January 26th, 2010 by BobDoherty in Better Health Network, Health Policy, Opinion
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One of my favorite movie scenes is from “Monty Python and the Holy Grail,” when an unfortunate soul pleads with the designated collector of corpses (this being after the plague, mind you) that “I’m not dead … yet.” The collector responds by whacking him on the head … until he is, in fact, quite dead.
This scene comes to mind as I blog about yesterday’s stunning GOP upset of the seat-that-used-to-be-held-by Ted Kennedy. If the election of Republican Scott Brown didn’t quite kill off health care reform, some Democrats are quite willing to complete the task. Read more »
*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*
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*
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.*
April 20th, 2009 by KevinMD in Better Health Network
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Walgreens made some headlines with their program to give free acute care services to those who are unemployed.
Before you think that they’re doing this out of the goodness of their hearts, Jaan Sidorov gives a more practical reason.
Doctors rarely would drop patients who have recently gone on Medicaid, or worse, lost their health insurance altogether. Why? As Dr. Sidorov writes, “Today’s patients with no or non-remunerative insurance were not only yesterday’s richly insured but tomorrow’s also. These providers know that when the economy eventually turns around, these patients are going to join the ranks of the employed/insured.”
Walgreens is applying the same principle. Today’s uninsured patients will, more likely that not, have insurance in the future, and will repay Walgreens back for helping them out during these tough times.
So, rather than patting Walgreens on the back for their kindness, you should be noting their business shrewdness instead.
April 8th, 2009 by KevinMD in Better Health Network
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Almost 30 percent of Medicare beneficiaries have trouble finding a new primary care doctor.
Expect that number to rise dramatically in the near future, as the number of Medicare beneficiaries balloons, and the amount of primary care physicians plummets.
The whole scenario is a perfect example of how poor physician access makes medical coverage practically worthless.
Contrary to popular belief, Medicare’s paperwork requirements and pre-authorization obstacles are just an onerous as those of private insurers. Combined with the continuing threat of downward physician reimbursements, and the baseline complexity of a typical Medicare patient, it is no wonder that doctors are dropping Medicare in droves.
This phenomenon with Medicare is likely going to spread nationwide, if the current plans for universal coverage go through without first addressing the primary care shortage.
**This blog post was originally published at KevinMD.com**
