Friday, September 18, 2009
Saturday, September 12, 2009
I will now focus on cost, the last of our pillars of healthcare reform. First, I feel compelled to point out that increases in healthcare spending are not necessarily bad.
- National healthcare expenditures1
- 2006 : $2.1 trillion
- projected 2009 : $2.5 trillion
- an increase of 18.3% over that period
(I chose 2006-2009 to make a point later)
- Expenditures as percent of Gross Domestic Product have increased from 13.8% to 17.6% from 2000 to 20091
- Average increase in healthcare costs from 2008-2018 projected to exceed rise in GDP by 2.1% annually1
- Medicare Trust Fund is expected to be turning to cash flow deficits beginning in 2016 2
- fund assets exhausted by 20372
- Private insurance premiums for families have risen 17.2% from 2006 to 20093
And, of course, we have been continually inundated by those quoting the daily number of bankruptcies due to healthcare costs, the negative impact to businesses…we are all well aware of this, and while we may disagree on some of the numbers being thrown out, none would argue that we can and should do better.
So if we accept the notion that healthcare costs are in need of control, then we can move on to determining the best course of correcting the cost issue.
If we want to first look at a government-based intervention, then we should ask ourselves a fundamental question. Do we have historical or current models of government intervention in healthcare similar to those that are the crux upon which the current plans are being developed by this administration? For if we do have these models, wouldn’t it be foolish to not evaluate the current plans in the context of these models? Shouldn’t we determine their effectiveness in reaching the goal of decreased cost? Remember the saying about those who do not learn from history. Fortunately, we do have models to evaluate.
I am going to hearken back to the
- State-only healthcare expenditures have increased 28% since program’s inception in 2006
- Total state healthcare spending has increased 42% since 20064
- Federal government allocated $360 million to
$1.5 billion granted over next 3 years
- As a comparison, national healthcare expenditures (meaning not using this plan) have increased 18.3% since 20061
- Per capita healthcare spending in
- Private health insurance premiums have risen over 9% annually on average during the last 3 years compared to 6.7% nationally 6,7
- Supporters suggested that the reforms would reduce the price of individual insurance policies by 25–40 percent 8
So in looking at these simple numbers above, we see that healthcare costs have increased 2.3 times more in
An equally concerning point in the numbers above is that this plan has also negatively impacted the private insurance market. The cost for private insurance has also increased at a 34% faster rate in
Another question that arises from the information above: if the federal government is filling in anywhere from $360 to now $500 million to cover part of the expense, then what will happen if a similar plan goes nationwide? Who will be there for our backstop to give us additional dollars?
Even with increased taxes on cigarettes (a tax mostly affecting low and middle income wage earners), an additional $100 million in fees on private companies signed by Governor Patrick in 8/2008, changes in the compliance laws for the business mandate that increases costs for small businesses, increased federal government spending (the list goes on and on), the state continues to struggle to cover the increased spending.9
This problem of cost containment with government intervention in healthcare is not specific to
- All offered new government subsidies and/or expanded Medicaid: ALL FAILED
- “There is little reason to think that the current
This is a quote from a group of Harvard physicians who understand that the current approach is not going to be successful. I included it because they are far from being labeled as independent or conservative thinkers and instead desire a single-payer system. And they realize that repeating failed past policies will not work.
I am not going to delve too far into our central government’s ability to control costs. If most of us applied a little common sense, I do believe that we would agree that the government controls costs very poorly. We keep hearing about the $500 billion in waste in Medicare – that does not sound like spectacular cost control.
I will be anecdotal for a second but how many of us remember joking about toilets and screws and wrenches going for tens of thousands of dollars? If a bank was unable to control costs and was wasting that kind of money, I doubt too many of us would be running to increase our savings in that bank. Yet we for some reason blindly believe that the government will change its ways despite decades of similar practices under the control of both Republicans and Democrats.
But to bring this back to numbers, I thought this graph below is interesting. The cost per patient has risen more quickly in the government programs than those in the private sector. The accompanying article goes through the arguments that I am sure will arise, so please read it and I will not rehash them here.11
If we need further proof, I say look no further than the bankrupt Medicare. And look at Medicaid funding. And look at Social Security. And look at the Post Office. Remember that little saying about fool me once, shame on you, fool me twice, shame on me.
I do look forward to the discussions regarding the best way to control costs. I am sure we will delve into competition, profits, overhead expenses of the government versus private industry, and more. This was to be a small view into “research trials” that have already been performed and by my estimation, based on numbers, have failed.
To finish this post, I’d like to us the following medical concept to explain my concerns.
Let’s say that I am setting up a research trial looking for a cure for prostate cancer and I made drinking sweet tea (this is
3. “Survey of Employer Health Benefits 2007,”Kaiser Family Foundation, http://www.kff.org/insurance/7672/upload/7693.pdf.; “Survey of EmployerHealth Benefits 2008,” Kaiser Family Foundation, http://ehbs.kff.org/images/abstract/7814.pdf.; “Hewitt Data Reveals Little Change in U.S. Health Care Cost Increases for 2009,” Hewitt
4. Kevin Sack, “
5. Centers for Medicare & Medicaid Services (CMS), Office of the Actuary, National Health Statistics Group, 2007.
6.“Health Benefits Survey 2007,” United BenefitsAdvisors, http://www.bio-medicine.org/medicinenews-1/survey-3a-massachusetts-employers—employees-paying-most-for-health-care-plans-10689-2/. John McDonough, “Massachusetts Health ReformImplementation: Major Progress and FutureChallenges,” Health Affairs (June 3, 2008): w285–97.“2009 CommCare Premium Contributions and Affordability Schedules,” March12, 2009 http://mahealthconnector.org/portal/binary/com.epicentric.contentmanagement.servlet.ContentDeliveryServlet/About%2520Us/Publications%2520and%2520Reports/Current/Connector%2520Board%2520Meeting%2520March%252012%252C%25202009/Affordability%2520Schedule%25202009%2520%25283-11-09%2520revised_2%2529.ppt#257,1,Slide 1.
7.“Survey of Employer Health Benefits 2007,”Kaiser Family Foundation, http://www.kff.org/insurance/7672/upload/7693.pdf.; “Survey of EmployerHealth Benefits 2008,” Kaiser Family Foundation, http://ehbs.kff.org/images/abstract/7814.pdf.; “Hewitt Data Reveals Little Change in U.S. Health Care Cost Increases for 2009,” HewittAssociates LLC, http://www.hewittassociates.com/Intl/NA/enUS/AboutHewitt/Newsroom/PressReleaseDetail.aspx?cid=5604.
Thursday, September 10, 2009
September 8, 2009
Dear Mr. Chambliss and Isakson,
I am writing in hopes that you would have time to meet on my next visit to DC later this week. I am a cancer doctor in the Atlanta area. At the onset of the latest health care debate, I was suspect of the effort having witnessed something similar firsthand in 1994 while a medical school student at Georgetown. As more information seeped from this bill (HR 3200) through the press, I was increasingly concerned by the transformative nature of the legislation being proposed by the Democratic congress. But it was the reactions of my patients that served as the primary impetus to throw a Town Hall in mid-July, an impromptu effort designed to give them an outlet to express their concerns with one another. Despite it's last minute organization, it managed to bring out over 300 concerned citizens on a weekday night with little notice. What was planned as a roundtable discussion among patients in a 50-seat auditorium turned into a full-fledged rally against this bill. Soon after, Town Halls broke out across America and the media was only too happy to portray these magnificent people as somehow un-American. The demand for more opportunities to discuss this bill led me to throw 2 additional Town Halls at a movie theater in my practice area (Lake Oconee) with crowds of over 500 showing for each. I also teamed up with Dr. Brain Hill, a colleague and friend, who managed to make himself famous for challenging Cong. David Scott at a Town Hall in Douglasville only weeks after my first one. What is most fantastic about the responses of the public at each of our events is the newfound interest that many of the retired folks have in the political process and their political fate.
I do think we will prevail in this fight. I see September and October as the months that will determine largely whether this is the banner to an Obama legacy or truly the Waterloo that Jim DeMint had forecast. Should the coolest heads prevail, I think we might be able to address the dire need to create a solution to our escalating societal medical care costs. It's never a wise thing, however, to create transformative policy when the electorate is so polarized. There isn't the urgency to act as there might be at a moment when a country declares war in self-defense, for instance. This is a long-standing problem that requires deliberation and clearly, for public buy-in, requires not just party cooperation, but more importantly, a trans-generational cooperative effort to accomplish such a substantive change. There are so few issues in front of the public at any given time upon which 20-somethings and 70-somethings can agree. But, there is no more important issue that requires this dialogue. Someone of good character and well-meaning intention needs to begin to set the tone. We need a figurehead in Congress with a steady mind and a steady hand and someone that the public finds trustworthy.
What my partner Brian Hill and I firmly oppose is any entity, regardless of political stripe, to overtake the argument and direct the exchange. What we have been able to demonstrate in our circles of influence in the Atlanta market is that by taking a stand for the patient, as we do every day at work, we are able to garner attention from both political parties and simultaneously motivate individuals towards activism. My Town Halls at one point all serve as a means of educating the patients on how to contact their Congressperson by phone and email. They stress a grassroots revival as a means of both disseminating information and countering the network firmly established by the opposition forces. We both believe that what is ultimately most imperative is the need to position the patient at the top of the reform-effort pyramid. To that end, who better to speak on the patient's behalf than those most likely to be affected by any government-mandated intrusiveness that accompanies reformation of the delivery system: their doctors. And so, we began our joint effort, Just2Docs, a name meant to reflect that impartiality towards the political entities and the simplicity in our design centered around patient interests and evidence-based reforms.
Of course our hope is that this debate will move towards a deliberate and well-vetted effort by both parties. While it is true that some needy citizens require greater inclusion in its benefits, our health care system is the world's best and need not be radically disrupted to accomplish this task. Yet I agree that as a country with a solid ethical foundation at its roots, we need to be inclusive of those who need better access - of this certainly no one can argue. I am of the belief that each of us has a kernel of morality that is able to withstand the transient shifts in political ideology that naturally accompany human progress through time. Were we to tap into that while simultaneously applying the unique brand of American industriousness that has elevated mankind since our country's inception, I believe we could all settle on the desirable outcome of concomitantly maintaining our superior standing while reaching even the most destitute of our fellow neighbors.
So, Saxby and Johnny, if I may ask: I would like to propose that we (collectively) consider the ‘face’ of the counterproposal that we offer to Congress as we advance this debate beyond the initial legislative offering. The public at my Town Halls (sans politicians) has responded very favorably to the physician-directed debate. It would appear to both Dr. Brian Hill and I that this is the most effective way to deliver an alternative to those open to one. The public, as you know, is skeptical of the tactics of either political party right now yet finds their doctors trustworthy 2:1 over their public officials. While we can only begin to scratch the surface of information at the fingertips of a large research think tank, what we CAN offer is the inherent ability to advance the correct reform measures that address our patients' needs first and have valid precedent. My patients are pleading that I continue to be involved and I suspect they are no different than any other doctor’s patients. So I would like you to know that you have 2 very willing servants in this cause down here in your home state of GA. I would welcome the call to help you in any way.
Please let me know if you would have any time whatsoever to meet on Thurs 9/10 as I will be in DC to attend the events that weekend.
David Lowther, MD
President - Southeastern Radiotherapy Specialists
Cell (706) 474-8170
Co-Founder – Just2Docs
Tuesday, September 8, 2009
Monday, September 7, 2009
I happened to be scanning through Yahoo news and stumbled across this dandy quote, which I’m referencing from the Kansas City article, although the quote itself appears in several hundred different places. (http://www.kansascity.com/444/story/1418881.html)
The message lawmakers will hear when they return to Washington "will be very different than what they heard when August started," said Jacki Schechner of Health Care for America Now. One idea her group will stress, she said, is that the politically smart vote, even in toss-up districts, will support widespread changes meant to expand health insurance coverage and options.
The problem here once again and the point that is missed by those who speak this way is that the ultimate goal is to improve this healthcare system, not to do what is politically expedient. How about doing what’s right to fix the system instead of what will get you elected? This may actually be a better approach to running our country. I hate the distracting noise of political gain usurping governmental responsibility to its citizens.
To go on, I was more than perturbed by a recent interaction with a Republican congressman at a town hall event. If I heard the word “Obamacare” one more time followed by the usual politic-speak, I might not have been able to withhold screaming aloud about the divisiveness of politics as opposed to the unification of ideas. This particular congressman mentioned that he used to practice as a physician, but he spoke and acted like a politician. He politely asked my colleague and me to supply him with our data. The task of gathering the information, which has actually taken quite a bit of our personal lives, has simply come from having the wherewithal to ask if the current idea of increased government intervention in medicine has in other historical or current models achieved our goals of healthcare reform: increased quality, increased access and decreased cost. One would think that this type of thought process should be paramount to anything that is being considered in DC, yet it struck this congressman as so unique. And that should scare us all.
Whatever happened to the idea about looking at historical outcomes? And this congressman is a physician. I assume he went through his medical career following the principles of critical thinking and evidence-based approaches to treatment options. Why does he then not take the same approach to treating the ills of our healthcare system, the ills of our society? Do people become so politically indoctrinated that they cannot think in an independent, well-informed manner? He should have been directing his staff to find this information, and he should have been presenting this information rather than the usual empty rhetoric. Do you, Congressman, understand that when you are voted to represent the people, we count on you to actually educate yourself with information, not political ideology, when deciding whether you are going to cast a vote for us on topics that affect our lives and our future? It is our expectation and it is your job.
I see your failing in this duty as no different than choosing the wrong treatment choice for pneumonia or strep throat or cancer, choices that should be driven by evidence-based outcome information, not personal whims. So this is a call to action for those in power. We expect you all to be making decisions that work for our society, not decisions based on political ideologies. It is time to stop being a politician and start being a real contributor to this country’s future. Our expectations as Americans are raised, and it is time for our elected officials to become something more than politicians. We are now watching, and if you are not up to the task, then it is time to move aside so that true progress for our nation is not weighed down by you. I mean no disrespect, but remember, respect is earned, not bestowed with any title – Congressman, Senator or even President. It is time to earn our respect.
Brian E. Hill, MD
Sunday, September 6, 2009
Access to healthcare can be a very difficult animal to evaluate. A multitude of studies have summarily demonstrated that those without health insurance utilize healthcare much less frequently than those with insurance. The uninsured are less likely to obtain preventive medicine, maintain a primary care provider, purchase medicines for chronic conditions or stay healthy. They are more likely to be unnecessarily hospitalized, have higher mortality rates for disease processes and experience lower five year survival rates for cancers. These are not good findings.1
Yet while these studies reflect that the uninsured without a doubt access care much less than those with insurance, the point that is unfortunately difficult to tease from this information is whether or not the lack of accessing healthcare is directly attributable to the lack of insurance. I do not doubt that the financial aspect of healthcare keeps the uninsured from seeing physicians, and I believe that some of the uninsured truly cannot afford any type of physician visit.
But to play the devil’s advocate, is this finding also a matter of priorities? I can only speak of prostate cancer screening as a urologist (and a primary care physician can include this in their screening), but an annual exam and PSA blood test based on Medicare rates will run $61.31/$91.97 (established versus new patient, moderately complex office visit) for the exam and $26 for the blood test (payment on an average charge of $79) (2009 Medicare fee schedule). Now, a visit for a more thorough health screening to include blood tests for diabetes, elevated cholesterol, kidney function, cervical cancer screening with pap smear or breast cancer screening with a mammogram will without a doubt increase the cost, but again, where does this fall amongst other “necessary” aspects of life: the average digital TV costs $690; a pack a day smoker at $4 per pack will spend over $1460 a year; the average cell phone bill is $635.85 per year2; the average annual cable bill is $8523. How about a $1 cup of coffee on the way to work every day? Our comparative examples can go on and on, but I think the point is obvious.
I always believe that perspective is important, and I believe this adds to that perspective a little. Most physicians that I know use Medicare rates in establishing payment for uninsured services, and we often allow paying part up front with the remaining covered on a payment schedule. Again, I am not denying a problem exists, but we can certainly not allow the lack of insurance to necessarily remain the sole culprit for the lack of accessing care.
So on to some more meat and potatoes of access and coverage.
For one initial point, I want to briefly comment on EMTALA (Emergency Medical Treatment and Labor Act). This is a law that requires hospitals to treat all emergencies without concern for payment until the patient is stabilized. This basically means that any emergent need of care is guaranteed in the
Before I dive too far into access, I am going to make a simple although often overlooked point. Universal coverage does not mean universal access. A simple card saying that you are insured means nothing if no one is available or willing to take that little piece of paper.
We are in the midst of a physician shortage.
- the AMA expects a 90,000-200,000 physician shortage by 2020 the
- we are expected to fall short by 39,000 primary care specialists by 20205
But it gets worse.
- 60% of physicians would not recommend a family member or friend to pursue a career in medicine6
- 49 percent of primary care physicians say that over the next three years they plan to reduce the number of patients they see or stop practicing entirely5
- Only 1 out of 4 primary care doctors would pursue primary care again5
This is nice article that gives further insight.
Commentary: Why primary care doctors are fed up http://www.cnn.com/2009/HEALTH/08/25/harris.primary.care.doctor/index.html
And as for my field (urology), the average age of a practicing urologist is 53.7 years, meaning that a lot of urologists are closer to retirement than they are to starting/maintaining a practice
So how has the current administration expressed their concern regarding the shortages? Sure, like previous administrations, they are pushing primary care initiatives, and that sounds great (although we will hopefully have time to look at the government’s approach and lack of success in achieving that goal later). And these primary care initiatives have been in place even when I was a medical student. But the following quotes are quite telling, and they have created an outrage amongst physicians.
WH Press Conference – July 23, ‘09
“A Doctor may look at the reimbursement system and say to himself you know what? I make a lot more money if I take this kid’s tonsils out.”
- President Barack Obama
“Town Hall” –
“…if a family care physician works with his patient….they might get reimbursed a pittance, but if they get their foot amputated, that’s 30, 40, 50 THOUSAND dollars the surgeon gets reimbursed immediately.”
-President Barack Obama
These quotes are insulting. And not only are they insulting but they are also wrong. The tonsillectomy quote doesn’t really need any further deconstructing. I cannot understand the audacity it takes to say something so plainly derogatory to the physician community. To even hint, much less openly state, that we in medicine are so deviant that we are willing to put a child at risk and operate on that child solely for our own personal gain, is more than I can tolerate, much less so when it comes from the mouth of my President. My blood boils every time I see these quotes, and it should for every physician out there that holds dear the values of our medical ethics.
But for the second quote, I will pass along a little info.
The Medicare reimbursement for a below knee amputation is approximately $700, not $30,000-$50,000. The President is off by a factor of at least 4500%. And just so that everyone is aware, that $700 (again, not $30,000-50,000) includes 90 days post-operative care. Oh yeah, and it includes the 60-70% of overhead that running a physician’s office entails. So when all is said and done, the orthopedic surgeon performing the below-knee amputation takes home ~ $250 (and the government later takes half of that in taxation).
So if physicians are continually abused, misrepresented and have their livelihood threatened, some will quit and others will never pursue a career in medicine. Remember, doctors get to choose their career.
To delve further into the access side of this, I will present data from
- Average wait time to see primary care physician in
- Now – 63 days7
- Average wait time to see any physician in
- In 2008, 1 in 5 in
Why is this happening in
So, has the
In any case, not only are we seeing access problems with increasing wait times, but this public option plan even falls short of achieving universal coverage. If
For comparative access info looking at the Canadian and
According to the OECD (Organisation for Economic Co-operation and Development) Health Data (2008), there are:
- 26.5 MRIs and 33.9 CT scanners per million people in the
- 6.2 MRIs and 12 CT scanners per million in
- 5.6 MRIs and 7.6 CT scanners per million in the
- average wait time of 17.3 weeks to see specialist and receive treatment
- median wait for a CT scan 4.9 weeks (just for comparison, I have a CT in my office for immediate results)
- MRI 9.7 weeks
- ultrasound 4.4 weeks
Why is something like access to imaging important to outcome? Well, studies have shown that life expectancy improves with advanced medical imaging.11 And it is the economic freedom with our current system that allows continued advancements in technology.
More access issues:
Government data show that an estimated 1.7 million Canadians—in a country of around 33-34 million—were unable to access a regular family physician in 2007. Without access to a family doctor, a person can’t obtain regular primary care or referrals for specialty medical services.12
Extrapolating that to the
If you aren’t aware of this breakdown, here is one place for the information: http://www.chamberpost.com/2009/08/health-reform-and-the-uninsured.html
So is the universal coverage in
So, in looking at the above, the access and universal coverage side effects of government involvement in healthcare have been decreasing access, increasing wait times for diagnosis and treatment, and a lack of universal coverage. And the notion of universal coverage not meaning universal access is continually proven to be quite true. The current administration is beating up the medical community and negatively impacting a physician shortage without the understanding that the resource of medicine is dependent upon those that deliver care. This does seem to match our goal of increased access and coverage. And if that is the case, then again, we need to ask ourselves, if this treatment plan does not achieve those stated goals, then why are we pursuing a plan that has repeatedly failed? It makes no sense.
7 “2009 Survey of Physician Appointment Wait Times,” www.merritthawkins.com