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Richard Young, MD

What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare

Wed, 03/24/2021 - 05:00

J Eval Clin Pract. 2021 Mar 24. doi: 10.1111/jep.13545. Online ahead of print.


Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.

PMID:33760312 | DOI:10.1111/jep.13545

Would Medicare for All Be the Most Beneficial Health Care System for Family Physicians and Patients? No: Medicare for All Would Cause Chaos and Fail to Control Health Care Costs.

Wed, 10/07/2020 - 01:05

Would Medicare for All Be the Most Beneficial Health Care System for Family Physicians and Patients? No: Medicare for All Would Cause Chaos and Fail to Control Health Care Costs.

Am Fam Physician. 2020 Oct 01;102(7):392-393

Authors: Young RA

PMID: 32996754 [PubMed - in process]

Improving quality in a complex primary care system-An example of refugee care and literature review.

Tue, 07/07/2020 - 00:18
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Improving quality in a complex primary care system-An example of refugee care and literature review.

J Eval Clin Pract. 2020 Jun 29;:e13430

Authors: Young RA, Nelson MJ, Castellon RE, Martin CM

RATIONALE, AIMS AND OBJECTIVES: Applying traditional industrial quality improvement (QI) methodologies to primary care is often inappropriate because primary care and its relationship to the healthcare macrosystem has many features of a complex adaptive system (CAS) that is particularly responsive to bottom-up rather than top-down management approaches. We report on a demonstration case study of improvements made in the Family Health Center (FHC) of the JPS Health Network in a refugee patient population that illustrate features of QI in a CAS framework as opposed to a traditional QI approach.
METHODS: We report on changes in health system utilization by new refugee patients of the FHC from 2016 to 2017. We review the literature and summarize relevant theoretical understandings of quality management in complex adaptive systems as it applies to this case example.
RESULTS: Applying CAS principles in the FHC, utilization of the Emergency Department and Urgent Care Center by newly arrived refugee patients before their first clinic visit was reduced by more than half (total visits decreased from 31%-14% of the refugee patients). Our review of the literature demonstrates that traditional algorithmic top-down QI processes are most often unsuccessful in improving even a few single-disease metrics, and increases clinician burnout and penalizes clinicians who care for vulnerable patients. Improvement in a CAS occurs when front-line clinicians identify care gaps and are given the flexibility to learn and self-organize to enable new care processes to emerge, which are created from bottom-up leadership that utilize existing interdependencies and interact with the top levels of the organization through intelligent top-down causation. We give examples of early adapters who are better applying the principles of CAS change to their QI efforts.
CONCLUSIONS: Meaningful improvement in primary care is more likely achieved when the impetus to implement change shifts from top-down to bottom-up.

PMID: 32596835 [PubMed - as supplied by publisher]

Increasing Spending on Primary Care to Reduce Health Care Costs.

Sun, 02/16/2020 - 15:24
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Increasing Spending on Primary Care to Reduce Health Care Costs.

JAMA. 2020 Feb 11;323(6):571

Authors: Young RA

PMID: 32044937 [PubMed - in process]

Family Medicine and Obstetrics: Let's Stop Pretending.

Fri, 09/27/2019 - 14:44
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Family Medicine and Obstetrics: Let's Stop Pretending.

J Am Board Fam Med. 2018 May-Jun;31(3):328-331

Authors: Young RA, Sundermeyer RL

PMID: 29743215 [PubMed - indexed for MEDLINE]

Coding Family Medicine Residency Clinic Visits, 99213 or 99214? A Residency Research Network of Texas Study.

Thu, 04/25/2019 - 04:56
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Coding Family Medicine Residency Clinic Visits, 99213 or 99214? A Residency Research Network of Texas Study.

Fam Med. 2019 Apr 23;:

Authors: Young RA, Holder S, Kale N, Burge SK, Kumar KA

BACKGROUND AND OBJECTIVES: The purpose of this study was to characterize Current Procedural Terminology (CPT) coding patterns for professional services in family physician (FP) residency clinics.
METHODS: Trained assistants directly observed during every other FP-patient encounter in 10 clinics affiliated with eight residencies of the Residency Research Network of Texas. Three investigators later independently coded each visit for the highest code level reasonably allowed. The primary outcome was the number of clinic visits that were actually coded as a CPT 99203/213 that could have been coded at a higher level.
RESULTS: In 850 physician-patient encounters where the CPT code billed was identified, the investigators completely agreed on the allowable code 93% of the time. Overall, a 99203/13 or lower or preventive services code was billed in 651 visits (76.6%), more commonly in resident visits (515/570 [90.4%] vs 136/280 for faculty [48.6%], P<.001). There were 476/660 (72.1%) visits coded at a 99213 or less that could have been coded as a 99204/214 or higher. This was more common in resident visits 385/434 (88.7%), but there was undercoding in faculty patients as well 91/226 (40.3%). We found very few cases of overcoding-16 total.
CONCLUSIONS AND RELEVANCE: FPs coding patient encounters in residency clinics undercode for their work, which leads to decreased clinic revenue. This may be because the primary care exception is felt to be too onerous to bill for higher-paid codes, or a lack of knowledge of CMS coding rules among residents and faculty, or other reasons.

PMID: 31013346 [PubMed - as supplied by publisher]

Primary Care Physician Characteristics Associated with Low Value Care Spending.

Wed, 03/13/2019 - 19:11
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Primary Care Physician Characteristics Associated with Low Value Care Spending.

J Am Board Fam Med. 2019 Mar-Apr;32(2):218-225

Authors: Barreto TW, Chung Y, Wingrove P, Young RA, Petterson S, Bazemore A, Liaw W

BACKGROUND: Previous work has shown that $210 billion may be spent annually on unnecessary medical services and has identified patient and hospital characteristics associated with low value care (LVC). However, little is known about the association between primary care physician (PCP) characteristics and LVC spending. The objective of this study was to assess this association.
METHODS: We performed a retrospective analysis by using Medicare claims data to identify LVC and American Medical Association Masterfile data for PCP characteristics. We included PCPs of adults aged 65 years and older who were enrolled in Medicare in 2011. We measured Medicare spending per attributed patient on 8 low value services.
RESULTS: Our final sample contained 6,873 PCPs with 1,078,840 attributed patients. Lower per-patient LVC Medicare spending was associated with the following PCP characteristics: allopathic training, smaller Medicare patient panel, practiced family medicine, practiced in the Midwest region, were a recent graduate, or practiced in rural areas. The largest associations were seen in Medicare patient panel size and geographic region. The average per-patient LVC spending was $14.67. LVC spending among PCPs with small patient panels was $3.98 less per patient relative to those with larger panels. PCPs in the Midwest had $2.80 less per patient LVC spending than those in the Northeast.
CONCLUSION: Our analysis suggests that LVC services are associated with specific PCP characteristics. Further research should assess the strength of these associations, and future policy efforts should focus on systemic interventions to reduce LVC spending.

PMID: 30850458 [PubMed - in process]

A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era.

Wed, 01/30/2019 - 08:32
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A Time-Motion Study of Primary Care Physicians' Work in the Electronic Health Record Era.

Fam Med. 2018 02;50(2):91-99

Authors: Young RA, Burge SK, Kumar KA, Wilson JM, Ortiz DF

BACKGROUND AND OBJECTIVES: Electronic health records (EHRs) have had mixed effects on the workflow of ambulatory primary care. In this study, we update previous research on the time required to care for patients in primary care clinics with EHRs.
METHODS: We directly observed family physician (FP) attendings, residents, and their ambulatory patients in 982 visits in clinics affiliated with 10 residencies of the Residency Research Network of Texas. The FPs were purposely chosen to reflect a diversity of patient care styles. We measured total visit time, previsit chart time, face-to-face time, non-face time, out-of-hours EHR work time, and total EHR work time.
RESULTS: The mean (SD) visit length was 35.8 (16.6) minutes, not counting resident precepting time. The mean time components included 2.9 (3.8) minutes working in the EHR prior to entering the room, 16.5 (9.2) minutes of face-to-face time not working in the EHR, 2.0 (2.1) minutes working in the EHR in the room (which occurred in 73.4% of the visits), 7.5 (7.5) minutes of non-face time (mostly EHR time), and 6.9 (7.6) minutes of EHR work outside of normal clinic operational hours (which occurred in 64.6% of the visits). The total time and total EHR time varied only slightly between faculty physicians, third-year and second-year residents. Multivariable linear regression analysis revealed many factors associated with total visit time including patient, physician, and clinic infrastructure factors.
CONCLUSIONS: Primary care physicians spent more time working in the EHR than they spent in face-to-face time with patients in clinic visits.

PMID: 29432623 [PubMed - indexed for MEDLINE]

The Full Scope of Family Physicians' Work Is Not Reflected by Current Procedural Terminology Codes

Wed, 11/29/2017 - 05:00

J Am Board Fam Med. 2017 Nov-Dec;30(6):724-732. doi: 10.3122/jabfm.2017.06.170155.


BACKGROUND: The purpose of this study was to characterize the content of family physician (FP) clinic encounters, and to count the number of visits in which the FPs addressed issues not explicitly reportable by 99211 to 99215 and 99354 Current Procedural Terminology (CPT) codes with current reimbursement methods and based on examples provided in the CPT manual.

METHODS: The data collection instrument was modeled on the National Ambulatory Medical Care Survey. Trained assistants directly observed every other FP-patient encounter and recorded every patient concern, issue addressed by the physician (including care barriers related to health care systems and social determinants), and treatment ordered in clinics affiliated with 10 residencies of the Residency Research Network of Texas. A visit was deemed to include physician work that was not explicitly reportable if the number or nature of issues addressed exceeded the definitions or examples for 99205/99215 or 99214 + 99354 or a preventive service code, included the physician addressing health care system or social determinant issues, or included the care of a family member.

RESULTS: In 982 physician-patient encounters, patients raised 517 different reasons for visit (total, 5278; mean, 5.4 per visit; range, 1 to 16) and the FPs addressed 509 different issues (total issues, 3587; mean, 3.7 per visit; range, 1 to 10). FPs managed 425 different medications, 18 supplements, and 11 devices. A mean of 3.9 chronic medications were continued per visit (range, 0 to 21) and 4.6 total medications were managed (range, 0 to 22). In 592 (60.3%) of the visits the FPs did work that was not explicitly reportable with available CPT codes: 582 (59.3%) addressed more numerous issues than explicitly reportable, 64 (6.5%) addressed system barriers, and 13 (1.3%) addressed concerns for other family members.

CONCLUSIONS AND RELEVANCE: FPs perform cognitive work in a majority of their patient encounters that are not explicitly reportable, either by being higher than the CPT example number of diagnoses per code or the type of problems addressed, which has implications for the care of complex multi-morbid patients and the growth of the primary care workforce. To address these limitations, either the CPT codes and their associated rules should be updated to reflect the realities of family physicians' practices or new billing and coding approaches should be developed.

PMID:29180547 | DOI:10.3122/jabfm.2017.06.170155

Early Career Outcomes of Family Medicine Residency Graduates Exposed to Innovative Flexible Longitudinal Tracks

Wed, 05/24/2017 - 05:00

Fam Med. 2017 May;49(5):353-360.


BACKGROUND AND OBJECTIVES: The Preparing the Personal Physician for Practice (P4) project used a case series design to study innovations in the content, length, structure, and location of residency training in 14 geographically diverse family medicine programs between 2007 and 2012. We aimed to explore how offering flexible longitudinal tracks (FLT) affected graduates' scope of practice, particularly in maternal child health (MCH), which included at least 17 months of focused training that increased each year over 4 years.

METHODS: We administered a cross-sectional survey to graduates of P4 residencies approximately 18 months after they completed training (2011-2014) and compared graduates of the John Peter Smith (JPS) Family Medicine Residency MCH FLT to all other P4 graduates.

RESULTS: The overall response rate was 81.8% (365/446). JPS graduates who completed the flexible MCH track (n=15) compared to all other P4 graduates (n=332) were more likely to deliver babies (13/15, 86.7% versus 48/324, 14.6%) and perform C-sections as the primary surgeon (12/15, 80.0% versus 15/322, 4.7%). Additional areas of expanded scope associated with the MCH track included endoscopy (4/15, 26.7% versus 10/323, 3.1%), the care of hospitalized adults and associated procedures (central lines, eg: 8/15, 53.3% versus 47/322, 14.6%), and the care of hospitalized children (13/15, 86.7% versus 111/323, 34.4%).

CONCLUSIONS: Graduating from the JPS MCH FLT was associated with a higher provision of maternal, child, and ill adult patient care services, including associated procedures.


The Challenges of Measuring, Improving, and Reporting Quality in Primary Care

Wed, 03/15/2017 - 05:00

Ann Fam Med. 2017 Mar;15(2):175-182. doi: 10.1370/afm.2014.


We propose a new set of priorities for quality management in primary care, acknowledging that payers and regulators likely will continue to insist on reporting numerical quality metrics. Primary care practices have been described as complex adaptive systems. Traditional quality improvement processes applied to linear mechanical systems, such as isolated single-disease care, are inappropriate for nonlinear, complex adaptive systems, such as primary care, because of differences in care processes, outcome goals, and the validity of summative quality scorecards. Our priorities for primary care quality management include patient-centered reporting; quality goals not based on rigid targets; metrics that capture avoidance of excessive testing or treatment; attributes of primary care associated with better outcomes and lower costs; less emphasis on patient satisfaction scores; patient-centered outcomes, such as days of avoidable disability; and peer-led qualitative reviews of patterns of care, practice infrastructure, and intrapractice relationships.

PMID:28289120 | PMC:PMC5348238 | DOI:10.1370/afm.2014

Maternity Care Services Provided by Family Physicians in Rural Hospitals

Sun, 01/08/2017 - 05:00

J Am Board Fam Med. 2017 Jan 2;30(1):71-77. doi: 10.3122/jabfm.2017.01.160072.


BACKGROUND: The purpose of this study was to describe how many rural family physicians (FPs) and other types of providers currently provide maternity care services, and the requirements to obtain privileges.

METHODS: Chief executive officers of rural hospitals were purposively sampled in 15 geographically diverse states with significant rural areas in 2013 to 2014. Questions were asked about the provision of maternity care services, the physicians who perform them, and qualifications required to obtain maternity care privileges. Analysis used descriptive statistics, with comparisons between the states, community rurality, and hospital size.

RESULTS: The overall response rate was 51.2% (437/854). Among all identified hospitals, 44.9% provided maternity care services, which varied considerably by state (range, 17-83%; P < .001). In hospitals providing maternity care, a mean of 271 babies were delivered per year, 27% by cesarean delivery. A mean of 7.0 FPs had privileges in these hospitals, of which 2.8 provided maternity care and 1.8 performed cesarean deliveries. The percentage of FPs who provide maternity care (mean, 48%; range, 10-69%; P < .001), the percentage of FPs who do cesarean deliveries (mean, 66%; range, 0-100%; P < .001), and the percentage of all physicians who provide maternity care who are FPs (mean, 63%; range, 10-88%; P < .001) varied widely by state. Most hospitals (83%) had no firm numbers of procedures required to obtain privileges.

CONCLUSIONS: FPs continue to provide the majority of maternity care services in US rural hospitals, including cesarean deliveries. Some family medicine residencies should continue to train their residents to provide these services to keep replenishing this valuable workforce.

PMID:28062819 | DOI:10.3122/jabfm.2017.01.160072

Managing Spaghetti Syndrome in Critical Care With a Novel Device: A Nursing Perspective

Thu, 12/03/2015 - 05:00

Crit Care Nurse. 2015 Dec;35(6):38-45. doi: 10.4037/ccn2015321.


BACKGROUND: Managing "spaghetti syndrome," the tangle of therapeutic cables, tubes, and cords at patients' bedsides, can be challenging.

OBJECTIVES: To assess nurses' perceptions of the effectiveness of a novel banding device in management of spaghetti syndrome.

METHODS: A simple color-coded elastomeric banding strap with ribbed flaps was attached to bed rails of adult critical care patients to help organize therapeutic cables, tubes, wires, and cords. Nurses were surveyed before and after use of the bands and after the nursing shift to assess the burden of spaghetti syndrome and the effectiveness of using the bands.

RESULTS: Use of the bands decreased the time spent untangling cords, reduced the frequency of contact of tubing with the floor, and diminished disruptions in care.

CONCLUSIONS: Use of a simple flexible latex-free elastomeric band may help organize therapeutic tubing at patients' bedsides and may promote improvements in nursing care.

PMID:26628544 | DOI:10.4037/ccn2015321

The correlation of family physician work with submitted codes and fees

Tue, 12/16/2014 - 05:00

Am J Manag Care. 2014;20(11):876-82.


OBJECTIVES: The income disparity between primary care and other physicians has been attributed in part to the evaluation and management (E/M) rules written by CMS. The purpose of this study was to examine the relationship between family physicians' work and their actual coding practices and fees collected under these widely used rules.

STUDY DESIGN: This was a direct observational time-motion study.

METHODS: A diverse group of 15 family physicians were shadowed over consecutive patient visits at their ambulatory practices, usually for a half-day of clinic. Data about each visit were recorded, including time parameters; number of issues covered; number of labs, images, and chronic prescriptions ordered; the physician fee code from the Current Procedural Terminology (CPT) system that was submitted; the actual payer for each patient; and the actual fee collected. The primary outcome was the correlation between the time spent for each patient's care and coding/financial measures.

RESULTS: The average total time a physician spent per patient including documentation time was 20.0 minutes. The average fee collected was $101.40, including patient co-pays. The correlation between the actual fee collected and the physician's time spent working on each patient's behalf was poor (R2 = 0.137, P < .001). There was a wide variation in times and fees for each CPT code category.

CONCLUSIONS: The existing E/M rules and CPT coding system have created office visit fees that correlate poorly with family physician work. These findings provide another justification for disruptive primary care payment reform.


Family physicians' opinions on the primary care documentation, coding, and billing system: a qualitative study from the residency research network of Texas

Wed, 06/11/2014 - 05:00

Fam Med. 2014 May;46(5):378-84.


BACKGROUND AND OBJECTIVES: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services.

METHODS: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved.

RESULTS: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals.

CONCLUSIONS: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.


Family physicians' suggestions to improve the documentation, coding, and billing system: a study from the residency research network of Texas

Tue, 06/10/2014 - 05:00

Fam Med. 2014 Jun;46(6):470-2.


BACKGROUND AND OBJECTIVES: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care.

METHODS: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84).

RESULTS: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme.

CONCLUSIONS: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.


Preventable acute care spending for medicare patients

Thu, 11/14/2013 - 05:00

JAMA. 2013 Nov 13;310(18):1984. doi: 10.1001/jama.2013.278604.


PMID:24219956 | DOI:10.1001/jama.2013.278604

Family physicians' perceptions on how they deliver cost-effective care: a qualitative study from the Residency Research Network of Texas (RRNeT)

Sat, 05/18/2013 - 05:00

Fam Med. 2013 May;45(5):311-8.


BACKGROUND AND OBJECTIVES: The aim of our study was to deepen our understanding of the factors that may explain the observational literature that more primary care physicians in an area contribute to better population health outcomes and lower health care costs.

METHODS: This study used in-depth, qualitative interviewing of family physicians in both urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking subjects to give examples and personal narratives demonstrating cost-effectiveness and cost inefficiencies in their own practices. An iterative open-coding approach was used to analyze transcripts to search for unifying themes and sub-themes until consensus among investigators was achieved.

RESULTS: Thirty-eight respondents gave examples of how their decision-making approaches resulted in improved patient outcomes and lower costs. Family physicians' cost-effective care was founded on two themes-characteristic attitudes and skills of the physicians themselves and a thorough knowledge of the whole patient. Family physicians also felt their approaches to gathering information and then making diagnostic and treatment decisions resulted in fewer tests and fewer treatments ordered overall. Family physicians also delivered care in less expensive facilities and generated lower overall charges for physician fees.

CONCLUSIONS: Family physicians perceived that their approaches to patient care result in medical decision making priorities and care delivery processes that contribute to more cost-effective health care. These outcomes were achieved less by providing preventive services and strictly adhering to guidelines but rather by how they individualized the management of new symptoms and chronic conditions.


What could family income be if health insurance were more affordable?

Wed, 10/03/2012 - 05:00

Fam Med. 2012 Oct;44(9):633-6.


BACKGROUND AND OBJECTIVES: Adjusted for inflation, household income has been relatively flat since the mid-1990s, but the inflation rate of employer-sponsored health insurance has been greater than both household income growth and general inflation for 50 years. We estimated the effect on average family income if health insurance inflation matched the general inflation rate since 1996, and those savings were given to employees as income.

METHODS: We used data from the Medical Expenditure Panel Survey, the Milliman Medical Index, and other federal sources to model the relationship between private health insurance costs and household income over the last 15 years.

RESULTS: If the cost of family health care costs had kept pace with the Consumer Price Index (CPI) rate since 1996, the average family income could have been $8,410 higher in 2010 ($68,805 versus $60,395), 13.9% more than actual earnings.

CONCLUSIONS: If health care costs had not exceeded the CPI rate since 1996 and if all the excess costs were converted into employee wages, median family income could be substantially higher today.


Who will have health insurance in the future? An updated projection

Wed, 03/14/2012 - 05:00

Ann Fam Med. 2012 Mar-Apr;10(2):156-62. doi: 10.1370/afm.1348.


The passage of the 2010 Patient Protection and Affordable Care Act (PPACA) in the United States put the issues of health care reform and health care costs back in the national spotlight. DeVoe and colleagues previously estimated that the cost of a family health insurance premium would equal the median household income by the year 2025. A slowdown in health care spending tied to the recent economic downturn and the passage of the PPACA occurred after this model was published. In this updated model, we estimate that this threshold will be crossed in 2033, and under favorable assumptions the PPACA may extend this date only to 2037. Continuing to make incremental changes in US health policy will likely not bend the cost curve, which has eluded policy makers for the past 50 years. Private health insurance will become increasingly unaffordable to low-to-middle-income Americans unless major changes are made in the US health care system.

PMID:22412008 | PMC:PMC3315130 | DOI:10.1370/afm.1348