August 12th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network
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During a recent emergency room shift, I treated a 12 year old boy for a swimmer’s ear. During the visit, I learned he was from the South and was in the area visiting relatives before starting school in a couple weeks. It turns out he’s been battling this pain for a couple weeks and his mom is convinced it’s because of all the swimming he’s done this summer. Instead of rushing him to his own pediatrician at home, she has been “riding it out” to see if the pain resolved on it’s own.
This was true music to my ears! Most parents rush their kids to the doctor at the first sign of ear pain, even though the current recommendations are to not use antibiotics in this age group unless the pain persists or worsens past the first few days. So, if his exam were abnormal, my decision making process would be much simpler.
What wasn’t music to my ears was learning I was the second physician to see the boy that week. The grandmother took him to see her physician when she had a scheduled appointment a couple days earlier, “just for a curbside” and learned that he did in fact have “an ear infection”. No medications were given or appointment facilitated with a pediatrician or other physician. This was truly just a curbside. The family was left with no alternative but to use the ER.
The ER often ends up being our only option when visiting an area out of town, isn’t it? If staying at a hotel, many do have a cool option that provides a physician call service so a physician will come to you, as I learned a couple year’s back in Disneyland. And, some cities do have free-standing urgent-care centers that can help with these sorts of non-911 situations. But, by and large, the ER is it in most areas and for most people.
What a backwards situation! The majority of sick people have situations that do not need the ER yet find themselves having to because there are simply no other options. Think about how much time and money would have been spared for this family and the system had that first physician just seen the child as an office visit and written the same prescriptions I wrote 2 days later during the ER visit. Think about the healthcare savings to the system and personal savings to families if we had the same theoretical options to the hundreds of thousands of annual after-hours urgent care visits our system sees each year but is current seeing in the wrong setting!
In the big picture, seeing a basic sick visit after hours in the ER is like trying to crack a nut with a sledgehammer. It makes about as much sense, too. The truth is we just have no place for the after hours regular sick people, which, by the way, are the majority of people who get sick after hours, especially if their doctor is in another state!
It’s really not a shock ER wait times are so long…ERs are over loaded with patient’s just like this boy. Until we find a better system, better take along your iPod and a good book should you find yourself heading to the ER. You’ll be in very good company waiting to be seen so may as well come prepared for the wait.
*This blog post was originally published at Dr. Gwenn Is In*
August 6th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
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The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary. I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.
He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.
He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income. Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did? I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?
I suspect it went into the overhead of the Clinic. This isn’t a knock on them, it works for their group, so fine. Other groups do essentially the same thing. It’s legal and morally defensible, and some docs don’t mind being salaried.
Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model. As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).
What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.
(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).
Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.
Salaries aren’t all bad, but they’re not the Key to Great Healthcare.
Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.
*This blog post was originally published at GruntDoc*
August 3rd, 2009 by Happy Hospitalist in Better Health Network, Health Policy
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With regards to a compromise by Blue Dog Democrats on setting the rates for paying doctors:
Waxman’s committee resumed work Thursday, with the goal of finishing Friday, after a week-and-a-half delay caused by objections from fiscally conservative Democrats. That rebellion was quelled with an agreement Wednesday that would protect more small businesses from a requirement to provide insurance to their employees, and restructure a new public insurance plan so it could pay higher rates to doctors and other providers, among other changes.
What did the the other Democrats have to say about that?
“This agreement is not a step forward toward a good health care bill, but a large step backwards,” 53 Progressive Caucus members said in a letter to House leaders Thursday. “Any bill that does not provide, at a minimum, for a public option with reimbursement rates based on Medicare rates — not negotiated rates — is unacceptable.“
Let me get this straight. In a world where Medicare and Medicaid pays less than cost, these Democrats want an option where doctors have the opportunity to lose money for every patient they take care of? If negotiated rates are unacceptable, exactly how is the Medicare rate acceptable. There is a reason why many Medicare and Medicaid beneficiaries cannot find a doctor to take care of them. Because the non negotiated rates are unacceptable.
Perhaps our Congressmen and women would like the 300 million Americans to take a yearly vote on the value of their service to this country. No negotiation. Majority salary wins. You just may not like what your constituents are offering you. And you just might quit. How’s that for unacceptable.
*This blog post was originally published at A Happy Hospitalist*
August 3rd, 2009 by KevinMD in Better Health Network, Health Policy
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Reducing health spending, as Congress is finding out, is difficult.
Some health economists have pointed to medicalization of common complaints, like erectile dysfunction and attention deficit hyperactivity disorder, as one reason. Indeed, Dartmouth researchers, who are cited as favorites of the current administration, feel that an “epidemic of diagnoses” is what’s making us sick.
But, Darshak Sanghavi writes in Slate that this may be a red herring, and clouds what’s really driving up costs, namely, the amount we spend prolonging the lives of the elderly. He points to David Cutler, an adviser to President Obama, and his analysis that “it costs far more to prolong the lives of the elderly ($145,000 per year gained) than the young ($31,600), and the rate of spending on the oldest Americans has grown the fastest.”
None of the current health reform proposals target this, understandably, because it would be politically difficult to tell elderly voters that we need to spend less on their care.
And because of that, Dr. Sanghavi rightly concludes that, no matter what gets passed, “we’re just putting off the day of fiscal reckoning.”
*This blog post was originally published at KevinMD.com*
August 3rd, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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I thought everyone knew the major goal of health care reform is to control spending.
Then why are Democratic leaders proposing changes that would outlaw some of the most successful cost-savings programs in the country?
Today’s The Hill reports on the new strategy to attack insurance companies as “villains.” No doubt, health insurers have a bad reputation and have done plenty to earn it. As the Hill reports, the message is going to be that the reform plan will lead to “capping what [insurers] can force you to pay in out-of-pocket expenses, co-pays and deductibles.”
But for at least half of Americans – those who work for large and mid-sized companies and their families – their “insurer” is actually their employer. And many of these employers have been using out-of-pocket expenses, co-pays and deductibles to improve employee health, and reduce the cost of care. They are creating strong wellness programs and creating financial rewards and penalties, all based on employee participation.
As I wrote in April:
Companies like Safeway, Wal-Mart, Michelin, General Mills, Marriott and so many others have implemented programs to create a “culture” of wellness among their employees and their families. Leaders at these companies constantly talk about living healthy lifestyles, and are paying to make it happen. At Michelin, employees get a cash reward for getting a biometric screening and for participating in company-sponsored health improvement programs. It even started work-site exercise programs, including yoga (although it found that with a workforce that was 82% male it had to call its yoga classes “strengthening and conditioning”).
General Mills published wellness statistics about its different plants and found that the workers in each one competed with the others to get the best scores for BMI and other important health metrics. Marriott found that by eliminating co-pays on drugs for certain chronic diseases, more employees followed doctors’ orders to take them, and although Mariott’s drug costs went up, overall health expenses went down. Abbott Labs brings in motivational speakers and set up weigh-in kiosks in its offices that took pictures of employees as they got healthier so they could see the difference. All of these companies reported on enthusiastic participation, and a sense among employees that their company cared about their well-being.
Safeway has taken this idea even further, and redesigned its entire benefits plan around this concept. Employees who live unhealthy lifestyles and refuse to participate in wellness programs pay more for their health insurance — just like a bad driver pays more for auto insurance. Safeway did this in a highly positive and motivational way, making available a wide array of free services to help employees be more healthy and enjoy lower health premiums. The results have been dramatic: Steve Burd, Safeway’s CEO reported at the WHCC that Safeway’s health costs have been flat since 2005.
This Safeway model – creating both soft and hard incentives for employee health – is one of the fastest growing trends in plan design. The idea is to give employees control over their own health care, including financial responsibility. When this happens, employees live healthier, look for value in their health care spending, and overall costs are lower.
And yet the statements from the Congressional leadership suggest they want to severely limit these kinds of innovations.
It may be good politics to demonize the insurers, but we should realize that “insurers” aren’t exactly who we think they are. Health reform that stifles the innovation that’s working at America’s best companies is no reform at all.
*This blog post was originally published at See First Blog*
