Medicare, Physician Shortage, Doctor Shortage - Doctors and Medicare's Dirty Little Secret

Many people, just as they become eligible for Medicare, discover that the insurance rug has been pulled out from under them. Some doctors — often internists but also gastroenterologists, gynecologists, psychiatrists and other specialists — are no longer accepting Medicare, either because they have opted out of the insurance system or they are not accepting new patients with Medicare coverage. The doctors’ reasons: reimbursement rates are too low and paperwork too much of a hassle.

Julie Connelly, “Doctors Opting Out of Medicare,“New York Times, April 1, 2009

I have a prominent friend, a staunch friend of doctors and long a leader of organized medicine, who has often told me words to this effect,” If it weren’t for Medicare, doctors would have supported single payer a long time ago.” Many doctors simply can't stomach Medicare's policies.

This bodes badly for the future. Some 78 million baby boomers will start becoming eligible for Medicare in 2011; a shortage on internists is developing and is expected to reach 35,000 to 45,000 by 2025; 29% of Medicare beneficiaries are already having a hard time finding a doctor; and only 40% of primary care doctors now take new Medicare patients.

The root problem is that Medicare pays less, usually 20% to 40% less than private plans, depending on the state and region of the country and the paperwork is time-consuming and distracts from care for other patients. For practices having a hard time making a go of it, new Medicare patients are simply not worth the trouble or the expense. Given the current Medicare fee structures, many doctors feel a single-payer Medicare-for-all would put them out of business.

For patients not yet Medicare-eligible, the best thing to do is find a primary care physician now. Most doctors are willing to let existing Medicare patients stay on. If you’re over 65 and don’t have a doctor, the best bets are to visit www.medicare.gov to find doctors enrolled in Medicare, or to identify a nearby urgent care center. There are 18,000 of these centers nationwide, and most take Medicare patients.

Another alternative is sign up with a concierge doctor. But these doctors generally charge about $1500 per patient per year. A website www.conciergemedicinemd.com contains a list of 500 concierge physicians.

The dirty little secret? Current Medicare payment and bureaucratic policies have alienated physicians and driven them away. Medicare, in essence, has priced itself out of business for about 40% of doctors, a shortage of which already exists. Unless Congress were to mandate that physicians have to take Medicare patients, a single payer system based on Medicare is unthinkable and unworkable.

Conclusion

For new Medicare patients there lurks an unpleasant surprise,

For them primary care practitioners will be in short supplies.

And many still in practice no longer take Medicare patients,

No matter what or how dire the patients’ medical situations,

Why? Between doctors and Medicare deep conflict underlies.

Immigration, culture, effect of, Effect of Immigrants on U.S. Health Care

The United States has experienced the greatest surge in immigration since the early 20th century, with one in five residents now a recent immigrant, or a close relative of one.

New York Times, “Remade in America: The Newest Immigrants and Their Impact, “ part of five part series, March-April, 2009, nytimes.com/immigration

The March 29 New York Times carries an article, “Foreign Ways and the Scars of War Test a Clinic in Minneapolis." The piece describes a clinic devoted to newly arrived immigrants at the Hennepin County Medical Center in Minneapolis.

The medical center is a 446 bed public hospital, renowned for its trauma center, its training programs, and its renal dialysis outreach programs. It has a tradition of turning no one way, and not asking about insurance status. Because of waves of new immigrants (an estimated 50,000 from Somalia alone, even more from Mexico, and a mix of other countries), the medical center spends $3 million a year on interpreters fluent in 50 languages, and $100 million of its $500 million budget on 20% of its patients born in other countries.

The article hit home because I spend 25 years practicing in a private hospital across the street from the Hennepin Country Hospital. I have great respect for the hospital, which exemplifies the social mission and generosity of the people of Hennepin County and Minnesota.

Newly arrived immigrants quickly acquire many U.S. health habits and many develop health problems common to Americans. For example, immigrants in the U.S. more than 5 years, compared to all U.S adults, are more likely to be obese( Hispanics, 44% vs. 32%), more likely to become diabetic ( Blacks and Hispanics, 10% and 8% vs. 7%), moe likely to become hypertensive (Blacks, Asians, and Hispancies 28%, 32%, and 35% vs 27%). Furthermore, immigrants’ longevity rates are shorter and infant mortality rates are higher, skewing our health statistics and adding to financial burdens because of the high rates of the uninsured among immigrants.

We should be proud America has become such a magnet for immigrants, but immigration. legal and illegal, has an economic downside because of multicultural differences and socioeconomic difficulties. For the U.S. being a melting pot can cause of meltdown of our health system’s statistics and finances.

Conclusion

One of five of us is now an immigrant or close relation,

of some other person recently arrived from another nation.

On the whole, it’s a good thing they choose here to reside.

But unfortunately having too many immigrants has a downside,

Immigrants strain our health system’s fiscal foundation.

Health plans, costs - CIGNA to Turn Health Plan Market Costs Upside Down?

In a March 30, 2009 The Health Care Blog, “Will CIGNA Remake the Health Plan Marketplace?”, Brian Kepper, prominent health care analyst from Jacksonville, Florida, asserts that CIGNA may turn the health plan market upside down and capture major market share from competing plans.

How?

By helping employer clients set up worksite clinics to radically reduce health care costs by having services delivered by primary care physicians to employees at the worksite in a medical home environment.

CIGNA, says Klepper, will do this by installing worksite clinics. In 2008, CIGNA opened clinics of its own in 4 Eastern locations. In 2009, CIGNA will encourage employer clients with 1,000 or more employees to set up worksite clinics.

Riding the Rising Worksite Clinic Tide

These clinics, says Klepper, are already growing at an “astonishing rate.” About one-third of Fortune companies with 1,000 or more employees already have clinics in place, and by the end of 2010, one third-more will have them installed.
Furthermore, these clinics will work in other worksites with 150 or so employees – school systems, universities, community colleges, unions, city and country governments, business parks, manufacturers, or service organizations.

How Clinics Lower Costs

These clinics lower costs in four major ways.

•They exchange higher health costs for routine outpatient care for much lower costs inside the clinic.

•They provide face-to-face management of patients with chronic disease, who consume 70% of a typical population’s health costs.


•They allow the primary care physician inside the clinic to select and collaborate with pre-selected specialists outside the clinic who provide expensive outpatient and inpatient care.

•They integrate personal care with occupational health – workers compensation, human resource testing for employement and drugs, retention and recruitment, and productivivity(absentism and presenteeism).

The clinics accomplish this cost lowering by.

•Having a salaried primary care doctor on site who is able to concentrate on delivering care rather than being distracted by practice business issues.

•Removing the usual cost barriers to care – time off and travels to access care off-site, unpredictable outpatient lab, x-ray and imaging costs, and highly priced prescriptions. Most clinics provide free generic drugs or brand name drugs at cost.


•By using onsite EMR systems containing best practice information.

•By deploying databases that direct primary care physicians to pre-selected specialists who achieve optimum results at reasonable fees.

A Conversation with CIGNA Medical Director

After a conversation with Jeff Kang, MD, CIGNA’s Chief Medical Officer, Klepper says,

“Dr. Kang confirmed that CIGNA will aggressively pursue its onsite clinic effort, that they do see primary care and medical homes as keys to creating improvements, and that they have many plans in these and other areas. He emphasized that primary care was only one of many efforts.”

“The proof will be in the results, of course. It is more than possible that other major plans are headed in equally innovative directions.”

“But, so far CIGNA appears to be sincere, focused and far ahead of other plans in creating very powerful model of health care delivery that does actually head the lessons of the last 20 years.”

"If they, or any health plan with similar aspirations, succeed, they will take the market and change the way American health plans operate.”

Hurdles and Opportunities

The hurdles to the CIGNA strategy are self-evident – shortages of primary care doctors, reluctance of many independent doctors who prefer autonomy to become corporate employees, the fact that small business employ 90% of Americans - but the opportunities are there too – primary care doctors seeking security, the chance to focus on care, and higher pay (most clinics pay primary care doctors at 30% above market rates; improved care at significant cost reductions, desperation of employers to lower costs, satisfy workers, improve their health and productivity, and to retain and reinforces their loyalties to their employers.

Summary

For CIGNA worksite clinics offer an opportunity,

to slash costs for their employer client community,

to capture greater health plan market share,

to facilitate convenient cost effective care,

and to work with employers in a spirit of unity.

Geisinger - Public Television Lauds Geisinger

March 30, 2009 – This evening public television lauded the Geisinger Health System in northeastern and central Pennsylvania . The system, founded in 1915, has 600 physicians in 55 locations and three hospitals. It provides care for over 2 million in 31 Pennsylvania counties.

The PBS program focused on Geisigner’s “Proven Care” approach to coronary bypass surgery. Geisinger’s bypass surgery comes with a 90 day warranty – i.e., if complications develop with 90 days, Geisinger will fix the problem without any additional bill. The approach is now being extended to cover births and hip replacement.

PBS was not the first to praise the Geisinger warranty. Before PBS, an article in the New England Journal of Medicinehad praised the system’s work (Thomas Lee, "Pay for Performance: Version 2.0"? August 8, 2007) and the New York Times had also favorably weighed in (Reed Abelson, “In Bid for Better Care, Surgery with a Warranty,” May 17, 2007).

In bypass surgery, Geisinger doctors identify 40 essential steps in the bypass process, then develop a checklist with procedures to make sure every step is followed, from risk evaluation to a daily aspirin regimen after discharge. The doctors, in short, stick to a systematic process to make sure everything goes right.

Geisinger’s 90 day warranty is an example of “systems engineering” in health care. A number of large integrated multipspecialty groups - Kaiser, Virginia Mason, Intermountain Healthcare, Partners Health, and various academic centers – are following this approach. Systems engineering advocates say, in essence, if you get enough health care people within a health system working together in an organized and systematic way to achieve specific goals, you will reduce errors and improve performance. This requires data, commitment, infrastructure, computer monitoring, electronic records, and physicians in intergrated large multispecialty groups. In American medicine , systems engineering is not common since only 4% of doctors belong to groups of 50 or more.

Conclusion

Improving care sometimes take systems engineering,

and a critical mass of doctors for team pioneering.

When quality’s good enough you can issue a warranty

to show your level of confidence and certainty

and you can give your results a public hearing.

Future, Prevention - Polypill Arrives Ahead of Schedule

You can’t say I didn’t telI you . One of the great things about writing a daily blog over an extended period of time is that sooner or later, you’re bound to be right.

This, by way of explanation, is my 787th blog dating back to December 2006.

One, on February 6, in a “2020 Blog,” I predicted in 2020 a pill would be developed to prevent many heart attack and stroke deaths.

Here is what I had to say.

One: "The U.S. has virtually ended deaths from heart disease and strokes with a daily poly-pill for everyone over 55. British researchers first described the poly-pill, made up of six medications: a statin, three anti-hypertensive drugs, folic acid, and aspirin.6 This multi-purpose pill reduces cardiovascular disease by controlling LDL cholesterol, blood pressure, homocysteine levels, and platelet function.”

“The poly-pill has extended U.S. life spans by 12 years. Alarmists in 2006 warned poly-pills would harm patients and increase Alzheimer’s cases. Not to worry. The malpractice lawyers have been neutralized, and we now have pills for every side effect, including dementia”

Two: Then on November 21, 2008, in “Start Simple, Think Big, Think Polypill, Think Longevity,” I had this to say.

“Major society-changing innovations are not for the timid or for seeker-of-devils-in-the-details or sludge-in-the-entrails.

“Major innovations begin with 2 steps:

1) Start simple.

2) Think big.

“What could be simpler than taking one pill a day to prevent future vascular disease for humankind? What could be bigger than warding off premature death in millions of people with interrelated metabolic disease?"

"This monumental innovation may not happen, but it’s worth a series of clinical trials, already underway. For the polypill manufactured by Dr. Reddy’a of Hyberabad, India, it’s a case of Reddy, Aim, Fire!”

Well, I’m pleased to say that a March 30, 2009 article “One-a-Day Heart Combo Pill Shows Promise” by the AP from a cardiology meeting in Orlando, Florida, reports the following, and I quote:

“ORLANDO, Fla. – It's been a dream for a decade: a single daily pill combining aspirin, cholesterol medicine and blood pressure drugs — everything people need to prevent heart attacks and strokes in a cheap, generic form. Skeptics said five medicines rolled into a single pill would mean five times more side effects. Some people would get drugs they don't need, while others would get too little. One-size-fits-all would turn out to fit very few, they warned. Now the first big test of the "polypill" has proved them wrong.”

“The experimental combo pill was as effective as nearly all of its components taken alone, with no greater side effects, a major study found. Taking it could cut a person's risk of heart disease and stroke roughly in half, the study concludes.”

“The study tested the Polycap, an experimental combo formulated by Cadila Pharmaceuticals of Ahmedabad, India. It contains low doses of three blood pressure medicines (atenolol, ramipril and the "water pill" thiazide), plus the generic version of the cholesterol-lowering statin drug Zocor, and a baby aspirin (100 milligrams).”

“The study involved about 2,000 people at 50 centers across India, average age 54, with at least one risk factor for heart disease — high blood pressure, high cholesterol, obesity, diabetes or smoking.”

“Four hundred were given the polypill. The rest were placed in eight groups of 200 and given individual components of the pill or various combinations. Treatment lasted 12 weeks.”

Compared to groups given no blood pressure medicines, those who got the polypill lowered their systolic blood pressure (the top number) by more than 7 units and their diastolic (the bottom number) by about 6 — comparable to levels for people who were given the three drugs without aspirin and the cholesterol drug.

“These drops were modest, probably because doses were low and most participants had only moderately high blood pressure to start with, Yusuf said.”

“LDL, or bad cholesterol, dropped 23 percent on the polypill versus 28 percent in those taking the statin drug separately. Triglycerides dropped 10 percent on the combo pill versus 20 percent with individual statin use. Neither pill affected levels of HDL, or good cholesterol.”

“Anti-clotting effects seemed the same with the polypill as with aspirin alone.”

Admittedly, I’m being a little too over self- congratulatory here. The idea for the polypill came not from me, but from two British researchers back in 2003, and a firm owned by a physician from India formulated the pill (1.Wald, NJ, and Law, MR, A Strategy to Reduce Cardiovascular Disease by more than 80%, British Medical Journal, Page 1419, 2003.
2.K.Srinath, “The Preventive Polypill – Much Promise – Insufficient Evidence,” New England Journal of Medicine, Page 212, January 18, 2007).

But as archy the cockroach, the creation of Don Marquis, might say, “whatthehell,,hellsbells, sometimes you have to blog your own horn.”

The Moral

That big innovations have to be complicated,

is a concept that is truly vastly overrated.

Take the heart and stroke prevention polypill,

It fulfills practically every innovation bill,

And it is just what the doctor indicated.

That's teh way I see it.

Liberals vs. conservatives - Answers to Liberal Litany on U.S. Health System "Crisis"

In my upcoming book, Obama, Doctors, and Health Reform, I have a chapter called “The Litany.” The Litany refers to the off-repeated but seldom countered complaints about the U.S. health system – that it costs too much, covers too few, creates too many bankruptcies, and leaves in its wake miserable health care statistics.

These U. S. statistics, compared to other industrialized nations, include: shorter life expectancies, higher infant mortalities, more uninsured. and more rapidly rising cost. Many of these statistics stem from the simple fact that one of every five Americans in now an immigrant or a close relative of one and that these immigrants are often beyond the reach of the health system.

Tone of Criticism

The general tone of critics’ complaints is: as a civilized nation, we ought to be ashamed of ourselves. Our health system is “in crisis,” and our old, poor, disabled, and sick are dying in the streets for want of care.

In response to these litany of complaint. John C. Goodman and Devon Herrick of the National Center of Policy Analysis, Linda Gorman of the Independence Institute, and Robert Sade of the Institute of Human Values in Health Care, have prepared a 20 page rebuttal “Health Care Reform: Do Other Countries Have the Answer?” they back their rebuttal with 87 references.

1. Does the U.S, spend too much on health care? Other countries, they say, “ aggressively disguise costs” and treat long term care, out-of-pocket spending, overhead costs differently than in the U.S.. Per capita, the U.S. uses fewer physicians, nurses, hospital beds, physician visits, and hospital days than median OECD nations. The average growth of our spending per capita is below that of over nations (3.7% vs. 3.8%) and has been so over the last four decades (4.4% s. 4.5%). Further, our waiting times for procedures are far shorter than other countries.

2. Are U.S. outcomes better or worse than those of other countries? The authors argue that U.S infant mortality varies enormously in the U.S. across racial and ethnic groups by factors of 2 – 3: 1 across cities and states for reasons that have little to do with health care. U.S. infants, once born, have high likelihood of survival. Five year survival from cancer in higher in the U.S. than in Europe. Our rates of hypertension and hypertension control are greater. And our rate of adverse events in hospitals is less. Our waiting lists for dialysis, hip replacement, knee replacement, bypass surgery and cataract surgery are much less. The authors comment, “It is not clear whether the U.S. spends too much on health care or other countries spend too little.”

3.Is the large number of Uninsured in the U.S. a crisis? The authors say that uninsurance is often transitory, that 83% to 86% are insured, and that our unprecedented influx of immigrants causes uninsured 2 ½ times that of the native born population. Of the 46 million uninsured about 12 million are illegible for Medicaid and other public programs. 17 million of the uninsured live in households of $50,000 or more, and more than half of these earn more than $75.000.

4.Does lack of health insurance cause premature death? The consensus of economic studies is that “insurance has a relatively small effect on health.” The authors argue that it is not known how much mortality and morbidity is due to lack of health insurance. They also point out that creating universal coverage by having people enroll in Medicaid may cause them to drop private plans, which may cause worse health outcomes.

5.Are medical bills causing bankruptcy? They cite a series of economic studies indicating that only 17% of ‘Medical bankruptcies” are actually so, that there are few statistical links between bankruptcies and health problems,

6.Are administrative costs higher for private insurance than public insurance?

Here is their comment, “The Congressional Research Service has estimated the administrative costs of Medicare at 2% of total program costs, compared to 10% of private insurance and 12% for HMOs. Some single payer advocates have uses this estimate as an argument for a universal Medicare program. These estimates ignore hidden costs shifted to the providers of care, and the social cost of collected takes to fund Medicare. A Millikan & Robertson study estimates that when these costs are included, Medicare and Medicaid spend two-thirst more on administration than private insurance spends on administration: 27 cents, compared to 16 cents, respectively for each dollar of benefits.”

7.Are low-income families more disadvantaged in the U.S. system? In Britain, the National Health Service, despite its 60 years in existence, has done little to equalize health care access. In Canada, the wealthy and powerful have much greater access to medical specialists than the poor. In Canada, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts. In all OECD countries, higher income people use the system more intensively than at higher costs than lower income people.

8.Can the free market work in health care? The portrayal of the US. as a more market driven system may be more perception than reality. In the U.S. 13 cents of health care money is spent out of pocket, and in OECD countries the average is 20 cents. In the U.S,. cosmetic surgery and corrective visual out-of-pocket costs have declined 30% over the last decade. Retail clinics have proliferated. They post prices, keep EMRs, and prescribe electronically. Systems operating outside of 3rd party payments and constraints have lower costs and better quality. Wal-Mart is and Target are offering $4 prescriptions for generic drugs, and more than 10 million of U.S. families are managing their own care through health savings accounts, and many countries, such as Singapore, South Africa, and Switzerland rely on private insurance mandated by government.

Conclusion

The authors conclude,” Support for government regulation of health care financing and delivery has been based on a narrowly selected data, while all but ignoring contrary data. We have attempted to correct the record by discussing some specific gaps and suggesting the U. S. health care reform would benefit greatly from a careful examination of the current success and future potential of market-based reforms.”

If I may summarize,

Be careful before accepting the prevalent liberal litany,

that the U.S health system should live in eternal infamy

that United States health statistics are uniformly poor,

compared to other nations with coverage door to door,

and that the market is for the few and not for the many.