What People Get Wrong About Healing Medicare

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By Debra A. Finnel, CEO, Ilumed

The current Medicare healthcare system is broken. It incentivizes the wrong actions. It benefits those looking to make a profit while it bulldozes over the people it purports to care for. The current system does not benefit taxpayers, beneficiaries, or healthcare providers. Some industry insiders suggest that fee-for-service (FFS) care is the solution. It is not. 

How the healthcare system broke down

A large percentage of experts suggest that private insurers and pharmaceutical companies are to blame for the state of Medicare today, but that doesn’t paint the full picture. Back in the 1980s, primary care physicians (PCPs) spent their lunch breaks doing rounds at the hospital, visiting their patients who were hospitalized, keeping their finger on the pulse of their care. If they had patients living in skilled nursing facilities (SNFs), they called those facilities at the end of each day. They took responsibility for their patients’ care no matter where they were. They were the connection for their patients.

But over the years, the system became fragmented and siloed. The hospitalists and intensivists didn’t know what the PCPs were doing and vice versa. PCPs got cut off from the patient. As a result, they started picking up more patients for their panels, spawning the churn-and-burn situation of today. The average PCP exam lasts 18 minutes according to a School of Public Health at the University of Minnesota study, yet longer appointments are critical for clinically complex patients—such as many Medicare beneficiaries who have one or more chronic conditions.

The rise of specialists coincided with these industry shifts. Doctors fresh out of med school saw they could make more money as specialists. As a result, patients started seeing a cardiologist, a pulmonologist, a nephrologist separately. No provider was connecting the dots. Patients were on their own to navigate not only the system but their various treatments. The prescriptions stacked up as did the adverse medication events.

Why FFS care is not the answer

Some claim FFS is the way to keep Medicare solvent. But the truth is, FFS doesn’t solve Medicare’s solvency problems because it’s not trying to solve the root issue: sicker people living longer and requiring more complex care. 

FFS patients are left to navigate an increasingly complex system on their own. As a result, often their health is not improving and they are most certainly not paying less for the care they do receive. In fact, the opposite is happening, all because of the erosion of the aforementioned fundamental relationship: the PCP and patient. You see, FFS doesn’t incentivize doctors to think holistically or preventively. It doesn’t give providers the tools to treat the most at-risk patients and to address their underlying barriers to health. At best, FFS is a Band-Aid reaction. At worst, it exacerbates silos and causes more fragmentation in the system.

Going Back to the Basics: Putting Patients First

We need to get back to the PCP as the central point of a patient’s care and empower them to become more hands-on. We need PCPs to develop deep relationships with their patients, to know the names of their patients’ grandkids and dogs. We need to give them the tools they need to help those most in need. We need to make the PCP once again the glue for the entire system. We need to give PCPs the ultimate responsibility for caring for their patients, wherever they are in the care continuum, and to work with the hospitals and SNFs and in-home care providers rather than in siloes. We need to get back to good old-fashioned care with a personal touch. 

Yesterday’s approach, today’s technology

In the past, a high-touch PCP model meant lots of driving and phone calls. It also meant three-ring binders. Back when I worked in a medical office, I kept color-coded binders. The red one was for the people who didn’t take their medications and their conditions got worse. How did we know? We had their prescriptions sent to the office for patient convenience.  Yet the unclaimed bottles stacked up. The doctors’ eyes opened when they saw how few patients took their medications as prescribed. While it was analog, we had the data we needed to act. We could identify those people who needed more attention and education.

Today, we don’t need our PCPs to do rounds at the hospital or create a color-coded binder system because there are quality data platforms that can stratify patients by risk. We can remove the busy work and focus on the real work for patients that improves their day-to-day lives. We can get them connected to a food bank that delivers if they’re struggling with food security. We can offer them transportation to and from the doctor if they struggle with mobility or lack transportation. We can connect them to mental health professionals if they’re struggling with social isolation and/or loneliness. FFS cannot do that. 

The Vision

In the movie Beatriz at Dinner, Beatriz (played by Salma Hayek) says to her dinner host, “You can break something in two seconds. But it can take forever to fix it.” Healing healthcare is hard. It takes time. It takes effort to turn around decades-long habits and break down siloes. Helping patients live their best lives takes dedication and creativity because no two people’s best lives are the same. 

But when you know better, do better. For decades, we’ve been learning how to improve healthcare, testing new approaches and developing new technologies. We as an industry must work together to eliminate healthcare’s most harmful siloes and unite clinicians focused on delivering healthcare with empathy and compassion. I ask the Medicare industry: will you join us?

About the Author

Debra saw an opportunity to make an incredible impact in the industry she has devoted her life to. So, she created Ilumed. Her 40-year resume is filled with important acronyms: COO of the publicly traded MSO Metropolitan Health Networks; EVP of the largest national MSO, Medical Care Consortium Inc (MCCI); and President of the AdvantageCare MA plan.