Saturday, June 27, 2009

Criticisms of the Kennedy Health Plan

First let me say that whether you agree with his politics or not, he has worked tirelessly to get healthcare reform for the last thirty years. That being said, I have a lot of problems with his proposal. I'm reviewing his first since it was one of the first proposals out and it has just been evaluated by the CBO (Congressional Budget Office).

I will not review any "plans" that have not been put forth as bills (i.e. obamacare). Little snippets are not appropriate to determine the good and bad of a plan. You need the whole thing to get proper context.

This is what i don't like about the Kennedy plan:

  1. Has local state exchanges (Market to buy heath insurance) rather than one large federal one. I prefer the federal exchange model as it increases the size of the risk pool which has more leverage for negotiating prices such as prescription drugs. And it requires less administration. Each state will have its own exchange with its own administrative costs and bureaucracy.
  2. Undermining of employer-based insurance. According to the CBO paper, this plan will REDUCE employer coverage for 15 million people. So while 39 million will get coverage through the exchanges, 15 million or so already had coverage, and according to the CBO there are other losses of coverage in the Medicaid sector, so there is only a net gain of 16 million insured.
  3. There is a fee for not being insured. In order for risk pooling to work, you need to have the whole population insured. In particular, the young healthy people who don't get employer coverage must be brought into the plan. This should be done by automatic enrollment, not by a fee. There should be some minimal catastrophic plan that you are enrolled in - if you have sufficient income, with the cost deducted by IRS filings. A $100 yearly penalty does not address the risk pooling issue and undermines the agreement with insurers to eliminate pre-existing conditions if all people under 65 are required to have coverage.
  4. Rather than continue the Medicaid bureaucracy, all Medicaid enrollees should be rolled into the exchanges and receive subsidies for the cost of the policy. If we have to create one bureaucracy (i.e. health care markets/exchange), let's eliminate one also (Medicaid).
Considering this plan costs 1 trillion over 10 years, there is too high a cost for too few added coverage. There are better plans out there. We should look elsewhere.




Wednesday, June 24, 2009

The death of paternalism. At first I cheered, now I have regrets. (Or second choice title: How Press-Ganey is changing medicine)

I wrote this article on SDM (Shared Decision Making), that talked about involving the patient in their medical treatment decisions. It lowers costs overall and increases patient satisfaction. Even less educated patients really appreciate being told they have a choice in their care. I thought it was a win-win. But then reality set it.

I recently have been confronted with a new reality. The Press-Ganey. For those of you that don't know what this is, it is a survey that administrators of hospitals use as gospel for who is the best hospital. It is all about customer satisfaction. I've always practiced that educating your patients in the ER is the best medicine. Whether on nutrition or the nature of their disease process, my patients always appreciate it. Or so I thought. Now I'm being told that my patients don't want to hear that. They don't want to be told to quit smoking. They don't want to be told that it is best to have a primary care physician as opposed to the ER - even when I refer them to a free clinic for the uninsured. They want that prescription for a z-pack. They want their vicodin. They want that head CT or that MRI and especially that foot xray for that stubbed toe.

If you address their "real" needs and try to address their real issues, you get bad reviews (i.e. Telling patients that you are giving them imitrex for their headache as it is a much better migraine medicine than demerol, and neurologist recommend not giving opiods unless nothing else works, does not make you popular). If you ignore the necessary education and simply give them the prescription they want, you get good reviews. Is this the best way of practicing medicine? According to administrators, we should continue our good practice of medicine, and address our patients wants and needs. Unfortunately, these don't always line up.

I get that the patient has a say, and in that say, they determine that they don't want to hear your doctor advice. They are there for a purpose. Anything else is irrelevant. I don't subscribe to the paternalist view that everything the doctor says is the only way. But sometimes what helps you is not what you wanted to hear, but what you needed to hear. And if I am being told to stop trying to help my patients understand their disease, and improve their disease and even PREVENT their disease - then what good is SDM? What good is Press-Ganey? What good is customer satisfaction?

I was all over the neat idea of SDM a few weeks ago. Now I am thinking that paternalistic measures weren't such a bad thing after all. If patients have a right to dictate their care, even if it is not in their best interest, what then is my purpose?

I welcome discussion on this topic.

Tuesday, June 23, 2009

Commenting on WhiteCoat's Blog Parts 1&2

I am soon to publish a book this fall with Wiley-Blackwell entitled "How to Survive a Medical Malpractice Lawsuit." I also write for the same magazine, www.epmonthly.com as has the WhiteCoat Blog. WhiteCoat is currently (bravely) blogging about his lawsuit experiences. He brings up a number of important issues that I think should be further pointed out, so the readers get the best value out of his experiences. I've run this idea by WhiteCoat and have been given the okay to go ahead.

Part 1:

There was one comment that I was afraid could be taken out of context by a plaintiff's attorney in a future lawsuit: "I ordered more tests than I probably needed to." But I'm not going to go crazy on this point. I'm not writing this to criticize WhiteCoat, but to offer a learning opportunity to other docs.

Important issues requiring further input:
  1. Re: Medical Records "Do I look that dumb to make a change in the records now?" Apparently doctors are that dumb and do it all the time. Never remove or change any records (beyond the approved methods of a one line crossout that is initialed, timed, and dated). You think you won't get caught. But you will. In ways you never conceived of. And it will ruin your case.
  2. Re: Looking up information "Once I had read the chart, I felt the need to validate the care I provided." This is totally understandable. And you should not do it. In Part 2, Vinny, WhiteCoat's attorney, makes this point, but by then it is too late. Now that the doctor has looked up information, the plaintiff's attorney has an easier time making it look like an authoritative source that can be used against him at trial. This is a key point. Once you are sued, do not look up anything until you've met with your attorney (at that point it is attorney-client privilege).
  3. "I notified the group I was working for at the time and they notified our insurer." When you get sued, you should contact the insurer yourself. It is okay to notify the group, however, in all likelihood, they already know as they were probably named in the lawsuit as well. Thus there could be a conflict of interest between you and your employer-now co-defendant. If you have an attorney, you can have them contact your insurer. However, letting the group take care of this can lead to bad habits where you don't take control over your case and let your employer make decisions for you that may or may not be in your best interest (that you might have the power to make yourself).

Part 2:

Important Issues:
  1. "I checked the attorney out..." Excellent! Most doctors don't evaluate their assigned attorney. They don't realize that there may be reasons why you don't want that particular attorney or lawfirm. How do you evaluate your attorney? It is a difficult question, much like asking to evaluate a doctor. I have an article I wrote at www.epmonthly.com about that (if it is not archived "How to choose an attorney" then email logan at lplaster@epmontly.com for a copy). I've also written a whole chapter on that in my book. In brief, asking peers as WhiteCoat did is a good start. Martindale is of questionable value. Do they settle a lot of cases or take them to trial? Are they a senior partner - usually defense attorneys make partner by winning lots of cases. However, I would like to point out, while WhiteCoat was concerned about the attorney being an expert in complex cases, this is a good thing. You want someone who is very experienced. You want a "big gun." You should be concerned if they hand you an attorney who only works on easy, simple cases.
  2. Advice Vinny gave to WhiteCoat is spot-on and people should pay attention.
  3. "Vinny's firm and the insurance company contacted me with the name of an expert that they had chose to review the case." Please note that sometimes insurance companies (on big cases or via standard random sampling) will have an in-house expert review. This usually doesn't happen on all cases, though perhaps there are some insurance companies that do. This "expert" is very different from the expert you choose to represent you at trial. These in-house docs are usually not actively practicing and often don't have credentials that are ideal for your particular case. They are there to give the insurance company an idea of whether they should settle the case or not. Realize that if you have it in your policy that you must give your CONSENT TO SETTLE, the insurance company can't settle unless you agree (Please find out if you have this and try to get it in your policy if you don't). No matter what the review says. If you have that clause in there, don't let yourself be bullied into settling a winnable case (i.e. your experienced attorney says it is winnable). Of course, there are other mitigating factors such as a verdict that could go over your policy limits. However, in general, settling is losing since you end up in the National Practitioner Data Bank. You should try to take most cases to trial. That being said, if you cannot get an expert to stand up for your care in court, you will have to settle.
  4. "But before the insurance company would consult another expert, I had to agree to abide by whatever opinion the expert rendered." I agree that WhiteCoat should have insisted on another expert, however, he should not have agreed to abiding by the second opinion. Unless it is explicitly stated in your policy, your insurance company is obligated to get the opinions of multiple experts as part of the normal review process. If multiple experts with proper qualifications say the same thing, as I mentioned above, you should consider settling. Otherwise, don't let you insurance company bully you into giving up rights that you have.
To be continued...

Monday, June 22, 2009

Medicare Reform Part 4 - New Model For Reimbursement - Hosptials

In my past blogs about Medicare Reform, I established the reasons for the need for Medicare Reform with some suggestions to control costs like shared decision making (SDM), Medical Ethics reform, and fixing Medicare Part D for Prescription Drugs.

Plus, I created a whole new physician reimbursement system based on an hourly rate that is determined by factors such as board certification, experience and quality incentives multiplied by a complexity factor that ensures that quality physicians who spend time with their patients are valued as much or more than doing a procedure on them.

In this blog, I continue with my suggestings for hospital reimbursement reform. Hospitals are barely getting by. My own administrator admitted to me that the only reason the hospital can function financially is because of the outpatient surgery center. That is the big money-maker. Pretty much everything else loses money for the hospital. And yet, my system will cause this avenue to decrease. Thus for hospitals to exists as an essential community service, there must be some way of funding hospitals to keep them open.

Here is my plan:
  1. The hospital has certain fixed infrastructure costs that have nothing to do with diagnosis: size of hospital and number of beds, environment issues (heating, air etc...), employee staff, laboratory and radiology infrastructure. I'm sure there are numbers out there that estimate what these costs are on a bed basis. Hospitals could then be given a lump sum to cover these fixed costs, which I believe could be in part covered by disaster-preparedness funds, as hospitals are an integral part of disaster planning.
  2. The lump sum could be added to based on a number of desirable factors such as: lower hospital acquired infection rates, above average mortality rates, lower nurse-to-patient ratio, higher proportion of R.N.s, higher numbers of uninsured patients treated, and rural or inner city status. Fines could be relegated for excessive mortality rates, excessive contamination rates, and things like excessive bed sore rates.
  3. Further lump sums will be allocated for the Emergency Departments with bonuses for low nurse-to-patient ratio, and high tech (nurse assistant)-to-nurse ratio, Level 1 trauma designation, number of available specialists on call, in-house hospitalists to admit patients, and dedicated fast-tracks. Plus, funds will be given for designated Observation Units that are fully staffed since those units (for certain diseases) significantly decrease overall length of stay and save costs, while improving efficiency and care.
  4. Beyond the lump sum amount, hospitals will then be paid a daily "rental fee" for each patient on the basis of the acuity of the bed (i.e. ICU and OR beds cost more than floor beds). In essence, Medicare is paying for the bed being used, AND the beds not being used (as a service that those unused beds provide to the community).
  5. Boarding of patients in the ER will be disincentivized since the more patients "rent" an ER bed, the more money a hospital makes. Thus rewarding efficiency. Medicare won't pay for a floor bed if the patient is in the ER (currently patients in the ER after admission get paid as if they are in that hospital bed even though they aren't there).
  6. Testing will be paid for on an individual test basis based on a standard fee schedule determined based on the actual cost of providing the service plus a 15% margin of profit (the infrastructure costs of these tests were dealt with in the above lump sum payment).
  7. To prevent abuse, like the previous blog for physicians, diagnoses will be used as a tracking device and compared amongst hospitals around the country, and those hospitals exceeding 2 standard deviations will be forced to receive only the median "rental charge" and "testing charge." The government will evaluate community needs by population to determine the number of beds (i.e. supply) to limit or encourage hospital growth as needed.
  8. For-Profit hospitals will have to come up with value-added solutions to obtain more money from patients willing to pay extra for those services. Could this lead to for-profits eventually getting larger numbers of wealthier patients? Yes. But the payment structure will be such that hospitals will receive more money for better quality, less for poor quality and non-profits will still have high levels of quality.
  9. Does this mean that the government through medicare will be subsidizing the insurance companies, since other insurers will only have to pay for testing and rental fees? Yes. But I believe that hospitals perform a public service and thus should have public subsidies for their infrastructure. Plus, savings that hospitals pass along to insurance companies leads to lower cost in health insurance overall, which benefits everyone. There could be some kind of hospital infrastructure rental fee that insurance companies pay to Medicare in addition to the bed and testing fee, so that insurance companies partake in the infrastructure costs. Or a Medicare infrastructure tax could be levied on insurance company's profits. I see a few options here.
  10. Complications will be paid. Documented errors will be paid as well (so as not to discourage the reporting of errors). HOWEVER, as mentioned above, there will be consequences for hospitals giving lower quality care.
I have read suggestions to the effect that surgeons whose patients have complications should not have those complications paid for. The only result of such short-sighted recommendations are having surgeons refuse to perform surgery on anyone with health problems, who are overweight, smoke, or are "too old." Instead, surgeons' individual complication rates per procedure should be compared to the statistical expected bad outcomes.

If surgeons' complications fall outside of 2 standard deviations of what is expected, they will be notified that they have been "red-flagged." These physicians should be reported to the American College of Surgeons (ACS) for more specific case review. The board would be best prepared to analyze patterns and determine the best initial remediation, such as additional CMEs and targeted education. After all, the goal is improvement of patient care. If initial measures to improve complication rates do not succeed, then there may need to be a period of time away from their practice to receive residency-type supervised surgery training in order to maintain their license to practice.

In summary, when it comes to Medicare reform, it is clear that the current system of reimbursement rewards high cost care that is not necessarily high quality. To improve Medicare access, reimbursement must be altered to change the incentives. My plan does just that. It is my hope that not just my ideas but other ideas will be looked at in the search for improvement with the health care system. Also, I hope that those ideas that are dangerous and counterproductive will be abandoned.

Wednesday, June 17, 2009

Drowning in Paperwork

First what I mean by paperwork is documentation. This can be through an electronic record, dictation, or good old-fashioned tree pulp derived paper.

Think your doctor doesn't spend enough time with you? Think it is because they are greedy and trying to see too much in too short a time? How about this as a reason - It is because physicians are drowning in required paperwork and have to jump through pre-authorization hoops by insurers. As an ER doc, I thankfully don't have to do the latter, but I spend about 2 hours of my 12 hour shift dictating. Until my throat is sore - especially when you see 30 patients and have to dictate on all of them.

First, check out this article "Physicians Spend 3 Weeks per Year on Insurer Paperwork." What was even more shocking was that Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. There are 52 weeks in a year, and while I understand clerical staff doing administrative work, nurses spend HALF of their time doing non-nursing work. Wow.

And this costs 31 billion dollars each year. I'll say this again, non-medical-care administrative time costs 31 billion dollars a year. In health care insurance-speak, that means 8 million more people could have had good health insurance (at $5K/year).

If I did not have to dictate, I could see six more patients per shift, or spend more time with the ones I have. Conversely, I recognize the need for good documentation for the benefit of the patient; not to mention for medicolegal reasons.

I remember I did an administrative month in my medical training, where I sat in on a meeting where they were discussing "How to increase nurse satisfaction" as morale was low. They put boxes around the ER asking for suggestions. In the same breath they talked about how they needed something tracked and said the nurses should do it and would now make the nurses fill out ANOTHER form as part of the discharge process. I raised my hand and suggested that if they want to increase morale, tell the nurses they have to fill out one less form; not give them one more. Needless to say, nobody "got it" and continued with their plans.

Healthcare providers went into the profession (for the most part) to deliver healthcare. But increasingly, we do so much that has nothing to do with providing healthcare. Which is why many physicians are going to all-cash practices - without insurance plans (includes Medicare/Medicaid) hassles to deal with, they can spend more time with more patients at a lower cost to patients.

Some suggestions include single-payer systems, as one payer means less bureaucracies to maneuver through. Whatever the system, politicians need to acknowledge that if they want higher quality care, they need to pay physicians for providing care, and minimize administrative duties for them and their staff (less staff would cost less too).

Regarding documentation, computerization has offered a solution that has pros and cons. I have used a few history/physical and order entry systems and have found, for me - a computer literate 75wpm typer - it saves time and is more legible. Many systems are overly complex and take too long for simple documentation i.e. it should not take 10 minutes to document an ankle fracture. I like these systems where I take a laptop in the room and document while in the room, order tests in the room, and before I leave, the nurses/techs are already there initiating my orders. I have to document and order stuff, why not do it in front of the patient where they can get more face-time and it doesn't interfere with the flow of the physician-patient interaction?

However, there are a number of problems: 1) Laptops used everyday have degradation of battery life and don't last more than a few hours, to say nothing of a whole shift. 2) Physicians who are not as computer literate will find the process frustrating as it takes longer for them to document. 3) Templates do not have good medicolegal documentation and make a poor narrative. 4) Free-form typing takes a long time, even with macro use. 5) Actually uses more paper than a paper system. 6) Major issues when computers are "down."

We have a number of hurdles to getting higher quality, higher efficiency, lower cost health care. Administrative costs are one of them.

Monday, June 15, 2009

Aging in America

I'm linking to an article I wrote in www.epmonthly.com Actually it wasn't an article, they just asked for personal experiences to handling the growing elderly population, and I wrote a letter back. Apparently, in mostly unchanged text, it made a great article I am proud of.

http://www.epmonthly.com/index.php?option=com_content&task=view&id=504&Itemid=28

Saturday, June 13, 2009

Medicare Reform Part 3 - New Model For Reimbursement

I ended the last blog talking about how the regional differences in spending seem inexplicable as the more you spend, the lower the quality. Huh? It's true. This excellent article talks more about this: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=1

There's controversy as to how to turn the high-spending areas into low-spending areas. Everyone agrees the problem is with incentives. I'd like to take it a step further - there are no incentives towards cooperation. While there are excellent organizations like the Mayo clinic that work that way, as I said in my previous blog, it takes a long time and a lot of resources to set up one Mayo clinic (10 years to be fully functional and efficient).

The above article points out that many physicians in an effort to compete have become businessmen, and have learned what to do to maximize compensation. There is little if any cooperation between primary care and specialists; it is a disconnected system where physicians and administrators have no concept of their costs (relative to others) and their quality.

If you don't create a zillion mini-mayos, how to you realign the payment structure so that it naturally allows higher quality, more cooperative care?

Here's my plan:
  • Assume that Doctors in "high supply-high cost" areas have incentives that get them this way, i.e. cardiology clinic work is not valued monetarily in remimbursement as a cardiac catheterization and stenting.
  • Also, primary care visits in general, monetarily, are not valued as highly as procedural work - despite concrete proof that primary care coordination of care increases quality and lowers costs. For hospitals, ORs and Procedure centers are the only money-makers. Caring for patients in the Emergency Department and on the floors and ICUs are money-losers.
  • And you assume that: Physician's most valuable asset is their skill set and their time with which to use that. Currently physicians with 20 years experience are not valued more under Medicare than a new graduate.
  • Then also: Through the administrative hassels of Medicare (and other insurance), much time is wasted.
  • You can conclude: paying physicians for their time and complexity of patient care, plus their experience, and coordination of care, would align physicians with what they actually do, and at the same time reduce the need for supplementation with higher cost care of questionable benefit.
Thus, I have a new, simpler physician payment system that will drastically reduce administrative costs, and realign incentives that would pay physicians for their skills and time.
  1. There will be a base hourly rate that will be paid to all physicians for their time spent with the patient. Physicians with longer training, board certification, longer years of experience, proper CME [and conceivably incentives for EMR use] will receive a higher hourly rate from the base.
  2. Added to the base also will be for Docs that participate in a cooperative group (also called Accountable Care Organizations), that I liken to the spokes of a wheel, with primary care docs (PMD) in the center, and specialists they work with forming the spokes. Peer review time they spend working with each other to track and optimize quality will be paid.
  3. The hourly is then multiplied by a complexity factor that is determined by age of patient (very old and very young are higher complexity), and number of medical problems (including social issues like smoking, drug usage, and alcoholism which complicate medical diagnosis and treatment).
  • How will this work? A primary care doc treating a hypertensive patient who is 70, with 8 medical problems, will get a higher rate (and consequently require more time spent) than for a hypertensive patient who is 20 and no other medical problems. A surgeon's complex followup on a diabetic food that won't heal will get paid based on time, not based on whether they went to surgery. No longer will one diagnosis be valued higher than another.
  • It is assumed that a doctor can treat a diagnosis in their field. More complex diagnoses take more time to treat and thus will pay more. Diagnoses will only be used for statistical tracking. If a physician spends time on the phone dealing with their patient concerns (easily verifiable by answering service and phone records), they should be paid for that service. Because studies show that time spent with the patient equals better patient care, and cheaper patient care.
  • I know what you are thinking. Doctors are going to be like lawyers and start billing 25 hours in a day. Or will say they are spending all this extra time with their patients to get more hours. I've got a simple solution for that: To prevent physician abuse, each patient submitted for payment will have a complexity code that is determined not by the physician but by a simple billing computer algorithm based on age and medical problems. An average time spent per diagnosis and complexity level will be computed on a national basis. Any physician with more than 20% of their charts 2 standard deviations above the mean will have a one year probationary period where they will only be paid for the mean time for a given diagnosis complexity. If they can bring their average back, they can receive normal billing. If not, they will have a 3 year period where they will only be able to bill for the mean time spent per complexity level.
  • In a special situation, hospitalists, and emergency physicians, will be paid an additional complexity assessment for numbers of patients seen in a shift that exceeds the "maximum" recommended number of their respective boards (in EM that is 2.5/hour) since those specialties can not control the flow of patients that come to them. Those specialties, primary care specialties, as well as on-call physicians who are called or called in, will get a complexity boost for patients seen on weekends, holidays, and between the hours of 5pm and 8am.
Why have I created this reimbursement system? For one, it is simpler - one that a computer algorithm could do the necessary calculations. Plus, it allows physicians to take more time with complex patients with chronic problems, which saves costs and improves care.
  • There will be no need to have "medicare police" to incarcerate physicians for Medicare fraud. Especially since physicians are not the drivers of fraud (from OIG Testimony on Medicare Fraud - July 25, 2000, which said of all the examples of types of fraudulent and abusive activities mentioned in the report, NONE of them were individual physicians.) Typically, they are fraudulent companies finding creative ways to game the system. Largest example of fraud: Rick Scott's Columbia/HCA paid a fine of 1.7 Billion dollars
This blog is longer than I thought, so I will end it here and address the hospital payment system changes in my next (and I think last) blog on Medicare Reform.

Thursday, June 11, 2009

Medicare Reform Part 2 - The Cost Issue

There are a number of problems with Medicare, and some things that work well. I'll start with the good:
  1. Guaranteed coverage for anyone over 65.
  2. Low administrative costs [Note: according to CAHI_Medicare_Admin_Final _Publication.pdf, the study shows there are hidden costs that nobody quotes, so the often mentioned 2% number is actually 5.2%, and the private sector while still higher, does not have the 20% administrative cost number; it is much lower, at 8.9%.]
  3. People are generally happy with their coverage.
  4. It's existence allows the private insurers a viable market: It does this by getting over-65-year-olds coverage and removes them from the general risk pool. This allows private insurers to make billions of dollars. However, if the high-cost "elderly" population (sorry Dad!) were included, private insurers would be less likely to enter the health insurance sales market at all, and then there would be no market, no competition, and the only choice would be single payer. Separating the two systems allows non-medicare patients lower rates than would occur otherwise. [Note: Medicaid is also a government supported health insurance, though mostly designed for the poor, and I believe this should not be separate. I think Medicaid should be dissolved into the general risk pool with the government subsidizing the premiums...but that is a topic for another blog...]
Problems with Medicare:
  1. Costs a lot, and is going to run out of money.
  2. Subject to the whims of legislation.
  3. Does not pay sufficiently, the costs of providing care for patients - thus causing more providers to refuse to see Medicare patients. And yet, Medicare overpays for prescription drugs, medical technology, and many procedures (they underpay some procedures too, i.e. appendicitis).
  4. Creates too much paperwork, has too many requirements, and high administrative costs for providers (many physicians are starting to practice a no-insurance, cash-only business model, that has less overhead, allows lower charges, and more time with patients to avoid these issues).
  5. Has a bizarre and complex reimbursement system.
  6. Criminalizes providers for making billing errors, even when errors of underbilling in many cases counteract overbilling, and that providers are not responsible for the bulk of Medicare fraud.

To address Medicare reform, you need to fix what is broken, which all begins with the most important item (Cost) that affects all the others:

1) High Costs: To some extent, high costs are inevitable with the elderly population. But there are ways to reduce these expenses.

A) Medical Ethics Reform: This is needed to properly address Medicare costs since the bulk of the expenses occur in the last 6 months of the patient's life. Clearly, we are not spending our dollars wisely. I can't tell you how many patients have been sent to me from a nursing home for "Emergency Care" on patients who will have no benefit in their quality (and quantity) of life. While I don't want the government deciding what is considered beneficial or not, I believe that if physicians (and nursing homes) were given strictly enforced protections from liability, they would do what is ethical and appropriate for a patient's condition. I personally don't think it is ethical to do "everything" for grandma because of family wishes, even though the living will she had put together specifically said not to do these painful procedures of questionable benefit. Without liability protections, I will continue to get 90-year-old contracted demented patients sent to me for a full stroke workup for a "change" in their behavior.

B) Medicare Experiments: There's good and bad. Home health, home peritoneal dialysis (instead of kidney dialysis), and coordinated care for chronic diseases are among a number of successful measures that dramatically decrease costs and improve health. However, the attempt to privatize Medicare has been an abject failure and the program needs to be shut down. In this case, costs went up, and quality and access went down.

C) Pharmaceutical coverage (Medicare Part D) needs to be revamped. In a perfect world (in my opinion), Medicare will now be able to negotiate prices. No reimportation will be done. Why? Some countries have lower prices for the same medicines than others, i.e. in Europe, the U.K. commonly imports medicines from lower-priced spain. Spain is simply better at leveraging it's population and negotiates better prices as a result. Medicare should be able to leverage at least as good a deal as Spain or Canada. Reimportation involves middle-men, and there is the potential for harm through similar appearing tainted medicines.

Next, all generics will be free to Medicare patients for certain categories such as: Antibiotics, Hypertension, Cholesterol, Congestive Heart Failure, Asthma and Diabetes for no extra fee. Non essential generics and non generics will be covered as part of the monthly fee Part D plan. Enrollees will no longer need to find a company to supply this (current complicated) service. Medicare will determine the montly cost of the program. The only restriction will be that medicines for which a competing generic exists will only be covered if the doctor certifies that the generic was at some point attempted and was unacceptable. The "doughnut" (or is that "donut") in coverage will be eliminated.

The reason for such easy access to medicines? Elderly patients who take their medicines will not be admitted to the hospital as often. That being said, many elderly patients are over-medicated as medicines are carried over year after year without evaluation of necessity. Under my plan, once a year, primary care physicians will re-evaluate the need for the patient's medicines (especially ones the patient has been on for years as prescribed by other the physicians preceding them).

D) Regional differences in treatment and spending: As I said in an earlier blog on SDM, there are variances in medicare spending with less spending correlating to higher quality. Most of that increased spending is due to physican preference in those areas for more invasive care, combined with increased supply and access to those more invasive treatments and specialists. Certainly SDM can help, but it only fixes a relatively small percentage of overall Medicare dollars spent unnecessarily (judged by no differences in quality improvement). It doesn't fix the supply issue (see a great paper by Dartmouth Atlas on Supply-Sensitive care).

I've seen much written about and talked about with regard to integrated care. Certainly, the Mayo clinic is an example of how this works and works well. However, to apply this and similar models would require all physicians becoming employees, and would require vast numbers of new organizational units be created - i.e. a mini bureaucracy (and we don't need more of that). Some have suggested an "illness fee" or "package price" that would cover all costs pertaining to that diagnosis, treatment and followup. Others suggest simply stop paying doctors and hospitals for high cost care that doesn't have higher benefit. But these solutions don't get at the problem - they are simply giving an aspirin for an aneurysm related headache (of course i would use a medical analogy...the aspirin may help the headache, but it won't fix the aneurysm and won't do anything to get at the core problem, and could result in a later catastrophic bursting of the aneurysm).

There is the supposition that the current fee-for-service situation is the problem. I don't completely disagree, but I don't agree with the above solutions either. I have created a whole new payment structure for physicians and hospitals to adjust payments to the desired effect - simplicity, decreased administration, improved quality, and lower costs. That will be covered in my next blog.

Tuesday, June 9, 2009

Medicare Reform Part 1 - Shared Decision Making

I've just gone through the myths of health care reform (so used to twitter I almost wrote #hcreform) and established that we need reform to increase choice, because right now we have socialized medicine.

There is a form of healthcare in this country that is single-payer, and it works (for the most part...). It is Medicare. And it is a behemoth; growing larger and more expensive by the day, yet unsustainable for physicians and hospitals to survive on the pittance of payments they receive relative to costs of treatment.

Clearly Medicare has problems and should not be the model of health care reform in this country. Certainly not in its current form. I have many suggestions on how to reform Medicare. Some are new ideas of my own. Some are ideas that are out there already.

First, I'd like to bring up a topic that is gaining a lot of traction, and something I only just learned about myself. It is called shared decision-making (SDM), and it is the new wave of health care cost reduction mechanisms that will soon impact how many physicians practice medicine. And it is not necessarily a bad thing.

First, I will go back one step:

Medicare, and by definition any Universal Health Care plan, suffers under the weight of cost pressures. We all know that Medicare is going to run out of money if something doesn't change. The same problems that plague Medicare will derail Universal Health Care. Unfortunately, the words "cost control" sound an awful like "rationing."

In my experience, controlling costs tends to mean restricting access to needed care, and cutting payments to providers of care (while increasing their paperwork, workload, and requirements). So I tend to be skeptical of a government push for cost controls.

However, there are some interesting patters that have been discovered that warrant discussion. Bear with me, I'll explain how the term "shared decision-making (SDM)" fits in shortly.

While Medicare has experience growth year after year above the national inflation rate, that is an average number, that according to the data compiled by the Dartmouth Atlas Project there is a wide variability of growth throughout the country, and in many cases neighboring cities and towns have dramatically different utilization rates (see map).

What the Dartmouth Atlas Project discovered (highlighted recently by testimony of Jonathan Skinner PhD to the Committee on Energy and Commerce, US House of Representatives, April 2, 2009), was that Medicare beneficiaries in higher spending regions are hospitalized more frequently for conditions that could be treated outside the hospital: i.e. for serious chronic illness, the frequency of physician visits is nearly twice as high in Miami as in San Francisco.

And yet, the Dartmouth brief, "Health Care Spending, Quality, and Outcomes: More isn't always better" demonstrates based on a number of studies over the past ten years, remarkably consistent results - higher spending does not lead to better quality of care, in fact, it is often worse.

There are certain conditions where the evidence is clear, and there is no dispute as to treatment, i.e. hip fractures in elderly patients need to be repaired. And Medicare spending on conditions like this are constant amongst all regions of the country.

There are also many conditions where the evidence is less clear, and there are many options as to how to treat, some more invasive, some more conservative. Individual doctor preference decides which option is pursued - hence the term given "Preference-Senstive Care." Examples of these types of conditions are chronic stable angina, hip osteoarthritis, claudication, carotid stenosis, herniated disc, and early stage prostate cancer. Thus, spending rates on these conditions varies tremendously.


The typical doctor-patient interaction is paternalistic, that is, the doctor makes the treatment decision and the patient usually goes along with that since "doctor knows best." But there is a growing movement to change this interaction to more of a collaboration where the doctor explains the diagnosis, the possible treatment choices, gives them materials that are from evidence based medicine (EBM) [note: we doctors love our acronyms...] to explain everything in terms they understand, and then ask the patient to make the treatment decision. The doctor can still give their opinion as to what they feel is the best course, but it is the patient who ultimately decides - i.e. medical management for herniated disc versus surgery.

Currently, if a surgeon wants to do a procedure on a patient, there is informed consent: The physician discusses the risks, alternatives and benefits of the procedure they feel you need. In other words, the treatment is already determined. In SDM (you knew I would finally get back to my topic, however circuitous the route), the physician gives out standardized materials that inform the patient on the current evidence of all treatments, then asks the patient their concerns and works with the patient to come to a treatment decision. The patient then signs a form accepting responsibility for any decision that was made, i.e. it is possible to have shorter survival from medical treatment for angina, and a patient picking that treatment choice would have to accept those risks.

As it turns out, when patients are given the decision-making ability, they typically choose the less invasive route. And this saves a lot of money to the health care system (Medicare in particular). Thus, there is a big push to roll out this new perspective on medicine, and Washington State is the first to enact this. While it would seem that only educated patients would benefit from SDM, a VA study showed that patients with less education were surprised to know that they had a choice in care. Patients are happy with this new model, which saves money, and protects the physician in the case of a bad outcome.

However, as someone who also writes on medical malpractice issues (www.epmonthly.com), I can immediately come up with a number of scenarios that could place a physician in legal jeopardy. I frequently encounter patients who are technically competent but experience poor judgment. If they are allowed to use their poor judgment to make a decision that leads to a bad outcome, could the physician be sued for "knowing" that a patient was making a bad choice? The law in Washington seems to be structured so that physicians are protected from bad patient choices. But a bill recently introduced by Congressman Earl Blumenaur (D-OR) H.R. 2580 "Empowering Medicare Patient Choices Act" does not seem to have any such legal protections. This bill establishes a pilot program that will take four years to fully assess whether this methodology would be a good choice for all of Medicare. Without significant medical malpractice reform, or protections from liability for patient decisions, I fear that physician acceptance will be low

But personally, I like a model that allows a team approach, educates patients better, and makes them feel empowered, and (if done as in Washington State) releases the liability for a decision from the physician and transfers it to the patient. Plus, it helps slow the growth of Medicare, and if applied to Universal Health Care Reform, could be an essential cost-control measure that is a win-win for everyone.

Next blog will talk about detailed Medicare Reform. See Part 2.


Sunday, June 7, 2009

Mental Health Break

Geno's World: Video: How to make homemade ice cream in a plastic bag. This has nothing to do with the topic, but I thought it interesting, and doable. Now back from your break, we have important work to do!

In the midst of my health care reform blog, I'm taking a mental health break to address the broken mental health system. In the 1981 Omnibus Budget Reconciliation Act (OBRA), federal funding for community mental health centers and other mental health and substance abuse services was eliminated. It was replaced by a block grant to the states that cut funding by 21% and made mental health facilities dependent on private funding to make ends meet. Thus the mental health safety net began to collapse. Looking at the STATISTICS, the number of psychiatric beds decreased by more than half, from 524,878 in 1970 to 211,199 in 2002, the corresponding bed rates per 100,000 civilian population dropped from 264 to 73, and beds in State mental hospitals (the ones that will treat you if you are uninsured) accounted for most of this precipitous drop, with their number representing only 27 percent of all psychiatric beds in 2002, compared with almost 80 percent in 1970.

And it is a huge problem. Nearly every day I have a patient declaring they are suicidal and need legally required treatment and evaluation by a psychiatrist. But they are waiting longer and longer to find a psychiatric bed at a psych hospital. It is not uncommon for patients to wait 16 hours in the emergency department, though the other day, I had a patient wait 41 hours. This sucks up a needed ER bed, nursing staff, doctor attention.

And when I brought this to the attention of the hospital administrator their response was, "Oh, we've had patients wait longer than that." I tried to impress him with the fact that more patients were LWBS (left without being seen) as a result of the longer wait times from the psych patients (there were 2 there that night, in an ER that has 9 beds) occupying 2 beds for a combined 56 hours. He was unmoved, though my exasperation did garner the response "I'll look into it."

The public funding cuts and closure of mental hospitals is compounded by a large uninsured population that is growing by the day. If you are insured and suicidal, you can find a bed. If you are uninsured, you wait, and wait, and wait. They are not the only ones who suffer. The patients not seen in the waiting room suffer as well. But the law says suicidal patients insured or not, must be seen by a psychiatrist before discharge from the ER. The law does not seem to account for the lack of mental health coverage though.

The laws either need to be changed, or else a complete reworking and expansion of our public mental health system needs to be accomplished as part of health care reform. That will probably mean going back to federal funding of mental health community centers as we did in the 1960s and 1970s. The block grant system isn't working. This is not a small problem. It is a big problem. One that has been ignored for far too long. Looks like we need to go back to the future to fix our problems.

Thursday, June 4, 2009

Dr. Brenner's Prescription for Change - Part 2

Before I get into the details of my health care plan, I'd like to resolve some myths about health care.

1. America has the best health care in the world so we shouldn't mess with it. FALSE. We rank far below the rest of the "developed" world in life expectancy and infant mortality. We spend more than any other country as a percentage of the GDP, but we have approximately 15% of the population (47 million) uninsured.

Those who have insurance increasingly find it doesn't protect them when they need it most. And those who have tons of money still discover that they can suffer from hospital diversion (no free beds in hospital so ambulances are "diverted" away), nurse shortages, defensive medicine and lack of on-call specialists. Not everyone is affected in the same way, but everyone IS affected and has a stake in making the system work better.

To be fair, I think the medical training and the medical technology innovations in America ARE the best in the world. But those successes shouldn't delude us into thinking that just because we are the destination place to train physicians, that our health care system is the best.

2. If we reform health care we will be left with socialized medicine. FALSE. If you say a lie often enough people start to believe it as truth. Nevertheless, it is still a lie.

First of all, we don't have free markets right now. Why? Because we subsidize insurance companies (and their shareholders) with tax-payers money.

a) Medicare, in particular, covers the "undesirables" that private insurers don't want. These people use a lot of resources and cost lots of money. By not having them in the risk pool, private insurers earn billions of our tax dollars through cost savings. If it were truly a free-market, ALL americans would be in the private insurer risk pool.

b) Employer paid insurance is not subject to taxation. The lowered tax burden is less money into the government coffers and thus indirectly subsidizes the purchase of health insurance offered by (mostly) for profit health insurance companies.

c) Employer-controlled health insurance is not a free-market. People can't decide exactly what kind of health plan they want. They have to pick amongst a limited number of choices. What kind of system tells you that you have a choice, but you MUST choose from this very limited menu? This happens under a dictatorship, communism and socialism.

Yes, you heard me right. I am comparing our CURRENT SYSTEM to the dreaded communists and socialists. So anyone who tries to say they don't want socialized medicine MUST reform the current system. What we have now IS socialized medicine, where the only beneficiaries are the shareholders of the very profitable insurance companies.

My next health care reform blog will go into more details about what works, what kinda works and what is failing.

Tuesday, June 2, 2009

Dr. Brenner's Prescription for Change - Part 1 of a zillion

So this is it. This is the main reason a I wrote this blog. This is the concise version of the book I wrote but never got published. You get it all, dished out in pieces that hopefully gel into an understandable view of a logical approach to healthcare reform.

For the record, I came up with these ideas years ago, with some slight updates based on present-day plans. Any resemblence to a current plan is completely coincidental and at the same time completely deliberate.

Why am I putting this out there? Well, there is a healthcare reform debate beginning to rage, and I see some good ideas, some bad ideas, some really really bad ideas, and some ideas that haven't even been addressed. Hopefully I can stimulate a debate. Or at least help people think about things in a way they hadn't before.

I've been told that one of my talents is being able to distill complicated topics into an easy to understand format. Perhaps that is because I spend a lot of time breaking things down into easy to understand pieces that I myself can digest. Once I've "gotten it" I can pass along the cliff notes version.

Realize, though my blogs may extend for a long period of time, what I am giving
is the cliff notes version. Most health care plans are 1000 pages or more. I think the clinton plan was four feet high.

So here goes, the beginning of my prescription to fix healthcare:


When creating any major policy change you have to ask three questions:

1) What do we have?
2) What do we want?
3) How can we make that happen without making things worse (through unintended consequences)?


The answers:

1) We have a health care system that is neither about health nor care. A system that fails to serve the needs of most Americans, yet has costs spiraling out of control.


2) I want a system that gives affordable high quality compassionate care that makes people healthier and more secure.

3) How can this happen? Use what already works, and specifically target the failures. See next Blog for further elucidation of how to accomplish this...

Monday, June 1, 2009

What is "Value-based" health insurance coverage?

I read this the other day:

Sen. Hutchinson touts value-based healthcare insurance coverage. In an op-ed in the Houston Chronicle (5/28), Sen. Kay Bailey Hutchinson (R-TX) wrote that rising healthcare costs "threaten the competitiveness of businesses in Texas and across the country and place an added burden on families who are struggling to make ends meet. Furthermore, our state and the federal government cannot indefinitely sustain the soaring cost of entitlement programs, like Medicare and Medicaid, which have helped ensure low-income and elderly Americans receive care...One of the most promising new concepts in health care delivery is Value Based Insurance Design, which offers the potential to simultaneously improve health care quality while reducing costs." This concept "embraces the simple yet transformative idea that cost barriers should be removed for 'high-value' prescriptions and treatments. A medicine or procedure is deemed high-value when evidence shows that we can maximize the health benefits to patients compared to dollars spent."



Why is this "transformative?" I've always wondered why treatments weren't covered for necessary medicines etc...that would keep people healthy and out of the hospital (which costs a lot more). Hepatitis vaccine isn't covered, but hepatitis treatment is. Stuff like that. So "value-based" healthcare basically says that a medicine or procedure has a huge benefit relative to dollars spent.


While I agree this should be done, I ask, why is this idea transformative? It is simple common sense. I guess not so common in the political arena.


Of course, I have noted potential for problems in the wording. What do they mean by "maximize?" I would use the definition: The value of a procedure or medicine is maximal if were that done, a higher cost medicine or procedure or admission to hospital will no longer be required.


Of course, that is what I would do. I would not put it past congress to do something completely different and render this good idea useless.

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