September 23rd, 2009 by ValerieTinleyNP in Primary Care Wednesdays
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As a primary care practitioner, I often am baffled by why Americans need insurance for primary, or day-to-day, care issues. When I’m talking about primary care, I mean those health problems that are considered routine, or day-to-day, problems including ear infections to poison ivy as well as many urgent care issues like sutures and draining infections. These account for a large portion of all health problems that occur in the U.S – and 80% of the things that typically up in the ER or urgent care.
My understanding is that the purpose of insurance is to protect our financial well-being and thus our financial nest egg. Investorpedia, which is part of Forbes Digital Media, offers the following definition: “Insurance allows individuals, businesses and other entities to protect themselves against significant potential losses and financial hardship at a reasonably affordable rate.”
This definition explains why we invest in insurance of all types: car insurance, home insurance and health insurance.
Then I wonder why our expectations and utilization of health insurance differs so significantly from home or car insurance. I pay a monthly premium for my car insurance, and it protects me against having to pay out large sums of money if I would be in a bad car accident. I don’t expect, however, my car insurance provider to pay for an oil change or new battery. Likewise, I pay a yearly premium for my home owner’s insurance, yet I do not expect the insurance company to foot the bill if I need a new screen door – but I certainly will turn to them if a tree crashes through my garage during a bad storm.
Then why should I expect my health insurance to pick up every small, day-to-day health issue that I have, particularly those that can cost less then $150, like a well-woman physical, help with pink eye, a tick bite or extricating a fish hook?
Don’t get me wrong; I feel that health insurance is a must to protecting anyone’s financial assets against a potentially catastrophic health event, like a tragic accident or illness. We all need to be ensured that we will not go broke if we are faced with such health issues.
I currently work for a primary care practice, DocTalker, is built to deliver affordable access to our medical team, round the clock, to ensure that our patients save cost and time. Our patients pay for a doctor’s fees when service is rendered. We base the fee structure on time and materials; our patients pay us for the amount of time they spend with the medical team. An office visit typically lasts for 15 minutes and costs $75. Believe it or not, roughly 75% of our patients pay less than $300 per year for their primary and urgent care health issues. I know of a lot of people who pay that in one office visit to the vet!
Our philosophy is that the faster we can talk to and treat our patients, the faster they will get better, thus saving them time and money from lost work, not to mention saving them in expenses from waiting to treat a condition that can worsen with time (like bronchitis). Once we’ve met with a patient face-to-face, we offer phone and email consultations, which typically cost $50.
The other thought is that if people pay, out-of-pocket, for their day-to-day care problems, then they will be more like to be aware of the cost and quality of the care they receive – much like they are with that vast majority of other purchases that they make, from a car to cell phone service to food. This will cause the consumer to demand a higher quality of care for a better price, and will lead to consumer choice and thus to consumer’s driving the market.
I don’t think that a price tag of $300 for the care of majority of primary and urgent care problems is really that much to ask; after all, many of us pay this much when we have a plumber come to the house to unplug a sink.
I think that my health is worth as much as an unplugged sink. I believe we do can it at a less expensive price. Don’t you?
Until next week, I remain yours in primary care,
Valerie Tinley, FNP-BC
September 22nd, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
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In his Big Speech, it was noticed that President Obama hedged a little bit in his language regarding the numbers of the uninsured. Despite the fact that the newly-released Census data reflects conventional wisdom, that the number of uninsured totals around 46 million people, the President cited “over 30 million” as the number of the uninsured. OMB director
Peter Orzag has a typically wonkish post explaining their numbers — about 39 million uninsured citizens & legal residents. Some of those — a few million, it seems — are eligible for various public health care insurance programs but for a variety of reasons are not enrolled. So they settled on the vague but defensible “over 30 million.”
Anthony Wright expands on this a bit over at TNR’s The Treatment, pointing out that, depending on how you count, the numbers could be much higher indeed. For example, the “millions” of people who are not enrolled in Medicaid and CHIP often are not because the states that administer the programs have in many cases raised administrative obstacles to enrollment, delayed enrollment and even closed enrollment, in order to reduce the strain on their budgets. And if you count the number of non-elderly Americans who at some point in the past two years were uninsured, the number is over 86 million — one out of three people. While at any given point in time, the numbers may be much lower, overall, the population of people at risk of being without healthcare coverage is quite large.
Yet, voices from the right continue to dispute even the more conservative census figures.
Yes, Those Uninsured Numbers Are Legit | The New Republic
It seems the attack on the 46.5 million doesn’t just seek to undermine the facts; it seeks to both minimize the problem, and place the blame for being without coverage on the uninsured themselves. […] But this pervasive argument by health reform opponents, made by Sen. Orrin Hatch on Meet the Press, or Rep. Dan Lungren at a town hall meeting here in Northern California, suggests their true stance… that most of the opponents simply don’t see a big problem in the first place. President Obama should not avoid this rhetorical fight. If opponents want to deny the established Census figures describing the health crisis, to minimize that the problem isn’t that bad, or to blame the victims of our broken health care system, that’s a debate I am confident health reform supporters will win.
I think this is right. The uninsured may not be the best sales pitch, because most people don’t see themselves as a member of that group, but reminding people that reform offers security & stability in healthcare coverage is a compelling promise. Moreover, as opponents of reform try to resurrect the “America has the best health care” argument, it’s handy to remind them that the health care system in the US really is terribly broken and in need of reform. As the specter of rationing is raised to scare voters, the fact that we are already rationing by income should not be forgotten.
*This blog post was originally published at Movin' Meat*
September 22nd, 2009 by Happy Hospitalist in Better Health Network, Opinion
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What’s wrong with using standard of care as the threshold of medical negligence? I walked you through a case, point by point, as to how the failure to diagnose cannot be considered negligence and why the process of the differential diagnosis must be protected from the fear based legal system we operate in.
When the differential diagnosis became a legal driven process, we physicians lost our ability to offer cost effective, clinical driven medicine. We became front seat drivers in the world’s largest Ponzi scheme known as the Medicare National Bank. A
99 trillion dollar black hole of defensive medicine.
What is it about the threshold of standard of care that makes it irrational? Why is that the standard for negligence? And what exactly is it? In six years of clinical hospitalist practice, three years of residency and four years of medical school, I have never taken a lecture, never seen a presentation, and never read a book about the mystical standard of care. In fact, I find myself grasping to comprehend exactly how to define its very existence.
The great legal resource,
Wikipedia, defines standard of care as
The requirements of the standard are closely dependent on circumstances. Whether the standard of care has been breached is determined by the trier of fact, and is usually phrased in terms of the reasonable person. It was famously described in Vaughn v. Menlove (1837) as whether the individual “proceed[ed] with such reasonable caution as a prudent man would have exercised under such circumstances.”
It goes on to define that reasonable caution as the
Bolam Test
Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 is an English tort law case that lays down the typical rule for assessing the appropriate standard of reasonable care in negligence cases involving skilled professionals (eg doctors): the “Bolam test”. Where the defendant has represented him or herself as having more than average skills and abilities, this test expects standards which must be in accordance with a responsible body of opinion, even if others differ in opinion.
I see a problem with what the standard has become. If everyone in my community orders a head CT for drunks with altered mental status, that represents an action by a responsible body of opinion. Does it mean it’s the right opinion? It does not. When the body of opinion has been contaminated by a persistent and progress fear of litigation, the standard defies the evidence, and itself creates irrational bars of achievement that can never be sustained. The responsible body has itself become irresponsible.
If we are to be a science driven profession, we must be allowed to maintain our integrity, without the fear of legal retribution for failing to uphold the irresponsible responsible body of opinion. Our standards are no longer based on science. When everyone orders the CT scan in drunks with altered mental status, the standard itself has become unreasonable.
Yet the marked deviation of the standard of care from the science of care marches on.
I have argued that standard of care is a local phenomenon. It is what ever the local community of professionals says it is, as they are the responsible body of opinion. The standard for evaluating a pulmonary embolism in downtown Chicago is not the same as the standard in rural New Mexico as it is in the jungles of Africa.
A lawyer previously responded that the local community should not set the standard. They argued that the standard should be a national, or perhaps an international evidence based standard. If science is science, there is no reason to believe that evaluating a pulmonary embolism in the United States should be any different than it is in the jungles of Africa. The most important factor in medical decision making if often not the science but the way the science is practiced on a local level.
The
standard of care in
McAllen, Texas is not necessarily the same as the standard of care at the Mayo Clinic. Is the cost difference legally driven or is it money driven at the local level? I suspect the contribution from both is enormous. Some argue that we should practice as Mayo practices. Mayo may be cheaper, but it isn’t cheap. I would argue that even under their payment model as a large salaried multispecialty organization with economies of scale, the ability to practice defensive medicine still thrives. Who says what costs $8,000 in McAllen but costs $5,000 at Mayo couldn’t be done for $2,000 if the victory against defensive medicine was won? I suspect it could, if physicians weren’t held to irrational standards by the unreasonable
reasonable body of opinion.
If the standard in McAllen is to do a heart catheterization on everyone with chest pain, that is what the community has decided. If the standard of care at Mayo is to do a cardiac stress test, that is the standard at Mayo. If the standard in the African jungles is to do a history and physical, that is the standard in the African jungle? What is the right standard?
The right standard is the one that doesn’t get you sued.
Now, are all three standards of care based on science? No. They are based on what the community of physicians has decided should be done. There will always be a large disconnect between evidence based medicine and clinical medicine. It is not reasonable to do a CT scan to evaluate a pulmonary embolism in the jungles of Africa if that is not the standard, even if the evidence suggests otherwise. Clinical factors should always drive the medical decision making.
Some have argued the standard of care should be founded in evidence based guidelines and not local practice expectations from responsible bodies of opinion. Rarely are guidelines clinically relevant in the hundreds of decision trees physicians make every day in their diagnostic processes. Guidelines are based on studies with limited populations of patients whose neatly defined age groups have packaged disease processes. The realities of clinical medicine make many guidelines unworkable and unreasonable.
My post here is an example of the limited value of guidelines in the differential diagnostic process. Not only are the guidelines often not relevant, they are often contaminated by medical societies and other big businesses with a money driven agenda and stealth conflicts of interest.We must also remember that most guidelines are not based on science but rather based on
expert opinion. All physicians are experts in their scope of practice and their opinions should therefore carry the same weight as the opinions expressed on academic based guidelines. Those that believe national standards should exist to drive standard of care practices across the vast clinical spectrum lack an understanding of what it means to be a physician.
Some lawyers wish to believe that having X, Y, and Z data points means doing A, B and C. Some wish to believe that failure to do so represents negligence as a responsible body of opinion would have done so.
I have never been introduced to this responsible body of opinion. I have no way of speaking for their recommendations. We have local culture driving decision making. We have limited national guidelines often corrupted by external influences. We have a legal system, who’s negligence is based on responsible bodies of opinion, opinions which have been established by fear driven medicine.
So what exactly does it all mean? When I order a lab or a test or a procedure or an x-ray to make my clinical decision making, I don’t sit there and think to myself, “What is the standard of care?”
I think to myself, “What is my expected action or reaction from doing this? What am I trying to accomplish?” I have never been introduced to this elusive responsible body of opinion. I have never been invited to a luncheon. This responsible body has never asked me out for a drink. I have never gone on a date with this body. I have navigated through ten years of clinical medicine and I have never once been formally introduced to this all knowing body of opinion.
By establishing the threshold of negligence as a vague responsible body of opinion, a concept which few physicians have studied, few physicians can quantify and few physicians trust, we have built exactly what the medical-legal-industrial complex has prepared for us: A high volume, high supply, high demand, high cost fear driven reality that we all pay for with out of control health care inflation.
If you think Mayo care is cheap, the time has come to consider that even the highest quality, lowest cost centers in this country could reduce their utilization of health care resources by 1/3, 1/2 or more if the fear of civil retribution for failure to diagnose was taken off the shoulders of passionate and devoted physicians from all fields of training and they were allowed the freedom to employ their differential diagnosis skills in a manner consistent with scientific inquiry and not a legal driven fear.
The longer we deny the fear, the quicker the end will be here.
*This blog post was originally published at A Happy Hospitalist*
September 21st, 2009 by Emergiblog in Better Health Network, Health Policy, Opinion
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Well, I lead a double life but it isn’t out dancing in formal wear!
“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”
There isn’t even time for that.
Besides, who attends a dance during on duty hours?
Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.
Oh yeah?
The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.
********************
My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.
That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.
I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.
I was afraid hubby was going to need smelling salts.
But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.
And then I heard it.
And then he lost me.
*****
There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.
“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system a system that is currently full of waste and abuse.”
“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”
Hundreds of billions of dollars? Billions? With a capital “B”?
Waste. Abuse. Fraud.
This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.
*****
But I have some questions.
What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.
Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?
And then there’s fraud…
That’s a crime, folks.
Hundreds of billions of dollars in waste and fraud?
The President must think that there are an awful lot of criminals in the health care system.
So what’s my point?
*****
My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.
What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?
This can’t be good.
I am in total agreement that our system can be streamlined, big time.
And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.
If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.
If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?
*This blog post was originally published at Emergiblog*
September 20th, 2009 by Toni Brayer, M.D. in Better Health Network, Opinion
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I read a good post from NYT about Health Care Reform and ‘American Values’ and it got me a thinkin’…just what are American Values when it comes to health care? Usually I get a little anxious when I see “American Values” in a sentence, because what usually follows is something about rugged individuality, pulling oneself up by bootstraps, getting the damn government out of our lives and those damn immigrants and welfare mothers who won’t work and want to live off others.
But I have listened to about ten thousand patients over the past 25 years, and I have a good idea of what these Americans want for health care. They are the silent majority…the people who work, study, raise their kids and seldom call into a radio talk show. They don’t have time to go to town hall meetings and shout slogans.
They range from age 17 to 101 and most of them are middle class. They come in all races…Asian, Black, White, Pacific Islander and mixes of all.
Some are wealthy enough to have multiple homes and private planes.
Some are uninsured and watch their health care spending very closely. Most were thrilled to get Medicare and I’ve never heard a complaint from a Medicare patient.
Here is my list of what these Americans think about Health Care:
- They do agree that everyone should be covered for basic health care and would pay higher taxes if they could believe that there would not be fraud and waste. (The recent banking meltdown has destroyed all confidence that government can regulate or be independent from special interests)
- They want choice of physicians and hospitals
- They are sick of insurance companies and all feel like they have been screwed in one way or another. They are shocked at how little insurance companies pay toward the doctor visit and the way those fees are discounted.
- They are technocentric and want tests, imaging, referrals and think “more is better” when it comes to health care. They think tests are cures. Because of the perverse incentives, the “more is better” philosophy benefits doctors and hospitals, but not necessarily patients.
- They fear losing insurance if they have it.
- They are confused about the current reform debate and mostly fear losing whatever coverage they now have, because they know how impossible it is to get by without any coverage at all.
There are no such thing as “American Values” because we are a diverse group of people. But we all have certain things in common. We want to be healthy. We don’t want to be screwed by anyone (big business or the government).
We want to be able to manage our own health care but we don’t want to have to decide between numerous health plans every year with pages of information that cannot be understood. We are tired of not knowing where all the $trillions really are being spent.
We want to know the price of a service up front, and we want a trusted physician to help us decide if that is how our money should be spent. We want smart, committed physicians to know us, and not hurt us.
Sounds American to me.
*This blog post was originally published at EverythingHealth*
