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.
Monday, May 28, 2007
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.
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