Dear Followers, my friend & colleague, Kathaleen Grant, MPA, has submitted a post on the Primary Care Physicians (PCP) role in modern Healthcare. We both believe, the PCP is essential for the continuation of quality care. Please read her expert comments. Thank you!
As a retired health care professional of nearly 30 years, I am keenly aware of the concerns regarding many changes taking place in the health care marketplace. Especially now with this Administration’s destructive handling of Obamacare/The Affordable Care Act, we are at risk for higher insurance premium costs and drug prices, with no end in sight.
More specifically, the recent health care merger of CVS Pharmacies and Aetna Insurance Co in the news has prompted discussions and confusion around the American dinner table and for good reason. What will happen to my drug costs that are already too expensive? How will my health care be impacted if at all?
What most people don’t realize in 2018 is that the health care industry in the United States has undergone mergers, large and small, for more than three decades with various outcomes. Usually these mergers have been between providers and providers, health plans and other health plans, or pharmaceutical co and other pharma. I will discuss the Provider mergers today. In major urban areas across the US, hospitals merged: New York Hospital Cornell and Columbia Presbyterian merged years ago to become the New York Presbyterian Health Care System successfully. UCSF Medical Center in San Francisco, CA and Stanford Medical Center in Palo Alto, CA merged in the late 1990’s only to unmerge soon after. Having been a senior manager in the UCSF Stanford Healthcare System, I can testify to several unfortunate facts. The primary reason that it failed was due to non-physician buy-in. As simple as that sounds, it was the truth. The leadership failed to obtain the full support of both the UCSF and Stanford Medical Faculty as stakeholders in this process of uniting as one medical center. So when it came time to deliver health care services, you can just imagine the conflicts and petty differences that broke out between department chairmen on each campus, resulting in haphazard service flow, etc. It was a disaster. I believe the same was true when NYU and Mt. Sinai went through a merger process, and as we all know are now separate entities. But for the most part, the entire country has had more or less successful mergers of health care provider organizations over the years. In addition to NY Presby in NY, there is Catholic Health Care West/Dignity Health in AR, NV and CA, Sutter Health in CA, the Mayo Clinic in AR, FL & MN, Ascension Health in the Southeast, Tenet Health is nationwide, Community Health in the So & Northeast, and the US Vet Affairs Dept is nationwide. These are in the top 10 in the country and are each comprised of hospitals, physicians, both primary care and specialists, outpatient care centers/clinics, labs, x-ray facilities, etc. Some may also have their own health insurance plans.
When these mergers began, you may recall the beginning of what we know as Health Maintenance Organizations (HMO’s) and Preferred Provider Organizations) PPO’s in health care insurance plans. When these mergers occurred, hospitals and physicians in private practices in the community were included. It was really the only way an individual primary care physician (PCP) could survive financially. If he didn’t join, patients who had the insurance accepted by the merged organization could not be seen by him. This is why you don’t see any Marcus Welby MD’s out there anymore! An HMO requires that you see your PCP for everything and he/she will refer you to a specialist if it is necessary. In a PPO, which is more expensive, you can choose any physician in the network generally and are not required to go through your PCP for care.
What has transpired over the past several years has been the rise of what are called “convenience” clinics. These are walk-in clinics sponsored by various entities. Walgreens has on site clinics as does CVS. In NYC, we have several hospitals that sponsor clinics. One is called City MD and they have locations all over. I have been to this clinic three times and diagnosed with fairly serious illnesses, treated and sent home. I received x-rays and labs at the clinic and overall excellent care and they billed my Medicare and secondary insurance, providing me with a patient clinic summary for my doctor before leaving. Having been a health care professional, I can honestly say that the clinic was very clean and the staff were efficient and customer service friendly. The physician spent at least 25 minutes with me and the entire visit was entered into their computer system for later reference.
Now I’ve just described one person’s experience and I can only hope that other clinics are run as well. But it brings us back to the main goal of primary care in preventive medicine and how this is being affected by the myriad of changes taking place on main street in America. The health maintenance organization was originally created by Kaiser Permanente, the idea being that a patient’s total health care needs should be managed by their PCP. When a specific problem occurs, for example a neurological issue that requires a specialist, the PCP would bring in that clinician to examine and treat the patient, sending a complete report back to the PCP so that all medical history resided in one place for the purposes of continuity of care. This is very important! This same model was copied by all of these merged health care organizations that created HMO’s over the years. So now, we have “convenience” clinics. They do ask who is your PCP and you are encouraged to get one if you don’t have one. The reason for creating the clinics in NYC was to deal with the tremendous overflow of our hospital emergency rooms. In my professional opinion, they should be fixing their ER flow rather than putting a bandaid on it by creating outpatient clinics, but that’s another issue for another time. The bottom line is people should find a PCP and use clinics for emergency use only, providing their PCP with the clinic summary of what was done. However, for those people who simply do not have a PCP for whatever reason, going to these clinics for care is better than no care. We have many chronic disease patients on the streets with no insurance, no Medicaid. Unfortunately, these clinics will not see these patients. This will not solve their problem. That will not happen until we have a change in Washington.
Finally, let’s return to the recent merger of a different color. This is a merger of a pharmaceutical and a health plan. CVS has 9700 pharmacies and 1100 walk-in clinics nationwide. Aetna is the third largest health plan in the country. These entities are no small players on the health care stage. In a quote from January 23rd’s issue of Forbes Magazine, “In theory at least, CVS has new incentive to bring down drug prices and push for the most efficacious…treatment choices to achieve more competitive insurance premiums.” While for profit in health care is a total negative for me, I find this merger somewhat intriguing and perhaps, dare I say, hopeful? CVS discontinued sales of cigarettes in 2004 and also banned all digitally altered photos on cosmetic products which promote eating disorders and depression. These are not so much the decisions made by a courageous health care organization rather than a business enterprise. All of the above encourages me to think that their mission statement may include quality care delivery at a truly competitive cost to the patient. If you have Aetna insurance, at this point it is unclear how much your premium will change, if any, because Aetna has other contractual agreements besides its new one with CVS. Only time will tell.
To summarize, the future of this new type of merger is an unknown at this point and we can only ponder the outcome, though I’m hopeful in this case. Based upon the health care industry’s history of mergers, primary care practices have no cause to worry nor do their patients. The concern would be if patients stopped going to their PCP because they found that a clinic was more convenient. In terms of better long term wellness, that is not a wise choice.
See you Wednesday and we’ll chat
“the Heart and pulse of the Middle Class”