you very much.
And I had to cancel 15 patients this afternoon to be here, but
to me, that was really important to get down here to say, you
know what, those 15 people, I'll have to fit them in another
time, because I need to represent the 75 million kids
here in the United States and the 9 million kids who don't
have insurance, because this is something that's really important.
But as a primary care doc, I'm making it a priority to be here.
And we are a community health center that is doing integrated
care, as you mentioned, the AAP created, I believe, the word the
medical home, or at least has really kind of defined that in a
way that talks about comprehensive coordinated
culturally appropriate care in a home where everybody serves that patient.
So in our center, we have pharmacists, we have OB
services, we have social work, we have nutrition, we have all
of those things that we need to help provide these kids the
services that they need.
I think that the most important thing that we're talking about
here, if we're talking about early intervention, we're
talking about primary prevention, we have to talk about children.
If the healthcare reform program does not specifically mention
children as a different entity within the program, then we've lost everything.
I think if we focus on adults, yes, I understand adults have
medical concerns, I am an adult and --
Mark Minier: But if we really want to look at how to prevent problems
in the future, then we need to look at children.
Medicaid is something that I think is often forgotten about.
We talk a lot about Medicare and how we're going to increase
funding for Medicare and how we're going to do all of these
programs, and then there's Medicaid over here, it's kind
of, oh, we'll deal with that later or we'll figure out what
we're going to do for children, but I think we really need to
spend close attention treating children as children and not
just little adults, who have very different problems and very different needs.
A Speaker: Could I respond to that as well?
Nancy-Ann DeParle: You know what, before you do, it do you mind if I -- because I
called on Tom and I haven't let him talk, so just let him go and
then I'll get you.
Thomas Menighan: Thank you.
And I resonate with mostly everything that's been said
around the table thus far.
You know, I'm Tom Menighan with the American Pharmacists Association.
I practiced community practice for many years, and I still own a pharmacy.
Pharmacists really can play a major role, to go back to the
first individual who you had on the webcast, many of those
people who wonder what's wrong with me walk into a pharmacy first.
And they look on the OTC shelves to see if there's something that
can fix their problem.
And pharmacists are too doggone busy in the back to come out and
spend the time helping that person because of a system that
doesn't put incentives in place to do that.
Now, if that individual was part of an integrated group that
allowed us to work with him to get him to the right doctor, to
get him into the system in such a way that we're going to
prevent issues, maybe it's something that could be treated
easily with an OTC, maybe it's something that requires care by
a nurse practitioner or physician or PA, that's what
we're all about, we triage all day every day, it's a big part
of what we do, but we're not in a system that incentivizes that.
If you shoot ahead of the duck a little bit here and you look at
healthcare technology, you'll see that the big push now is in
diagnostics, and diagnostics are getting closer and closer to the
patient all the time.
As that happens, they are going to find their way to pharmacies
and they are going to be asking questions in pharmacies.
So a system that prevents people from trying to fix a problem
with the wrong things is just as important as one that helps us
send them to the right places, and we would love to work with
you to build that kind of system.
Those systems don't have to be in four walls, they can be virtual.
There are a lot of things we can do with wires, and there are
people in this room that have done a lot of work in that regard.
Nancy-Ann DeParle: That's great.
Thomas Menighan: You know, I guess just to point out,
sometimes we get the question, can what we're professing with
regard to MTM scale.
I can tell you that the model that we built with immunization
has truly scaled.
Today we have over 80,000 pharmacists trained to do immunizations.
In this coming flu season, we'll do over 5 million immunizations.
We can scale.
Nancy-Ann DeParle: That's great. Jan.
Jan: I'm going to combine my comment now with a couple of
things that have been said and one of the questions that's been
asked, but I'm with the American Academy of Nurse Practitioners
and I'm the director of health policy, and one of the things we
can tell you is that we have 125,000 nurse practitioners out
there that are very interested and willing to put their
shoulder to all of this.
We are the fastest growing group of primary care providers at the
present time, so.
Nancy Ann DeParle: How long does it take to become a nurse practitioner?
Jan: Well, it takes -- in the long haul, it takes six years to
become a nurse practitioner, because you have to become a
professional nurse first, and then you go back to get your
graduate work in order to become an advanced practice nurse and
to be a nurse practitioner, so we're talking about a
significant period of time, it's true.
The thing that nurse practitioners have done through
the years is incorporated prevention in everything they do.
They are very hot on disease prevention and heath promotion,
so this has been something that has been incorporated in the
medical home model that we've been talking about.
The coordinated primary care model that is holistic,
et cetera, has been our mantra for -- forever, that's the way we do
things, and we feel it is very much couched in our nursing
background, to which we add the medical expertise.
And that's one of the things when you're looking at this, we
certainly need more nurse practitioners and we certainly
would like to have some help in producing more of them as well.
But we also know that some of the models that are out there
that would be really useful that we need to have people look at
relate to the question that was related to chronic care.
The nursing models that are out there that have been so
significant aren't being picked up and looked at in terms of
what can be done in relation to dealing with chronic care, and
yet they are the most successful models.
And so I think looking at some of the nurse practitioner
literature and the nursing literature and the group of
studies that have been done and trying to see how we can plug
that into the system I think would be a very good thing, and
we're willing to try whenever you're ready.
Nancy-Ann DeParle: Please help us.
Sort of like transitional care.
A Speaker: We have a question from the Internet again.
Yeah, we actually have had a couple of comments.
There are a lot of different discussions going on online in
response to what you're saying.
One talks about, you know, people who don't have insurance
or people who know folks who don't have insurance and just
have primary care can't be a priority then, but there's a
woman who has cancer and two young kids and just talks about,
you know, now she needs to try to treat her cancer without
insurance, but the importance of if she had had primary care from the beginning.
There was a discussion about incentives and how, you know,
people at work or trying to just incentivize people to focus on
prevention, wellness and really prioritize primary care.
And then there was a conversation about ER use and
primary care, and how because a lot of people don't have
insurance or delay care, they often wind up going to the ER
where the care is much more expensive, the condition is much
worse, and that contributes to longer waits at the ER.
So thank you to Bob and Erica and Amanda, Lynn and Tim for those comments.
Nancy-Ann DeParle: And it contributes to higher costs for everybody who is
insured, so it's just a vicious cycle going the wrong way. Maggie?
Maggie Mitchell: I'm Maggie Mitchell here on behalf of
American Dental Hygienists Association.
I just wanted to jump in quickly and say, as long as we've had
all of the talk about prevention, that as you all
know, because we all have a mouth --
We've all been children, we're all now adults,
but we all have a mouth, and dental hygienists are the
preventive professional in the oral healthcare team, and there
is no workforce shortage right now of dental hygienists.
There are 150,000 currently licensed in the United States, and so --
Nancy-Ann DeParle: Why is there no workforce shortage with dental hygienists?
Maggie Mitchell: Well, they just -- there was, there was.
Nancy-Ann DeParle: There was, yeah. And they addressed it.
Maggie Mitchell: That's been one of ADHA priorities is to
encourage -- it's mostly women, I was going to say women, it's
women and men, but it's a lot --
Nancy-Ann DeParle: But when you look at the
other shortages, you have to be honest and say in some cases,
it's reimbursement or it's working conditions.
I mean, when I threw out that question at the beginning, I was
serious about how can we prevent -- like Dr. Roston, you know,
the people that you practice with, I bet there's people in
your community who are saying I'm done with this, I'm tired of
it, how do we --
A Speaker: Well, as a matter of fact, that's actually
happening as we speak.
Nancy-ann DeParle: Yeah. So how do we keep them doing it?
Anyway, I interrupted you, Maggie.
Maggie Mitchell: So, but I was just going to say we
strongly urge that oral healthcare be included in this
whole overall healthcare reform debate.
A Speaker: You know, you can't gum an apple.
Nancy-Ann DeParle: Bob and then --
Bob: Yeah, just a few comments.
I work for the American College of Physicians, but I'm not a
clinician, I'm a policy guy, and so my world is focused on what's
going with Congress right now.
And I think here in the discussion today, it strikes me
how important that we have a comprehensive approach.
If we deal with workforce by itself but don't deal with
coverage, we're going to fail.
If we deal with coverage without dealing with workforce, we're
going to fail.
So we have to start with the premise everybody has to have affordable coverage.
Everybody has to have affordable coverage that covers primary
care and preventive services.
We need a workforce of physicians, nurses, PA's and
others to provide care to these people that hopefully will have insurance coverage.
And I think a very big part that we haven't really talked about
too much is payment reform.
Right now in our system, we overvalue procedures, we pay
physicians, nurses and others on an a la carte fee-for-service
basis, we pay for fragmented care and uncoordinated care.
You know, we all talk about teams, why don't we have high
functioning teams, because that's what we pay for in the United States.
In part, I think the answer to keep people in practice is to
start by reforming the current payment systems.
And yesterday Medicare had a big announcement that it proposed a
bill to raise payments to primary care clinicians very
substantially, which is the very first step, but then we need to
move to other payment models that are aligned with value,
because we believe that primary care will be shown to be the
best value in the healthcare system.
Nancy-Ann DeParle: Great. Daniel?
Daniel Tippett: My name is Dan Tippett, I'm a practicing
physician assistant in Virginia, and I'm also an educator as
well, so I speak very strongly about workforce issues.
Two comments I wanted to make, but first, I certainly
appreciate all that all of you do for the health of all of our
patients that we take care of.
But one, we're very supportive of the idea of the medical home
and I want to emphasize that PA's are part of the medical home concept.
The notion that we offer an insurance plan for someone with
a very high deductible is very counter-intuitive to prevention
and wellness, and then we wait for something to happen for the
disease so we can treat it.
And so certainly we're going to have to shift the philosophy of
how we look at the patient as a whole and the idea of prevention.
When it comes to workforce issues, I cannot emphasize
enough the need for more clinical sites.
I had a conversation with Congressman Glenn Nye who is in
our -- is representing our district, and it's not just
about providing more seats in a classroom, it's the clinical
side when we have to go out and get preceptors to actually want
to teach students in the clinical setting, and I think
that's going to be the real issue, not just for physician
assistants, but for physicians, nurse practitioners and --
Nancy-Ann DeParle: How do we do that?
Daniel Tippett: Well, he asked me the same thing, and the
honest answer is I -- quite honestly I think we're going to
have to incentivize physicians to want to teach.
My wife is an obstetrician, she has medical assistants, LPN's,
nurses, nurse practitioners, physician assistants and
physicians all wanting to get into her practice on top of
taking care of her patients.
So there has to be an emphasis of prioritizing your patients
first, but then having the altruism there, but that's
clearly an overload on the system, and we're going to have
to find more individuals that are going to be willing to take
on the education of more providers if we're talking about
increasing the workforce.
A Speaker: You probably all see -- those of you in education, this was
certainly when I was a first-year med student, there
was a ton of us that wanted to do primary care, we couldn't
find preceptor sites.
And that's not the only reason we didn't all go into primary
care, I did, but I was -- by the time I got to my fourth year, I
was one of a handful out of 200 who did.
And that's repeated itself, I would imagine, in every area,
that we just couldn't find a role model, and the role models
we did have were not happy.
And why would you want to go into something like that, that
was -- that was everybody, my friends who were nurses,
dentists, all of it.
A Speaker: Well, we have programs that are having to turn students away
because they can't find enough clinical sites.
We've had programs that have closed because they can't find
enough clinical sites.
So this is absolutely the key issue.
A Speaker: Another part of the problem is also that not enough of the
providers are reimbursed in any way.
We have a system in which, for example, physician residents can
come in and, you know, the hospital is reimbursed for
training those physicians, but we as an institution, my
hospital is not reimbursed for training nurse practitioners or
nurse midwives, and so as a certified nurse midwife in the
inner city, I work with a largely uninsured population,
all on Medicaid, these women come in with no dental care,
they need behavioral health resources, they need preventive
care of all types, and they are not able to access that care
until they are pregnant.
So once they are pregnant, we have a window of opportunity
then, you know, a nine-month period in which we are their
medical home, they come to me for everything, they are -- we
develop a relationship with them and we refer them for those much needed services.
But then again, while I would love to train more nurse
midwives to, you know, fill this void, we can't do it because
there's no -- there's no funds for it or it really drains our
resources, so it's really a big problem.
Nancy-Ann DeParle: Yeah. Carolyn.
Carolyn: I'm director of nurse-midwifery and women's
health nurse practitioner program at Georgetown
University, and I've actually spent the greatest part of my
career as a practitioner, and we always had students, and the
lineup was as you speak, I mean, the demand was far more than we
could possibly take, at a time when reimbursement was dwindling
for the practice, and, you know, we're getting fewer and fewer
cents back on the dollar while we're trying to train more and more students.
Now I've -- I jumped the fence and now I'm in education, and
I'm begging, I mean, literally begging my friends in practice
to please take my students, because I -- the limitation on
the number of students that we can take is literally based on clinical sites.
And we're sitting in the middle of Washington, DC, where there
are healthcare providers, as you all know, that we're falling
over, but trying to get those sites is incredibly difficult.
A Speaker: And in my --
Carolyn: There's no incentive.
A Speaker: Exactly. And in my situation, we -- at the nurse midwives, we
already train family practice residents for, you know, in obstetric care.
Carolyn: Yeah, she turned me down.
A Speaker: And I have to turn her -- but it's because my
hospital administration will not allow me to take a nurse midwife
student because they feel that, you know, they are not getting
anything out of the deal.
Where, you know, we're already training the family practice
docs, so it's really a big issue.
Nancy-Ann DeParle: Yeah, it's very difficult.
Keith and then Michelle.
Keith: Thank you.
We do have the greatest healthcare system in the world,
but unfortunately we're paying the price for it.
And go to answer the young lady back to the lady that has cancer
and can't afford her treatment, she can't afford the much needed
medications, because in this country, we're paying more than
any other country in the world.
The largest purchaser in this country, the federal government,
is paying more for medications than anyone else.
The largest group paying more for those medications than
anyone in the world.
And to go back to Medicaid, Mark mentioned Medicaid is often
forgotten, the high price of those medications when
pharmacies are reimbursed on average manufacturer's price
below what we actually pay for that medication, what are we going to do?
We're going to drop those contracts.
I ran a spreadsheet when average manufacturer's price first came
out, ran the numbers, and I actually lost money on every
prescription for Medicaid, every generic prescription that I filled.
So there's no incentive to use a much cost-effective alternative
with generic medication, so what are we going to do?
We're going to change that patient to a brand name
medication and end up paying more.
Now, the folks -- if I took that Medicaid contract, and I don't
mind giving the numbers, my net profit below what I actually
paid for that medication was minus $20,000, at 2 percent, 2.4 percent Medicaid.
I'm very low Medicaid in my area.
The average in Virginia is about 16 percent.
Now, when you get out to the valley, in the rural areas,
you're looking at 50, 60 percent or even higher.
And that is access, people are going to -- pharmacies are going
to drop those contracts, and folks and our patients are not
going to have access to their much needed medications.
So we're paying the highest price in the world.
A Speaker: We have questions at this end of the table.
Nancy-Ann DeParle: Okay. I'm doing the best I can.
Michelle, and then I'll come on this end. Okay?
Michelle Herbert Thomas Thanks.
I'm Michelle Herbert Thomas, and I'm a pharmacist down in
Richmond, and my family owns three pharmacies.
And my job within our company is -- well, I love what I do and I
work with patients every day, it's a little bit less
traditional when it comes to pharmacy practice, but I wanted
to comment on access to care.
With my two main responsibility areas are medication therapy
management, and there are definitely access issues.
There's not -- there's not a problem accessing a prescription
drug, you know, if you have your coverage, but beyond that,
medication therapy management access is very low.
We have thousands of patients, and many of those patients have
Medicare who should get medication therapy management
coverage, but of all of those, each -- twice each year, I get
the opportunity to provide medication therapy management to
a handful of patients through the Medicare services, and
that's because the insurers are offering service -- medication
therapy management services that aren't directly offered by the
individual pharmacist who takes care of the patient.
The patient doesn't know the person.
And whether or not they are contacting and doing anything
with those patients, I do not know, but I know that the
problems that exist with those patients, it appears to me that
it's not being done.
A Speaker: Letters don't work.
Michelle Herbert Thomas: Letters and calls from an outside person who is not aware
of what's going on with that patient is not really the most
effective way to help improve their care using medication therapy management.
So the access is very, very low to a service that I think we all
agree is -- is a needed service.
It's just not getting to the patients that need it.
So that was the first thing I wanted to comment on, and really
very much appreciate that Medicare coverage is there for
that service, but we just really need to expand it.
The second area of responsibility I have is I run a
diabetes education program that is an integrated program, I have
a nurse and a dietitian and myself, the pharmacist, we
receive referrals from physicians to provide diabetes education services.
In most cases in our program, it's people with newly diagnosed
diabetes, so they are very much out of control, they are very
scared, they don't know what to do, they need help with, you
know, from -- my role is to help with, you know, what medications
are doing to help them and what they need to do to work with
lifestyle issues and how medication works in with that.
But again, as a program that is nontraditional, that's not in a
hospital system, in the Richmond area, there are three ADA
recognized diabetes education programs that are available for
patients to select from, two of those three are based in hospitals.
So there's -- there are several insurers who refuse to
compensate us for our services because we are not
hospital-based. So --
Nancy-Ann DeParle: Why would that matter?
Michelle Herbert Thomas: we have to turn down all
patients who are State of Virginia employees and all
patients who have Aetna, then physicians say, well, I can't
refer patients to them, I don't remember who I can't refer
there, so, you know, that means we have less opportunity to help patients.
And really with three diabetes education programs in all of the
Richmond area, that's not enough as it is, and for us to not be
able to have access to those patients, I think there's a lot
more people we could help.
Nancy-Ann DeParle: Why would the fact that it's hospital-based make a difference
from -- clinically why would that matter?
Michelle Herbert Thomas: I wish I understood that.
I think that, you know, having called multiple times and asked
and gotten the same answer, it sounds to me like, you know,
they get national contracts, so if it's a hospital system, you
know, they can -- they can contract with, you know,
diabetes treatment centers of America across the country, and
they can't let anyone else in.
So, but that really does limit access to diabetes education programs.
Nancy-Ann DeParle: Bruce, okay.
Bruce Roberts: Nancy, I really appreciate this
opportunity to be with you today, and I think it's really --
I commend you for bringing together practitioners.
The other forums I've participated in, we've had
health systems and physicians and, you know, all sorts of
folks, and bringing this focused under primary care I think makes
an awful lot of sense.
I think primary care really is going to hold a lot of the
answers to healthcare reform.
From -- I'm Bruce Roberts from the National Community
Pharmacists Association, I'm a community pharmacist.
And I think that a lot of what's been said, whether it be aligned
interests, a fully integrated system, we all I think would
agree that that is where we need to go.
With pharmacy specifically related to those areas, I think
that there's some -- I would just highlight some real
problems out there in healthcare.
With pharmacy, you know, said for every dollar spent on
prescription drugs, there's a dollar's worth of problems.
There's studies that back that up.
And so the realty of how do we pay for healthcare reform if we
can just get the pharmacist integrated into the healthcare
system and begin to really make sure prescription drugs are used
correctly, we can save an awful lot of healthcare dollars.
I mean, there's great examples of where, you know, pharmacists
and physicians and the rest of the healthcare team have worked
together to make sure that patients adhere to their
medications with models that align the incentives between,
you know, all the different players, and healthcare costs go down.
I mean, it's amazing the money that can be spent.
And so one of the things that I would really recommend that you
give serious consideration to, and some of the bills that are --
the language is coming out or beginning to talk about it, and
the President has talked about it an awful lot, and that is the
whole interoperability of healthcare, the technology that
is going to be required.
Because we can talk about all of these wonderful things about an
integrated system, but if we don't have the systems in place,
we don't have the technology to embrace that, you know, whether
it's from electronic medical record from a prescriber to, you
know, the pharmacist, and we're all integrated in a way that
drives maximum value to those patients, we'll never get there.
So I think it's really, really important.
And from pharmacies' perspective, too, we have in
instances been siloed in healthcare.
Medicare Part D is an absolute tremendous example of not -- of
how not to do it.
Because you have the prescription drug benefit and a
siloed, all it's about is driving down the cost of the
drug, and there's no incentive, I mean actually there is --
there's a disincentive for prescription drugs to be used
correctly, because the reality is if you don't take them, the
insurer, whomever the Medicare Part D provider is, does better.
And so we really need to make sure that we, you know, we're
aligning those interests, we're making sure that we have a fully
integrated system, and pharmacy can -- I think pharmacy can play
a real significant role in helping control those costs as
long as they are considered.
And we appreciate in the medical home that, you know, it says
nontradition providers can -- are going to be part of that,
but I think we need to get more specific to say, you know, what
practitioners are going to be involved in the medical home.
A Speaker: We've got another set of comments I think from the
Internet, and then Mary had her hand up right before Jenn had her comments.
A Speaker: So there was a discussion about (inaudible) primary care
which we had just been talking about, and Michael from St. Paul, Minnesota,
talked about how support for training is really
important, so it touched on what we were talking about here.
Brian from Washington, DC, talked about shortages in all
professions, physicians, nurses, pharmacists.
And Julie from Reno, Nevada, said that the number of students
at her college taking classes in nursing is tied to the number of
faculty they have for nursing.
And so she talked about the need for more faculty.
And then there was a long discussion on costs and primary care.
Angela and Justin and Diane talked about the high cost of COBRA.
There was a comment from Florida about the high cost for small
businesses for all types of care, the highority (phonetic), primary.
And then there was a discussion as well about liability premiums
and making it financially reasonable for people to stay in
primary care by trying to lower premiums.
And Julie and Mary also talked about premiums as well.
Nancy-Ann DeParle: Who is next? Mary. Mary and then Jean.
Mary Alvord: I'm Mary Alvord, I'm a full-time psychologist
practitioner, as well as a business owner, small.
We have two offices in suburban Maryland, so I manage the
practice as well.
So a lot of these issues that are being brought up resonate
both from various hats.
But I wanted to talk about a couple of things.
I guess the stigma of mental health and making sure that
psychologists are truly viewed as health providers, and that
parity really becomes implemented in a way that
psychologists are on the table, because so many people file
complaints about physicians or others, but they don't want to
go and file any complaints to insurance regarding their mental
health issues, and I think it's because it's so much of a stigma.
But in addition, I work primarily with children
adolescents, so I want to make sure, like Mark, that they
really are not just little adults, it takes specialized training.
Psychologists are doctorly trained to, beyond sort of the
adult, to work with children adolescents, and so many parents
are reluctant to have -- to even use insurance when they do.
So that's another issue that needs to be addressed, I think
that's partly the stigma.
We need prevention for children.
We create all of these -- just as we all have mouths, we were
all children, and create habitual patterns.
You know, the obesity epidemic now is created to -- is related
very much in part to lifestyle choices, and we're trying to
educate, but there isn't the incentive for people to do a lot
of work in that.
So I'd like for parents to be able to get some preventive
services and not wait until the children's problems are so great.
We work collaboratively with schools, with pediatricians, and
many psychologists, I know many providers are less reluctant --
more reluctant to work with children because of all of the
time, the extra time that is spent collaborating that's not
reimbursed at all.
Nancy-Ann DeParle: Thank you. Jean.
Jean Carter: Thank you.
I'm Jean Carter, I'm also a psychologist, and I have a
practice here in Washington, DC.
And I wanted to actually to pick up on one of the things that
Mary just said, or she stole it out of my mouth, around stigma.
That's a very significant issue around -- around mental health.
And people think of mental health as over here and
separated off from the notions of behavioral health, and so all
of what we've been talking about about prevention is really about changing behavior.
We often think about it as, you know, we get these tests with
these numbers, and that's part of prevention.
And it is part of it.
But then what do you do with those and how do we help people
change their behavior so that the prevention actually becomes
a lifestyle change, actually becomes the kinds of activities
that people need to engage in for better health and for health promotion.
So incidentally, sort of on the side of that, I would love to
see us talk about healthcare homes rather than medical homes
so that we expand the notion to a broader perspective that
includes things like behavior change.
One of the issues that we face in expanding this notion of
mental health to behavioral health is that the mental health
coverage, which is what pays psychologists, is often in a
carve out, which means that it's limited, it's separate, it can't
really be integrated in the same way into healthcare more broadly
as long as it's kept carved out.
And in addition to that, the limits that we end up facing is
that the CPT codes, the procedure codes and the
diagnostic codes that psychologists can use and other
mental health providers are limited to only certain kinds of
services, so we're limited to things like psychotherapy, which
doesn't translate well to helping with issues of
compliance around meds.
So expanding the notion of how psychologists can be paid, how
mental health can be paid for and how we can move it to
notions of behavioral health I think would be a tremendous
thing for us to be able to do.
Nancy Ann DeParle: I think Randolph is next.
Randy Brooks: Thank you, Ms. DeParle, we appreciate the
invitation, and applaud what the President is doing on
healthcare, it's a tremendously difficult topic.
I'm Randy Brooks, I'm an optometrist practicing in
New Jersey, and I'm the Presidentof the American Optometric Association.
Like Mark, I'm a practitioner and changed all of my office
hours today for patients, because this is an important
thing to do.
Nancy-Ann DeParle: Thank you, we apologize to your patients.
Randy Brooks: Not at all.
Optometrists render about 70 percent of the primary eye care
in this country.
We are in 7,000 communities, and in 3,000 of those communities,
we are the only eye care practitioner.
And we render care from a perspective that is both
preventive as well as medical care.
Our practitioners are in rural settings and urban settings and
we do see shortages.
We encourage increased involvement in community health centers.
Prevention and early intervention is a tremendous
key, as we've heard it here today.
Bill and I served on an NCQA committee and we found that you
could achieve a lot more bang for the buck in terms of early
intervention and care, because not only is there less spent on
disease management when intervention occurs early,
whether it's a diabetic patient or a glaucoma patient, but it
also is a contribution to less lost time at work.
Every day in our office, we counsel patients, whether it's
on their A1C, smoking cessation, control of their hypertension,
or a nutritional therapy on macular degeneration.
We see cost of medicines as a huge issue in this country.
Many patients come in and afford their copay, but they can't
afford their medicine.
And when I prescribe the medication, I have to look
toward the affordability and whether the patient will be
adherent and compliant with the therapy.
Our primary focus and our primary concern is on everything
that's being -- generally being patient centered, patient is the
important person here, not the practitioner, and the patient
needs a choice, the patient needs access.
The patient needs access for whatever the covered service is,
whether it's routine eye care which may be covered under a
routine vision plan, or medical care that we render and be
seeing like glaucoma patients or removing a metallic foreign body
from someone's eye.
To me, it's critical that the patients have their choice of practitioner.
If a practitioner is able to and licensed to provide that
particular service, provides quality care, there shouldn't be
any artificial restrictions or boundaries on who provides that care.
So we feel that's an important piece to the healthcare picture. Thank you.
Nancy-Ann DeParle: Has everybody had a chance to speak once at least?
Okay. As we're repeating some people now. Okay, Mona.
Mona: I'll defer to Jan, she's going to have -- she
really wants to talk.
Nancy-Ann Deparle: Okay.
Jan: I just wanted to bring up the health IT thing.
There was a mention of small business issues, which kind of
triggered my thinking a little bit, because that's one of the
big frustrations I think everybody in this room has, is
that, you know, money was put in the stimulus package for health
IT, and I don't imagine anybody that's sitting in this room,
well, maybe a few, but most of us had -- you know, weren't able
to see any of that money, and yet these are the practices, our
practices are the small practices that really need
shoring up, and those of us who are dealing with vulnerable
populations, we need help with -- with being able to establish
medical records as well, but it's very hard to kind of get
that over the top, and it's something that parity in a lot
of these things would be really helpful.
Nancy-Ann DeParle: Thanks. Mona, go ahead.
Mona: Thank you.
One of the things -- I go back to my pediatrician colleague
over there, is the CHIP program and the Medicaid program and
that kind of thing, you have a lot of practices that are not
330 grantees, like the FQHC look-alikes, like all of the
nurse managed centers, like the small -- but they are serving
the vulnerable population and they have no access to any of
the stimulus monies.
Nancy-Ann DeParle: Mark, I guess.
Mark: I just want to pick up on what Mona said as well, and
also kind of going way back to what Keith said about Medicaid contracts.
And I'm very fortunate, I work for an FQHC who I'm salaried, so
I don't have to worry about my reimbursement from Medicaid.
I have 100 percent Medicaid population or uninsured or
Medicaid eligible, but I don't worry about what my
reimbursement rate is because we are contained within an FQHC,
but that practitioner who works in a rural community or in a
small community that needs to decide will I take a Medicaid
child where I'm not going to be reimbursed for what I actually
do, I think the business person in you at some point has to say
I can't do it, even if your heart says I want to.
They may for a while do as much as they can to see that kid and
do what they can for them, but at some point the bottom line I
think ends up becoming so important that they have to deny
care to those kids.
So I think that, again, going back to Medicaid and making sure
that all FQHC's are protected, I'm kind of happy about that,
that the individual practitioners and smaller
practices as well are also looked at far as their
Medicaid reimbursement rate.
A Speaker: The electric company won't accept zucchini. Yes.
Nancy-Ann DeParle: No, they won't. Just doesn't work. Michelle.
Michelle: Thank you.
I just really wanted to add on to the pediatric, the issue with
pediatrics as it relates to diabetes, and I think one of the
most difficult family issues to deal with is a child who
develops a chronic illness.
And when it's diabetes, the child ends up in the hospital
and everything changes for that child, everything changes for that family.
Medicaid, at least in the State of Virginia, does not cover
diabetes education services at all.
So a child of a family who is without the privileged life does
not get any training on how to live past that diagnosis, and
they are in and out of the hospital and they don't know
what to do and it's a very scary way to live, and it takes a long
time for them to figure out how to manage that disease without
that, you know, without that background of education on
management, so I think that's another way that system is kind
of failing the children.
Nancy-Ann DeParle: Keith.
Keith: We've talked about a number of ways to save
healthcare dollars long-term.
We talked about outcomes, paying providers incentives to increase
outcomes, we talked about medication therapy management,
but what else can we do to lower healthcare costs.
If the federal government is going to be a stakeholder in
this, they need to know what they're paying for.
We need to have a transparent system, no hidden fees, no
hidden costs, no hidden rebates.
They need to know what they're paying for, and it needs to be
a transparent system.
I'm not saying that companies can't make a profit.
If they're aligned with the private insurance or whoever,
companies need to make a profit.
You know, they have stockholders, you know, I'm a business person as
well and I need to make a profit and meet payroll and pay myself hopefully.
But we need to have a transparent system to know what
we're paying for, and that's one huge way to lower healthcare
dollars in the long run and it makes it more affordable in
healthcare premiums, it lowers drug costs, it lowers costs
across the board.
Nancy-Ann DeParle: Thank you. Tina.
Tina: We also have to pay for the right care at the right time.
Going to the question about the ER problem, you know, the use of
especially -- you know, in my population in inner city
Baltimore where, you know, nobody has insurance and the
average community patient in my practice for midwifery is maybe
19 years old, possibly Hispanic, African-American, high rates of
major socioeconomic problems and behavioral problems, substance
abuse, HIV rates are very high in the city, and these people
don't have primary care, and the only care they get, like I said
before, is when they are pregnant.
And so they come in and because we're able to have a practice in
which we can reach out to them, we've encouraged them to call us at any time.
We always have a midwife and a doctor on staff at the hospital,
and they are encouraged to call so that we can eliminate some of
the walk-in problems that are seen, especially in OB, and
amongst the uninsured and the uncovered, but also this is a
problem in everybody's ER, people don't have a place where
they can go and a place -- a relationship with a provider at
all of any kind.
And so you end up spending so much money just trying to cover
the problems that you could have possibly paid for had you
established a person for that patient to contact.
So I think that's one of the ways in which we can really
improve care, is to just get in there, get people the care that
they need at the right time so that they are not going back.
You know, if we can get to a woman in early part of pregnancy
and talk to her about her lifestyle, her behavior, prevent
the diabetes from happening, prevent the preeclampsia from
happening which costs us so much money.
You know, childbirth is the number one reason for admission
to the hospital in this country, and we throw so much money at
it, but we don't have the best outcomes in the world.
And there are practices -- in my practice, for example, we have a
14 percent C-section rate and a very, very high-risk population
because of the way that we -- the integrated practice they we
have and the fact that these people are managed in a women's
medical home type model by nurse midwives in collaboration with
the physicians and the rest of the healthcare team, and we're
saving the system an incredible amount of money, but it's just
one little practice.
If you could expand these types of practice settings that have
proven to make a difference that people don't really know about
that are out there, I think we can really save the system a lot
of money and also prevent all of this ER admission that happens
that really bogs down our system.
A Speaker: Yeah. Fred.
Fred: Well, moving back a little to 30,000 feet to sort of
incorporate a lot of what different people were saying
today, I think most of us here would agree that the
patient-centered medical home, although the name nobody likes,
I mean, a lot of people think they are being sent to the
"home," but for lack of a better term, that's where we really
want to be in the future.
And evidence will guide us toward the best way to deliver
that care, the best mix of professionals to do it.
But in the meantime, there are a number of the chess pieces that
we do know we need to get in alignment.
We need -- we desperately need workforce stability among
those already there.
And I just look back in my 25 years in practice, when I first
went into practice, I did the little exhibit where I helped
them start the RBRVS system, I had my little clipboard with the
timer, my life was totally different then than it is now.
Most of what I was -- did for a patient was in the exam room and
dictating immediately following the visit.
Now that's perhaps half of my time.
I had time to teach med students, residents, nurse practitioner students.
I don't have time, even before my public policy hobby, to do that.
And I think what we have to do is we have to have
some transitional issues.
Granted, the current payment system is imperfect, but we need
to stabilize those who are currently in practice and have
happy practitioners who can be role models, who can teach and
who provide an opportunity to bridge that toward where we all
know that we need to be eventually.
Nancy-Ann DeParle: Amen.
Nancy Ann DeParle: That's right.
That's great. All right, yes, Diana.
Diana: I would like to back up a little bit to some things
I've heard around the table today, and that is certainly
that we need all hands on deck, we need all people to be able to
do what they are capable of doing without artificial
barriers, and I think that that's the 800-pound elephant in
a lot of rooms, is allowing people to do what they know how
to do, which they have been educated to do, and, you know,
evidence is out there, there is evidence.
And, you know, we have -- we have to address those artificial barriers.
Some people are unhappy in primary care because they are
limited to certain things that they wouldn't be if we didn't
have these artificial barriers.
I also wanted to comment on the Medicare -- I mean the Medicaid issue.
In my state of Indiana, because nurse practitioners can't be
primary medical providers, we have -- we have practices where
you have these available excellent providers, but they
can't see the patients because the physician panel is full.
So they drive past your clinic 30 miles down the road in their
rickety old car at $4 a gallon of gas or $3, whatever it is
now, when there are two perfectly willing, educated,
ready to work primary care providers who are underutilized,
and that happens all the time.
I work in a rural area that's between a bunch of different
towns, and my practice is the safety net for a large town
where no one takes Medicaid anymore.
They just don't want to deal with it. And --
Nancy-Ann DeParle: So what's the solution to that?
Diana: What's the solution to that?
Use all the people you have.
Nancy-Ann DeParle: Yeah, remove the barriers.
Remove the barriers.
Diana: Use the people you have. Get rid of the barriers.
You know, how do you do that?
You X these things off the books, because they are
old-time, old-fashioned, old-thinking, fossilized ways of thinking.
Nancy-Ann DeParle: Are you talking about state scope of practice laws?
Diana: Well, just -- there's federal barriers,
there are federal barriers. I can't order home care.
I've taken care of Ms. B for 15 years and she now needs home
care before she goes to the nursing home or wherever else she goes.
I can't do that.
I've taken care of her, I've managed all of her chronic
medical problems, but when she has to be at home and she's on
Medicare, I can't order that.
I have to find someone, I have to find someone who doesn't know
this patient at all, who trusts me because they know me, that
will say, oh, yeah, sure, okay, okay, and, you know, and they --
Nancy-Ann DeParle: Charge you to sign it.
Diana: Well, or charge you, you know, you do pay
collaboration fees, I do.
And the same with hospice, you know, you've taken care of this
person, they've developed cancer, you know, they've been
through all of their treatments, they are at the end of their
life, we want them to have a comfortable way of leaving this
world, and I can't order hospice.
I can be an attending in hospice, but I can't order it.
We have to go find somebody who doesn't know this patient at
all, who has to then step in and order this hospice that I can then carry on with.
I mean, those are things that are just so stupid and
frustrating for us in the field.
I just, you know, it just is a very, very difficult thing.
And I've done this for 18 years, you know, I was a nurse for many
years before that, and that would be one of the things that
would make me just want to throw in the towel and walk away.
A Speaker: And it's the same thing at pharmacy.
I mean, pharmacy -- pharmacists are not recognized as
practitioners, they have no recognition under Medicare Part B.
I mean, it's the same thing.
I mean, to the extent that you can get all of these
practitioners working together to make sure that the patient is
taken care of, get rid of these artificial barriers so that the
entire team can work together, ultimately we can drive much
better outcomes at much less cost than the system we have today.
Nancy-Ann DeParle: I have to ask Dr. Roston, do you agree -- well, go ahead.
Dr. Roston: I would love for us to evolve toward a constantly changing
practice environment. And I understand that the Administration has taken some
great strides toward improving the rather flawed PQRI program,
but to me, I would love to have the data that shows exactly what
the right mix of providers is in our practice, adding certain
types of either physicians, PA's or nurse practitioners, whether
that improves quality, lowers costs, and that will . evolve over time.
But I think importantly for all of us, we need to be the first
one to get the feedback on the quality of care that we provide.
It can be spun off to as many other entities that want it, but
it shouldn't be claims kind of data being thrown at us and just
interfering with our work cycle.
We need to have sort of a dimming kind of continuous
quality improvement approach, and I think a lot of these
issues, I mean, Mona and I were talking earlier, one-on-one, we
could handle an awful lot of the things that -- you know, that we
talk about in theory being difficult.
I mean, when we first met, the ACP and nurse practitioners have
been talking with each other, we gave examples of particular kind
of patients, and once we talked about real world examples, we
found out we had a lot more in common and we understood that we
face common challenges.
In theory, you know, in the past we maybe talked past each other,
but we need to have more communication and we desperately
need help from an Administration, because we have
more in common in our daily frustrations than we do in opposition.
A Speaker: So we're getting close to our time, and we have some comments
from the Internet, and, Nancy, I could spend all day here, but
part of Jenn and I, our job is to make sure she can get to her
next thing that she has to solve the healthcare crisis on, so.
I do want to mention, though, that we will be -- there's an
opportunity to kind of continue to contribute your ideas
So I want to say that to not cut off anyone in the audience or on
the Internet that didn't get a chance, but would like to keep
this dialogue going.
So, Jenn, did you have more?
Jennifer Cannistra: Yeah. I guess I'll just do some larger summary comments.
There have been a bunch of discussions going on.
But Jeanette mentioned, you know, we need to remember that
preventive care will keep costs down and reduce the number of
visits to hospitals and give people more time who really need attention.
And Crystal goes down how so many people are dying of
diseases that are preventable, and so, you know, focusing on
primary care from the get-go is really important.
And then Deb talked about how we need to teach preventive care
and really focus on healthy education, childhood nutrition
and also lowering childhood obesity.
But everyone very much agreed with what you were saying, so,
you know, they appreciate the discussion.
A Speaker: So there were a couple of themes, I know Nancy-Ann gets
the last word, but it's -- we've done a number of these in the
White House and just listening kind of outside from the town
halls that we're doing across the country, but then a lot of
the dialogues that have been going on that some of you have
hosted in your homes, and a lot of it centers back to kind of a
mutual respect, and especially in the world of primary care, I
think that's something that's constantly reverberating, and
it's not just mutual respect of what our titles or our
identities are, but it's the mutual respect with transparency
and with the industry complex, whether it's pharmaceuticals,
insurance, doctors, hospitals -- we didn't really talk about
hospitals here, but when I was in practice, that was a constant
tension for our community practice was our main hospitals
and kind of we always felt like we were in opposition to each
other instead of working hand in hand.
So the mutual respect aspect, I've been taking a lot of notes,
which I'll get to Nancy and then the rest of the team, but really
realigning incentives and making sure that what we're paying for
is really high quality and the right care at the right time,
and also understanding that we don't necessarily have the
answers to what the right care or the right mix is, but that
we've got to be open to evolving as a system so that we can make
room for that.
And then the health IT issues, I think there are a number of us
that have been very supportive of the President's, thankfully
to all of you, who has really championed getting health IT and
really taking this to the forefront of the public
conversation, but that's certainly not the end.
And so keeping working on that and making sure it's truly accessible.
And then workforce issues all around, I don't think anyone --
maybe the dental hygienists are in good shape.
Nancy-Ann DeParle: That was a bit of good news.
A Speaker: That's like so we can take that back and say check, we
finished that up.
Everything else is still -- They haven't gotten -- A
Maybe you should teach us what it is you're doing
that's working. So I don't know with that, Nancy, if you want --
Nancy-Ann DeParle: I found this very inspiring, and in thinking about it,
we have done a number of these discussions.
And one thing that really struck me about this one is how
constantly the patient was at the center of this whole
conversation with each of you and the comments that you've made.
And I find that really inspiring.
And you've expressed some frustration with the way things
work right now and your inability to really treat the
whole patient and make sure that they are getting the preventive
care and primary care that they need.
But also thank you for highlighting some of the models
that are working out there.
And the community health centers and some of the things that you
are doing around the country that are working and that we can
build upon as we look toward hopefully a healthier future for America's families.
And so I just want to thank you for the work that you are doing
and for continuing to go help us to try to craft a better -- a
better system going forward.
So thank you very much for taking the time.
Panel: Thank you.
Apologize to your patients again --
for missing the afternoon.
Thank you.