As I’ve blogged about before (here, here, here and here), a big reason reform is going so badly is this: Reformers don’t understand how people react when you try to make changes to their health benefits.
Companies across America have been making changes to health benefits for years.
Reformers seem to have ignored the lessons of their experience.
These are plans that offer better coverage if care is done based on evidence-based guidelines. It’s similar to the “comparative effectiveness” ideas that are so important to some of the reform proposals.
The National Business Group on Health published a study of challenges companies face implementing these plans. The study tried to understand how employees feel about these kinds of changes to their benefits.
Here are three of the major findings.
1. Most employees believe that more care is better care. Employees tend to view the idea that sometimes less care is the right care as “both unfamiliar and counter-intuitive.” Quality care is viewed as “trying as many things as possible, including new or alternative treatments.” In other words, you get what you pay for, and efforts to pay less are interpreted as efforts to give less.
2. Employees are suspicious of their employer’s motives. Employees tend to assume that their employer just wants to save money, and doesn’t really care about the quality of care they get. They suspect that moving to an evidence-based plan design is really just the first step toward more severe restrictions on choice and access.
3. Employees worry that employers are overstepping their bounds. Employees report worries that their employer wants to influence treatment decisions. They feel strongly that those decisions should be made by them and their doctor.
Reformers made a big mistake by focusing so intently on health care cost savings as the “single most important fiscal issue we face as a country.” It’s almost as if they decided to pick a way to promote reform that would create the most resistance.
Spend less on health care? That was almost certain to be understood as meaning you want to deny me or my loved ones the care we deserve. A panel of government experts deciding what treatments are effective? Who are they to tell me and my doctor what’s right? And don’t you dare tell me the reason you want to do all this is to make sure I get the best care.
Reformers have stumbled into a trap of their own making. Based on the continuing effort to demonize those who raise objections, they still don’t see it.
This is why reform is going so badly.
*This blog post was originally published at See First Blog*
Dear President Obama,
I am in favor of Health Care Reform and I agree with you that universal coverage and eliminating the abuses that both patients and doctors have suffered at the whim of the for-profit insurance industry must be curtailed.
But I also want you to fix Medicare. Medicare is so bureaucratic that expanding it in its current form would be the death knell for primary care physicians and many community hospitals. The arcane methods of reimbursement, the ever expanding diagnosis codes, the excessive documentation rules and the poor payment to “cognitive, diagnosing, talking” physicians makes the idea of expansion untenable.
May I give you one small example, Mr. President? I moved my medical office in April. Six weeks before the move I notified Medicare of my pending change of address and filled out 22 pages of forms. Yes, Mr. Commander in Chief…22 pages for a change of address. It is now mid-August and I still do not have the “approval” for my address change.
I continue to care for my Medicare patients and they are a handful. Older folks have quite a number of medical issues, you see, and sometimes it takes 1/2 hour just to go over their medications and try to understand how their condition has changed. That is before I even begin to examine them and explain tests, treatment and coordinate their care. Despite the fact that I care for these patients, according the Medicare rules, I cannot submit a bill to Medicare because they have not approved my change of office address.
I have spent countless hours on the phone with Medicare and have sent additional documentation that they requested. I send the forms and information “overnight, registered” because a documented trail is needed to avoid having to start over at the beginning again and again. I was even required to send a signature from my “bank officer” and a utility bill from the office. Mr President, I don’t have a close relationship with a bank officer so this required a bank visit and took time away from caring for patients…but I certainly did comply.
I am still waiting to hear from Medicare. At my last call they said they had not received yet another document, but when I gave them the post office tracking number, they said it was received after all. They could not tell me when or if they will accept my address change.
I have bills stacking up since April and I just found out that they will not accept them if they are over 30 days old. I have cared for patients for 5 months and will not receive any reimbursement from Medicare. The rules state I cannot bill the patient or their supplemental Medicare insurance either.
Believe me, Mr. President, I commend you for taking on such a huge task. Please also know that Medicare reform is needed along with health care reform.
A loyal American ,
Internal Medicine (aka: primary care) physician
On Saturday, Breitbart.com posted an article about President Obama’s most recent town hall meetings and closed with the following paragraph:“Obama is yet to reveal a detailed plan, but promises to expand coverage, control spiraling healthcare costs, rein in insurance companies and prioritize preventative care.”
I’ve been looking for an actual plan since Health Care Reform was seriously proposed. In July, Rahm Emanuel, Obama’s Chief of Staff, was quoted in the Washington Post, stating that the Administration had decided against having an actual plan for Reform since it would expose the administration to criticism. Yet, I remained optimistic about Reform, and relished the chance to debate the facts as our Nation turned its focus upon a topic I have long been passionate about.
Unfortunately, my optimism waned as an honest and forthright debate about how to implement Reform has become ever-elusive.Disappointed in the turns this debate has taken on its journey through our national consciousness, I am leery of the simplistic viewpoint portrayed so often… “You are with Obama or against him” …. “You’re a Republican or a Democrat” … “You are for Reform or against it …”
Determined to find Obama’s plan, I began my search by reading his speech to the AMA, surfing the White House website, watching his ABC infomercial all the way through Nightline, and observing a number of town hall meetings.I went on to plaster the walls of my home office, to the amusement of my wife, with everything the President had said, color-coded on poster boards.
By July, as I looked around my office I realized that I was surrounded, not by a plan, but by a group of wishes, beliefs, hopes and ideals. I love the way it sounds when I say “prioritize preventative care” and I long for a day when the $100 million salaries of insurance company CEOs has been “reined in.”However, I am not naïve enough to expect this to happen without a coherent plan.
I used to believe the White House would propose a bona-fide plan.Instead they are implementing a strategy that combines the president’s rhetoric with the defensive tactic of refuting critics of Congressional plans or the President’s zeal.
Even after the House passed their Reform bill (the first actual HC plan to come out of Washington), I can’t make myself take down all of those poster boards leaving me surrounded by inspiring and hypnotizing ideals. Yet I fail to see how the House bill will transform these beautiful ideals into reality as it creates multiple new government agencies and burdens doctors’ offices with more clerical responsibilities — new for the busy doctors of tomorrow:the physician quality reporting initiative, cultural and linguistic competence training, financial disclosure reports between providers and suppliers, and national priorities for performance improvement.
John Mackey, CEO of the Fortune 500 company Whole Foods, wrote an op-ed piece about HC reform for the August 11 Wall Street Journal. His editorial includes understandable plans, worthy of intelligent debate while being based in large part on the health care benefits Whole Foods currently has in place for 36,000 of its employees, and includes the following recommendations:
1.Promote high-deductible health insurance plans and HSAs by removing legal obstacles.
2.Equalize the tax laws so those buying individual insurance can enjoy the exact same tax break employer related insurance customers receive.
3.Encourage competition by allowing insurance companies to compete across state lines.
4.Enact tort reform since insurance costs, frequently over $100,000 per doctor, are passed back to all of us in the form of higher prices for health care.
5.Make costs transparent so we can all understand what health care treatments cost.
6.Enact Medicare Reform.
7.Whatever reforms are enacted it is essential that they be financially responsible.
Three days later, instead of arguing the merits or demerits of Mackey’s plan, an ABC News story focused on the controversy his editorial had stirred up after briefly touching on some of his ideas. Spcifically, the ABC story focused on the boycott by many of his customers with one expressing the following belief, “I think a CEO should take care that if he speaks about politics, that his beliefs reflect at least the majority of his clients.”Another described Mr. Mackey’s position as a slap in the face to millions of progressive-minded consumers.The author quoted four customers pledging to not buy their food at Whole Foods anymore and added them to the implied masses gathering on Twitter and Facebook.
Fortunately, one customer, Frank Federer, was quoted as saying, “At a time when most folks are more inclined toward rancor than discussion of facts, I applaud John Mackey.”
So do I.
A realistic map showing us how to get from point A to point B is missing in the Health Care Reform debate.Facts are one thing in short supply to plot a course on this map.While the main ingredient in the fertilizer used to grow Whole Foods produce is in abundance, there’s just not enough for some of Mr. Mackey’s customers.
Like many other people, Ms. Krinsk thought that her prescription information was private. But in fact, prescriptions, and all the information on them — including not only the name and dosage of the drug and the name and address of the doctor, but also the patient’s address and Social Security number — are a commodity bought and sold in a murky marketplace, often without the patients’ knowledge or permission.
But given the money involved, I’m afraid it isn’t.
But with the pharmaceutical industry soon to release $150M dollars of ads promoting health reform as they cozy up to Congressional leaders, the conflicts of interest for patient’s privacy are staggering. Further, the promotion of the electronic medical record, personal health records, and ultimately, cloud computing (where no one will know where health data resides), are firmly part of the health reform landscape.
Now before people think I’m totally against the EMR, let me be candid: I’m not. It does facilitate care and is an incredible means of communication between physicians and laboratories and pharmacies and the like. When used properly, they are miraculous.
But the risks of losing information remain huge. Certainly, the above referenced New York Times article notes that safeguards are supposed to be enacted to prevent this wholesale marketing of your health data.
But suddenly, we learn of a White House snitch line where they will collect e-mails of people who might be spreading “misinformation” about the health reform efforts underway. (Thanks to my previous blog post, I am happy to report I’ve been reported! ;)) But this occurs at a time when privacy issues in health care must be seen as paramount and electronic medical records protected as secure.
Ooops.
So now we have a White House eager to build a snitch line as they cozy up to pharaceutical interests that are already selling personal information from prescription data, all while trying to promote the security of electronic medical records to the masses.
Who are they kidding?
But then, shucks, just think of the marketing possibilities for the government:
And lest people think I’m too partisan (who me?), the Republicans with their travel junkets aren’t any better.
Sheesh!
-Wes
Reference: White House blog with snitch e-mail link at flag@whitehouse.gov .
*This blog post was originally published at Dr. Wes*
By 4: 30 am Saturday, the previously healthy 65-year-old female had a fever and lower extremity weakness. A family member heard her repetitive moaning. The patient got up to void, but could barely negotiate the one step up to the hallway. As she negotiated the hallway, she staggered.
By 5:00 am she was in the ER.
*****
The patient was taken to an exam room. Vital signs were taken and it was noted that the patient’s fever was “extremely high”. The doctor came into the room and the temp was re-taken. Extremely high. The patient had no insurance and was not verbal; the doctor discussed options with the family member.
The goal: find the source of the fever and begin treatment. A CBC, Chem 14, a urinalysis, an IV and hydration would be started. No lactate level would be done; the doctor stated it would be pointless to run a test that she already knew would be elevated based on clinical presentation. Blood cultures would be drawn, but not sent immediately. As the doctor explained, they are expensive and it would take days before the test results would be back.
In this facility, payment was expected at the time of treatment and a detailed estimate was provided to the family. The low end of the estimate was the deposit.
*****
By 8:30 am Saturday, the fever was still raging; the lab tests were normal. The patient was in ice packs with a fan in an attempt to lower the fever. An IV antibiotic was initiated; hydration was on-going. An internist and a neurosurgeon were consulted as the patient was experiencing lower back pain in addition to the profound weakness. The patient was admitted.
Further tests were proposed: lumbar x-ray to rule out spondylitis and, given the patient’s age, a chest x-ray to rule out occult pneumonia. The pros and cons of each test were fully explained along with rationale and the cost.
*****
The radiographic exams were normal. A loose bowel movement that morning had been blood-tinged. The patient had been medicated for pain. A second antibiotic was started. The next step would be an abdominal ultrasound, as no obvious source for the fever had been found. The rationale for the test and the cost were discussed and the family gave the go-ahead.
The spleen. Enlarged and mottled on ultrasound. A call was made to the family to discuss needle aspiration to rule out lymphoma.
*****
Monday morning the patient’s fever was down. She was eating. She was voiding. She was still weak, still moved slowly and awkwardly. She would be discharged home on oral antibiotics with the results of her spleen aspirate pending.
*****
It’s been a week now and the patient is acting 100% normally.
The patient was my dog, a 10-year-old, 70 pound Shepherd mix. We still don’t know what nearly killed her last weekend. The spleen aspirate was abnormal, but not lymphoma. The fact that the fever responded to antibiotics (as did the weakness) leaves us with the feeling that it was an infection in such an early stage that the source was not obvious.
I realize veterinary medicine is not human medicine, and a million holes can be found in my attempt to draw a parallel between them. But a few things crossed my mind during this experience:
(a) Tests were not done just for the sake of testing or because a printed standard said they should be. This was not template medicine dictated by any outside organization or government regulations.
(b) The doctor/patient relationship was unencumbered by insurance company approvals, government regulations, billing, coding or the number of patients that had to be seen in a certain time frame.
(c) there was full transparency regarding what each test would cost.
Maybe the human health care system can take a few pointers from what the veterinary world has been doing all along.
(P.S. I just realized you can read this story from the vantage point of ME being the third-party payer standing between the vet and my dog, deciding what would be “covered” – i.e. paid for. Interesting either way….)
*This blog post was originally published at Emergiblog*
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