There’s good reason debate over the Affordable Care Act (ACA) and Republican attempts to repeal and replace ACA is so acrimonious. I call it the “Calendar Test” and outlined it recently.
The Calendar Test is a thought experiment that asks whether a reform can improve some people’s well-being without harming others, based on the time required to provide quality patient care. Proposals failing the test are merely redistributive—a zero-sum game with winners and losers.
A couple of spoilers: First, I believe ACA failed the Calendar Test, as do conservative alternatives like the House GOP’s American Health Care Act (AHCA). Second, numerous policies are available at the federal and state levels that pass the test and, therefore, offer a greater possibility of cross-ideological support.
How It Works
Here’s the test: A hypothetical primary care physician (PCP) works 10 hours per day. For five hours, the doctor does things other than examine patients: administration, electronic health record (EHR) maintenance, and reading journals and patient charts. For the remaining five hours, the doctor sees 20 patients for 15 minutes each.
Now, enact a reform promising four new people appointments with this PCP today. In response, the doctor can work an extra hour or more, squeeze four new patients into the calendar by cutting each appointment by 2.5 minutes, or cancel four of the original 20 appointments from the day’s calendar.
To complete the thought experiment, add four patients a day to this doctor’s and every doctor’s calendar every day of every year. How will doctors feel about their options?
Increasing the workday from 10 to 11 hours is unlikely to appeal to most doctors. Plus, longer workdays will raise the aggregate cost of care—the opposite of reformers’ hopes of reining in costs.
Cutting 2.5 minutes from each appointment will reduce the quality of care. Most 15-minute appointments already consist of EHR data entry and polite chatter. (“Is your work going well?” “Is your wife feeling better?”) The doctor can’t dispense with EHR maintenance, and cutting polite chatter would diminish the doctor-patient bonds, a valuable component of care.
Arbitrarily kicking four people off the calendar will likely be detrimental to some or all of those patients.
Learning from Mistakes
Fortunately, a fourth response is possible and can pass the Calendar Test: Shift some of the burden of care from physicians to non-physicians, machines, and patients themselves.
ACA clearly failed the test. It promised coverage and care to tens of millions of previously uninsured people, plus a long list of free preventive services to hundreds of millions of people. But ACA did not substantially alter the number of doctors, nurses, hospital beds, laboratories, or medical devices. Nor did it markedly change how we combine these resources into care.
Hence, ACA created millions of winners and losers, financially and medically. Doctors increasingly rush through appointments. Many patients experience longer wait times. Some patients avoid appointments because of the expense or inconvenience. EHRs were supposed to ease doctors’ administrative load and leave more time for doctor-patient interaction. Accountable Care Organizations and the Medicare/Medicaid Innovation Center were designed to find efficiencies. Hope exceeded reality.
Conservatives would do well to profit by these cautionary tales. Will health savings accounts and malpractice reform significantly lighten doctors’ calendars? How about buying and selling health insurance across state lines? Or establishing small business health plans? Or shifting control of Medicaid from federal to state officials?
Like the ACA’s authors, conservatives will likely discover that these ideas largely fail the Calendar Test. Each idea has virtues, but the results would be largely redistributive, failing to shift the burden of care from physicians onto other providers, patients, and technology.
Passing the Calendar Test
Several policies, however, can lighten the doctor’s calendar by changing how care is delivered:
Enable Medicare and other insurers to compensate doctors for email and phone consultations.
Establish greater ease of entry into state telemedicine markets when in-person interaction with a physician is less essential.
Reform the process by which the Food and Drug Administration approves medical devices. Increasingly, digital technologies can enable laypeople to self-administer high-quality care that formerly required a physician.
Allow broader scope of practice to nurse practitioners, pharmacists, therapists, and other non-physician providers.
Break down corporate practice of medicine restrictions that discourage entrepreneurs and managers from outside of health care to bring their expertise in managerial efficiency to the medical sector.
Drop regulatory barriers to low-administrative-burden practice structures and payment mechanisms, such as direct primary care.
Eliminate certificate-of-need laws and regulations, which discourage the purchase of labor-saving technologies.
Allow greater ease of online prescribing in appropriate segments of the drug formulary.
Eliminate barriers to entry by out-of-state and international health care providers.
Allow Medicare, Medicaid, and other plans to reimburse high-quality overseas hospitals for procedures.
Remove barriers to out-of-state volunteer doctors, nurses, and others to assist patients in underserved areas and disaster sites.
Although these and similar ideas may prove controversial, they are not, for the most part, partisan or left/right ideological controversies. And unlike redistributive reforms, they offer the chance of better care for more people at lower cost, year after year.
Robert Graboyes ([email protected], @Robert_Graboyes) is a senior research fellow with the Mercatus Center at George Mason University, where he focuses on technological innovation in health care. He wrote Fortress and Frontier in American Health Care, teaches health economics at Virginia Commonwealth University, and is a recipient of the Bastiat Prize for Journalism.
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