Government vs market reforms - What’s The Right Mix of Private and Government Health Care?

This is April 30, the very last day of national poetry month,

A fitting time, I would say, for a poem about the trillioneth,

$2.2 trillion, to be precise, on health care the U.S spends

A number that an annual rate of 8%-10% always ascends.

It’s said by some only in God can we trust,

But other say it’s realistic data or go bust.

It’s either data,

Or costly errata.

With these thoughts firmly in mind I came across this table,

the numbers of which the rest of this poem will enable.

Health Care Insurance

Private Insurance 67.9%

Employer-Based 59.7%

Direct Purchase 9.1%

Government Insurance

Medicare 13.6%

Medicaid 12.9%

Military 3.6%

Uninsured 15.8%

For me that puts the whole matter in context

Whether your politics are concave or convex.

Some say these numbers call for more federal mandates,

Or, at the very least, for extensive marketplace rebates.

I’m not so cocksure,

We can for all insure.

My reasoning may be a bit light,

But the numbers seem about right.

A two-thirds burden for the private sector,

Just over one-fourth to the government specter.

What worries me is the final one-sixth of the mix

The feds and business together have that to fix.

Physician Business Ideas - Straight Talk about Physician Practices

John McDaniel, 57 year old president of a physician practice management company, called the other day from New Orleans to talk about the lay of the health care landscape.

John’s company, Peak Performance Physicians, manages physician groups throughout the country. He is a former hospital CEO and has been in the physician practice management business for about two decades.

John talks straight. Indeed, I would call him a pragmatic fundamentalist who does not sugarcoat issues facing physicians, such as flat or dropping incomes weak cash flow, physician shortages, overcrowded schedules, and pay cuts from the 3Ms – Medicare, Medicaid, and Managed Care.

Among other things, John says,

• Many physicians are dropping out of HMOs and PPOs that offer low rates of reimbursement. One of the most commonly dropped plans is UnitedHealth, though this is tough where United has dominant market share. John cited one physician, a neurologist, who has withdrawn from 16 plans.

• To bolster cash flow and decrease accounts receivable, more and more physicians are asking for payment before the patient leaves the office. This may account for as much as 20% to 25% of revenues.

• Only 25% of the groups he manages or consults with have installed EMRs. These groups await better and less expensive systems with a tangible return on investment.

• Young doctors are increasingly turning to hospitals to help them get started in practice. Given their educational debts and costs of starting a practice, there is simply no other way to establish themselves.

• The influx of women doctors into medical practice is altering traditional thinking about how many doctors we need. He cited the case of a 12 woman obstetrical practice in which each partner worked a three day week. He pointed out that was the equivalent of a full-time four person group.

• As many as 75% to 80% of doctors undercode because they fear a federal audit. John says this is too bad because an annual audit would quickly reveal undercoding, and corrective coding would greatly increase revenue for most practices.

• John says the American public will never be sympathetic with doctors who complain of low reimbursement from Medicare, Medicaid, and managed care. To the public, most doctors are wealthy, and no amount of moaning, groaning, or whimpering will correct that misperception. What people understands is lack of access. If enough doctors restrict access and can justify that restriction, the public and the politicians will come around.

Reece, personal musings - Life's Little Instruction Books

If you seek moments of truth and instructions to pursue it, read Life’s Little Instruction Book (Rutledge Hill Press, Nashville, Tennessee) It comes in two small volumes and contains 1028 pieces of distilled wisdom from a father to his son, who was departing for college.

Here are 35 of my favorites, followed by 12 of my own making.

1. Never give up on anybody. Miracles happen every day.

2. Think big thoughts, but relish small pleasures.

3. Never deprive someone of hope; it might be all they have.

4. Never resist a generous impulse.

5. Leave everything a little better than you found it.

6. Give people more then the expect

7. Don’t think expensive equipment will make for lack of talent or practice.

8. When you make a mistake, take immediate steps to correct it.

9. Listen to your critics. They will keep you on your toes.

10. Accept the fact that regardless of how many times you're right, you will sometimes be wrong.

11. Remember the 3 Rs: Respect for self; Respect for others; Responsibility for all your actions.

12. Take off the convention badge as soon as you leave the convention hall.

19. Share your knowledge. It's a way to achieve immortality.

20. Love someone who doesn't deserve it.

21, Have a firm handshake.

22. Look people in the eye.

23. Sing in the shower.

24. Keep secrets.

25. Always accept an outstretched hand.

26. Make it a habit to do nice things for people.

27. Don't allow the phone to interrupt important moments. It's there for your convenience, not the caller's.

28. Keep it simple. Be modest. A lot was accomplished before you were born.

29. Remember no one makes it alone. Have a grateful heart and be quick to acknowledge those who helped you.

30. Visit friends and relatives when they are in hospital; you need only stay a few minutes.

31.Answer the phone with enthusiasm and energy in your voice.

32. Keep a note pad and pencil on your bed-side table.

33. Million-dollar ideas sometimes strike at 3 a.m.

34. Remember that 80 per cent of the success in any job is based on our ability to deal with people.

35. Don't expect life to be fair.

And here are a dozen of my own.

1. Health care costs will not grow to the sky.

2. Listen to your spouse and your nurse. They are giving you honest opinions
you won't get elsewhere.

3. Not everything in health care computes.

4. Buy a huge wastebasket. Keep it full of material you’ll never read again.

5. It’s never too late to innovate.

6. For the health care entrepreneur, there are always niches and sons of niches.

7. Click often on Sermo, Google, and Wikipedia. They will tell you most of what you want to know – early, soon, and quickly.

8. He who constantly throws dirt loses ground but gains a sense of humus.

9. Be skeptical of information technologists doctors don’t use. If doctors don’t use it, patients will not benefit.

10. Your patient’s time is just as important as yours.

11. Universal coverage without access to primary care doctors is meaningless..

12. To patients, convenience means not waiting to receive care.

Book Review - A Little Book

I wish to acquaint you with my little 38 page book Navigating the Maze of the Health Coverage & Access: A Quick Guide for Physicians (www.practicesupport.com, 800-067-7790).What follows are the book’s introduction and table of contents.

INTRODUCTION

“The pernicious aspect of this cry for universal coverage is that it is too easy for politicians. The hard work is getting at the underlying inefficiencies in the health system, the perverse incentives that have everybody in the dark.”

Joseph Antos, PhD, Health Policy Expert, The American Enterprise Institute, “Coming Soon: Health Care Debate, Part 2,” New York Times, March 2, 2008

This little book contains 20 quick takes on health reform for doctors and patients. I present it as questions and answers on leading reform issues of today. This small manual is not intended to be exhaustive or inclusive, but rather to be instructive. Despite the 20 topics covered herein, the book lacks 20/20 vision.

The health system is complex. This book is simple. It follows Kipling’s instructions. Write on the Whats, Whys, Whens, Hows, Wheres, and Whos.

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who

Rudyard Kipling, 1865 - 1936
The Just-So Stories (1902), The Elephant’s Child

I do not pretend to be an expert on all reform issues, but I have learned a thing or two while writing three books over the last three years – Sailing the Seven C’s of Hospital-Physician Relationships, Voices of Health Reform, and Innovation-Driven Health Care.

The health system is more complex than it need be. The system, which critics insist on calling a “non-system,” is, in many ways, the worst of all possible worlds - a bewildering mix of arcane government rules, Byzantine private red tape, obstructive legal entanglements – and, for patients, waiting, waiting, waiting, not knowing what to expect.

An April 5, 2008, New York Times story, “In Massachusetts, Universal Coverage Strains Care”, reports that some patients must wait over a year for a physician in a primary care doctor’s office. And this in a state with more doctors per capita than any other state. Project this picture to states with far fewer doctors, and you begin to appreciate the magnitude of the universal coverage problem.

I believe in intelligent informed consumers and commonsensical doctors, acting together and deploying user-friendly Internet engines – Sermo, Google, Wikipedia. The three have exploded in growth over the last two to ten years and will galvanize reform. Information technologies will help lead the way out of the health reform wilderness.

Nobody is closer to patients than doctors. Together, with the help of electronic communication, redesigned practices, and more and better paid primary care doctors, patients and doctors will prevail.

Although I look at computer-generated information as a powerful transformative force, I do not believe in the Internet as the do-all and be-all. Doctors’ offices need broad band access, but they do not need electronic medical record systems with all the bells and whistles and the $50,000 per doctor investment required to install and maintain them.

Nor should every doctor aim for a “paperless” office. Canadian pulp manufacturers are doing more business than ever, thanks to paper downloading of Internet files. Much talk about health 2.0, and health 3.0, is sheer balderdash, geekspeak and cyber-chutzpah.

Paper has its place in the form of small manuals, check-off lists, and management modules. Besides, as Dr. Daniel Pallestrant , founder of Sermo, has observed, a computer in the same room situated between a doctor and a patient changes the human chemistry between the two. Some things are best expressed through the head of a pen rather than the click of a mouse. Computers are not magical machines. They are human tools.

CONTENTS

Chapter One HEALTH 2.0 1

Chapter Two SERMO 2

Chapter Three GOOGLE 4

Chapter Four WIKIPEDIA 5

Chapter Five UNIVERSAL COVERAGE 7

Chapter Six CONSUMER-DRIVEN CARE 9

Chapter Seven MEDICARE CUTBACKS 11

Chapter Eight TRANSPARENCY 13

Chapter Nine PATIENT SAFETY 15

Chapter Ten HOSPITALS AND PHYSICIANS 17

Chapter Eleven PAY FOR PERFORMANCE 19

Chapter Twelve THE UNINSURED 21

Chapter Thirteen EMRS AND PHRS 23

Chapter Fourtee RETAIL CLINICS 25

Chapter Fifteen ACCESS 27

Chapter Sixteen HARD TRUTHS 29

Chapter Seventeen HEALTH PLANS 31

Chapter Eighteen BIG PHARMA 33

Chapter Nineteen ENGAGING PATIENTS 35

Chapter Twenty MEDICAL TOURISM 37

Medical trends - The American Doctor Story: Reflections on Ten Trends

I’ve been reading The American Story: The Age of Exploration and the Age of the Atom (Channel Press, 1956) – a series of essays by historians on transforming events and individuals. The common theme is American exceptionalism - molded by our frontier mentality, individualism, distrust of authority, the U.S. Constitution, dissatisfaction with the status quo, and determination to better things. These same traits apply to American doctors today.


1) American Doctors Seek Reform

A survey of 2193 doctors published in the April 1 Archives of Internal Medicine indicates 59% of doctors favor universal coverage. This survey is misleading for 2 reasons. It polls only a small number of doctors polled. And it doesn’t distinguish between single payer and incremental reform. It’s no secret American doctors are dissatisfied with the status quo, and it’s known most favor “incremental reform.” Doctors have a bad taste in their mouth over Medicare, and an even greater distaste for managed care... A truly national survey, such as the one now being conducted by Physicians Foundation for Health System Excellence, an organization representing doctors in state medical societies, will likely show what sort of reform doctors have in mind.

2) Convenience Care Will Be Wave of Future

Craving for convenience is driving health care reform. There is even a Convenient Care Association (www.convenientcareassociation.org). Thirst for convenience takes multiple forms - nurse-run retail clinics, doctor-managed retail clinics, worksite clinics, urgicenters, free-standing emergency rooms, surgicenters, and multispecialty ambulatory centers. Cash-only clinics, retainer practices, doctors making house calls, work calls, and hotel calls, and non-office based doctors bearing laptops and making e-visits are variations. All sorts of facilities are springing up in suburbs. A central theme is: go to where the patients are rather than waiting for them to come to you. Patients want convenience – nearby locations, longer hours, shorter waiting times, easy payments, and doctor’s practice who delivers convenience will grow.

3) High Tech, High Touch Will Prevail

In his 1982 book, Megatrends, John Naisbitt, after studying American newspapers for 10 years, concluded for every high tech health care development, Americans sought a high touch counterpart. For every coldly scientific specialist, Americans seek a warm generalist. For every major cancer center, there is a holistic component. Americans frequent the offices of alternative practitioners twice as often as they visit regular doctors. The trick for doctors is to find the right balance between alternative medicine and traditional medicine. Dr. Neil Baum, a medical marketing expert, says the best way to strike a balance is to ask patients about alternative therapies, show neutrality and understanding, and form and develop referral relations with legitimate alternative practitioners. Health plans cover 40% of acupuncture procedures and 80% of chiropractic care. American doctors will learn to live with alternative medicine. It’s here to stay.

4) Achieving Quality and Performance Goals Unlikely

Today the rage is to measure quality and performance of doctors through use of data. Indeed, these measurements and data accumulations have become the raison d’etre for health plans and regulatory agencies. Yet data documentation and analysis has yet to make much of a difference in efficiency and costs. Indeed, over the last 14 years studies by the Agency of Healthcare Research and Quality have shown little linkage between costs and quality. The reasons may be simple: it’s easy to measure costs, but quality resides in the eyes of beholders. Health quality doesn’t yield itself to metrics; it’s based on human relationships, expectations, and outcomes. And it’s difficult to judge physicians’ impacts on outcomes because most outcomes depend on what patients do outside of hospitals and doctors’ offices and on their socioeconomic status. Doctors have no control over how income interacts with race, gender, and education, yet these principle factors that influence health and longevity.


5) Ideas That Lower Costs Are Scarce

Experts say 70% of high health costs are due to new technologies. This may be, so the search is on for technologies that lower costs. These technologies are rare, and most focus on IT technologies – aggregating costs to identify costs of total system encounters of a given disease, data channeling patients to low cost providers; predictive modeling to show most effective intervention strategies, instant nanotechnology testing at the site of care, use of e-visits to avoid office visits, and websites, such as Carol.com, showing patients what providers offer the best value for the buck. Other ideas include: doctors dropping all health plans and dealing with patients directly, cash-only practices with low overheads, preventive wellness programs cutting high cost chronic diseases in the bud, and high-deductible plans making patients more conscious and responsible for spending their own money


6) Doctors Need New Capital Partners

In the health care marketplace, the hard truths are it takes money to compete, to market, to save money and to make money. Every doctor’s health care bright new idea requires start-up capital to test its validity and marketability; every doctor organization needs capital to recruit doctor believers, to integrate, and to lay down infrastructure to establish its creditability; and every physician and every physician group must interdigitate in some way with other health care players. These are some of the reasons why doctors are partnering or being acquired by hospitals; why physician entrepreneurs are seeking out venture capitalists; why corporations are turning to doctors to help them cut down on health costs; why health plans have decided that low pay for less care doesn’t work, and more pay for coordinated care or bonuses for measurable outcomes for certain diseases might be the answer. The search for capital will create new bedfellows.

7) “Cottage Industry” to Transform

The one-on-one relationship of patients with doctors is a tested, time honored, and honorable tradition and it will continue. But it will surely change in the face of cost pressures and search for more productivity, greater convenience, and lower costs. Decentralization outside of hospitals and traditional doctors’ office is already well underway. The idea of hanging out a shingle and waiting for patients to come to you is under stress. In the future, it is likely doctors in “medical homes” and other settings will oversee teams of nurses so more patient care can be supervised; patients with chronic conditions will be handled routinely in their homes or at work through telemedicine and home visits; many patients known to the doctors will be treated through telemonitoring and audiovisual communication; and those patients who do come in for evaluation will come bearing their personal health records or computer-generate histories based on their complaints, symptoms, age, and gender.

8) More Minimal Invasiveness and Robotic Surgeries

In the quest to minimize pain, avoid complications, shorten recovery time, achieve standardization, and lower costs, minimally invasive techniques are currently in vogue and will grow in use. The most common gateway to most of these techniques is clearly either through either the vascular system – stents, catheters, ablation procedures, and implanted devices – or through laparoscopic approaches featuring small incisions, remote manipulation, visual manipulation, and things like gastric bands. Other examples are “virtual” examinations of the bronchial tree, GI tract, biliary tract, or genitourinary system. . Finally, there is robotic surgery, most commonly performed in major academic centers and large hospitals using the De Vinci system, performed on over 40,000 patients last year..

9) Problems of Managed Care

It is not an overstatement to say doctors consider themselves at war with managed care organizations that have appointed themselves as remote guardians and overseers of care. More and more doctors and their organizations are suing health plans for underpayment, delaying and rejecting claims, unwarranted bundling and lowering of fees, eliminating patients for pre-existing illnesses, canceling policies for costly patients, underpaying for out-of-network care, or so simply steering patients to lowest-cost providers, and in general, basing physician performance on a cost-basis. To doctors, the problems of dealing with health plans go even deeper and raise these questions: Who is health plans to judge what went on at the patient encounter when the plans were not there? Doesn’t what health plans do constitute the practice of medicine? Isn’t doctor time devoted to paperwork a sheer waste of training and talent? And isn’t the physician skyrocketing overhead, due largely to hiring staff to handle claims, an unreasonable health care cost?

10) IT Will Fall Short of Promises

Finally for physicians, there are the over-hyped promises of IT as the panacea for better care, lower costs, higher quality, and greater safety. So far studies have shown only marginal or no benefits of “paperless” practices. The siren songs of EMRs, PHRs, clinical protocols, evidence-based care sound too good to be true, and they ignore expenses of installation and management, lost productivity, low returns on investment, and difficulties of convincing partners and staff of value. What is needed are lower cost systems that talk to each other, portable easy-to-use entry devices, user-friendly systems adapted to practical clinical use, studies showing a positive return on investment, less harassment and pressure from those who have never been in practice, financial incentives to use the systems, systems that address the true needs of patients and doctors at the point of care.

Emergency Rooms – Troubles and Transformations

Scarcely a day passes that you don’t read something about. ERs. Today, April 25, the Los Angeles Times and USA Today have the honors.

• The L.A. Times report “ Exodus of specialists from ERs raises concerns,” says California specialists are staying away “in droves” from ERs for various reasons – more uninsured patients, language barriers, high malpractice risks, and disruption of family and private time. Lack of specialty coverage is particularly acute in community hospitals, which have no house staff to cover. And in California, specialty shortabes are mounting, as the state cuts back on Medi-Cal because of budget overruns.

• The USA Today report “More ERs move away from hospitals “ is more upbeat. It simply says hospitals and entrepreneurial doctor groups are building more free-standing ERs, often miles away from hospitals. These new facilities have more amenities but still have life saving equipment. They have no medical ward to transfer to

The new disconnected ERs offer convenience to patients and can ease overcrowding in nearby hospital ERs. Freestanding ER grew 23% from 2005 to 2006, jumping from 146 to 179, according to an American Hospital Association survey. About a dozen more are opening or are planning detached ERs in Florida, Minnesota and Texas. In Connecticut, Middlesex Hospital has two freestanding ERs miles away from its main campus, with ambulance and helicopter services for critical patients.

Answers are evolving to relieve the ER crisis, manifest by overcrowding, ambulance diversions, lengthy waiting times, delays in transfer to medical or surgical wards, and lack of specialty coverage. Some hospitals are hiring full-time specialists and more critical care and hospitalists to meet the crisis.

I interviewed the physician who headed the California Emergency Physician organization. He had a few suggestions for helping to make ER physicians more productive: have a physician at the front door doing the triage, hire a scribe to follow the ER doctor around to document the encounter, do away with some of the software programs the doctor must open and close, minimize the bureaucratic demands of the various hospital department, pay specialists to cover.

Meanwhile numbers of free-standing ERs are growing. They’re open around the clock, offer shorter wait times than hospital-based departments, and reat a variety of illnesses and problems, such as fevers, broken bones and serious cuts. The growth of stand-alone emergency departments helps “decongest” overcrowded hospital ERs. Competition among hospitals stimulates expansion in fast-owing suburbs. Among other reasons for building free-standing emergency departments are: shortening travel times for suburban or rural residents; gaining a foothold in a growing suburb; and competing with a rival hospital.

Free-standing ERs have troubles and critics. Perhaps 10% of patients need to be transferred to hospitals. A stop in a freestanding ER may delay treatment for critically ill patients. Care in free-standing facilities costs more than urgent care centers. Ambulance services are refusing to take heart attack or stroke patients to free-standing centers . Legislators are concerned freestanding centers may not have the standards of hospital ERs.

Stand-alone emergency centers are part of convenience driven care movement featuring in-store clinics, work site clinics, and doctor-owned urgent care centers. Some of the questions being asked are: Are quality, safety, and continuity of care being sacrificed on the altar of convenience? What is the role of entrepreneurial physicians in building and owning free-standing ERs? Who sets the standards for these new centers?