The doorknob question, that important or embarrassing question our patients traditionally ask at the "close" of an encounter is a long-standing and common phenomenon. The chorus of this phenomenon, however, is changing from, "Oh, Doc, I've got this rash..." to "But Doc, I don't have the cash..." All too often prescriptions go unfilled and followups unscheduled because patients simply can't afford them. Physicians find themselves scouring the $4 prescription lists for a suitable alternative, which may or may not exist, or seeing if the local supermarket is still offering free antibiotics. Cost has become the rate-limiting step in our ability to treat, and is as paramount to our patients as their illnesses.
Years of school and training, constant review of emerging research, we as physicians spend much of our time and lives becoming expert in medicine. But along the way we also become expert in patient care. Medical students are taught how to communicate complicated medical pathology and treatment to patients in "layman's" terms because if they don't understand what we feel is necessary, they won't be able to carry out our prescribed course of treatment. So too, is it vital for us to communicate the complicated healthcare delivery issues we see every day to our representatives in "layman's" terms. If they don't understand what we feel is necessary, they won't be able to carry it out, and our patients and our ability to care for them will lay casualty.
There are many clamoring voices in the ongoing healthcare debate, but of all of these, ours is the one that is expert in patient care. The potential power of the physician voice is strengthened when we speak together. Just as a multidiciplinary care team needs to be on the same page when advising a care plan to a patient, we must harness the power of unity and clarity when offering our prescription to the ailing healthcare system.
The "doorknob questions" of comprehensive healthcare reform aren't just being asked in our offices, they're being asked on Main St, Wall St, Pennsylvania Ave and just about every other street in the country. And we as physicians need to come to a consensus on our answer. Failure to do so may not only compromise our ability to care for patients, but may prove far more dangerous and deadly than not taking a second look at that rash.
Years of school and training, constant review of emerging research, we as physicians spend much of our time and lives becoming expert in medicine. But along the way we also become expert in patient care. Medical students are taught how to communicate complicated medical pathology and treatment to patients in "layman's" terms because if they don't understand what we feel is necessary, they won't be able to carry out our prescribed course of treatment. So too, is it vital for us to communicate the complicated healthcare delivery issues we see every day to our representatives in "layman's" terms. If they don't understand what we feel is necessary, they won't be able to carry it out, and our patients and our ability to care for them will lay casualty.
There are many clamoring voices in the ongoing healthcare debate, but of all of these, ours is the one that is expert in patient care. The potential power of the physician voice is strengthened when we speak together. Just as a multidiciplinary care team needs to be on the same page when advising a care plan to a patient, we must harness the power of unity and clarity when offering our prescription to the ailing healthcare system.
The "doorknob questions" of comprehensive healthcare reform aren't just being asked in our offices, they're being asked on Main St, Wall St, Pennsylvania Ave and just about every other street in the country. And we as physicians need to come to a consensus on our answer. Failure to do so may not only compromise our ability to care for patients, but may prove far more dangerous and deadly than not taking a second look at that rash.
how can we come to a 'consensus'. my colleagues have one view, my friends another. my specialty society and my state society lack consensus.
ReplyDeleteeven 'harry and louise' are confounding things....
I'd say dropping a Byzantinely complex bill the size of the Gutenberg bible on the desk of Congresscritters and demanding it be foisted on the American people without debate is more confounding.
ReplyDeleteI note with some amusement that Healthcare Reform has been changed to Health Insurance Reform. This must poll better.
In 2003 and again in 2007, Obama declared for singler-payer yet admitted that we would arrive there incrementally, a public plan's being the first step. Now, he declares there's no single payer in our future. He can't have it both ways.
Also, if insurers are the villains, why does Business Week trumpet "The Health Insurers Have Already Won?" If the truth is out there, could someone please provide the link?
IMHO, we don't need these bills to accomplish health insurance reform. What we need is to build Reinhardt's 3 legged stool:
1) Insurance Companies accept all comers.
2) Individual mandate to buy insurance.
3) Subsidies so the poor can fulfill the mandate.
I'd humbly add a fourth, allowing consumers to purchase plans across state lines.
That certainly did not take 1000 pages (House Bill) or 600 pages (Kennedy Bill.) So why the complexity? Unless there's another agenda ...
reinhardt, the man responsible for giving so much to hmo's and taking even more away from physicians?
ReplyDeletefor thirty years his failed advice has led to collapse of fee for service medicine, yet has still failed to contain costs - because the flawed economic models he uses do not fit the health care system particularly well. this failure has led us to this juncture and a need for a health care debate at all. (his ideas are not part of any solution)
in yesterday's nytimes reinhardt, citing flawed insurance company data on physician outliers, concluded "The situation is so irrational...(if) You worry about credit card charges, you scream for consumer protection — why not scream for it here?”
fortunately, the ny attorney general sees this data differently. consequently, the major insurers settled with him on this issue amid allegations of fraud just months ago!
it's tiresome to see the insurers and reinhardt at it again, but still with no new data. these folks are not our friends.
Getting back to the question of building consensus, I would argue there already is some. The AMA has come up with a list of principles that must be a part of any meaningful reform. Those principles are to:
ReplyDelete-Expand Coverage
-Improve Quality
-Reform Government Programs
-Reduce Costs
-Increase Focus on Wellness/Prevention
-Payment and Delivery Reforms
In designating principles for reform, we have established consensus. Where we lack consensus is in the approach to achieving reform. By endorsing HR 3200, the AMA chose a strategy they felt would lead to meaningful reform. They rightfully decided that issues like fixing the SGR, covering the uninsured and liability reform were ones worth falling on our swords for. Opposing a public plan was not one of those issues (nor could it be, given the clear lack of consensus in June on how AMA members felt about a public plan). Besides, the AMA knew that there would be much less support for a public plan in the more moderate Senate and Obama Administration than there was in the House. Liability reform was left out of HR 3200, but I have a hard time believing the AMA would keep insisting they will be able to deliver liability reform if they weren't certain they could. With so many members threatening to leave, the AMA is well aware of what a failure to deliver would do to membership.
So the AMA chose to endorse HR 3200 as a strategy to achieve its principles in health reform. This leaves us with two options. The first is that we as physicians can sit around complaining about how we don't agree with the strategy. Alternatively, we can choose to do exactly what the AMA has done: recognize that no strategy is perfect, accept certain political realities and present a unified voice of physicians to make sure our big issues get included in the final package. With declining public support for health reform, legislators needs physician backing to achieve reform. I would argue that endorsing HR 3200 has serendipitously given us more leverage in the discussion, but I'm sure others would disagree. Regardless, no single physician, county or state medical society or specialty society has the unique ability the AMA has right now to give us liability reform, expanding coverage or fixing the SGR. Presenting a divided front and undercutting the message only makes it less likely that physicians issues will actually be addressed.
Consensus? How about these issues?
ReplyDeleteSanctity of the Doctor - Patient relationship.
Patient access to quality healthcare.
Meaingful med mal reform.
Ability for physicians to privately contract.
Ability for physicians to balance bill or not bill, without penalty.
Transparency - all costs and fees clearly stated up front - Doctors, Insurance companies, hospitals. Markets can't work if costs are unknown.
Collective bargaining - Congress should revisit Goldfarb v Va State Bar.
Finally, Bills that are so complex that lawyers can't make sense out of them are not Reform.
doc 99,
ReplyDeleteRe: 'Transparency - all costs and fees clearly stated up front'
is it the insurance plans we should look to in order to restore transparency?
Surely, you have read about the Ingenix settlement ($350m)for fraudulent database on UCR that shortchanged patients and physicians!
Did you know that the 'non-partisan' Lewin Group is owned by Ingenix?
The markets are not 'free'
Oh I'd agree ... third party payors are the problem. And I'm happy we have consensus on that. Included in third party payors is ... the government. Again ... all costs/payments should be posted for all to see - doctors, hospitals, and third party payors. Negotiations begin with knowing the price.
ReplyDeleteI think we can all agree the IRS should not have a role in healthcare.
ReplyDeletehttp://legalinsurrection.blogspot.com/2009/08/irs-new-health-care-enforcer.html
Yikes!
DID YOU KNOW?
ReplyDeleteThe Federal HMO Act of 1974 ... limits member cost sharing. Co-payments may not be greater than 50 percent of the cost of providing any single service and not, in aggregate, more than 20 percent of the cost of all basic health services. The total of all co-payments made by an HMO member in a year may not exceed twice the annual premium for that member's coverage.
from an anonymous poster (folks, we can all be anonymous, its a blog!)
ReplyDeletehad no idea. a member cannot pay more than 20% of the cost of all basic health services? this is services that the member uses, right?- Do you know if anyone has actually studied to see if this is followed? I see my doc's eob's and with a 30$ copay, we often pay well more than 20% of the cost of a service or all services for a particular doctor. Even using the managed cost company's reduced fee, which is often half, sometimes less than half of the doctor's fees.
And the total co-payments cannot exceed twice the annual premium. So we are safe, in theory, after our copays add up to 30,000, as our premiums total about 15,000. Up to 45,000 per year.
Does this HMO act apply at all to other types of plans? ppo's? epo's?
anonymous
another anonymous poster writes:
ReplyDeleteOn the one hand, having healthcare consumers pay part of the cost reduces utilization which drives down healthcare costs. Yet, this money is going back in the pockets of for-profit companies rather than helping to lower costs more broadly. Perhaps regulation is needed requiring co-payments be deposited into a fund for reducing premiums or providing charity care?
i like the way you think.
ReplyDeletebut, i'm not sure of the exact relationship between consumer out of pocket and health are costs though. while increased out of pocket seems to reduce utilization - i'm not sure the impact on cost is established.
and my view on the health plans is that they work 'on commission'. i.e. their profit is related to premium dollars, not related to their work - they keep a percentage of the revenue that streams through their coffers. if they improve revenue, whether by increased market share or just increased premium it works for them. other than establishing a (false but public) raison d'etre, the idea of cost containment doesn't really serve a business purpose for payers.
i am reminded of an old joke that goes something like this, "this guy has a nephew who is kind of slow. so he brings him around the neighborhood park most days to 'show off' to his friends just how slow this kid is. he plays this game with the kid where he offers the kid a quarter in one hand and a dime in the other. the kid can choose one or the other, and the kid gets to keep the coin. each time, the kid chooses and keeps the dime. the uncle plays the game over and over, without regard for how humiliating this must be for this 'slow' kid. one day, one of the uncle's friends had enough and took the nephew aside to ask him why he would choose the dime, when a quarter is worth 2.5 times as much. the reply went like this, ' i've played the game 2500 times with uncle, and i've made $250! if i took the quarter, he wouldn't play the game anymore."
the american public, i fear, is quite comfortable in the role of the uncle.
This comment has been removed by a blog administrator.
ReplyDeletei am reposting on behalf of doc99. there was a bad word that didn't (in my view) enhance the message - sorry, i'd like the discourse to appear civil, in case the grownups are watching
ReplyDeleteREPOST:
The Competition Option
One element of the health care debate that is quite misleading is the belief that the “private” sector cannot efficiently and fairly provide health insurance and therefore the government option is the only option. That’s one myth you won’t see exposed on the Obama White House Health Care info site.
Our current reality is a balkanized insurance system that in fact gives some insurers a monopoly in some regions of the country. They don’t really have to compete because they are given a safe commercial environment that does not punish them for overspending, inefficiency or lousy customer service. And if you think a Government single-payer option will bring you health heaven on earth then I will be happy to pay for your psychological counseling.
We need to inject some legitimate competition into the system.
Why not establish as a requirement that any company who wants to provide health care coverage and sell such insurance must cover every state in the Union?
How about as a license to do such business the companies will not be allowed to deny coverage based on pre-existing conditions? Here is a point where the Federal Government could and should legitimately intervene–provide either a tax credit or a back up Federal insurance (think along the lines of the FDIC) that would mitigate a companies risk in covering folks with existing conditions.
Let’s be clear about one thing. We are not going to change human nature. Let’s look at human nature with respect to money and taxes. If you impose higher taxes in one state, say Maryland, on people who make more than $1 million dollars then don’t be surprised when those who fall in that category start leaving the state for states that do not impose a state income tax–Florida, Texas, Nevada, Tennessee, New Hampshire and Washington.
What do you think would happen if a state like Maryland decided to slash taxes on millionaires? Folks with that kind of cash are more likely to move there. They will buy more of everything–services and products. When they buy those things they pay a sales tax and they end up helping support the jobs of everyone who provides said services and products. Conversely, if those wealthy folks bug out the subsequent demand for goods, services and products drops off. That’s human nature. As long as there is a cheaper, better alternative people will seek it if they can.
That’s one reason I return to an idea I raised in an earlier post–no member of Congress should be given government provided health care. Every member of Congress should be required to get their own insurance. Same for pensions. Why? As long as they have guaranteed health care and retirement they have zero incentive to fix these problems. They got theirs. You? Go **** yourself.
The path to genuine reform of the health care system is to ensure that there is transparency and competition in the insurance industry. The current system is for insiders and lobbyists. It is not what you do or how well you do it. Nope. It is who you know. That ain’t competitive.
now, the privates (payers) have had 30 years to get it right - you really need to give them just one more chance. it's analogous to an abusive relationship - the abused always come back one time too many.
ReplyDeleteps i do appreciate the post, just not the language
Oh ... and the Indian Health Service - a real Public Option - is getting it right? Or the VA? Or Medicaid? GMAB.
ReplyDeletePS ... If a Canadian style system won't work in Canada, why do you think it will work here?
http://www.google.com/hostednews/canadianpress/article/ALeqM5jbjzPEY0Y3bvRD335rGu_Z3KXoQw
Sen. Conrad has offered a Co-op plan as an alternative and HHS Secy Sibelius went off the res with this as well. Also, the President over the weekend now says the Public Option isn't essential for "reform." So what are we talking about, anyway?
Finally, riddle me this - if HR 3200 involves the IRS with helathcare, why on earth would anyone, let alone the AMA back this turkey?
i'm unaware of any legislation proposing canada style health care. no one is suggesting that the govt is going to buy the hospitals.
ReplyDeletepublic option, for which support seems diminished, is limited to a health insurance plan, and a plan alone afaik
According to Barney Frank, Public Option is a necessary first step on the road to Single-payer. Heck, the President himself said the same in 2003 and again in 2007.
ReplyDeleteReefer Madness?
ReplyDelete