Repairing the Healthcare System

It Is Not Only Older Physicians Who Are Discontent: Part 1

Stanley Feld M.D.,FACP,MACE

It has been said that the older physicians are the only physicians upset by the way they are being treated by the healthcare insurance industry. The claim is older physicians are spoiled by the golden days of medicine. My reply to that statement is nonsense. When a professional is treated as a commodity no matter what his age discontent is generated. The older physicians are products of the silent generation. When the younger physicians are pushed to the edge we will hear lots of noise and have lots of rebellion. The rumblings have started.

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates.

Uwe Reihardt said it all to my surprise in a letter to the editor of the New York Times in May 2008.

“Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

Many examples of discontent from younger physicians can be sited. As these physicians gain experience and understand that the healthcare system is a business to the facilitator stakeholders whose only concern is the bottom line the patient-physician rebellion will pick up steam. The facilitator stakeholders account for 80% of the healthcare dollar and add little value.

“A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; “Your days aren’t busy enough already?” I asked.

The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.

He smiled wanly. “Just look at my eyes.” They were bloodshot.“This whole week I haven’t slept more than about six hours a night.”I asked when his work usually got done. “It is never done,” he replied, shaking his head. “See this pile?” “He pointed to five large manila packages on a shelf above his desk.” “These are reports I still have to finish.”

“As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.”

The discontent is building. Physicians are fed up with what they perceived as a loss of professional autonomy. They can not stand the unwarranted restrictions on their medical judgment. As demand for physician services increase we are experiencing larger and larger physician shortages.

Another physician complained. “I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.” Managed care is like a magnet attached to you.

A 42 year old physician complains that he continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

The endless abuse on professional integrity amazes me. A high school graduate sits in front of a computer screen deciding on what a physician can or can not do. Another healthcare insurance company assistant sits in front of a computer billing screen reducing reimbursement on questionable computer programming decisions. The appeals process is difficult and time consuming for physicians.

“Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.””

How long do you think young intelligent physicians will tolerate this abuse? How long do you think it will take to train another compliant work force? America has a physician shortage that is about to accelerate.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Some One Is Making Money On Medicare. It Is Not Doctors

Stanley Feld M.D.,FACP,MACE

“The Bush administration proposed on Thursday to crack down on the aggressive marketing of private Medicare insurance plans by outlawing unsolicited visits and telephone calls to beneficiaries, regulating commissions paid to sales agents and increasing the fines that could be imposed on insurers.”

If Medicare insurance coverage loses money why would an insurance company go after the Medicare business?

My answer is that Medicare doesn’t loss money. The government losses money by paying the healthcare insurance industry high fees to administer Medicare. I believe these fees are non discoverable in the context of the billing and reimbursement process.

Medicare Advantage is the private Medicare Plans sold by the healthcare insurance industry. The healthcare insurance industry has used high-pressure sales tactics led some people to sign up for unsuitable Medicare policies.

The government does not have the authority or manpower to regulate marketing of Medicare Advantage coverage. The Bush administration’s view is “states should not have the authority to regulate the marketing” of private Medicare plans. Doesn’t the Bush administration position on state authority sound smart?
It is a good thing we have freedom of speech and the press in America. It is a good thing we have the right to have political action groups. Political action groups have the ability to educate citizens and increase awareness about problems we face.

Paul Precht, policy director of the Medicare Rights Center, a group that counsels beneficiaries, said: “We need Congress to give the states a greater role in enforcement. The federal government does not have the manpower.”

The problems are door-to-door marketing of private Medicare plans, outright solicitations in parking lots as well as solicitations at free lunches.

The America’s Health Insurance Plans always welcomes new proposals and rules but say the proposals or rules goes too far.

Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said she welcomed the proposals, though they go further than the industry had recommended in a few areas like cold calls.

The healthcare insurance industry has been marketing Medicare Advantage Plans by offering food and faulty healthcare coverage through misleading advertising. There will be no more “Have Lunch on Us!” fliers.
However, the fines proposed are less than the financial benefit derived by the healthcare insurance industry. The fines will probably not be a deterrent to abuse because of the government will be unable to enforce the rules.

Another important abuse is policy switching. Insurance agents’ commissions increase by policy switching.
The responsibility of the government is to educate the buyer to beware. The responsibility of the buyer is to beware of the tactics and abuse of the healthcare insurance industry.

Many carriers now pay higher commissions in the first year. Some pay only for the first year, with no commission in later years. This creates a “financial incentive for agents to encourage beneficiaries to change plans each year,” the administration said.

A $200 fee in addition to your Medicare premium payment increase the total cost of healthcare coverage. Medicare Advantage plans are healthcare plans offer patients private insurance. However, it appear that the coverage is not much different than traditional Medicare insurance. The government relinquishes most of its control over the reimbursement payment system to the healthcare insurance industry.

The National Association of Healthcare Underwriters issue the same “yes,but” statements as the America’s Health Insurance Plans.

Jessica F. Waltman, a vice president of the National Association of Health Underwriters, which represents agents and brokers, said, “We agree that insurers should eliminate financial incentives for agents to make quick sales and shift beneficiaries from one plan to another without regard to their health care needs.”
But, Ms. Waltman added, small differences in commissions in the first and subsequent years may be justified.

Uwe Reinhardt said physicians receive 20% of healthcare expenditures and 50% of that 20% goes for overhead.

Where does the other 80% go? When healthcare policy makers speak of healthcare reform they should remember that 80% of the Medicare dollars are used to pay the private healthcare insurance companies administrative fees and hospital charges. The majority of the money is not spent to pay physicians.  They should think twice before destroying the infrastructure that delivers medical care (physicians) to our senior citizens by constantly decreasing physicians’ reimbursement. The healthcare policy makers should concentrate on how to reduce 80% of the Medicare dollars spent on other non value added services.

Politicians Are Hard To Trust : Part 1

Stanley Feld M.D.,FACP,MACE

It is getting harder and harder for senior citizen on Medicare to find a physician who takes Medicare patients. Many physicians are not taking Medicare reimbursement because the government continually decreases reimbursement. In many cities Medicare reimbursement is lower than the overhead of the physicians’ office practice. This year a 10.6% reimbursement cut is due to go into effect July 1st. The 10.6% decrease in reimbursement for physicians is irrational thinking. Physicians collect only 20% of the healthcare dollar. A ten percent decrease in physician reimbursement will save the government only 2% of its healthcare expenditures. The 10.6% means a lot to the practicing physician. The government should be concentrating on who collects the other 80%. It should be figuring out how it can decrease the other 80% of its expenditures.

Texas physicians and the Texas Medical Association are usually pretty proud of their Republican Texas Senators. The Senators have recognized the importance of standing up for patients and their physicians. However, on June 26th 2008 Sens. John Cornyn and Kay Bailey Hutchison broke their promise to protect our senior citizens ability to obtain Medicare coverage from a physician of their choice. After the house of representative passed a bill 355 to 59, the senate failed to pass it by one vote. Either Texas Senator could have altered the outcome.

“Sens. John Cornyn and Kay Bailey Hutchison last night chose to protect insurance companies’ profits instead of protecting our patients’ health. All Texas physicians should be deeply offended by their decision, and we need to let them know exactly how we feel.”

They voted against the bill to forestall the looming 10.6-percent cut in physicians’ reimbursement. The Senate bill fell one vote short of being passed. Either Texas senator could have made the difference. They played partisan politics with our patients’ health. They also voted to defend unnecessary overpayments to certain Medicare Advantage health plans. The private Medicare Advantage plans have been ripping off seniors for years. Finally, something was going to be done about the proposed reduction in physicians reimbursement. Our Texas Senators let us down after promising to support us.

You can contact both senators at these telephone numbers or email addresses and ask them to change their vote.
• Sen. John Cornyn: (202) 224-2934

http://cornyn.senate.gov/public/index.cfm?FuseAction=Contact.ContactForm

• Sen. Kay Bailey Hutchison: (202) 224-5922

http://www.senate.gov/~hutchison/contact.html

John Cornyn is up for reelection. He is begging patients and physicians for their vote. He is up against an underfunded Democratic underdog. I do not think Senator Cornyn thinks an underfunded underdog can beat him. I think he might be in for a big surprise. I do not think Texans want to vote for someone who does not defend effective patient care.

It is up to the politicians to keep their promises and defend their voters. This is especially true when it comes to patient care.

I am positive he does not understand what has to be done to repair the healthcare system. It is not cutting physicians’ reimbursement. It is changing the healthcare system as I have outlined.

“ Resolution 6331 flew through the U.S. House of Representatives earlier this week. It stalled in the Senate last night. The bill would:

• Stop the cut, continue current rates for the rest of this year, and provide an additional 1.1-percent increase in 2009;
• Give Congress 18 months to devise a long-term replacement for the sustainable growth rate financing formula, as we demand in TMA’s Texas Medicare Manifesto;
• Extend the Geographical Practice Cost Index, which protects physicians practicing in most of Texas; and
• Provide parity for Medicare mental health benefits and increase coverage for preventive services.”

The great disappointment to me is you can not trust politicians. Yet at election time they will say anything to get our vote.

Sen. Kay Bailey Hutchison is a nice woman. She is planning to run for Governor of Texas. It will be very difficult for me to vote for someone who goes back on her word.

I am writing to my senators about my outrage. Will you?

Our vote is a powerful tool. We must use it wisely.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

RHIOs Fail To Thrive, New Study: Part 2

Stanley Feld M.D.,FACP,MACE

A RHIO is a network of information (Regional Health Information Organization) of all the patients’ charts in a region. Anyone can get patient information and physician care activity instantaneously with proper authorization. The RHIO would be great if we lived in a non litigious society  and an environment of total trust. It could work if everyone would keep this information private. The data collected could only be used for the benefit of patients and physicians and not against patients or physicians.

The recent published study revealing RHIOs failures made several important points. The first being physicians and patients must feel compelled to participate.

“These findings suggest that nationwide electronic clinical data exchange will be much harder than what many people have envisioned,” Adler-Milstein said in a statement released by Health Affairs. “The expectation has been that we will have RHIOs throughout the country that bring together all the providers in their region and engage in comprehensive data exchange. In reality, we’re seeing few established RHIOs and those that are established only have a small number of participating groups exchanging a narrow set of data.”

The second important point is RHIOs must be financially sustainable. Who is going to pay for the data collection and storage? I suspect patients would pay for it in higher costs. 

“According to the article, “it is not clear whether even more mature RHIOs have a clear path to becoming financially sustainable.” Most of those RHIOs deliver results of laboratory and radiology tests to doctors, and the article says this is the where the return on investment is most achievable.”

If RHIOs are not financially sustainable then the government has to provide more funds. At a time when the government is economically stressed there are no funds for failed experiments.

“If we want RHIOs to attain the vision of comprehensive health information exchange, we need to increase our investments in them,” Adler-Milstein said. “Otherwise, many of these RHIOs will be unable to sustain themselves under the current market-oriented approach.”

 Dave Minch, Chair of HIMSS HIE Steering Committee published a stunning letter that says it all.

“As a provider who strives to do the right thing, I am not happy when people accuse the provider community of shunning data exchange simply for competitive reasons. That can't be farther from the truth.”
It is simple to point the finger at physicians. Physicians are an easy scapegoat."

 Dave Minch goes on to tell it as it is.

“We have a very large private network that encompasses as many physicians as will subscribe to it because we want our physicians to have as much data about their patients as possible. No, its not competition we are afraid of.”

Patients fear of loss privacy. Physicians fear litigation. Policy wonks who think RHIOs are a great idea might not have taken this into consideration. Once there is significant malpractice reform, adequate safe harbor rules, and appropriate physician incentives RHIOs might work.

“Note the word "private". That's our present requirement, because of the litigious nature of our society, and especially in today's economy when inappropriately disclosed data can be the meal ticket of a lifetime. If HIE is to become truly widespread, there have to be standards and there have to be safe harbors for those of us willing to pay the necessary security costs to keep our patients' data out of the hands of those who would violate patient privacy mandates. The first prosecuted security breech of exchanged data will set the industry back 10 years. And you can bet that it will happen without nationally instituted standards and protections. So, who wants to be first?”

There is nothing more to say. The government ought to fund my ideal electronic medical record. Patients ought to own and have access to their records. It should be patients who are responsible for providing their records to whomever they choose.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

 

 
 

Disinformation and Media Spin: Part 2

Stanley Feld M.D., FACP, MACE

Dr. Aaron Carroll and Dr. Ronald Ackerman, the principal authors of the 2003 survey and 2008 letter in the Annals of Internal Medicine, states very clearly that physicians support a national health insurance plan. They does not state whether physician support a government run single party payer plan.

"Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance," study author Dr. Aaron E. Carroll, director of Indiana University's Center for Health Policy and Professionalism Research, said in a prepared statement.”

However they seem to be saying that physicians want the government to take over.

 "Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy," Ackermann said in a prepared statement.”

The source data is not available in their 2008 letter published in the Annals of Internal Medicine. I have evaluated the source data in their 2003 survey. The survey consists of two questions. The questions have misleading implications. Both questions start by asking one “to assume the principal goal of any national health insurance proposal is to arrange health care financing for all U.S. citizens”. In 2008 I believe most physicians would agree there should be universal healthcare coverage.  The real question is do physicians want the government as the single party payer?

Question 1 asks “ do you support or oppose government legislation to establish National Health Insurance?”

Does that mean the government creates a plan that should cover everyone or does that question mean the government establishes a National Health Insurance that it administers as a single party payer?

Question 2 implies the former. “Do you support or oppose a National Health Insurance plan where the entire healthcare is paid for by the government?”

The survey design is flawed.  Therefore it cannot yield valid conclusions. However, let us assume we could draw conclusions from the data in the survey.

 

Figure 2 describes the characteristics of the respondents in the survey.1650 physicians completed the survey sent to 3250 physicians. Only 1263 physicians had their characteristics compared to the AMA Physician Master file of 733,183 U.S. Physicians. What happened to the characteristics of the other 387 included in the survey? Does this 30% drop in number of physicians invalidate any power to arrive at conclusions for the data?  Does the number of physicians in the survey represent a large enough number of physicians to represent the 733,180 physicians in the U.S.?

 None of the mean insurance types, primary practice settings and primary practice locations was available in the AMA Physician Master file. This is one of several flaws in the study
The most important characteristics of the 1263 physician respondents was missing. How many physicians were in private practice? How many physicians in the survey group were employed and salaried by a university or hospital? What is the percentage of survey group physicians in private practice who received an institutional salary? These characteristics would have a effect on the physician response to the questions.

Additionally, any study whose published results present percentages without actual numbers or statistics has conclusions that are suspect. 

Physician attitudes about National Health Insurance Financing are the most important table in the article.(Figure 3). The results are presented in the most misleading way. If a physician assumed that a national health insurance plan was universal coverage without a single party payer they might choose one answer to a quick survey. They might have thought the question meant the government would be the single party payer. 19% generally oppose, 21% strongly oppose and11% were neutral. The 11% neutral respondents might have been uncertain of the meaning of the question.  If opposed to a single party payer they might have chosen to remain neutral. Therefore 51% of physicians might have opposed a national health plan as opposed to the 40% in the survey.

The answer to question 2 was important. It nullifies the principle authors’ message.  33% of physician strongly opposed, 27% generally opposed while 14% were neutral to a government paid for National Health Insurance plan. A neutral answer to this question could mean to some that the government would give me less grief than the healthcare industry has in recent years.  Only 9% of physicians strongly supported the government as a single party payer.  Again, we do not know the actual number of these physicians in private practice with monthly overhead. We do not know if the sample is valid or the results statistically significant. The number of physicians opposed to a single party payer was not discussed in either the 2003 or 2008 press release.

 Only three predictors of physician support for governmental legislation to establish national health insurance plan were statistically significant. (Figure 4) The statistically significant predictors of support for national health insurance plan in reality support opposition to a single party payer according to the data presented. The statically positive predictors were inner city physicians vs. non inner city physicians, Medicaid vs. non Medicaid providers, and primary care vs. specialists. The predictor chart did not separate out the demographics of the physicians in each category.

 

In the last table the percentages of physicians in favor of the federal government as the sole payer was soundly defeated by all specialties. All of the specialties represented voted below 50% for the government to be the single party payer.

Here we see the data telling us one thing and the authors, through the use of the media providing a sensational but false conclusion from the data. The survey was poorly designed with little statistical significance.

Quoting Dr. Carroll, a primary author "Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance,"

 

The moral of my story is to not believe anything until you see the data, the source of the data, and the methods used to evaluate its validity. Unfortunately, this is very hard to do. Refereed journals have been delegated as our surrogate evaluators. To my disappointment it seems the American College of Physicians has not fulfilled its obligation to practicing physicians of internal medicine. 

It looks like the few governing physicians of the American College of Physicians and the Annals of Internal Medicine have chosen instead to pursue their own agenda and not the agenda of science at the expense of their member physicians and their patients.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

 

Medicare "Drifting Towards Disaster": Says U.S. Sec. HHS

Stanley Feld M.D.,FACP,MACE

US Secretary of Health and Human Services Michael Levitt said Medicare is lurching toward disaster. Secretary Levitt has studied the problem for eight years. He has tried to introduce some innovative policies along with some poor policies. It seems as if only the poor policies survive.

“ Medicare is lurching toward disaster and it is too late for the Bush Administration and Congress to do anything about it, U.S. Health and Human Services Secretary Michael Leavitt said on Tuesday.”


He said the next administration will have to act to stop rising costs and get control of the $400 billion federal health insurance plan for the elderly, which now covers 44 million people.

$400 billion dollars is twice the cost of the war in Iraq. This amount only partially covers 44 million senior citizens. There are deductibles and co-pays. The insurance premium for Medicare is almost as expensive as private insurance for persons collecting retirement plan money. Medicare is an entitlement that should not be expanded to 300 million people. Do the math. The cost would be $2,727,272,727,273 dollars a year and rising, in addition to the premiums and co- pay citizens would be paying.

"Higher and higher costs are being borne by fewer and fewer people. Sooner or later, this formula implodes,"
Leavitt said in a speech to the right-leaning Heritage Foundation and American Enterprise Institute think-tanks.

It doesn’t matter if he was talking to a right or left leaning organization. It takes a blind man to see the wheels are coming off and no one is doing anything about it. All it takes is a little common sense to know something creative has to be done.

There are many innovative changes that can be made easily. One would be an emphasis on effective chronic disease management. Another would be effective malpractice reform in each state to decrease the need for physicians to practice costly defensive medicine.

A national health plan run by the government would do is stifle innovation and run up the cost. If we compound the healthcare problem by adding all U.S. citizens to a government paid for and directed single party payer system we will accelerate disaster.

“There is serious danger here," he added. "Medicare is drifting towards disaster."
"It troubles me that this matter is not receiving more attention in the presidential candidates' discussions. The next president will have to deal with this in significant part," he said.

Doesn’t Secretary Levitt know the presidential candidates do not understand the issues, the problems, the potential solutions? He should speak out. The solutions are easy if all the stakeholders’ incentives are aligned. The recognition of patients as the primary stakeholder is critical. The needs of the physicians as medical care providers have to be understood. The needs of secondary stakeholders have to be modified and adjusted.

Disinformation and Media Spin: Part 1

Stanley Feld M.D., FACP, MACE

A recent headline in the Washington Post declared that “Majority of U.S. Doctors Back National Insurance Plan”. It should be noted that the original article was published in the Annals of Internal Medicine, the official journal of the American College of Physicians, in 2003. A 5 year follow-up letter was published with incomplete data on April 1, 2008 reevaluating physician attitudes. The Washington Post article quoting a press release stated that the 124,000member American College of Physicians, the nation's largest medical specialty group, endorsed a single-payer national health insurance program.

In 1993 the American College of Physicians generated significant backlash from member physicians all over the country. Many physicians quit the American College of Physicians. I recall the CEO, at that time, was forced to resign over the issue of calling for a single party payer.

I can’t believe that the executive committee of the American College of Physicians has once again tried to manipulate public opinion through the media by originally publishing the 2003 article and updating it with a letter from the same authors in 2008.

In my opinion, the original survey was a poor study. The original study and follow-up letter further contaminates the Annals of Internal Medicine and American College of Physicians’ credibility as spokesmen for practicing primary care internists.

Our sound bite society would believe the media headlines “Majority of U.S. doctors back national insurance plan”. The message is clear: The majority of U.S. physicians advocate a single party payer system.

Neither government nor the healthcare insurance industry has appreciated the value of primary care physicians or the importance of the patient physician relationship. Both reimburse inadequately for cognitive therapy. They have not wanted to reward the therapeutic value of the problem solving ability of primary care physicians.

Primary care physicians who have had any practice experience know the difficulties in collecting for services rendered from the government. They have also experienced an endless string of price reductions. Primary care physicians have faced the same problems with the private healthcare insurance industry.

I appreciate that the price of health care is sky rocketing. However physicians” fees are falling and not sky rocketing. I have pointed out that facilitator stakeholders are benefiting more than the primary stakeholders (patients and physicians).

It is hard to believe the majority of physicians in this country want the government (Medicare) as the single party payer for medical care.

The Washington Post article states “A majority of American doctors now support the concept of national health insurance, which represents a shift in thinking over the past five years, a new survey finds."
“Typically, national health insurance plans involve a single, federally administered social insurance fund that guarantees health coverage for everyone. In most cases, these plans eliminate or substantially reduce the role of private insurance companies.”

Unfortunately the media report what the press release tells them has been found in the study.

“Physicians For A National Health Program” published this press release. The Washington Post copied the press release.

This is disinformation with media spin at its height. The public usually accepts the data as valid findings when presented by the media.

The study had 2,193 physicians. The physicians responding to the survey are supposed to represent 733,183 physicians in America.

"A survey conducted last year of 2,193 physicians across the United States found that 59 percent support "government legislation to establish national health insurance," while 32 percent oppose it, and 9 percent are neutral. In 2002, a similar survey found that 49 percent of physicians supported the concept, while 40 percent opposed it."

A larger sample size with a better survey questionnaire might have come to a different conclusion. If one accepts the survey sample and sample size as valid the study shows the percentage of physicians who want universal healthcare coverage but not universal coverage under a government run single party payer system. The press release leads us to the single party payer preference.

“Typically, national health insurance plans involve a single, federally administered social insurance fund that guarantees health coverage for everyone.”

The AMA has recommended universal coverage, as do most physicians. The problem of the uninsured is large. However, neither the AMA nor most physicians in private practice recommend the government as a single party payer. Private practitioners understand the problems inherent in government run organizations as do most consumers
.
In the next blog I will publish the original data and my commentary on the survey results. It will be clear how the data is manipulated to reach conclusions that should not be reached.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Health Clinics Inside Stores Likely to Slow Their Growth

Stanley Feld M.D.,FACP,MACE

In 2006 I stated "the creations of free standing retail clinics (convenient care clinics) are complicated mistakes.” I thought they would distort the healthcare system even further. I believed it would also be difficult to establish positive cash flow quickly or ever. When investors realize these clinics will have a difficult time making a profit they would be closed.

I said “I think Wal-Mart and CVS are indeed putting their reputation and good will on the line and are going to get a nose bleed.”

“The boom in walk-in health clinics located inside pharmacies, supermarkets and big-box retailers is showing signs of slowing.”

Hailed as an inexpensive option for treating minor health ailments like sore throats and rashes, the retail clinics have grown in number to 963 as of May 1 from just 125 three years ago. The clinics typically feature nurse practitioners who can prescribe basic drugs. The price for a visit ranges from $50 to $75.

“ But in recent months, retail health- clinic operators based in New York, Nevada, Indiana and Alabama have closed their doors, shuttering 69 clinics in 15 states, including ones operating inside outlets of Shopko Stores, Meijer Inc., in New York, Nevada, Bi-Lo LLC, Wal-Mart Stores Inc, and the Medicne Shoppe unit of Cardinal Health Inc."

“Now, the biggest retail-clinic operator, CVS Caremark Corp., says it is scaling back expansion plans for its MinuteClinic brand.”

The math is easy. It is very difficult to generate a profit with uncomplicated cognitive services. The In Store Clinics investors did not realize the resistance from primary care physicians and the communities they service. If these clinics have any chance for success they would have to be a direct extension of the community physicians’ care.

“Tom Charland, the owner of industry consultant Merchant Medicine LLC says the venture capitalists and private-equity firms that backed many of the retail clinic operators failed to appreciate how complicated and expensive the clinics are to operate. Research shows that patients are enthusiastic about the clinics' convenience and quality of care, but acceptance has been slow.”

I do not think the consultants understand the problem. There is a difference between medical care and healthcare. When someone is sick he wants to see a doctor and not a healthcare provider. Another problem is these clinics can not be profitable if they do not provide ancillary services. Ancillary services are not within the scope of practice for nurse practitioners in most states. A third problem is that if these clinics were seeing enough patients to create positive cash flow they would have the same long waiting times and become as inconvenient as community emergency rooms.

“Some operators are finding that the clinics are complex to manage. Earlier this year, CheckUps, a clinic operator based in New York, abruptly closed 23 clinics that it operated inside Wal-Marts in Florida, Mississippi, Alabama and Louisiana. It was stretched thin by operations in multiple states, says company spokesman William Armstrong.”

"You have to have a critical mass of stores seeing a high number of patients to get somewhere," he says. He adds that new clinics need to spend a lot of money on marketing to build public awareness and that the clinics become expensive quickly. "We ran out of operating funds," he says.

The big box stores and pharmacies opening In Store clinics are on the verge of another complicated mistake. Rather than affiliate with the convenient care companies, who have not done well, they are reaching out to hospital systems well known in the community.

"Tina Galasso, an analyst who follows the retail clinic industry for Verispan LLC, says the cost of setting up an in-store clinic runs about $500,000. That is one reason why much of the future growth in walk-in health centers is expected to come from big companies with deep pockets and from hospital systems that are already well-known within a community and don't have to spend so much on marketing."

Hospital systems tried to establish “DOC In the Boxes” in the mid eighties as a strategy to capture patients in the surrounding area. They failed in the mid eighties because they were competing with local physicians who were hospital system staff members. The establishment of these clinics was a strategic move to “increase the hospitals’ product line.” The practice of medicine is more than a product line and a commodity. No one seems to understand this.

In a strategy that combines both elements, Wal-Mart plans to partner with hospital systems to open as many as 400 co-branded store clinics by the end of 2010, up from about 50 sites in operation now. That approach is a departure from an earlier strategy under which Wal-Mart leased space to operators like CheckUps that weren't associated with hospital systems.

It amazes me to see local hospital systems competing for the Wal-Mart contract. Where is their corporate memory? Where is the building of trust between physicians and hospital administrators to create stronger institutions? If physicians do not know how to provide convenient care, the hospital system teach them how to provide it. Hospitals are always saying they want to create partnerships and trusted relationships with physicians in order to provide better care for the patients in the community. Do it and don’t create more dysfunction in the healthcare system.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Dr. Feld. Why Only Pick On The Healthcare Insurance Industry?: Part 3

Stanley Feld M.D.,FACP,MACE


In summary, one stakeholder did not create a dysfunctional healthcare system. Since everyone believes the healthcare system is broken the main question is how can it be fixed.The major beneficiary of the largess and the worst offender in generating dysfunctions is the healthcare insurance industry.

As a secondary stakeholder in healthcare, the healthcare insurance industry adds little value to the treatment of a sick patient. It is essential that consumers understand the abuses to the healthcare industry in order to know the cure.

All the abuses of every stakeholder must be eliminated in order to have a viable healthcare system. The abuses and overuses have been outlined in my response to Matt Moledeski’s comment. The present dysfunctional healthcare system is the result of adjustments and reactions to changes imposed on the various stakeholders by each stakeholder to the disadvantage of the consumer.

The key questions are

1. Who is the primary stakeholder?

Answer: the patient

2. Who are the primary utilizers of resources?

Answer: the patients

3. Who should be the primary controller of the utilization of resources?

Answer: the doctor and the patient. Presently, the government and the healthcare insurance companies, in an attempt to control utilization of resources, restrict patient access to care when they deem it appropriate.

4. Who is the primary generator of disease?

Answer: A. The patient and his lifestyle.
             B. Industries promoting disease generating life styles.
             C. Industries generating toxic material into the environment.
             D. Agencies and industries that create unaffordable and inaccessible medical care.

5. Which diseases utilize the most resources?

Answer: Complications of chronic disease. 90% of the healthcare dollar is spent and taking care of the complications of chronic diseases. If we could avoid generating chronic diseases and their complications we could reduce our healthcare costs by correcting the problems in section 4. Healthcare and healthcare insurance would then become affordable.

5. How do you set up a system that encourages the avoidance of the complications of chronic disease?

Answer:A. Put the patients in charge of their healthcare dollar.

B. Let them keep the money they do not spend in a reti rement trust.
C. Insure consumers for large expenses.
D. Reward them financially for good health and the avoidance of complications of chronic diseases     and penalize them for bad health habits (i.e. obesity).
E. Require complete transparency by all the stakeholders
F. Provide an Electronic Medical Record financed by users by the click
G. Put in place effective malpractice rules to eliminate defensive medicine
H. Require hospitals to reveal actual costs of services to patients
I. Empower and require state boards of insurance to withhold licenses to sell insurance in the  state that abuse patients and physicians. The ineffective financial penalties are providing a profit center for these abuses to the healthcare insurance industry.

Consumers will boycott inefficient companies and business that charge too much.

The healthcare dysfunction started with a government entitlement rather than a government subsidy. It preceded government imposed price controls followed by healthcare insurance company abuse. Physician, patients and hospitals reacted to the abuse.

It will end with consumers controlling their healthcare dollars, employers and the government providing the funds to consumers along with financial incentives for consumers to control healthcare costs.

The concept of imposing a bureaucracy on top of a single party payer system is a solution that can not work.


The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

Dr. Feld. Why Only Pick On The Healthcare Insurance Industry?: Part 2

Stanley Feld M.D.,FACP,MACE

This post continues my reply to Matt Modleski’s comment. If one views the dysfunction in the healthcare system as a gradually evolving process is it clear that all the stakeholders have contributed to its dysfunction. As each stakeholder adjusted to the changes, the healthcare system became more dysfunctional.

“ The number of scans, tests and procedures that are done each year unnecessarily because the facilities that are built (many Physician owned) are put to use is also a big part of the problem. This has been documented in study after study (some of them conducted by physicians).”

In the studies Matt refers to patients going to these testing clinics could be getting better care than the non physician owned clinics? Remember quality of care has not been clearly defined by policy makers or the healthcare insurance industry.

Physicians in academic medicine have not precisely defined quality medical care. However, everyone talks about it. I do not believe you can assume physicians are doing the test simply to make a profit.

I do think there are a lot of unnecessary procedures done in many hospital outpatient facilities and physician owned facilities. Many of the procedures are done because physicians are forced to practice defensive medicine. There are many law suits in the pipeline presently because of missed diagnosis.

Patients with vague symptoms at the time of physician visits need to be tested to detect possible disease. Almost everyone experiencing automobile accidents with the slightest head trauma automatically undergoes a CAT scan to rule out a cerebral bleed. President Reagan did not get an automatic MRI or CAT scan when he had his subdural hematoma.

Diagnoses that would not otherwise be made are made early through testing using new technology. Clinical judgment has lost its place in the defense of malpractice suits. The costs of using new technologies has an enormous impact on the cost of medical care. Yet no one has precisely defined quality medical care . Nonetheless, physicians have been accused of over testing when they control their intellectual property.

A significant number of malpractice suits would disappear if the government changed some liability rules. The rule change would make malpractice claims less attractive to malpractice attorneys. Malpractice attorneys receive one third to one half of any settlement. A change in the contingency rule would decrease lawyers’ incentives and frivolous malpractice claims. The government has to put limits on damages for certain claims and change the adjudication process. Plaintiffs attorneys’ have resisted these changes.

The state of Texas has made these changes. there has been a marked reduction in malpractice claims as well as malpractice premiums.

The reasons for the overuse of the healthcare system have not been publicized in the media or by organized medicine. Overuse of the healthcare system makes a sensational story for the media and it is easy to blame physicians. I am not interested in defending physicians. However, one should give physicians the benefit of the doubt since you trust them to deliver the best medical care possible. If you do not like what they suggest pick another physician. I would not rely on a healthcare insurance company’s employee looking at the computer screen to make a medical treatment judgment about my health.

There are also lots of unnecessary tests done because of increasing patient demand. Patients learn from the media and online what needs to be tested. Cholesterol testing and bone density testing are increasing. When the compliance rate is analyzed only 30%- 50% of people who should be tested are tested. When they were tested only 30-50% treated stayed on the medication after 1 year. Think about it. If everyone was tested and treated appropriately the cost of testing and treatment would increase while the cost of the complications of these chronic diseases would fall precipitously. The greatest cost is the cost of treating the complications of chronic diseases.

Matt complains about physicians owning the facilities to test patients. Why should physicians give their intellectual property away to hospitals when they can do the test more conveniently and cheaper in their office?

Physicians detect, treat and teach patients how to become professor of their chronic disease so patients can be knowledgeable in managing their disease. This is the definition of cognitive therapy. Cognitive therapy is not reward by the government or the healthcare insurance industry. Isn’t this a perverse circumstance since 90% of the healthcare dollar is spent of the complications of chronic disease?


“The system is broken and commoditized reimbursement, regardless of the quality of care, is a key component, but so is the overtreatment of patients by financially driven providers. Every now and then you hint as much, but you would be helping everyone by giving it equal airtime with your perspective on the woes created by the insurance companies.

Physicians’ intellectual property has been discredited and devalued. Physicians are intelligent people who have accepted the fact that their credibility is challenged. They are trying to figure out way to make a living taking caring for patients in the best possible way. They also want to figure out how to protect their intellectual property. They try not to react to a healthcare system that has challenged their skills and integrity.

Patients are at fault by believing medical care is a right. Obesity is an epidemic and generates chronic disease and the complication of chronic disease. The adherence to hypertension therapy is less than 50% leading to strokes and myocardial infarction. The adherence to diabetes treatment is less than 40%. Shouldn’t society be putting energy and money into solving this problem?

The question is where did the dysfunctional behavior start? It started when the healthcare insurance industry started gaming and controlling the healthcare system for profit after the government instituted price controls.

My solution is my ideal medical savings account putting the patient in control under the appropriate set of rules. The consumer is the only stakeholder that can force the government to make the correct rules!

"Keep doing what you do, I read your stuff every day".

"Cheers,

Matt"

Matt, thanks for your comment.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.