GLASGOW – A local physician was one of three from Kentucky and 13 from across the country who were invited to and attended a “listening session” at the White House recently, so they could share their observations on how health care laws have affected their practices and patients, as well as ideas for moving forward.
William Thornbury and the other doctors met with Tom Price, the secretary of the U.S. Department of Health and Human Services, and Seema Verma, administrator of the Centers for Medicare and Medicaid Services, as well as other administration officials on June 14, which was before a working draft of a Senate version of a proposed new health care law to replace the Affordable Care Act, which came to be known as Obamacare, was released.
Thornbury, who said he covers several little niches including primary care, single practitioner and telemedicine, said the doctors at the table represented a mosaic of experiences, types of practice and positions.
He happened to be seated between Price and Verma and was chosen to speak first, he told the Glasgow Daily Times during an interview at his office, and he said he shared a few observations about the mixed effects of the ACA.
“The Affordable Care Act, aka Obamacare, has given some people that did not have insurance insurance. It has gotten those people to me and other physicians like me and that's a good thing,” Thornbury said.
On the other hand, the co-pays, and especially deductibles, have risen so high for people who have obtained private insurance that they can't afford to go to the doctor anyway, so they miss follow-up appointments or put off coming in until the level of care they need escalates, and then it ends up costing even more, potentially in terms of their health as well as in dollars.
He also told the group in Washington, D.C., about a woman he knows who is a single mother of three, and when she purchased, through the health care exchange, insurance as required by the ACA, even after subtracting the subsidies for which she was eligible, her cost was $700 a month. Then, “the kicker,” as Thornbury put it, was that because she couldn't afford that and had to stop paying for it after a few months, she had to pay a penalty of $350 the first year and $650 the next year, and she expects it to be $700 or more for this year.
“What I don't hear is, these are the working poor, and these are the people it's really disadvantaged the most, because these people can't come to the doctor. They can't get the care that they need. Now again, there are people that come to see me that never had [coverage] before, and I think that's great, but there are more of [the former] than [the latter type] …,” Thornbury said. “That's what it really comes down to in a primary care physician. We are charged – the primary care physicians, family physicians – with taking care of the nation's primary care needs. We drive the majority of the health dollar, and we can't do our work because of the way the insurance system is set up today.”
So, overall, he told the Daily Times, the adverse effects related to coverage is outweighing the positive effects of having more people covered through either insurance or expanded availability of Medicaid.
He also expressed concern to the administration and fellow medical professionals about how the ACA is negatively impacting rural hospitals, particularly through payment policies and the removal of payments to help with the disadvantaged care hospitals were getting to help offset those who couldn't pay for care, because, presumably, everyone would have insurance coverage in some form. But the working poor are still having difficulty bearing the brunt of those deductibles, and when they can't pay, the hospitals and doctors still have to cover those expenses.
He does see some net positives with the ACA, he told the Daily Times. For starters, it has drawn more attention to health care issues.
Thornbury said he believes it's good to have protections built in and help from the federal government on pre-existing conditions. He said he believes society has come to a place where it won't tolerate not having pre-existing conditions covered, so they have to be addressed.
Coverage of screening services has also been very helpful, he said.
The second part of the invitation for those doctors was to make recommendations for improving the system, and Thornbury has plenty of ideas about that.
“Our health system needs to focus on lowering the cost of health care, not the cost of the deductible, not the cost of the copay,” he said, adding that he believes those insurance costs would go down in turn.
His No. 1 suggestion was related to the extensive and pioneering work – including several peer-reviewed, published studies and developing their own technology from the ground up seven years ago – that he and colleagues have done with telemedicine and e-medicine.
“Why can I not, as a doctor, with my own patients that are established with me, why can I not take care of them on this device (a phone) – instead of you missing work for four hours when you don't need to, instead of filling up my office just to come in so I can get paid? I can't get paid unless I see you. What in the heck is going on with that?” Thornbury asked. “There's no reason. … It wastes so much time and so much effort and so much money to have you come here and see me just because I get paid that way.”
He said chronic-disease care accounts for approximately 75 percent of the health dollar.
“That can only be provided by your primary care work force. … These things have to be monitored and followed over long periods of time,” he said.
But 30 to 40 percent of primary care can be done online, he said. Patients provide information and can upload photos if relevant, then the doctor can often set forth a course of action on just that interaction; in a minority of cases, a phone discussion or even a video chat is deemed necessary, he said. The doctor could also determine it is a matter that really needs to be handled in person. Handling more patients online and on the phone then allows him to free up more in-person appointments for those who need them, he said.
“I need leadership from the government to help with that, and that leadership comes from [the Centers for Medicare and Medicaid Services]. CMS has got to promulgate that and make that OK. They've been dragging their feet on this for a decade and it is not OK. We have got to take our largest driver of health care – chronic disease care – [and] put that to our most efficient delivery model, which is online care. It just takes pennies to do this. You've got to put those together.”
Thornbury's other main recommendation is to support direct primary care initiatives – arrangements in which the patient and physician contract directly for services at a particular price. He asks why an insurance company that simply siphons off money that could be paid directly to the doctor.
“In places where they've done this, for working families, it lowers their health cost by 50 percent,” he said. That, in turn, allows them to afford insurance as needed for the more catastrophic issues that arise, for example.
Thornbury passionately advocates for a medical home model forwarded by the late Johns Hopkins pediatrician Barbara Starfield.
“When people are cared for by primary care physicians that they know, that are established, those communities, those patients and those health systems, those countries, at every level, get better outcomes and lower costs and it has never been disproven, ever,” he said.
But Medicare and Medicaid don't support it, which makes it prohibitive for doctors to practice.
Thornbury said leadership – not partisan bickering and blocking – is what is needed to advance health care to where it needs to go.
“We need people solving problems. We have a very sick system. We have to do something together to fix it,” Thornbury said.