I am struggling with the fiscally conservative approach to health care policy this weekend, since I have just finished reading Greenspan's memoirs and find a number of interesting insights.
Given the apparent anti-competitive stance of my last post on retail clinics, I am feeling a little schizoid.
But the more I think about it, I am more convinced than ever that retail clinics are harmful because they alter the landscape in ways that could be ultimately negative for health outcomes. If there is a need for non-ER, after-hours facilities to provide care for minor medical urgencies, it is partly the result of labor shortages in the face of increasing demand. I'll be blunt; nobody in their right mind will take the lifestyle impairments of 24/7 availability out of their primary care office given the current regulatory burden, liability and low level of remuneration in primary care. There are not enough primary care docs to meet the demand and they are not sufficiently well remunerated to provide the level of care it takes to keep people out of ER. They need more resources, but instead, I see resources going to retail clinics and moreover, benefiting large, profitable pharmacy conglomerates at the expense of primary care.
I am furious at Massachusetts because not every state has a progressive (note I did not say liberal) tradition of protecting the common good and a regulatory structure to support it. It is hard for me to believe that intelligent, well-meaning people with a commitment to public health have such a distorted and short-sighted view of the world that they truly believe they are doing good by allowing retail clinics greater sway. To be honest, I had not previously followed the story and do not now have a full understanding of the arguments in support of retail clinics in Massachusetts, but the result produces a visceral response in me. I am guilty of knee-jerk reaction in this case. Most of my arguments are at Paul Levy's Running a hospital and they do not require repeating here.
One statement in Greenspan's book that I think is relevant for some reason is that "too low a risk-adjusted return implies a waste of resources and productivity." From a macro-economic perspective, I can understand that.
Workers (including physicians), capital and other resources will be distributed according to their risk-tolerance, the risk and return profile of their chosen activity and the depth of their personal resources. Some people take 12 years to finish their neurosurgery training because they perceive that the return on their time and effort (as well as the opportunity cost of deferred income) justifies those resources. The return is measured in dollars and some qualitative sense of their happiness and vocational satisfaction.
Others complete their three or four years of primary care residency and get to the workforce a little faster, expecting to live a somewhat less stressful life and earn a little less for the same effort. But that income cannot be so low that it no longer provides an incentive for working harder. There is a risk that, at some point, reimbursement can become so low as not justify working harder. There is a point, where you just show up for work, do your eight hours and pay the mortgage. Sometimes the headaches of additional patients, hours away from family and satisfying regulatory masters just do not make it worth any effort beyond just staying afloat until retirement.
In the end, you have got to love what you do, enjoy the training environment enough to survive and make an assessment of what you can reasonably accomplish as well as what it is worth in future income and satisfaction.
Those who put in their three to four years to become primary care physicians do not expect the same reimbursement levels as people who have invested a greater part of their lives in training, but as the differential in reimbursement between specialists and primary care grows, two things will happen:
a) more people will gravitate to specialties until primary reimbursement catches up due to the supply-demand equation. There will be shortages as a consequence, frequently manifest by a lack of primary care access.
b) as the demand for primary care grows, primary physicians will simply not be willing to put up with requirements from hospitals, ER's, specialists and even patients that impose greater uncompensated responsibilities and liabilities. In other words, there is no incentive to work harder and longer, to make sure after-hours coverage exists.
Retail clinics provide the opportunity for primary care providers to seek additional revenue, at low risk, low effort and high compensation. It is ultimately good for them. What the heck; if they can compete and do well in the system, all the more power to them.
But wait a minute! Whose system is it? What is the purpose and objective of our system? I did not see the words "to improve the financial health of physicians" in the mission statement of any non-profit in the country, much less that of a progressive state such as Massachusetts.
Surely retail clinics are going to help pharmacies generate prescriptions, revenues and excess profits. It is definitely good for them and probably for the markets and the economy as a whole. But as I perused the Massachusetts Public Health Council Web Site, I did not find that the health of the public's 401K investments was part of their mandate.
I did, however find that the Council is composed of the chair of a University pediatrics department, an infectious disease specialist, an emergency physician, University chancellors, policy wonks and the like. I did not find a single person with academic primary care credentials who could indicate the potential of adverse impact on the primary care workforce. Also the majority of PHC members, necessarily come from the large contiguous urban core of Massachusetts, which is traditionally over-doctored and thus not subject to the same degree of primary care pressure as other parts of the country. Come to think of it, I bypassed Boston in 1996 because their academic primary care presence was just so darned weak. Those who have struggled in the shadow of the center of the American academic medical machine were much braver than I. Boston is simply not representative of the rest of the country, or perhaps even of the the state as a whole.
The thoughtfulness of a group of academics is usually measured from the perspective of their primary research or advocacy priorities, not the search for unintended consequences.
Let's return for a minute to the economics of the situation as an educated non-economist can understand it: "too low a risk-adjusted return implies a waste of resources and productivity." In health policy terms, I would interpret the "return" to refer to the health status of the population as adjusted for their baseline risk determined by age, gender, social and socio-economic status. If we had a good way of measuring the risk-adjusted return of our health investments according to some macro-economic unit (such as a state, for example,) and we found that it was high, we could infer that resources are deployed efficiently and effectively. If the return was low, I think Greenspan would assert that resources are not efficiently distributed amongst various health care activities in a manner consistent with the greatest good.
The return in question is not necessarily a financial one, although dollars could serve as a proxy for health, if one were to consider future health expenses.
Primary care resources are tight, so any distribution into activities that do not provide dividends in measurable indicators of health status will presumably diminish the absolute level of returns in other areas of health care activity. If we were to take diabetes as an example, reduced access to appropriate facilities could potentially result from the diversion of limited resources to retail clinics. We can only imagine the future impact of such a reduction in access on health outcomes for diabetics as well as any number of other chronic diseases.
Retail clinics do not better the health of the population for the amount of resources they consume. They have the potential to reduce congestion in ER's but do not address the underlying lack of a sufficient primary care workforce. Thus, it is possible that ER's will simply become congested with sicker patients over time, because those patients had worse access to primary care and suffered as a consequence. The alternative would have been to provide an incentive to non-profit community health centers (yes, I have a vested interest) to provide longer hours and expand into more areas in the state. I suspect that if they have not been able to do so, it is because they are unable to recruit a sufficient number of primary care providers at their current level of resources. Massachusetts and Boston in particular benefits from some of the highest concentration of federally-qualified community health centers in the country.
Remember, I am a non-economist and just a poor CMO of an FQHC in rural America, hardly able to compete with the best minds Boston has to offer this country. I know it would take several months of work to elevate my argument to the level of academic credibility and formulate a methodology to verify the hypotheses contained therein. But I have read similar arguments before in the academic literature, so I don't think that the Council was entirely ignorant of what we know about primary care and its importance to a health system. For my part, I have to go out and recruit a half-dozen physicians, respond to our local hospitals' needs and do what I believe is best to positively impact the overall health of my community. I hope our authorities let Massachusetts do the tinkering and use our regulatory powers to adjust the competitive environment with an actual health outcome in mind, and not just the health of our hospital emergency rooms.
I'd like to think that's what Alan Greenspan would say.