How Healthcare Reform Could End the Stepchild Status of Primary and Behavioral Healthcare: A Talk with AAFP Board Chair Dr. Ted Epperly
Ted Epperly, M.D., FAAFP, a family physician in Boise, Idaho, who follows a patient-centered medical home model of care that incorporates behavioral health, is board chair of the American Academy of Family Physicians. In recent months, he has spoken with President Obama on several occasions about his concern related to the shortage in primary care and the incentives (or lack of incentives) our country offers medical students to consider primary care. He says that primary care and behavioral healthcare providers have been considered 'stepchildren' in the past, but that he’s confident healthcare reform efforts in Congress could provide some remedy.
Dr. Epperly wrote in an AAFP statement earlier this year, “If America is to right the ship of health care and turn it toward a system of higher quality, improved efficiency, better outcomes, less cost, and decreased geographic and ethnic disparity, it must increase the number of primary care physicians. We cannot meet that goal without dramatically changing the policies that affect our medical education system, graduate medical education and the incentives that draw students to careers in primary care. This decline has nothing to do with the value of primary care and everything to do with a system that claims to support primary care but fails to actually act on its pronouncements.”
Dr. Epperly speaks with BHC today about these important issues facing primary care and behavioral healthcare providers.
Dr. Ted Epperly: As the President of the American Academy of Family Physicians I was asked to join the Carter Center Medical Home Summit that they held in July and there were four family doctors that were there along with experts from the mental health and behavioral health and substance abuse arena, as well as from the prevention communities, all with the idea being how can we integrate what is done in primary care mental health and prevention so that we can all maximize and align our talents and skills to care for patients. There’s good data that shows that integrated mental healthcare with primary care is very beneficial to patient care both in terms of quality and cost. The data is shocking, people that have severe persistent mental illness actually die 25 years younger than patients that have severe persistent mental illness that also have primary care, so if you have a mental illness and are being treated only in the mental health arena and the primary care problems are not being seen and treated that results in a 25 year younger death, which is quite shocking.
So as you can imagine then, the question becomes, how can we bridge across mental health and the silos that exists with mental and behavioral health and substance abuse and bridge across to primary care so that patients that have more than one problem i.e. more than mental illness, i.e. diabetes, heart failure, cancer, hypertension, hyperlipidemia, asthma, emphysema, etcetera, can have some sort of integrated care model so that those other things can be simultaneously cared for.
So that was the purpose of the Carter Center Medical Home Summit: How do we bring these diverse entities that typically in the past work more in silos and help integrate them and from the Carter Ccenter experience, then came a action arm of let’s take the message to Capitol Hill so that we can help educate others, congressional staffers, both from the House and Senate side, as well as other healthcare professionals.
Now with that said, I will just say that if you take a look at primary care practices across the country, and mine in Boise, Idaho is a perfect example. We have 17,000 patients that we care for and 40 percent of those have mental health problems, so primary care already is taking care of a fair number of mental health problems, primarily depression anxiety, bipolar disease, we have schizophrenia and schizo-effective disorders, as well, and a ton of substance abuse problems from alcoholism to cocaine and methamphetamine abuse etcetera. Sp there is already a natural partner in primary care that has a lot of mental health training and experience in our primary care physicians, our family physicians that can partner better with the mental health community, substance and prevention communities to bring this together.
One more point that I would just make and then I’ll let you ask some questions, but I’ve mentioned the quality in terms of if the two can be joined and results in longer lifespan for patients. But the other thing I’ve mentioned earlier was cost.
So one of the things I presented at the Carter Center, as well, is that if you take a look at patients with problems with medical diseases, chronic conditions, heart conditions, high blood pressure, asthma, diabetes, etcetera, and you compare the costs of those patients’ conditions for those without mental health problems compared to those same problems with people who have mental health conditions, their costs almost doubles across the board. And the reason for that is that those people with mental health problems having higher out of pocket cost, higher cost for their medical conditions, is that mental illness clouds one’s judgment in terms of timely care, of compliance, of education, in regards to what to do to help yourself with those problems.
So again, here lies the important opportunity of bringing together a trusted personal relationship with a primary care physician, which is where health happens. It happens at the interface of a relationship and working then in a synchronized fashion with the medical problems that patients have and the mental problems they have in a manner that incorporates the expertise and skill of the mental health community and the prevention community. And one thing that I said to the group was that primary care is like a neck that connects the body and the head. It connects the body full of other chronic medical problems with the head that has mental problems because people are one person, they’re whole people. And what we need to do and what the metaphor of all this is, is to provide a neck. It’s to be able to connect the two so that we can care in an integrated way with a whole person.
BHC: Dr. Epperly, in your opinion, are policy makers in healthcare reform, adapting their healthcare reform ideas to embrace your concerns?
TE: Yes, thati is a very good and key questions so the healthcare reform bills both on the House and Senate side are replete with incentives around enhanced payment for primary care. We recognize that if we’re going to build the system we need for the future instead of the system we have in the present that there must be better payment in valuing what primary care does and what primary care does is it focuses more on healthcare than sick care and what I mean by that is more on prevention, more on wellness, more on chronic disease management so that we are absolutely preventing these things from becoming larger problems, as apposed to treating the back end of healthcare when people are already sick and then need procedures done.
What is keeping the work force so imbalanced right now and a healthy balance by the way of a work force across the world is about 50 percent generalist and about 50 percent sub-specialists. Right now in America as we talk today, that balance in the United States is 70 percent sub-specialists, 30 percent primary care physicians, and the last decade of medical school is 90 percent sub-specialty selections by students and only 10 percent going into primary care.
So as you can see, we have this terribly out of balanced work force. So at the time when we’re trying to give improved healthcare across the country to people and get them all into primary care for what primary care can do to help them we have exactly the wrong types of doctors to care for them. The easiest way in our country to start to right the balance is how payment is done. So if incentives and alignments and payment are now done that values primary care and values health and illness prevention, values mental health, values keeping people healthy as apposed to treating them when they’re sick, then those payments will have to increase. Those payment increases will then help medical students see that primary care is a viable field. Right now, you come out of medical school with on average about $150,000 in medical loans and you can go into primary care where you going to work 65 hours weeks and barely scrape by, or you can go into sub-specialities where you make two to five times more. So that’s the biggest imbalance in terms of what’s driving the work force imbalance, and that’s payment.
So the first thing is that payment has to be rectified so that we start to get a better balance of work force, scholarships and loan repayments will also help students defray and pay for expenses so that many can choose to be primary care physicians without finances driving their choice. And what I would say in regards to what happens on the mental health care side of this equation is that psychiatrists and other mental health workers also need to be valued for those services that they provide in better ways. Mental health has always been a poor stepchild to procedures, so has primary care, and that’s why primary care and mental health both suffer in this country.
The other category that really suffers in our country is dental healthcare, and so those three become the biggest Achilles tendons of our entire health care system. So if you want them improved, then you’ve got to pay them better. So mental health can’t be down graded in terms of how payment works or we’re not going to get again folks doing mental health care and if the compilation of care then in my office now values keeping Mrs. Smith’s heart failure and hypertension in good control and at the same time keeping depression and anxiety in good control (and by the way, I then can leverage that relationship I have with her to help her lose weight and to exercise and to stop then smoking,) then you can see the value of what that saves the system in costs. So if you want that kind of complex care, then you’ve got to pay for that kind of complex care. Unfortunately it’s terribly undervalued so that Mrs. Smith’s heart attack 10 years later or her amputation of her right leg because her diabetes is out of control or her chronic renal failure now that gets her on dialysis, all those get paid top dollar where we could have paid on the front end of this adequately so that we’ve got both access and affordable quality timely care for her that could have saved her and the system hundreds of thousands of dollars on the back end.
So that’s then when you take a step back at healthcare reform. Right now, what’s going on, all the bills both in the House side and the Senate side, are replete with payment increases for primary care and making this concept of the patient-centered medical home at the epicenter of the reform movement. And I think it’s that that’s gaining both a lot of speed and a lot of attention, long overdue attention that the mental health and prevention communities are recognizing. Finally, we’ve got a model here of healthcare that we can team with in a way that’s going to help start to solve a lot of the problems that exists with patients in our country.
BHC: One other note that comes to mind in hearing you talk about it would be that if there are indeed 47 million uninsured people right now who perhaps can only afford to go to the ER when things get really bad because they can’t afford to go to a primary care physician or to any organized offsite practice other than a hospital, then there’s not going to be enough primary care physicians around once we do get those people insured, and they haven’t had an opportunity to develop a relationship with a primary care physician in order to know that there’s a benefit of compliance and so it makes sense all the way around.
TE: One thing I say to just the question and the issue you’re bringing up is that healthcare coverage, healthcare insurance doesn’t equate to healthcare. In other words, because of this primary care shortage, I used the example that if we gave everybody overnight free bus passes, but we only had two buses in town to put them on, then we’ve not done much to solve the problem of transportation. It’s the same in healthcare. If we suddenly give everybody health insurance, or healthcare coverage, but we don’t have the workforce to care for them, then all we do is compound then already problematic system and Massachusetts, the state of Massachusetts has taught just exactly this lesson in 2006 they gave 97.6 percent of they citizenry healthcare, everybody had coverage, but what did it uncover? It uncovered they didn’t have enough primary care physicians so what happened in Massachusetts is waiting times to see primary care physicians doubled form 30 to 60 days. It increased ER utilization, which is a point you were making, and it increased healthcare system costs in their state.
We know across the board that for the same sorts of problems that can be seen in primary care offices in a timely and accessible way, if those same patients go to the emergency room, it’s at least a 5 fold increase in cost and so the whole point in having a more robust primary healthcare system is one keeping them out of the emergency room in the first place and out of the hospital for an admission in the second place and that is way again folks are focused on let’s get back to the basics here, the basics are bread and butter primary care unfortunately the most undervalued, underpaid and under respected part of our healthcare system.
BHC: And so Dr. Epperly, when you look at one of the first problems you mentioned where we need to fix the reimbursement models. If we get buy in from payers and we get the healthcare reform that we need to motivate that so more people will go into primary care how do we then tackle the problem of changing that for medical schools because healthcare reform wouldn’t necessarily drive that, would it?
TE: That’s a good question — clearly you get it. That’s going to be tough, there are ways in which it can be done, part of that would be potentially tying NIH grants which are a large source of income to medical schools with a work force outcome, in other words, the way NIH grants work is you get a score, it’s a competitive process medical schools then get grants based on the score they get, well if you tied work force production i.e. how many number of primary care physicians, family physicians, general internists, general pediatricians does your school produce and if you have over X percent, then you get extra points for your NIH scoring if you have fewer then X percent, then you don’t get points, so you could start to align incentives for how medical schools get funded to help produce the workforce.
Now it’s an amazing thing because you think state legislatures would have quite an impact on saying to medical schools, “Listen, you guys are failing in producing enough primary care physicians for our communities, especially our rural and inner city communities.” But what happens with medical schools like I was saying is that when you take a look at their budgets and where the money comes from, in my neck of the woods, you take a look at medical school incomes and 2 percent comes from the state legislature, so the state can say, “Look, you're failing in your mission.” And the medical schools say, “I’m getting 98 percent of my money from other sources so, I hear you, but tough.”
And so that is a bit of the dynamic. You think, a legislature can say, “Look, you've got to do a better job with this.” But that’s not what drives medical schools. So it’s got to be a reworking of alignment of incentives, one. Number two, there must be a comprehensive, cohesive policy that’s developed. You would think that the United States has a healthcare workforce policy. Well I’m here to tell you there is no such policy. It is a total free for all in terms of what medical schools produce and what kind of physicians come out of them/ There is no cogent, thoughtful approach to what should be the mix of our workforce, and how we should go about training more primary care doctors to make sure that rural America and inner city America and suburban America are treated and cared for. There is no policy, none, zero.
Sso one of the other things in the healthcare reform bills is let’s put together workforce center and let’s develop a workforce policy that's so long overdue. And you can tell from the conversation that I’m having with you, Robin, that America just has to get on the ball. We have been totally driven by the almighty dollar to the exclusion of quality healthcare in this country.
Lt me just share a couple facts, which you may know. America pays more for healthcare than all other countries in the world. We pay more than twice the next-closest country. We pay about $7,500 per person for healthcare on average across the United States — 2.4 trillion dollars — but what we get for it is we rank 20th in the world for healthcare outcomes, we rank 37th in the world for an effective and efficient system, and we rank 54th in the world for having a fair, just and equitable system. We have this tremendous amount of money being spent with mediocre to poor outcomes and the reason for that is that we have a have-and-have-not system. Those that have means can get their CAT scans tomorrow. They may not need them, but they can get them tomorrow. And those without means live sicker and die younger because they don’t get any care at all.
And so, in a country like ours, you’d think we would have this sense of serving the greater good of our people, but what tends to happen is that that doesn’t happen at all. So that’s what needs to be corrected in the system. That’s why it’s a big deal. It’s why the workforce and the policy and the integration of primary care, why the incorporation of mental healthcare — all these things that have been long neglected need to finally come together at one time to try to get this right for our country.
BHC: And maybe one of the solutions is that if you can’t drive the medical schools as easily, maybe you can help drive the students, in that if there are student loans that are grant-based from the government and you have a better qualification, some sort of payback incentive to go into primary care -- sort of like how I’ve heard hospital systems do. They’ll help pay for tuition for a nurse when there’s a nursing shortage if the nurse agrees to work in their hospital system for a number of years afterward. And so I’m wondering if something like that could be put in place.
TE: Yes, exactly scholarships on the front end of medical school meaning that if you go into primary care we and then you serve areas that we’ll send you, we’ll pay your way through medical school. It's a perfect solution to that. And on the back end, after residencies, loan repayment so that if I’m a primary care doctor or I’m a family physician, and I go settle in a place where my skills are needed, then those loans are repaid. That’s how I got into — that’s how it worked for me. I got accepted to medical school at the University of Washington in Seattle, Washington. I was the oldest of five kids and my father owned a single-cash-register grocery store and didn’t have the means to help me financially. And I took a scholarship to help pay for medical school with the United States Army and what the military said was, “Look Ted, we’re more than happy to pay your way through medical school but when you’re done you’ve got to give us four years of your time.” And I said okay, and that’s how that worked.
Now if my state of Idaho had done the same thing for me, Robin, and said, “Okay Ted, we’ll pay your way through but you've got to give us four years of time wherever we’re going to place you in rural Idaho, where the greatest need is,” I would have done that in a heartbeat. I knew nothing about the Army, but see, they didn’t have the vision of having a type of scholarship like that. And so, you're dead-on right that that’s the way in which both medical schools and legislatures now can get into the game, if you will, and try to help with incentives that get that type of workforce.
You touched on one other thing that I didn’t mention about medical schools being part of the solution as well, and that is admission policies, so that admission committees start to look for the types of kids that have a service orientation that helps them want to be primary care doctors as apposed to sub-specialists. And so, those kids can be looked for. They typically tend to be a bit older candidate. They tend to be from rural areas; they tend to be more minorities; the tend to be from blue-collar families. And so often, the admission policies to medical schools where you take the brightest kids, the 4.0s and the perfect scores on the SATs and the MCAT tests and you take them into medical school, and many, many of those kids have an orientation in life where a sub-speciality is perfect for them. And of course, we need at least half of our workforce [in sub-specialities] so, great! But what about the other half in terms of kids that are just outstanding kids. They’re the 3.8 or 3.9 kids that don’t get the perfect scores on the SATs, that are very service-oriented perhaps, and have done some things in their life, so perhaps a little bit older, that want to be a primary care doctor. Many of those kids, because of the competitive nature of medical school, aren’t getting in.
So I think admission policies must change so that we try to get the sorts of people recruited into medical schools that are going to help fill this workforce for us in this country. But I can tell you, of all the things we talked about, the thing that will change it the fastest is valuing what it is that primary care doctors do by paying them more. And I’m not saying that we need to add more money to the system. There’s enough money that’s wasted in this system of 2.4 trillion — if we do a better job with primary care, we decrease ER visits; we decrease the number of procedures that need to be done; we decrease the number of hospitalizations; we decrease the number of readmission rates to hospitals because people can’t find basic good primary care; we decrease the doubling of healthcare costs because mental illness is seen by primary care physicians (and primary care problems aren’t seen for many with severe persistent mental illness) — all those sorts of things. There are tons of money that’s saved in the system that could more easily pay for that.
And I’ll just use a model from another country. I’m going to pick Norway right now. Norway, of all the physicians in the country of Norway, the highest paid are their primary care doctors and their family physicians. And the reason that is in Norway, they’ve come to recognize that they want a healthcare system, not a 'sick-care' system. And so, wellness, chronic disease management, health promotion, timely management of mental health problems in congruity with primary care management, keeps their nation healthier. Because of that, they have lower healthcare costs, higher quality.
That’s the system they’ve created, and thats what America has to eventually try to get back to. Promoting health, as opposed to waiting for disease to happen and then paying gobs of money to treat disease. It’s just amazing to me.
BHC: When you look at it from 5,000 feet, it makes so much sense, and I think once you get down to ground level, everybody gets so caught up in the minutia that all they can worry about is people are just resistant to change, and yet it’s so badly needed. Dr. Epperly, I really want to thank you so much. This has been such an invigorating interview and I thank you for taking the time again.
TE: We cannot implement health care reform and we cannot provide financial access to health care for all Americans unless we can keep the second half of that promise — that Americans will have an accessible doctor to care for them when they need it.