Sunday, September 6, 2009

Topic 2 of 3: Access / Universal Coverage

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 US. I say this because at one town hall, a discussant brought up a friend of hers whom had just tragically died at home because she was uninsured and did not want to go to the ER despite feeling ill. Now that is a travesty, and we all see the awfulness in that situation. But I also see a person who had access to healthcare but ultimately chose not to access that care. If she had accessed that care, she may be alive today. She would have undoubtedly developed further financial difficulties, maybe even had to declare bankruptcy, but as is often mentioned, you can go bankrupt many times, you only die once.

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 American Academy of Medical Colleges has predicted a 124,000 physician shortfall by 20254

- 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

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” – Portsmouth, NH, Aug 12, ’09

“…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 Massachusetts. I will cover Massachusetts in more detail when we get to costs, but I am using the Massachusetts model since it adopted a public option plan, developed the Commonwealth Connector, and has basically acted as the template for the current ideology on healthcare reform associated with increased governmental involvement.

Massachusetts accepted the plan in 2006. We now have 3 years of data to evaluate this as an experimental model. So what have we seen with regards to access—just getting in to see the doctor?

- Average wait time to see primary care physician in Boston, Massachusetts in 2007- 34 days

- Now – 63 days7

- Average wait time to see any physician in Boston - 50 days

- In Atlanta - 11 days7

- In 2008, 1 in 5 in Massachusetts reported problems being able to find a doctor or get an appointment8

Why is this happening in Massachusetts? I don’t know. Maybe physicians are leaving, maybe they are retiring, or maybe the influx of new patients is outstripping the current supply. But I do know that in the reality of my group, two physicians over the age of 55 have expressed that they will retire if they feel that they have to make medical decisions based on cost-effectiveness as opposed to patient-centered care. And they are not alone. And as we can see above, we cannot afford to lose working doctors.

So, has the Massachusetts plan at least achieved universal coverage? Because the plan has certainly worsened access since it was initiated. Well, despite employer and individual mandates, one study found that 30% of the previously uninsured population remains uninsured (650,000 to 200,000) for a 2.6% current uninsured rate9. However, in March 2008, the U.S. Census Bureau conducted its annual door-to-door survey and found a 5.4% uninsured rate. To compare the plan’s effectiveness in decreasing the uninsured, we need to look back to the initial rates of the uninsured. The Massachusetts Household Survey on Health Insurance Status, 2007 from the Division of Health Care Finance and Policy, Executive Office of Health and Human Services estimated a 6.4% uninsured rate in 2006. This means that few of the uninsured (6.4% to 5.4%, maybe 2.6%) have truly been covered. I have seen uninsured rates from Massachusetts in 2006 ranging up to 8.4% on other estimates, but this 6.4% is from the state government’s own figures.

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 Massachusetts, which had one of the lowest uninsured rates in the US in 2006 at the onset of this program, has been unable to cover its citizens, how will that plan work when the US population is beginning with an uninsured rate almost double Massachusetts’ initial rate? Again, the numbers don’t add up.

For comparative access info looking at the Canadian and UK systems as single payer models:

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 US

- 6.2 MRIs and 12 CT scanners per million in Canada

- 5.6 MRIs and 7.6 CT scanners per million in the United Kingdom

In Canada10

- 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 US population of 306 million would mean that 18.5 million US citizens would not be able to access healthcare. While I won’t go through the full breakdown the 46.7 million uninsured, the number thrown around as “the true uninsured” is around 10-15 million.

If you aren’t aware of this breakdown, here is one place for the information:

So is the universal coverage in Canada equating to universal access? The numbers certainly aren’t bearing this out. Despite coverage, the same percentage of Canadians is having as difficult a time accessing healthcare as our uninsured. Remember, coverage does not equal access.

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,”




11 13


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