Researchers Project Cost of Family Health Insurance Premiums Will Surpass Household Income by 2033
Updating estimates of who will be able to afford health insurance in the future in light of the 2010 Patient Protection and Affordable Care Act that reformed health care payment in the United States, researchers now estimate that the cost of an average family insurance premium will surpass household income by 2033. This compares to a 2005 estimate that the cost of insurance premiums would surpass household income by 2025.
Analyzing data from the Medical Expenditure Panel Survey and the U.S. Census Bureau, researchers developed an updated model of insurance premium cost and household income projections. Projecting out to 2040, they found that if health insurance premiums and national wages continue to grow at recent rates and the U.S. health system makes no major structural changes, the average cost of a family health insurance premium will equal 50 percent of the household income by the year 2021 and surpass it by 2033. If out-of-pocket costs are added to the premium costs, they find the 50 percent threshold is crossed by 2018 and exceeds household income by 2030.
While at first glance the change in the projection might be perceived as progress, in part due to a recent slowdown in the rate of premium increases, they point out that during that same period, employee contributions to insurance premiums and out-of-pocket expenses have grown faster than overall premium costs, suggesting that insurers are shifting costs onto patients in other ways. The authors assert the slowdown in the rate of premium increases has been offset by higher deductibles and copayments and fewer covered services. They conclude that continuing to make incremental changes in U.S. health policy will likely not bend the cost curve, which has eluded policy-makers for the past 50 years. Unless major changes are made to the U.S. health care system, private insurance will become increasingly unaffordable to low-to-middle income Americans.
Who Will Have Health Insurance in the Future? An Updated Projection
By Richard A. Young, MD
John Peter Smith Family Medicine Residency Program, Fort Worth Texas
Jennifer E. DeVoe, MD, DPhil
Oregon Health and Science University, Portland
Update on Primary Care Initiatives from the Innovation Center at the Centers for Medicare and Medicaid Services
Richard Baron, MD, MACP, Group Director, Seamless Care Models for the Center for Medicare and Medicaid Innovation, an entity created by the 2010 Patient Protection and Affordable Care Act to test new models of health care delivery to improve the quality of care while lowering costs, highlights some of the Center's new primary care programs and initiatives. He notes that by changing delivery models and moving to a payment model that rewards physicians for quality of care instead of volume of care, the country may be able to achieve the kind of health care patients want to receive and primary care physicians want to provide. Collectively, he asserts, the Center's programs communicate a vision for the future of primary care and have the power to change the national conversation. New Pathways for Primary Care: An Update on Primary Care Programs From the Innovation Center at CMS
By Richard J. Baron, MD, MACP
Centers for Medicare and Medicaid Services, Baltimore, Md.
Call to Expand Federal Funding for Primary Care Training
To revitalize the national primary care workforce and ensure access to care following passage of the 2010 Patient Protection and Affordable Care Act, policy researchers at the Robert Graham Center in Washington call on policymakers to increase funding for Title VII, Section 747 of the Public Health Service Act, which is intended to increase the quality, quantity and diversity of the primary care workforce, but which has been severely cut over the past two decades. They contend that new and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and, ultimately to improve the responsiveness of teaching hospitals to community needs. They conclude that failure to launch a national primary care workforce revitalization program would put the health and economic viability of the United States at risk, and they call on Congress to act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually — a small investment in light of the billions that Medicare currently spends to support graduate medical education.
The Next Phase of Title VII Funding for Training Primary Care Physicians for America's Health Care Needs
By Robert L. Phillips, Jr., MD, MSPH
The Robert Graham Center, Washington D.C.
Barbara J. Turner, MD, MSED, MA, FACP
University of Texas Health Science Center, San Antonio
Replacing the Idyllic "Lone Physician" Myth with a New Paradigm That Reflects the Realities of Modern Practice
In a reflection piece, researchers present an alternative to the heroic figure of the mythical "lone physician" that acknowledges the current realities of primary care practice. This new, more collaborative alternative places the primary care physician within the context of a highly functioning health care team. They assert this new paradigm fulfills the collaborative, interprofessional, patient-centered needs of new models of care, and may help to ensure the work of primary care physicians remains compassionate, gratifying and meaningful.
The Myth of the Lone Physician: Toward a Collaborative Alternative
By George W. Saba, PhD, et al
University of California, San Francisco
With the March/April issue, Annals builds on last issue's theme of multimorbidity, the coexistence of multiple chronic health conditions in a single individual, a phenomenon that is growing at an alarming rate and bankrupting the U.S. health care system. Because of the negative consequences and high cost associated with multimorbidity, it has received growing interest in the primary care literature and is now acknowledged as a research priority. With this in mind, three articles and an editorial in the current issue dive into the challenges of measuring multifaceted morbidity, offering tools to assess value and integrate patients' complexity. An accompanying editorial from U.S. Department of Health and Human Services details a strategic framework developed in 2010 by the Department to ensure a more coordinated and comprehensive approach to improving the health of patients with multimorbidity.
Huge Variation in Studies Estimating the Prevalence of Multimorbidity, Researchers Cite Differences in Methods
Marked variation exists among studies looking at the prevalence of multimorbidity with respect to both methodology and findings. In a systematic review of 21 studies reporting on the prevalence of multimorbidity, researchers observed the largest difference at the age of 75 years in both primary care (with prevalence ranging from 4 percent to 99 percent across studies) and the general population (with prevalence ranging from 13 percent to 72 percent across studies). They conclude differences of this magnitude are unlikely to reflect differences between populations and more likely to be due to differences in methods. In addition to their differing geographic settings, the studies differed in recruitment method and sample size, data collection, and operational definition of multimorbidity, including the number of conditions and the conditions selected. All of these differences, they assert, affect prevalence estimates. The researchers call on investigators designing future studies to consider the number of diagnoses to be assessed (with ≥12 frequent diagnoses of chronic diseases appearing ideal) and should attempt to report results for differing definitions of multimorbidity (both ≥3 diseases and the classic ≥2 diseases). Use of more uniform methodology, they conclude, should permit more accurate estimation of the prevalence of multimorbidity and facilitate comparisons across settings and populations.
A Systematic Review of Prevalence Studies on Multimorbidity: Toward a More Uniform Methodology
By Martin Fortin, MD, MSc, CFPC, et al
Université de Sherbrooke, Quebec, Canada
Measuring Multimorbidity: A Review of Measures Suitable for Primary Care Research
To assess the impact of multimorbidity, it is necessary to measure it. In a systematic review of 194 articles studying different measures of multimorbidity and morbidity burden suitable for use in research in primary care, researchers identify 17 different measures, some of which are more established than others. The measures most commonly used in primary care and for which there is greatest evidence of validity are disease counts, the Charlson index, and the Adjusted Clinical Groups System. They conclude that different measures are most appropriate according to the outcome of interest and the type of data available. For example, they conclude that researchers interested in the relationship between multimorbidity and health care utilization will find most evidence for the validity of the Charlson Index, the ACG System and disease counts; but evidence is strongest for the ACG System in relation to costs, for Charlson index in relation to mortality and for disease counts or Charlson index in relation to quality of life. Other measures such as the Cumulative Index Illness Rating Scale and Duke Severity of Illness Checklist are more complex to administer and their advantages over easier methods have not been well established. The authors call for more research to directly compare the performance of different measures.
Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings: A Systematic Review and Guide
By Alyson L. Huntley, BSc, PhD, et al
Bristol University, England
Objective and Subjective Measures Needed for Complete Assessment of Patient Morbidity
A comprehensive assessment of a patient's morbidity requires both subjective and objective measurement of diseases and disease burden, as well as an assessment of emotional symptoms. Comparing two different approaches to measuring morbidity — 1) objective measurement using ICD-9 diagnosis codes and 2) subjective measurement using patient-reported disease burden and emotional symptoms — researchers conclude both are needed. Analyzing data on 961 older adults with three or more medical conditions, researchers found morbidity measured by diagnosis code was more strongly associated with health outcomes of higher utilization; whereas self-reported disease burden and emotional symptoms were more strongly associated with patient-reported outcomes. The authors conclude that accurate measurement strategies to account for morbidity burden will become increasingly important as we develop new methods for evaluating patient-centered care delivery for complex patients.
Association of Patient-Centered Outcomes With Patient-Reported and ICD-9-Based Morbidity Measures
By Elizabeth A. Bayliss, MD, MSPH, et al
Kaiser Permanente, Colorado
Health and Human Services' Strategic Framework for Tackling the Enormous Health System Challenge of Multimorbidity
An accompanying editorial from the Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services attempts to bring a greater sense of order to the vexing challenge of multimorbidity. The authors outline a strategic framework developed in 2010 by the U.S. Department of Health and Human Services to ensure a more coordinated and comprehensive approach to improving the health status of individuals with multiple chronic conditions. The framework, intended for use by clinical practitioners, policymakers, researchers and others, is organized into four major goal areas: 1) strengthening the health care and public health systems; 2) empowering the individual to use self-care management; 3) equipping care providers with tools, information and other interventions; and 4) supporting targeted research about individuals with multiple chronic conditions and effective interventions. The three articles on multimorbidity in the current issue, the authors contend, represent progress toward the framework's fourth goal.
Toward a More Cogent Approach to the Challenges of Multimorbidity
By Richard A Goodman, MD, MPH, et al
Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services
Primary Care Physicians Order Lung Cancer Screening Tests in Asymptomatic Patients Despite Lack of Evidence
Primary care physicians in the United States frequently order lung cancer screening tests for asymptomatic patients even though major expert groups do not recommend it. A nationally representative survey of 962 primary care physicians, which used clinical vignettes to assess screening practices, revealed 57 percent of respondents ordered at least one of three lung cancer screening tests (chest radiograph, low-radiation dose spiral computed tomography or sputum cytology) in the past 12 months for asymptomatic patients. Thirty-eight percent reported ordering no tests. Further analysis revealed physicians were more likely to have ordered screening tests if they believed expert groups recommend lung cancer screening or that screening tests are effective; if they graduated from medical school 20 to 29 years ago; if they would recommend screening for asymptomatic patients, including patients without substantial smoking exposure; and if their patients had asked them about screening. The authors conclude primary care physicians need more information about lung cancer screening's evidence base, guidelines, potential harms and costs to avert inappropriate ordering.
Lung Cancer Screening Practices of Primary Care Physicians: Results from a National Survey
By Carrie N. Klabunde, PhD, et al
National Cancer Institute, Bethesda, Md.
How the Medical Culture Contributes to the Harassment and Abuse of Family Physicians in the Workplace in Canada
The current medical culture appears to contribute to harassment and abuse in the workplace of family physicians in Canada. Interviews with 23 female and 14 male practicing family physicians in Canada revealed four ways in which the medical culture intentionally or unintentionally contributes to the facilitation and perpetuation of abuse in the workplace of family physicians: 1) modeling of abusive behaviors, 2) status hierarchy within the medical community, 3) shortage of physicians, and 4) lack of transparent policies and follow-up procedures after abusive encounters. The authors discuss these findings using the criminology-based broken window theory that asserts when lesser criminal acts, such as broken windows, are tolerated, more vandalism and other types of crime will eventually occur in the community. They assert that effective elimination of abuse must start from efforts that begin on the first day of medical school and continue through residency training and into clinical practices.
How the Medical Culture Contributes to Coworker-Perpetrated Harassment and Abuse of Family Physicians
By Baukje Miedema, PhD, et al
Dalhousie University, Fredericton, Canada
Video Elicitation Interviews: Powerful Qualitative Method for Primary Care Research
Researchers at the University of Michigan describe the concept and method of video elicitation interviews and provide practical guidance for primary care researchers who want to use this qualitative method to investigate physician-patient interactions. During video elicitation interviews, researchers interview patients or physicians about a recent clinical interaction using a video recording of that interaction as an elicitation tool. Video elicitation is useful, they point out, because it allows researchers to integrate data about the content of physician-patient interactions gained from video recordings with data about participants' associated thoughts, beliefs and emotions gained from elicitation interviews. This method also facilitates investigation of specific events or moments during interactions. They conclude that while video elicitation interviews are logistically demanding and require considerable time and resources, the detailed data they produce make the effort worthwhile for many important research questions in primary care.
Video Elicitation Interviews: A Qualitative Research Method for Investigating Physician-Patient Interactions
By Stephen G. Henry, MD, and Michael D. Fetters, MD, MPH, MA
University of Michigan, Ann Arbor
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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.
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