Dr. Jim Hill is a friend of mine and co-developer of the National Weight Control Registry – the nation’s largest database of individuals who have lost at least 30 pounds and kept off the weight for at least 1 year. Jim has been studying their commonalities – and has determined that there is in fact a recipe for long-term weight loss success. I shared the recipe with ABC news today. My interviewer (Natasha Barrett) was really funny, and had tendencies to blurt questions in the middle of our conversation (such as: “what do you think of granola bars?”)
I recently wrote about the heroic efforts of volunteer pilots involved in Mercy Medical Airlift and Air Compassion for Veterans. I met Steve Craven on a shuttle to a Red Cross event with US Defense Secretary Robert Gates. Steve kindly explained a little bit about what some airlines are doing to contribute to our active duty and veterans’ medical transportation needs. I was soon contacted by American Airlines to help them with awareness efforts of their own veterans initiatives.
I interviewed Captain Steve Blankenship, the Managing Director of Veterans Initiatives at American Airlines. Feel free to listen to the podcast or read a summary of our discussion below.
Dr. Val: Tell me a little bit about yourself, Captain.
Blankenship: Being a veteran myself (20 years with the US Cost Guard) a count it a real privilege to serve our veterans. During my first 8 years with the Coast Guard I was a helicopter rescue crewman doing search and rescue based out of Miami, Florida. I eventually went to navy flight training and retired from the military in 1991 and was hired to fly for American Airlines for the next 14 years. In 2004 I helped to launch their Veterans Initiative.
Dr. Val: Tell me about Operation Iraqi Children and Snowball Express.
Blankenship: There are so many children who have never been in uniform, but who have paid the ultimate price of losing a mom or a dad in war as they defend our freedoms. American Airlines is particularly proud to be supporting childrens’ initiatives. The Snowball Express program involves private flights around the country to pick up kids and their surviving parent to take them on a fun-filled trip during the difficult winter holiday season.
Actor Gary Sinise helped to co-found Operation Iraqi Children where we shipped over 25 tons of toys and educational materials to Iraq. Our troops were able to give out 10,000 individually wrapped gifts to young children in Iraq.
Dr. Val: What about American Airlines’ support of the iBot Mobility System for wounded veterans?
Blankenship: The iBot is a special kind of wheelchair (designed by the guy who created the Segway) that allows its user to sit at an eye level with someone standing next to them. They can also climb stairs. To date we’ve raised over $700,000 to buy these iBot Mobility devices for our wounded warriors.
Dr. Val: What else is American Airlines doing for veterans?
Blankenship: We fly wounded warriors and their families on charter flights from Brooks Army base to Disney World. We have three dedicated “yellow ribbon” airplanes that we use to fly recovering service men and women to events so they can get out of their rehab centers for a period of time and have fun with their families. This kind of charity comes naturally to us because American Airlines was founded by a military veteran and over 10% of our current staff are either active duty military personnel or veterans.
Every day we go to work, we recognize that the right and privilege we have to fly our airplanes and transport our passengers was paid for by the men and women who wear the cloth of our nation. American Airlines is continually looking for ways to thank them and support the efforts of our military.
Dr. Val: How do military and their families find out more about your programs and services?
Blankenship: They can send me an email directly and I’ll make sure they’re referred to the right place.
Asking a bunch of doctors and nurses what they want out of health care reform is like asking a group of teens what toppings they want on a pizza: You’re going to get a lot of different answers, with the loudest proclamations reserved for what they don’t want.
Such a group came together July 17 at the National Press Club in Washington, D.C. at an event called Putting Patients First, hosted by Better Health. The unanimous conclusion: Get government out of the health care delivery continuum.
Val Jones, M.D., CEO of Better Health, said, “I don’t think people outside the doctor-patient relationship should be making life and death decisions” on behalf of the patient or doctor. Rep. Paul Ryan (R-Wis.), the event’s keynote speaker, said government has an obligation to establish conditions for free markets to thrive. Ryan blamed insurance companies for the problems with health care today – essentiually stating that insurers dictate the care that providers can deliver – and he called for a solution that does not involve heavier government.
“Government bureaucracy is not the answer to insurance bureaucracy,” Ryan said. The government’s failure to control costs in Medicare and Medicaid “shows us we should get government out of the way and put more faith in the market. Providers should compete against each other for our business.”
Ryan claims that the so-called ‘public option’ in President Obama’s proposed health care reform initiative would allow the government to be “referee and player in the same game,” and that companies hoping to compete for consumer health care dollars would be at an unfair disadvantage. Obama’s plan would result in “cookie-cutter standards” for determining individual patient care, set unfairly low reimbursement rates and create an economic barrier to young talent hoping to enter the medical profession.
Ryan added that Obama’s plan offers no incentives for people to get and stay healthy, which would lower health care costs. But offering reduced insurance rates to a consumer who, say, quit smoking or lost excess weight “would be illegal” under Obama’s plan, Ryan noted. “So there’s no incentive” for people to take better care of themselves. Ryan has a plan that he says would include a “carrot and stick” provision to reward people for maintaining a healthy lifestyle.
Between two expert panels, Robert Goldberg, Ph.D., co-founder of the Center for Medicine in the Public Interest, showed a video, complete with scary background music, of patients in Canada and the U.K. complaining about abhorrent wait times to see doctors and government-mandated denial of life-saving treatments. Goldberg concluded that government-run health care in the U.S. would yield a similar system, with patients wasting away in the long shadows of a bureaucratic monster while doctors and nurses stood by, helplessly bound by the new rules. (One panelist later noted that polls show 70 percent to 80 percent approval among Canadians for that country’s health care system.)
The event did yield some progressive ideas for improving the U.S. system.
Alan Dappen, M.D., associate clinical professor at Virginia Commonwealth University School of Medicine, Department of Family Practice, and founder of DocTalker, a practice in Fairfax, Va., has moved a huge chunk of his patient consultation onto the phone. Patients still pay for his time – just as they would for an office visit – but the system is much more efficient than having every patient come in for every ailment. “If you have a tick bite or an ear infection I don’t necessarily have to see you,” he says. Further, he says, the documentation for treating such minor ailments “should not go through 30 people” at an insurance company to ensure the doctor is paid or the patient is reimbursed. “That’s just ridiculous.”
Dappen has been practicing this way for eight years and says it takes on average 10 minutes to solve a patient’s issue over the phone. “Most of our patients are helped to satisfaction,” he said. And as a result of the time saved on patient visits, he added, he has time to do house calls – and is the only doctor in Fairfax County who does so.
Rich Fogoros, M.D., a former professor of cardiology and cardiac electrophysiology and longtime practitioner and researcher who is now a consultant and writer, suggested that primary care physicians go “off the grid” – i.e. refuse to participate in any insurance plan. That, Fogoros said, will force regulators and insurers to acknowledge that current practices by insurance companies have destroyed the doctor-patient relationship.
Kevin Pho, M.D., an internal medicine physician in Nashua, N.H., and author of the blog Kevin, M.D., said the most common complaint he hears from his patients is how little time they get to spend with him during a typical visit. “We are incentivized to see as many people as possible,” Pho said, not to provide the best care possible for each patient. One solution: hourly pay for doctors, siilar to the ‘billable hours’ system used by lawyers.
James Herndon, M.D., an orthopaedic surgeon and chairman emeritus of the Department of Orthopaedic Surgery at Partners health care (an integrated health system founded by Massachusetts General Hospital and Brigham and Women’s Hospital) in Boston, Mass., voiced concern about doctors in hospitals who won’t take care of the uninsured and underinsured. The doctors “keep pointing them elsewhere until they end up in the trauma unit, which is the last resort,” he said. “I would mandate that [all doctors on staff] see their share” of those patients.” Herndon added that he favors “public support,” such as some form of a tax, to ensure doctors are compensated for providing that care. He also conceded that the health care industry has become too profit focused. “The CEO of United Health made $1.2 billion” in one recent year. “We need to get rid of excess profit in insurance.”
Kim McAllister, R.N., the author of Emergiblog, said that, no matter which plan emerges from the ongoing debate in Washington, “People will circumvent it by showing up in the emergency room.” She recounted a story of a patient in California who went to the emergency room for a headache – twice – because he couldn’t get a timely appointment with his physician. She favors a health care savings account model under which each consumer could then “decide what provider they see and when they see that person.” McAllister suggested allowing the money to roll over from year to year – another nod to rewarding healthy lifestyles – although she strongly implied that allotments would be scaled based on a person’s income.
And this hit a point on which most of the participants seemed to agree: For consumers who really cannot afford health care in a free-market system, the government should have funds available to help them pay.
Those on the left will pretty much sacrifice everything to attain their goal of universal coverage.
But, in this well-reasoned piece by conservative economist Tyler Cowen, expanding coverage won’t necessarily control costs, which is a more imperative issue. The bandied about means of cost control, such as electronic medical records, cutting provider payments, and preventive care, all will have little nor no impact in controlling costs.
Take physician reimbursements, for instance, a favorite target of health reforms. According Princeton economist Uwe Reinhardt, a favorite son among policy wonks, cutting physician pay by 20% would only reduce spending by 2%.
Furthermore, under the current payment system, simply cutting provider reimbursements will only give more of an incentive to do more procedures to make up for lost revenue.
The hard truth is that care will be rationed, and that’s something the Obama administration is unwilling to admit. Indeed, as Mr. Cohen writes, “if we aren’t willing to take even limited steps to conserve resources, we shouldn’t be spending any more money elsewhere.”
Cost control first before universal coverage, and therein lies the central contention of the debate.
And the worst case scenario, as progressive blogger Ezra Klein correctly surmises is, “that the final bill will include a pricey expansion of coverage paired with a speculative and uncertain set of cost controls.”
*This blog post was originally published at KevinMD.com*
[Dr. Jim Herndon is a past president of the American Academy of Orthopaedic Surgeons, and chair emeritus of the department of orthopaedic surgery at Partners Healthcare]
***
The challenges of health care reform are enormous. To expect that the vast array of problems that exist today will be corrected or solved in a couple of months is totally unrealistic. Witness the moving target of announced changes and options occurring daily in the press and media in general. And add to the confusion…these changes are being developed at the top (Congress and the White House)…not from the bottom up (from doctors, nurses and other health care providers, and importantly, patients). In their place are the powerful lobbyists…the health insurance industry, the hospital industry, the drug industry and even organized medicine (AMA)…who wield their influence over our policy makers by all sorts of tangible (financial donations) and intangible (spouses of leaders on corporate boards) pressures.
I must admit, although occasionally said without real meaning…I don’t hear an outburst of support for the essential mission/purpose of health care…the health of our citizens…”the patient comes first”. Where is the patient…who is supposed to come first…in this national debate?
Everyone knows that health care is expensive. In 1970 health care spending consumed 7% of the Gross Domestic Product. In 2009 health care spending is consuming 16% or more of our Gross Domestic Product. It is increasing more rapidly than inflation. Yet, as a nation, we have not…in all these years…had a serious conversation about Americans’ health. Where is it in our list of priorities? I don’t think we know. From recent events we do know it is lower than the need to remove Saddam Hussein from power…it is lower than bailing out investment companies and banks…it is lower than stabilizing the mortgage market…and it is lower than bailing out two automobile manufacturers. I am not knowledgeable enough to question the priority of the bailouts of banks and financial institutions or the mortgage companies…but I do question the priority of removing another country’s dictator or bailing out two automobile manufacturers instead of allowing them to proceed through bankruptcy in our court system…over health care reform.
Too often in my lifetime I have seen the importance of health care reform pushed down the list of priorities over other needed programs…to wait for another day. How important is the patient, the health of Americans today? How far are we going to push the profession of medicine from “a calling”…a profession, as President Obama states to “a business”. It is known that patients trust their doctors, but not our health care system. When will patients begin to trust their own doctors less? It will happen if and when they believe doctors are more “concerned with the pulse of commerce” rather than the “pulse of their patients”. I submit we are getting very close to this tipping point…in losing the trust of our patients and society in general.
There is no unanimity of opinion regarding the health care reform debate…amongst Democrats, amongst Republication…amongst the public…amongst physicians in general…and orthopaedic surgeons specifically. I asked a few young physicians in an orthopaedic residency program their opinions about the health care reform debate. All believed that every American should have basic health care insurance coverage. Obvious to them, it would include coverage for care of patients with acute fractures or patients with severe pain or loss of function. They admit not knowing much about the “public option” and the swirling politics going on. They also were not comfortable with defining what situations or problems would not be covered by insurance…although they agreed that some restrictions above “basic care” would have to be implemented.
Their responses reminded me that in 1990, when I was in graduate school for an MBA…we had a class debate about whether health care was a right or not of all citizens? Although the discussion was lively and some felt health care was a privilege, the class conceded that health care was a right of all citizens…admitting historically it was considered a privilege for the few who could afford it, but then (1990 or earlier?) health care had become a right for all in the US. I then asked a few of my colleagues who enjoy leadership positions in the field of orthopaedic surgery their opinions regarding health care reform. They also could not agree on the issues of this debate.
One area where they did agree was that academic medical centers are not well positioned for the future…especially those that depend on state funding. We have already witnessed this in Massachusetts where apparently the state has decreased funding to some teaching hospitals that traditionally have cared for a large number of uninsured. Now that most citizens have insurance, they are seeking their care in other hospital emergency departments. My colleagues also agree that physicians will receive lower payments for specific treatments or participate in “bundled” payments to the entire healthcare team/facility for comprehensive care of the patient.
Otherwise my colleagues disagreed. On the one side some support the public option and universal coverage…although “the devil is in the details”. For this group they have become tired…like so many American physicians…with the convoluted way we finance health care and the associated paper trail/documentation overload. The system has made some patient conditions profitable and others not profitable…described by one as “perverted incentives”. These physicians (me included) are angry at the loss of our professionalism as hospitals and physicians chase dollars and not the health needs of each patient and the public. On the other side (against public option), my colleagues have some agreements…most orthopaedic surgeons are supportive of care of the uninsured and underinsured, especially for patients presenting with acute problems to hospitals’ emergency departments. Most also agree that there needs to be a serious realignment of incentives and improved collaboration of hospitals and doctors.
But they have many disagreements…including the provision of elective care. They argue…with good reasons…that with continued rising costs to practice medicine (rent, electronic records, employee wages and benefits, malpractice insurance, increased personnel requirements for the administration/paperwork overload) and continued reductions in reimbursement (Medicare, for example, pays an orthopaedic surgeon today approximately 50% of the reimbursement it paid for a total hip replacement in 1990)…it is becoming increasingly problematic to provide elective care for the underinsured and uninsured. They commonly ask…”How can you provide care that costs more than any receipts”?
Other disagreements include: the single payor system…they don’t believe it will work; although well-intended, they believe these reforms will result in overall lower quality of care for patients; that emergency departments will still be used by those with insurance because patients can see a physician at the patients’ convenience and avoid long delays to see a doctor in his/her office…for example there is a 40-day wait to see an orthopaedist in his/her office in Boston; the continued tremendous demands by American patients to have the latest technology, the latest treatment…even if evidence for its use is unknown; skepticism about the prevention of disorders that have a genetic basis, i.e. osteoarthritis…in the foreseeable future; the simple fact that to reduce errors and overuse/misuse of tests by an electronic medical record and computer physician-order system will cost enormous amounts of increased spending in the short term…before cost savings are eventually realized… and to draw attention to one specific unsolved problem area…Workers’ Compensation…where orthopaedists, daily, see ineffective treatments being used and large numbers of patients on disability.
Briefly, the follow are factors that have led to increased and inefficient health care in the US: high administrative costs; overuse of services and new technology; an increased prevalence of chronic disease; tremendous geographic variations in care; increased payments not resulting in improved quality; a continually high number of medical errors and complications; a broken professional liability system; a shift in costs from the uninsured to the insured; a predominant third-party payer system; overuse and misuse of care; focus changing from the patient to the pocketbook; insurance company abuses (cherry-picking healthy patients, denying care of patients with chronic disease, deliberately lowering the normal of “usual and customary” fees…to name a few); and continued issues of fraud and abuse, especially in the Medicare and Medicaid programs.
Finally I would like to close with the official position of the American Academy of Orthopaedic Surgeons (AAOS) on health care reform: “Any changes to the health care financing and delivery system…the well-being of the patient must be the highest priority. The AAOS strongly supports reform measures…that provide individuals with patient-centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment”.
The AAOS is opposed to a single-payer health system or even a federal health care authority. The AAOS suggests “a number of tax initiatives…that will level the playing field and make health care coverage more affordable”. There should be “adoption of policies that restore equity and enhance market competition”. The AAOS also “strongly believes that patient empowerment and individual responsibility are necessary components of health care reform. Health choices should be recognized and preventive care should be promoted”.
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