Stanley Feld M.D.,FACP, MACE
Some of the ideas in Barack Obama’s healthcare plan are good. However, some of the ideas have defects. The defects will render execution of his healthcare plan impossible. The complexity of his bureaucratic machinery will make his plan inefficient and costly.
· Quality and Efficiency.
“ Participating insurance companies in the new public program will be required to report data to ensure that standards for quality, health information technology and administration are being met.”
I have stated that measuring quality medical care has not been accurately defined. Quality medical care should be measured by positive medical outcomes at the least cost. Successful medical outcomes have to be linked to successful financial outcomes.
Inaccurate quality measurements are presently being used to judge physician performance. The system is called Pay for Performance (P4P).
Hemoglobin A1c testing is an example of a presently used quality measure. Does the physician do four hemoglobin A1c’s per year in treating his diabetics? HbA1c is a measurement of glucose control over a 3 month period of time. The result is a valid measurement of glucose control.
The four measurements of HbA1c are in itself meaningless. The importance of the measurement is to track patients’ HbA1c improvement over the year? How much of the improvement was due to the physician’s treatment? How much of it was due to the patient’s effort to improve his HbA1c? Did the improvement in HbA1c prevent the patient from developing a complication of Diabetes Mellitus?
Did the improvement keep the patient out of the hospital? The results and cost savings from these results are the parameters that should be measured to make the judgment of the quality of care and not the measurement of HbA1c itself. The dual fulfillment of the responsibility of the physician and patient should be measured. None of these goals are included in the definition of quality measurements at this time. Until they are we do not have an accurate measurement of quality medical care.
Before the government can demand that participating insurance companies in the new public program can ensure that standards of quality are met quality has to be defined. If the healthcare insurance companies are determining quality the government is essentially putting the fox in the hen house to have a feast.
Lowering costs by modernizing the healthcare system is an essential idea. The responsibility for the cost of care should not be a burden of the government. It should not be a burden on the employer who is providing the benefit. It should be a burden of the consumer (patient). It should be the consumer’s responsibility to take care of him. The employer and government should aid the consumer in his ability to fulfill his responsibility for his wellness and effective and efficient care if he is sick.
Lower Costs by Modernizing The U.S. Health Care System
- Reducing Costs of Catastrophic Illnesses for Employers and Their Employees:
Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers' premiums.
Many of the chronic diseases are the result of our social behavior and environment. Obesity, pollution, drug addiction, smoking, and public hygiene generate many chronic diseases. Who should be responsible for our social behavior and environment? Should it be the government, our employer, the state, or our neighbors?
I believe the government should be responsible for developing programs to eliminate pollution as it did in the past with smoking. Our government has dropped the ball with its public service campaign against smoking. It can be done if Congress and the President had the courage to do it.
The government could also do much to reduce obesity and drug addiction. However, it must be up to the consumer to be responsible for himself. Obesity and drug addiction are tinder box problems for our healthcare system. Coal burning electricity plants are another problem. It increases our carbon footprint but this impact is not even a required measurement for license. The indiscriminate use of antibiotics in cattle feed lots is another tinder box problem. The problem could be a mutation of an antibiotic resistant infectious disease epidemic. Barack Obama should be talking about solving these problems and not providing a rebate for employers who have employees with catastrophic illness.
- Helping Patients:
- Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure. Obama will require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care, give doctors better information and lower costs.
This is a great idea. Presently these programs are not supported by the government or healthcare insurance companies.
Traditionally the government sets up pilot programs to test every concept. However, when the pilot study for the effect of managing chronic disease failed, it failed not because the concept of chronic disease management was wrong but because the design of the pilot was defective.
· Coordinate and Integrate care.
Over 133 million Americans have at least one chronic disease and these chronic conditions cost a staggering $1.7 trillion yearly. Obama will support implementation of programs and encourage team care that will improve coordination and integration of care of those with chronic conditions.
This is another great idea. The emphasis for reimbursement has to shift from procedural medicine to cognitive medicine. Since cognitive medicine has not been well supported with reimbursement, physician care has migrated to procedural medicine. Diabetes education is an essential element in teaching the patient how to become a “professor of their disease”. It is essential that patients know how to self manage their diabetes. Diabetes education program must be supported so that physicians can afford to develop diabetes education centers in their office. The diabetes education must be an extension of the physicians care. It does not work in a free standing clinic that is uncoordinated with the physician. It has to be a team management effort with the patient in the center of the team and the physician the captain of the team. It must be a team effort so the patient feels connected and cared for.
None of the infrastructure for chronic disease management is in place presently. I am happy that in Barack Obama’s healthcare plan there is awareness of this essential element to repair the healthcare system. However legislative regulation must occur for this to become a reality.
· Require full transparency about quality and costs.
"Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs."
It must occur if there is going to be any improvement in the costs of the healthcare system. However, if all we have is a single party payer (the government) with the administrative services outsourced to the healthcare insurance industry price transparency will not occur. There will be no competition for healthcare insurance coverage. The lack of competition means the lack of innovation.
Barack Obama has some good ideas.The ideas will fail because big government is king. It is big government’s role to control the lives of the people rather than creating programs which promote people to control their own lives? Most people can be trusted. If they can not control their own lives under proper incentives and supervision they should be penalized. The government should not try to control the lives of the people.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.