April 20th, 2009 by KevinMD in Better Health Network
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Walgreens made some headlines with their program to give free acute care services to those who are unemployed.
Before you think that they’re doing this out of the goodness of their hearts, Jaan Sidorov gives a more practical reason.
Doctors rarely would drop patients who have recently gone on Medicaid, or worse, lost their health insurance altogether. Why? As Dr. Sidorov writes, “Today’s patients with no or non-remunerative insurance were not only yesterday’s richly insured but tomorrow’s also. These providers know that when the economy eventually turns around, these patients are going to join the ranks of the employed/insured.”
Walgreens is applying the same principle. Today’s uninsured patients will, more likely that not, have insurance in the future, and will repay Walgreens back for helping them out during these tough times.
So, rather than patting Walgreens on the back for their kindness, you should be noting their business shrewdness instead.
April 1st, 2009 by DrRich in Better Health Network
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Recently, DrRich offered for your consideration a brilliant proposal that would assure at least some continued advances in pharmaceutical therapy, while at the same time providing for drug price controls.
DrRich was gratified to find that the majority of comments and e-mails he received regarding this proposal were quite complimentary. Sure, there were the obligatory cavils that the drug companies deserve what they’re getting (the essential evil nature of drug companies was, of course, a point that DrRich cheerfully conceded from the outset), and that certain interest groups (breast cancer, AIDS, etc.) even with government price controls would continue funding research aimed at treating certain specific illnesses (a prospect which ignores that translating the kind of basic research done by, say, the NIH into actual useful products requires specific companies to risk hundreds of millions of dollars in product development; see here), but on average the response to DrRich’s proposal was most favorable.
That proposal can be summarized as follows. Each American would formally elect to participate or not in a voluntary plan of price controls. Those who elected to participate would be entitled to receive any legal prescription drug at low prices set by a sympathetic government board, as long as the drug had been on the market for some fixed amount of time. (DrRich arbitrarily suggested five years, but that number could just as easily be set at 10 years, or any other value.) Those who choose not to participate in the price control plan would have to pay whatever the drug companies wished to charge them for all their prescription drugs – but they would be eligible to receive new prescription drugs immediately upon FDA approval (that is, the five- or 10-year waiting period would not apply to them). Finally, individuals would be able to change their status (from participant to non-participant, and vice-versa) only every two years.
Just as is the case with the drug price controls currently under consideration by the Obama administration, DrRich’s plan would achieve low drug prices for anyone who elected to participate. But DrRich’s plan offers, in addition and in distinction, a mechanism by which pharmaceutical progress could continue, albeit at a slower pace than we see today. That is, it provides a population of individuals willing to pay full price for new drugs, thanks to whom the drug companies will be induced to continue spending on drug development.
As a result, even those who choose to participate in DrRich’s price control plan would be able to count on a pipeline of new drugs, which would become available to them at very low prices after the mandated five- or 10-year delay. This is a very useful feature that would not be available under Mr. Obama’s price controls. Indeed, participants in DrRich’s plan would be placing themselves in a situation reminiscent of that experienced by Canadians today. (Canadians, of course, can rely on a steady stream of new, cheap drugs which come to them, with some delay, thanks to a population of individuals south of their border who are paying full freight for those same drugs.)
All we need now is to launch a grassroots movement to convince our legislators that this proposal offers all the benefits of the drug price controls now under consideration by the Obama administration, without its major drawback (i.e., a complete stifling of pharmaceutical progress). Then, having done that, we will simply need to set up the federal bureaucracy to establish and administer the participation status of every American, and a government board that will set the official prices of all prescription drugs. With the kind of streamlining in federal processes and procedures promised by the Obama administration, we should be able to implement DrRich’s plan in a matter of just a few years.
The Punch Line
There is, of course, a punch line.
Now that you have had ample time to digest the favorable implications of DrRich’s proposal, and can plainly see the wisdom behind it, you will be delighted to know that you don’t actually have to wait for federal legislation and the establishment of a vast new price-control bureaucracy in order to participate. You can participate today, right now, with nobody’s acquiescence but your own.
Here’s how. Simply declare to yourself that DrRich’s system is already in place, and that you are a participant, and that the only drugs available to you are the ones that have already been on the market five or 10 years or longer. (You can choose your own personal waiting period.) When you see your doctor, insist – demand – that he/she prescribe only older drugs. The price of most of these drugs will be set not by a government panel, but by WalMart (which for many common generic drugs has set a co-pay of $4). By declaring yourself as boycotting the brand new drugs that are being sold (unfairly, of course) at the highest premium, your personal drug costs will be remarkably reduced – just as if federal price controls were really in place.
Furthermore, since currently there really aren’t federally-mandated price controls, drug companies are not yet constrained from investing in new drugs. As long as this situation continues, there will be a steady stream of new drugs exiting that magic five- or 10-year boycott period you have set for yourself, and thus becoming available to you under your personal, voluntary price control plan.
And best of all, if you were suddenly to develop a medical condition that clearly calls for one of the brand new drugs, one that wouldn’t be available to you, either temporarily under DrRich’s Voluntary Price Control System, or ever under a government-mandated price control system (because under the government plan the drug never would have been developed in the first place), you won’t need to wait five or 10 years (or forever) to get that drug. Since you are really only “pretending” there are drug price controls, the moment you decide that a system of price controls is no longer accruing to your own personal benefit, you can simply ask your doctor to write you a prescription.
So: those clamoring for government price controls on drugs can have them today – this very afternoon. They can experience every aspect of price controls (both low prices and the unavailability of new drugs) in a way that places them in no worse a position (indeed, in a far better position) than if government price controls were actually in place, and without reducing the options for everyone else.
Indeed, considering the above, the only way it would make sense to continue demanding mandatory price controls would be if something other than reducing drug prices were the chief motivating aim.
DrRich leaves it as an exercise for his regular readers to determine what that motivating aim could possibly be.
**This blog post was originally published at Dr. Rich’s Covert Rationing Blog.**
March 19th, 2009 by KevinMD in Better Health Network
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In a surprise, President Obama has signaled a willingness to discuss medical liability as part of the health reform process.
Good for him for standing up to the trial lawyers, a core constituency of the left.
That’s a good sign, as the costs of defensive medicine brought on by the broken malpractice system, should be addressed if there is any hope of reducing health care spending.
Trial lawyers like to say that medical malpractice represents “less than one percent of the cost of health care,” but that fails to account for the substantial sum attributed to defensive medicine doctors practice to avoid the threat of malpractice, estimated to be $210 billion annually.
Furthermore, the argument that malpractice reform will harm patients “by limiting their ability to seek compensation through the courts” doesn’t hold water either.
That’s because the current system does a miserable job of compensating patients for medical errors, where more than 50 cents on every compensated dollar goes to pay lawyers and the courts. Not to mention that a typical malpractice trial may last years before an injured patient receives a single penny.
So, don’t believe the arguments of the trial lawyers, who prefer the financial security of the status quo.
Any alternative system, such as no-fault malpractice, mediation, or health courts, will go a long way both to reduce the cost of medical care, and fairly compensate more patients for medical errors at a significantly more expedient rate.
Lawyers are aware of these facts, and to their credit, are going on a preemptive offensive to head off tort reform. If I were the AMA, I would start pro-actively circulating some of the above talking points, rather than reacting to the trial lawyers.
**This post was originally published at KevinMD**
March 4th, 2009 by Dr. Val Jones in Primary Care Wednesdays
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By Alan Dappen, M.D.
What Goes On In the Back Office
“The Funnel” details how physicians’ must treat patients if they expect to stay in business. Herding patients through “The Funnel” is meant to depersonalize every problem into 10-15 minute slots. It’s not that doctors don’t care, in fact, morale on the assembly line of primary care is terrible. It’s just that there seems to be no solution doctors have found to sustain the financial realities they face under the insurance-driven system. I’d like to show you some cold hard numbers.
The healthcare system has been a gold rush of opportunity. In sixty short years the healthcare has brought wealth to lawyers, drug reps, insurance companies, malpractice coverage, transcriptionists, billing specialists, authorization departments, performance evaluators, and certification organizations, just mention a few. Each fill their niche, presumably to add value and quality to the service. As they’ve tagged along in the healthcare system, the patient’s $20 co-pay covers less and less, while a physician’s office pays for more and more. Those that are making money off of the healthcare system are often predatory, inadvertently driving up the cost to the patient, hence causing insurance premiums to double by 2016.
Below details the monthly expenses for a typical primary care physicians practice (not supporting obstetrics). Most of the expenses listed are in line with a those costs for running a typical business. However, what is alarming are the salaries for administrative, or non-physician, staff salaries, which consume about one third of the incoming money received. Many members of this staff are billing specialists needed to negotiate the ever-changing rules and regulations of the third-party insurance providers and receptionists, as well as schedulers and managers to get you into The Funnel.
Table based on both Medical and Dental Income and Expense Averages, 2004 Report Based on 2003 Data, published by the National Association of Healthcare Consultants; and expense records provided by doctokr Family Medicine.
Doctors, like all of us, can’t work for free, and want to receive a paycheck that will allow them to live comfortably, raise a family and pay off their large debts from medical school. Let’s say the above medical office paid their doctor a yearly salary and benefits of $162,750, the office then would need to bill $36,845 a month to stay in business. Since a doctor can only physically see patients a total of six hours per day (or 120 hours per month), this equates to a doctor needing to bill $307/hour to simply break even. At a more granular level, each minute costs the doctor roughly $5. Doctors have figured out that they can further reduce this per minute cost if they band into larger group practices.
But here’s the rub: the patient pays for 3-4 minutes of the physicians overhead (the $20.00 co-pay), leaving the doctor and his staff to bill and fight for every dollar they can make from the insurance company. Six hours of “patient care” translates to another four hours of uncompensated work while the physician completes medical notes, follows up with hospitals, specialists, and labs, answers patient call and prepares for the next day. The standard work week is 50+ hours before adding nights on call and weekend coverage which is done for free.
How do doctors survive? They employ billing specialists, they speed up their visits, they “upcode” their notes when possible. But most importantly, doctors deploy “The Funnel,” which brings us back to where we’ve started.
Until next week, I remain yours in primary care,
Alan Dappen, M.D.
March 1st, 2009 by Dr. Val Jones in Health Policy, Opinion
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The AMA’s communications department kindly sent me a copy of a letter that they (and 9 other professional society CEOs or Presidents) recently sent to Barack Obama and 12 members of congress. I’ve been blogging about the fact that healthcare providers in general, and physicians in particular, do not seem to have much of a voice in healthcare policy. In fact, from what I can tell, Dr. Nancy Nielsen is carrying the torch almost exclusively. I don’t mean to belittle anyone’s efforts, it’s just that I’ve noticed that she is often the only physician at the highest level policy meetings.
So it was with great interest that I read the group letter to Obama et al., wondering what collective message our physician leaders were trying to get across. The writing was academic – using terminology familiar to those heavily steeped in medicine – and emphasized the creation of a patient-centered culture supported by evidence based medicine.
However, the letter raised an interesting question in my mind: Will members of congress read and understand it? I believe that the most effective letters to congress are likely to share three qualities: 1) they must be emotionally provocative 2) they must be written at about the 6th grade reading level 3) they must be brief.
Why Letters Must Appeal To Emotion (“Cultural Competency”)
Dr. Nielsen said at a recent Medicare Policy Summit that speaking with Senators can be “pure theatre.” That has been my observation as well. Decades of experience speaking in large committee meetings have taught them that amusing sound bites or emotional outbursts get attention. In fact, it may be the best way to get things done in congress. For example, did you know that the reason why kidney care is the only disease-based eligibility under Medicare is that Shep Glazer testified before congress during one of his dialysis sessions?
Washington , D.C. , Nov. 4, 1971 – In the most dramatic plea ever made on behalf of kidney patients, Shep Glazer, Vice-President of NAPH, testified before the House Ways and Means Committee while attached to a fully functioning artificial kidney machine.
Minutes before, in the corridor outside the hearing room, Shep told reporters from the AP, UPI, and the Washington Post, “Gentlemen, I am going to tell the Committee that if dialysis can be performed on the floor of Congress, it can be performed anywhere.” As his wife, Charlotte , connected him to the machine, he continued, “Kidney patients don’t have to be confined to hospitals, where expenses are $25,000 a year and more per patient. It’s much cheaper in a satellite unit or at home. I want to show the Committee what dialysis is really like. I want them to remember us.”
My point is that in congress, as opposed to medical meetings, emotion is king. Physicians have a hard time speaking from the gut, since we’re trained to speak from data – because we know that the gut can be misleading. However, my plea to physician groups is this: let’s collect our data, understand the science behind our point of view, and then present our advice in a way that is persuasive to congress. That means we’d probably benefit from a few theatre classes (can we get CME credit for them?) I’m not suggesting that we become undignified in any way – I’m just saying that personal stories, case studies, and appeals to emotion are the currency on the Hill. If we want attention, we’ll need to find a way to make our points in their own language.
For example, I was listening in to a recent Senate hearing on healthcare finance, when a Republican senator began his introductory remarks about “out of control spending” with this:
I must tell you that I have major concerns about our current approach to spending. We’ve already sunk billions of dollars into all kinds of bailouts and programs without any clear benefits. But every time I bring up the excessive spending issue, you’d think I was a skunk at a picnic…
An amusing analogy, and one that resonated with his peers. This Senator understood the culture to which he was speaking. In other words, he had a “culturally competent” message.
Why Letters Should Be Written At About The 6th Grade Reading Level (Health Literacy)
Dr. Richard Carmona told me that one of the first things he learned as Surgeon General was that the American people understand health information at a 6th grade reading level. Thus, there is no point in making a 100+ page medical report on the health hazards of smoking the corner stone of a public smoking cessation campaign.
Health information must be written in a clear, and actionable manner – but it must also be delivered in such a way that it resonates with diverse communities. Letters to congress are no different – many of our congressmen and women do not have advanced medical or science degrees. We must be sensitive to that and write to them in a way that makes it easy for them to understand what we’re hoping to accomplish.
Why Letters Must Be Very Brief
Much has been made of the fact that many people who signed the recent 1000+ page stimulus bill hadn’t actually reviewed it. In fact, it is estimated that 306 members of Congress voted for a bill they had not read.
Of the 535 members of the United States House and Senate, 246 House members and 60 members of the august Senate voted for the $787 billion stimulus bill without having read a single one of the bill’s 1,071 pages or having any idea of where all of this money borrowed from our grandchildren is going to be spent.
So if our members of Congress don’t read the stimulus bill, will they take the time to read long letters from professional societies? I think you know the answer.
Conclusion
The AMA should be applauded for their lobbying efforts on the part of physicians in Washington. However, my personal view is that letters to congress may be more effective if they are written in a concise, jargon-free, compelling way that respects the “culture” of congress. We physicians hear a lot about “health literacy” and “cultural competency” – and must remember to apply those principles to letter-writing campaigns.
Will any letter influence congressional decision-making? It’s hard to measure the “ROI” of group letters to congress – and certainly they’re only one part of a larger strategy. However, it behooves us physicians to find ways to reach across the cultural divide to speak to congress about the issues that trouble us all: the fate of patients. Letters may be helpful, but an increased presence in Washington, along with some heartfelt reasoning, may be our best shot. Perhaps the Broadway actors affected by the economic recession could help us out?
