Marcy's Soap Box

Rationing Care

2009-05-11T10:05:00.000-07:00

It’s all about your money… or is it?

There are many reasons healthcare is as expensive as it is, including the advance of science and technology. But the absence of a competitive marketplace, overwhelming government regulations, and uncompensated mandates are also central to the problem.

Prior to government’s intrusion into the “sickness” market back in 1965 with the Medicare and Medicaid programs, patients could exchange a chicken for a tetanus shot. Patients knew their family physician as a friend. They did not find themselves waiting for hours in waiting rooms and they did not receive a surprise bill from the hospital when their insurance didn’t pay. Most often, they paid for their care at the door and it was affordable.

That said, a homeless person, injured on the street, would likely be able to walk out of the hospital after receiving emergent treatment after suffering an epidural hematoma (bleeding in the head). But, all the money in the world could not have saved Nastasha Richardson because she was unlucky enough to have hit her head in Canada, a government run and government rationed healthcare system where patients may not pay for their care.

In contrast, Americans decided that in the event of catastrophe, everyone will get care and every emergency room will be equipped to take care of a “real” emergency. It is a public commitment and we pay taxes to support that effort.

As we watch our government take over our lives and our health without debate or deliberation, we can only hope that Congress might start to take their “let’s deal with reality” medications and settle down to consider the precarious future they are navigating for America’s citizens.

Bear in mind that rationing in the case of Canada is not just about waiting in line to have your blood drawn or suffering an extra 3 years with back pain before your surgery is scheduled. Government run systems do make sure that treatment is NOT just about the money (our money). All the money in the world could not have saved Ms. Richardson. The government had already decided that helicopter transportation was NOT “appropriate or necessary” to move patients to medical centers where their lives would be saved.

In England, NICE, a group of so called experts, not unlike our new CER (Comparative Effectiveness Research) Committee, decided recently that a drug would NOT be made available for the treatment of some kinds of breast cancer. There is some good news in the case of British women who are diagnosed with breast cancer. They can still come to the United States and pay for treatment because we have not (yet) allowed our government to take over and destroy our most valuable possession, our RIGHT to make choices about our life and wellbeing and to pay for those choices personally.

Patients from all over the world who want to make a personal choice about their health care can still go outside their own government provided programs and insurance directed health care systems and purchase what they need in the marketplace, particularly if they are buying elective and routine services. On the other hand, American seniors who receive their care thru Medicare cannot purchase care from a Medicare provider (hospital or doctor) if the service is a “covered service.”

You can buy a mammogram for $75.00 and yearly lab work is less than $50. If a patient were to use their insurance to pay the claims, the mammogram would have been well over $200 and the lab over $200 and the claims would have paid as part of the deductible. Medicare pays the hospital (for the x-ray and the reading) $131.50 on average. Buying healthcare is not as much fun as shoe shopping but I would argue both are a necessity for our better health. As long as you are a non-Medicare senior, health care is affordable and negotiable.

If Americans would follow the trail of dollars spent in healthcare, they would soon
realize it is government mandates, regulations, and price setting that have accelerated the
rise in costs in health care, the same government who wants to tax and spend its way into our hearts and medicine bottles. The Massachusetts experience reinforces the fact that government intrusions only increase the cost of care. But, America’s free market, available to the world, remains the best opportunity to invest in our health. It isn’t about the money; it’s about our freedom to make life choices. It’s about life and death, America’s life and death and the preservation of our basic liberties.

Ordinary People

2009-04-07T15:28:00.001-07:00

I’m sorry for Mr. Daschle. After lobbying the entire country, giving speeches to the tune of over 5 million dollars over several years, and writing a book, Mr. Daschle, his Senate partners and the president thought that he would be “the person” to redirect the delivery of American health care. But, President Obama reconsidered his nomination when it was clear that Mr. Daschle had stepped outside the “acceptable” and the Senator withdrew his nomination.

I understand that our elected officials really believe that they are “prominent.” Whether its paying taxes or how they drive or fly to work, they don’t do it like we do. The President said it all when he referred to you and to me as “ordinary.”

I am an “ordinary” doctor and I take care of what President Obama describes as “ordinary” patients. That said, there is not a day when government regulations and mandates get in the way of my opportunity to give my patients a better day. Every day, I spend hours filling out forms so that the government directed Medicare Part D pharmacy plan might approve the medication that my patient has taken for the last 10 years. A person (I’m sure ordinary) who has never met my patient and has no specific education will decide if we might continue my patient’s life saving medication. This is the plan that Congress has written for us ordinary people.

Every day, my patients share their most innermost secrets and I deliberate a life strategy with them. It’s a great job, a privileged profession. And it works wonderfully when the government doesn’t think that they know better.

The recently published survey by the Physicians’ Foundation demonstrated that the ordinary doctor has just about had enough. 150,000 physicians are predicted to be leaving the clinical practice of medicine within the next 3 years mostly because of regulatory restrictions and obstructions to care. In the meantime, our elected officials have voted to expand the SCHIP program by millions of patients. The SCHIP program is heavily regulated and not many physicians accept SCHIP and Medical insurance. Who will take care of these ordinary people?

Personally, I am NOT comforted by the idea that Barney Frank or Harry Reid will be voting on the appropriate treatment for colon cancer. Nor, do I believe Congress has any business in the personal lives of ordinary people.

As part of the stimulus package, Congress wants to spend taxpayer dollars to assist physicians in their purchase of office based EMR (electronic medical records) systems even though it has been clearly demonstrated that the systems currently available decrease productivity and may actually increase medical errors. In exchange for government assistance, we would be required to give the government patient data. No thank you … I took an oath. Congress and CMS (Medicare) continue to push P4P (Pay for Performance) systems when government studies show that these programs don’t increase quality and decrease cost. Cynically, I wonder if this is part of a stimulus package to push paper.

What we do know is that individualized, personalized care based on the patient-doctor relationship reduces cost, decreases hospitalizations in number and length of stay, increases the quality of care, and increases patient productivity.

Just today, I had the most inspiring experience. An 86 year-old teacher who has been my patient for over two decades completed CT scans of his lung, abdomen, and pelvis to evaluate his cancer. 14 months ago, this otherwise very healthy teacher and sailor had faith in our relationship and agreed to have his hepatoma (liver cancer) surgically removed, not the usual treatment for a man his age. A year later, when he developed metastasis, we asked him to consider chemotherapy. Together and with his oncologist, we strategized his chemotherapy and his general care, again a protocol that was not written anywhere. We believed he could decrease his lung lesions and improve his air hunger. Today, his scans show that he is clear of cancer. I cried.

I’m sorry Mr. Daschle. I’m sorry for all those who will follow you. You can write books about government run health care systems and the government can continue to create any number of regulations hoping to control our patients’ private lives. But you will never feel the ecstasy that I feel right now. Ordinary patients who have indefatigable trust in their ordinary doctors will always have faith in the miracles we make happen every day.

a medical home

2009-04-07T15:23:00.001-07:00

THE MEDICAL HOME- a perspective

I remember growing up in a small community in Ohio and feeling comforted by the fact that my mom was always home to greet me after school or to pick me up to take me to my special activity. Dad was consistently home for dinner. Life was routine. I felt secure and comfortable. That’s probably what most of us feel when we think of home: a place where we are comforted, where there is some sort of stability. That place where we can close our eyes and know where the refrigerator is. Home is the place where we know we belong.

When I became a doctor, I tried to give my patients that same feeling about my office. I understood that healthcare was about relationships, communication, and cooperation: the patient/doctor relationship, doctor/doctor communications, and doctor/nurse cooperation.

I chose not to employ a nurse practitioner because I want my patients to always know that I am there for them. I chose to make most of my own calls to colleagues because I feel that is the best means of communication. Patients who choose me as their doctor know how our office works because we are purposely transparent; no need to lock up the food in this office. We invite all our patients to come in sit down and get to know us.

Over four years ago, I divorced myself from the “care follows financing” healthcare delivery system that has overcome our industry. I started to work directly for my patients as a concierge physician in order to “practice my profession.” I retrofitted a better medical home. Since that time, my patients and I live in a comfort zone; knowing that 24/7, there is someone to answer the phone and it’s usually me.

You can imagine the sick feeling that overwhelmed me when I was asked by experts leading the government’s conversation in health care reform, “who was on my team?” Team? Had my cozy medical home suddenly become an orphanage of residents in need of a team (presumably of social workers and case managers)?

Those of us engaged in the practice of “direct care” have built a business around a medical home that belongs to our patients. Our model is built to provide care in a comfortable and consistent setting. It is not just the pictures on the walls that make our (medical) homes peaceful and personal. It’s the welcoming gestures and the mutual respect that comes with taking the time to really listen to our patients and to coordinate a strategy that offers them that better day.

It’s helpful that the reception area is not overflowing with waiting patients exchanging detached glances but rather there is great coffee, cheese and crackers, and plenty of great big comfy chairs that are not chained to the wall. No patient appreciates or deserves a cold chair, a chilling stare, or that awful closed glass window when they are anticipating bad news. Visions of the movie “Home Alone” do not conjure up an image of paper gowns or cold empty rooms. That’s why we use thick jersey spa gowns when we ask our patients to change into their exam attire.

And just like families, medical homes come in all sizes and shapes. Mostly they suit the needs of the professional and his or her patients. Most of the practices are limited in number in order to provide the time necessary to do our jobs. Sharing is an integral part of most every home and it’s a part of most direct practices. While charity is not common in government run institutions, it is a natural element in the lives of most professionals the world over.

Over 10% of the patients in my practice pay me nothing and they get precisely the same care as the patients who pay me. It’s a pleasure and a privilege to give back and know that I have the time to offer my expertise, my life is enhanced and the lives of my patients are improved as well. My patients donate time to 501C-3 organizations in exchange for my scholarship. Everyone wins.

An open door policy isn’t as brutal as people seem it think. It isn’t hard being available 24/7. Usually, it means a phone call from a friend in need: someone I know well. When asked, most Americans say that they want access to affordable health care, the knowledge that their doctor is available. It’s always nice to have a key to the front door, so to speak.

The passion that my colleagues and I have to preserve the medical home and the sanctity of the relationship(s) that we have with our patients is as real as our patients’ trust and love. The necessity to safeguard the professionalism that we have earned so that we can provide the discretionary judgment to assist our patients with decisions about life and death is indispensable to the conservation of the integrity of the science.

America was built around the principle of a supportive family. Over the years, reams have been written about the disintegration of the family unit as the root of much of our cultural chaos. I don’t really think it takes a community if the comforts of home are maintained with consistency.

Healthcare is not much different. The inability for a patient to have their own personal doctor, someone who knows him (or her) who will advocate for them is probably the greatest frustration suffered by Americans in need of care. I would hope that America would work hard to maintain the “old fashioned” medical home before we purposely turn mom and dad into matrons of an orphanage where no one has a place to call their own and everyone is served the same dull pabulum in place of a nutritious meatloaf every Monday.

Home sweet home is not an institution to be judged by the federal government. It is a place we go to belong, to reinvigorate, to strategize and build our lives. Medical homes belong to our patients and must never become government fashioned institutions. Dickens wrote fiction about a failed cultural era that dehumanized children and sanctioned disrespect and cruelty. We must not allow his historical perspective to become a 21st century American reality.

Dear Santa letter 2008

2009-01-03T11:30:00.001-08:00

Dear Santa:
This is truly a monumental moment for me. Being Jewish, I have never had the urge to write to you, but in the spirit of "change" and crossing over, I had this overwhelming need for audacious hope and a prayer. Being Jewish, I accept the stereotype of sometimes arriving late to the party. That said, my wishes are priceless if not timeless.

My list is short. I am only asking for reason and sensibility to come to our nation and our leaders. And, if you'll throw in ethical behavior and a sense of morality, I'll leave extra milk and cookies.

You see, even as a graduate of Wellesley in Economics, I can't grasp the concept of purchasing a "legal" swap in the face of selling short. Isn't that sort of like buying fire insurance while your house is burning and knowing that with the taxpayer's help, you'll recover your mortgage and enough to buy another luxury condo? I mean, talk about Christmas. Rep. Barney Frank and his buddies in Congress must have had a few too many hot toddies when they were thinking that they could actually regulate and mandate "toxic" mortgages for the poor and get the taxpayer to pay for their "vision."

My concern is that this same "team" is going to continue to make decisions affecting my future and the future of all our children. They are about to embark on decisions regarding the health of the nation.

To date, this discussion about health care reform really has me guessing what medication combination this country has been taking... clearly an overdose. It is not clear how we can rationally discuss "health" insurance. Health is not an insurable commodity. Rather, sickness is the unpredictable event that we might insure and health is an investment, like buying good shoes or wearing a warm coat (with a wool lining in the winter months).

Trying to insure the health of all Americans is likely to bankrupt the nation for sure. Massachusetts, a state smaller than the county of Los Angeles is already in financial trouble and they are only two years into their state system having insured an additional 3% of their residents. Hawaii had to pull the plug this year on its new state-funded health insurance program for children when it found out that virtually all of the children in the program previously had insurance, but their parents had dropped it in order to sign the children up for for the new taxpayer-funded program. (Now you see why I am asking for "reason.")

If you could just inject good sense into Secretary-designate Daschle's brain, maybe he would see the way to suggesting that the government might only provide catastrophic insurance (even in the Medicare program) and only for those who are not able to make their own purchase. I know that you can help our leaders with the intellectual argument that government controlled, population based health care is just not good for any individual person. It is politically correct and very expensive egalitarianism. But, if in the end, the reform we engage is reforming our government mandated insurance opportunities to mean ONLY catastrophic insurance for sickness or accident, we will have allowed for the purchase of valued additional health benefits in a free market. Santa, this is the rational conversation that I am putting at the top of my list of wishes. Americans deserve no less.

Reason would suggest that all Americans should make their own personal investment in their life and in their health. That was the intent of our forefathers when they constructed the constitution and established our protected rights. Those rights did NOT include any obligations on the part of the government to impose the services of hospitals, physicians, or employers to guarantee a level of health or preventive care. Our rights are our opportunities to engage and do not include obligations of any professional to serve us.

If we are going to legitimately engage reform, we must first confirm our duty to deal with confirmed fact. (I guess that is another wish. Could you spread a whiff of intellectual integrity over all the conversations about health reform?) Health is indefinable on a "population basis.” We resort to the discussion about insurance when we really want to talk about affordable accessible care. We have never been able to successfully "sell" health across a population. Let's stop that conversation before it bankrupts us further.

Reason would have us believe that every American deserves health care choices and that those choices should be "value based.” Reason would suggest that we need to make our health care delivery system transparent (that does not mean that the government has a right to any patient's health record). It is time that hospitals and doctors post retail prices. Rational health care purchases can only be made with information about cost and the specific utility for an individual patient.

And finally, Santa, as long as we are "facing the facts,” I would ask that we engage a societal debate about the morality of establishing law that defacto creates a class of citizens who are forced into retirement and Medicare at a defined age. Morally, the nation has decided to pay for the continued "health" for those seniors who are mandated into a (relative) non-productive state of co-dependence. But, that decision fails to protect the working public and sanctions an economically unsound system that robs the elderly of their opportunity for continued productivity and taxes "pre-seniors" far too heavily. That 1965 decision was about power and lacked reason and forethought.

It would seem that any debate about health care reform must include a much fuller discussion about all the social systems the government has mandated since 1965 when the nation established this new sense of moral collectivism… but forgot to fund it. Unfortunately, in that new "morality" the rights of individualism that were truly the basis of our constitution were thrown overboard, much like tea from a ship moored in Boston.

Santa, it is reason, rational thought, and responsible debate that every American deserves to hear in the Congressional deliberations about reforming the means by which we deliver sickness insurance and health opportunities to America’s patients. Most important, please infuse a new sense of respect for the rights of every individual to make their own choices for their health and for their life.

PS: next year… if all goes well, you’ll find physicians’ waiting rooms filled with patients eager to speak with their individual doctor about their personal health choices and that better day that our forefathers dreamt would be every American’s dream: the right to personally invest in life and health in pursuit of happiness.

Marcy Zwelling-Aamot, MD FACEP
562-596-7584
Los Alamitos, California

Letter to the editor

2009-01-03T11:28:00.000-08:00

Below is a letter to the editor in reference to this article..

Thank you so much for some very good suggestions about saving money while maintaining good health in your article Cut health costs, not your care, (December 9, 2008). I would like to add that investing in a medical home thru a physician engaged in a "direct practice" is another means of investing in your health. Providing a retainer up front to pay for all your care is a wonderful means of making sure that you have an ongoing relationship with a caring physician thru the year for relatively few dollars. Imagine being able to talk to your physician thru an email or having your doctor's cell phone number. Why waste money and time in a waiting room or an emergency room? Investing in a relationship with a primary care physician with your HSA or FSA dollars is a great opportunity to get the best care for fewer dollars and the cost of catastrophic insurance is far less than the usual HMO or PPO. Personal choice is not expensive and the value is "priceless."

Marcy L Zwelling-Aamot, MD FACEP
562-596-7584
Marcy@choicecare.md

From the Los Angeles Times
Cut health costs, not your care
Balancing your budget shouldn't mean your health pays the price. Here are smart ways to manage both.

This is an expanded first installment of an ongoing Health feature on cutting costs, not care--with tips for balancing your health and budget needs. Part one covers: Drugs, Doctor visits, Surgery, Flexible spending accounts, Preventive care, and Insurance.
By Francesca Lunzer Kritz

December 29, 2008

Amber Eyerly, 32, says she's never been much good at saving money. But with only minimal raises, at best, expected for 2009 at the Los Angeles public relations firm where she works, Eyerly carefully studied her health insurance benefits package this year to see where she could trim costs.

She made one cut for 2009 by signing up for a medical flexible spending account, which takes money, pre-tax, from each paycheck to spend on healthcare costs and reduces her taxable income. And when she read that, unlike trips to a specialist, visits to her primary care doctor don't require her to first pay down a health insurance deductible, Eyerly arranged to have her dermatology records for a minor skin condition sent to her primary care physician, who now writes prescriptions for any dermatology medicines the young executive needs.

Eyerly's personal health cost review is being repeated across the country, as the economic downturn worsens and jobs -- and the benefits that often come with them -- get slashed. "Millions of consumers are weighing their medical costs and trying to see what expenses they can jettison to save some money," says Cathy Tripp, a senior consultant in the Minneapolis office of benefits consulting firm Watson Wyatt. A Watson survey of 2,500 U.S. employees released this month found that 17% of those surveyed had avoided a recommended doctor's visit this year to save costs (the question was not asked in the firm's 2007 survey). And 17% did not fill a prescription or skipped doses of prescribed medicine, an increase from 13% in 2007.

But healthcare leaders worry that short-term savings could lead to serious illness, and even deaths. "We're seeing that consumers are willing to take risks by not doing what they perceive to be small things, such as putting off going to the doctor and deciding not to pay for medicines," says Dana Goldman, head of health economics at research firm Rand Corp. in Santa Monica. "That puts the individual at risk, but the potential harm doesn't stop with them," Goldman says. "It also becomes a problem for society if, for example, infections spread because some people don't fill a needed antibiotic prescription, or if an increase in hospitalizations for chronic illnesses places a deeper financial burden on a hospital or city."

Says J. James Rohack, president-elect of the American Medical Assn.: "Consumers need to take steps to stay healthy, such as getting exercise and losing weight, if necessary, and finding help through private and public channels to help pay for healthcare costs."

FLEXIBLE SPENDING ACCOUNTS

Save by reducing taxable income

Surprisingly, these accounts, offered by many companies, even small ones, are often not used by consumers -- so if you didn't sign up for 2009, consider it next time around. Employees of companies that offer the accounts can have set amounts (minimums and maximums are set by each company) taken from their paychecks pretax and put into these accounts to be used for health expenses as major as brain surgery or minor as contact lens solution. (Each company can decide what it will allow in its specific plan; you can get a good idea of allowed expenses under the federal government's flexible spending program at www.fsafeds.com/fsafeds/eligibleexpenses.asp. According to Laurie Brubaker, a benefits expert with Aetna, which administers some of these accounts for businesses, setting aside $2,000 from a salary of $25,000 will create a tax savings of $450. Use Aetna's calculator to match your allocation with your salary at www.aetnafsa.com/fsa/index.php.

Spend it or lose it

Many people often don't open an account because any money left at the end of the year is forfeited. Cathy Tripp, a senior consultant in the Minneapolis office of benefits consulting firm Watson Wyatt, suggests making a list of medical needs for the year, including prescription sunglasses and new contact lenses or a visit to the doctor to check on an allergy, and making those appointments before the benefit year ends. And remember: The money is deducted over the course of 12 months, but the full amount you choose to set aside is available to you from the first day of your benefit year.

DRUGS

Review what you take with a doctor

Shopping for lower prices isn't necessarily the first step you need to take if you want to lower your prescription drug bill, says Michael Cohen, president of the Institute for Safe Medication Practices in Horsham, Penn. First, review the drugs you take (a good practice once each year regardless, doctors say), to determine whether you still need the drug or that dose and whether you could safely substitute a less expensive option for the drug.

A visit with your doctor to review the drugs is your best bet. If you're concerned about the cost of the visit, you can ask if the doctor will go over your list by phone. (And see below for strategies to reduce the cost of an office visit.) A local pharmacist can also review your drug list and make suggestions to your physician for changes, but never stop taking a drug unless the doctor has specifically given you the OK.

Ask your pharmacist if your particular medicines can be split or if you can use two lower doses to make up the dose you need. Review the costs, including any co-pays. Those options can sometimes save money over the cost of buying the exact dose prescribed. Then . . .

Price shop

Sure, the corner drugstore may be convenient, but it may also be expensive. According to the National Center for Policy Analysis in Washington, D.C., comparing prices among local pharmacies can save consumers almost 10% on brand-name drugs and up to 81% on generic drugs. You can check comparison prices in your area at www.destinationrx.com, but also call the local pharmacy to confirm. And some pharmacies may match competitors' prices. Costco's prices for brand-name drugs often rank among the lowest, and the warehouse store doesn't require a membership fee for people buying only prescription medicines.

Don't assume Internet prices are cheapest. Local pharmacy prices for a 30-day supply of the cholesterol drug Lipitor (80-milligram dose) hovered around $83 recently. The same drug cost $119.99 at drugstore.com.

Go for the generic

This year, many pharmacies, supermarkets and big retail stores such as Walgreens, Ralphs and Target began offering hundreds of generic drugs for as low as $3 per month per prescription. Not all stores offer all generics for the low price, and the list can vary from chain to chain, so check by phone or at the store's website. CVS charges $10 per year for a savings pass that entitles cardholders to buy 90-day supplies of more than 400 generic drugs for $9.99 each. That fee also gets you some discounts on nonprescription drugs and on visits to its Minute Clinics, staffed by nurses who can give some vaccinations and treat minor illnesses. As the economy continues to falter, expect more deals from drugstore chains. Kmart, for example, lets many customers at most stores buy one of several nonprescription products such as pain relievers and a decongestant for the discounted price of $1 each time you buy a prescription, for a savings of about $3 to $6. Find the website addresses for the stores you frequent and sign up for alerts.

Buy in bulk

Sixty- and 90-day supplies of drugs are often cheaper by mail order and at retail stores than a 30-day supply. That's especially true for people with insurance coverage for prescription drugs; buy a 90-day supply and most insurers charge only a two-month co-pay, which can be a savings of at least $20 per year for each generic drug you take, and at least $80 per year for brand-name drugs. Consumer Reports Best Buy Drugs advises checking online prices, for U.S. and foreign pharmacies, at pharmacychecker.com. Use the price per pill to compare the costs on the site, and factor in the shipping costs that most sites charge. The Food and Drug Administration offers advice at www.fda.gov/buyonlineguide on buying drugs online through only verified Internet pharmacies.

Scout for coupons and offers

You can get discounts on some brand-name drugs by looking for coupons on the drug's website (plug the drug name into a search engine to find the site) or at www.internetdrugcoupons.com. Discounts can sometimes apply to co-pays as well.

Check out other cost-saving programs

Additional deals that can save you money include the Together Rx Access card, sponsored by 10 drug companies and offering discounts on many brand-name drugs, and the SunRx Discount health pass, sponsored by pharmacy benefits manager SunRx. Checkwww.togetherrxaccess.com or call (800) 444-4106 for income eligibility and the current list of drugs that qualify. Anyone without insurance (as well as many small business owners) can sign up and print out the SunRx card, which offers -- at participating pharmacies -- up to 15% on many brand-name drugs, up to 70% on many generic drugs and some money off nonprescription drugs. Sign up at www.sunrxdiscount.com/Healthpass or call (800) 650-3184.

DOCTOR VISITS

Delay may lead to serious problems

Even if you have insurance and are paying only a co-pay to see a physician, the costs can mount, especially if you have young children. But not seeing the doctor when necessary could result in a far more serious illness -- and far more serious costs, says Carolyn Clancy, head of the federal Agency for Healthcare Research and Quality (AHRQ). So . . .

Talk with your doctor

J. James Rohack, president-elect of the American Medical Assn., advises people facing economic problems to be upfront with their physicians about cost concerns. "The doctor cannot waive a co-pay required by insurance -- that's a part of his or her contract with insurers -- but doctors may be able to help with some costs, such as providing samples of certain medicines," he says. Consumer advocacy groups such as the Medicare Rights Center, based in Washington, D.C., and New York City, suggest trying to negotiate the fee if you're paying out of pocket. Doctors have to wait weeks to months for payment from insurers, and may be willing to forgo some profit for faster payment, says Paul Precht, communications and policy director for the group.

Insured? Stay in your network

If you do have insurance and have been seeing doctors outside your plan, ask physicians, colleagues or friends if they can recommend doctors from your list. That may mean saying goodbye to a trusted physician, but it can save you more than $100 on a single visit. Ask your out-of-network doctor if you can stay in touch by e-mail or phone if you have questions, and also ask if the doctor would consider joining your insurance network.

Try bartering

People who own their own business, such as plumbers or lawyers, may consider barter to help pay doctor fees. Joanne Levine, who owns a PR firm in Chicago, does public relations for a few companies in exchange for barter credits that go into an account with a bartering firm. Levine has used the credits to pay for care by a periodontist, an optometrist, a surgeon and a dermatologist. "But not very many general practitioners are registered with the firm I use," she says. There may be fees involved in maintaining a barter account, so this option may be best for people who pay for other expenses through bartering as well. Find information about barter memberships at www.bartermax.com or the International Reciprocal Trade Assn. at www.irta.com.

Go to a retail clinic

If you or a child has a minor problem such as a low fever, a scratchy throat or a minor skin infection, a retail clinic may be all you need. They're staffed by experienced health professionals, typically registered nurses or physicians' assistants. Fees are about $50 to $65 for a visit, often well below doctors' offices, and if you have insurance, you may be charged just a $10 or $20 co-pay, well below the cost of an emergency room visit co-pay or fee. Check the websites of clinics, such as Minute Clinic (owned by CVS), at www.minuteclinic.com and Take Care (owned by Walgreens), at www.takecarehealth.com; there may be a discount offer that can save you an additional $5 or $10.

Visit community health centers

These local clinics offer care on a sliding scale, based on income. If you're not eligible for free care, the centers will work with you on payment options, which could include helping you find financial assistance in your area.

INSURANCE

How to get -- or keep -- a policy

In danger of losing your job, and the health insurance that comes with it, in 2009? Take a breath. This is a topic we'll revisit often in 2009, but we have some basic advice right now.

Take COBRA

If you lose your job in 2009, before you officially leave the premises, ask the firm if it would consider paying for your health coverage for an extended period of time, says Emily Spitzer, executive director with the National Health Law Program in Washington, D.C. If not, and if the firm offers a COBRA (Consolidated Omnibus Budget Reconciliation Act) plan, sign up for it for at least in the short term. It's an opportunity to pay for the same health insurance you've had while employed with the company. Though firms are allowed to charge up to 102% of what they pay to cover you, and, if applicable, any dependents, it is likely to be the most comprehensive coverage for the least amount of money, Spitzer says. During that period, you can look at other health-insurance possibilities, including an employed spouse's insurance options, an individual policy and public assistance, if you qualify. But buy yourself that time. Remaining insured is important; not just because of a possible emergency, but also because an interruption in coverage for you, or for a dependent who has an ongoing medical problem, could mean a delay in coverage for a preexisting condition, even when you get the new job and its benefits.

Then do your research

Here are some resources that should help:

California's Health Consumer Alliance:

www.healthconsumer.org, a partnership of consumer-assistance programs;

Families USA:

www.familiesusa.org/consumer-info, a nonprofit seeking affordable healthcare for all Americans;

HealthCareCoach:

www.healthcarecoach.com, a project of the National Health Law Program.

SURGERY

Ask financial questions first

The AHRQ's Clancy says too often the only question patients have about surgery is where to park on the day of the operation. But many hospitals offer free parking for one car (with a patient's identification number), so don't worry excessively about that . . .

Talk with the hospital brass

Whether or not you have insurance, a meeting with a financial officer at the hospital could help with costs. Showing a willingness to pay, even if over time, can generate goodwill, says Mark Rukavina, executive director of the Access Project, based in Boston, an affordable healthcare advocacy group. Some hospital financial staff workers may work with your insurer ahead of time to let you know what costs will be covered and what you will have to pay out of pocket. If you can't pay, the financial office may be able to direct you to financial assistance options, or set up a payment schedule.

Don't agree to use a credit card or retirement account

Recently, articles in the Wall Street Journal and Business Week have reported on some hospitals running credit checks on patients seeking care, before treatment is even provided. In some cases the check has turned up assets such as an available credit limit on a credit card, or a 401(k) account, and the hospitals have asked patients to use those assets to guarantee and then pay their bill. Rukavina of the Access Project advises against using credit cards to pay medical bills unless you plan to pay the bill in full by the end of the month. If not, your medical bill rises by the monthly interest fee you pay, and not paying it can result in penalties and higher fees on all of your credit cards because of the changes to your credit score. And any early use of a 401(k) account will trigger penalties and leave you without resources for retirement, the reason you set up the account in the first place. If you are asked to use these resources, Rakavina advises asking to see the hospital's chief financial officer and to insist that you be allowed to set up an extended payment plan. Consumers who find themselves in this predicament can visit the Access Project website for assistance at www.accessproject.org.

Consider surgery in a foreign country

Medical tourism, having surgery in a foreign country such as Singapore or Thailand, has been making headlines as a lower-cost option for people without insurance -- surgeries can cost as much as 90% less, according to the Medical Tourism Assn., a trade organization. However, the National Business Group on Health, which advises large corporations about healthcare expenses, recently issued a brief that pointed out concerns about medical tourism, in addition to benefits, such as a risk to patients who speak English only but must interact with medical staff who do not. The American Medical Assn. says people who opt for surgery in a foreign country should arrange for a doctor to monitor them on their return. That, of course, would involve additional fees, especially if the doctor thinks follow-up care or even a repeat surgery is necessary.

So far, most insurance companies don't cover surgeries overseas, though WellPoint, which insures millions of Californians, is doing a trial run with a small company in Seattle. If successful, WellPoint and others could cover the option for a larger number of people beginning in 2010. Because of the huge cost savings, largely due to lower salaries and lower-cost malpractice insurance in many foreign countries, insurers could decide to waive all co-pays for foreign surgeries, in addition to covering travel and lodging costs for the patient, and, often for a travel companion as well. For more information, have a look at the Medical Tourism Assn.'s website at www.medicaltourismassociation.com, or contact PlanetHospital, a firm in Calabasas that arranges surgical care overseas.

At least one company, North American Surgery Inc., based in Vancouver, Canada ( www.northamericansurgery.com), negotiates on behalf of individuals and small companies and is able to offer prices for many surgeries at U.S. hospitals that can rival foreign rates. The company checks on accreditation and even patient outcomes before signing on with surgeons and hospitals, but you'll want to check on your own as well, and ask your primary-care doctor to speak with the surgeon you choose.

PREVENTIVE CARE

Early detection can pay off

Even if you have no known health problems, certain tests such as mammograms and prostate exams should be done regularly so that any indication of a problem can be detected as early as possible, Clancy says. AHRQ recently created test checklists for men,www.ahrq.gov/ppip/men50.htm, and for women, www.ahrq.gov/ppip/women50.htm. And . . .

Look for free or low-cost screenings

Many associations offer free screenings for many conditions at certain times of the year. Type the name of the condition and the word "screening" into a search engine to see what's available. In the Los Angeles area, screening dates are often posted at www.healthycity.com, or you can find some free tests by calling 211. Type in "health observation days" at healthfinder.gov and you'll find a calendar with an observance day for just about every disease. Organizations often hold screening programs on those days, and websites for hundreds of organizations that offer information, and, often, free or low-cost tests are listed.

Look after yourself

The AMA recently introduced a program called Healthier Life Steps -- a guide for consumers with or without their physicians. Go to www.ama-assn.org/ama/pub/category/18471 .html. The point here is that by stopping smoking, losing weight, exercising and controlling chronic diseases, Americans can save money on healthcare and be healthier. For example, when Mike Huckabee, the former governor of Arkansas and a presidential candidate, was diagnosed with diabetes, he opted for losing weight and exercising and never took -- and so never spent money on -- any medication.

health@latimes.com
___

Doing the numbers on medical tourism - is it worth it?

2009-01-03T11:24:00.000-08:00

Carol Lloyd
Friday, January 2, 2009

What with the glories of the new, new economy, it's easy to imagine consigning "health and fitness" to the ash heap of personal history. Remember when we could afford yoga and Pilates? Or when we didn't price-shop for vitamins?

During rough economic times, big-ticket treatments not covered by insurance pose an even greater challenge. If you need knee surgery, or back rehab, or God forbid, the dental nightmare my husband faced last year - two crowns, two fillings and two root canals to the tune of $3,700 - it may be time to think selfishly, act globally and consider the benefits of medical travel.

Patients have been crisscrossing the globe in search of better, cheaper and more expedient health care for centuries. Legend has it that ancient Greeks traveled to the coastal city of Epidaurus for cures. Twenty years ago, the phrase "medical tourism" generally evoked images of bargain-basement boob jobs, not state-of-the-art heart surgery. But in the past few years, increasing numbers of Americans (along with Canadians and Europeans weary of long waiting periods) have begun globetrotting for pricey procedures.

With more countries - from Singapore to South Korea - building modern hospitals catering to First-World patients and accreditation organizations vetting them for quality, the industry is developing the standards and protocols that will allow medical tourism to go mainstream.

"For a long time, some people said it was just a fad," says Melissa Skelton with the Medical Tourism Association, a nonprofit organization that sponsors the Medical Travel Congress and publishes Medical Tourism Magazine. "Now with the economy and the credit crisis, more people are waking up and paying attention."

Indeed, for the 47 million uninsured Americans, boarding a plane to see the doctor already offers an irresistible two-for-one: travel the world and save money. But if insurance companies and employers embrace and incentivize medical outsourcing, the profile of the medical tourist will change. Joining the armies of un- and under-insured Americans will be fully insured patients who are getting extra perks to cross borders for treatment.

A recent study by Deloitte Center for Health Solutions concluded that the number of Americans traveling for medical care will soar: from 750,000 last year to 6 million in 2010. Although some experts question that prediction, most agree that medical tourism has the potential to transform the way Americans access health care.

"I'm not sure the numbers will rise that fast, but it's growing," said Patricia Look, a benefits and compensation analyst with J. J. Keller & Associates, whose recent white paper explored the rise of institution-sponsored medical tourism. In her paper she profiled a handful of early-adopting employers and insurance companies that are offering elements of medical tourism as a part of their health plans. "Institutions are slowly jumping on the bandwagon."

Not surprisingly, the good doctors at the American Medical Association haven't issued a ringing endorsement of this medical outsourcing. They rightly caution that a lack of legal recourse in case of medical malpractice and doctor and hospital credentialing makes medical trips potentially dangerous. Yet earlier this year they did issue guidelines suggesting that they know which way the trade winds are blowing. (The guidelines recommend seeking care from accredited hospitals, bringing medical records, learning about legal rights regarding malpractice and understanding the risks of long-distance travel after procedures.) Also, a number of major medical centers - including Duke Medical Center, John Hopkins Medical Center and Columbia University Medical Center - have partnered with international hospitals, indicating a growing awareness that medical tourism is here to stay.

While experts calculate medical tourism's benefits for institutions, my family's experience offers testimony of its appeal for individuals. During a recent trip to Costa Rica, my husband got his dental work done for a fraction of the American price - about $950 - paying for the price of the rest of the trip. Encouraged by his gleaming smile, I subjected myself to "Chequeos Medicos Plan B" - one of several preventive health exams offered at CIMA, a brand-new hospital in San José, run by the Dallas-based hospital chain. In six hours, I received a mammogram, full blood work, fecal and urinalysis, cardio stress test, abdominal ultrasound, chest X-rays, eye exam, meeting with an internist, consultation with a nutritionist and breakfast for $397. By my calculations, I would have spent several thousand dollars for the same number of tests and it would have taken no fewer than 10 visits to the doctor spread over weeks or even months.

No trip into any hospital nowadays guarantees a safe return for your body, but some certainly promise a better return on your buck.--

Freelance writer Carol Lloyd is the author of "Creating a Life Worth Living."

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/01/02/CM6314G2BV.DTL

This article appeared on page P - 4 of the San Francisco Chronicle

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Letter to AMA... Privacy considerations

2008-08-26T11:52:00.001-07:00

Dear Mr. Nelson:

My name is Marcy Zwelling. We have not met. I am a delegate to the AMA from California and a passionate advocate for my patients and quality health care.

I am aware of a series of lawsuits in the Northeast involving IMS, a vendor of my patients' private health care data and physician prescribing habits. I know that the AMA has intimate details of the lawsuit(s) and that the case is now at the Appeals Level. I believe that the AMA allows physicians to opt out of the AMA Rx data mining program but not many doctors know about this. That said, I absolutely appreciate the fact that the AMA has made it is so much easier to find the opt out on the website. I opted out months ago and had to "re-do" my efforts today. I don't know how that glitch happened.

The conflicts of interest are huge. I believe that the AMA suffers these conflicts more and more as our membership numbers go down. It is publicly quoted that the AMA made $46 million dollars on the "sale of data". I think that this lawsuit presents the proverbial "fork in the road". The AMA has the opportunity to finally stand up for physicians, our rights, and our patients privacy by standing with the State of New Hampshire against data mining.

I want nothing more that the AMA's continued success but we cannot be successful if we continue to live in this world of conflict. Our AMA's patient privacy policies are well conceived and I applaud the efforts of those before me who had the wisdom to articulate the "line in the sand". I believe that this data mining violates our privacy policy and is only the tip of the iceberg. Companies like SureScripts (now Rx-Hub) sell my patients' data to any "covered entity" under HIPAA. This practice is a huge invasion of privacy, all legal under HIPAA. I would love for the AMA to work to legislate against any sale of any patient data but... to get to that place, I think you first must take a position in this appeals case. As they say....... "what are you going to do? Not what do you say or think?"

We all know that clinical health data can be used wisely. We all want clinical data to be used by the right people in the right studies and at the point of service for individual patients. But, that is NOT what happens now. It is, however, the "umbrella" that others are using in order to give themselves access and that is wrong.

The licensure to utilize patient data MUST be authorized on a case by case, one event at a time basis, with FULL disclosure to our patients. HIPAA, as you know allows for the use of data by "business associates" [Business associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.] We are all aware that patients receive inquiries from all "business associates" all the time proving to me that identified data is sold at will. Patients have brought this to my attention. (I don't bill insurance so if anyone has information about my patient that is privileged to THIS office it would be thru their PBM and an Rx).

I was shocked to here that even Dr. Robert Kolodner, the current Coordinator of the Office of National Health Information Technology, was surprised to know that data was being exchanged and sold so freely (or so he said). it seems that there has been little conversation about this violation of our patients' privacy. Shouldn't this be a priority of the AMA? I took an oath. Every Medical Doctor receiving an MD degree in the US took that oath "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal."

I believe that the AMA has at its core the obligation to stand up for the profession and our patients and put a stop to the practice of data "mining" and the practice of data distribution and sale. Our patients' data is just that... belonging to our patients. It is a privilege to have the data and to use it for the specific betterment of their health and not for the utility of any other entity. While I believe that we must find a way to safely license the use of CLINICAL data after full disclosure and with our patients' informed consent, that must come after we have secured their privacy.

This is our moment. We must seize it. The AMA has an amazing opportunity to re-examine its core values and to do the right thing.

I eagerly await your reply and I thank you for your most serious consideration.

Marcy

A little humor...

2008-08-05T15:46:00.002-07:00

MEDICARE COVERAGE IN A NUTSHELL

The phone rings and the lady of the house answers, 'Hello.

'Mrs. Sanders, please.'

'Speaking.'

'Mrs. Sanders, this is Doctor Jones at Saint Agnes Laboratory.
When your husband's doctor sent his biopsy to the lab last week, a biopsy
from another Mr. Sanders arrived as well. We are now uncertain which one
belongs to your husband. Frankly, either way the results are not too good.'

'What do you mean?' Mrs. Sanders asks nervously.

''Well, one of the specimens tested positive for Alzheimer's and the other
one tested positive for HIV. We can't tell which is which.'

'That's dreadful! Can you do the test again?' asked Mrs. Sanders.

'Normally we can, but Medicare will only pay for these expensive tests one
time.'

'Well, what am I supposed to do now?'

'The folks at Medicare recommend that you drop your husband off somewhere in
the middle of town. If he finds his way home, don't sleep with him.'

Linda Holderman, MD, FACS... on the Governor's plan

2007-09-22T16:16:00.001-07:00

The Governor’s Plan: Patients without Doctors
Linda Halderman, M.D., FACS

According to Governor Schwarzenegger’s Senior Health Policy Advisor, the Governor’s Health Care Proposal will add 900,000 Californians to Medi-Cal, the State’s version of Medicaid. This expansion of government-funded medicine helps meet the Governor’s goal of decreasing California’s uninsured population. There is one problem the proposal fails to address, however:

There aren’t enough doctors to care for them.

A MATH PROBLEM IN SACRAMENTO

During a conference with the Governor’s Senior Health Policy Advisor and the Deputy Legislative Secretary for California’s Department of Health and Human Services, I posed this problem.

“How many more California doctors do we need to accept Medi-Cal to cover an additional 900,000 patients under the Governor’s proposal?”

“We’re not really sure,” came the answer.

“How many doctors are we ‘short’ under the current system?” I asked.

There was a pause.

“We don’t have that exact information right now.”

Surprised but still hopeful, I continued.

“Okay, can you tell me how many doctors in California actually accept Medi-Cal patients?”

“Oh, yes! 35,000 doctors are contracted with Medi-Cal.”

“Good. Of those 35,000, how many of those actually treat significant numbers of Medi-Cal patients, as opposed to just being contracted and accepting a tiny number of patients each year?”

Again, silence. Realizing that the information would have to be found elsewhere, I changed the subject.

“Under the Governor’s plan, will there be a way to attract more doctors to participate in the program?”

“Absolutely. We’re ‘incentivizing’ the stakeholders to increase access by raising some reimbursement rates. They might end up just 20% lower than Medicare.” [Author’s note: Medicare rates in central California are some of the lowest in the region, 20-40% lower than private insurance. Medicare is currently slated for a 10% cut in 2008, followed by a 5% cut for each of the successive six years.”]

“Do you know how much rates would have to increase to attract doctors?” I wondered, thinking that at the current Medi-Cal rates, a 10% increase would make a Breast Cancer Surgery consultation worth $26.50.

“We’ll have to get back to you on that.”

WHERE HAVE ALL THE DOCTORS GONE?

California physician participation in Medi-Cal is the lowest of any State-sponsored program in the United States. Medi-Cal payments to California physicians rank 49th in the country. The rates are based on 1969 data, with only a single increase in 20 years.

Because Medi-Cal reimbursement is often less than the cost of keeping a doctor’s office open during the visit (e.g., $24 for a consultation with a Breast Cancer Surgeon, $253 for a two-hour breast-preserving cancer operation and 90 days of care that follows), accepting Medi-Cal destroys the viability of California medical practices. In order to keep their doors open, the vast majority of California doctors must refuse or severely limit the number of Medi-Cal patients they accept.

Under the current system, nearly 60% of patients in the Medi-Cal program report significant difficulty finding a doctor. Wait times are long, particularly for specialists and mental health professionals.

RURAL PATIENTS—ON THE FRONT LINES

In underserved areas like the rural central California town where I practice, this problem is magnified.

When financial necessity forced me to stop caring for women with breast cancer in September of 2007, I had spent four years operating at a loss. My patient population consisted of 90% uninsured and underinsured women covered only by Medi-Cal or the State’s Breast Cancer Early Detection Program. My practice hemorrhaged $10,000-15,000 each month.

In the weeks before I stopped practicing, I begged the only Breast Cancer Surgery specialist in the region who still accepted Medi-Cal to care for my patients. She serves one afternoon per week, about four hours, at a County-funded clinic 30 miles from my office. She graciously agreed to add my patients to the time slot available and worked hard to expedite the evaluation of women newly diagnosed with breast cancer.

This group of my patients created a six-week waiting list at the clinic. The wait will likely soon reach four months, and is expected to increase when primary care doctors in a 70-mile radius from my practice learn that they no longer have access to a local surgeon.

PATIENTS NEED REAL DOCTORS, NOT PAPER SOLUTIONS

The California Governor achieved extraordinary success in the sport of bodybuilding, in the entertainment industry and in business after humble beginnings as an immigrant to the United States without English language skills or financial resources. His accomplishments are the result of hard work, good decision-making and a willingness to see gold where others saw only worthless, tarnished metal.

But the Governor’s Health Care Proposal does not reflect his brilliant history of success. Instead, he has accepted uninformed opinions and bad advice to craft an idea that has proven impossible before it is even implemented. I hope that Governor Schwarzenegger reconsiders this plan and instead seeks input from those with practical, common sense solutions that serve to improve access to healthcare for California patients in more relevant places than merely on paper.

Dr. Halderman (www.lindahalderman.com) is a Board-Certified General Surgeon practicing in rural south Fresno County.

Value based- Patient Centric Healthcare

2007-05-28T23:02:00.000-07:00

Everyone has heard the one about what happens when you ask 10 doctors the same question; you get 15 different opinions. The most fascinating part about that joke is that it is true. Some have gone so far as to say that converging doctors is much like herding cats. No argument there, either.

The healthcare system reform debate hasn’t done much to harmonize the diverse and often disagreeable doctor community. Everyone and every organization claims to have “the” solution. Most answers, however, are directed towards an opportunity to fortify assets, protect turf, or build a legacy.

But, among practicing physicians, the patient-doctor relationship is sacrosanct and that remains the one commandment and guiding principle. The reform that would shadow that one revered ethic must be that patient care should be focused on patient need. That is why the concept of Pay for Performance (P4P) is illogical if not irresponsible. That said, it is illustrative of so much of what is wrong with our healthcare system today.

Fortunately, we have seen signs that “the truth” is rising in the Eastern sky. Recent studies driven by the P4P ideology fail to demonstrate that patients’ outcomes are improved. No surprise. Editorials have warned that high-risk patients may have a hard time finding a physician.

The discussion laid out about P4P in the media would appear righteous: the government and the health plans want to pay physicians and hospitals that perform better. That might work if 1) the doctor were working for the government or the health plan 2) the work performed had proven value and 3) the payment was value based. But, we work for our patients and our work product should be driven by our patient’s specific individual needs, not by an unproven statistical analysis.

Population based health care (what is good for one, is good for all) has never been proven to be cost effective or quality driven. Moreover, the point could be made that it might be dangerous for those patients receiving unnecessary services. Pay for performance and other financially driven health care reform models will only lead America down the road of industrialized health care, a hazardous choice; rather peculiar in a market where everyone wants their own personalized website and IPod.

It is hard to rationalize doing mammograms in a 90 year old women, only to receive a bonus payment and it is wasteful to ask a hospital to repeat an echocardiogram just for documentation purposes because a patient has a history of congestive heart failure that is 20 years old and stable. But, that represents P4P. Really, it is not Pay for Performance. It is more like Perform for Payment. Talk about an “old” profession.

As physicians, our time should be spent individualizing the care of every person who puts their life in our hands. Our expertise should be employed to make our patients’ lives better. Every surgical procedure ought to be specifically designed to suit the surgery necessary and every medication protocol should be developed around the patient’s specific lifestyle, medical needs, and life goals.

By centering care on patient need, costs will be trimmed. As it is, millions of health care dollars are lost in a system that is more about maintaining an administrative infrastructure than about evidence based methods to further patient health. The idea that the government or a health plan can define our patients’ health is preposterous if not arrogant. The philosophy of treating to “normal” rather than optimal cheats our patients of their ultimate potential.

P4P is an administrative quagmire built on the premise that physicians are so demoralized that we would rather fill in the blanks than hold our patients’ hand when they are in pain. Indeed P4P could be adequately achieved without a physician ever talking to the patient. Envision Lucy and the Chocolate Factory: P4P motivated health care reform is an assembly line of prescriptions, lab tests, and procedures running independent of patient need. It loses its humor when it is about your mother, or child.

The American doctor was not trained to be an indolent pawn. We were trained to lead, to inspire and to protect. Our professional tools are a valuable asset and should be used to better our patients’ day. Doctors are not a commodity available for trade on the open market. And our patients are not the collateral they will become if P4P continues to deliver a “report” that mirrors “teaching to the test”.

“Conventional wisdom”, “usual and customary” were never part of the vernacular until we lost our way and allowed the health care delivery system to be financially driven. Standards in healthcare were originally established as minimums but the current system has perpetuated the concept of standardization as a means of payment. So it is with P4P.

Healthcare system reform needs rehab. America must relieve itself of its addiction to government or health plan run health delivery systems that only serve to industrialize the personal health needs of our patients. Studies show P4P doesn’t work. We knew that, now everyone knows that.

Pavlov was about dogs and should not define a health care delivery system. Our patients deserve the respect of a health care system driven by the patient-doctor relationship. As physicians, we are determined to maintain our focus on the best, individualized, patient centric care and the opportunity to optimize our patients’ day.

The summer of Reform....

2007-05-27T19:16:00.000-07:00

This summer we are all going to be inundated with health care reform propaganda. The reality is that the governor is determined that we need reform. The leaders of the legislature have teamed together to help accomplish that goal.

Why do I call reform propaganda? Health care is a multi-billion dollar industry and the reforms placed on the table to date are more about financing systems than about care. I have written my recommendations to the Governor. Exerpts from that letter are below:

One thing is clear after reading the Governor’s “blueprint” for California health care reform. There seems to be consensus that the government thinks that the health care crisis is a funding problem. I might suggest that approaching health care reform from a funding perspective could be dangerous. I (personally) don’t believe that you will find an answer with a dollar sign attached.

The (current) health care delivery system is driven by opportunities for funding. And that is the problem. If we continue to solve the problem by promoting more regulation and taxes, we will only continue to fuel the dilemma.

Health plans have dominated the health care conversation since the 80’s. As a nation, we have come to believe that access to care is an insurance issue. The premise is wrong. While insurance is a fact of life and a necessity, it was designed to be an actuarial bet, not first dollar coverage. Insurance should be available “ in case of emergency” to protect against unexpected losses due to a health crisis. Insurers have “reinvented” the basic foundations of insurance coverage and in so doing; have actually added to the obstruction to care. Premiums have become much too expensive and care is inconsistent with patients’ needs. Throwing more money into this broken system doesn’t fix it but it could make the health plan CEO’s pretty rich.

So what do we do to modify this “too expensive, unresponsive insurance system? To repeat, we don’t add to the problem by throwing more people into the insurance market and assume that they will get the care that they need. And, we don’t “tax” the employers in the State. That only deepens the crisis, kind of like feeding the lions more food for fodder.

1) I suggest that first you allow the insurance industry the opportunity to do what they were made to do, act as a broker in the actuary market where insurance can act as a hedge against the financial doom that can come with unforeseen medical expenses. And further, where patients are allowed the opportunity to purchase the care that they need in a transparent market place.

Actuaries are experts in:
a) Evaluating the likelihood of future events,
b) Designing creative ways to reduce the likelihood of undesirable events,
c) Decreasing the impact of undesirable events that do occur.

Let me make the illustration for you.

A patient with a large deductible generally has a lower monthly insurance premium and patients with HSA’s have an even better opportunity to invest in their health. Going onto the Blue Cross website, you will find that the HSA plan saves a family over $150 per month. That amounts to $1,800 per year that can be invested by that family in preventive care or other elective health deliverables.

The good news is that the city of Long Beach, acting in the interest of the Long Beach residents, has built a website where access to care has become as simple as finding the retail price of most anything needed in the health care marketplace from surgery to drugs.

http://www.healthylongbeach.org

In the end, the patient has choice and has all the incentive to keep healthy. Premiums might even be reduced once this type of transparency becomes the focus of the reform that the Governor could establish: all this without the imposition of any new tax. The free market is the best home to place the responsibility to reform the health care delivery system. The residents of California can make great decisions for themselves and for their families IF they have the opportunity and the education.

2) There are too many insurance / government regulations and mandates. And… too much money is lost to administrative hassle.

Again, let me give you some specific examples. The silent PPO loophole provides a means for insurers to take billions out of the delivery system. Those administrative dollars do nothing to fund real care. Rewarding an administrator with increased revenue for robbing hospitals and doctors of reasonable reimbursement is an embarrassment for the health care industry and needs to be stopped.

Another example of waste is the misunderstanding on the part of the governor that he can control the medical loss ratio. We need to look more carefully at the HMO industry. There is not one health plan in the state including the State sponsored MediCal that operates with a 15% administrative budget / profit margin. If you do an investigation of how money flows, you will find that most of the health plans have developed a number of sub corporations and each of those sub corporations takes 15%. Administrators are paid out of each sub corporation and money sits in bank accounts while care is obstructed. The HMO has hospital funds, transplant funds, Out of Net Funds and I wouldn’t be surprised if they also had the “who done it fund”. It doesn’t take much of a stretch to question how they pay such incredible dividends to stockholders and their CEO’s multi-millions at the same time. The industry is rolling in money. The problem is that the majority of those dollars pay administrators and stockholders rather than providing health care. …And that from the mouth of a capitalist.

Each time the state provides us with another mandate, there is another excuse to provide administrative jobs and another level of hassle. Please don’t do that any more. Please. Most of us providing care, physicians, nurses, physical therapists, and radiology technicians just want to work for our patients not for a 3rd rate administrator who only goes to work to make sure that I work harder or that my patients don’t get what they need. I am not in the business of building bigger government and my patients’ illnesses shouldn’t be funding a CEO’s third yacht.

3) We should look at the Governor’s thoughts about increasing MediCal rates as a means of increasing reimbursement to physicians. There are few primary care physicians in the fee-for-service MediCal business. Most all primary care doctors who accept MediCal serve the state thru the HMO industry. All the dollars that are anticipated coming to doctors will only continue to fill the pockets of administrators and administrative organizations like LA-Care. LA-Care has more than 100 million dollars in a fund that theoretically should be in the hands of the Los Angeles county provider network so that we can take better care of our patients. I don’t see any benefit in promoting a bank account, do you?

4) Taxing providers (hospitals or physicians) is just a bad idea. It is insulting. I know that the governor is looking for someone to “share” the responsibility but I would offer that the physicians and hospitals in this state have been the safety net for the system for years…. We continue to work hard to provide what we believe to be the best care in the world for the patients that we love as part of our families.

Consider if you will the fact that physicians remain in an educational environment well into our 20’s and enter the workplace environment with often a quarter of a million dollars of debt to address. My friend and colleague is still paying her debt at $1200 per month and she is in her mid 40’s. She anticipates another 13 years until her loan is paid off. All that for the PRIVILEGE to serve. We take call limiting our opportunities to be with our families and we generally find ourselves working 12-16 hour days at a minimum. All that for the PRIVILEGE to serve. We are often the target of lawsuits because of bad outcomes that have little or nothing to do with the decision making at our hands. There are no bonuses when things go well. At the same time, the State has mandated additional education in pain management and has prohibited us from negotiating with insurance companies and legislators seem to enjoy taking pot shots at MICRA. All that for the PRIVILEGE to serve.

And finally, we find ourselves forced into accepting reduced reimbursement from a silent PPO network. You can imagine our shock that while we were trying to protect our incomes by electing to “not contract”, we were served with a ban against balanced billing by our governor who theoretically is a believer in the free market. All that for the PRIVILEGE to serve.

I am shocked that physicians are asked how we could share in the responsibility when we have assumed ALL the responsibility. We carry the responsibility with us to bed every night and into our retirement. We carry the responsibility with us when we vacation and when we volunteer to transplant kidneys in foreign countries. The physicians of this state and across the country ARE health care and we want to work with the governor to make it better. But we can’t do that until we can come to the table to discuss LEGITIMATE HEALTH CARE DELIVERY REFORM….Reform that is divorced from serving to punish us for a system that has let our patients down…. A system that has served to line the pockets of administrators over caring for people.

So let’s talk about real reform.

1) Price transparency that allows for the promotion of a strong doctor-patient relationship. “Accountabilities” in the hands of those directly involved in the decision making (the patient and the doctor)
2) Better patient education to make the patient a better purchaser of care
3) Health literacy reform to legitimately provide patients with the information they need to make health care decisions for themselves and their family.
4) Tax relief and vouchers so that low-income patients can still choose the right care for themselves and their families.
5) A refined look at Health Care IT with grants so that we can find the means for patients to have their own patient data available at the point of service (not EMR’s) (this will clearly save billions and improve care)
6) Eliminate P4P and all the administrative costs attached to rewarding physicians and hospitals for procedures that have never been demonstrated to improve outcomes.
7) Insurance reform that encourages insurers to define payments very simply so that patients know more precisely what their insurer will pay for. An insurer would define their payment with a precise number ($300 for an MRI). Then the patient can pay their share ($200) of a $500 MRI. That is my definition of price transparency. I think it beats defining the benefit as 50% of the usual and customary for in-network and 30% of the U&C for out of network. (What does that mean anyway))
8) Rid the market place of the silent PPO and allow for the opportunity for physicians to openly negotiate with health plans and with self insured groups
9) Supplement the cost of health education so that physicians are not left with more than a quarter of a million dollars of debt before starting a business
10) Increase State funded nursing education to increase the pool of nurses. There are thousands of potential nursing students who cannot find room in our nursing schools. The governor agreed to impose the nursing/patient ratios without the nurses available to do the job. There is an obligation to maintain a supply of great nurses to take care of our patients.

These are my ideas for health care delivery system reform. I think that any new funding should go to educate providers (including nurses). Insurance and funding reform should be aimed at removing the veil that keeps patients and doctors from making educated choices.

I believe that the key to reform is to find the means to enhance the doctor-patient relationship by enhancing the education of both parties and allowing a marketplace that promotes the opportunity for the best decision-making. Let’s focus on the things that matter, our patients, and not on making the middleman richer at the expense of patients, employers, hospitals and physicians.

AMERICA NEEDS HEALTHCARE THAT IS VALUE BASED AND PATIENT CENTRIC

2007-02-04T22:17:00.000-08:00

Everyone has heard the one about what happens when you ask 10 doctors the same question; you get 15 different opinions. The most fascinating part about that joke is that it is true. Some have gone so far as to say that converging doctors is much like herding cats. No argument there, either.

The health care reform debate hasn’t done much to harmonize the diverse and often disagreeable doctor community. Everyone and every organization claims to have “the” solution. Most answers, however, are directed towards an opportunity to fortify assets, protect turf, or build a legacy.

But, among practicing physicians, the doctor-patient relationship is sacrosanct and that remains the one commandment and guiding principle. The reform that would shadow that one revered ethic must be that patient care should be focused on patient need. That is why the concept of Pay for Performance (P4P) is illogical if not irresponsible. That said, it is illustrative of so much of what is wrong with health care today.

Fortunately, we have seen signs that “the truth” is rising in the Eastern sky. Studies driven by the P4P ideology trying to demonstrate cost savings or better quality care have all failed. No surprise.

The discussion laid out about P4P in the media would appear righteous: the government and the health plans want to pay physicians and hospitals that perform better. That might work if 1) the doctor were working for the government or the health plan 2) the work performed had proven value and 3) the payment was value based. But, we work for our patients and our work product should be driven by our patient’s specific individual needs, not by an unproven statistical analysis.

Population based health care (what is good for one, is good for all) has never been proven to be cost effective or quality driven. Moreover, the point could be made that it might be dangerous for those patients receiving unnecessary services. Pay for performance and other financially driven health care reform models will only lead America down the road of industrialized health care, a hazardous choice; rather peculiar in a market where everyone wants their own personalized website and IPod.

It is hard to rationalize doing mammograms in a 90 year old women, only to receive a bonus payment and it is wasteful to ask a hospital to repeat an echocardiogram just for documentation purposes because a patient has a history of congestive heart failure that is 20 years old and stable. But, that represents P4P. Really, it is not Pay for Performance. It is more like Perform for Payment. Talk about an “old” profession.

As physicians, our time should be spent individualizing the care of every person who puts their life in our hands. Our expertise should be employed to make our patients’ lives better. Every surgical procedure ought to be specifically designed to suit the surgery necessary and every medication protocol should be developed around the patient’s specific lifestyle, medical needs, and life goals.

By centering care on patient need, costs will be trimmed. As it is, millions of health care dollars are lost in a system that is more about maintaining an administrative infrastructure than about evidenced based methods to further patient health. The idea that the government or a health plan can define our patients’ health is preposterous if not arrogant. The philosophy of treating to “normal” rather than optimal cheats our patients of their ultimate potential.

P4P is an administrative quagmire built on the premise that physicians are so demoralized that we would rather fill in the blanks than hold our patients’ hand when they are in pain. Indeed P4P could be adequately achieved without a physician ever talking to the patient. Envision Lucy and the Chocolate Factory: P4P motivated health care reform is an assembly line of prescriptions, lab tests, and procedures running independent of patient need. It loses its humor when it is about your mother, or child.

The American doctor was not trained to be an indolent pawn. We were trained to lead, to inspire and to protect. Our professional tools are a valuable asset and should be used to better our patients’ day. Doctors are not a commodity available for trade on the open market. And our patients are not the collateral they will become if P4P continues to deliver a “report” that mirrors “teaching to the test”.

“Conventional wisdom”, “usual and customary” were never part of the vernacular until we lost our way and allowed the health care delivery system to be financially driven. Standards in healthcare were originally established as minimums but the current system has perpetuated the concept of standardization as a means of payment. So it is with P4P.

Health care reform needs rehab. America must relieve itself of its addiction to government or health plan run health delivery systems that only serve to industrialize the personal health needs of our patients. Studies show P4P doesn’t work. We knew that, now everyone knows that.

Pavlov was about dogs and should not define a health care delivery system. Our patients deserve the respect of a health care system driven by the doctor-patient relationship. As physicians, we are determined to maintain our focus on the best, individualized, patient centric care and the opportunity to optimize our patients’ day.

California health care reform

2007-01-28T19:07:00.000-08:00

California health care reform

Schwarzennegger and Health Care
Concentrate on healthcare…throw out the politics…(for a change)

As professionals, there is a routine that most physicians perform when dealing with our patients. First, we ask the patient to explain their problem(s) in detail. We ask questions to clarify their complaint and then we thoroughly examine the patient. This is generally followed by more testing to narrow the family of solutions and finally by a strategy or plan of action to cure the problem.
After reading the governors’ plan to come to a “healthy California”, I am concerned that the Governor didn’t do his homework and examine the problem thoroughly enough. I fear that his strategy can only end in the compromise of patients' lives and welfare.
I do remember a physician who once told me that one way to win a debate was to be so irrational that people stop listening and just agree with you to shut you up. But, this crisis is too critical and I am sure that the governor wanted the stakeholders to stick around for the dessert so I can’t believe that this plan is anything but a miscalculation. That said, physicians must be at the table and we must stay engaged in order to provide the governor with much needed guidance. I think it only fair to ask that the governor give physicians and our patients the respect of a workable plan, comprehensive but reasonable, legal and legitimate.
The governor fell prey to the health insurance and government fallacy that the access to care problem is an insurance problem. It is not. Moreover, in some instances, health insurance has proven to be a huge obstacle to good care. Ask a child who has MediCal insurance and suffers with intractable seizures about the year long waiting period to see a neurologist. Interview the patient with HMO insurance who had to quit their insurance in order to get the chemotherapy necessary to save their life. What we NEED to do is find the means to allow our patients access to the care they NEED when they NEED it.
Let me just elaborate on a couple of points in the “plan” itself. Most are familiar with the anti-trust constraints that prohibit physicians from negotiating fees, leaving doctors without a means of passing any tax or unfunded mandate on to any patient who has insurance including Medicare. That 2% tax will come right out of the back pocket of every treating physician in this state. A 2% tax on total revenue could mean a real tax as high as 40% on net revenue for oncologists who purchase the drugs they administer to their patients. It was the governor, himself, who rendered an Executive Order prohibiting physicians from Balance Billing their patients. Any thought of passing this tax on to our patients is erroneous. It can’t be done legally here in California.
As for the increase in MediCal dollars: those dollars will only enrich the intermediaries and health plans. There are few physicians who remain in the MediCal fee-for-service marketplace. Most MediCal doctors have already been forced into managed care by the state and those few physician specialists who remain outside the HMO purview will be forced out of MediCal fee-for-service by the new regulations coming from the federal government. Ergo…… none of those increased reimbursements are going to land in the office of doctors practicing medicine. As for the pay for performance criteria strapped on for good measure, I will refer the governor to the latest Journal of the American Medical Association (JAMA) that demonstrates that these measures prove nothing, do not show any improvement in outcomes, and are a total waste of time and money.
As for the medical loss ratios that are intended (I believe) to minimize administrative fees, look at the financials of the health plans operating in California. The real administrative cost of care is upwards of 60-70%. Most of these administrative costs are hidden in the sub-corps that the health plans have implemented.
One thing is clear and that is that the quagmire we call health care is complicated and makes little sense. The solution, however, is not found by ignoring reality or by insulting those of us who work hard to promote legitimate and good care.
If the governor is serious about providing better care to more people, I would advise that he open up the market place and make things more transparent. Many patients stay away from emergency rooms when they should be seen because of the potential cost or because of the misperception that they must have insurance to be seen. If it were known that a visit to the ER for an earache is $75, many parents would see that their children are cared for long before the earache keeps them out of school for 2 weeks. As it is, the threat of a $2500 bill for an MRI is a huge deterrent to care. If the real cost of $300 (approx) were known and advertised, I would imagine many would have that knee looked at and fixed and be back to work rather than remain on welfare complaining of chronic pain.
As for all the unfunded mandates and all the new pay for performance measures, these have been proved to be of little consequence so far as better care. Giving doctors 2-3 years to revise our peer review process and minimize medical errors would dramatically improve the quality of care. This is a much healthier means of engaging physicians than taxing us, threatening us with more regulations or asking us to do unnecessary tests just to get paid.
These two changes (no money added) would go further than all the measures in the governor’s plan. No one gets angry or feels compromised; more people get better care; the cost of care goes down; and the State of California once again may stand proudly as the first state to step up to the plate and deal with health care without wasting money or making any one stakeholder richer or more powerful. In the meantime, the State can help make health savings accounts more available and follow the federal government when it comes to their deductibility. This would lower the cost of premiums across the state.
I would implore the governor to not make this only about healthcare financing. This reform should be only about meeting the genuine needs of our patients in an open marketplace where patients have “real” informed consent and doctors have the opportunity to offer choices that are not based on “what’s covered”. Healthcare will only be affordable when our patients can invest in themselves, not in a “government mandated purchasing pool”. Insurance must remain an actuarial bet available to purchase at a reasonable rate, not a 1.6 billion dollar stock option for a CEO.
Our healthcare delivery system is in crisis. I believe that the citizens of this state are deserving of the serious consideration of a plan that has their interests at heart, where politics is removed from the discussion, and where stakeholders don’t have to go to anger management class to participate in the conversation.