JustCare

Tag: Primary care doctor

  • Primary care through CVS? Financial incentives pose a serious concern

    Primary care through CVS? Financial incentives pose a serious concern

    Lucia Ryll shares her opinion in MedPage Today on the risks posed by CVS’ latest move into primary care. Ryll recognizes the obstacles many people face accessing primary care, including delays that can result in poor health outcomes. She questions whether CVS Health offers a solution in the form of primary care doctors at its clinics, given CVS’ financial incentive to maximize profits.

    CVS Health now has nearly 10,000 retail stores. It also operates just over 1,000 MinuteClinics. Caremark, its Pharmacy Benefit Manager (PBM) serves 105 million people. It sells 6,000 CVS-branded medical products. And, it provides health insurance to 34 million Americans. Enlisting a large team of primary care doctors to deliver primary care at CVS clinics is its latest business initiative.

    CVS’ expansion into primary care will be through its MinuteClinics renamed HealthHUBs. With this expansion, CVS will engage primary care doctors to provide care to individuals, sell these individuals medicines through its pharmacies, cover medicines through its insurance plans and build its formulary (list of covered drugs) through its PBM. What does that mean for individuals who rely on CVS for these services?

    No question that it could mean easier access to primary care for people, as most people live close to a CVS.  But, financial incentives could get in the way of CVS providing people with high-quality care.

    CVS as insurer should have an incentive to keep people out of the hospital, to keep its spending down. But, will it deny access to hospital care inappropriately, because hospital care is expensive, in order to maximize profits? CVS could do so through prior authorization requirements and mandates for people to receive less costly treatments, perhaps requiring a telehealth visit or a visit to a HealthHUB before going to the hospital.

    And, who knows what incentives CVS will give the primary care doctors at the HealthHUBs. These primary care doctors might be financially disincentivized to refer patients out of network even if they need out-of-network care. They also might be financially incentivized to prescribe patients drugs on the CVS Caremark formulary rather than lower-cost drugs. Physicians are human and subject to the same financial incentives as everyone else.

    What’s most concerning is what we are seeing throughout Medicare Advantage–a financial incentive to keep people in poor health from enrolling. The CVS Health plan might find that it maximizes profits by avoiding enrolling people with complex and costly conditions.

    Yes, it’s fair to think that CVS has the leverage to bring down health care costs and improve quality in our health care system. But, there is no sign that it’s willing to do so. In fact, a whistleblower lawsuit that Just Care reported last week indicates that CVS is in it for CVS, failing to include generic drugs on its formulary or to stock them in its pharmacies when brand-name drugs generate greater profits for CVS. With these brand-name drugs, CVS profits at the expense of its enrollees who are forced to pay more out of pocket for their drugs.

    Bottom line: CVS’ for-profit vertical integration easily could undermine access to quality care, lead to poor health outcomes and drive up healthcare costs for enrollees in its health plan. There’s virtually no transparency into what CVS is doing. Who will ensure that CVS is held accountable for bad acts?

    Lyll suggests that global payment models, through which a healthcare system is paid a flat rate could be helpful. But, with little transparency as to how CVS operates, there’s cause for serious concern. No data, there’s no way to know whether there’s value. And, a fixed payment to a healthcare system leaves it up to the system to decide what to pocket for itself and what to pay for. That’s a scary situation, as we have seen over and over again, with chain nursing homes among other health care businesses.

    I’m with Susan Rogers, MD,  “[CVS] is not a system designed to improve healthcare while saving money. There is no way that a system with middlemen whose mission is to make money can do so with providers whose mission is to deliver healthcare that is needed and not deny that care to increase profits. This is a system that will destroy the core of patient physician relationships when decisions are made driven by making profit, not by what doctors feel is indicated.”

    Here’s more from Just Care:

  • Questions for your primary care doctor if you have Medicare

    Questions for your primary care doctor if you have Medicare

    As you might know, the federal government is moving towards a “capitated” payment model for everyone with Medicare, paying insurers, private equity, and other intermediaries a flat fee for each enrollee and handing over to them the power to decide when to cover enrollees’ care and what care to cover. These intermediaries might have your best interests at heart, but they also might be focused on maximizing their profits and not your care needs. Your primary care doctor should be able to help you understand whether you are getting the care you need.

    If you’re in a Medicare Advantage plan, you signed up for coverage that an insurance company oversees. Some Medicare Advantage plans do a better job than others of ensuring you get the care you need. Others inappropriately delay and deny care a lot of the time.

    If you’re in traditional Medicare, an insurance company or private equity intermediary might be overseeing your coverage and you might not know it. Until 2021, that was never the case. You should find out whether there is an intermediary, sometimes called a Direct Contracting Entity or DCE. It is possible that this intermediary will try to inappropriately delay or deny your care through its preferred network of providers. You should know that, even if you are in a DCE, you have still have easy access to the doctors and hospitals of your choice and coverage of all medically necessary care through traditional Medicare outside that network.

    To help you decide whether your primary care doctor will provide you with the care you need or whether you are better off disenrolling from your Medicare Advantage plan or switching primary care doctors and opting out of your DCE, find out the answers to these questions.

    1. Is your primary care doctor employed or working under contract for an insurance company or a private equity firm?

    • If you are in a Medicare Advantage plan, the answer is always yes.
    • If you are in traditional Medicare, the answer could be yes or no. You should be able to find out the answer by calling 1-800-MEDICARE or by calling your primary care doctor’s office. If the answer is no, you are not in a Direct Contracting Entity and no one should be interfering with the care you receive. If the answer is yes, the federal government likely involuntarily enrolled you in a Direct Contracting Entity, and you have the right to opt out.

    2. Is anyone directing your primary care doctor as to how to handle your care? How is it affecting the care your primary care doctor delivers?

    • Is your primary care doctor unable to spend adequate time with you?
    • Is your primary care doctor being directed to refer you only to lesser quality doctors and hospitals?
    • Is your primary care doctor ever prevented from getting you the care the doctor thinks you need?

    If the answer to any of these questions is yes, you might want to consider finding a new primary care doctor and opting out of your DCE or Medicare Advantage plan. Tip: If you are in traditional Medicare, you always have the freedom to use whatever doctors and hospitals you would like, regardless of what your primary care doctor recommends. And, so long as you have supplemental coverage–Medigap, retiree coverage from a former employer, or Medicaid, virtually all your costs will be covered.

    If you are in traditional Medicare and your primary care doctor suggests you either drop your Medicare supplemental coverage or move to a Medicare Advantage plan, ask why and beware. 

    • Dropping your supplemental coverage if you are in traditional Medicare or moving to a Medicare Advantage plan will prevent you from being able to get care wherever you’d like because your out-of-pocket costs could be very high.
    • Moving to a Medicare Advantage plan restricts your choice of health care providers and often limits your ability to get care at centers of excellence and from the best specialists. Your annual out-of-pocket costs could be as much as $7,550 for in-network medical and hospital care alone.
    • Whether you drop your supplemental coverage and remain in traditional Medicare or switch to Medicare Advantage, you very well may never be able to get supplemental coverage again. Your right to buy supplemental coverage is extremely limited.

    If you have questions, please email [email protected].

    Here’s more from Just Care:

  • Round up: Emergency care

    Round up: Emergency care

    As you know, health care costs can be sky high. Regardless of what you pay, your health outcomes depend heavily upon the quality of care you receive. Since emergencies are by definition unexpected, it’s important to think about what could be in store for you and to plan ahead for a medical emergency.

    Preparing yourself:

    Making sure Medicare covers your care:

    The importance of a good primary care doctor:

    Your hospital care:

    Thinking about costs:

    And, for the broader picture:

     

  • Roundup: Your doctors and your health

    Roundup: Your doctors and your health

    Some doctors are a lot better than other doctors. As you get older, it’s especially important that you and your loved ones have doctors who listen to you, who do not undertreat or overtreat you, and who work with you to think through your health care wishes and your treatment options. These days, many doctors are looking at their computers and their watches during the patient’s visit, and those doctors should be avoided at all costs. Here’s a bunch of things to think about as a caregiver and as a patient:

    Take care of your health:

    Choose your doctors carefully:

    Make the most of your doctor’s visit:

    Speeding your recovery:

  • It’s time to expand our National Health Service Corps

    It’s time to expand our National Health Service Corps

    Jonathan Michels writes for Jacobin on our homegrown army of  doctors in the US National Health Service Corps. These primary care doctors have been practicing in underserved communities throughout the US for 50 years. It’s time to expand the National Health Service Corps.

    We have a shortage of primary care doctors. One report finds that by 2033, the US will be short 55,200 primary care doctors. Today, people struggle to get the preventive care they need, along with referrals for specialty care. In the next decade, the situation is likely to only worsen.

    President Biden’s American Rescue Plan commits an additional $1 billion to the National Health Service Corps. Michels calls it “a model for universal programs.” It is not profit-driven and is designed to meet the individual needs of the people it serves.

    Members of the National Health Service Corps. include physician assistants, social workers, nurses, mental and behavioral health specialists and physicians. Most of them practice at Federally Qualified Health Centers, sometimes called FQHCs or community health centers. There are thousands of FQHC sites throughout the country treating patients of all-income levels. But, FQHCs primarily serve  people with low incomes and charge people on a sliding scale.

    FQHCs serve about 26 million people each year. About half of them have Medicaid. Among other things, FQHCs provide vaccinations and health screenings. With more staffing and resources they could serve a lot more people.

    The American Rescue Plan’s $1 billion will pay for tuition and offer loan forgiveness to people in the National Health Service Corps. Medical education is so costly and can leave students in substantial debt. The National Health Service Corps. recognizes the need for primary care doctors. It responds to the reality that few students opt to go into primary care medicine because it is not nearly as lucrative as specialty care.

    Michels sees an opportunity to enlist members of the National Health Service Corps. in the Medicare for All movement. He argues that for Medicare for All to succeed, it will need an army of doctors advocating for it. The National Health Service Corps. participants appreciate the value of social solidarity and serving the public good. They would be excellent leaders in the movement.

    Here’s more from Just Care:

  • How to prepare for your doctor’s visit

    How to prepare for your doctor’s visit

    Whether you’re in good health or poor health, in a separate post I explained why it’s important to have a good primary care doctor. And, I’ve provided four questions to help you know whether your primary care doctor is meeting your needs. Here, I want to help you prepare for your doctor’s visit, so that you make the most of it.

    1. Confirm that your doctor accepts your insurance. If you have traditional Medicare, ask if the doctor accepts assignment, which means that the doctor accepts Medicare’s rate as payment in full. If you have a private insurer such as Aetna or Cigna, to save money, make sure the doctor is in-network. Always find out how much more you may have to pay out-of-pocket.
    2. Ask a family member or person you trust to join you. No matter what your age, it’s always good to have a health care buddy, a second pair of ears to listen to the doctor’s advice and, ideally, to take notes. You may also want your buddy to ask questions. The doctor’s visit can be stressful. You can decide to have your buddy be present for some or all of the visit – you are in charge!
    3. Make sure you bring a list of your medications with you, both prescription drugs and over the counter. And, ask your doctor whether you should be taking all these drugs.  It may be that you don’t need to be on a drug or that one drug you’re taking interacts poorly with another one. As you collect the bottles, think of any concerns, side effects or questions you have about your treatments.
    4. Make a list of all the questions you have for your doctor and other information you want to share, including any symptoms and concerns you have about your health. [Editor’s note: If you go alone to the visit, be sure to bring a pen and paper to take notes and repeat the doctor’s advice in order to confirm that you understand it.]
    5. If it’s your first appointment, you want to be sure to let your doctor know about any chronic conditions and any other health problems you have, as well as diseases that run in your family. If possible bring past medical records, test results, and your immunization records. You can ask the last doctor you saw to provide this information to your doctor, or you can sign a release form to have your new doctor’s office request your prior records.  If you are already an established patient of the doctor, be ready to provide your doctor with any major family health updates—for example, if your brother has been recently diagnosed with high blood pressure, or a parent was diagnosed with cancer.
    6. Check with the office if you are expected to come on an empty stomach to your appointment. There are only a few tests that need to be done in the “fasting state” (meaning, no food or drinks other than water for 12 hours). If you are expected to be fasting, tell the office if you are taking medications that require food, or if you think this will be difficult for you for any reason. Remember that most routine tests are not affected by drinking water, but being dehydrated could lead to slightly abnormal results.
    7. If your doctor is suggesting a test or treatment, to avoid overtreatment, be sure to understand why you need it. What are your options? How will it help? Are there side effects?
    8. Be sure that when you leave the office you understand your diagnosis and what you need to do, as well as when and how to contact the doctor and when to make another appointment. If you need a new prescription, make sure you know when to take it and what to do if you experience any side effects.

    [Editor’s note: This post was originally published on June 29, 2016.]

    Here’s more from Just Care:

  • Every American needs a primary care doctor

    Every American needs a primary care doctor

    The National Academies of Sciences, Engineering and Medicine (NAS) just released a report urging that the federal government invest heavily in primary care as part of its public health infrastructure. Every American should have a primary care doctor. Will the Biden administration act on the NAS’ advice?

    The NAS describes primary care as a “public good,” much like public education. Primary care practices generally include physicians, nurse practitioners and mental health providers.

    The report’s authors want every American to either choose a primary care provider or have them assigned one by their insurer or employer. At the same time, the authors recognize that primary care is withering in the US.  COVID-19 took a toll on the already weak primary care infrastructure in place in the US. Many primary care practices were forced to lay off staff or, worse still, close down.

    The report’s authors want major government investment in primary care and recommend that Medicare and Medicaid pay primary care providers more and specialists less. They believe that the US will not have a strong health care system without a strong primary care infrastructure. It is critical for improving population health, for saving money and for keeping people from dying prematurely.

    When you have good primary care, you are more likely to detect health issues early. You are more likely to have good care management and coordination. Having a primary care provider also promotes continuity of care. And, that in turn makes it easier for people to get needed care.

    Other wealthy and middle-income countries invest far more heavily in primary care than the US. In the US, primary care represents about $1 in every $20 in health care spending. Other wealthy nations invest nearly three times that in their primary care infrastructure.

    Here’s more from Just Care:

  • Schedule your doctor’s appointment early in the day 

    Schedule your doctor’s appointment early in the day 

    In 2011, a paper published in Proceedings of the National Academy of Sciences revealed that judges are more lenient on defendants early in the morning and immediately after lunch. They are less tired and less rushed. Not surprisingly, new research reveals that primary care doctors provide better care early in the day. Schedule your doctor’s appointments in the morning!

    Researchers at the Penn Medicine Nudge Unit looked to see when doctors ordered colon and breast cancer screening tests for eligible patients over the course of the day. They wanted to see if there were patterns. Did patients get better preventive care services at particular times of the day?

    They found the same pattern with almost all doctors. More patients who saw their doctors early in the day received orders for cancer screening tests than patients who saw their doctors at the end of the day. The data: 64% v. 48% for women eligible for breast cancer screenings and 37% v. 23% for men eligible for colonoscopies. These are preventive care services these patients should be getting.

    Similarly, patients who saw their doctors early in the day were more likely to have screening tests than patients who saw their doctors later in the day.

    In a separate study, the researchers detected patterns in doctor’s providing flu vaccinations. They found more vaccinations early in the day. Yet another study found that doctors who saw patients later in the day were more likely to prescribe unnecessary antibiotics and opioids.

    The researchers believe that “decision fatigue” may be one reason why patients appear to get better medical attention early in the day. People tend to make less good choices after they have had to make a lot of other choices. Doctors and patients both may suffer from decision fatigue at the end of the day. Rushed visits at the end of the day when a doctor’s or patient’s schedule is jammed up can also contribute to poorer medical care.

    The researchers suggest a couple of ways to correct this problem. Electronic health records can nudge doctors’ assistants to advise patients to get their screening tests and flu vaccines. A mailed reminder to patients can also be helpful.

    Here’s more from Just Care:

  • Why you might want a female doctor

    Why you might want a female doctor

    Tara Parker-Pope writes for the New York Times that people who have a female doctor appear to have better health outcomes. The evidence from several studies suggest that it could be that both men and women do better with female doctors because they are better listeners. 

    A recent study published in the Proceedings of the National Academy of Sciences (PNAS) finds that female heart patients live longer when treated by female doctors. Female heart patients have greatest risk of death if treated by male doctors, but their risk of death is reduced when the male doctors have worked with female doctors or treated a lot of female patients.

    Researchers looked at over 580,000 heart attack patients in Florida over 20 years. They saw that male and female emergency room patients were less likely to die when the treating doctor was female.

    A 2016 Harvard study had similar findings. The researchers looked at 1.5 million Medicare patients who were in hospital. They found that the male and female patients who had female doctors had a reduced risk of death as well as a reduced likelihood of being rehospitalized after discharge than patients treated by male doctors. While the difference in risk of death was small–around 0.5 percent–if male doctors had the same outcomes as female doctors on the total Medicare population, it would mean 32,000 fewer people dying each year.

    Based on the data, one explanation for better outcomes with female doctors is that they rely a bit more on the evidence when treating patients and hew more closely to the clinical guidelines.

    Researchers at Johns Hopkins Bloomberg School of Public Health conducted a meta-analysis of studies of doctor communications. They found that female primary care doctors do a better job of listening to their patients than their male counterparts. The female doctors spent two more minutes with each patient, which amounts to 10 percent more time with them.

    If you have a male doctor you like, you still should make sure the doctor is a good listener, who takes you seriously. It’s important your doctor pay attention to you, not interrupt you precipitously and show an understanding of your health needs. You also need to be good at speaking up for yourself. Good communications is a very important element of good health care. Doctors will good listening skills are better able to understand symptoms, which can be important, especially for heart patients.

    Here’s more from Just Care:

  • Good incremental primary care delivers better health, longer life

    Good incremental primary care delivers better health, longer life

    If you’ve ever questioned why having a good primary care doctor is so critical, Atul Gawande explains in no uncertain terms in the January 23, 2017 New Yorker. In a nutshell, well-trained primary care doctors understand the whole range of issues affecting a patient’s health; and, they take an incremental approach to treatment that often delivers better health and longer life.

    Gawande tells us about spending time with a primary care doctor and patient with a serious chronic condition at the Graham Headache Center in Massachusetts. Rather than prescribing a battery of tests to help treat the patient’s migraine condition, the doctor has the patient explain his 40-year history of suffering from debilitating headaches and listens. The patient describes trying a battery of treatments to no avail, with his migraines only becoming more severe and more frequent.

    Gawande then shares with us that, after four years of slow and steady progress, the patient’s migraines have largely subsided. What was the treatment? The patient kept a diary of each migraine attack and met with his doctor every three months to adjust treatment based on the diary entries. That simple. But, the patient’s improvement was barely perceptible to the patient during the first three years. It took four years for the migraines to stop recurring at a frequent pace and devastating intensity.

    Gawande also describes a patient whose face is entirely swollen seeking treatment at a clinic in Jamaica Plain, Massachusetts. Again, rather than delivering the battery of tests to rule out conditions that are unlikely, the doctor takes advantage of her understanding of the patient’s full condition and the trust she has built with her patient. She takes “the long view.”

    “They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.”

    This approach led the patient’s medical team to determine she was allergic to naproxen, which she took to relieve migraine pain, and that it was causing the swelling.

    The big problem, according to Gawande, is that we do not value incremental care. Primary care doctors tend not to have the resources at their fingertips to diagnose and treat patients that are available to specialists. And, their annual income is on average half of that of specialists. So, it can be hard to find a good primary care doctor. But, especially if you suffer from one or more chronic conditions, a good primary care doctor can improve your health and extend your life immeasurably.

    Gawande notes that many Medicare Advantage plans charge high copays for primary care visits, deterring people from getting primary care. With traditional Medicare and supplemental coverage, you have no out-of-pocket costs. And, no matter which Medicare option you choose, Medicare covers the full cost of many preventive care services.

    Here’s more from Just Care: