Sunday, July 17, 2011

Health Savings Accounts: A Return of the Obvious

It requires an unusual mind to undertake the analysis of the obvious.

Alfred North Whitehead, Science and the Modern World

July 17, 2011- I have a dear friend, Donald Copeland, MD, a 77 year old family physician in Cornelius, North Carolina. Over his lifetime, Don has been in solo and large group practice. He has organized large groups . He has taught family medicine at Bowman Gray. He has been around the block. Don has a gift for the obvious. He believes in most situations - a solo primary care physician, teamed with a dedicated nurse, dealing with a patient with a health savings accounts – can effectively, efficiently, and inexpensively - deal with common clinical situations. He believes in a close patient-nurse-doctor relationship, and he believes most patients, armed with an HSA, will make the right choices for themselves.

Given this context, I am pleased to note Congress has began to return to its senses by removing some of the restrictions placed on HSAs by the ACA on March 23, 2010.

Here, in brief, as reported by Kaiser Health News, is what is going on.

Bill Offered To Undo HSA Health Law Provision

July 15, 2011

Bipartisan legislation was introduced Thursday to remove restrictions on tax-exempt health spending accounts — a revenue-raising provision of the health law that was estimated to garner $5 billion over 10 years.

The Hill: Another Provision Of Health Care Reform Law Comes Under Bipartisan Assault

Lawmakers in the House and Senate introduced bipartisan legislation Thursday to remove restrictions on tax-exempt health spending accounts, the latest provision of the health care reform law to come under attack by Democrats. The bill would nix a provision that since January has required a prescription for buying over-the-counter medicines with medical savings accounts such as Flexible Spending Arrangements and Health Savings Accounts. The language was added as a way to keep the bill's costs down because it was estimated to save $5 billion over 10 years by cutting down on unnecessary drug purchases (Pecquet, 7/14).

Kansas Health Institute News: Kansans In Congress Offer Bill Repealing Part Of ACA

U.S. Sen. Pat Roberts and U.S. Rep. Lynn Jenkins, both Kansas Republicans, have partnered on legislation that would repeal a portion of the Affordable Care Act. As of Jan. 1, the federal health reform law disallowed the purchase of non-prescribed medications with money from tax-free medical savings accounts such as Flexible Savings Accounts, commonly known as FSAs. Roberts and Jenkins joined U.S. Sen. Ben Nelson, a Nebraska Democrat, and U.S. Rep. Shelley Berkley, a Nevada Democrat, in introducing legislation today that would repeal that prohibition (7/14)

And here is an interview I conducted with Doctor Copeland for my 2009 book, Obama, Doctors, and Health Reform (I-Universe).

CHAPTER THIRTEEN, View of a Family Physician from Rural North Carolina

It’s much more important to know what sort of patient has the disease than what sort of disease the patient has.


William Osler, MD, 1648-1919

The family doctor was an institution. If there has been a change, the physician is not primarily to blame. On the contrary, it’s a tribute to the profession that the older idealism persists in such an unfavorable environment. The fault – if fault there be – is that the profession is now practiced in an industrial world dominated by business.

Walton H. Hamilton, MD, Medical Care of the American People, 1932

There’s no other profession as personal as the medical profession. If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them, they will lose their patients and will be nothing more than over-educated, hired technicians.


Donald Copeland, MD, 2006

Prelude: Dr. Donald Copeland and I go back a way. We were the early organizers of the High Performance Physician Institute. We were dedicated to the proposition that information technologies could be a boon to medical practice. Now Don isn’t so sure, nor is I, nor is he confident that bigger organizations or tighter management are the answers to the doctor shortage, and to addressing the problems of primary care. One answer may be to train more family physicians to be personal physicians for physicians and their families and to train more nurses with patient care skills.

Q: You’re a family physician with vast experience. Share with me your background.

A: I graduated from Davidson College and the University of North Carolina Medical School. I did a mixed internship in Peds/Med at The Medical College of Georgia and a residency in family medicine at Macon Hospital in Macon Ga. In 1965 I started a solo practice in Mooresville, NC, later moved into a rural group practice with six doctors in Clinton, North Carolina.
In 1975 I went to the Bowman Gray School of Medicine to help start a successful family practice program. In 1981 I went back to my hometown area of Davidson, North Carolina, which is 20 miles from Charlotte. The solo practice that I started grew into a large family practice group of eight doctors in three sites. Now there are about 25 doctors in 10 or more sites. Novant hospital system acquired the practice. It’s now a major source of family medicine in counties in and around Charlotte.

Q: And what’s your take on hospital systems acquiring and hiring physicians?

A: I don’t think it’s a good concept. It seems to me physicians are handing over their license to practice medicine to the hospitals. We ought to be paying primary care doctors more so they can exercise their professional independence. But directly or indirectly a family physician generates $ 1 million for the hospital. Also if you’re working for a hospital, you feel obligated to order all tests and procedures from the hospital. That can be exorbitantly expensive and drive up the cost of care.

Q: What are you doing now that you’ve retired?

A: After I retired I started working two days a week for the Public Health Department of Lincoln County, and I worked as medical director of TIAA-CREF (Teachers Insurance and Annuity Association-College Retirement Foundation- an investment management fund) for 4 or 5 years until my job there was outsourced to Walgreens. Now I’m just practicing two days a week. I forget to tell you that before I attended medical school I was a medic in the Army for two years, and the GI Bill paid for my education.

Strong Views Backed by Experience

Q: I know you have strong views on primary care. For example, I gather you think people are making it more complicated than it needs to be.

A: When I first started practice 1965, the main thing was to have a doctor and a nurse. We took care of everything; we managed our practice, admitted and discharged patients from the hospital, and referred them to the proper specialists.

Q: I’ve heard you say you think the medical home is nothing more complicated than the nurse and the doctor.

A: Not exactly. There are other people needed to support a practice. It depends on the economics. It’s expensive to hire a lot of people. In my other practice, I had a lab girl, a radiology girl, and a business office.

But the key person is a personal nurse to communicate with my patients, get the chief complaint, to set up the room, take vital signs. The idea of a team approach in the practice of medicine is not something new to “the medical home."

Q: The medical home people say you need to hire a chronic care coordinator to put the team together.

A: That’s a nurse. I conduct a chronic care clinic over at Lincoln County. I have a nurse, and that’s it. I’ve got a great lab, but not a lot of other people and a receptionist. That’s the team. You don’t need a patient coach, a nurse educator, and a nutritionist. The people following up patients on the outside don’t need to be in my office. The social service people can do that.

Rural Physicians, Urban Internists, and Health Savings Accounts

Q: I was speaking recently to a Professor of Medicine, and he was saying the roles of a rural family physicians and an urban internist differed.

A: The urban internist that I know seems to have limited themselves to adult physicals, diagnosing and treating chronic diseases with many of their patients on Medicare. The hospitalist and sub-specialty internist has taken much of their practice.
They do female physicals, but they don’t do pelvic exams. In Winston Salem, the internist did the physical and the Ob-Gyn doctor did the breast and pelvic exam. So every woman required two doctors. When I went to Bowman Gray we stopped that practice on our patients.

Q: I understand you think health savings accounts and high deductible plans would help restore the doctor-patient relationships, and you’ve been working with community banks to make that happen.

A: I think the patient should manage their own finances HSAs are catching on. My daughter has a health savings account. But she has to be careful about hospital charges, which are outrageously high. The data is showing that people with HSAs are more careful about the fees they’re being charged. When I was at TIAA-CREF employees with HSAs would ask for a generic drug because the prescription cost was coming out of their pocket. HSAs are the easiest way to get insurance companies out of the office. It then comes down to the doctor and the patient.

Q: So you believe getting the third party out of the equation is important.

A: Absolutely, including the Federal Government. The insurance company has no right to tell the patient what kind of care they get. The Aetna Partners in Care concept is to implement a medical homes model with the patient’s personal physician in charge for all care the patient needs. In turn, Aetna will provide the physician with detailed clinical data to assure patients receive the right care, at the right time, at the right place. That sounds like Insurance Company directed care to me.

Increasing Primary Care Visit Codes

Q: I’ve heard you say, the solution to the primary care dilemma is quite simple. You just double the coding rate for office visits.

A: I was talking about Medicare rates. Those rates are too low, and barely cover overhead. The overhead rate is about 60%. I’m a firm believer that everybody who graduates from medical school should make at least $200,000 a year. I think that figure is fair when I’m paying my lawyer $300 an hour when I make a 10 minute phone call. He charges a minimal hourly rate. It’s ridiculous.
One hospital CEO in Charlotte makes $4 million a year. That’s outrageous. Personnel that aren’t directly related to patient care shouldn’t be the highest paid people in health care... Most physicians do well economically, but a lot of money in health care is going to the wrong people.
I read a statement recently where someone was complaining that their 900 bed hospital had 900 employees in the billing department, but didn’t have a nurse for every bed. My wife had some lab work done at a local hospital, and the charge was $1700. I can get the same tests done for $42 at a commercial lab. That’s outrageous.

Providing Comprehensive Care for Medicaid Patients in North Carolina

Q: Just to switch the subject, I read that in North Carolina, a system for taking care of Medicaid patients has been developed whereby doctors are paid a monthly fee for taking care of a panel of patients, and it’s been quite successful.

A: Doctors in rural North Carolina, and we are a rural state, have joined in with the Social Service people to coordinate care of Medicaid patients. They’re paying doctors about $2.50 per member per month. It’s successful in that it’s saving money for the state. I m not sure it’s making the doctors any money, but they embrace the concept because they have to take care of those patients anyhow, and it helps to have somebody helping manage these people outside of their offices.

$50 Billion for Electronic Medical Records

Q: President Obama has recommended the government spend $19 billion over the next five years to make electronic medical records mandatory, and there’s underlying threat to restrict payment only to those doctors with electronic records. What do you think?

A: It’s ludicrous. You and I know that I know enough about electronic records to know that EMRs are just a way to keep records. How can EMRs transform medicine? EMRs advocates say EMRs are a way of teaching or telling us how to practice medicine, but most of the people promoting them have never practiced medicine.

Organization Overkill

The President of Duke University Health System is saying we need electronic records and medical homes to take care of more patients and address the issue of the dwindling supply of primary care doctors. He doesn’t have a clue to what he is talking about.
He says, and I quote, “An immediate and serious commitment must be made to actively explore new patient-centered primary care centers that more effectively apply to the skills of extenders – nurse practitioners, physician assistants, managers, and even health coaches as part of integrated physician care.”
That’s nonsense.

Q: And you regard the Duke President’s words as mumbo jumbo – a symptom of organizational overkill.

A: Mumbo-jumbo is not the expression I would use.

Q: Careful now, I’m a Duke Medical School graduate.

A: This reminds of a famous infectious disease specialist, Dr. Robert Peterdorf, a wonderful infectious disease expert, who came to Bowman Gray to give a lecture on primary care. I asked him, “What do you know about primary care?” He didn’t have a reply. The problem is that people who try to teach us how to practice primary care have never practiced it. I have.

Practicing Primary Care

Q: Yes, you have. You’ve practiced solo, you’ve practiced in large groups, and you’ve trained people to practice it.

A: At Bowman Gray, we trained our doctors to practice in rural areas. The problem with some of these residency programs they’re training people to be half-trained internists. You have to train people to deliver babies, perform minor surgeries, sew up lacerations, apply a cast, inject a joint, biopsy a suspicious skin lesion, treat a skin rash, and make a tough diagnosis. That goes with the territory. In other words, we should teach family physicians to practice comprehensive medicine

Personal Relationships Paramount

At Bowman Gray, we taught residents to practice in modules as personal doctors with personal patients with a personal nurse to help. Our residents had personal patients, and they took personal care of them. The goal was to teach the resident to work with their patient to practice good health habits, prevent illnesses, seek proper medical care when needed, and when necessary help the patient through the medical maze. This concept wasn’t only for the individual but the family as well.

The way to improve health care in America is to train more family physicians as we did in 1975 to be personal physicians, and train nurses with patient care skills as they were taught in the three year diploma schools that existed when I began practice. The method of payment should be between the doctor and the patient, ideally from an HSA account and a major medical insurance policy not tied to the place of employment

Q: So you think personal relationships are fundamental to it all.

A: Of course. Who would think otherwise? The problem with outpatient clinics in academic medical centers is that they’re impersonal. That’s a terrible way to teach doctors how to practice medicine. I want medicine to be personal - between the doctor and the patient – not some third party. Besides, my granddaughter is going to medical school, and I want to do what I can to preserve the personal element. That’s what makes medicine such a great profession, and the lack of the personal element is what’s wrong with corporate medicine and third party care.
Summary
A family doctor Donald Copeland,
copes by taking a principled stand.
Inside-out he knows primary care,
And what he hasn’t seen is rare.
For him medical homes come down
to doctors and nurses in command.

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