Back to Being Me, Part 4

To continue my thoughts about healthcare:
Why the new healthcare law will fail miserably (part 4):
1. It totally fails to address the real problems in the US healthcare system.
a. Over-indulgence by the insurance companies.
b. Unsustainable growth (in this case, by Universal Coverage).
c. No tort-reform on law suits.
(read prior posts to catch up on these points)

d. No accountability for the Publically Insured.

One point that has been relatively untouched by the media and the discussion groups that I have seen is the differences in responsibility and accountability between privately and publically insured patients.
My insurance has a co-pay and a deductible. I can look at two different physicians or two different tests (as courses of action) and I have to decide which is best for me medically, but I ALSO have to consider which is best for me financially. I will have to pay 20% of the bill, so there is a substantial difference between a Physician who charges $100 for an office visit -vs- one who charges $600. Or there is a tremendous difference between an Ultrasound which costs $600 -vs- the MRI that costs $6,000. I am forced to weigh the potential benefits as compared to the out-of-pocket expense. i.e. the MRI may not statistically provide better information.
The same is not true for Public Aid. At *best* most PA plans have a flat co-pay per visit. So, if one doc charges $100 for the office visit and recommends a $600 ultrasound, there is no reason for the publically insured patient to choose that route over the $600 office visit and $6,000 MRI, because there is no vested financial interest on the part of the patient. They pay the same amount (usually nothing).
It is a fact that fewer publically insured patients maintain a Primary Care Provider and get regular preventive care. It is also a fact that more publically insured patients use the Emergency Room as a Primary Care Facility. The reason is not a stretch. There is no financial deterent to someone who pays for no part of the visit. I look at paying 20% of a $200 office visit as a far superior choice to paying 20% of a $2,000 ER visit. If there is no financial accountability, why would anyone care?
Unfortunately, the new healthcare law ceases to address this, very real, problem. I work at an inner-city hospital, where 8 or 10 hour ER waits are standard. Most inner-city ER's run less than 20% privately insured. Additionally, it is estimated that less than 50% of these ER visits are actually emergent. The ER's are plugged up with people who choose to use them rather than to establish care with a PCP. It is my experience, that when these patients are stabalized and set up with a PCP, the vast majority of them will NEVER keep the PCP appointment. In clinics that I have managed, Publically Insured "New" patients have almost a 40% no-show rate...over 400% more likely to No-Show than a Privately Insured "New" patient.
How will universal insurance affect this kind of situation? I think our best indicator would be to look at Massachusetts, since it is the only state that already mandates Health Insurance. In MA: preventive visits are down, ER visits are up. Ironically, the ER visits are not up solely because of Publically insured...they are also flooded with Privately Insured patients who can not get in to see a PCP, because the PCP offices are backed up for MONTHS due to the mandatory, unsustainable growth (see previous post). This has now given Massachusetts the distinction of having:
1 the slowest care in the country,
2 the highest percentage of ER visits, and
3 the most expensive healthcare in the US. Look these stats up on the internet, they're scary.
Thankfully, the rest of the country will soon be modelled after MA, so they won't be alone.
I have yet to see the positive side of this law....

Back to Being Me, part 3

To continue my thoughts about healthcare:

Why the new healthcare law will fail miserably (part 3):

1. It totally fails to address the real problems in the US healthcare system.

a. Over-indulgence by the insurance companies.

b. Unsustainable growth (in this case, by Universal Coverage).
(read prior posts to catch up on these points)


c. no tort-reform on law suits.

When President Obama gave his healthcare pitch to congress (and the nation), he had only a few points that made both sides of the aisle applaud. the biggest was the promise that there would be reform on malpractice insurance and lawsuits (tort reform). If anyone notices, this never made it into the law. Now, let's not be critical of Mr Obama. He truly did want to know if the healthcare system had a problem with frivolous lawsuits. He wanted to know so badly that he tasked his Secretary of Health and Human Services, Kathleen Sebelius, to find out for him. She said that frivolous lawsuits probably only cost insurance companies about 5 billion dollars a year...not enough to be worried about. Ultimately, she said that tort reform/lawsuits aren't a problem. I was PERSONALLY relieved to hear her unbiased opinion. Oh, as a sidenote, prior to being the Secretary of Health and Human Services for Obama, Sebelius served as executive director and CHIEF LOBBYIST for the Kansas Trial Lawyers Association. So naturally, she is impartial to matters concerning lawsuits/lawyers.
First off, I don't find a 5 billion dollar savings to be something that is just brushed aside.
Secondly, there is no way to put a price tag on the cost of frivilous lawsuits because they cause reactions that are not measurable. For instance, they are the driving force behind "defensive medicine." For those not in healthcare, "defensive medicine" is when a Physician orders every possible test available, despite a lack of clear medical necessity, because they are afraid of getting sued if they miss something...even if the patient had no indications/symptoms. Thousands of times every day, an expensive MRI is ordered, when its likelihood of showing anything more than an Ultrasound, is statistically insignificant. Physician documentation and language has changed from "evaluate for symptomatic XXXX" to "rule out XXXX." That may seem like an insignificant change, but it costs patients millions (and probably billions) of dollars every year in additional co-pays and out-of-pocket expense. The end result is NOT the hope of finding some undiagnosed illness...it's the ability to sway a jury, in a court of law, to view the physician as someone who did everything possible...even beyond "standards of practice." And I won't even get into the fact that if an insurance company denies a medically indicated test it's the doctor who gets sued if there is a bad outcome....
Thirdly, is the fact that the original 5B in savings doesn't factor in the steady increases in malpractice insurance. I think that very few people have any idea what it would be like to be forced to make a split-second, life-and-death decision based on: limited current patient information, no comprehensive medical history, and no background of events...and know that if you're wrong, you could be sued and lose everything. So, many types of practices pay hundreds of thousands of dollars per physician, per year in malpractice insurance. And who pays for that? The doctor? you and I both know that it is passed on to the patient in higher costs. And again (referring back to my previous posts), the ones who truly pay for it the most are the uninsured.
There needs to be tort reform. There needs to be regulated price caps for insurance, and there needs to be lawsuit caps on liability. $10M won't bring gramma back. yes, her death may have been unfortunate. yes, given the situation her death might have been post-poned. but $10M? It doesn't bring her back. It doesn't make the pain go away. All it does is drive up costs for everyone...and encourage frivolous lawsuits from everyone on the planet who lost a loved one...regardless of circumstance. And those lawsuits cost money, even if the healthcare provider is proven to be not-at-fault.
If we want true reform on the lawsuits, there is one simple way to reform it. Make one tiny law: if you lose a lawsuit, you have to pay for the defendent's legal fees and damages. Frivolotry, thinks twice.
It seems that this entire law does nothing but give more power and less regulation to the insurance companies...while doing nothing for the patient or the provider.

Back to Being Me, Part 2

To continue my thought that was so rudely interrupted by the oil spill:
Why the new healthcare law will fail miserably (part 2):
1. It totally fails to address the real problems in the US healthcare system.
a. Over-indulgence by the insurance companies. (see previous post before continuing)
b. Unsustainable growth (in this case, by Universal Coverage).
Several years ago, I was managing a sub/sandwich shop. We expanded to a new location because business was good. The new location was huge and nice, all new equipment, all new staff, etc. On our 5th day in business, the owner showed up and announced that he had put an advertisement in the local paper, to print on Friday. What he failed to tell us was that the print ad was a buy one, get one free. When Friday night rolled around, the shop was swamped. We didn't have enough staff, the staff that we did have was under-trained and unprepared, and worst of all, there wasn't enough product. It was a fiasco. The horrible service that night did irrepairable damage to the store's future business. It was labelled as 'slow,' 'inefficient,' and 'inaccurate.' And all were true for the same reason: demand flooded supply.
Now, back in 2010, we understand the lesson, but fail to make the application to healthcare. If there are suddenly 30,000,000 more 'customers,' we have a huge and sudden problem. There are not enough docs to go around. There are not enough exam rooms. The clinics are understaffed. In a normal, supply-vs-demand, free-market world, the demand rises slowly and supply follows. Unsustainable growth in patients requires sudden growth in facilities and providers. We will see niether of those.
Polls among medical students and early-practicing Primary Physicians are all reporting that less people plan to be practicing primary medicine next year than this year...and the trend is sharply downward for every foreseeable year. The reasons? Over-worked and under-reimbursed. The only way that supply catches up with demand is when there is incentive for growth. Half of the previously-uninsured people, entering the healthcare realm, will be on public insurance. The reimbursement from state aid is as low as 6 cents on the dollar; substantially less than it costs to actually see the patient. *And no one seems to be asking the question about where the states are going to get the money to 'insure' the 15M people. That money is not addressed in the healthcare law, it is laid on the already-cash-strapped states to fund for themselves.*
The point is...it's hard to recruit doctors who will not make any money or build clinics that will operate in the red. The options are few, but here is what is being talked about in the healthcare circles that I am in:
1. limiting the number of patients seen...all walk-in clinics, first come, first serve. This is known in the European/Canadian healthcare system as 'rationing'
2. having advanced practice nurses doing the work of primary care physicians. This is also known as 'reducing quality.'
BOTH of these were warned about, but the government ignored the warnings.
3. charging people a 'retainer fee' in order to have a primary care physician (this is already done in Massachusetts...it had to be done as soon as the state passed their mandatory coverage law).
or the most frightening, and yet most realistic:
4. Hospitals/clinics/physicians opting OUT of the federal/state programs. They simply don't contract with the government. They pay higher taxes, but they are not obligated to provide care for Medcicare/Medicaid patients. They close their Emergency Rooms, and only accept clinically-referred patients to their inpatient units. This is already happening all over the country, in response to the new law. And think about this: the places that are already caring for the non/under-insured patients will close their doors to both. The bill may provide more people with insurance...but end up PROVIDING CARE TO FEWER!
This law will collapse on itself because it fails to understand one of the simplest laws of business...supply and demand.