A new vision for health care

Being an election year and the start of a new decade, 2020 was the right time for ACP to make a bold plan for the future, said ACP President Jacqueline W. Fincher, MD, MACP.

In January, the College did just that when it released a series of policy papers and editorials on its new vision for the U.S. health care system. Of course, a global pandemic was not in the plan.

“My presidential year certainly did not start off the way I wanted it to in April, under the cloud of this invisible viral enemy we're dealing with, but I'm thrilled for the privilege of representing the organization that has helped me so much, personally and professionally,” said Dr. Fincher, who is a partner at the Center for Primary Care–McDuffie in Thomson, Ga. “I don't think I would still be in private practice out in a rural area if it wasn't for ACP and all the help that it's given me.”

During the COVID-19 crisis, the College has been hard at work providing daily updated information on COVID-19 and advocating intently for internists, as seen in the final provisions of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, she said. “The paycheck protection plan and other provisions of the CARES Act are the main things that will keep my practice afloat and my staff employed over the next two to three months,” Dr. Fincher said in April. “If we didn't have those loans and presumed forgiveness of them, we would have to lay off staff, and I'd probably be out of business in two months.”

To get a better understanding of ACP's vision for health care, ACP Internist spoke to Dr. Fincher about the highlights of the health policy papers, the feedback they've received, and how the current public health emergency might have played out differently if this vision had been reality.

Q: What led the College to publish this new vision for health care?

A: In July 2018, our Board of Regents and our two major policy committees … were weary of playing “whack a mole” with a broken system that does not serve patients or their physicians well. It costs too much and leaves too many people behind. With a new decade on the horizon, along with a big election year for the President and the Congress, we wanted to envision a better health care system that really puts the patient at the center of care and values the primary and specialty care of that patient by internal medicine physicians. In addition, we wanted both political parties and all the candidates to specifically address health care and provide them with options to get to universal coverage.

At the time, I was the Chair of the Medical Practice and Quality Committee and Sue Bornstein, MD, FACP, was the Chair of the Health and Public Policy Committee. With guidance from the outstanding ACP Governmental Affairs staff in D.C., we initiated an 18-month plan to create a more comprehensive and holistic system. Because internal medicine encompasses so much of all of health care, who better to envision an ideal health care system that provides universal access and coverage than us?

Q: How did ACP develop these policy papers?

A: ACP always goes to the evidence in the literature and the current situation in our country and others throughout the world. We don't put out policy based on opinions; we put out policy based on evidence. That evidence, as reviewed by our committees, our governance, and our members, is what helps us decide what key policies are appropriate to focus on. It was mostly the Health and Public Policy Committee and the Medical Practice and Quality Committee, along with their staffs, that were writing the papers. Drafts were then sent out for reviews by the Board of Regents and the Board of Governors and shared with the Governors' advisory councils and/or their Chapter Health and Public Policy Committees. The drafts were then updated and rewritten into final form by the Committees, then reviewed again by Board of Regents prior to the final approval. Because this undertaking was so comprehensive and involved so many aspects, we gave this set of policy papers twice the amount of time we usually provide for feedback. Whenever a policy paper is written, it is sent out for comment for 30 days, but this time, it was sent out for 60 days and widely publicized that we wanted their input. Every single comment that was provided by reviewers was responded to by the staff and the policy committees. The papers went through several edits prior to the final approval.

Q: What are some of the highlights of this new vision?

A: The first paper is more of a summary of the key points, and then the additional three papers go on to address coverage and cost of care, health care delivery and payment system reform, and then addressing social determinants of health.

As you look at the vision statements and the recommendations, the bottom line is we want affordable health care for everybody. We want everybody to have access to it, and that's been a policy of the ACP since the early 1990s, of universal coverage and access. We need coverage for and access to the care, and at a cost that the patient can afford, but also that our country can afford. We address payment and delivery systems that really put patients' interest at the center and truly support physicians and the other clinicians on our care teams to deliver that care.

One of the things that is clearly outlined in the papers is how we must invest in primary care that has been so underfunded for two decades. There must be equitable payment for the complex cognitive care that internists are known for providing on the same level as procedural care. We must also align the financial incentives for health care systems, hospitals, and physician offices in order to achieve better outcomes for our patients, lower the cost, and reduce the inequities in health care. Significant emphasis is also placed on the current inefficient administrative burdens that are just ridiculous at times, acting as barriers to care, and extracting so much time and effort in our offices and in the hospital.

In my own practice, for 36 physicians spread out in eight offices, we have seven full-time staff for every physician. We are heavily weighted, unfortunately, on the administrative side more so than the clinical side because of these very complex administrative and billing issues. If that was more transparent, but also more aligned among all the payers, it would make it so much easier and would require so much less staff.

Q: You mentioned that ACP has recommended universal coverage for decades. With that in mind, how would you describe the media coverage and feedback for this new vision for health care?

A: Everybody's got to have some form of insurance so that when they get sick, they have access to health care, because we know people who do not have health care insurance coverage do not have appropriate access to the care that they need. So that's been a longtime policy and has been out there for almost 30 years. What was different [this time] was, how do you get there?

So the splash, if you will, was that there are two ways to get to universal access and coverage. You can do it through a public option, with much greater regulation of the insurance companies, or you could do it through a single-payer plan. So the media ran with “Medicare for All.” Our ACP policy papers don't say “Medicare for All”; they say a single-payer plan. So it is frustrating when you outline, “There are two options, the public option with greater insurance company regulation or the single-payer option in order to get to universal coverage,” and the headline was only, “ACP endorses Medicare for All.” I think a lot of physicians, medical organizations, and even our own ACP members may have been caught off guard.

We have many comments from our members that have been very supportive of the papers in general. Some comments were particularly more supportive of a single-payer plan, while other comments were angry that a single-payer plan was even considered. Still many other comments were supportive of the public option with greater insurance company regulations as the best alternative, but were also frustrated that it has not been publicized by the media much at all. And finally, other members' comments expressed disappointment that market-based strategies were not considered as an alternative. The reality is, market-based strategies have not worked to get us to universal coverage and by definition can't get us to universal coverage.

Q: How might the COVID-19 pandemic be different if this new vision were in place?

A: We have certainly undervalued public health and primary care over the past two decades. The COVID crisis has pointed out and underscored the total underinvestment in public health. We were woefully unprepared for this pandemic. If our public health departments and the CDC had been fully funded (and more) over the last 20 years instead of gutted, we would be much more prepared. We would have anticipated it sooner. We would have had testing more readily available. We would be more prepared with our national and state stockpiles of critical medical equipment, like personal protective equipment and ventilators.

We would have every local county health department able to rise to the occasion with testing and contact tracing. We would know the prevalence of the disease in our communities and be able to quickly isolate and flatten the curve much earlier. We would know the number of asymptomatic and presymptomatic people walking around. We would be able to trace contacts so much quicker and easier. So right off the bat, from a public health point of view, if we had been investing in public health all along instead of cutting it back thinking, “Well, it'll never happen,” we'd be in a way better position today.

I also think if every person in this country had a primary care physician and was part of a patient-centered medical home—again, something the ACP has been promoting for 20 years—then patients would have access to the care that they need.

We just can't afford to keep up this broken system because we're spending way too much money, and we're finding out through this pandemic nightmare that we do have limited resources. They're not unlimited. So we have to move forward in a way that provides the care needed at a cost patients and our country can afford. And considering that we spend more than any other country per capita on health care, we can do this. It is not beyond our ability to change and do a better job. One of the key messages of our new vision papers is that better is possible. We believe it, we've put it in writing, and we think we have provided the road map to get there.