April 23rd, 2009 by DrRob in Better Health Network
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Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject. While my post was just a gripe about the problem, the comments were mainly focused on solutions. How do you fix the problem? I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.
You have to realize that I’m basically chicken (as are most doctors). I like to point the finger and avoid the fingers of others. It’s much easier to gripe than to fix things. It’s much easier to criticize than it is to say things that can be criticized. But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured. Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.
So here are my suggestions:
1. The government has to take on tasks that are in the best interest of the public.
Preventive healthcare should be paid for. This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.
There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears). Simply building a relationship between people and primary care physicians also has benefits by itself.
The overall goal is to improve the overall health of the American public. Promote behavior that deals with problems when they are still small or before they happen at all. Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.
2. Promote proper utilization
One of the main costs to any system, public or private, is overutilization of services. Any solution that does not somehow look at utilization will automatically fail. More care costs more.
Here are areas of increased utilization:
- Emergency room visits for non-emergencies.
- Visits to specialty physicians for primary care problems.
- Unnecessary tests ordered – more likely in a setting where the patient is not known.
- Patient perception that “more care is better.”
- Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital. This causes duplication of tests.
Solutions to these problems include:
- Better access to primary care or other less costly care centers
- Increase the ratio of primary care to specialists
- Care management for high utilizing patients
- Public education (not through the press but through better public health).
- Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
- Make the malpractice environment less frightening to doctors. A large amount of questionable care is given to protect physicians from lawsuits. (A good example is PSA Testing. Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).
How does this help the problem of the uninsured? It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.
3. Fix problems with Pharma
Medication costs are a huge problem to my uninsured and insured populations. There are many reasons for this, but some of them are simply due to a bad system. For example:
- Medication discount programs cannot include Medicare patients. Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
- High cost of generic drugs. When a drug goes generic, there is usually only a slight drip in the price. The system allows only limited competition for price, so the cash price remains high. Encourage cost competition.
- Drug Rebates. This raises the overall cost of drugs to everyone. Rebates are sent to insurance companies by drug companies for inclusion on the formulary. It pretty much looks like extortion. The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate. These need to be eliminated.
- Get rid of direct to consumer marketing of drugs. This is pure capitalism that encourages over-utilization.
All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.
4. Address Conflicts of Interest
Insurance companies are largely publicly-traded companies. This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue. Having them the ones managing care is like putting the kid in charge of the cookie jar. Insurance companies should get back to the business of insuring. Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).
Insurance companies promote themselves as healthcare companies. They don’t provide care, and they shouldn’t. Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.
How does this help the uninsured? It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance. It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place. If insurance costs less, there are less uninsured.
5. Focus on the “uninsurable”
5% of Americans account for over 50% of the overall cost of care (reference). These are the uninsurable people – those who are truley expensive to treat. There needs to be very close management of these people. Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government. It also leaves them unmanaged. Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition). These people need management, either in a “medical home” or by some sort of care management.
There you have it. Follow these rules and everything will be fine.
Yeah, right. Alright everyone, have at it! Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.
*This blog post was originally published at Musings of a Distractible Mind.*
March 25th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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Anyone working in healthcare has a moral responsibility to do the right thing, for the right reasons, and at a reasonable price; however, this is not happening. Today’s healthcare system is too expensive and it is broken. If it wasn’t broken, the current administration would not be focusing so much money and effort on fixing it. Likewise, 42 million Americans would not be uninsured creating two different standards of care within our country. Many decisions have already been made: providing government backed insurance coverage for the uninsured, encouraging the use of electronic health records systems (EHRs), and creating comparative effectiveness research boards (CERs). Much of what has been suggested sounds good but was passed by our legislature before seeking the input of those responsible for implementing these new policies and plans. Fortunately, President Obama’s administration is seeking input now and it is the responsibility of anyone working within the healthcare system to speak up and be heard.
Many hard-to-answer questions should have been asked before solutions were posed. Why is healthcare so expensive? How can the intervention of government lead us to better and more affordable healthcare? Although integrated EHR systems may prevent the duplication of tests and procedures, how can medical practitioners best use these systems to prevent mistakes? How will future decisions be made – between doctor and patient, or will the new CER Boards grow to do more than merely advise? How would the American people react to more controversial ideas, such as health care rationing to control exorbitant costs incurred at the end of life?
In my last post, I closed with a promise to share some ideas regarding healthcare reform. First, we should try to reach a consensus as to what is broken before implementing solutions. In Maggie Mahar’s book, Money-Driven Medicine (2006), her concluding chapter is titled, “Where We Are Now: Everybody Out of the Pool.” This title screams for change as she makes a convincing argument that all parties involved in healthcare need to rethink how we can work together to fix a broken healthcare system which seems focused, not on healthcare, but on money. Today, Uncle Sam has jumped into the pool feet first, creating quite the splash, and he is spending large sums of money to lead healthcare reform without first reaching a consensus as to what is broken in this system.
The American Recovery and Reinvestment Act of 2009 will direct $150 billion dollars to healthcare in new funds, with most of it being spent within two years. Health information technology will receive $19.2 billion of these dollars, with the lion’s share ($17.2 billion) going towards incentives to physicians and hospitals to use EHR systems and other health information technologies. According to the New England Journal of Medicine, the average physician will be eligible for financial incentives totaling between $40,000 and $65,000; this money will be paid out to physicians for using EHRs to submit reimbursement claims to Medicare and Medicaid, or for demonstrating an ability to ‘eprescribe’. This money will help offset the cost of implementing a new EHR, which can cost between $20,000 and $50,000 per year per physician. However, after midnight, December 31, 2014, this “carrot” will turn into something akin to Cinderella’s pumpkin, becoming a “stick” that will financially penalize those physicians and hospitals not using EHRs in a “meaningful” way.
At our office, doctokr Family Medicine, we use an EHR, but consider it a tool, much like a stethoscope or thermometer, used to facilitate the doctor-patient relationship, not a tool to track our reimbursement activities. I would not argue against EHRs, but there is no evidence they will make healthcare more affordable and improve the quality of care delivered – unless you believe the $80 billion dollar a year savings “found” in the 2005 RAND study (paid for by companies including Hewlett-Packard and Xerox- incidentally, companies developing EHRs). I believe it will take far more than EHRs, financial incentives, and good data to fix our broken healthcare system.
Difficult decisions await those willing to ask the hard questions but don’t expect any easy answers to present themselves on the journey towards effective healthcare reform. My partner and I believe we have found answers to some questions and are moving forward, in our own practice, now. Asking why healthcare is so expensive and feeling frustrated with the high cost of medical software, we have written our own EHR, containing costs for our patients by keeping down our overhead expenses. Our financial model is based on time spent with the patient, not codes and procedures, which helps us to avoid ‘gaming’ the system and wasting time.
A familiar adage states that there are no problems, only solutions. I suggest, though, that there can be no solutions without problems. Find the right questions and opportunities abound. Earlier in this post, I asked how government intervention can lead us to better and more affordable healthcare. It can’t, at least not without the help and guidance of doctors, patients, industry, insurance companies, hospitals, and anyone who understands what is at stake with health care reform. We all share in the responsibility to try.
Until next week, I remain yours in primary care,
Steve Simmons, MD
March 18th, 2009 by AlanDappenMD in Primary Care Wednesdays
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The U.S. government finally has announced intentions to become involved in our $2.2 trillion healthcare system. Now everyone wants to say something. Most longtime players in healthcare indignantly rebut any new input and opinions with “How dare you! … You stay away from my holy cow of entitlements (insured patients), or salary (doctors), or bonuses (insurance companies), or profits (pharmaceutical companies), or the ability to sue (lawyers.)”
I join my voice to President Obama’s statement that the single most important problem to solve in our healthcare systems is cost. The tidal wave of catastrophe rushing towards America is the expenditure of healthcare dollars doubling every 7-10 years.
Few will argue against the ideal of universal health coverage, yet this noble ideal comes with an enormous price tag and many less than honorable behaviors by all players in the system. The wasted and misallocated money lost every year in healthcare makes Madoff’s Ponzi scheme look like child’s play, and yet it continues. We finally have awoken the dormant giant of politicians to do what no one else says they will do, and the government’s intervention in the form of healthcare reform seems imminent.
Doctors were captains of the healthcare system until 1980s. They were dethroned because health care costs had doubled every seven years since 1945. Then insurance companies gladly took the helm. Guess what? After 20 year of their leadership, the price of healthcare has continued to double on average of every 10 years. Now the government is positioned to step in and fix it.
Big Brother might “force” each of us healthcare players to be held accountable including all of us as patients. This fear of change leads to finger pointing, name calling, blaming, grandstanding, and claiming, “Oh the ridiculous price healthcare … it’s not my fault and I shouldn’t have to change or fix it.” Nothing could be further from the truth. We all have to fix healthcare, and never forget, it’s about the price.
How do we create a health care system that provides the widest access, the best bang for the buck, the fairest distribution of money, and inflates at the same speed as the rest of the economy?
For primary care, two pathways are clear: the career path or the professional practitioner path. With the career model, doctors can work for someone else (like Kaiser, Medicare, an insurance company, or a hospital), and can expect a salary and benefits. In return, these employers oversee and influence how career doctors do their jobs, their hours, their interactions with patients, how they communicate with patients, and often what medications should be prescribed. We have 20 years of experience with the “career pathway.” We allowed others to interfere in the doctor patient relationship, help us ”manage” our patients, and decide what’s “reimbursable.” The soul of our work and the trust of our patients evaporated. Many believe this pathway will spell the extinction of the primary care “specialist.”
The other pathway is the primary care doctor as a professional, with a mission that focuses on the patient not just for quality, but for trust and price, and following these key objectives:
- Restoring the soul and viability of the doctor patient relationship,
- Delivering the highest quality care, and
- Restoring a pricing integrity which reduces cost.
This professional primary care doctor will restore the patient-doctor relationship with a modern office that is mobile, can be reached anywhere and anytime, has virtually no staff, minimal overhead costs, transparent pricing, and is powered through a customized software that finds the patient chart, instantly looks up any pharmacy or radiology center, can contact any specialist, can instantly look at differentials, drug interactions, gets notifications when patients have something “due,” has a large number of patient education resources that can be emailed to the patient including articles from the medical literature and refereed internet sites that can educate patients, and does all the billing from the same platform the moment that the note is closed.
An individual’s day-to-day health is not “best managed” under third-party payers. We need insurance or government to manage expensive problems or catastrophe, like cancer, serious injuries or ongoing health problems. Yet sixty years of conditioning has left most unable to see the obvious: extract the day-to-day care cost from the insurance model and return these funds to all Americans (about $700 billion/year), stop holding the consumer hostage, make doctors compete again for the consumer on price, quality, knowledge, access, convenience, relationship — just like every other service industry. Finally, bring an end the $20 co-pay mentality for the patient and “the funnel” for the doctor.
This is possible, and is being done today with the practice I founded, doctokr Family Medicine, (www.doctokr.com). Our patients pay out-of-pocket for all the primary and urgent care healthcare services they receive. We charge on a transparent time-based fee basis, where five minutes of the doctor’s time costs around $25. Our patients can contact or see us anytime, day or night, and consult with us via phone, email, in our offices or by house calls, with over 50% of all of our patients’ healthcare issues being resolved by phone or email. About 75% of our patients pay less than $300 per year for all of their primary and urgent care needs. We’ve built a relationship with each patient and spend as much time as they want with us.
In the weeks ahead I invite all readers and colleagues to consider the road less traveled. Consider primary care doctors standing-up, reclaiming their profession, embracing and being embraced by the American population. And imagine happier patients and doctors, healthier patients and that the delivery of that care costs 50% less than now.
Until next week, I remain yours in primary care,
Alan Dappen, MD
March 11th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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Over the centuries, many societies have elevated the medical profession in thought and deed. Not that long ago this was true in the U.S., when our citizens showed more respect for doctors as professionals and fellow citizens than is demonstrated today. Now, everyone seems to agree that healthcare reform is drastically needed, and many are speaking out. Yet, the frank indifference to the opinions of doctors by those outside the medical profession mutes the voice and counsel of doctors on the subject. The AMA (American Medical Association) and many other physician groups are speaking out on reform, but their voice is diluted by a cacophony of assumptions, opinions, and by legislation existing and proposed. A new healthcare system has been formed, in large part, without seeking the input of those needed to make it work: practicing physicians.
Recently, I overheard a discussion regarding healthcare reform while eating lunch at a local restaurant. The debate hinged on who is most qualified to make healthcare-related decisions. The following consensus was reached: no one today should complain about the government taking over healthcare because allowing insurance companies to make all the decisions in the past resulted in a broken healthcare system. Those surrounding this particular lunch table agreed that the time had come for government to have their turn, while opposition could best be characterized as siding with the insurance companies. I wonder: can the debate really be so simply framed?
Saddened by the realization that such a discussion could be loudly and passionately debated without mentioning doctors, I resisted the urge to point out that physicians had made the healthcare decisions before insurance companies gained control. The fact physicians were not even mentioned attests to the sad truth that for many people doctors are merely seen as one part of a broken healthcare machine. Most physicians see their lot differently, and consider themselves as being in a veritable state of conflict with health insurance companies; however, our participation in a failing healthcare system has afforded these very same companies with the opportunity to put physician’s faces on their failed practices, with public opinion supporting this assumption.
Regardless of your opinion on Medicare, this last major government intervention into healthcare can help illustrate the very point that I am trying to make. On May 20, 1962, President Kennedy argued for Medicare, addressing a crowd of 20,000 at Madison Square Garden. The President was televised gratis by the three major networks reaching an additional 20 million people in their homes. Two days later, the AMA rebutted his argument, purchasing thirty minutes on NBC, with their speaker reaching an estimated audience of 30 million people. This broadcast, more far-reaching and influential than the President’s, delayed the proposed Medicare system by several years. Forty-seven years ago, people in this country wanted to know what doctors had to say before major decisions regarding healthcare were made. Today, they do not.
As the discussion about healthcare reform continues, practicing physicians must be heard from to interject real medical experience into the debate and, hopefully, guide the future of healthcare by influencing legislation existing and proposed. I am trying to remain optimistic despite the concern I feel in noting that the American Recovery and Reinvestment Act of 2009, section 3000 (pages 511, 518, 540-541) exemplifies the minimization of medical practitioners, using terminology like “Meaningful” ‘USERS’ to describe physicians.
The question is now raised: what should medical practitioners do to be heard, to influence healthcare reform, to play a leadership role in this time of change? When I write next time; I will share some of our ideas, put them on the table, if you will. But, I would encourage you to proffer those suggestions that you might have. It appears we can either speak up now or choose to be “meaningful” later.
Until next week, I remain yours in primary care,
Steve Simmons, MD
January 16th, 2009 by Dr. Val Jones in Health Policy, News
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The Kaiser Family Foundation and Harvard School of Public Health teamed up to survey Americans about their healthcare reform priorities (Kaiser has been doing this every year since 1992). A random sample of 1,628 adults participated in the telephone survey between December 4-14th, 2008. The results were presented at a press conference that I attended on January 15th.
Although you might want to view a presentation of the entire webcast here, I’ll summarize the points that I found the most interesting:
Dr. Robert Blendon (Professor of Health Policy at the Harvard School of Public Health) offered some fascinating commentary on the survey results:
1. Americans Are Fickle About Healthcare Reform Issues. Most public opinion polls do not take into account the degree of conviction with which people describe their health reform priorities. In reality, the public is generally quite ambivalent regarding the specifics of how to achieve reforms like improved access to care, and decreased healthcare costs. The Kaiser survey clearly demonstrated the public’s tendency to agree with specific reform ideas, but then change their minds when the potential downsides of such initiatives were described. So for example, most survey respondents liked the idea of an employer insurance mandate (requiring employers to subsidize employee health insurance costs), but when asked if they would favor it if it might cause some employers to lay off workers, then they no longer supported the mandate.
2. Public And Government Priorities Differ. While the public is primarily focused on relief from skyrocketing healthcare costs, the government is focused on healthcare delivery reform.
3. Americans Don’t Want Change To Affect Them. An underlying theme in the survey was that the average respondent didn’t want to pay more for healthcare, and they also did not want to be forced to change their current care and coverage arrangements.
4. It’s All About Money. America is in a near economic depression, and therefore the healthcare reform climate is very different from that of 1992 (when the Clinton reform plan stalled). Middle income Americans in an economic downturn are not willing to pay more taxes. The only way forward in our current economy is to find a revenue stream for reform that does not increase taxes on the average American. Blendon summarizes:
“It isn’t enough that all the groups agree on how to spend money on healthcare. ‘Who is going to pay?’ is the critical issue.”
At this point in time, it looks as if the American public is most supportive of the healthcare reforms listed below (but their opinion is certainly subject to change, depending on how the political discussions unfold, and how the media influences the debate). Blendon also cautions: “This doesn’t mean that this is a sensible health reform plan, it’s just what has public support at the moment.”
Healthcare Reform Initiatives Currently Favored By Americans
Expanding Coverage
1. Health insurance mandate for children
2. Fill the Medicare doughnut hole
3. Tax credits to employers to help them offer coverage to more employees
4. Health insurance for the unemployed
5. Eliminate medical underwriting (“pre-existing condition” carve outs and such)
6. Expand Medicare to cover people ages 55-64 who are without health insurance
7. Require employers to offer health insurance to their workers or pay money into a government fund that will pay to cover those without insurance
8. Increased spending on medical care for veterans
9. Increased spending on SCHIP
Controlling Costs
1. Negotiate for lower drug costs under Medicare
2. Allow Americans to buy prescription drugs imported from Canada
3. More government regulation of healthcare costs
4. More government regulation of prescription drug costs
5. Regulate insurance companies’ administrative spending and profits
Raising Revenue
1. Increase the cigarette tax
2. Increase income taxes for people from families making more than $250,000 a year
***
As you can see, the public supports reform that would result in substantial increases in healthcare spending without a clear idea of how to pay for those initiatives. Our government, in partnership with healthcare’s key stakeholders, is going to need to come up with a reform plan that identifies new revenue streams to cover the costs associated with expanding coverage. I find it hard to believe that increasing taxes on cigarettes (and a few very wealthy Americans) is going to be sufficient. If ever there were a time to nurture our American entrepreneurial spirit, it’s now.
