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.
Saturday, September 22, 2007
Monday, May 28, 2007
Value based- Patient Centric Healthcare
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 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.
Sunday, May 27, 2007
The summer of Reform....
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.
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.
Sunday, February 4, 2007
AMERICA NEEDS HEALTHCARE THAT IS VALUE BASED AND PATIENT CENTRIC
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.
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.
Sunday, January 28, 2007
California health care reform
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.
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.
Subscribe to:
Comments (Atom)
