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Sunday, March 28, 2010

The evolution of the hospital meeting on reducing spending and improving quality

We have had 3 of these meetings so far at our hospital, and so far the interest level has been high, and the ideas have been good.  This next meeting, this coming Tuesday, catches me just after returning from Haiti, and may be losing some momentum, what with the recent passage of the health care reform package.

I would propose at this meeting to do several things.

First, I think that we should at least discuss gathering cost data for the hospital. I would like to know what the average patient or patient's insurance company is billed for various diagnoses, as an inpatient and in the emergency room. I would like to know how much the hospital actually gets paid.  I would like to know how much uncompensated care is delivered, and would like to see what impact health care reform has over the next year. I know this kind of data is sensitive, but without it we are working in the dark.

I would like to go over the provisions of the health care reform package in a little more detail to see what impact we might expect to see from it, and what changes we might need to make in order for the impact to be positive.

I would like to discuss the idea of having quality and cost case conferences to see where money is being spent and evaluate what the impact of some of the most expensive procedures really seems to be.

I would like to discuss ways we can support primary care doctors in caring for their patients with the aim of keeping non-emergency patients out of the emergency room.

I would like to start thinking of continuing medical education presentations that address cost effective treatment of common conditions.

I would hope to continue to gather ideas from doctors and staff about perceived waste, so that we can focus our money and effort in directions that matter, and I would like to go over the ideas we have had so far and see where we are with respect to putting them in action.

How do Haitian patients' expectations resemble those of American patients?

My trip to Haiti was satisfying, the people remarkable, and though many things about Haiti were very foreign, there were some definite and unsettling areas of similarity between the patients I saw there and those I see in the US.

I expected to see people with horrible and potentially curable injuries and infections, and thought that bringing antibiotics would be exceptionally useful. Instead, I found that most people were very healthy, and that they had complaints that didn't correlate with any physical findings of ill health, and which certainly were not life threatening. Many of these discomforts appeared to be related to various forms of overuse, such as headaches related to carrying five gallon buckets of water on their heads for long distances, and pelvic disorders related to having many babies.  In general they were disappointed if I didn't have a drug or a test for their particular condition, and many were unconvinced or under-impressed with my explanations for their symptoms. I saw quite a bit of obesity and hypertension, and the hypertension was not treatable other than with instructions for lifestyle changes, since the vast majority of people could not afford a medicine that they would have to take daily, and I would feel uncomfortable prescribing one and being unable to monitor any blood tests or regular blood pressure readings.

So the general problems were related almost entirely to lifestyle and the patients wanted to get out of a doctor visit some sort of resources, be it a test or a pill.  The test or the pill had value, and since I was doing work for free, this was a chance to get something for nothing.

Now, not all of my interactions were of this type, and there were people glad of an explanation, also people for whom a consultation or a medication had real value, but most of my patients really did not need a doctor and seeing me did not particularly improve their health.

In the US this same dynamic is at work. People pay for insurance, or in the case of Medicaid, insurance is paid for them, and they wish to get value out of the resource outlay.  Tests are great, medication are great, all have intrinsic value, even if I, the doctor, don't see it that way. Unlike in Haiti, where very little is available in terms of medication and testing, in the US we spend huge amounts on both of these things, encouraged in many cases by the wishes (or presumed wishes) of our patients.

In Haiti, medical care and medications are available, to a limited extent, but though they are very inexpensive, they are outside of the means of most Haitians. In the US, procedures and medications are also available, but also cost more than most American's can really afford.

After a day of consultations in Haiti, examining people in a dark concrete room which was about 95 degrees and rarely giving them what they were expecting, my helpers and I decided that the whole process would have been much better if people had been expected to pay something, anything, even one goud (equivalent to a few cents). The patients would have self selected more appropriately and would have valued the interaction more. The same is true, I think, for American patients. I believe that having a real sort of contractual interaction with a caregiver focuses the interaction more effectively and gives it more value. I think the very fact of a medical appointment being paid for by insurance, as necessary as it has become, removes this important defining feature from a medical encounter.

Thursday, March 25, 2010

Welcome Home: Health Care Reform Bill Passes Congress

I just got back from 2 weeks in the Haitian island of LaGonave to find out that in my absence congress actually passed health care reform.  Organized medicine is generally in support of it, as I am generally in support of it, and I hope that we can now get to work and do what we can to make it live up to what I see as excellent potential for reducing costs and improving quality and accessibility.

On my dining room table, though, was the local newspaper, with a headline about our governor, Butch Otter, who had been fuming that Idaho would resist enactment of the new bill. Some information just makes me tired, and seeing this explosion of outrage over something which, though certainly not perfect, is a really good start, makes me tired. I then read an article in the New England Journal by T.S. Jost which addressed the issue of state resistance to health care reform.  He expresses the issues well, and with good detail.

"I know of two other significant state campaigns — one ongoing, one historical — to rally or support state citizens in resisting federal law. In the ongoing effort, more than a quarter of the states have now legalized medical marijuana in the face of a federal prohibition. Although the Supreme Court has emphatically upheld the authority of the federal government to outlaw medical marijuana, the Justice Department announced last fall that the prosecution of users of medical marijuana was not “an efficient use of limited federal resources.”5 It is possible that the federal government will eventually conclude that it is not possible to enforce the individual mandate for health insurance. But if individuals successfully resist accepting responsibility for being insured, there will be no way of expanding affordable coverage in a system that depends on private insurers. If government funding of health care must therefore be increased, it may not be the result resisters want.
In the historical effort, demagogues such as the late Senator Harry Byrd (D-VA) mounted the Campaign for Massive Resistance to school desegregation in Virginia and other states during the 1950s and 1960s. Virginia passed a series of statutes intended to maintain the strict segregation of its schools, even going so far as to close the public schools in one county for 6 years. The legislation was held unconstitutional by the federal courts, and the campaign eventually collapsed. Today, most Virginians regard the whole episode as an embarrassment. The state legislature has even adopted reparations legislation to help people who were denied an education during the campaign. Perhaps if health care reform is successfully implemented and Americans come to fully appreciate its benefits, they will look back at the current efforts with similar embarrassment.
These resistance efforts are not about law — they are about politics. But of course at this point, health care reform is only about politics, except insofar as it is still about the morality of equal treatment for all."

This article was published before the package was signed into law, a couple of weeks ago.  The republican efforts in congress now to weaken this law are painful to watch. From my vantage point it looks like they are diverting energy that should be spent on other issues, wasting taxpayers' money on political posturing.
P.S. I will be posting some very cool stuff, with pictures if I can figure out how, on Haitian culture, positive social change and sustainable technology.

Sunday, March 7, 2010

a nearly instant solution to health care woes

Most peoples' health care needs are, or could be, taken care of by a primary care doctor. These needs are not being met because primary care providers are both too expensive and in short supply. A standard doctor's appointment may be billed at over $100, easily, and cost even more if lab tests are ordered. The uninsured just can't afford it, and the insured are hurting because their insurance costs so much, and this is in part due to the fact that care is expensive, and that patients go for more expensive urgent and emergency care because they can't get in to a primary care doctor.

But primary care is not very expensive at all to provide. A good full time primary care doctor manages 1600-2000 patients at a time. If each one of them paid $200 each year to that primary care doctor, the doctor could make a good salary and handle the 50-60% overhead which is common in medicine. Most of the uninsured could afford that much money, and it is far less than is usually spent on medical care by insurance companies and patients.

So how could this work on a large scale? Right now health care insurance costs per family are around $10,000, and most families use no more than primary care, or would if it were available when they needed it. Out of pocket medical expenses are harder to calculate, but are hundreds and often thousands of dollars for people who go for medical care. This is a lot of money, and makes $200 look like peanuts.

I would propose that all primary care be pre-paid. All insurance companies would rebate their insured $200 to be used to sign up with a primary care doctor. For this, they would have regular primary care when they needed it, and the doctor would not have to bill the insurance company and the patient would never have to worry about costs. $200 would probably also cover lab tests done in the doctor's office, since the overhead involved in billing would be gone, and the doctor would be able to see significantly more patients because they wouldn't be wasting time associated with documenting billing codes and time spent in order to be paid by an insurance company. At the end of a year, the insurance company would calculate the amount of money they saved (which would probably be huge due to savings on claims management staff and reduction in spending related to insured patients not getting timely preventive care) and would then be required to rebate a certain percentage of their savings to the patient and to the entity paying the premiums (employer, government or individual.) Everybody would win. Doctors would make an good salary and not hassle with billing. Patients would either get money back on insurance premiums, or in the case of medicare and medicaid, have some kind of a health related rebate, employers would pay less and medicare and medicaid would see their costs significantly lower. If a patient decided to go out and spend their $200 check on beer rather than on medical care, they would not get a rebate at the end of the year, and would also not be eligible for open access primary care.

This would not deal with every problem in medicine.  It does nothing to deal with the high cost of hospital care, and doesn't deal with specialty care issues. It does, though, reduce overutilization because getting adequate primary care keeps patients out of emergency rooms and hospitals where much of that overutilization occurs. Also, in this system, patients would have some pressure not to partake of excess CT scans and consultations because these would be paid under the old system, complete with complex bills, copays and out of pocket costs. Since satisfaction would be higher in primary care because frustration and wasted time would be lower, it would probably make more medical graduates go into primary care, and reduce older physician burnout.

Friday, March 5, 2010

watching Cspan

During my lunch hour (25 minutes more like) I went to the gym where I caught up on a small portion of TV.  I have been avoiding the news about health care reform legislation lately because it feels like an “Obama’s gonna fail” fest. But today I had a TV all to myself and there was a representative from New Hampshire on CNN, telling me, live, how he felt about the budget reconciliation process and the health care reform bill that might pass.

The Republican congressman said about what the standard line appears to be about health care reform: “The majority of Americans don’t want to see this bill pass.”  He said that it was too expensive, that small business would no longer be able to afford health insurance for employees, that it would put 17% of the nations economy into the governments hands, that it would make health care a puppet of the government.
It is absolutely clear from this that he hasn’t read the health care bill.  It has many faults, but what he said was grossly inaccurate. And even if he had read the bill, it isn’t the bill that’s going to be voted on, so how are his comments even relevant? And as for some invented percentage of the American populace not wanting the bill to be passed, how could that possibly be relevant when the American people have even less of a clue than he does what would be in the bill? I can’t believe that my taxes go to pay the salaries of people like this so they can stand up and say stuff that is completely lacking in data or sense.

Health care reform detractors also keep returning to the statement that it’s all going to suck, no matter what we do, because health care costs are just going to keep on going up.  There is huge amount of thinking and writing happening right now in the medical community about ways to reduce costs, and the magnitude of potential savings is huge, precisely because so much in medicine is grossly overpriced right now, and so much waste is uncontrolled.  The pessimistic attitude put forth by lawmakers may be self fulfilling, but with a little bit of common sense, costs could go way down. Basic medical care is just not that expensive to provide and providing it could drastically reduce the need for the not so basic expensive medical care.

It is true that we have to tread lightly on an industry that accounts for 17% of our GDP because that represents many jobs and much of our industry. Legislation should strive not to be heavy handed, and changes should occur slowly.