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Tuesday, January 26, 2010

Why is always in the last place you look: medical expenditures at the end of life

Now this is a rather obvious point to make, but it still bears making. I keep hearing people  shaking their heads over the fact that costs for medical care in the last year of life far outstrip the costs before that time.  In an article published in Health Services Research, based on costs of care over 10 years ago, showed an average yearly cost for Medicare recipients of a bit over $7000, but a cost of over $37,000 for the last year of life.
Now if I knew I was going to die, I certainly wouldn’t want to spend $37,000 receiving boring and unpleasant medical care. But if I knew that the Apple company was going to do so well, I would have bought low.
Of course medical costs are high in the final year of life, because that is the year of life when most people are sickest, and therefore are getting the most amount of medical care. Certainly having discussions with patients about what they want when they get close to the end of their lives will save money.  This will reduce the horrendous “flail fests” when a person clearly approaching death with no reasonable chance of survival is subjected to ridiculously intensive life support.  This can even reduce everyday wasteful medical expenditures, such as expensive consultations, feeding tubes and the like in the cases of people who are clearly dying of the diseases of old age that take away quality of life and are not reversible.
Having “end of life” discussions will help in all sorts of ways to focus effort on improving the quality of life and the quality of death for people who are exiting the world. They will also save money that can be diverted to providing basic and vitally important health care to people who really need it.
All this said, in the best of all possible worlds, we still want medical expenditures at the end of life to outstrip medical expenditures before that time, because we do want to make sure that care is given in the most appropriate way possible when people are very sick.  In the best of all possible worlds, though, that disparity will be significantly smaller than it is now.

Monday, January 18, 2010

Rewrite: the senate health care plan

After reading the senate’s health care bill I felt frustrated. Why must it be so long? Why must it be supported only by democrats? Does it really have to be that complex? Couldn’t the important things be gleaned from the rest, resulting in a bill that was less than 2000 pages? To resolve my feelings of frustration, I again took to my keyboard.
If I were queen of the world*, the health care reform bill before congress would be shorter, sweeter and more to the point than the present one, and would be passed by a majority of both political parties. Like the present bill, it would attempt to improve quality, reduce cost, and allow everyone who needs it access to health care. Unlike the present bill, my reform bill would not include measures to improve health behaviors specifically, because that is just too much for a single piece of legislation.
(*Now if I got to be god, instead of just queen of the world, I could make more radical solutions happen, including an affordable single payer or a system that used insurance only for very high priced outcomes, along with prices for health care that were low because of lack of insurance administration costs.)
Goal 1: Allow access for everyone to medical care
• Create one website in which all insurance companies could be represented, and have these participating companies offer a single, low budget plan which would be available to everyone, regardless of need. Medicare would be one of these companies. The cost of the plans and the coverage would be decided on by consensus between all the involved insurance companies with an advisory board including doctors and public health officials. There would be telephone operators who would be able to assist people without computer access.
• Everyone would be mailed a summons to sign up for insurance, with information on how to access the website or operator.
• Everyone would be required to sign up or provide proof of insurance by an employer or private insurance.
• Payment for these policies would be based on a simple sliding scale of ability to pay.
• Insurance companies would be reimbursed at the end of the year by the government for costs exceeding income from premiums, within a certain budget.
• Each insured person would be issued a health credit card that would carry insurance information and a link to computerized medical records. Billing would be done directly online when the provider documents the visit, based on resources used, and would not require billing clerks.
Goal 2: Improve quality of health care and reduce cost and waste
• A simple and elegant medical record system would be created, for online use, by the best minds in medicine and information technology. This would be free to all providers and would be accessible via the internet to all providers, with privacy protection, and with links to individual medical records through the health credit card.
• Advisory boards in each state made up of providers, medical cost specialists and public health advisers would be funded to pinpoint areas of waste and care inadequacy. This would include evaluations of preventive care practices. These boards would be in charge of administering innovative care grants and grants for improvement in health of communities.
• Each state would be charged with the responsibility to re-design the system of malpractice compensation so that the total cost of administering the system was decreased, malpractice insurance costs were significantly decreased, and significantly more injured patients were compensated. These changes would need to prove that they also contributed to reducing medical harms. If at the end of 3 years this was not achieved, the states would be subject to a system designed federally.
• All providers of health care would be required to post prices charged for all services.
• A board would be created of doctors, nurses and administrators, charged with reduction in complexity of documentation. Studies of time required for documentation in office care, hospitals and nursing homes would be performed, and at the end of one year, recommendations would be produced that would reduce that time by 50% with the eventual goal to reduce time spent on documentation to 10% of present standards.
• Federal government would subsidize continuing education classes for providers in cost effective medicine including appropriate use of technology at the end of life, with enhanced reimbursement to practitioners involved in such education.
• Budgeting for payment for providers and services would be determined by consensus of the insurance consortium, including their health care provider advisory board.
• The consortium of insurance companies which includes Medicare would be charged with designing a commission to investigate insurance billing fraud and overbilling, to be paid for by the consortium as a joint effort.
Goal 3: Ensure an adequate health care workforce
• Immediately provide stipends to support medical education for primary care including general surgery, pediatrics, family practice and general internal medicine based on need. Also provide stipends for nurse practitioner training and for training physicians’ assistants.
• Change the relative value scales of payment of primary care and procedures so that primary care visits are reimbursed at a higher level.

Sunday, January 17, 2010

Reader's digest version: the health care bill

Yesterday I spent about 5 hours digging through the senate version of the health care bill. It will probably bear significant resemblance to the bill that is finally passed, and since I am eventually going to need to know what is in the bill, I decided to go ahead and read it. It was not short. In fact, it was incredibly long. Many of the 2074 pages consisted of corrections in wording or lengthy descriptions of the formation of various commissions, which I skimmed. Some points were worded so abstrusely that I just couldn't figure out what they were saying, so I did not address them.

I was generally impressed with the time and thought put into the creation of the bill. I must say, though, that when I finally sit back and evaluate the thing, I think it suffers from its ridiculous length and complexity. It has ended up looking like a wish list written by a monstrous consortium of well informed visionaries. If even a portion of it actually ends up being accomplished it will profoundly change the way our country looks at health and health care. This will probably be a good thing.

I have attempted to distill the bill into a document that a person could reasonably hope to read and maybe understand. I am sure there are inaccuracies due to the fact that apparently there is another dialect of English generally in use by law makers, and it is not my dialect.

Goals of the health care bill fall into 5 categories, and specifics of the bill generally fit into those categories.

Goal 1: Make health care coverage affordable to all Americans

•    Create plans which cover minimal essential health care needs to be provided by health insurance companies or coops, payment for which would be subsidized by the government as needed. 
•    Regulate the insurance companies who provide these plans such that they behave in a way that protects patients from becoming impoverished for care, and in such a way that health is promoted. These regulations include:
o    no lifetime limits on coverage
o    no unreasonable annual limits
o    no policy cancellations
o    no co-pay for agreed upon preventive services
o    unmarried children will be eligible for coverage on parents' policies up to age 26
o    benefits summary must not exceed 4 pages of 12 or greater font and must be understandable to average enrollee
o    within 2 years  health insurance companies must demonstrate that their practices improve outcomes, decrease hospitalizations and medical errors and promote wellness
o    patients will receive rebates if their premiums substantially exceed the services they receive
o    no exclusions based on pre-existing conditions
o    cost of policies can vary based on age or whether the patient smokes, but within certain limits

•    Create an insurance exchange within 90 days of enactment to cover people who have been uninsured and are difficult to insure for various reasons.
•    Create an internet site to connect consumers to choices of affordable insurance.
•    Government will help reimburse companies for payment of insurance for early retirees (people under age 65 who retire and are not eligible for Medicare).
•    Provide loans and grants for creation of health care cooperatives.
•    Simplify forms relating to coverage and payments.
•    Essential health benefits must include:
o    ambulatory services
o    emergency care
o    hospitalization
o    maternity and newborn care
o    mental health and substance abuse treatment
o    prescription drugs
o    rehabilitation
o    labs
o    preventive and wellness services
o    dental and vision coverage for kids
o    limitation on deductibles to $2000 for individual and $4000 for other plans
•    Each state will establish exchanges for state residents to purchase health insurance, thus fostering competition. One exchange, the American Health Benefit Exchange, will serve individuals and families, and the Small Business Health Options Program (SHOP exchange) will service businesses looking to insure workers.
•    Insurance exchanges will be evaluated within 5 years.
•    Communities may design their own health insurance options in order to reduce administrative costs.
•    States may enact their own plans for covering low income individuals.
•    There will be tax credits to help pay for premiums for individuals with incomes up to 4 times the poverty line, and for small businesses.
•    Medicaid will be expanded to cover people up to 133% of the poverty line, and there will be increased support of the Children’s Health Insurance Program (CHIP). There will be simplification of the process of applying for these and there will be outreach to at-risk populations.
•    Medicaid coverage will be expanded to cover such things as free standing birth centers.
•    Individuals will be required to maintain minimal essential coverage for themselves and their dependants, and fines will be phased in for noncompliance. Exceptions will be made for people who are part of a religious based health care ministry or are registered as having a religious basis of objection, people in jail, and those for whom the only available insurance costs more than 8% of their income.
•    There will be medication discounts during the “donut hole” gap in Medicare drug coverage (the time after the cap on insurance coverage and before the out of pocket maximum is reached.) The gap will also be reduced.

Goal 2: Improve the quality of health care

•    Programs will be supported to provide “health homes” for treatment of chronic conditions, coordinating care through a group of providers.
•    Provide money to pay for maternal, infant and early childhood home visits
•    Increase hospital payments based on performance for several diagnoses (pneumonia, heart attacks, congestive heart failure and surgeries.)
•    Increase provider reimbursement based on quality indicators.
•    Establish a center for Medicare and Medicaid innovation.
•    Pilot program for bundling payment for episodes requiring hospitalization.
•    Pilot program for evaluation of home based care by physicians and nurses.
•    Improve payments to critical access hospitals (rural hospitals in underserved areas) for participation in delivery system reforms.
•    Pilot program to look at cost effectiveness of providing hospice services along with certain Medicare services.
•    Improve formularies for Medicare D so more medications are covered by insurance.
•    Fund health care delivery quality research addressing best practices and patient safety.
•    Fund creation of practice teams for Patient Centered Medical Homes.
•    Fund medication management services.
•    Provide funding for systems that improve emergency services including trauma care, public health.
•    Develop a program to facilitate shared decision making between doctors and patients in choices of care.
•    Establish a Women's Health office of the Department of Health and Human Services.
•    Patient centered outcomes research: provide more money to evaluate which treatments work and to compare cost effectiveness.
•    Increase funding for protection from elder abuse.
•    Fund research into pain treatment.

Goal 3: Reduce costs

•    Medicare will not pay for costs associated with health care acquired conditions.
•    Adjust payments for home health care to more accurately represent value and expense of care, including hospice.
•    Re-evaluate billing codes, especially codes used multiple times for a single visit, codes that have the fastest growth and codes for new technology, and re-calculate the relative value scale which is used to determine Medicare payments for various billing codes.
•    Reduce payment for the technical component of imaging multiple body parts.
•    Oversee Medicare Advantage programs.
•    Reduce part D subsidies for high income patients.
•    Reduce waste in drugs dispensed in nursing homes associated with 30 day refills.
•    Hospitals will be required to publish standard charges.
•    Reduce overall Medicare reimbursement increased to hospitals and nursing homes based on productivity.
•    Establish a board to decrease per capita growth in Medicare spending.
•    Increase transparency of costs and payments related to physician ownership of hospitals and nursing homes.
•    Increase surveillance for fraud and fines for fraud in Medicare.
•    States are encouraged to develop and test alternatives to the present civil litigation system.
•    Excise taxes will be levied on high cost employer sponsored health care (employee will be charged 40% of excess benefit) and 5% excise tax on cost of cosmetic medical procedures.
•    Increase oversight of drug sampling and payments for brand name drugs.
•    The senate notes that 3 elderly or disabled individuals can be cared for in home and community based services for the cost of 1 cared for in a nursing home. Voluntary insurance for community based services will be established.

Goal 4: Improve availability of care

•    Establish a commission to improve and increase the health care work force.
•    Enhance student loan programs.
•    Repay loans for certain primary care and public health students.
•    Increase funding to the National Health Service Corps significantly (1 billion by 2015).
•    Fund certain nurse practitioner managed clinics.
•    Increase training programs in family practice, general internal medicine, physician’s assistant programs, pediatrics, including needs based fellowships, support public health dentistry and training for nursing home care providers.
•    Support primary care dentistry including hygienist clinics.
•    Provide training grants for mental health providers, advanced care nurses.
•    Increase payment for primary care services by 10%.
•    Increase payment for general surgery in shortage areas.
•    Provide money to start clinics in underserved areas.
•    Adjust Medicare payments based on geographical differences in cost of living.
•    Pilot program to increase payment to Medicare dependant urban hospitals, along the lines of critical access hospitals in rural areas.
•    Improve Medicare payments to low volume hospitals to preserve access.

Goal 5: Promote health

•    Create an advisory group to set specific goals for Americans and a national strategy for achieving those goals.
•    Support the work of a preventive services task force to evaluate the effectiveness of preventive services, and introduce community preventive services task forces.
•    Fund school based health centers.
•    Medicare will pay for annual preventive visits with personalized prevention plans.
•    Medicaid will pay for smoking cessation services for pregnant women.
•    Fund community transformation grants to create healthier communities (including improvement of food at schools, programs to increase activity, work based wellness services, reduction in ethnic disparities.)
•    Fund grants to enhance wellness in seniors.
•    Increase spending for public health programs such as personal responsibility education.
•    Require nutritional labeling of menus at restaurants.
•    Allow reasonable break times for nursing mothers.

Monday, January 4, 2010

Obama and the left: newyorker.com

Obama and the left: newyorker.com

Video: David Cutler

Video: David Cutler

the $25 plan

I would like to make $120,000 a year.  It seems like a reasonable amount to make after becoming good at what I do, and after an expensive and time consuming education, and not entirely out of reason given that the average salary for an internal medicine doctor like myself is $150,000. Despite being well established, busy, and taking call and seeing patients in the hospital, as well as providing various services for the hospital and for a set of group homes for developmentally disabled people, I don’t make anywhere close to that much money.

I would also like to provide high quality care to patients for a reasonable price.  Presently I charge about $160 for an appointment that takes me about 30 minutes, give or take an hour, to complete. That seems kind of steep. The reason I charge so much is that most of what I do, solving problems over the phone, reviewing tests, consulting colleagues, signing my name about a million times a day, is unpaid work.
An average internist takes care of 1500-2000 patients. That is to say that at any given time, there are that many people who consider a given doctor to be “my doctor.” A doctor like me, who works a more gentle schedule, would probably be responsible for 1200 patients.  In my schedule, I would tend to see about 40-50 patients per week, about 50 weeks per year. My overhead is about 50% or a little more, just depending on how things go.

What would be wrong with a plan to cover just visits with me or the folks in my small clinic which would cost $100 a year as a basic fee (to cover the things that I normally do for nothing) and then $25 for an office visit? As I calculate it, that should be a salary of about $120,000 with overhead taken into consideration, and affordable basic health care for whoever was interested in it. Overhead might be considerably lower since these folks would not need to be billed.

People would still have to pay for things like x-rays and blood tests, but much of the really important stuff is not that expensive, and if patients had some stake in bringing the costs of procedures down, or consuming more wisely, things might get cheaper.

“Concierge medicine” resembles this, only with a steeper per year cost and an emphasis on special treatment for the patients involved. Practices that do “concierge medicine” are apparently quite popular in some places, but tend to cater to wealthier clientele.

A system like this could co-exist with insurance: increasing numbers of patients are so underinsured that an office visit would cost them more than $100 to start with, and even the adequately insured patients might like the opportunity to completely bypass the complexity of insurance billing.  Most of the uninsured patients I see could afford this.