President Obama recently declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.” And indeed, finding a way to provide universal health coverage to every American is one of the focal points in today’s health care debate. There are a variety of ways we can achieve this, ranging from a Medicare for all, single payer system to requiring everyone to purchase health insurance. But no solution can work unless we first deal with the shortage of primary care doctors.
After all, what good is having health insurance if you can’t find a doctor to see you?
As a primary care physician in Nashua, New Hampshire, a city that borders the state of Massachusetts, I have had the luxury of closely observing that state’s health reform efforts. And to their credit, Massachusetts currently enjoys near-universal health coverage, in part because of the mandate requiring every resident to obtain health insurance. Many policy experts are predicting that a national plan will closely emulate the Massachusetts model, so it’s worth noting any potential consequences.
Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits. In fact, since the universal coverage law was passed, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that treating simple conditions in the ER can be exponentially more expensive than an office visit. It’s no wonder that the plan has placed significant fiscal strain on the state’s budget, which is struggling to contain soaring health spending.
This affects hospitals like Boston Medical Center, which primarily serves the city’s poor. The state’s mandatory health insurance law is causing the medical center, according to a front page story in last Sunday’s Boston Globe, to brace “for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families.”
Furthermore, consider the words of family physician Kate Atkinson, who practices in Amherst, Massachusetts. She had decided to temporarily accept new patients, as 18 doctors in her area had recently closed their practices or moved away.
“There were so many people waiting to get in, it was like opening the floodgates,” she says. “Most of these patients hadn’t seen the doctor in a long time so they had a lot of complicated problems. We literally have 10 calls a day from patients crying and begging.”
She closed her practice to new patients 6 weeks later.
I witness this phenomenon myself every day, with patients from Massachusetts routinely crossing the border to New Hampshire looking for a new primary care doctor. These are people with chronic conditions like heart disease, diabetes, depression, and high blood pressure – all who need a regular physician to follow them.
And keep in mind that Massachusetts has the highest density of doctors per capita in the country. What do you think will happen to states that do not have a comparable supply of physicians?
Moving away from Massachusetts, let’s look at two other examples where universal coverage was promised before ensuring adequate primary care access. One would be our military veterans, who are guaranteed health care through the Department of Veterans Affairs, also known as the VA. Earlier this decade, the wait to see a primary care doctor in the VA routinely exceeded 50 days in various parts of the country. Although that number has improved, a recent report by the Office of the Inspector General concluded that more than a third of veterans still waited a month or more to see a doctor. And with tens of thousands returning home from Iraq and Afghanistan straining an already overburdened VA health system, it’s no wonder that my practice in Nashua, New Hampshire sees a fair amount of veterans who are unable to obtain timely care from their local VA clinic up north in Manchester, or from down in Boston.
Next, consider the care Native Americans receive via the Indian Health Service. Despite having guaranteed health care coverage, President Obama himself cites Indian reservations in South Dakota that have some of the lowest life expectancies in the Western Hemisphere. American Indians are twice as likely to die from diabetes when compared to whites, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease. Although each of these conditions can be treated or prevented with timely primary care, according to a 2005 Government Accountability Office report, patient waits within the Indian Health Service for routine women’s care and general physicals lasted anywhere between two and six months.
It is encouraging that the President and members of Congress recognize the threat that the primary care shortage poses to their health reform efforts. But some of the solutions being discussed, such as reducing medical school debt, increasing funding to the National Health Service Corps, and training more mid-level providers like nurse practitioners and physician assistants, fall woefully short. None will have any immediate impact, which will be especially critical if there’s a distinct possibility that already overwhelmed primary care doctors will be responsible for almost 50 million additional, newly insured, patients overnight.
Instead, we need to value primary care, and make it central to our health system. Rather than being encouraged to squeeze in appointments and rush through office visits, doctors need to be incentivized to practice patient-focused primary care, including, managing chronic diseases, providing preventive medicine guidance, and taking the time to counsel patients.
There’s no question that we need to find a way to provide health coverage for every American. But we must do so in a responsible manner, and that starts with ensuring that we have a strong primary care system first.
*This blog post was originally published at KevinMD.com*
Well, you knew it was only a matter of time until the press started covering the court of public opinion – meaning polls. This story came out last night from the Houston Chronicle entitled, “Poll shows falling support for health care reform.” It seems as if the University of Texas Health Science Center at Houston and Zogby International – have found that public support for congress and health care reform seem to be declining.
The authors conducted an online poll that found 50 percent of respondents oppose a bill introduced by U.S. House Democratic leaders this week that would overhaul the system and pay for it by raising the taxes of the wealthiest Americans. Forty-two percent said they support the bill.
Now, I know what people say at this point – it’s bad data – who was the polling sample of – blah, blah, blah. One poll says this and another poll says that – who do you believe? It doesn’t matter who you believe. It matters who the people inside the beltway believe as they start to see these numbers come out.
The poll shows there is strong support for providing insurance for all Americans, but little for increasing taxes to pay for it. Increasing cigarette taxes was favored by 50 percent of respondents, the only tax option favored by at least half of respondents. Less than 20 percent favored increased co-pays and deductibles, rationing care, eliminating Medicare Advantage plans and decreasing home care reimbursement.
Does anyone really think that this will all be done by the August recess? As usual, the strategy is to push something through the House, something through the Senate, and the real bill be decided behind closed doors in conference committee. It worked with the so-called “stimulus” bill. But reading the quotes coming out of the Senate, a lot of people, on both sides of the isle are uneasy with this time frame. Each day gets more interesting, and not in a good way.
I belong to a terrific organization that brings together C-level executives, once a month, to discuss issues each of us face. It’s called Vistage. One of the subjects we talked about yesterday was health care. It was like a focus group made up of seasoned, senior executives from many different industries.
The discussion revealed the tremendous divide between what ordinary Americans think about health care and what policy makers in Washington are doing. It’s a combination that is almost certain to ensure that whatever reform passes may make our problems worse, rather than better.
At the meeting were about 30 executives, representing everything from financial services, commercial real estate, manufacturing, high technology, pharmaceuticals, insurance, retail, non-profits, travel and others. Although all thought health care costs were in a state of crisis in America, I did not hear anyone say this was the case in their business. To be sure, some complained that health costs were high, and that there were few alternatives available. But others described changes they had made to their plan designs that had actually reduced their corporate health expenses.
We talked about the proper role of government, the comparative worth of systems in other countries, the responsibility of people to take care of their own health, end-of-life care, over-treatment, the uninsured, access to care, comparative effectiveness, and our own expectations of what the system should do for all of us. There was no consensus among this group of 30 business leaders as to these subjects and what we should do about them, other than that they are important topics that we need to address. I suspect this is true outside of this group, too. Indeed, the huge collection of issues that fall under the category of health care reform is something I’ve pointed out before.
But the President and leaders in Congress want debate on health care to end. They want a a bill to pass in the next couple of weeks.
Most of the group members were surprised to hear that Congress had already drafted legislation and was getting ready to vote on it.
It’s a remarkable thing. We are in the midst of trying to redesign the largest health care system in the world, and we’re barely debating the merits of it. How many members of Congress will have read the 1,1018-page bill once they vote on it? How many Americans will understand what implications it has for their health care if it — or something like it — becomes law?
The President often says that the status quo in health care is “not an option.” The trouble is, the status quo in health care is a rapidly changing thing. Today, every day, employers and doctors and so many others are busy making real, meaningful changes to our health care system. Not by waiting for committees of Congress to pass legislation, but by getting together and doing things that improve the quality and cost of care and the lives of patients. We need to be listening to their stories, and learning from them. Congress hasn’t done this, and can’t now.
There is an opportunity to build a real consensus around the important issues we talked about yesterday. We can transform our health care system in ways that make all of us proud. But it can only happen by working through these hard questions, not by hurrying to pass a bill before the August recess. Those who say we have a once in a generation chance to reform health care today may be right, but not for the reasons they think. By passing bills without consensus on this deeply important and emotional issue, they are ensuring that no one will really want to try to reform health care again for a very long time.
Which leaves us very much where we started. I will continue to do my part to share the important stories of how real people are making real reform. The political attention to reform may end sometime this year, but the reality of people trying to figure out what to do when sick will continue.
*This blog post was originally published at See First Blog*
My Interview With President Obama On Health Care Reform
I met President Obama yesterday. I interviewed him at the White House about his proposals for health care reform. But naturally, as we greeted each other, I asked about his throwing out the first ball at the All Star Game the night before.
“Were you nervous about bouncing the ball?” I asked. He grinned. “I will say it’s actually nerve-wracking,” he said. “When they hand you the ball, there are just a lot of things that can go wrong.” I found that to be a perfect metaphor for his assuming the Presidency of the United States and attempting to overhaul the health care system.
The biggest news from yesterday’s interview: President Obama has changed his position from the campaign trail and now believes that health care insurance should be mandated for all Americans, with a hardship exemption.
Dr. LaPook: Ultimately, philosophically, do you believe that each individual American should be required to have health insurance?
President Obama: I have come to that conclusion. During the campaign, I was opposed to this idea because my general attitude was the reason people don’t have health insurance is not because they don’t want it, but because they can’t afford it. And if you make it affordable, then they will come. I’ve been persuaded that there are enough young uninsured people who are cheap to cover, but are opting out. To make sure that those folks are part of the overall pool is the best way to make sure that all of our premiums go down. I am now in favor of some sort of individual mandate as long as there’s a hardship exemption. If somebody truly just can’t afford health insurance even with the subsidies that the government is now providing, we don’t want to double penalize them. We want to phase this in, in a way that we have time to make sure that coverage is actually affordable before we’re saying to people “go out and get it.”
The interview went very smoothly and fairly predictably until we reached the following exchange:
Dr. LaPook: You’ve said that if doctors have the information, they’ll do the right thing. And generally, I like to — I’m a physician and practicing — I think that’s true. But actually, there are a lot of times when that’s not the case. For example, angioplasties — elective angioplasties, where you open up a clogged artery in the heart. It turns out that about 30 percent of them are unnecessary, that they’re done and you try to open up an artery of the heart, but really it’s no better than medication, and doctors know this, but they still order them.
President Obama: Why are they still ordering them, do you think?
I will admit that he took me by surprise by turning the question on me. Suddenly I was not in a one-way interview, I was in a conversation. Politics aside, it was clear to me that he was listening and he was curious.
Dr. LaPook: I think that because they believe — there’s this thing about — if an artery’s closed. It’s got to be better if it’s open, and it turns out that’s not true. So they have on the one side their intuition as a physician, in their bellies, and then there’s the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?
President Obama: I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices. And at the very least, you’re not taking money out of physicians’ pockets for making the better choice. So it’s a combination of better information and then, I think, a different system of reimbursement that says, “let’s look at the overall quality of the care of the patient.”
My conversation with President Obama illustrates a crucial focus of the current healthcare debate: figuring out if the American people are getting their bang for the buck when doctors order tests, perform procedures, and prescribe medications. The current buzzwords among doctors and politicians are “evidence-based medicine” (is there proof that something works?) and “comparative effectiveness” (if there’s more than one way to do something, what works best?). An Institute of Medicine workshop about evidence-based medicine began today in Washington, with the following listed as “issues prompting the discussion”:
. “Health costs in the United States this year will be about $2.5 trillion—nearly 17% of the economy.
. The United States spends far more on health care than any other nation, 50% more than the 2nd highest spender and about twice as high as the average for other developed countries.
. Overall health outcomes in the United States lag behind those achieved in other countries.
. Consistent with the per capita figures, many researchers studying the nature of U.S. health expenditures feel that 20% of our expenditures do not contribute to better health.”
Expert groups are currently trying to establish guidelines for reimbursing health expenses based on clear results from well-designed clinical studies. The problem is that for many medical issues, there is no definitive, evidence-based approach. Clinical medicine is often based on inexact, immeasurable tools such as intuition and experience. As doctors, we don’t have the luxury of waiting for the twenty-year study to be completed. We have to treat the patient now, as best we can, without perfect information.
In the absence of definitive data, we will need to account for clinical judgment in an overhauled health care system. What will happen when the doctor suggests something the insurance company says is not indicated? Opponents of a public option for insurance warn about the danger of having a bureaucrat in between the patient and the physician. But that threat already exists in the current system every time an insurance company decides whether to approve a claim. Wendell Potter, former head of Public Relations for Cigna, recently told
Bill Moyers about Cigna’s decision to deny a liver transplant to a 17-year-old girl, Nataline Sarkisyan, even though her doctors at UCLA had recommended the procedure.
A public-relations uproar forced Cigna to reverse its decision; the company subsequently explained its reversal as an exception, saying the surgery was approved “despite the lack of medical evidence regarding the effectiveness of such treatment.”
Ms. Sarkisyan died hours after Cigna’s decision, without having received the transplant.
A critical flaw in the current system – and one that must be addressed in any overhaul – is that the same people who refuse to pay for a recommended course of action are the ones who consider the appeal of that decision. And, lo and behold, they usually end up agreeing with themselves! In more than two decades of medical practice, I have spent countless hours trying to get various services covered by payors. One encounter – when I tried unsuccessfully to get a stomach-acid lowering pill approved for a patient who needed it -ended up as an example of twentieth-century frustration in
Letters of the Century.
Yes, our current health care system is not sustainable and we do need an overhaul. But there is no “exactly how” and we cannot afford to wait for one. There are so many nuances to the moving target of health care and so many unknowns that it is impossible to create a perfect solution on paper. I’ll settle for an imperfect solution that addresses the most important problems first and represents the best efforts of our most thoughtful experts. But it should not be set in stone. It must include provisions to mature gracefully into versions 2.0 and beyond.
An illustration from “Physical Therapy for Zombies”?
Seriously.
The crutches are way too long and there is no banister on the stairs.
Actually, I don’t even see a second crutch.
Is the nurse is standing by or running up to rescue this guy?
If he is trying to elope, he isn’t going to get far!
********************
I figure if you are trying to understand something, begin with how it affects you. Make it personal, and it’s easier to grasp.
So I took on my health insurance coverage. I am covered through my employer, but surely I could get comparable coverage as an independent buyer.
Right?
*crickets*
*****
I am covered by Anthem Blue Cross. You know, Blue Cross. The company that used to be the Gold Standard of health insurance? The one my physician no longer accepts because of their reimbursement rates? I figured my best bet was to check out and compare coverage from the same company, so I hit the Anthem Blue Cross website to try and get a quote.
You can get an overview of policies, but they make you put in your phone number so a representative can call you. I didn’t mind, as I had some questions. I spoke with Danny, who was very helpful.
But before I go any farther, you should know one thing. Just in case you are looking to purchase a private plan.
If you have insulin-dependent diabetes, Anthem Blue Cross will not issue you a private policy.
Whoa. Found that out when I asked about pre-existing conditions. I had always heard that folks were denied coverage for pre-existing conditions, but to actually hear it coming from a representative floored me.
*****
If I wanted to quit my nursing job tomorrow and make my living blogging (offers accepted), I would need to purchase insurance. I could go with COBRA and buy through my hospital for 18 months, or I could buy my own policy.
The payment for COBRA coverage for a family of three adults (ages 55, 52 and 19) is $2157.00 per month. That is $25884 per year, and includes everything from pediatric well-baby checks to maternity coverage.
Twenty Five Thousand, Eight Hundred and Eighty-Four dollars a year.
Pardon me while I go take a meclizine, just typing that number gave me vertigo.
Private PPO insurance for the same family of three, through the same company, with coverage for brand-name medications is $897, or $10,764 per year.
Huge difference.
On the surface.
*****
To get the private-pay plan you must be vetted. Screened. They will take you if you have high blood pressure, but only if you are controlled and have been on meds for a certain amount of time. Same with high cholesterol. Same with GERD. I’ve already mentioned the diabetes. If you don’t meet their criteria, it’s “buh bye”.
My friend in Human Resources told me that our insurance coverage was “more robust” than what was offered in the private plan. Our deductibles are less, our out-of-pocket per-year expenses are less, our co-pays are much less.
She was right.
But I am still confused.
And I have a lot of questions.
Why is my employer paying for coverage I no longer need? I’m long past needing the services of a pediatrician and maternity coverage is not an issue (been there, done that, may my ovaries Rest in Peace). Why can I not opt out of these things, saving my employer money? What if I did not want coverage for mental health, for example? The private pay plan is available without maternity care.
Why can’t I have the money that is spent on my health insurance premiums (more than some people make in an entire year!) put in a savings account that allows me, as an individual, to choose what type of coverage I want to have? And have whatever is left available to pay co-pays and deductibles? They are paying the money anyway – why not put it in the control of the patient/employee.
Where the hell does the private insurance industry get the authority to decide who they will and will not cover? Is that not discrimination?
What happens when/if I develop an illness that would have denied me private coverage to start with? Am I dumped? Is the illness covered? For how long?
And I still don’t understand…
Why my doctor charges $140 for a visit, I pay $15 and the insurance company pays another $40, and my doctor winds up with only 39% of his fee? No wonder he doesn’t take new patients with Blue Cross. What other profession has no control over their reimbursement?
Why, with my background as a nurse, I still am unable to make sense of an “Explanation of Benefits” report. There is an actual fee, a negotiated fee, a deductible, a co-insurance portion and then what is left is for me to pay. And trust me, the amount paid by either the insurance and/or myself never, ever amounts to the actual fee. Ever.
Why I have a bill for lab tests and screening exams that far exceeds what my deductible is for the year, and yet the deductible is not yet satisfied. Seems to me I’ve paid out the deductible-times-five and yet it is still not satisfied.
I don’t even know where to start to try and get an handle on this.
Either I’m an idiot or the system is way out of control.
Maybe both.
But I do know this. I am a 52-year-old woman who is welded to her employment solely for the medical benefits. I’m getting older, I am going to need coverage for conditions and diseases that I did not have to worry about in my 30s. Every decision I make, whether it be a new job or attending school full-time at a university will be decided by the availability of health insurance and what it covers.
Thank god I have that coverage.
I just wish I had more control over how it was applied.
Lord knows I could do it more efficiently.
*This blog post was originally published at Emergiblog*
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