Health Care Reform Should Not Write Off Small Medical Practices

While I've generally been of an optimistic wait-and-see approach to the recently enacted health care reform legislation, I have been concerned to note that a fair amount of it seems optimized to large medical organizations.

For example, the billions to be spent to create incentives for doctors to use electronic medical records (EMR) does nothing to require uniform code standards so that various EMR products would still be able to communicate and share data with each other. I hesitate to spend up to $40,000 in start-up costs alone, only to find that my EMR system can't share data with other offices or hospitals.

Also, the use of medical practice data for statistics gathering is not useful in small office practices because of the smaller number of patients. This really presupposes medical groups with tens of thousands of patients like Kaiser or the VA.

This article reports on a meeting with two White House officials basically stating that doctors should get ready to enjoy a life in Big Medicine. Frankly, if I enjoyed working for Kaiser or the VA, I'd already be doing that.

I do find it unfortunate that the present administration's approach to stimulating businesses and propping up banks similarly seems to almost solely be directed to enterprise-scale businesses and large banks and not the small "mom and pop" businesses and local credit unions.

As far as I'm concerned, entrepreneurship is what makes America great!

Health Care Reform

So, I'm getting a lot of folks asking how I feel about the passage of the health care reform bill (H.R. 3590- the Patient Protection and Affordable Care Act), and how I think it's going to affect me and other doctors.

Mind you, these are my opinions based on following these issues for years as a doctor.

If you want to read the actual documents of this bill and of the bill that will proceed through the Senate for the President's signature (H.R. 4872- the Health Care and Education Affordability Reconciliation Act of 2010), this article provides links to the full source documents.

More manageable, plain English 20+ page summaries of these bills (pdf) can be found here and here. This and this are for folks who like FAQ lists.

Generally, I like what I see.

I think it's great that the first things on the table that should occur in the next months include extending coverage for young folks to 26 years old on their parents' insurance, setting up insurance pools for people with pre-existing medical conditions, closing the Part D "donut hole" and covering preventive care for MediCare patients, and doing away with insurance company practices of capping coverage, refusing to insure patients with medical conditions, and stopping your insurance when you become ill.

Do I agree with requiring people to have insurance?
Do. The. Math. Or, consider whether you really feel okay about your taxes and premiums paying for the medical care of a healthy 20 or 30 year old who decided not to pay for insurance and then develops diabetes or has an accident. Did requiring drivers to have insurance cause premiums to go so high that you can't afford to drive? Or, is it better that if you get in an accident and the other guy is at fault that his insurance covers it because he has to have it?

Do I think it's going to bankrupt health care?
No. I believe the Congressional Budget Office.

Will it "cut down on Medicare"?
No. Remember the closing the donut hole part?

Is it okay to pay for this with taxes?
Please. We're talking tax hikes of 3.8% on unearned income of people filing over $200,000/year, or couples filing jointly over a quarter million dollars a year. People in these tax brackets have seen a 300% increase in their earnings in the past 10 years. The rest of the country (adjusted for inflation) has stayed flat over this time. I believe the super-rich can and should afford it.

But, what about my own insurance?
No downside. There's nothing in this law to keep you from staying on your present insurance if you like it. However, you might find it reassuring not to have a $1-3 million dollar lifetime cap on it if you develop and expensive problem like a cancer or a bad car accident. Also, formation of risk-sharing pools in each state should make it possible for you to get your own affordable insurance if you get fired, go to part-time, retire before 65, decide to go into business for yourself, or just don't want to go to Kaiser if the boss decides to change everyone to Kaiser. Bummer.

The government? Involved in health care?
The government already is involved; MediCare, MediCal and the VA. As far as I can tell, the private sector insurances have otherwise had free reign since World War II. I am as frustrated as any doctor with run ins with Medicare, but I also have run its with Kaiser, Blue Cross and Blue Shield. I am perfectly happy to let the government have a go at it. Heck, the seem to do just fine with having a military, enforcing the law and putting out fires. I also must say I've never had a letter or parcel lost by the Post Office.

How do I think it will affect me and my practice?
Dunno, but I remain optimistic. I look forward to not losing patients because they lose their jobs or their boss goes cheap (Kaiser). I look forward to seeing my college students and recent grads without the burden of them having to pay out of pocket. Hey, there's a good chance my own insurance rates will go down and/or that I could more easily retire before 65! Having an influx of available new patients who now have insurance? Sounds good.

Next? More jobs!

Health Care Reform

On the eve of a vote on health care reform in the House, this link shows a brief summary of the bill's content.



For those with a yen for source documentation, this link is to a pdf file that shows the entire content of the bill.

Health Care Reform Bill HR 3962

Patients have been asking me what I think of the government's efforts at reforming our health care system.

I've posted once or twice in this before covering the general principles and how US health care stacks up in terms of cost, administration and quality compared world-wide.

More recent patient inquiries were more along the lines of how I, as a doctor, feel about the specific proposals and how I see it affecting me and my patients. Up to now, there hasn't been much I could specifically say since the reform bill before the US House of Representatives was a work in progress. That is, until last night when it passed the House. Reform must now be approved by the US Senate, so it's quite likely that it will be different than the present House Bill before it is presented to the President of the United States for signature into law.

At present, HR 3962:

• Would take effect by 2013
• Would require Americans to purchase medical insurance or pay a penalty of 2.5% of income, subject to exemption due to hardship
• Would expand Medicaid/MediCal to be able to cover about 30 million Americans who currently are too poor to buy private insurance, but too "rich" to be eligible for Medicaid or MediCal (MediCal is the California version of Medicaid, which is a Federal program providing insurance to people close to the poverty line)
  
• Would close MediCare's "donut hole" in Part D drug coverage, and change incentives in the currently scandal-prone MediCare Advantage insurance products
  
• Would lift the exemption of health insurance companies from anti-trust laws, which up to now have kept them from being investigated for their practices
• Would forbid insurance companies from denying insurance based on gender or pre-existing medical conditions
• Would forbid insurance companies from the practice of rescission, in which they investigate you background upon receiving expensive claims to find ways to retroactively deny your coverage
• Would create a governmentally sponsored "public option" for those who choose it over privately available insurance.
• Would forbid covering the cost of abortions except in cases of rape, incest or threat to the health of the pregnant woman using Federal funds rendered to insurance products
• Would, according to the Congressional Budget Office, be cost neutral
• Would be partially funded through a 5.4% income surtax on couples filing jointly over $1Million in income, or individuals filing over $500,000 in income
• Would also be funded by changes in the existing MediCare and Medicaid programs, details of which are unclear at the time of this writing (the bill is about 2,000 pages long)
• Would help to fund continuing medical education for doctors and nurses

Personal politics aside, I think this is a step in a good direction. I cannot see a problem with a cost-neutral program that would make affordable health insurance available to over 96% of our fellow Americans.

Requiring everyone to have health insurance is common sense. Otherwise, healthy people skip insurance leaving sick people as the main insurance participants which results in continually increasing costs. This gets passed on as increasing premiums in a system that still has to fully and publicly absorb the costs of the healthy uninsureds when the get ill or injured. It makes as much sense as requiring auto insurance, which protects every driver against the possibility of having to pay out of your own insurance even though the other driver was at fault but has no insurance.

As to the carve-out of Federal funds to public and private insurances in the coverage of abortion, from a purely pragmatic point of view that's going to be a real accounting nightmare. From an ethical point of view, I think it's pretty silly since everyone pays taxes that pay for things that one may not use or like. That's just the nature of taxation, government and shared resources in a democratic (as opposed to theocratic or dictatorial) society.

I do hope that some provisions for enforcement are made; it's one thing to illegalize price-fixing and rescission by insurance companies, and quite another to enforce it.

I still remember receiving my settlement checks from several major insurance companies a few years ago in which the were sued in class action filings under RICO statutes and chose to settle rather than undergo a public trial during the heydays of the HMO's. It's not good when every single one of the country's biggest health insurance companies are basically willing to admit that their business practices are indistinguishable from the Mafia.

I also look forward to the day that I don't lose patients from my practice because of a change in their employment or their boss's choice of insurance.

Frankly, I also look to the possibility of lower insurance costs without lower insurance quality for my practice.

I don't know how this will effect my bottom line, though if the "public option" were to reimburse at MediCare rates plus 5%, that would be just fine. The days are long gone when insurances paid much above flat MediCare rates unless you were the biggest fish in the pond. MediCare+5 along with MediCare (independently of the Reform Bill) considering lowering reimbursement of expensive procedures in order to increase payments to primary care services would be mighty welcome to little guys in the trenches like me!

Perspective on Health Care

This link is to a well written op-ed from the Washington Post and is worth a read. It's fairly brief, to the point and quickly summarizes the similarities and differences in structure, cost and quality of health care in various industrialized nations compared to the U.S.

It certainly reflects the data on the subject, and also my experience of health care in other countries as experience by me, my family or as related by my patients.

Presidential Candidate Health Care Reform Proposals

The New England Journal of Medicine in its October 16th issue provides a review of Senator McCain and Senator Obama's proposals for improving health care in our country.

This journal is one of the most widely read, well-researched and respected professional medical journals in the world and these reviews are presented for an audience of physicians and other medical professionals.

They are well worth reading as they are understandable to a broader audience which would include anyone with an interest in the opinion of one of the most prestigious medical journals in the country.

To summarize,

Early in his campaign, Obama recognized that the success of health care reform rests on the plan's ability to slow spending growth and make health care affordable for everyone. His plan would reorganize the health-insurance market — but not change the basic financial incentives in the system that drive up spending. Although the plan would significantly increase the number of Americans with health insurance, it remains to be seen whether that would come at a price Americans would be willing to pay.

The choice facing health care professionals, like all Americans, is basic: Who deserves to be trusted with the stewardship of America's health care system? The McCain proposal violates the bedrock principle that major health policy reforms should first do no harm. It would risk the viability of employer-sponsored insurance and the welfare of chronically ill Americans in pell-mell pursuit of a radical vision of consumer-driven health care. Senator McCain's plan does not demonstrate the kind of judgment needed in a potential commander in chief of our health care system.

Health Care Reform

So, I'm going to break team here a little and post on a directly political issue (as opposed to clinical or regulatory/insurance concerns).

This is not intended to be a personal soap box on politics in general; I am simply getting a lot of questions on this lately, and I presume it is due to the national-level debate in the setting of the upcoming Presidential elections in November.

What is Health Care Reform?

That being said, let's clarify some terms. Part of the problem is the overuse, misuse or misunderstanding of some words used in public debate on health care in our country.

"Socialized Medicine"

Right off the bat, no one is proposing "socialized" medicine. Period. If we accept the definition of socialism here as advocating government ownership and administration of the means of providing medical services, then you may notice that no one in our debate is suggesting that the federal government should outright own all the hospitals and medical practices and that all doctors should be employees of the federal government. This would approximate the National Health Service in the U.K.

So: throw away "socialized medicine". No one. Repeat, no one is suggesting this. The motives of politicians using this term to stifle debate, or arouse anxiety or anger should be questioned.

"Universal Health Care"

"Universal health care" is a nebulous catch-all phrase that has no specific definition, save that it is meant to mean all things to all people. Generally, the term is used where improving the availability of health insurance and decreasing the number of people in our country who have no insurance is intended.

While no one could reasonably object to any genuine effort to make health insurance more available to more people, you may notice that any such proposal typically includes specific actions like tax credits for purchasing medical insurance, negotiating with health insurance companies at the table, or offering more incentives to HMO's.

Unfortunately, none of these ideas really addresses the underlying causes of our problems with insurance costs or health care costs. Certainly, including insurance companies as equal partners in any planning is like including the foxes in round-table discussions concerning the security of the chicken coop.

The insurance companies are the only interested party who is satisfied with the status quo, because they are the only interested party who is making serious profits at this, and are the only ones who are distinctly for-profit only in their fullest intent and by definition. (Yes, doctors make a profit. We do have bills to pay, kids to put through college and such. However, the ethical and professional mission of the doctor or hospital or clinic is to provide the best possible medical care for its patients.) Patients, doctors, hospitals and politicians all want substantial change.

So: IMHO, any "universal coverage" plan that includes the insurance companies as equal partners and tries to keep their role as close to the status quo as possible without upsetting their apple cart is doomed from the outset to represent little to nothing in the way or substantial and meaningful improvement and change.

"Single Payer"

"Single-payer insurance" or "national health insurance", or "MediCare for all" is advocated by many (disclaimer: including me- more on that later). This would approximate France or Germany's (or. to a lesser extent Canada's) style of health care. Actually, it would approximate the way health care is administered in virtually every developed nation on the planet except ours.

This would mean that all citizens are entitled by right (and not by bought privilege) to a basic level of health insurance from birth to death. This would typically be through a single large insurance pool composed of all citizens and administered by a single large insurer, which is usually the federal government. The State of Oregon has a roughly similar State administered health plan.

"MediCare for all" is a term used to mean the same thing, but in a way that may convey more meaning than the technically accurate but confusing "single payer". Let's face it, the only folks who use the term "payer" here are medical professionals, insurance people and policy wonks. Average folks think "insurance company". MediCare provides for doctor visits, annual exams, cancer screening, care of acute and chronic medical problems, labs, tests, ER, hospitalization and surgery. If you want and can afford more coverage, then you are free to buy it from whoever you choose. Thus, "MediCare for all" is meant to convey the idea of such insurance being extended by the federal government to all citizens, and not just those who are over 65 or disabled.

As is already practiced in many of the other developed countries of the world, the federal government could administer a publicly funded or supported health insurance that would cover the same things that MediCare covers (as described above) and extended to such care appropriate for children, as well. Insurance companies (through employer-based means or otherwise) would fill the niche in the marketplace for those who want to buy more coverage such as improved drug, durable medical equipment or long-term care coverage, or perhaps as specific riders in the same way you can buy homeowners insurance riders on your cameras or jewelry or computers if their value exceeds the basic plan coverage.

So, what do you think about health care reform?

Again, I get asked this a lot by patients in my office, hence this post. I have tried to define all terms as accurately as possible though I'm sure it's evident that I feel the best plan would be for our government to adopt a single-payer model that mirrors every other developed country in the world.

I see no sense in doing so just because everyone else is doing it. I feel we should do so because of the following facts (repeat, facts: not opinions, facts):

• We do not have the world's best medical system, we have the world's 37th best medical system.
• We do moderately well in terms of measurable health quality (24th best), but
• we do very poorly in terms of being able to care for all our people (55th best), though
• we excel (1st best) in emergency care.
• We spend twice as much money per person for this level of performance.
• Unfortunately, one must wonder whether this translates as follows: we have the best emergency care in the world because we have to, since so many people have no other way to get medical care they go to the ER for it or wait until they're crashing and burning to show up, and thus our overall levels of infant death, lifespan and disease occurrence and care suffer for it.
• Economic models prove that having health insurance where you split the pool of people who are insured as we do will lead to exactly the problems we face where people often find that no one will insure them, or they cannot afford available insurance. (Harford, T. 2006. The Undercover Economist, Oxford University Press, pp. 109-110, 113-16, 119-23.)

Additionally, I myself have moral and ethical qualms with the status quo.

• I think it is wrong to have to change doctors because of your insurance or your job.
  
• I think it's stupid to put the entire choice of your insurance in the hands of your boss (not because your boss is necessarily mean, but because your boss has the most incentive of any player in the game to keep the cost as low as possible).
• I think it's wrong for 47 million fellow Americans to have no health insurance. That's 16% of our entire country! That's 1 of every 6 men, women and children! Note that this doesn't even count people who are on MedicAid or MediCal which has so few doctors who will accept it you may as well be uninsured in many respects (these folks are referred to as "under-insured").
• I think it's wrong for the most common cause of personal bankruptcy in our country to be unpayable medical bills. Half of all personal BK's are because of this, and 76% of these BK's involved households that already had medical insurance at the time of the illness.
• I think it makes bad business sense to not significantly change a business model that costs twice as much as other businesses in the marketplace, and in which you are the 37th best producer. Personally, I aim to be the best and not settle for Top 40. Let's stop saying "Thank goodness for Slovenia (#38)!" No offense to Slovenia, I just expect better for the amount of money we're spending.
  
• I think adequate medical care should be a right, and not a privilege that you have to purchase. I do not believe that it is acceptable for those of us who are less wealthy to be left to die younger. ("[i]nasmuch as you did it to one of the least of these My brethren, you did it to Me", if I may make so bold.)
  
• Yes, I put my money where my mouth is. MediCare, TriCARE, MediCal, Workers' Comp and union commercial insurers typically pay quite poorly. However, I have patients on all these insurances because I think you should have a doctor and get medical care regardless of whether or not you are old, a veteran, poor, injured on the job, or are a labor union member. (Mea culpa. If I were a baseball fan, I guess I wouldn't be a Yankees fan. Besides, I'm from Pittsburgh. I still remember Roberto Clemente!)

So, frankly I hope to eventually see a single health insurance in our country that covers all our citizens from cradle to grave and still has doctors and hospitals in the private sector where competition will still create incentives to do the best possible job of providing professional medical care.

Even though some of my previous posts reflect some apprehension on my part with the federal government administering the insurance, it really makes the most sense for them to do so. At least, it makes as much sense as calling the police and the police responding as an arm of the state, and not as the result of several calls to local and competing privately owned security companies.

Even if a 10% increase in income taxes had to occur to fund this (tax is to government as income is to your household), would you still be ahead? Certainly, I would. Given the cost to me of insuring my family and my employees I'd still be cash ahead. That doesn't even begin to include the other costs and savings in not having to pay a billing service and freeing up my registered nurse to work with patients and not dicker with their insurances.

Mind you, some proposals suggest this level of tax increase. Others propose that the costs of providing a national health insurance would be more than offset by savings in doing so (The Physicians' Working Group for Single-Payer National Health Insurance, 2003. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance, Journal of the American Medical Association, 200 (6). 798.).

What about you? Run the numbers, do the math. Compare an increase in 10% on your income tax against the costs of your health insurance premiums or deductions from your pay for this, the amount you spend on deductibles and co-pays. Heck, add in the lost income and vehicle maintenance and fuel costs of going to Folsom or Sac for this if you have Kaiser or some HMO. If those costs are higher than a 10% income tax increase for you, let me know.

But, also add in other factors and hidden costs.

What if...

• Every neighborhood had an after hours clinic that would even do house calls?
• You got pregnant and didn't get refused health insurance because your pregancy is a pre-existing medical condition? Hey, what if actually your insurance included more maternity and paternity leave and home care after the delivery?
• What if when you were diagnosed with a really serious disease like cancer, it meant that your insurance stepped up and covered more of the costs when you most needed it?
• What if everyone had insurance, but it didn't affect your choice?
  
• Would it mean maybe we could do better at preventing deaths that are preventable with good medical care? That would be nice, since right now we are 19th best in this out of all 19 major industrialized countries.
• Hey, for that matter, what if better coverage didn't come with higher taxes?

Just sayin'...