Maybe Doctors Can Learn From Lawyers

On May 2, an article was published in the New York Times, titled “Top Judge Makes Free Legal Work Mandatory for Joining State Bar”.  The article describes how more and more people need urgent legal services but cannot afford them.  It goes on to describe the pros and cons of requiring lawyers to provide some free services (pro bono) as a condition for joining the New York State Bar.

We have a similar problem in health care- a large number of people who cannot afford health care services.  And I am not talking about insurance.  I am talking about the doctor and hospital visit.

In health care, we have doctors refusing to see patients because Medicare or Medicaid do not pay enough.  And these patients have nowhere else to turn.  The doctors use the threat of refusal as a key part of their strategy when negotiating for higher reimbursement.

How can we allow this?

In a previous post on this blog, I have proposed that doctors be required to accept Medicare as a condition for receiving or renewing their DEA license (federal level- the DEA license is what allows them to prescribe), and to accept Medicaid as a condition for receiving or renewing their Medical license (State level).

We place physicians on a professional and social pedestal, and their incomes are higher than that of any other profession.  In return, we should require something of them- not grant the right to walk away from persons in need.  Doctors, take a lesson from the lawyers, or lose your protected, lucrative turf!

 

We (the consumer) are about to get trashed!

I saw three articles that disturbed me last week.  Taken together, they are no less than frightening.  All were printed in the New York Times.

First came an article titled “Insurers alter cost formula- patients pay” (New York Times, April 24).  The main point is that insurers have changed the way in which they reimburse doctors and hospitals.  The reimbursement has gone down, so the patient’s portion has gone up.

The second article, also printed in the New York Times on April 24, is called “Pricing confusion adds to pain at hospitals”.  The main point here is that hospital bills appear to have no rhyme or reason, with the price for the same procedure in the same geographic area varying wildly, sometimes by a factor of ten or more.

Finally, in the New York Times on April 25, “Debt collectors pursue patients in hospitals” describes how employees of a collection firm, “Accretive Health” are actually allowed front line positions in their client hospitals where they can, and do, get right in patient’s faces demanding payment for expected or past services, sometimes before emergency services are provided.

Now put all of this together-

  1. We don’t know what something will cost and may be off by a factor of 10
  2. Whatever it does cost falls more and more on our shoulders to pay
  3. We will subjected to very extreme collection practices, including denial of services, until we pay what we owe.

Now compare this to the experience of citizens of every other advanced country in the world- costs are simply not allowed to come between a person and their need for health care.

We, the consumer, are about to get trashed, and it is time to do something about it! (Stay tuned for future posts).

Should we keep the health reform law? #healthreform #obamacare #supremecourt

Shortly, the Supreme Court will begin deliberating the fate of the health care reform law (Obamacare).   One of the key provisions of the law concerns the individual mandate– the requirement that everyone purchase insurance or face penalties.

I have commented on this particular issue in a previous post.

In addition the the very constitutionality of the law, the Supreme Court will also decide whether the rest of the law will stand if the individual mandate is overturned.  This principle is called “severability”.

So we might wind up with an all or none decision- if the individual mandate goes, so does the requirement that insurers cover those with pre-existing conditions.  So does the prohibition against setting the price of an insurance policy based in part on gender.

So here is my question:  on an all-or-none basis, should we keep the health reform law or repeal it?  What do you think?

On an all-or-nothing basis, how do you feel about the health reform law?

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The Trend Towards Adult Day Care

A recent article in the New York Times describes a trend where elderly patients can be treated through a home based managed care model, rather than in a nursing home.  This model is generally referred to as “adult day care”.

It’s about time!  Why should patients be required to spend their entire existence in a nursing home, at much higher cost, when they can live in their own homes and receive visits from medical professionals and other caregivers?  Moreover, it has long been known that people much prefer to be cared for in their own homes, including during their final days- yes, people prefer to die at home than in an impersonal institution.

The luxury of being treated (and dying) at home has long been reserved for the well-off, who can afford private nurses and all of the related home-based equipment.  The thinking has long been that if the government is paying (Medicaid), then you need to be in an institution.

Too bad that it has taken a financial crisis- state budgets under pressure, led by Medicaid costs- to get state programs to relent and allow people to be cared for in an environment that is less expensive, more comfortable and inherently safer- the home.

A Brief Comment on the Ryan Medicare Plan

Medicare is too expensive and becoming more unsustainable every day.  Congress has also demonstrated that they will bow to special interests before implementing what they have already passed- the so-called “doc fix”, whereby reimbursement cuts to physicians that are already mandated by law are deferred, year after year.

One approach is the Ryan plan, named after Representative Paul Ryan of Wisconsin.  Without delving into the details of the plan, which are debated hotly by very partisan commentators, one great flaw in the plan appears to have escaped comment:

That is, the notion that physicians will compete for patients, thereby reducing costs.

This assumption is deeply flawed for one simple reason- there is a well documented shortage of physicians.  Economics 101, and the basic law of supply and demand, teaches us that if the supply is low, the price is correspondingly high.

Physicians will never have to compete aggressively for patients (the Ryan Plan assumes that they will) as long as there is a shortage of physicians.  Rather, patients will have to chase physicians and endure long wait times to get an appointment.  Physicians will continue to raise fees, not lower them, and they will threaten to stop seeing patients whenever their fees are reduced- hence the “doc fix”, which happens year after year.

If Medicare is changed to a voucher system, as Rep. Ryan proposes, seniors will be at the mercy of physicians, who are in short supply, and who will retain any negotiating leverage as long as there is a shortage of physicians.

Until we are able to address the shortage of physicians (train more and/or allow the greater use of nurse practitioners, midwives, pharmacists and other “physician extenders”), it is wrong to place seniors in this ruinous position.

Health Care Reform and the Mandatory Purchasing of Insurance

Is it right to require people to purchase health insurance?  I have mixed feelings on the subject.

First, I understand the concept of insurance and of “pooled risk”- the notion that the premiums of those whose homes do not burn will be used to pay for damages to the homes that do burn.  And I understand the need for everyone to participate in order for this system to work at its best.

The part where I struggle is when we are delivered to a voracious, for-profit industry like so many lambs to slaughter.  There should be, at the least, a “reasonably priced”, non-profit option (we can discuss what a reasonable price is separately).

When I discuss this with my friends, they invariably point out that auto insurance is mandatory.  To which I reply, “If one does not wish to pay for auto insurance, there is an alternative- it is called Public Transportation.

What alternative exists in the health insurance discussion?  If we choose to not purchase an overpriced product from a for-profit health system, what alternative do we have?  What happened to the “public option”?

So here is where I end up: if a reasonably priced, non-profit alternative exists, I support mandatory coverage.  But if the only option is to pay into an overpriced, for-profit system, then I do not support mandatory coverage.  What do you think?

What are your feelings about mandatory health insurance coverage?

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What happens when the pie is shrinking?

Throughout my entire life, the economic pie in the US has been growing. This has made possible civil rights, women’s rights and a number of safety net programs. Now, we are entering a time when the pie is shrinking, or at least perceived to be shrinking.

When this happens, people are unwilling to share. What used to be “I am doing well, so you can have a little” has become “What I gave you before, well I need that back”.

This is what is driving our nasty and unproductive politics. The question is, “What do we do about it”?

Game theorists look at this as a form of dividing the pain. And there is no universally agreed on definition of fairness, especially when dividing pain.

Where we need to start though, is understanding the situation we are in, and where this tends to lead us if we are unaware- that is, towards selfishness, unreasonableness and conflict.

The pie is perceived to be shrinking. Let’s understand this and manage through it in a way we will look back on and feel proud.

Does this make sense?

Have you ever considered-

Someone is hungry, so they stand outside a restaurant asking for food. Eventually the owners may call the police. Someone is homeless, so they stand outside a hotel or motel asking for a room. Again, the owners may eventually call the police.

Because this person is homeless and hungry, eventually they collapse from exposure and/ or hunger. Now, we have a very expensive hospital bed and a very expensive hospital meal just for them.

Something to think about…

The 7 Stages of Managing Our Health Information

Why did Google pull the plug on Google Health?  Why is consumer adoption generally low across the entire landscape? In my opinion, the consumer has still not embraced the change required for this to happen.  It will happen.  We’re just not there yet.  To explain this, I offer “The 7 Stages of Managing Our Health Information” (adapted from Elisabeth Kubler-Ross’ “The 7 Stages of Grief”).

Stage 1:  “Wait a minute, I have to pay for that now?”

Stage 2: “I can’t afford all of this! I don’t know what to do! I should have lost weight, quit smoking, taken better care of myself!”

Stage 3: “This is outrageous! Can’t we go back to the old way? It’s the government’s fault!  It’s the insurer’s fault!”

Stage 4: “Oh my God, I am so screwed!  Who is going to help me?”

Stage 5: “Maybe I need to do something about this.”

Stage 6: “I seem to remember something about Online Tools and Resources.”

Stage 7: “OK, I’m signed up now.  Let’s do this!”

Note: Progress through this framework is not smoothly linear.  Some jumping back and forth occurs.

In my opinion, consumers are generally in stages 1 through 3.  The light bulb will go on, and business models will become viable, when a large number of consumers get to stage 5.  As I stated, we as a country are not there yet.  But with the coming changes to Medicare and Medicaid, and the ongoing increases in deductibles, copayments and coinsurance, we soon will be.  Stay tuned.

For two very thoughtful, insightful discussions on why Google pulled the plug, see Missy Krasner’s post at “The Health Care Blog”, and Janice McCallum’s post at “Health Content Advisors”.

Finally, I am interested in what you think about consumer readiness.  Please take the following brief poll, using the “7 stages” framework above.  Select up to 3 answers.

In general, at which stage are most consumers when managing their health information? Select up to 3 answers.

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Would you sacrifice choice this time around?

In the ’80’s and 90’s, when HMOs first became widespread, we all experienced lower costs but less choice- we had to choose from a list of doctors and hospitals, i.e. “in-network providers”.  But costs did stop rising, and in some cases actually fell.

Then came the managed care backlash and insurers allowed a much broader choice of doctors and hospitals.

Health care costs have nearly tripled since 1990 and now, the federal budget and nearly every state budget is threatened by extremely high health care costs.  Of the many methods being used to try to contain costs, limiting consumer choice of providers is once again a common approach.

The way this works in practice is that health plans offer one set of prices for using “in-network providers”.  If we use “out-of-network” providers, the amount we have to pay out of our own pockets is higher.  Sometimes much higher.

Here is the question: How do you feel about having a limited choice of doctors and hospitals in return for lower costs?

Is limiting our choice of doctors and hospitals fair, if costs are significantly lower?

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Should wealthier people receive more and/ or better health care?

As health care costs threaten more and more of our economy, various methods of addressing the challenge have been proposed, the Ryan plan for Medicare being one of the best known.  In this plan, the Medicare system is revised to provide seniors with a fixed voucher to cover insurance premiums purchased through the private sector.  When the voucher is used up, patients will have to pay out of personal funds.

Clearly, the well-off will be able to afford more care after the voucher is gone.  Is this right?

This blogger believes that the quality of some things should vary with wealth:

  • the well-off should drive nicer cars
  • the well-off should wear nicer clothes
  • the well-off should eat at fancier restaurants

But some things should not vary with wealth:

  • fire protection
  • water quality
  • food safety

So here is the question- should the amount and quality of health care a person receives vary with wealth?  What do you think?

Should financially well-off people receive more and/ or better health care than those who are not well-off?

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Fourteen Zeroes!

Part 1- the problem.

If you look at our present level of health care spending ($2.6 Trillion), and project it forward, growing at 6% annually for the next 20 years, the total exceeds $100 Trillion.

That’s 14 Zeroes:

  • Just for health care
  • Just in America
  • Just for the next 20 years (if we look at 30 years, the number is over $200 Trillion).

That number is incomprehensible.  Not only is it not sustainable, it is not even possible to finance this number.  Yet, that is the path that we are on.

The present discussion aims to “bend the cost curve” and to somehow shift the burden:

  • Blame the insurers
  • Blame the pharmaceutical companies
  • Reduce provider reimbursement
  • Limit what Medicare pays on behalf of seniors.

Whomever we choose to blame, we are clearly headed for a scenario where we all  work our entire lives just to pay for health care, and when we get old, all of our assets, if there are any left, get paid over to our huge, for-profit health system.

We must fundamentally restructure our health care system, and our expectations of living and of dying, or life will become one long health-care payment treadmill.

Part 2- the discussion.  Please answer the following questions. One answer per question:

What is the responsibility of consumers (the system calls us "patients")?

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What is the responsibility of insurers?

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What is the responsibility of the government?

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What is the responsibility of providers (doctors and hospitals)?

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What is the responsibility of suppliers (pharmaceutical companies and device manufacturers)?

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Now, please consider all of the answers you provided.

What do your answers, taken together, mean for the 14 zeroes in our future?  Something to think about…

Should physicians have the right to refuse Medicare and Medicaid patients because they are not paid as much as they feel they should be? What options does society have?

This is a tough one…

On the one hand, physicians have to run their practices, which costs money.  They want to live well, as we all do, and that costs money.

On the other hand, they provide a vital service which not just anyone is allowed to provide- so in a way, they are on “protected turf”- protected through licensing and long years of training.

But when physicians refuse to see Medicare or Medicaid patients, those patients have nowhere else to turn.  In fact, the threat of physicians refusing Medicare is often used as a reason not to cut Medicare rates.

This sets up a sort of “health care hostage situation”, where we, as a society, can no longer afford the costs of care, but seem to be powerless to do much about it.

So here is the question.  Actually 2 this time.  What do you think?

In return for the right to practice medicine, should physicians be required to accept at least some Medicare and Medicaid patients?

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As a society, what should we do when physicians refuse to see Medicare and Medicaid patients because the pay isn't high enough, and we have nowhere else to turn? Select up to 3 answers.

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Who owns patient data?

When we visit a doctor, hospital or pharmacy, lots of data is generated:

  • X-rays
  • Lab tests
  • Prescription information
  • Physician notes

That information is exchanged among physicians, hospitals, pharmacists and insurers, all to assist in the care of the patient and to support the billing and payment system.

Yet, there is potential to mis-use this information:

  • Data mining to target potential customers
  • Data used for coverage decisions
  • Data used for research purposes

And further, when a patient moves or simply wants to maintain their own files or health record, they frequently encounter resistance from the doctor or hospital when requesting copies of their record or tests:

  • fees
  • outright refusal
  • “The HIPAA law won’t let me give it to you”

So who owns patient data?

What do you think?

Who owns the data that is generated when an individual visits the doctor, hospital or pharmacy. Check all that apply.

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Take Charge of Your Own Health Care!

It is becoming more and more important for each of us to take charge of our own health care and not depend on the “system” to do everything for us.  The costs of care are slowly being shifted towards the individual.  Consider:

Trends in private insurance:

  • increased premiums, copayments, coinsurance and deductibles
  • insurers can no longer deny coverage for pre-existing conditions (a good thing), but this coverage is becoming much more expensive

Trends in Medicare:

  • increasing age of eligibility (proposed)
  • increasing premiums for part B coverage
  • increasing annual deductibles and copayments
  • limitations on government responsibility (proposed voucher system)

Trends in Medicaid:

  • reduced eligibility
  • increased copayments
  • fewer physicians will accept it
  • shifting patients into managed care programs

What all of this means is:

  • health care will become more expensive for the individual
  • access to the system will become more difficult

To protect ourselves, our health and our finances, we must each become more self sufficient and take charge of our own health.

Here are some things that we, as individuals can do:

  • Adopt healthier habits (diet, exercise, stress avoidance or stress management)
  • Do your own research and have your own opinions about what is best for you
  • Request (and receive) copies of your test results and exams
  • Use a Personal Health Record (PHR), and keep copies of your test results in this PHR
  • Ask your doctor educated questions about your plan of care.  If you don’t understand something, discuss it
  • Ask about the safety of drugs and medical devices
  • Join disease or care-focused groups.  Network, and ask people with similar conditions about what has worked for them.
  • Research the cost and reputation of the doctors and hospitals who will be treating you

Most important, stand up for yourself.  After all, it is your health, your life, and increasingly, your money.