September 18th, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Health Policy
No Comments »
In a recent interview with Dr. Oz on Good Morning America, Dr. Oz told Diane Sawyer that he doesn’t think any of the proposed health care plans will work. Why? As Dr. Oz told Diane:
“What we haven’t done is get to the very root reality of the flaws we have in the health care system. True health care reform cannot happen in Washington. It has to happen in our kitchens, in our homes, in our communities. All health care is personal.”
Dr. Oz pointed out that the United States has twice the disease that is found in Europe. He believes that we have to find it impossible for Americans to not embrace good health. According to Dr. Oz:
“If I make your workplace conducive to walking at lunch, or working out at some time during the day, or I get people to use the stairs more by creating incentives to do such, then people will start doing it naturally.”
All you have to do is walk around any place USA compared to anywhere else around the globe to know this is true. Or, just note our friends from around the world who are visiting our country on vacation. Striking how much healthier our friends from other parts of the world appear – and act. They seem more vibrant, have more energy.
For these reasons, Dr. Oz isn’t hopeful any of the healthcare reform plans will work. He feels that until people start living more healthy, how the health care system is paid for is really moot. In his words: “The big debate right now in Washington is health care finance. It’s how are you going to pay for it. I don’t care which program we pick. I’ll tell you why. Because none of them are going to work.”
The sad truth is, he’s right. Americans have shown themselves to be very untrustworthy on the health care front with heeding doctors warnings about healthy living. Until that changes, until we find a way to make healthy living more appealing, how the system is paid for isn’t the path to reform.
After listening to President Obama last night, where does that leave us? No where useful. Sure…he talked a good talk about the insurance changes needed for the economics of the system to work but that has nothing at all to do with the true reforms needed in our system for not only personal health care but the actual ability to practice medicine, a topic the President barely covered last night.
I felt President Obama did an adequate job calming the waters of the misconceptions of the bill he is trying to put forward but let’s not mistaken that bill for the type of true health reform our country will need in the end. That type of reform, as Dr. Oz, pointed out, has to come from within each of us and the start of that may be as simple as looking in the mirror and accepting more individual responsibility for our own bodies and what happens to them.
What about savings, you ask? If we all care for our bodies better, we’ll all save by saving ourselves the time and expense of doctor’s visits, prescriptions, procedures, operations, and treatments of all kinds. Those savings will not only be in dollars to our bank account but years to our lives. Doesn’t sound too bad, huh?
*This blog post was originally published at Dr. Gwenn Is In*
September 16th, 2009 by KevinMD in Better Health Network, Health Policy, Opinion
No Comments »
by Charles W. Patterson, MD
Health care reform has long been one of my main interests and currently, it seems to be everyone else’s. The President said he thought a single-payer system would be best, but submitted a proposal he thought could be passed. The outcome is in doubt.
Actually, the single-payer system is the second best possible solution. The government would hold the money but would remain vulnerable to political manipulation, bureaucratic inefficiency.
The best system would be a well regulated “Everybody Hold Your Own Money and Pay Your Own Way System.” It would empower patients to deal directly with their caregivers without third-party interference or regulation and lead them to become sensitive to the potential benefit and the cost of their care.
This could be accomplished without taxes and without insurance premiums by a properly designed system of health care savings accounts (HCSAs). These should be funded with pre-tax money from regular automatic savings, like payroll deductions, and everyone should have one from birth. Children’s accounts should be funded by their parents. In only a couple of years, normally healthy people would save enough to stay ahead of their health care expenses. They would save the same money they now pay in insurance premiums, so once in place, the new system would cost less because no money would go to insurance company administration and profit, and unnecessary procedures and tests would decrease because people would keep the money they didn’t spend.
When any account becomes large enough to cover anticipated needs (with, say, 90 percent probability) the extra money could be rolled over into a retirement account, or children’s HCSAs. At death, a person’s HCSA could be rolled over to heir’s HCSAs, after an inheritance tax which would be used to fund HCSAs for the poor and unhealthy. Everyone would keep the money they didn’t spend, so they would not spend it unnecessarily.
Government’s role would become only regulatory. A commission might be needed to determine a fair market value for services and patented drugs, but it is likely that market forces would control these and make the mix of available services more appropriate to people’s needs.
To insure that account money was spent on effective care, and not wasted or stolen by fraud, standards of medical practice should be established with a Wikipedia-style online system to allow each licensed practitioner and researcher to propose, amend and vote on standards of practice in his or her’s field. A true consensus statement would then be available on every relevant standard of practice, which would be more up to date and represent truly effective practice, better than the opinions of a panel of “experts.”
The quality of evidence on any issue varies from one study to the next, and leaves room for differences in opinion about what is good treatment. HCSAs should be allowed to pay for all procedures which received an overwhelming vote of approval, and not for those with overwhelming disapproval. The more money in an account, the lower a procedure’s vote would need to be to have it included. The list of approved procedures would change, and its quality would improve as fast as new evidence and experience accumulated.
Regulations should also end patents for new drug which do the same thing as established drugs, as well as new preparations of established drugs. Advertising of prescription drugs should end, because it leads to unrealistic expectations and misdiagnosis. And these regulations should require saved money to be invested conservatively.
Charles W. Patterson is a psychiatrist.
*This blog post was originally published at KevinMD.com*
September 16th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
No Comments »
The debate on Health Care Reform has devolved into partisan politics with each side denigrating the ideas of those they oppose instead of objectively searching for real and effective reform. In the September 4 issue of the Washington Post, an Alec MacGillis’ article “The Unwitting Birthplace of the ‘Death Panel’ Myth” shows how partisan politics brought about the destruction of a very good idea. The piece details how those on the far Right disingenuously represented a provision in the House Health Care Bill to compensate physicians for time spent counseling their patients about end-of-life decisions.
I’d like to add a physicians’ perspective to both Mr. MacGillis’s story and an important aspect of life … death. I applaud the efforts of those who tried to have this provision added to the HC Reform Bill and believe that it supported the doctor-patient relationship while trying to preserve the dignity of human life. I ask: “Are we really supposed to believe that paying physicians to talk to their patients about death will lead to the creation of ‘Death Panels’?”
If you were to collapse right now and an ambulance sped you to a hospital Emergency Room, physicians and nurses would work to save your life, exhausting all options. If you survived a prolonged effort at resuscitation this would likely be your ticket to a stay in the Intensive Care Unit (ICU) and with luck you would survive to resume your normal life as you had before. It seems simple, right?
Wrong.
A whole host of what-ifs come to mind. What if you have terminal cancer? What if you are chronically ill? What if you have already spent months in an intensive care unit and desired never to experience that again? What if you are left brain dead, to be characterized euphemistically as being in a persistent vegetative state? Would you want your body to be kept alive, cast adrift without your mind to steer it?
I could go on and never run out of possible what-if scenarios. That’s what you have your doctor for and if you haven’t talked to your primary care doctor about scenarios specific to you, then you have surrendered control of how you die to a combination of chance and the decisions of your family. Furthermore, you are transferring all responsibility for these decisions from yourself to your loved ones and that includes the guilt that comes with making hard decisions.
Here are three tools that can express your wishes and absolve your loved ones from the burden of near-impossible decisions while also allowing you to protect the dignity of your own life as you alone can truly define:
1. Living Will: A legal document which goes into effect if you can no longer speak for yourself. It will make your wishes regarding a variety of life prolonging medical treatments known to the physicians treating you. One example would include whether or not to be kept alive in a persistent vegetative state by tube feedings. It is also referred to as an advance directive.
2. DNR Order: This stands for “Do Not Resuscitate.” In the event that your heart stops beating or you stop breathing, Emergency Personnel will be required to try to ‘bring you back.’ This includes electric shocks, chest compressions, and putting a tube into your windpipe to breath for you. These invasive techniques can be life-saving but for some patients only delay death for a short period of time. Since being shocked by electricity, having someone break your ribs doing chest compressions, or having a plastic tube in your throat are all painful, one’s doctor should make clear to their patient if these efforts would be futile and a DNR order fully explained. It does not prevent you from being treated.
3. Durable Power of Attorney for Health Care: Families (usually spouses and adult children) can make health care decisions for you if you are unable to. But families tend to disagree and by assigning a power of attorney you have the chance to pick someone whose views more closely match your own or who you trust to follow your own wishes.
It takes time for a physician to adequately answer questions regarding end-of-life decisions and for most primary care doctors today, there is no time for it. I used to be scared to mention a DNR or living will to my patients, aware that doing so could translate into an hour wait for every person scheduled to see me for the rest of the day.
If primary care doctors were reimbursed for time spent discussing end-of-life decisions more people would have living wills and DNRs, and this would pay both financial and ethical dividends to our society. We would not waste so much money on people at the end of their life; and I am quite comfortable stating that to keep someone alive by artificial means when they wouldn’t have wanted it is wasteful. Ethical dividends would include protecting the dignity of human life, easing the emotional burden of loved ones in a time of crisis, and giving some control to individuals in deciding how they die — an unavoidable aspect of life that our society needs to honestly discuss and plan for. We will all die but many of us first suffer needlessly and at great expense because we didn’t plan for it ahead of time.
Until next week, I remain yours in primary care,
Steve Simmons, MD
September 14th, 2009 by EvanFalchukJD in Better Health Network, Opinion
No Comments »
Eight quick reactions to the President’s speech:
1. It was a good speech. Reaction around the blogosphere and elsewhere seems to be dependent on how you felt about reform plans going in. If you were in favor, you thought it was terrific (warning strong language at the link); if you were against, you thought it was disingenuous.
2. The interesting question is how people who weren’t sure will react. By this I mean people who are anxious that reform will affect their health care in ways they don’t like. There is still the mixed message that created this anxiety in the first place. On the one hand, the President repeated “Nothing in this plan will require you to change what you have. “ Sounds like no big deal. On the other hand, he quoted Ted Kennedy as saying the plan “is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.” Sounds like a very big deal. Which is it?
3. The boorish Congressman who screamed “you lie!” at Obama during the address must have been confused and thought he was at a town hall meeting. But I’ve always thought it would be cool if we had a “Question Time” like they do in the UK. Presidents would have to face much more interesting and uncomfortable questions than they otherwise get, and it would make for a terrific spectacle. Obviously this wasn’t the time or place for that sort of thing. And if we ever do get an American Question Time, representatives will have to come up with better questions than “you lie,” too.
4. The President talked about “30 million American citizens who cannot get coverage.” This is different from the 46 million “uninsured” he usually talks about. The Associated Press thinks the other 16 million are people who could buy or otherwise get coverage but choose not to, as compared to those who want coverage but can’t afford it.
5. I was surprised to hear the President give more than just a nod to the Facebook health care status update meme. I mean he quoted it directly: “in the United States of America, no one should go broke because they get sick.” This must be the first time a President has ever quoted something from Facebook in an address to Congress – it’s some kind of a milestone for social media. Thoughts on that meme are here.
6. The President talked about the uncompetitive insurance market, noting that “in 34 states, 75 percent of the insurance market is controlled by five or fewer companies.” It sounds like he’s not just talking about the “public option” when he talks about creating competition in these markets. His idea of insurance exchanges and a federal health insurance regulator seem to be direct challenges to the state-by-state system of insurance regulation. It will be interesting to see the reaction of state insurance regulators to this speech.
7. I was right: the President didn’t talk about the three things I said he wouldn’t talk about. In fact, he said almost nothing about the delivery of care- it was all about how to pay for it.
8. The President got some laughs with his comment that he thinks “there remain some significant details to be ironed out.” He’s right, and there’s the rub. Whether and how that ironing out happens was the question before the President’s speech, and it’s still the question today.
*This blog post was originally published at See First Blog*
September 14th, 2009 by Shadowfax in Better Health Network, Health Policy
No Comments »
Ezra Klein – The Provider Problem
Medicare keeps costs down somewhat better than private insurers, though not as well as private insurers did in the ’90s, and they do it by paying providers less money. Providers hate them for it, and that’s why doctors and hospitals and drug companies and device manufacturers have been so aggressive in opposing a public plan able to use Medicare rates. It’s also why Medicare’s growth rate is totally unsustainable — Congress keeps delaying the cuts in doctor’s payments that the Medicare law requires.
Ezra has an interesting post in which he posits that the problem in health care economics is that the rate of inflation of health care persistently exceeds the general rate of inflation. Fine; I do not think anybody is in disagreement on that point any more. He goes a bit further, wrongly, I think, in implying that the solution is just to pay doctors less.
The background here is that in the late ’90s, Congress decided to impose a cap on how much medicare expenses for physician services could increase in any given year, using a complicated formula called the Sustainable Growth Rate, which was indexed to GDP growth. I should note that for some reason, Congress decided not to cap the increase in expense on hospital services, but to let the growth of Medicare Part A accelerate unrestrained. (The hospital industry must’ve had better lobbyists.)
The SGR ran into trouble immediately, and required pay cuts for physicians, and Congress repeatedly caved and canceled the pay cuts. So, Medicare Part B grows year over year, at a rate ahead of that of inflation, and the logic seems simple: we need to pay physicians less!
But that ignores the fact that much of physician’s revenue does not go to that physician’s income. Most doctors (ER docs being an exception) have offices to maintain, nurses and assistants to pay, healthcare premiums for this employees, in addition to the malpractice insurance and billing expenses. Medicine is not a low-overhead game any more! My gut feeling was that physician income has been stagnant-to-declining over the last decade.
So I went to the Bureau of Labor Statistics and I manually pulled the data on physician income over the 1999-2008 timeframe, and the inflation rate for the same time span and saw that I was more or less right:
Note that for the first six years, physician income was less than inflation, and 2006-7 was only a little bit above the overall inflation rate. Also note that for two years physician income was actually negative. 2008 was the only year in which physician income increased faster than inflation.
A note as to methodology: the BLS tracks doctor’s income by specialty, not as a single profession. I pulled the data for General Internal Medicine, Family Practice, and Surgery, and averaged them. Including surgery, unsurprisingly, greatly improved the income figures. Internists’ and Family docs’ income lagged inflation every year but 2008. This was not weighted, either — there are many more Internists and FPs than surgeons, while I weighted them equally. (Also, the BLS changed data collection methods in 2002, creating a spurious increase of 33% that year, so I threw out that year and interpolated for the above graph.) This is not a rigorous analysis, but it gets the point across that individual physician income has not been the driver of overall healthcare inflation. If anything, I think these methods tend to understate the degree to which physician income has stagnated during this period.
So why have global physician expenditures gone up so fast during the last ten years when physicians are, by and large, not seeing the increase in their bottom lines? Several reasons, I think:
- As overhead costs increase, doctors squeeze more work into the day just to keep up with rising expenses.
- As the baby boomers age, and as lifespans continue to increase, patients are older & sicker, and physicians appropriately provide more intense care to this needier population.
- As new technologies, procedures and therapies are developed, physicians employ them more, generally at increased cost.
- For Medicare in particular, the graying of America simply means there are more people enrolled in Medicare.
So while doctors are providing more services, the increases are in low margin services or the increases are consumed by increased practice expenses. I am sure there are more factors as well.
So, Ezra’s suggestion that simply paying doctors less (i.e. implementing the SGR-mandated cuts) would have some effect on reducing the global expense for physician services, it would do little to change the trendline towards increasing costs. Put another way, it would lower the setpoint of the curve without changing its slope. It would also, incidentally, have a dramatic effect on physician compensation, since the other costs of a medical practice are fairly inelastic, and the lost revenue would come directly out of doctor’s salaries.
I don’t have a solution to the costs problem, and I am not sure anybody else does either. Cutting hospitals’ reimbursement would have terrible effects; hospitals are under tremendous economic stresses as it is, and I know most hospitals have razor-thin profit/surplus margins. Medical devices are expensive, but they are so critical to the improvements in health care that I do not think anybody has the stomach to cut them. Pharma probably should be cut, but their lobby has defended them very well. There’s no good answer.
But it is overly simplistic to think that doctors’ compensation is at the root of the runaway costs problem.
*This blog post was originally published at Movin' Meat*
