The Good Clinic’s chief medical officer, Rebecca Hafner-Forgarty, delivered the following speech on December 2, 2021 during the CTeL Digital Health Summit in Washington, D.C.
Good morning. I’m Becki Hafner-Fogarty, a family physician and chief medical officer of The Good Clinic — the third start-up company where I have held a leadership position. While it’s pretty different from my first two companies, all three have one thing in common: they were founded with a mission to remove barriers to healthcare access.
When I think about barriers to access, I like to group them into three main buckets: coverage, clinicians and cars.
The Affordable Care Act made significant inroads in improving financial coverage for healthcare. But until we achieve universal coverage, patients’ ability to pay will still determine whether they get care, whether it is the right kind of care, and how much care they will receive. The most common reason for personal bankruptcies today is catastrophic health care expenses. According to an article published in the American Journal of Public Health in 2019, 66.5 percent of all bankruptcies are tied to medical issues—either because of excessive costs for care or time out of work. An estimated 530,000 families turn to bankruptcy each year because of medical issues and bills. And more than 50 percent of those infected with COVID-19 or who lost income due to the pandemic are now struggling with medical debt. (Source: The Commonwealth Fund)
I never set out to be a poster child, but here I am—a baby boomer primary care physician—retired from clinical practice about 10 years ago. Believe me when I say I have many colleagues who could also serve as poster children. Pandemic-associated physician deaths and burnout have exacerbated the physician shortage. In a recent Washington Post-Kaiser Family Foundation poll, 3 in 10 healthcare workers have weighed leaving their profession. More than half are burned out. And about 6 in 10 say stress from the pandemic has harmed their mental health.
With apologies to my friends at the AMA, the remedy for the physician shortage is to continue toward robust, team-based care. Non-MD clinicians such as NPs, PAs, RNs, PTs, and others need to be recognized, welcomed, privileged to practice to the full extent of their training and REIMBURSED for the care they provide. While we need to train more physicians, many of these other professions have a training cycle that approaches half the 7-12 years it takes to train a physician. We also need to get aggressive about preparing more of these valued care team clinicians.
I also believe it is important here to show my primary care bias. A strong focus on patient-centered primary care is the only hope for bending the ever-increasing cost curve. Research in 2016 by The Oregon Health Authority and Portland State University has shown that when done well, patient-centered primary care can deliver reduced total service expenditures per person (approximate $41 per person per quarter) and result in $13 savings in other services (e.g., specialty care, emergency department) for every
$1 increase in primary care expenditures.
So not only do we need to train more clinicians rapidly, we must make sure to wisely invest in and incentivize programs that focus on training primary care clinicians of all stripes.
I use cars for alliterative purposes, but it’s really a stand-in for transportation. For centuries, physicians and nurses took care TO their patients. Beginning in the early 20th century, the rise of diagnostic and therapeutic technologies nearly completely shifted that locus of care. Going to the doctor became the norm. In the last 20 years, we’ve begun to see a resurgence of taking care TO the patient in the development of telemedicine and a renewed interest in house calls. However, both patient acceptance and reimbursement were spotty at best. And then came COVID. The pandemic- associated lockdowns forced us literally overnight to rely almost exclusively on telemedicine to deliver care TO our patients. The pandemic has demonstrated in spades that telemedicine technologies can allow clinicians to safely and effectively deliver care to patients of all ages in their homes. Until the Telehealth 1135 Waiver, clinicians were unable to be reimbursed for using telemedicine to care for the very patients who could benefit the most from bringing care to them in their homes: the elderly, disabled, poor, rural.
While we will be dealing with the effects of the backlog of pandemic-related delayed medical care and treatment for years, the rapid, widespread deployment of telemedicine has provided necessary care to millions of Medicare beneficiaries and other Americans. The rapidly expanding telemedicine technologies have supported improved efficiencies, allowing clinicians to provide more care to more patients during a time of growing provider shortages.
Things are still far from perfect. Where I live in rural Minnesota, I still deal daily with the frustrations of poor internet connectivity, and connectivity deserts exist across this country in both urban and rural areas. Hopefully, Build Back Better can help us address this through more cable and cell towers and by moving to satellite broadband. We also need to embrace innovation in getting needed medications to patients. Rural pharmacies are quickly disappearing. Mail and other delivery services will need to be supplemented by remotely located vending machines and unmanned aircraft deliveries. We will need the policy changes to allow these innovations to happen.
Before I stop for questions, I do want to highlight one aspect of the 1135 waiver that I believe CMS has gotten exactly right: the requirement for a pre-existing clinician/patient relationship for reimbursement to occur. The rapid growth of telemedicine has at least in part driven the growth of “transactional” health care: do a telemedicine visit and get your Viagra or your Zpack and never “see” that particular clinician again in your life. “Relational” health care, on the other hand, uses telemedicine and other tools to support and improve the care provided in the context of an ongoing doctor-patient relationship. I believe that telemedicine’s real value and potential lies in its use to make it easier for me to access my doctor, my NP, and my care team.
As I said just a bit ago, things in telemedicine are still far from perfect. But we cannot allow the perfect to be the enemy of the good. The vast majority of us spend our healthcare careers working to provide the right care at the right time and in the right way for our patients. Our experiences, safely and effectively providing care via telemedicine over the last 20 months to CMS beneficiaries and other Americans should stand as the strongest argument for making the waiver permanent.
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