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How To Fix Healthcare

Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject.  While my post was just a gripe about the problem, the comments were mainly focused on solutions.  How do you fix the problem?  I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.

You have to realize that I’m basically chicken (as are most doctors).  I like to point the finger and avoid the fingers of others.  It’s much easier to gripe than to fix things.  It’s much easier to criticize than it is to say things that can be criticized.  But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured.  Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.

So here are my suggestions:

1.  The government has to take on tasks that are in the best interest of the public.

Preventive healthcare should be paid for.  This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.

There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears).  Simply building a relationship between people and primary care physicians also has benefits by itself.

The overall goal is to improve the overall health of the American public.  Promote behavior that deals with problems when they are still small or before they happen at all.  Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.

2.  Promote proper utilization

One of the main costs to any system, public or private, is overutilization of services.  Any solution that does not somehow look at utilization will automatically fail.  More care costs more.

Here are areas of increased utilization:

  • Emergency room visits for non-emergencies.
  • Visits to specialty physicians for primary care problems.
  • Unnecessary tests ordered – more likely in a setting where the patient is not known.
  • Patient perception that “more care is better.”
  • Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital.  This causes duplication of tests.

Solutions to these problems include:

  • Better access to primary care or other less costly care centers
  • Increase the ratio of primary care to specialists
  • Care management for high utilizing patients
  • Public education (not through the press but through better public health).
  • Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
  • Make the malpractice environment less frightening to doctors.  A large amount of questionable care is given to protect physicians from lawsuits.  (A good example is PSA Testing.  Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).

How does this help the problem of the uninsured?  It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.

3.  Fix problems with Pharma

Medication costs are a huge problem to my uninsured and insured populations.  There are many reasons for this, but some of them are simply due to a bad system.  For example:

  • Medication discount programs cannot include Medicare patients.  Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
  • High cost of generic drugs.  When a drug goes generic, there is usually only a slight drip in the price.  The system allows only limited competition for price, so the cash price remains high.  Encourage cost competition.
  • Drug Rebates.  This raises the overall cost of drugs to everyone.  Rebates are sent to insurance companies by drug companies for inclusion on the formulary.  It pretty much looks like extortion.  The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate.  These need to be eliminated.
  • Get rid of direct to consumer marketing of drugs.  This is pure capitalism that encourages over-utilization.

All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.

4.  Address Conflicts of Interest

Insurance companies are largely publicly-traded companies.  This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue.  Having them the ones managing care is like putting the kid in charge of the cookie jar.  Insurance companies should get back to the business of insuring.  Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).

Insurance companies promote themselves as healthcare companies.  They don’t provide care, and they shouldn’t.  Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.

How does this help the uninsured?  It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance.  It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place.  If insurance costs less, there are less uninsured.

5.  Focus on the “uninsurable”

5% of Americans account for over 50% of the overall cost of care (reference).  These are the uninsurable people – those who are truley expensive to treat.  There needs to be very close management of these people.  Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government.  It also leaves them unmanaged.  Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition).  These people need management, either in a “medical home” or by some sort of care management.

There you have it.  Follow these rules and everything will be fine.

Yeah, right.  Alright everyone, have at it!  Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.

*This blog post was originally published at Musings of a Distractible Mind.*


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One Response to “How To Fix Healthcare”

  1. Laurence Milgrim, MD says:

    I have been following you , here and on Twitter, and your questions and answers on healthcare reform are the hardest to resolve, and truthfully, probably will not be resolved. We are all aware that the mess we are in was in part created by the Clinton Administration. The failure of Hillary's healthcare reform which was due mostly by the Insurance Administration Lobby to prevent the introduction of a government run program to start socializing our system paved the way for increased HMO penetration. This, when failed, pave the way for the system we have now, which is an amalgam of both HMO restriction and old-from Major medical, (premiums with deductibles). The catch is that premiums are at “sold to the highest bidder”, deductibles are far more than seen during the Major A and B days. The added catch is that with the RVU system that only insurance companies and doctors are aware of (the public does not understand how we get paid), payouts to doctors are low, which will equate to some of the problems that you allude to in your answers on this blog page.
    Look at #1. I agree, the government has to take a stake, but PREVENTIVE healthcare is a misnomer. It does not exist. to Prevent medical illness, which in turn would prevent excess spending (spending on a cancer that did not get detected early, spending on HTN that was not stopped due to lifestyle change), it is not in the hands of the Govt. Nor is it in the hands of the MDs. It is in the hands of the PUBLIC. Since the PUBLIC will not take care of itself, prevention is unattainable. We will all be caring for those who have not taken care of themselves. In fact most of your carreer has probably been spent caring for Diabetes, HTN, and there sequelae–all PREVENTABLE if the patient had wanted to earlier in life. This will not change.

    #2 Promote proper utilization- again I agree, but #1 and 2 are interrelated. The main reason why there is overutilization is because of uninsured and lack of sufficient payment for MDs due to RVU system. doctors routinely overtest to one, avoid negligence lawsuits, but more routinely, to increase their pay because the base office visit pay for an uncomplicated issue does not routinely cover the expense for the visit. So in office testing becomes a must to increase the revenue. When it comes to the uninsured, if #1 ansd 2 were combined in the form of govt run clinics and hospitals, just as a basic discussion, then those uninsured would go to these places (similar to other socialized countries' systems). This will take off the first burden of this system, what will be left is the insured. So how do we change this fiasco? Get rid of all the insurance companies and start again? Not likely. the CEO of Humana made over 9 million last year. He will not go down without a fight.

    #5 Focus on the uninsured– NOPE! Focus on the Insured! the uninsured will be taken care of by the govt. The insured is 95% of the population ( as you state) but is most of the monetary burden. I do not have the answer, but the expression “When in Rome” seems to come to mind here. My answer, fight fire with fire. Create a for profit health care plan that will compete with the main players. Have it structured as it used to be–low to moderate premiums with deductibles. BUT the key are these ingredients: One, all claims paid. Two, no preapprovals. Three, no precertifications. Four, no need for MDs to sign on to accept assignment, all claims paid!. Five, new pay fee schedule which will compesate MDs fairly, thereby decreasing excessive unnecessary testing to pad bills–hence decrease costs.Six, Give MDs option to accept assignment ( if the pay is good, there would be no need for an MD to balance bill the pt). This is done at a level less than the going rate for a family plan which now averages 14,000 with a 4000 deductible per family member. If you take out the restrictions in the present system, it will actually work better. This new insurance company will take time to get off the ground, but if Mom and Pop harware store is looking at health insurance, and they have to choose between United at 14,000 a year or NEW INS CO at 6,000 a year with all claims paid no matter what, soon enough the big five will toppple. I am a physician. I am an ENT in Connecticut.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

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Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

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“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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