Health Reform: The Altitude Affects the Attitude

Attitude is a little thing that makes a big difference.

Winston Churchill

If I were to identify two things that turns physicians off about health reform, it would be the altitude, and a set of attitudes.

This altitude and set of attitudes include.

• Big Brother, government and managerial experts, know best.

• These experts, political and social theorists and analysts, know more than individuals at the point of care.

• A centralized health system reflects collectivist compassion, not repression of individual freedoms and choice.

• Statistics on average population behavior are more important than individual heuristics.

• You cannot trust doctors - their training, their experience, their intuition, their motives.

• You cannot trust patients - their knowledge, their instincts, their choices, their decisions on how to spend their own money.

. You cannot trust markets, which express citizen behavior at street level.

• You can trust data, "In God we trust, all others bring data” as the managerial mantra goes.

• Information – truckloads, wheelbarrows, computer drives, and databases full – will solve all problems, empower all people, improve all outcomes.

• Artificial intelligence is the Holy Grail and will ultimately support, supplement, and even supplant human intelligence.

• Physicians do not have the interests of their patients in mind, they only have their personal interests in mind.

• Physicians, hospitals, and other caregivers, not patients. are responsible for most bad disease outcomes.

• Wisdom on health care matters resides at the top of the pyramid, where power is concentrated, rather than at the bottom of the pyramid, where care is created.

• If we make care free to all, impose enough rules to regulate care, and build a big enough bureaucracy, costs and demand will go down, when in truth, the opposite holds true.

• If we lower physician and hospital rates, discourage specialists and encourage generalists through payment reform, coordinate and concentrate care in large organizations, manage, prioritize, and systematize the behavior of all concerned, and transform the culture from individualism to collectivism, all will be well, the physician shortage will ease, and physicians and the public at large will come to their collective senses and reach consensus that what's good for all is good for each.

Attitude is an intangible, You cannot weigh it, or otherwise quantify it. But you can examine it, sense it, feel its consequences, and acknowledge its impact, for better or worse.

Accountable “Control” Organizations

What’s in a name? That which we call a rose by any other name would smell as sweet.

Shakespeare, Romeo and Juliet

To zealous health reformers the name Accountable Care Organization (ACOs)sounds and smells sweet. To them, ACOs will make physicians and hospitals accountable, will save money, will lift quality of care, and in the process, ACOS may even save Medicare.

Substitute the word “Control” for “Care” in the name, however, and the ACO concept soon begins to fall apart. When it comes to who sets the rules, collects, distributes, and loses money, defines quality, and directs patients, “control” is everything. To doctors ACOs by another name, Accountable Control Organizations do not smell as sweet.

Who would enter into a relationship in which:

• losing is a given, at least for the short term;

• an outside agency sets the rules;

. Your competitor disperses the "savings";

• distribution of "savings" is delayed;

• government is the principle beneficiary.

These are a few of the reasons many physicians regard Accountable Care Organizations as Accountable Control Organizations – and therefore, as DOA (Dead on Arrival).

History As Guide

If history is any guide, these physicians may be dead right. At least that is my experience. In the early nineties, as chair of a Physician Hospital Organization (PHO) in a 250 bed hospital, I helped introduce 100 bundled bills for hospital procedures, for which the hospital took a 10% discount and the specialty physician groups a 3% discount. We backed the bundled bill with reinsurance in case the cost exceeded the collective bill.

Our bundled bill concept failed in the marketplace because the state Blue Cross organization rejected the concept. The Blues preferred to negotiate with hospitals and doctors separately, presumably as part of a “divide and conquer” strategy.

At about the same time, two colleagues and I launched the National Organization of Physician Hospital Organizations. The name had a nice ring and zing – physicians and hospital working together for the common good and to lower costs.

But, alas, the PHO concept lasted only a few years. Physicians quickly complained hospitals controlled the process. Doctors dubbed “PHOs” as “HPOs,” and the PHO concept died in the cradle. We tried to save our organization by changing the name to “National Organization of Integrated Care Organizations,” but that too failed.

What lessons did I learn from our failure?

• The name of an organization is important, but it is not enough.

• Physicians are reluctant to enter into an organization relationship in which they are guaranteed to lose money.

• Physicians and hospitals view themselves as competitors as well as collaborators.

• The success of any collaborative effort depends on health plans as well as hospitals and doctors.

• Specialists , on whom hospitals depend for the bulk of their revenues, are reluctant to enter into a binding hospital relationship, when they are doing well on their own.

In the current exercise in name calling, I would introduce a word of caution about the word “accountability.” Who is “accountable” for costs of care? Doctors and hospitals? Yes. But patients, too, through their unhealthy behaviors and compliance or non-compliance with doctors’ orders are accountable too. Indeed, patients may be a more potent factor in determining outcomes than either doctors or hospitals.

Finally, I am skeptical whether ACOs will ever get off the ground because of:

• expense of hiring lawyers and consultants.

• paperwork and time needed to meet federal rules.

• presence or absence of a primary care base.

• effectiveness of incentives for patient behavior.

• need for expensive interoperative IT systems.

I doubt if all these conditions and underlying psychological factors can be resolved in a timely enough fashion to control costs, either in the short or long term.

Health Reform: Look at Massachusetts First

If you doubt the likely effects of health reform on health care, says Kevin Pho, MD, in its widely-read blog, Kevinmd.com, "Look at Massachusetts first." In its stab at universal coverage, now four years old, Massachusetts has seen these consequences: overcrowded ERs, longer waiting times to see doctors, more than 50% of primary care doctors closing practices to new patients, and the highest health care premiums in the nation.

So much for lowering health costs and expanding access. And all of this in state with more primary care physicians per capita than any other state, in a state with fewer uninsured than any other state, and in a state with an individual mandate and a health plan said to be a model for Obamacare.

In his blog, in essence Kevin says, “It’s the lack of primary care doctors, stupid!” He displays a chart from the Incidental Economist showing we have only 1/3 as many general practitioners as other nations.

Now comes further confirmation of the basis for our problems of cost and access from a new survey from the American College of Emergency Physicians, who are on the clinical front lines in America’s ERs.

Here is the NPR report on the survey.

“Hospital emergency rooms (ERs), the theory goes, get overcrowded because people without health insurance have no place else to go. But that's not the view of the doctors who staff those emergency departments, says NPR.

The real problem, according to a new survey from the American College of Emergency Physicians, isn't caused by people who don't have insurance -- it's caused by people who do, but still can't find a doctor to treat them.

• A full 97 percent of ER doctors who responded to the survey said they treated patients "daily" who have Medicaid (the federal-state health plan for the low-income), but who can't find a doctors who will accept their insurance.

• At the same time, 97 percent of ER doctors also said they treat patients daily who have private insurance and primary care doctors, but whose primary care doctors sent them to the emergency room for care.

• Apparently that's because the patient's need for care arose during a time when that private doctor's office was closed.

• Since these insured patients are more -- not less -- likely to use the emergency department, 89 percent of physicians in the survey said they believe the number of visits to emergency rooms will increase as the new health law is implemented. “

Source: Julie Rovner, "Emergency Room Doctors Say Health Law Will Make ER Crowding Worse," NPR, April 28, 2011.

As Kevin Pho says, “Having health insurance doesn’t guarantee access to care. Period.”

Of Health Reform’s Conspiracies and Theories

Every doctor has a poet inside.

Anonymous

I am not a conspiracy buff,
Of paranoia I’ve had enough.
This applies to health reform,
Some see it as a singular form,
of a liberal or socialist plot.
that will cost taxpayers a lot.
as an evil, unspoken conspiracy,
as a burgeoning bureaucracy.
But many of us with a conservative mindset
see it as a sure path to more national debt,
as misguided with noble intentions,
as over-riding federal interventions.
Government, we say, should be less monumental,
And markets more incremental and fundamental.

Doctor Puns and Health Reform

At long last, someone has taken puns seriously. A former world champion of punning, winner of the 1995 O.Henry Pun-Off World Championships, John Pollack, has written a punstaking book on punning. The 212 page indexed hardcover goes by the name of The Pun Also Rises (Gotham Books, 2011). The book has a revealing subtitle How the Humble Pun Revolutionized Language, Changed History, and Made Wordplay More Than Some Antics.

The book doesn’t have much to say about punning and health reform, although it has these entries on matters of health.

Flabbergasted - appalled at how much weight you’ve gained.

Abdicate - to give up all hope of ever having a flat stomach.

Balderdash – a rapidly receding hairline

Rectitude – the formal, dignified bearing adopted by proctologists.

There are no puns on doctors’ attitudes towards health reform. Fair enough. Anyway, These puns would tend to be negative because most doctors feel the health reform law treats them harshly, decreases their incomes, questions their clinical acumen, prefers computer judgment to human insights, and seeks to organize them into new business models designed by outsiders.

To fill the void, here are a few irreverent and alliterative puns on doctors’ reactions to the health reform law, which physician surveys indicate is about 60% t negative.

Allergists say,“ Scratch it,” while Dermatologists cry, “It’s a rash move.”

These allergic reactions are understandable because these specialists tend to be in solo or small fee-for-service practices. The new law treats these practices punitively.

Gastroenterologists have a negative gut feeling about it, while Neurologists think the Administration has a lot of nerve.

These gut and brain specialists distrust elitist D.C. pundits.

Obstetricians feel those who made the law were laboring under a misconception while Ophthalmologists considered the idea shortsighted.

The delivery system experts and visionaries claim they don’t need punctilious meddling.

Pathologists yell, "Over my dead body!" While Pediatricians cry, "Oh, Grow up! "

Please forgive them, Lord, for their pungent remarks.

Psychiatrists think the whole idea is madness, while Radiologists can see right through it.

In other words, shrink-wrap it or give it a lethal ionizing punch.

Surgeons have decided to wash their hands of the whole thing.

Actually, they would prefer to puncture and drain it.

Internists think it is a bitter pill to swallow, and Plastic Surgeons say, "This puts a whole new face on the matter."

In reality, both have aligned themselves into punt formation.

Orthopedists say cast it aside, Urologists say,” Smash it and pass it.”

If it ain’t broken, don’t fix it, and if it’s caste in stone, it too shall pass, like this bad pun.

Anesthesiologists think the whole idea is a gas, and Cardiologists don’t have the heart to say no.

In other words, reform may be a laughable idea, but no good procedure goes unpunished.

Head and Neck Surgeons say not in their neck of the woods, and Otolaryngologists say they have had an each full.

These two are simultaneously puntificating and going for the jocular.

Tweet: Puns may be the lowest form of humor and doctors may be serious people, but that doesn’t make doctors immune to bad punning

Who’s Afraid of the Big Bad Heath Reform Wolf? “Wolf!” “Wolf!” Said the Doctors

Preface: At the risk of crying Wolf! once too often, I have said repeatedly that behind the physician shortage looms a health care – and a political -crisis. Sufficient numbers of physicians will be key to successful reform. The following New York Post column gives detailed reasons why.

Doc Holiday: Behind the Coming Physician Shortage

By Michael Tanner, Cato Institute, May 1, New York Post

The doctor is not in.

The United States already faces a growing physician shortage. As our population ages, we require more and more intensive health care. At the same time, enrollment in medical schools has been essentially flat, meaning we are not producing new physicians at anywhere near the rate we need to. In fact, according to the American Association of Medical Colleges, we face a shortfall of more than 150,000 doctors over the next 15 years.

And it could get a whole lot worse.

The health reform bill signed into law last year is expected to significantly increase the number of Americans with health insurance or participating in the Medicaid program. Meanwhile, an aging population will increase participation in Medicare. This means a greater demand for physician services.

But at the same, the bill may drive physicians out of practice.

Existing government programs already reimburse physicians at rates that are often less than the actual cost of treating a patient. Estimates suggest that on average physicians are reimbursed at roughly 78% of costs under Medicare, and just 70% of costs under Medicaid. Physicians must either make up for this shortfall by shifting costs to those patients with insurance — meaning those of us with insurance pay more — or treat patients at a loss.

As a result, more and more physicians are choosing to opt-out of the system altogether. Roughly 13% of physicians will not accept Medicare patients today. Another 17% limit the number of Medicare patients they will see, a figure that rises to 31% among primary care physicians. The story is even worse in Medicaid, where as many as a third of doctors will not participate in the program.

Traditionally, most doctors have been willing to take some Medicare patients either out of altruism or as a “loss leader,” to reach other family members outside the Medicare program. Others try to get around Medicare’s low reimbursement rates by unbundling services or providing care not covered through the program. (Nearly 85% of seniors carry supplemental policies to cover these additional services). With many office and equipment costs fixed, even a low reimbursement patient may be better than no patient at all for some doctors. This is even more true for hospitals where Medicare patients may account for the majority of people they serve. And doctors can take some comfort in the fact that Medicare is pretty much guaranteed to pay and pay promptly. The same is not always true of private insurance.

But if reimbursements fall much more, the balance could be tipped.

The government’s own chief actuary says that reimbursement cuts could mean “reductions in access to care and/or the quality of care.” Once the cuts hit hospitals, they too will be in trouble. Medicare’s actuaries estimate that 15% of hospitals could close. Inner-city and rural hospitals would be hardest hit.
Nor is the pressure on reimbursement rates likely to be felt solely in government programs. The health care law contains a number of new regulations that are already driving up insurance premiums. The government is responding by cajoling and threatening insurers. If insurers find their ability to pass on cost increases limited, they too may begin to cut costs by cutting reimbursements.

For a lot of older physicians, retirement in Florida may begin to look like a very good option. Roughly 40% of doctors are age 55 or over. Are they really going to want to stick it out for a few more years if all they have to look forward to is more red tape (both government and insurance company) for less money? Those that remain are increasingly likely to join “concierge practices,” limiting the number of patients they see and refusing both government and private insurance.

And, at the same time, fewer young people are likely to decide that medicine is a good career. Remember, the average medical school graduate begins their career with more than $295,000 in debt.

A 2010 IBD/TPP Poll found that 45% of doctors would at least consider leaving their practices or taking early retirement as a result of the new health care law. And, an online survey by Sermo.com, a sort of Facebook for physicians, found that 26% of physicians in solo practices were considering closing. Of course, not every doctor who told these polls that he or she would consider leaving the field will actually do so. But if even a small portion depart, our access to medical care will suffer.

In fact, we have already seen the start of this process in Massachusetts, where Mitt Romney’s health care reforms were nearly identical to President Obama’s. Romney’s reforms increased the demand for health care but did nothing to expand the supply of physicians. In fact, by cracking down on insurance premiums, Massachusetts pushed insurers to reduce their payments to providers, making it less worthwhile for doctors to expand their practices. As a result, the average wait to get an appointment with a doctor grew from 33 days to over 55 days.

Promising universal health coverage is easy. But what does universal coverage mean if you can’t actually see a doctor?

Tweet: Health reform promises universal coverage, but what happens if there are no doctors to care for you?