1992
Public Health Service
Primary Care Policy Fellowship

"A Policy for Health Care Prioritization"

William G. Bithoney, M.D.
Associate Chair, General Pediatrics
Harvard Medical School

Rosemary Duffy, D.D.S., M.P.H.
Acting Branch Chief
Dental Education and Special Initiatives Branch
Bureau of Health Professions

Paul M. Fischer, M.D. *
Private Practice
University Family Medicine

Carmelita Grady, M.P.H.
Project Director
Grass Roots Education Initiative for Health Care Reform
National Medical Association

Don G. Kruse, M.D.
Administrative Medical Director
Yukon-Kuskokwim-Health Corporation

Kenneth J. Veit, D.O., M.B.A.
Vice President of Academic Affairs
Philadelphia College of Osteopathic Medicine

* Presenter

BACKGROUND

Health care costs in the United States have risen to a level beyond which the public is not likely to pay. Despite high expenditures, 40 million Americans remain uninsured, and another 40 million are underinsured. Furthermore, 150 million have no dental insurance. The two factors of rising cost and shrinking access, have led to defacto rationing of health care services, based on income. We believe that the public’s health would greatly improve if rationing decisions were explicit, rather than implicit and will outline a strategy for achieving this goal, consistent with the President’s plan for comprehensive health care reform, as well as the other major plans currently under consideration.

PREMISE 1.    In the near future, there will be universal access to a basic level of health care services.

EVIDENCE

Universal access to a basic level of services is a component of each of the major plans for reform. Nine out of 10 Americans support a fundamental change in the U.S. health care system to include universal access. This sentiment is a result of rising insurance rates, and the rising numbers of uninsured. These increasing costs are reflected in the fact that 85% of the uninsured are in-fact employed.

We support the President’s focus on plans to improve health care efficiency by increasing the use of coordinated care, reducing administrative costs, and accomplishing malpractice reform. But, we are concerned with the present plans to base the decisions regarding basic health care benefits on the size of the insurance tax credit and to make these decisions by cooperation between States and private insurance companies. Instead, we believe that a decision should first be made regarding which services should be provided, and then determine the appropriate level of expenditure. Furthermore, the basic coverage should be established at a national level with public comment; not driven by state/insurance company discussions.

PREMISE 2.    The most and best health care services will be based on primary and preventive care provided on a basic level of expenditures.

EVIDENCE

Given the limited funds available for basic health care, it is essential that these services be provided with great efficiency. As the Government supported Medicare Outcome Study has recently shown, primary care physicians - - such as Family Practitioners - - are considerably more cost effective in the provision of care than specialists. We therefore propose that one element of the basic health care plan include access to a personal primary care provider, such as a primary care physician, dentists, nurse practitioner, or physician assistant.

Many preventive services have been shown to be cost effective and should be included. At this time, the United States has lower immunization rates for one year olds for polio than the African country of Botswana. Eighty percent of children covered by Medicaid have not had a routine visit to a dentist. Only 25% of the known hypertensives currently have their blood pressure under control. This leads to a four-fold increase in risk for coronary heart disease, and a seven-fold increase in risk for stroke. At this time, only 20% of the at-risk population for serious sequelae of influenza receive the vaccine. This full immunization could result in 20,000 preventable deaths per year.

To avoid expensive illness care, preventive services must be explicitly included in the basic health care plan. The current policy to exclude preventive services from health insurance plans has been a tragic and expensive mistake.

PREMISE 3.    Decisions regarding prioritization of basic health benefits should include public input regarding the value of these services.

EVIDENCE

Many of the health care services – beyond primary and preventive care – will necessarily be difficult to provide at an acceptable cost in a basic health care plan. Should we perform coronary bypass surgery on a 90 year old, or dialysis on a person with terminal cancer? To answer these difficult questions, we propose that decisions be made by combining cost effectiveness data with public input regarding the value of these services.

BENEFITS OF THIS PROPOSAL

1. This plan is consistent with all current proposed payer systems; including insurance from tax credits, employee benefits, Medicare, Medicaid, or single payer. Each of these approaches is dependent on a basic health care scheme - only payment policies vary.
2. Medical innovation would not be stymied. Services, other than those in the basic Federal health care plan would be covered by other private insurance (like Medigap plans today); by States with special resources and needs; and as part of research programs.

SHORT TERM STEPS FOR HHS

1. Support pilot projects, including the proposed Oregon Medicaid plan, to explore the optimal way to design and provide basic health care programs. Each pilot program should be formally evaluated to better understand how public input can be best included in health care services prioritization, and to determine the burden of mortality and morbidity which occurs from explicit rationing decisions are made.
2. Support further research on issues of cost effectiveness, so that this information can be reliably available for the informed marketplace.
3. Incrementally expand the payment for preventive services - including dental – provided under Medicaid/Medicare, followed by formal evaluation of the effect of this payment change on total costs and health outcome.

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