July 13th, 2009 by DrWes in Better Health Network, Health Policy, Opinion
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It was supposed to be delayed gratification.
After all, that’s the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you’ll be rewarded if you just stay with it long enough. It’s the myth that perpetuated through medical school, residency and fellowship, and our poor residents, purposefully shielded from the workload they’re about to inherit, march on.
But then they graduate and find that just as the population is aging, chronic and infectious diseases are becoming more challenging, health advances and potential are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.
Physicians get it – burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don’t even put it this on the table.
At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect “quality” and “perfect performance,” while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours. We must become more efficient!
Deal?
*This blog post was originally published at Dr. Wes*
July 13th, 2009 by DrRich in Better Health Network, Health Policy
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Even with the soaring popularity of our new President, and the general feelings of goodwill projected toward him by Americans and non-Americans alike, and despite the fact that the party he leads holds large majorities in both houses of Congress, and despite the general agreement by both political parties and by all the major stakeholders in the healthcare universe that the time has finally arrived for substantial reform, one gets the sense that Mr. Obama is losing some of the initiative on his healthcare reform plan.
Some of the leaders in the Democratic party (who, really, are the only ones who count) have balked at the price tag that has been attached to the Obama proposals (estimated currently at $1.5 trillion over 10 years, and most admit this projection uses the rosiest of assumptions), and now they’re balking as well at the much-desired (by the Obama administration, at least) “public option,” the Medicare-like insurance plan for all.
Worse, new schemes for healthcare reform – schemes which differ in fundamental ways from the Obama proposals – seem to be springing up all the time, and furthermore, many of these new proposals seem to be taken seriously by the press and by members of Congress. Even if none of these new plans ever ends up going anywhere, the mere fact that people in positions of authority are calling for them to receive honest consideration is a strong indication that the Obama plan might not come to a vote any time soon.
It is also a sign that Congress might be balking a bit, preparing to break sacred protocol, and actually preparing to subject any healthcare reform bill to careful consideration and debate prior to voting on it. Such action would be in stark contrast to the now-standard practice – honed with the TARP bill, the first (and one prays, only) stimulus package, and (in the House) the Cap and Trade bill – of voting on major legislation without a single congressperson taking the time to read it.
It seems clear (to DrRich at least) that the administration’s overarching strategy is (while invoking a sense of ultimate urgency), to ram through all of its incredibly high-cost policy initiatives, before the general sense of crisis and panic among the populace dissipates, and before sober reflection reveals to us that we’re already hamstringing our posterity with crippling debt. (Our motto: What’s our posterity ever done for us, anyway?) So any delay can only spell trouble for the Obama health plan.
Fortunately, DrRich is here to reassure the Obama administration that the thing is still well in hand. While the road may be a bit bumpier than you might have hoped, it still leads where you want to go.
To see why, one simply needs to consider for a few minutes those alternate reform proposals now circulating amongst policy wonks. DrRich will briefly describe three of these alternative proposals, ones that seem to have gained at least some traction, and which may on the surface seem to be quite good (and thus the most threatening to the Obama plan). Then he will demonstrate why these plans simply cannot work.
The Healthy Americans Act, sponsored by Sen. Ron Wyden (D-Oregon), requires that individuals buy private health insurance that at a minimum would offer “Blue Cross standard” care. Individuals would be able to afford this insurance (which will be available to all regardless of age or medical history) because everybody would get a big raise (by statute) when their employers no longer have to buy it for them. People earning less than 400% of the poverty level would receive government subsidies to purchase their own insurance. The Wyden plan has the great advantage of having been “certified” as being budget-neutral by 2014 – so “officially” it would be a trillion or two cheaper than the Obama plan over the next decade.
The Patients’ Choice Act, sponsored by four Republican Congressmen (Coburn, Burr, Ryan and Nunes), also places ownership of health insurance in the hands of individuals, instead of the employers. Individuals will buy their own insurance, which will be available to all, and which will be available through one-stop shopping via state-run “regional insurance exchanges.” Families will recieve a tax credit of $5700 ($2300 for individuals) to purchase this insurance, and those with low-income would receive further subsidies. Those who do not make an active insurance choice will be automatically enrolled in a private plan paid for by the tax credit.
And finally (finally for this blog post, at least), there is Bob Laszewski’s proposal, the Health Care Affordability model. Laszewski is a noted healthcare blogger and well-respected policy expert, and accordingly, his proposal is being taken quite seriously by some members of Congress. Laszewski is so smart and his proposal is so detailed that one with DrRich’s limited capacity has difficulty getting through the whole thing. But essentially he proposes to have the feds set formal cost-cutting targets which every private health plan must meet. Those who fail to meet these targets will lose their tax advantages (i.e., companies that continue to provide their products will no longer get tax deductions). Clearly, this will provide a strong incentive for insurance companies to meet those cost targets, and healthcare costs will, accordingly, eventually come under control. Lazsewski emphasizes that his proposal is not really a stand-alone plan, but can be attached to any other plan that’s out there. It will simply give insurance companies the added incentives they need to actually cut costs.
Now, DrRich is not opposed to any of these plans. In fact, he rather likes the Wyden plan and the Republican plan, because they both place the consumer in charge of choosing his/her own health insurance, and they provide for better competition among insurance products within the marketplace.
But alas, all of these alternate plans (and any plan that relies on private insurance) are doomed. The reason is simple. As DrRich has pointed out several times in the past, health insurance companies are no longer interested in providing health insurance. You can’t institute a healthcare reform plan that relies on private insurance – no matter how logical and wonderful that plan might otherwise be – when the insurance companies are all desperately seeking an exit strategy.
People, listen up. The health insurance companies just don’t want to play any more.
Private insurance companies have had 15 years of more-or-less unfettered free-reign to institute any efficiencies they want to. They entered the fray in 1994 (after vanquishing with extreme prejudice the Clinton’s attempt at healthcare reform) with great confidence and enthusiasm, cheered on (initially, at least) by the public and by public officials alike. In the ensuing years they’ve tried all kinds of legitimate ideas for reducing healthcare costs, such as managed care, gatekeepers, clinical pathways, disease management programs, pay for performance, wellness programs, medical homes, and even a ruthless consolidation of the industry to achieve “efficiencies of scale.” They’ve also tried sneaky and underhanded ideas for reducing cost, like cherrypicking patients, making specialty care as inconvenient as possible, browbeating PCPs into zombie-like compliance with care directives, refusing to cover expensive-but-effective services, and cancelling the policies of tens of thousands of patients after they get sick, based on trumped-up technicalities. They’ve tried everything short of dispatching teams of Ninjas in the dark of night to slaughter their most expensive subscribers in their beds.
Yet the cost of healthcare continues to skyrocket, entirely unabated. And despite annually increasing their premiums by more than 10%, insurance companies can see that they have no prospect of long-term profitability.
The insurance companies have shot their wad. They are in despair, entirely bereft of ideas. They want out, and they are now working their exit strategies as hard as they can.
The last thing they want is for Congress to adopt the Wyden plan, or the Republican plan, or the Laszewski plan, or any plan that relies on THEM to figure out how to get healthcare costs under control. They regard such a prospect with the same enthusiasm you’d get if you told a battered, shell-shocked WWI doughboy to leap from the trenches one more time, and trudge through bullet and shell, across 200 yards of mud, blood, barbed wire and bodies, to attack that same machine gun nest once again. Somehow they just don’t believe that, this time, the results will be any better.
This is why the insurance companies are “complicit” with the Obama plan. The Obama plan offers them, at worst, a graceful exit strategy that they can break gently to their shareholders, over time. With luck, they may end up with a long-term business as claims processors for a government plan. They may even get one last windfall in profits, from government-supplied insurance premiums for some of those 47 million uninsured. At the very least, the Obama plan won’t expect them to control the cost of American healthcare. Indeed, the Obama plan expects them to be completely incapable of competing with its public insurance option.
The Obama plan will allow the health insurance companies to stay in the relative safety in their trenches, hunker down, and await the armistice. Any alternate reform plan that hopes to be successful will need to offer the insurance industry a deal at least as sweet.
So as the move toward healthcare reform begins to bog down, President Obama still has an ace in the hole: the insurance industry has nowhere else to go. The support Mr. Obama enjoys from that industry is offered not out of mere political expediency, but out of utter necessity. The undying support of the insurance industry will likely make the administration’s healthcare reform plan unstoppable.
DrRich is glad to have been able to ease the administration’s concerns as their hour of darkness approaches.
*This blog post was originally published at The Covert Rationing Blog*
July 12th, 2009 by Happy Hospitalist in Better Health Network, Expert Interviews
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I discussed my thoughts on risk and how all physicians theoretically carry the same risk, not because one field has more bad outcomes than another (which they obviously do) but because all physicians are trained to be experts in their field of training. This expert training should theoretically create no difference in risk between different subspecialties, as long as all physicians practice within their scope of practice.
In a follow up post, I discussed my experience with discharging patients from the emergency department and how this increased my risk exposure not because the science of the discharge is wrong, but rather because the perception of negligence is greater. I discussed the irrational standards of care that have been created out of a legal necessity to avoid litigation at all costs. An irrational standard that creates exponentially infinite costs that are bankrupting this country with little to no benefit to society as a whole. By expecting perfection on an individual basis, an expectation that will never be achieved, we are risking the implosion of affordable care for all. This is physician driven. Driven out of a fear of bad outcomes, which sets irrational standards, which creates negligence when those impossible standards cannot be achieved.
And a reader hit the nail on the head with this comment. I couldn’t have said it any better.
as a hospitalist, you are at the bottom of the funnel in the risk cascade.
If you continue to send pts home from the ER, by numbers alone, somebody is going to have a bad outcome and it’s all going to fall on you.
If you are willing to accept this, more power to you.
Problem X- undifferentiated, high risk, broad ddx type problem.
ie chest pain, dyspnea,abdominal pain,fever,headache, etc.
PMD busy in office, doesn’t want to deal with it.
sends pt to ER for “work-up”
-if something goes awry, “I knew he was sick, so I sent him to the ER”.
Then:
ER gets pt, checks a “pan-panel” and multiple imaging studies.
If anything turns up–admit to hospitalist.
If negative-“I don’t know what’s wrong, better admit.”
Hospitalist is now last one standing; if send pt home and adverse outcome= “Doc HH, you mean two physicians thought this pt was too sick to be at home, yet you sent them home?”
Safe move is to always admit–as you say, if adverse outcome in house, doesn’t seem as bad.
Now, you have a three way risk pie–and any specialists that were called to consult.
Not great medicine, but the risks are too high to hold it all by yourself
I can’t tell you how true this is. This is the basis of establishing irrational standards of care. The last bolded section says it all. You the patient, have become the legal hot potato in your journey through your illness. The rational being, if you put the responsibility of certain aspects of care on someone else, it is that someone else who will ultimately be responsible should a bad outcome occur.
The lawyers want you to believe this doesn’t exist. I can tell you categorically, 100%, without a doubt that patients are treated like hot potatoes, in one way or another, with just about every encounter they experience in American medicine.
I have a really hard time playing that game when I have experience and science on my side. At some point, physicians need to be held accountable for the irrational standards they have implemented out of fear and establish standards based on most likely plausible explanations, not the least likely explanation. Until we can do that for our profession, we are a big part of the problem for the financing of this country’s health care needs.
*This blog post was originally published at A Happy Hospitalist*
July 12th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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Many Americans look to Canada, as an example of a government-run health care system that works.
But is that really what it is?
Health care in Canada is funded mostly publicly, but is provided mostly privately. That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.
Americans often call this system “single payer,” but it’s really not true. There are many other payers.
For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums. Millions of Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services. There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost. As much as 30% of Canadian health care expenses are funded through these non-government payers.
However paid for, supply (and funding) for health care has not been able to keep up with increasing demand. The result has been well-documented: long waits for health care services. Waiting is a normal part of the Canadian health care experience, with provincial governments publishing information on wait times and working to fix them. The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”
And so an interesting dynamic has emerged.
Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles. But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet. As wait times have grown, so has a burgeoning private market.
Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day. So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis. While politically controversial, it made it possible to serve more patients without the need for additional government funding.
These types of ideas have grown, extending now to stand-alone diagnostic centers. A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary. This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work. So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources. They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face. Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system. And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.
Other kinds of private centers have opened up as well. Some operate almost as membership-only medical practices, offering much of what might be considered primary care. Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis. For certain specialties like orthopedics, some even offer complete hospital surgical services.
The Canadian system remains very different from the American one. Canadians do not want their system transformed into anything that reflects American “rugged individualism.” And yet the natural human desire to look after oneself and ones family poses dilemmas. When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.
We’re all entitled to that kind of help — Americans, Canadians, whatever.
The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.
*This blog post was originally published at See First Blog*
