 Welcome, welcome to the seminar series on ethical issues and health reform. My name is Mark Siegler and on behalf of the McLean Center, I'm delighted to welcome you back to the first talk of this quarter. If you haven't noticed, this quarter is the winter quarter in Chicago. We have a rich program coming up for the quarter. It includes Dr. Wang's leadoff talk today. I see Harold Pollock in the back. Harold is going to be speaking next week on the topic of the Affordable Care Act and disability policy and we'll have other speakers, Anup Malani and Nancy Ann DeParle as well as many others. So I'm delighted to welcome you back. First talk is the fourth in our series that is co-sponsored with the Institute of Politics and we're joined today by Steve Edwards and Darren Riesberg who along with David Axelrod are the senior leaders in the Institute of Politics. Gentlemen, welcome. Now I'm delighted to introduce our speaker today, Dr. Albert Wang. Dr. Wang is an associate professor of medicine, the associate director of the Chicago Center for Diabetes Translational Research and the director of an exciting new center for translational and policy research in chronic diseases. Dr. Wang received his A.B., M.D. and M.P.H. degrees from Harvard and came to the University of Chicago in 2001. Dr. Wang studies clinical and policy issues at the intersection of diabetes, aging and health economics. His main research has focused on medical decision making for elderly patients with type 2 diabetes and over the past decade, Albert has established one of the most active research programs in geriatrics diabetes in the country. He's the co-principal investigator of an NIH sponsored diabetes and aging study. Dr. Wang has received many honors including the research paper of the year award from the Society of General Internal Medicine and membership in the Young Turks, the American Society for Clinical Investigation. For one year, Dr. Wang was the senior advisor in the office of the assistant secretary for planning and evaluation in the Department of Health and Human Services. Today, Dr. Wang will be speaking on the topic, you see it up here, the impact of health reform on the doctor-patient relationship. Please join me in giving a warm welcome to Dr. Elbud Wang. Thank you very much. Thank you to the McLean Center and thank you to the Institute of Politics for inviting me to speak and sponsoring this event. This is an outline of the talk and I'll be fairly faithful to this. I'm going to first lay down a framework for you about what I think determines the quality of the patient-doctor relationship. I'm going to describe what I believe are core variables that affect the quality of the patient-doctor relationship. And then I'm going to take you on a little bit of a journey through health care reform starting with health reform in the 1960s, what people thought was going to happen then to the patient-doctor relationship, what they thought was going to happen to doctors in their livelihoods. And then I'll move into more recent form of health reform, the Affordable Care Act, review its major components and then go down through at least the major components and talk about how they might affect the patient-doctor relationship. So laying down this framework, it still does boil down to who the patient is and who the doctor is in this relationship. Certainly the context of how they interact, whether or not they can interact, the nature of the health care system all can affect the patient-doctor relationship but I still think it does matter who the patient is and who the doctor is and these two players still are very important in the quality of the relationship that they have. So patients, you know, they come to the relationship with different expectations. They have expectations based on what they've heard. They read publications. They may rely on reviews of doctors on the Internet. They rely on referrals. They depend a lot on the reputation of physicians in medical schools where they went. And so they come to the relationship with some expectations and they may have different desires about what they want from the relationship. And so this is as variable as there are human beings in terms of what they want personally, what they want from there, what they expect culturally from a patient-doctor relationship. I think it also can't be understated how the patient-doctor relationship is affected by the presenting medical problem that the patient has. And that definitely affects the relationship. Is it a complex problem that is really at the edge, that requires the forefront of medicine thinking? Or is it something that has an established treatment protocol, an established way of diagnosis that most doctors can handle? And depending on the nature of the presenting problem, the patient has totally different experiences with the medical system, has completely different expectations for what they want and reasonable or unreasonable. And of course, the patient is affected by the external influence of the health system when they arrive in the office to visit with a doctor. And it is amazing to me, just in my practice over the last decade, how small things, what we think are small things that occur to a patient outside of the visit affect their expectations or affect their experience with the doctor. So literally getting a frown from a desk clerk or having difficulty making an appointment with you already alters the nature of the expectation that the patient has and can affect the patient-doctor relationship. Was it difficult to get access to you? Was it difficult to get access to information? I have found that my patients will bring bills from prior visits where they are still having difficulty paying off the last visit and going through an X asking why did you order this test, why did you order this test? Those costs of healthcare, costs of medications that we prescribe, even if we prescribe them with our best intentions, can come back to affect and sour the patient-doctor relationship. So that's all from the external influence of the health system. And many of you who have practiced medicine for a long time know that patients disappear from our panels for whatever reason. Patients move away. They lose their jobs. They lose their insurance. And that disrupts the nature, the longevity of the relationship that we can have with them. Doctors, I think, in many ways affected patient-doctor their relationship by simply who they are. A lot of this has to do with who we select into medical schools. Do they have, does the doctor have native empathy? Are they good at communicating? We all know that we select into different medical specialties to some extent based on our personality and what kind of experience that we want with patients on a regular basis. So those of you who are pediatricians, you like to see children bounce back from illness. You like to see them bounce back. For those of us in medicine, we're not afraid as much of the long, dragged out burden of chronic diseases. Over time, as we practice medicine more, we acquire long-term experiences with patients. That affects the way we approach new patients that we encounter. It affects the way we approach old patients that we've had for a long time. You'll notice that I do think that the quality of decision making and the effectiveness of the physician in terms of expediting the right therapy or the right diagnostic strategy is very important. But you'll notice that I've ranked this lower than I think communication. I think you can actually be an average to not so good medical decision maker. But if you're excellent at communication, your patients will probably love you. And of course, doctors and their interactions with patients are affected by the external influence of the health system, whether we want to or not. I think many of us choose different, to practice in certain areas because we want to avoid some of these things. But the reality is that the nature of reimbursement affects the pace in which we see patients. Financial incentives are certainly going to become a larger player in terms of how we behave and interact with patients, including pay for performance, pay for quality. And the culture of the clinical setting that we practice in certainly affects I think the patient-doctor relationship. And this is a sort of a description of what I believe are the core variables among the external influences that can affect the patient-doctor relationship. The amount of time that we have to interact with patients is a chronic and constant complaint among doctors. We just don't have enough time to deal with the patients that we have. So the length of time during the face-to-face encounter is still held, it's still believed by many doctors to be really, really important. And as it shrinks or gets longer, affects the quality of relationships. Whether or not we're able to maintain long-term relations with the patients as I mentioned earlier, the length of relationships affects the quality of our interactions. In this audience we have a number of experts in health disparities and those of you know that language and racial concordance between patient and doctor can also play a big role in terms of the quality of relationships. And increasingly I think we're being pushed and it's already happening. We're beginning to interact with patients increasingly outside of the traditional face-to-face encounter, either through web patient web portals that are now incentivized as part of the high tech act. Telephone of course has been a long-standing way of interacting with patients, increasingly using email. And increasingly we're going to be incentivized to use things like decision aids, which are basically ways of delivering information about medical decisions to patients that involve them in making decisions. And of course we can't say enough about, you know, the title of this talk talks about doctors, but it's definitely more than doctors. Our nurses, our nurse practitioners, physician assistants, medical assistants, they're all part of the overall experience between a doctor and a patient. So those are what I believe are the core variables in terms of the nature of the relationship between patients and doctors. It's the patient's expectations, their medical problems, the doctor, their native empathy, their ability to communicate. But there are also, of course, external influences. So I'm going to segue a little bit into the 1960s and the 1950s. I didn't exist at that time, so I can't really speak from any direct personal experience. But, you know, perhaps this was the way that medicine occurred before Medicare and Medicaid. I'm not sure. And you see that the patient is paying with a pig and chicken for his care. But there was a time before Medicare and Medicaid, and we'd love feedback from any physicians here who knew what it was like at that time. But around the time that Medicare and Medicaid were being discussed or entertained as really the major transformation in American healthcare, there was this old argument about what would happen to the doctor and patient relationship if there was the passage of Medicare and Medicaid. And you'll notice that this argument, which is that there was a good old time and that doctors and patients were able to interact in a free way, unfettered, and then there would be suddenly government takeover with the passage of Medicare and Medicaid. This is basically the same exact argument that was used around the time that the Affordable Care Act was discussed, and it's almost exactly the same argument that was used. I know that we had, the head of the American Medical Association recently here, the AMA has certainly changed dramatically over the last 40 years, but the American Medical Association actually officially opposed the passage of Medicare. And the chief spokesperson was Ronald Reagan. And this came back to haunt Ronald Reagan when he ran for president in the late 70s. But Ronald Reagan in this eloquent advertisement talks about how the passage of Medicare would ruin American medicine. He first, and then I have provided some quotes from the talk, but he talks about how basically how the patients would lose privacy if there was Medicare. Now in our country, under our free enterprise system, we have seen medicine reach the greatest heights that it has in any country in the world. The privacy, the care that is given to a person, the right to choose a doctor, the right to go from one doctor to another would be basically destroyed by the passage of Medicare. And actually the interesting thing, I think he was speaking for the AMA, he talked a lot about the loss of freedom for doctors. And in the second paragraph, he talks a lot about how doctors would not be allowed to practice where they wanted, they wouldn't be able to choose the specialty that they wanted, that doctors would lose their freedom with the passage of Medicare. Of course, Reagan and the American Medical Association were largely wrong. So you have to realize that they were talking around the time of the Cold War, and so there was a lot of sort of anti-socialist themes in those prior comments. Government did end up playing a far larger role in medicine with the passage of Medicare and Medicaid. So those fears were certainly confirmed. But interestingly enough, almost everything else they were concerned about didn't happen at all. So for doctors, there's basically at this time, and the time since Medicare passage, there's been no requirement to enter specific fields. There's no tracking of what happens to residents, despite the fact that Medicare funds graduate medical education almost entirely. There's no regulation of where practices are located, and so we've had ongoing maldistribution of physicians throughout the country for decades. And we've actually now got more, we've got incredibly wide variation in income and reliance on public payers among different specialties in medicine. So this is a description of physician-meaning incomes from 2004 by specialties. And I mean, one of the points of this slide is to show that there is wide variation from the top among hemoc and orthopedic surgery to the lows of family practice and geriatrics in terms of mean income. But overall, none of these physicians are poor. They're all doing very, very well. So physician incomes over the last four decades have gone up, and physicians have done overall very well. What's interesting is where this income comes from, and there is considerable variation in terms of specialties and their reliance on public payers. And this, to some extent, plays a role in terms of why there's going to be a heterogeneous experience in terms of the patient-doctor relationship by specialty. So the fields that rely the most, well, so this is not explained, but this is the amount of money for outpatient income for a provider from Medicaid. The purple is money that comes from Medicare. This lighter color is money that comes from private insurers, and this is money that comes from the, on the far right, is money that comes from out-of-pocket payments from patients. So not surprisingly, the physicians that rely the least on public payers are plastic surgeons, here with the largest amount of payment from out-of-pocket costs, and then it's also not surprising the fields that are more reliant on Medicare, which includes geriatrics and nephrology, which just happens to fit the care of the elderly. Not surprising that should be from Medicare, and care of people with end-stage renal disease, which is all paid for by Medicare. So if anything, physicians have done very well since the passage of Medicare and Medicaid, and there's wide variation in terms of where they get their money from public payers. So what's happened to the actual encounter between the patients and the doctor? What's happened to the visit? And this has actually been the subject of a small line of research around visit time. And this is data that comes from the National Ambulatory Medical Care Survey, an analysis led by Elmer Abo. And what he did was he characterized what happened to the length of clinical visits and what happened during clinical visits. Doctors always complained that there's not enough time to do all the things that they want to do. An economist, David Mechanic, had reported earlier in the New England Journal that visit times have actually gone up and said, doctors, why are you complaining? You're having more time to spend with your patients. And we found that, in fact, that did happen, that visit times had gone up from 18 minutes in primary care to 21 minutes on average over time for primary care visits. But what happened was that the number of things addressed during the visit also went up at the same time, from 5.4 items addressed during the visit to up to 7.1, meaning that the general intensity of the visit and the amount of content that was discussed during the visit had actually gone up, which is why doctors feel the pressure during encounters to do more. So that's sort of the state of things since the passage of Medicare. Doctors have done reasonably well. They're under probably a little bit more pressure to deliver more medicine or more medical content than they had in the past. So here I'm going to attempt to summarize in a single slide how I envision the Affordable Care Act. The Affordable Care Act is a very, very long law, but these four components, I believe, are the four main central areas of focus for the Affordable Care Act. So first is private insurance market regulation. And so that includes things like the inclusion of 26-year-olds on a family health insurance plan. That includes things like the inability to deny someone coverage because of preexisting conditions. Actually, insurance market regulation includes the changes in the medical loss ratio. So now insurers are required to spend the majority of their dollar on health care, not on profits, not on administration. And I'll go into more detail on each of these areas. The second major component, which has not gotten that much attention, but is a focus on cost containment. And this includes the creation of the Center for Medicare and Medicaid Innovation. The University of Chicago is one of the few institutions in the country to actually have two innovation awards, one led by David Meltzer and one led by Stacey Lindow and Dorian Miller and others involving CommunityRx. And those are examples of experimentation in terms of health care financing that the Secretary of Health and Human Services can disseminate widely throughout CMS. And then I'm going to talk in more detail about two innovations in payment reform, one called the Patient Center Medical Home and one called the Accountable Care Organization. And those have direct implications for, I think, the patient-doctor relationship. The third is investment in the health care workforce. This actually gets even less attention than the other areas of the Affordable Care Act. Many of you may not know this, but primary care doctors who receive Medicare payments have been actually getting a 10% bonus for being primary care doctors throughout the last few years. This includes things like shifting unused residency spots from one part of the country to another part of the country. One of the reasons that it has received very little attention is that it's actually gotten very little money to do the things that it is supposed to do. And finally, the fourth component which gets the most attention in the Affordable Care Act is, of course, insurance coverage expansion. And you certainly, in the last few months, heard a lot about the messiness of creating the insurance exchanges. You've heard a lot about the irregularity in which Medicaid expansion has been occurring across the country. And all of that has a potential to affect the patient-doctor relationship. And just to remind you why insurance coverage expansion was part of the law is that we have this segment of the pie of the population, 16%, that remain uninsured of around 50 million people in a population of 300 million people. And then among this uninsured, you can sort of describe the uninsured in terms of their incomes. These individuals are in lighter blue, are basically very, very poor, but not yet poor enough to meet eligibility for old Medicaid eligibility requirements. And these individuals have a little bit more money and are the individuals expected to buy health insurance on the insurance exchanges, the state and federal exchanges. So I was telling Mark earlier that he gave me one of the richest topics to tackle, but probably conceptually one of the most difficult to think about. But here's my best attempt at thinking about how each of these four major components could affect the patient-doctor relationship. So when I first thought about private insurance market regulation a couple of years ago, I really thought that it just should be a good thing. The overall intent of insurance market regulation is to make it easier for individuals to obtain and keep their insurance. And if that actually did, if that was the case, then patients should have better access to doctors and should maintain longer relationships with their doctors. And that would be in general very good for the patient-doctor relationship. But it's actually, of course, turned out to be more complicated in this, and unfortunately it depends on specific circumstances of the patient, what form of insurance they have, where they are in the country, what kind of doctor they're trying to see. So just to give you an example of how there's variability from provision to provision among this bucket of insurance market regulation, certainly allowing children to stay on a parent's plan up until the age of 26 years of age, that's a great thing. It helps affect young individuals who have no insurance and it affects the core variable of access to doctors, so it makes access to doctors better, and that should have a positive effect overall. Certainly banning the use of pre-existing conditions to deny coverage for health insurance, especially in the small individual marketplace for insurance, this is beneficial for individuals who are chronically ill who have no insurance, and again should have a positive effect by making it easier to get access to doctors. Many in this audience are specialists who take care of individuals with very complex diseases like inflammatory bowel disease or complex cancers. For those of you who take care of those patients, I think some of you may be aware that the ban on lifetime spending limits is particularly beneficial for this patient population. Before I left Washington, one of my patients was a woman in her 50s who had inflammatory bowel disease. It had about like 10 surgeries, I think, over her lifetime, and was about to reach her million-dollar lifetime limit, and she said, make sure that this doesn't get touched. So if you're a really chronically ill person who's been privately insured for years seeing specialists, this part of the law should help you maintain your relationships with your specialists and be good for the patient-doctor relationship. But we've obviously, this is far more complicated in the last couple of months. I think this probably fits in the law of unintended consequences. In the last couple of months, you've probably heard that several million people have lost their health insurance, which they purchased on their own in the small individual insurance marketplace. And these are individuals who were many of them self-employed, who had bought a Kaiser plan, for example, in the Washington, D.C. area, and were suddenly told that that plan no longer existed. So what happened was part of insurance market regulation was a requirement for all insurance to meet minimum standards. And what they did was they defined in the law something called essential health benefits. If you read the essential health benefits, they seem quite basic. For example, the health plan should cover prescription drugs. It should cover inpatient hospitalizations, outpatient visits. But it included things also like obstetrics and gynecology, family planning, preventive care. For whatever reason, plans that were offered in the past didn't have all those 10 components. And so because they don't meet the essential health benefit requirements, many of these plans were being canceled. And so because of that, these individuals with self-insurance basically began to lose insurance, and the Obama administration has unfortunately backed away from enforcing this and has allowed them to keep their insurance. But this has obviously caused an unintended disruption in patients maintaining their access to their doctor. And I started this section by saying that this turned out to be far more complicated than I originally thought. But you can think of it in another way. If you put yourself in the shoes of an insurance plan executive, you're basically being required to meet more requirements. You're now required to spend your money in a certain way. And at the same time, you're trying to be inclusive, have more people join your insurance plans, but also contain costs. So if you're an insurance executive, you're going to do things to try to control costs while you're being squeezed. And so one thing that has happened already is that the insurance plans that are being offered on the exchanges for individuals who have a little bit of income to spend on health insurance, they're going to basically try to control costs by restricting the network of doctors that a patient on these new insurance plans can go to. By controlling the provider network, they can try to control costs. The other thing that will also potentially has already happened is that because insurers feel squeezed, they may pass on their costs to individuals and employers and patients. And so premiums may also go higher because of these changes in insurance market regulation. It's also important to, I think, say a few words on what's also happening in the world of employer-based insurance. In the prior pie chart I showed you, the vast majority of the country is still in private employer-sponsored insurance. And you've probably heard in the news that large companies like Sears and Walgreens and other corporations in the Chicago area have actually started to change their behavior. For example, now employees of Walgreens are expected to purchase their insurance through private exchanges. And over the last decade we'd also seen shifts of costs from employers to employees so that you'll notice that deductibles are becoming higher, cost shifting to employees than happening for at least a decade. So it's not entirely clear that the Affordable Care Act is the direct cause of these changes that employers have undertaken, but it's certainly fair to ask what these disruptions have occurred anyways. But the Affordable Care Act certainly has done something to seemingly seem, has seemingly accelerated changes in the way that everyone has behaved in regards to health insurance for better or worse. So let me shift gears from insurance market regulation, which I thought was simple but is actually more complicated, to something that was already complicated to begin with and is now more complicated, which is efforts to contain costs. So if we attempted, on this grid what I've done is I've basically shown you a continuum of different ways that we could contain healthcare costs. We could contain costs through the traditional fee-for-service system. And then on the other end of the spectrum are bundled payments, or global payments. And you've seen other speakers in the prior talks talk about this continuum of change in the way we pay for healthcare. In the middle are intermediate mechanisms, including penalties, incentives, the creation of the medical home, and creation of accountable care organizations. It's clear that if you try to contain costs by changing the traditional fee-for-service system, you basically cause damage to the patient-to-doctor relationship because doctors and hospitals, sensibly enough, want to maintain revenue and income. And so if you simply do things like lower fees for services as a way of cost containment, doctors and hospitals behave in ways to compensate. So the traditional way for a doctor, if a fee-for-a-visit goes down, they're basically going to just increase the volume, to compensate and maintain income. And over the last year, I've had the opportunity to visit doctors in China and in Korea who provide diabetes care. And in Korea, they see 60 patients in the afternoon. And in China, they see 80 patients with diabetes in the afternoon. And that is the product of the fee-for-service system in those countries. The payment is so low that the volume has to be compensated. And actually, that's not too far off from behavior of some doctors in the United States. I'm going to use a lot of cousins who practice medicine. A cousin who does pediatrics in the suburbs. 60 children a day is not unusual. That's a lot of patients. And that probably doesn't lead to a good patient-doctor relationship. Whether or not things like bundle payments lead to better doctor-patient relationships is not entirely clear, but certainly better coordination among doctors for complex patients, better coordination of services could be beneficial. So I'm going to talk a little bit more about the most commonly discussed models, which are those intermediate models, the medical home and the ACO, and how they might affect the patient-doctor relationship. In general, they have a lot of common themes that should be beneficial to the way we interact with patients. So one common theme is that they want more continuity of care over time and place. They want the doctor, in particular, to think about how their interactions with the patient could lead to changes to hospitalizations, ER visits, and they want the doctor to be somewhat an overseer of all those activities. So doctors and patients, doctors and providers are the focus of the effort to incentivize change. And most of the new payment models require that doctors and healthcare providers in hospitals meet some minimum standards of quality of care. So these are sort of common themes of these new models. In the Patient Center Medical Home, which has been around for at least over a decade, it is very popular among employers, including IBM, many private payers are involved in medical home experiments, and certainly Medicare and Medicaid are very high on the medical home. Typically, the financial mechanism is very simple. Doctors who practice in a medical home that meets minimum requirements get paid a $15 to $20 per member per month fee on top of routine fee-for-service medicine. And the medical home I could summarize in one phrase would be, it's a proactive, comprehensive form of primary care. It's the kind of primary care that I think all of us would want. Wouldn't it be great if your doctor reminded you of upcoming preventive services that were needed rather than sort of waiting to see you at a visit? Wouldn't it be great to be able to see your doctor after hours or on the weekends when it was convenient for you? Wouldn't it be great to interact with your doctor through a web portal for simple questions that could be addressed through those mechanisms? So it's kind of proactive primary care that we all would want. I think the only problem with the medical home is it's not entirely clear to me this will actually save money. In one demonstration project that was done at the Group Health Cooperative, it did improve diabetes care pretty dramatically and did lower costs within an existing HMO network. But whether or not that can be proven to be the case in other settings is not clear. So overall, I mean, all these things should make patients happier and should make doctors happier. You know, expanded hours with better access, electronic patient portals, and then it includes many elements of quality improvement, including chronic disease management programs which hopefully will lead to a more activated patient at the time that a doctor needs a patient. So all these things should have a positive effect on the patient-doctor relationship. Now, in prior talks you've heard a lot about, I'm talking about the accountable care organizations and I worked specifically on the Medicare ACO as it was being rolled out. And it's part of the Affordable Care Act and it's essentially in very early days where some of the earliest ACOs didn't get started until the end of 2012. And it's part of a multi-component effort to link accountability to payment. And there's at least two forms of... multiple forms of the ACO. One is the traditional Medicare ACO. But there were also sites that were labeled pioneer ACOs who were asked to meet even more stringent standards than traditional Medicare ACOs. And private insurers like Blue Cross Blue Shield have now also created accountable care organizations. You may have heard that, for example, the Medicaid healthcare system entered into an ACO agreement with Blue Cross Blue Shield. And so the... and I think throughout the country there are about 200 federally sponsored ACOs. So what does an ACO do? So it's basically a voluntary group of physicians and hospitals and other healthcare providers sort of the army of the willing that are asked to assume responsibility for care of a defined population of Medicare beneficiaries. For the Medicare ACO they're asked to care for at least 5,000 Medicare beneficiaries. They're supposed to meet high-quality standards of care but also reduce costs of care. And if they're able to reduce costs of care they're sharing the savings with Medicare. So you can sort of see that it's a very... sort of a difficult concept to wrap your heads around because if you're a hospital why would you ever want to try to save money? Why would you want to try to reduce your revenue from a payer purposely? And it's interesting to see what's happened with ACOs over time. There's some regions of the country where there's... any hospital you go to is part of an ACO or multiple ACOs. Most people recognize that Massachusetts is ACO land. So why are some of these hospitals going out of their way to become ACOs? Many of them basically believe that it's preparing them for the world of bundled payments. They see that reimbursement is going to be lower in the future and they want to be able to deliver care in that kind of system. And they feel like the ACO prepares them for this. In other cases I think some of the leaders of these organizations just want to... they want to be at the head of things. They want to be part of experimentation as it occurs. So the ACO and the patient-doctor relationship it's not as clear as the medical home in terms of what it will do to the patient-doctor relationship. It certainly will be beneficial in terms of increasing collaboration between healthcare organizations. Wouldn't it be great if you knew that your patient who was in the de-cam suddenly popped up at Northwestern's ER for some unclear reason and you were able to address that need before or soon after the fact. Population management in general would be also excellent in terms of being able to identify individuals who are mis-preventive services that need to come in or just for some reason lost the follow-up. And I think one of the principle part of the Accountable Care Organization though that sort of makes the patient-doctor relationship potentially problematic is that it does focus almost entirely on reduction in healthcare costs. And there will be times and there will be medical decisions where the patient and the doctor will have different ideas about what they want to do. And it's not necessarily pleasant also for a patient to suddenly receive a call from an external body that's not the doctor about services they've received at another facility. So there's sort of this challenge which is that the doctor and population manager and payer are all sort of being confused and I think when that happens patients have potentially conflicting relationships with their doctors. So I will spend very little on the healthcare workforce investment although in subsequent slides I'm going to talk a lot about the physician workforce. In the short term because the investment in this has been so small and also because of the nature in which it takes doctors are like trees it takes a very long time for them to grow it's very unlikely that any of this investment will lead to short-term changes in the patient-doctor relationship. However, long-term the workforce investment will be beneficial I think. National healthcare policy makers for better or worse love primary care and areas of the country that have a large number have a fairly high density of primary care doctors to population have in general better health, lower costs and so I think in general having better access to primary care will be beneficial. There's an interest in training doctors to work with other disciplines, pharmacists nurse practitioners, physician assistants therapists in general that should lead to a better form of medicine and there are potential changes to graduate medical education that are being considered ensuring that we train people to be able to work with electronic medical records doctors in the future are going to have to be able to analyze data in ways that older doctors did not have to. So moving on to probably the big kahuna of the Affordable Care Act which is insurance coverage expansion. So the original estimates that most people use which was based on the idea that all states would adopt Medicaid expansion was that there would be 30 million people by 2014 or 2015 who would be newly insured because of the Affordable Care Act and that's not going to happen because of the Supreme Court decision on Medicaid and so I'm going to lower that to around 20 million so there are going to be all these and actually there already are several million newly insured individuals now in the healthcare system but the number of doctors and the healthcare providers that are in existence are not going to expand at the same rate and basically in the country there are around 210,000, 220,000 primary care doctors for example and that number is largely static and it has not changed and you have this sudden inflow of around let's say 20 million people so it's not only a patient it's not only a supply and demand problem but it's basically whether or not doctors will accept the new forms of insurance or the kinds of insurance that the newly insured have in particular there's a lot of concern about the Medicaid population where are they going to go where are they going to get their care now that they have insurance having insurance only gets you part way to having access to healthcare so in a couple of different national studies that were done based on the 30 million estimate it's actually kind of surprising most of these estimates most of these studies have found that the actual imbalance in supply and demand would actually not be that large we live in a country of 300 million people we're talking about adding 20 million more people with health insurance and many of these people are actually not sick and so most of the analyses have accounted for the other thing to note is that many of the uninsured are already getting healthcare right now it's not like we're going from zero to 60 they're getting some care probably not as much care as they need and so the actual change in demand for services may not be as large as people would imagine but most national estimates say that we need about 2% more primary care doctors than we did before the Affordable Care Act and it amounts to about 4 to 7,000 more doctors primary care doctors to meet that demand and just to give you a context for what that number means we produce around 7,000 new internal medicine resident physicians per year that's about what we produce per year so the 2% the 7,000 doesn't seem actually that daunting it's actually not that bad the problem in this analysis that I did when I was in government is that the actual distribution of where the uninsured the newly insured are and where providers are is not distributed they're not lined up, they're not matched up so we undertook this analysis where we looked at the imbalance of supply and demand by states and then by small areas sort of viewed through the lens of a city and so if you take that 7,000 and you look at it from the perspective of states you'll see that and this is assuming that all states undertake expansion insurance coverage expansion equally you'll see that it's very the actual additional need for doctors is not the same from state to state and that's because some states start with high levels of uninsurance some states start with high levels of primary care provider supply and so the areas where there's complete imbalance is where we really have problems and the blue states are states that have very low expected surge in demand for primary care doctors and these states, these numbers represent percentage of the original baseline supply at most would need 1%, 1.3% in some of these northeastern and upper Midwest states the red states, and this has been said before in prior talks in the series these states which have happened to also decline to expand Medicaid in particular Texas has this incredibly large uninsured population but also has a low primary care primary care provider density and so has a need for primary care providers of 5% of the baseline supply California is also in potential trouble with around 3% need so it varies by state and some of the states maybe they had a crystal ball and they knew that this was coming and so that's why they declined to expand coverage but it's completely variable by state but even within a city it's also variable and so this may be a familiar map to those of you in the audience it's a map of Chicago of course and the darker colored areas primary care service areas are ones that have the highest expected need for primary care providers in the city and it's not surprising that this area in the west and this area in the southeast southwest have some of the highest needs for more doctors in this particular neighborhood here I think the numbers are they have 40 primary care providers but they have a 10% need for more doctors in other words they need four more doctors in that neighborhood in order to meet expected surge in demand for more primary care so I'll talk a little bit about the organ experiment but the Massachusetts experiment experience is also very informative and interestingly there are a lot of stories about how the initial with the initial passage of Romney care that there were a lot of there was an increase in visits to the emergency rooms by newly insured and that there were long wait times to get in to see a doctor and that certainly was the case and what I would tell you is that we need to be a little bit patient with all forms of health care reform including the Affordable Care Act and a more recent survey with doctors in Massachusetts actually 70% of them support Massachusetts health reform and there's no difference in favorable opinions by primary care or non-primary care about 24% of doctors said that wait times actually got worse with Massachusetts health reform but 60% said that there was no change and this is after several years of Massachusetts health reform being in place so that initial year of surge may be disruptive but over time this data suggests that things calm down once the newly insured are sort of incorporated into the system and this is illustrated by patient wait times in recent Massachusetts physician surveys where there's really not much change in physician wait times to see a new patient by specialty I mean it's not great but it's basically hovering around 50 days to get in to see a primary care doctor and internal medicine for whatever reason it's really easy to see an orthopedic surgeon and just a comment about the organ experiment so recently last week you may have noticed that the organ experiment which was the Medicaid experiment where some patients, individuals were randomized to early enrollment in Medicaid and others were not and in early years basically financial ruin was lower among people with Medicaid they were less depressed and they got more diabetes care actual measures of diabetes care did not change within the short time frame last week they published an article in Science showing that ER visits certainly rose with Medicaid expansion among those who got Medicaid earlier basically all forms of health services rose in people getting Medicaid earlier in Oregon which is I think somewhat similar to what happened in Massachusetts whether or not that remains the case over time I think is the question so historically government programs have not and I hope I've proven that to you with how well doctors have done over the years government programs have not fundamentally undermined the patient-doctor relationship in America doctors have not been negatively affected by Medicare, Medicaid in fact they have benefited in Massachusetts health reform has to support a majority of physicians and wait times to see a doctor are basically stable now in Massachusetts over now at year 9 the quality of patient-doctor relationships is determined by core variables that are more important determinants of patient-doctor relationships than health reform itself I think that things like population the expectations of different generations lifestyle expectations of young doctors or older doctors and technological changes and shifts have actually had a bigger will have a bigger effect on the patient-doctor relationship than health reform itself the Affordable Care Act will have some of these effects on the patient-doctor relationship depending on what kind of insurance you have what your health status is the physician specialty you're in where the doctor practices and probably more importantly where in the country you're seeking care so the challenges for clinicians is that medicine cannot be practiced without considering cost of care or efficiency anymore we all have to become more knowledgeable about insurance, coverage, payments and the health system in general to help our patients we don't have to be as good as a social worker but we've got to be able to communicate with the social worker and how will you respond to these new incentives and penalties and new forms of payments are you going to accept the newly insured these are questions for any physician or healthcare organization I think there's a profound challenge for medical educators which is how do we continue to successfully recruit these young people with the ideal characteristics for patient-doctor relationships in this changing time and should we really consider alternative characteristics to MCAT scores or GPAs I mean I know that those are important I was selected into medical school with that old system but what about commitment to a community or things like that some medical schools have considered that as criteria for entry into medicine should we train students how do we train students to react when involving healthcare system and innovations in healthcare practice and how do we do that if there are more strings attached to funding for training programs so I'm going to end with a last piece of data which is the Affordable Care Act doctors and patients so it turns out who do the patients really trust to talk about the Affordable Care Act believe it or not, it's us so these are the percentage of patients who would trust information from a doctor or nurse about the Affordable Care Act and they trust us above everyone else particularly anyone else down here on the other hand where have they gotten their information they're not getting information from us they're getting information from the news media who they trust the least this doesn't make any sense but we have a role to play in explaining the health system to our patients and helping them navigate all the changes that have happened so we're the most trusted voice we're a rapidly changing system we have a foot in the patient world I think we're respected by policymakers most of the time and so that's an opportunity to lead the system through a period of transformation I think one that we probably haven't taken up enough thank you very much Dr. Wannis talk is open for questions, comments that's a great question so the question is how do we identify basically high quality care or high value care in medicine and I think this actually gets to the problems that we're having and I've actually chronically had with measuring quality of care most of the performance measures that we're using I can guarantee you they're terrible and they either under they're under measure quality of care that we provide or completely miss the boat actually and actually academic medical centers in particular I think struggle with this we certainly know that our doctors are quite smart but how do you measure the smart diagnostician how do you measure the more efficient work up than the sloppy work up and those sort of things I think there are some ways focusing on patient reported outcomes may be one way one avenue to doing this so there's great interest in Medicare for example in actual measuring patient functional outcomes rather than relying on performance measures that are based on medical records you doctors are the most trusted source of information on the quality of care but doctors are also in general quite certain about what the specifics actually are and they will be asked by patients all sorts of complicated questions that you may want to answer to how can doctors increase their specifications so that they're actually in good positions to assist their patients in navigating the practical challenges that health performance another that's a great question so how do we actually serve patients by helping them to understand the Affordable Care Act when the doctors themselves don't understand the Affordable Care Act and on top of that I think the physician population is pretty conflicted about how they feel about the Affordable Care Act I think there are several physicians actually in Congress most of them pretty opposed to the Affordable Care Act so if you're opposed to something you're not going to try to learn it but in any case I don't know exactly the right answer it's sort of the same educational problem that we have with young people as well where do we squeeze that in already practicing CME doesn't work very well in terms of conveying information about changes in clinical practice and how do we educate people maybe it's through CME or other avenues I think some of the physician organizations like the American College of Physicians has tried to create summary articles about the Affordable Care Act for practicing doctors that could be a source of material for education but definitely it's a challenge at every level of training and the career of a doctor but I've never seen a subject laid out as clearly as you did Saif Nguyen I don't mean this as false praise but it's true before the Affordable Care Act you often see one of them covered by the media which is the expansion of coverage leaving the other three alone right it is certainly a challenging law to summarize and to digest and honestly it took me a year in Washington to really understand what was going on there's always new things that pop up because the law was so dense great question and you describe very eloquently I think what I was trying to convey in a messy way which is that when the doctor is also controlling the purse strings as well it creates conflicts in the patient-doctor relationship so thus far I think it's still too early to know what has happened with the initial 200 ACOs so far through the grapevine you hear that leadership in these ACOs are banging their heads against the wall to try to figure out how to contain costs it's a very challenging question from our meeting with the advocate chief medical officer this summer we know that the typical things they've tried are trying to reduce variation in practice which does come down to the interaction between a patient and a doctor but they focus mainly on standardization of procedures in the operating room as a way of containing costs changing the way that they purchase supplies so it's not come down to the individual patient-doctor interaction in the visit yet but it wouldn't surprise me if that they found an outlier in terms of healthcare costs that they would go after that I was surprised that the small number of primary care physicians who were needed to meet the anticipated demand would not increase as far as medical graduates or Caribbean medical graduates be one solution to that over a short period of time that's interesting so as you know the United States medical school system and hopefully there's an educator in the audience who can correct my errors that I make in my statements but there is going to be an opening of I think many new American medical schools in the coming decade and this is because of expectations that there's going to be a long-term shortage of physicians in the United States those new American medical graduates will likely fill graduate medical spots that are actually occupied currently by foreign medical graduates they'll actually push the foreign medical graduates likely out so that means that the barrier to what you're talking about is actually the number of residency spots in the United States and I don't know if there's any possibility of expansion of the number of GME spots in the United States so the answer is that is not likely to be a solution the other solution that policymakers really love is the idea that there will be suddenly a flood of physician assistants and MPs as you can imagine a single primary care physician working with an army of 10 MPs or PAs as a way of I hate the word but extending the effect of that doctor and so in some of these medical home experiments they have teams where there's a relatively small number of doctors but many extenders or mid-levels who can provide care for basic conditions thank you just a comment and a question if the private insurance regulation component of the ACA was sort of intended to preserve the patient-doctor relationship or increase access, prolong access it seems to me that it will never achieve that if it preserves employer-based health insurance since the average individual changes jobs every 18 months and therefore insurance plans is not to mention you don't have any control over who your insurance options are going to be from your employer so I think it will never achieve that goal while employer-based health insurance is in place I guess my other comment is just a question if you could speculate on how if we had adopted a single care system that would have impacted the doctor-patient relationship well you're certainly right that when I talk about improvements or changes to improve access or to improve longevity of relationships it's the incremental difference from the baseline and the baseline will continue to be there which is that people switch jobs they switch insurance and the law does not does not help, does not eliminate that experience certainly it would be phenomenally easier to implement and I do think it would probably be beneficial to long-term relationships if we did have a simplified form of insurance in the United States politically that was never going to happen it's not going to happen and so anyways I would love to live in that world but we don't okay one or two more questions hi thanks for being here as insurance companies try to become more competitive and reduce the cost of their premiums and there's an increase in patient co-pays co-insurance does it take the doctor out of the hot seat a little bit in a relationship to say we have these two courses of treatment this one is going to cost you X amount in terms of your contribution this one is going to cost you Y how does that change the relationship that's a great question so the shift of costs to employees or the shift to beneficiaries of bearing the cost of healthcare it actually does have this unintended beneficial effect of basically making it not forbidden to speak about healthcare costs and and I think that may make it easier for doctors to talk about these things when you talk to doctors who work in safety net practices they're used to talking about money all the time everything all decisions are made with cost consciousness and actually it's possible that if we all practice medicine in that way that cost of healthcare wouldn't be that high as they are so I think there's one thing you've noticed that the ACO and the medical home there's a lot of reliance on providers and doctors to make changes and one of the complaints that you get here from the doctor community is that there wasn't enough movement to push put the pressure on the population on P patients because ultimately they they play a role and so we're all patients and we're all patients at one point or another and I think that shift is not necessarily a bad thing so yesterday was our first day of the doctor-patient relationship course with some of the ethics follows and I got to moderate in a couple of classes it seems the first year medical students brought up in their discussion of the doctor-patient relationship they have already brought up the issue of being concerned about being sued and how being a good doctor you know sort of equated to not getting sued or you know sort of avoiding that it made me a little sad that you know so early in their in their education they're already sort of concerned about this so I'm wondering where do you think you know with the ACA what's the future sort of the impact of these medical legal issues affecting how we practice and how we interact with our patients so I'm certainly no expert in tort reform so I'll the standard line is that that malpractice and response the threat of malpractice only explains a fairly small fraction of excessive health care costs tort reform is not part of the Affordable Care Act it's certainly very politicized very popular among Republicans not popular among Democrats who I think receive donations from lawyers and but it is I don't know that is a that's certainly something that certainly could be addressed but it's certainly not part of the Affordable Care Act itself but people have talked about maybe this will be the next wave of trying to address the health care system interestingly enough one of the arguments for tort reform is to contain health care costs so there's this curious phenomenon that has occurred which is that health care costs have actually not risen as much in the last few years it's quite dramatic and it's not due to tort reform didn't happen it's probably too early for the Affordable Care Act to take credit if that was the reason for tort reform then it may go away I'm sorry