Archive for the ‘Medicare’ Category
Saturday, December 4th, 2010
 I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access.
Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture.
But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs?
That is the problem with which most governmental entities are now faced.
Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.”
Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care.
Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them?
This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for.
If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine?
If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available.
As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least.
Don’t get sick and you’ll be just fine.
Posted in Access to Care, Funding Crisis, Insurance, Medicare | 32 Comments »
Friday, August 13th, 2010
 A new study released in JAMA shows that the number of annual emergency department visits between 1997 and 2007 increased from 94.9 million to 116.8 million — nearly twice as much as would be expected for population growth.
Also published recently was the Department of Health and Human Services’ 2007 Emergency Department Summary (.pdf file here). Lots of interesting statistics.
Most of the increase in ED visits were due to Medicaid patients. One quarter of the 117 million visits to the emergency department in 2007 were made by patients with Medicaid or SCHIP. Seventeen percent of visits were covered by Medicare. In other words, 42% of hospital ED visits (50 million or so) are paid for by the state or federal government.
The graph to the right from the San Francisco Chronicle shows how emergency department use by Medicaid patients is now more than five times the rate of emergency department use by patients with private insurance – and since they are from 2007, these numbers don’t include the impact from the recession.
Further breakdowns in demographics from the DHHS report include high ED utilization rates for children less than 1 year old (88 visits per 100 US infants), patients older than 75 (62 visits per 100 US persons), homeless persons (72 visits per 100 population), blacks (74.6 visits per 100 black persons), and nursing home residents.
In addition, the number of “safety net” hospitals – defined as those who treat patients regardless of the ability to pay – increased by more than 40% from 2000 to 2007.
Before you start blaming Medicaid patients for health care crisis, think about why there is a disproportionate use of emergency departments by Medicaid patients. If you or your child has a medical problem and few private physicians will accept your insurance, what are you supposed to do? You go to a place where they will accept your insurance and you get relatively timely care (as opposed to an appointment 4 months in the future). Although there are undoubtedly people that abuse the Medicaid system, in general, it isn’t the patient’s fault for having Medicaid. It is the fault of the government for failing to adequately fund and monitor the Medicaid program.
With the increase in visits, there are longer waits and less availability of medical care.
Because the JAMA study was based in California, I did a little searching and found that 61 California hospitals closed between 1998 and 2008 and 14 more California hospitals closed their emergency departments. That’s a loss of 75 emergency departments in 10 years.
The San Francisco Chronicle article notes that California hospitals are facing an additional $17 billion in payment reductions over the next 10 years. I’m sure that will translate into many more hospital closures.
Oh. And health care reform will add between 11 and 22 million additional patients to Medicaid – you know … that good insurance that all the doctors’ offices take. Then what?
I know this is another “sky is falling” post. But I think that it is important to show how health care policy changes are affecting access to medical care in this country.
Posted in Access to Care, Medicare, Policy | 26 Comments »
Monday, July 26th, 2010
Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it.
The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize.
According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered.
They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities.
Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.”
The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England?
Providers will also be paid based on outcomes and performance.
So far, sounds like a lot of changes heading in the direction of free market medicine.
The plan would also both increase payments to … and increase involvement of … primary care providers.
And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs.
One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality.
But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.
Posted in Health care reform, Medicare, News Commentary, Policy | 6 Comments »
Monday, July 12th, 2010
 Revealing article in Bloomberg online today about the latest way in which elderly patients are getting screwed by the system.
Medicare reviews all admissions and if the patients don’t meet indications for admission, the hospital doesn’t get paid by Medicare. Medicare has also recently implemented a mercenary system called Recovery Audit Contractors (or RAC for short) in which third parties audit hospital charts to see whether Medicare “overpaid” for a patient’s visit. If the auditor finds an “overpayment”, the auditor gets to keep a percentage of that overpayment. Just as an aside, most states have laws against percentage “fee splitting” such as this since paying someone on a percentage basis creates a conflict of interest that encourages the contractors to do things to enhance their income.
Hospitals have the ability to classify Medicare patients as an “observation” admission during the patients’ stay. “Observation” admissions are apparently paid at a lower rate, but don’t come under as much Medicare scrutiny. Additionally, under Medicare rules, “observation” patients may have to pay a 20% co-payment that wouldn’t be required if they were admitted. Medicare “observation” patients also have to pay full price for any subsequent care that is rendered after they have been discharged. For example, if a Medicare patient needs a nursing home care or physical therapy after a hospital stay, Medicare will pay if the patient has been admitted for three days or longer and will not pay if the patient is classified as an “observation” stay. The Bloomberg article gives an example of one 76 year old patient who was saddled with more than $36,000 in bills based on his “observation” stay for eight days.
Another 90 year old woman was billed more than $11,000 after fracturing her hip and then undergoing five weeks of physical therapy so that she could walk again. Sorry, grandma, you weren’t admitted. You were only “observation.” Pay up.
If a patient is a borderline case, hospitals appear to be leaning toward keeping patients in “observation” status. The number of patients receiving the “observation” designation doubled between 2006 and 2008.
Also note how Medicare is planning to penalize hospitals that re-admit too many patients, which will only increase the number of patients classified as “observation” status.
On one hand, hospitals get paid more for admitting Medicare patients.
On the other hand, hospitals could be accused of false claims and penalized for admitting Medicare patients who don’t meet Medicare’s strict admission criteria. Medicare’s RAC mercenaries will be combing through charts because they have a financial incentive to find patients who have been “inappropriately” classified as “admissions.”
So hospitals play it safe and classify more and more Medicare patients as “observation” status.
Who gets stuck in the middle?
The patients … many of whom worked their lives and paid into a system so that they would have medical care when they reached age 65.
Now they’re finding that they only have “insurance.”
Posted in Funding Crisis, Medicare | 15 Comments »
Thursday, May 20th, 2010
 Sorry about the sparse posting lately – have been away in Washington at an ACEP conference
Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.
I attended some excellent lectures about leadership.
- Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
- I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
- I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.
There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.
And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.
I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.
“What do you think about the SGR?” He asked.
- Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.
“Do you think that the AMA represents the views of physicians across the country?”
- Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.
“How would you make the health care system better?”
- Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
- The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
Why should health insurance cover routine medications and routine medical care? It shouldn’t.
- Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
- Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.
“What do you think still needs to be included in the health care bill?”
- Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
- Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point - in almost all cases, caps don't save physicians money, they save insurance companies money - but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won't be able to practice. There has to be a happy medium].
- Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?
We had other discussions, but this post is already getting too long.
You naysayers want my ideas? Here they are.
Now try to show me how they won’t work and come up with some better ideas.
Posted in Access to Care, Defensive Medicine, Funding Crisis, Health care reform, Medicare, Policy | 43 Comments »
Thursday, March 11th, 2010
I had planned to log on and write a quick post reminding docs that they have less than a week to decide whether or not to remain a participating provider in Medicare in the face of 21% payment cuts — and to encourage docs to drop Medicare.
Wait. Seven months of foregoing 21.2% cuts to physicians costs the government an extra $100 billion.
That means that 12 months of foregoing cuts would cost $171.4 billion (divide $100 billion by 7, multiply by 12)
Dividing $171 billion by 21.2%, we get a total Medicare payout to physicians every year of $808.6 billion dollars.
Mrs. WhiteCoat gets paid about $70 for an average office visit for a Medicare patient – usually after having to pay her office manager for a couple of hours of time to figure out why Medicare refused to pay the first three times the claim was submitted. Let’s round up. Say Medicare pays $100 for an average doctor visit. Dividing $808.6 billion dollars total physician payments by $100 per doctor visit means that the total number of doctor visits – just for Medicare patients – is a little more than 8 billion per year.
Eight billion visits divided by 50 million patients means that every single Medicare patient is seeing a doctor an average of 161 times per year – more than three times per week every week for the entire year.
Look at it another way. Dividing $808.6 billion by 50 million Medicare patients means that physicians are being paid an average of $16,172 each year for every Medicare patient in the country.
So what are all of us rich doctors complaining about?
How about politicians who are full of hot air.
Where’s the money really going?
Posted in CMS, Medicare, News Commentary | 23 Comments »
Saturday, October 10th, 2009
ERP here again while WC recovers from the revelling in Boston
Personally, I agree with medicare and insurance regulations that require that someone receive some REAL benefit in order to be covered for an admission to the hospital. Even the “social dispo” admits usually serve a purpose – preventing elderly or the otherwise helpless or nearly helpless from injuring themselves or insuring they get proper medical treatment like antibiotics or seizure medications. However, if you can be safely discharged from a medical AND social point of view (ie no admit-able diagnosis exists AND you can either care for yourself or someone is there to care of you (like in a nursing home), you should have to pay out of pocket if you (or your relative) demand you be admitted. You can’t just come in for “tests” or to see a “specialist” or to “recuperate”. I am sorry, if you are demanding and non-indicated admission, prepare to ante up.
The other day I had several situations where elderly, demented, bedridden, and or chronically ill elderly people from nursing homes were admitted solely because the entitled relatives refused to allow them to be transported back to the home. They had no acute diagnoses requiring admission but their relatives had such a fit that the PMD’s acquiesced and admitted them. Now, the hospital has to try to recoup payment from medicare. This is an epic waste of resources and public health care dollars.
Here is what I did. I documented that the patients had NO indication for admission and recommended the patient (ie family) be charged fully for the admission, thus destroying the hospital’s ability to bill medicare. My hope is that the hospital not even try for medicare reimbursement and instead submit their entire bill to the entitled family, and if they refuse to pay, send them to collections. Hopefully they will learn that there is no free medicare lunch. Who knows, maybe the hospital will reprimand me. Regardless, I had to do it.
Posted in Funding Crisis, Insurance, Medicare | 23 Comments »
Monday, September 28th, 2009
When an unconscious intoxicated multiple trauma patient was brought to the ED, we did a bunch of CT scans to look for injuries. Fortunately there wasn’t anything life-threatening. He was admitted and was later discharged in good condition.
I then got a memo from the hospital several days later stating that Medicare would not pay for the CT scan of the patient’s cervical spine. There is a list of diagnosis codes for which Medicare will reimburse hospitals for performing a CT scan of the cervical spine. That list is contained below. If one of the selected codes is not on the patient’s final diagnosis list, then Medicare tells the hospital “tough luck” and pays the hospital nothing for the scan. As part of Medicare’s Conditions of Participation, the patient may not be charged for the exam unless the patient specifically agrees to the charges. When Medicare doesn’t pay, almost always the hospital gets stuck holding the bag.
If a patient is a victim of multiple trauma and is unconscious, CT scans of the cervical spine are more likely to show significant injury. This study showed that in multiple trauma patients, CT scans picked up on 98.5% of fractures while cervical x-rays only picked up 43% of fractures. It is uncommon to pick up ligamentous injuries on x-rays or CT scans – generally need an MRI for those.
If physicians choose to do a CT scan on an unconscious or poorly responsive patient, according to the “permissible” diagnosis codes, in most cases hospitals have to hope that either an injury or some type of cancer shows up on the CT scan. Otherwise, the CT scan won’t be reimbursed and the hospital eats the cost.
What are the other options in multitrauma patients?
We could just do only x-rays of the cervical spine, and, if negative, tell patients that everything is OK because the government won’t pay for CT scans unless you meet certain criteria. The 57% of patients with cervical spine fractures missed on x-rays will have all their medical needs met under the new health care reform measures anyway.
Or, while bleeding to death and strapped to a backboard wondering if they’re going to live or die, we could give patients an ABN form to sign. “Medicare might not pay for this test, if Medicare doesn’t pay for this test, do you agree to pay the cost of the test yourself — assuming that you live, of course?”
We could always perform x-rays on everyone’s necks first and make up notice some “abnormality on radiological or other exam of the musculoskeletal system” to justify the CT scan. That will be a 793.7 to all you CPT coders.
We could just say that notice that the patient winced in pain when the neck was palpated – causing “cervicalgia.” That’s CPT code 723.1.
Or we can just practice good medicine and let the hospitals get shafted by the system.
Of course, if hospitals get shafted enough by the system, they end up closing or reducing services. Then access to care suffers. You get what you pay for. Do a search for “hospital bankruptcy closures” and see how often it happens. Here are a few examples.
CT scan payments are just one example of the cat and mouse game that constantly goes on between those providing the services and those “paying” for the services.
It is also an example of the “Golden Rule” – he who has the gold makes the rules.
Things aren’t going to get better.
(more…)
Posted in Access to Care, Medicare, Policy | 24 Comments »
Saturday, August 8th, 2009
Mass left some questions in the comment section that I thought were insightful and added to the discussion about health care policy. So I’m treating them like an interview.
1) I’d like to know how Dr Whitecoat is an “Independent Voice for Emergency Physicians”? Does that mean that all or most independent ER docs are conservatives or Republicans or anti-HR 3200? It would seem so as there are plenty of references in his blog to the loaded phrase “socialized medicine” as well as (at times indirect) links to groups like CAHI (the health insurance lobby) or the NCPPR (a conservative lobby) or to other conservative blogs. Either admit you’re a proud conservative or give some left-leaning blogs and groups some links.
First, I’m not, nor have I ever asserted, the “Independent Voice for Emergency Physicians”. That phrase refers to the magazine Emergency Physicians’ Monthly, and you won’t find a better forum in emergency medicine for emergency physicians to express their views. You could even submit an article and have it published if it was germane to the practice of emergency medicine. Dis me, but don’t dis the mag.
I actually had to go look up conservative versus liberal qualities on a web site before I could respond to your challenge. I’d have to agree that if I had to choose between personal responsibility and government intervention, I’d pick the former. However, the news is replete with stories about how people and businesses, when left to their own dealings with the public, take advantage of others. Government intervention is necessary to establish and enforce rules by which everyone must abide.
2) How would WC doc define “socialized medicine”? Are patients in the VA system, or those who have Medicare or Medicaid part of such a system? Does it matter that Medicare patients have higher satisfaction than other insured patients? I would submit that if WhiteCoat Doc would term universal healthcare as “socialized medicine,” then I can call the present system, “Darwinian every-man-for-himself medicine.” Unwieldy, but accurate.
Socialized medicine = publicly funded health care. Period. I don’t think that anyone can draw a line between “socialized” medicine and “single payer” medicine (in which government pays, but does not participate in delivery of care). The “golden rule” always applies – he who has the gold makes the rules. Look at the Medicare system now. The government pays for care, but conditions payment on a plethora of byzantine rules. Fail to follow the rules – even if you provide the care – and you don’t get paid. Technically, even though the government is not “providing” the care, it is orchestrating the care – sometimes on an “ubermicromanagment” level.
Many people are content with Medicare because they get what they want at no current cost to them. Don’t forget that most people receiving Medicare have paid into the system through payroll deduction for all of their lives. I think that people in stories like this or this or this would disagree with your general assertion that Medicare patients have “higher satisfaction than other insured patients”. Being “insured” by Medicare doesn’t mean much if no providers accept it. Our Medicaid crisis right now is what Medicare will look like 10 years from now unless the system changes.
3) Is this blog written from the perspective of a professional concerned about his income, independence, status, the overall health of his patients, or some mix of these? While I too am a physician, I don’t believe that physicians’ and patients’ interests always go hand-in-hand. There is no shame in defending our incomes and status – let’s just not delude ourselves that our positions are always for the good of the patients.
This blog is written from the perspective of what a single speck in the universe of physicians happens to find interesting at the moment. I’m not going to go through a psychiatric profile to answer your question. If you like the blog, let me know. If you don’t agree with me, post a comment and challenge me. If you don’t like it, go read a blog that aligns more with your interests. I won’t be offended.
Physicians’ and patients’ interests can’t always go hand-in-hand. Physician interests should be aligned with patient interest, but at some point, paternalism must occur. We have to do what we believe is in the patient’s best interest even if the patients don’t realize it. Patients interested in multiple narcotic prescriptions from multiple physicians shouldn’t be allowed to receive them. Patients who think antibiotics cure colds shouldn’t just get antibiotics because they want them. Patients, and a lot of physicians, have to learn that sometimes doing nothing is better than doing everything.
Are there some specialists who go “scoping for dollars”? Absolutely. That practice must be stopped, but unfortunately, there is little disincentive to doing too much right now. In fact, our government has created monetary incentives for performing procedures. Guess what many physicians make their living doing.
4) If some believe that it is not our health care system’s fault — but other factors like income disparities, personal habits, etc — that we have much higher per capita healthcare costs but worse infant mortality and lower life expectancy than other countries, isn’t it incumbent on us as advocates for our patients’ health to see money directed AWAY from the medical system into areas of the economy that actually WILL improve those health statistics?
Some of the largest costs in US health care are provision of end of life care and caring for critically ill patients. The same things that make our system so unique are also crushing our system under the weight of their expenses. We have to choose what we as a society want out of health care. Do we want to provide coverage for everyone at the cost of rationing or eliminating payment for many expensive treatments? That might mean limited or no cancer treatment, curbs on who is eligible for dialysis, limits on chronic ventilator care, and governmental “quality control” oversight on who is and is not resuscitated during a code. We’re probably headed down this path anyway because the system is hemorrhaging so much money, but the government is now faced with the frog in the boiling water conundrum. Throw a frog in boiling water and it jumps out. Put a frog in a warm pot and turn up the heat until the pot boils and the frog doesn’t leave. I personally think that the government is floating a bunch of health care trial balloons to see just how fast it can turn up the heat without too many frogs jumping out.
5) Which Republican health care bill currently being proposed ought we to support as an alternative to the current “Obamacare” legislation?
I haven’t read them all and probably won’t. I posted some of my ideas on how to improve health care here, here, and here. Scalpel also had a great set of posts a couple of years ago. I just went over to his blog to link to them and he re-posted them two days ago for everyone. See here, here, here, and here. Incorporate some of these ideas into a bill and see what kind of traction it gets.
6) Given that the US spent 8.8% of GDP in 1980, up to 13.9% of GDP in 2001, and then most recently 16% of GDP for health care in 2007,
(http://www.kff.org/insurance/snapshot/chcm010307oth.cfm) — does anyone think this is sustainable and if not, what are our options? If “rationing” is out and no one (doctors, hospitals, health insurance) wants to get paid less and no one wants any restrictions of any kind on costs, should we all fly to other countries for health care?
Medical tourism is a free-market alternative for medical care. If cost is what is most important to people, then they will go to the centers that provide care at the lowest cost. However, if you fly to another country, do you know the qualifications of the doctor treating you? Do you care? If cost is all that is important to you, why not get Lucy VanPelt from the Peanuts to give you psychiatric counseling for five cents? Lower costs have to be weighed against quality. It will be difficult to legislate our way to higher quality medical care – if that is what we want. We’ll never have low cost, fast care, and quality care.
Two quick ways to drop costs and increase quality in the current system:
1. Divorce employment from health care coverage. Employers use health care benefits as a means to obtain and retain employees, but employers also try to find the least expensive ways to provide such coverage. Just let patients purchase their own insurance. Let the companies reimburse all or part of their premiums if that’s what you want. Then employees wouldn’t have to worry about COBRA coverage and insurance companies could extol their virtues to the consumers who actually seek their services – not to the employers whose bottom line is cost.
2. Create a government mandate (there’s my liberal side kicking in) that all prices for health care services must be clearly posted before a patient receives the services. Everything down to the last Kleenex box. If you don’t post a price for it, by law it is provided at no cost to the patient. Once people saw the wide disparity in pricing, they wouldn’t have to go to other countries for their care. They would just flood hospitals that provided the lowest prices in the US. Those hospitals would reap larger profits and expand. Other systems would either compete or fail. I guarantee that prices would drop significantly.
7) Since physicians seem strangely wedded to the idea of the private health insurance industry being the intermediary in our medical system, does it bother anyone that most areas of the US now have near-monopolies by private insurance companies in the markets for medical insurance? (http://www.marketwatch.com/story/study-confirms-health-monopoly-fears)
How does one reconcile the facts that “socialized medicine” in places like France, Germany and the UK are associated with frighteningly “high taxes” (used in menacing ways in posts) but that we spend at least 50% per capita more on health care than any other country? Is it possible that higher taxes are offset by…. something else lower?
Think about how the insurance industry monopolies affect care in those areas of the US.
Are you prepared for a country-wide monopoly and the restrictions that will go with it?
9) When the following post recommended by WhiteCoat doc (http://www.fundmasteryblog.com/2009/07/16/reform-healthcare-culture-and-politics-first/) explains how the free market indeed does work for the medical system, are there, um, more practical examples available than Lasik (a cash-on-the-barrel and completely elective procedure) and traveling abroad for health care? Does any ER doc discuss with a patient the pros and cons of all proposed tests (CMP vs BMP vs cardiac panel vs cardiac enzymes, etc) and radiological studies (MRI vs CT vs ultrasound) including full disclosure of the costs of these tests?
I don’t think that any time-dependent service can be entirely free-market. If people are unconscious or having a heart attack, they can’t request transfer to a less expensive facility.
Regarding non-emergency care, few, if any, emergency DEPARTMENT physicians discuss cost, risk, benefits of any procedure. I bet that 99.9% of physicians don’t even know what the tests cost. Probably the biggest reason for nondisclosure is what you alluded to – everyone wants the best health care that someone else can pay for. Patients want the latest and greatest … as long as it is covered by insurance. If everyone had to pay out of pocket for everything, you better bet there would be a lot more discussion. Patients would demand it. I’ve had patients refuse helicopter transport to tertiary care centers because of cost. They would rather accept a larger risk of dying than be saddled with any portion of a $15,000 transport bill. The discussions would result in a better-educated patient and would be a good thing.
The malpractice climate encourages low-yield testing to “prove” that disease doesn’t exist. Right now the “defensive medicine” mindset is so deeply ingrained in many physicians’ minds that it will be difficult to change. The best way to mitigate that risk is to educate the patient and let the patient make a decision. But as the Happy Hospitalist says, FREE=MORE and until patients have some skin in the game, little disclosure will happen because there is no disincentive to not providing it.
Posted in Access to Care, Insurance, Medicare, Policy | 43 Comments »
Thursday, August 6th, 2009
I put the blog on autopilot while I was away for a few days.
I was a little surprised by the reactions to the Health Reform Bill post. My intent in posting that e-mail was to generate discussion and encourage everyone to actually read what our elected officials are putting forth as the law controlling our health care for the foreseeable future. I had planned to do a point-by-point analysis, but didn’t have the time before I left, so I picked the end-of-life issue to comment because the comments made by the person who created the e-mail sounded inflammatory. They were. It seems as if the mere fact that I posted the e-mail meant to most people that I ratified all of the contents. Not true.
However, some of the comments were still on point. Had hoped that others would analyze the wording similar to what I did with the end-of-life issue. Oh well.
For those who did look at the bill and post specific comments, I want to address them.
“Page 22: Mandates audits of all employers that self-insure! (Section 142(b))”
Here’s the exact text:
COMPLIANCE EXAMINATION AND AUDITS
(A) IN GENERAL – The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance.
The language “shall” is a mandate, it is not permissive. The wording of the remainder of the sentence is poor, but it appears that the mandate requires the commissioner to conduct audits of whether qualified health benefits plans are complying with federal requirements. Unlike Shadowfax’s assertion, the wording does not “require[] ‘random compliance audits and targeted audits in response to complaints.’” Instead, the plain language states that the mandated audits “MAY INCLUDE” random compliance audits and targeted audits. The language does not limit the audits to those vehicles and states nothing about the degree or extent of the audits.
Little different, don’tcha think?
Since Shadowfax also picked out the “All non-US citizens, legal or not, will be provided with free health care services” statement, let’s look at that one, too.
Section 401 changes Chapter 1 Subchapter A of the Internal Revenue Code to impose a 2.5% tax on a portion of the adjusted gross income any individual who does not have acceptable health care coverage. The exact language is
‘(a) Tax Imposed- In the case of any individual who does not meet the requirements of subsection (d) at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of–
‘(1) the taxpayer’s modified adjusted gross income for the taxable year, over
‘(2) the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer.
Section 6012(a)(1) of the IRS Code is here and it makes no mention of what the “gross income specified” should be, so I am unclear how the 2.5% tax will be computed.
However, the language of the Act creates exceptions for certain classes of people who have to pay this tax. Those exceptions include
(2) NONRESIDENT ALIENS- Subsection (a) shall not apply to any individual who is a nonresident alien
AND
(5) a “RELIGIOUS CONSCIENCE EXEMPTION” where individuals do not have to pay such tax if their religious tenets make them conscientiously opposed to receiving benefits of any private or public insurance.
Another part of the Act, Section 246, states
SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for affordability credits [note: See Section 241] on behalf of individuals who are not lawfully present in the United States.
Now let’s do a little critical thinking.
EMTALA requires hospitals to provide a screening exam and stabilizing treatment to any patient coming to the emergency department and requesting care. Hospitals are mandated to evaluate and stabilize regardless of ability to pay.
According to this new Act, nonresident aliens are statutorily exempt from paying into the system.
Also according to this new Act, the federal government will not pay for care of individuals unlawfully in the United States.
Adding these three things together, who ends up paying for the care of undocumented/nonresident aliens and those who express a religious exemption?
Still “BOOOOGUUUUS!”?
Frydoc commented about a National ID card. Guess what? I think it would be a great idea. How much money could we save if every patient could be tracked from hospital to hospital and we could pull up previous testing whether the testing was done down the street or across the country? No repeat testing because you didn’t know the same test was done a week ago. Drug seekers that doctor shop – eliminated.
I think that a national ID card would vastly improve the continuity and quality of healthcare in this country.
Nick Dupree brought up the issue of Special Needs Plans and “restricting enrollment”. The title of this section in the Act is actually misleading. The title is “SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT ENROLLMENT”
On first blush, it may seem as if the special needs patients may have their enrollment restricted. Actually, according the Social Security Act section that the Act references, the Act allows some plans to restrict enrollment only to patients who have special needs. In effect, the Act tries to create more available care for special needs patients.
Surprised to find several people who criticized the post by making a general statement about the bona fides of the e-mail when they didn’t put forth any factual data to support their statements. Isn’t that exactly what you criticized me for doing?
At least I got some people to look at the proposed legislation – myself included.
Even after reading all 2541 sections, I still have a lot of concerns.
Want to respond to the questions Mass posted in one of the comments after I get some sleep.
Posted in Access to Care, Medical-Legal, Medicare | 32 Comments »
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Deconstructing Socialized Medicine?
Monday, July 26th, 2010Socialized health care is great, and it’s a money saver, too. That’s why England is looking to decentralize it.
The health care budget in Great Britain has tripled in the past 13 years and the budget needs to stabilize.
According to the manifesto titled “Equity and excellence: Liberating the NHS” which was presented to the Parliament, England is planning to change the way in which health care is being delivered.
They’re planning to abolish primary care trusts, which currently make decisions about who gets what health care. They want to increase the choices available to patients. In fact, the plan sets out by stating that “Patients will be in charge of making decisions about their care.” “Shared decision-making will become the norm: no decision about me without me.” Patients will also be able to rate the quality of care provided at hospitals and clinical departments so that other patients can make an informed decision whether to go to those facilities.
Government micromanagement will also decrease. In fact, the document’s Executive Summary specifically states “The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.”
The Health System will only evaluate clinically credible and evidence-based outcome measures, not process targets. “We will remove targets with no clinical justification.” Does that mean that they won’t have to play medical Bozo Buckets in England?
Providers will also be paid based on outcomes and performance.
So far, sounds like a lot of changes heading in the direction of free market medicine.
The plan would also both increase payments to … and increase involvement of … primary care providers.
And there’s a lot of feel good discussion of how the plan will increase quality of care and efficiency of care – all while reigning in costs.
One of the experts in the Times article highlighted a problem with the plan “The real mistake [is creating a plan] motivated by the principle of efficiency savings. History shows clearly that quality will suffer as a consequence.” Goes back to that whole principle about “Fast care, free care, quality care. Pick any two.” It appears that British patients may be faced with a decision whether they want to pay more money for better quality.
But I still have to credit Great Britain for this new plan, because I think there are a lot of good ideas here.
Posted in Health care reform, Medicare, News Commentary, Policy | 6 Comments »