Thursday, August 13, 2009

Response to Paul taylor

I was recently browsing the website of a local hospital, actually looking at their careers section when I came across a tab with a link to a blog written by their CEO. He has a detailed description of why his particular hospital is a good model, and a barebones idea for healthcare reform. Lots of good information but this my repsonse to his white paper where he details his ideas. It's a good read in case you're interested

Just want to start out by saying that I think you have a lot of great ideas for healthcare reform in America. That being said, I fundamentally disagree that it is necessary to implement a single payer system to accomplish these things.

The first thing I’d like to address is that I don’t believe OCH can be used as a practical model for the majority of hospitals. You’re successful in a niche market created by a “perfect storm” if you will. You claim to be an organization that can’t be included in a list of “cherry pickers”. I respectfully disagree. The reason you’re able to succeed is that there are two large health systems capable of eating much more loss than you are in the area. These two health systems, take the most critical, urgent cases, that generally require more care, are more expensive to treat, and have greater risk of non repayment. You don’t have to deal with cancer, or trauma’s, or burn victims, Patients that all are high risk in the sense they require a lot of care, and you have no idea if you’ll be reimbursed for that care. You can send all of those cases away. You’re ER is more like an urgent care facility in it’s ability to treat acutely ill patients. You don’t have to pay to maintain equipment you may only once a month. You don’t have to pay for lab equipment you may only use once a month, etc… In essence, by limiting services, you are able to cherry pick cases that are relatively easy to deal with, ensuring your Medicaid/medicare reimbursements cover your costs. You provide a valuable service to the community, and I applaud your ability to cut cost, but when comparing yourself to one of the two major health systems in Springfield you’re comparing apples and oranges.

You go on to say
“Hospital emergency rooms are not very efficient places to treat people, but it is our country’s current version of universal healthcare. Those who are opposed to universal healthcare should have sufficient courage of their conviction to propose the elimination of EMTALA. Those who advocate reliance on total free market reform must consider if they are willing to let people die on hospital parking lots. If not, then they should acknowledge that we already have a universal healthcare system and focus on how to pay for it and manage it in the most efficient manner possible”

I agree with your major points. I also understand that you make an attempt to account for people that abuse the system by allowing ER’s to send patients PCP’s in the event of a non emergency. This would require you to get rid of emtala laws. What happens the first time an ER physician makes the wrong call? And that patient dies in the parking lot? A pretty hefty lawsuit, that’s what, except now the patient’s family can go after the really big fish called the government as well . There are too many Americans with a sense of entitlement and entirely too many that are abusive of the system. These ideals aren’t going to change because a new system is in place, You’ll still have patients present to the ER for pregnancy tests or a cold or minor issues. As long as the threat of a lawsuit hangs over the head of a physician they’ll continue to work up patients and spend an ungodly amount of money doing so. Only this time, the health system won’t be there to encourage them not to, because they know they’ll be paid.

At the beginning of you’re proposal you say
“The rising cost of healthcare is making American companies struggle to be competitive and driving jobs overseas. The cost of providing healthcare for their employees and retirees was one of the leading causes of the recent bankruptcies filed by automakers GM and Chrysler”
Yet, you later say The basic benefit coverage would be financed for the elderly through Medicare, for the poor through an expanded Medicaid program, for the employed through mandated coverage paid equally by the employer and employee. So every employer is now required to pay into the system. What about small businesses that only have a handful of partime employees that hire college or high school kids? They’re mostly family owned, How does this help small businesses that already have a hard time paying for benefits for employees? Where’s the cap is it every buissness regardless of size? What about restaurants who pay below minimum wage to servers, whose wage is made up in tips and offer no benefits? These are costs that will be passed along, or the businesses will close.

The way I read your proposal, My employer will be required to pay a premium, I’ll still have a premium, I’ll still have to pay Medicare and Medicaid and on top of it, you also want me to buy private insurance to simply pay the outrageous 30% copay? Sure does seem like a lot of money out of my pocket. One thing most people tend to forget, is that the workforce is getting smaller and smaller, so fewer and fewer people are going to be around to drive these programs. We need to remember that the baby boomers are getting ready to retire, and the onus for their care will be placed directly on the shoulders of a younger workforce with fewer participants. In a town hall meeting in MT president obama lauded medicare as a great example of government run healthcare, then went on to say it will be bankrupt in 8 years without major reform. I guess he and I have different ideas about what a success is. You can’t have a program that will cover 1 generation, then leave subsequent generations to pay for it, and struggle to find ways to keep it afloat, or from bankrupting America.

There are about 304 million Americans, and the number that keeps getting thrown around is 46 million uninsured Americans.
That is 15 percent of America. Should we scrap a system that works for 85 percent of America because of a 15 that struggle to find it? As you so poignantly stated, we already have universal healthcare because of emtala. Access to care isn’t the issue, cost is. We CAN control costs without further government involvement. You also know that a large portion of healthcare waste comes from redundancy that happens because of too many government regulations on care. You said “We can make healthcare better and more affordable if we empower general practice physicians and give them the freedom and means to care for patients independently using their judgment, experience and intelligence—augmented (only when necessary) by the positive aspects offered by technology, specialists and medical towers” I agree, but The government is yet to show that they can effectively manage a health program without bringing it to the brink of bankruptcy and overregulating the ever loving crap out of it. Do you really think physicians would be allowed to truly care for their patients? The government would establish a standard of care to be followed precisely or their would be no payout. A government run system, when it’s the only game in town will face all the same pitfalls that private insurance companies do. Doing so without a profit motive can be a positive or a negative thing.

You hinge being able to pay for the system on the idea that everyone would now be included in the pool. Everyone that doesn’t have coverage falls into one of two catagories, those too sick or too high of a risk or those too poor to afford it? So who exactly are you reffering to? Young college kids with no income? I get labeled as greedy because I like my health insurance and am annoyed with the idea of paying even more into a system than I already do. I’m one of the young healthy individuals that pays more into the system than I use. I served in the military when I was younger and had health care through them, I earned a degree and found a job that offers a great health package, and now I should be punished for working hard? I’m already paying into a social security program I’ll never use, now you want me to pay into a universal health system that may or may not be there in 40 years when I really need it. There won’t be enough people added to the pool to make up for the cost of the poor and the sick that would be added to the system. Instead of charity care, and a whole system being able to absorb small losses at a time, you have uncle sam absorbing all of those losses. Your also essentially asking people that can barely put food on the table to have more taxes taken out of their check, while now requiring them by law to buy secondary insurance just to cover the outrageous copay.

Most people agree that you have to have some skin in the game to prevent abuse of the system but what if those people don’t have any skin to contribute? Is the federal government going to go after them? Are they going to be put in jail for not being able to pay for healthcare, then becoming an even bigger drain on the economy?

I’ll move onto some things I really liked but disagree that we need a universal payer system to achieve. You said
We provide an across-the-board forty percent discount for the uninsured based on our belief that those without coverage should never have to pay more than Medicare pays. We allow uninsured patients to pay what they can without having to beg for charity or fill out complicated forms “proving” they deserve charity. We trust our neighbors.
In some healthcare systems, the uninsured are actually compelled to pay more than the government pays hospitals for the same service—often more then twice what Medicare pays”

I can’t think of a bigger fundamentally problem than a lack of pricing transparency in healthcare. To give you an idea of the issue, in our hospital a cbc costs an insurance company about 15 bucks, medicare or Medicaid about 5 and self-payer 50 bucks. We have to have pricing consistency and transparency. Everything should be out in the open in terms of cost to you. Then maybe you get to choose if you want that extra 50 dollar box of tissues.

You said;
“Comprehensive medical malpractice tort reform has to be part of the overhaul of the healthcare system. Malpractice litigation is expensive and inefficient. Malpractice litigation must accept at least some of the blame for making the practice of medicine technology driven instead of being directed by the wisdom and experience of a general practice physician with a unique insight into a particular patient.”

Patients need to stop thinking of a medical mistake as a possible lottery ticket, it just creates bad medicine. Although, earlier you did say “The fact is that the actual economic cost of malpractice litigation has little bearing on today’s high cost of healthcare” so you contradicted your assertations when describing how wonderful your health system is.

You said:
Private, for-profit insurance companies would be hired to do claims processing under Americare. The insurance lobby will furiously oppose Americare, and it will be politically necessary to offer something to lessen the pain of lost profits. A reduction in profit-taking by private insurance has to happen no matter which healthcare reform program ultimately prevails. The country simply can not afford to pay for healthcare while putting billions of dollars every year in the pockets of the “middle men.”

The beautiful thing about the military, is that there is little confusion, they basically have an SOP on how to scratch your ass, less confusion means money saved. Things like record keeping or claims processing HAVE to be standardized, however, we need to keep government monkeys from extending that standardization even further into patient care. Patient care should be only in the hands of the doctors.

You said;
No reform of healthcare will be meaningful over the long term without an increased emphasis on the primary care relationship between physician and patient and a related increased reliance on generalists over specialists. While there may be a number of ways to accomplish this change, it will no doubt require enhanced compensation for primary care physicians and decreased compensation to hospitals and subspecialists. The best means of accomplishing this goal would be by bundling payments for services. CMS has already begun this transformation but it has to go much further.

A lot of private insurances have climbed on the PCP bandwagon in the last few years. I think it’s vital to American culture for PCP’s to be an integral part of patient care. It would help change the attitudes of everyone about healthcare and help to institute an awareness that your health is your responsibility and should be managed with the help of a doctor, rather than I’m going to live anyway I want, then I’m going to go to the ER when I’m in a diabetic coma. However, I worry that fewer and fewer doctors are going into family practice because it’s not financially lucrative to do so. There needs to be an incentive to be a PCP rather than a highly paid specialist that can pick and choose their patients.

Finally, rather than looking at your system and seeing it as a success of government run health care, I see it as a success of a true free market system, there was a need to fill in a community and you were able to fill that need through transparent pricing and getting rid of financial incentives to physicians to see one type of patient over another, I don’t agree that it’s a model that can be easily reproduced though. It is refreshing to see a lawyer write a blog about humanity, and about the need to take care of our brother’s and sister’s rather than just about money. Sorry this is so long, but I wanted to address a lot of things. I’m sure I’ve even forgot to write down many of them.

This statement is against every ideal that the constitution every stood for.
Public health, safety and welfare concerns trump individual liberties every day in every town in America. Mature, rational adults understand the necessity of laws ensuring public health, safety and welfare.
The constitution was specifically set up to basically allow a system where you can do anything you want so long as it doesn’t infringe on the rights of you neighbor. Remember the ole Ben Franklin quote that says those who sacrifice freedom for security, deserve neither I think that is applicable here.

Wednesday, August 12, 2009

Obamacare 2009

Just wanted to write a rundown of a few thoughts I have about the federal health plan that is in the house right now.

My first issue is with the utter lack of consideration for the constitution. Essentially, in creating a national health option, the federal government is creating a monopoly that no one will be able to compete with. I'm pretty sure this is against every single ideal of a free market system. Also, the bill states "There shall be no aministrative or judicial review of a payment rate or methodology." It's on page 124 in case you're interested in looking it up. What's great about our system of checks and balances is that nothing is above judicial review. Except of course what a team of politicians decides is an appropriate pay out for services rendered within obamacare. So the first strike is that the plan is unconstitutional.

The next issue I have is how in the world we plan to pay for this? It's been stated in many places that the U.S. spends upwards of 17% of the GDP on healthcare. Already one of the hightest rates in the world, while only providing coverage to a small portion of the population. If you add the rest of the citizens of this country it doesn't take a rocket scientist to understand you'll need more money. I think no matter what price tag you put on it you'll vastly underrate the amount really needed. When we run out of money for the program one of three things will happen. You'll see either a tax hike, or rationing of care along with decreased payouts.
The population that stands to get the most out of the bill are people with no skin in the game. The same people that get back more in a tax refund than they paid into the system. There is only so long that a dwindling work force can support the healthcare needs of the nation. We've already seen this issue at work with social security. Fewer and fewer people are paying into a system that needs to support more and more people. The numbers just don't add up. The plan is just not fiscally viable. Strike two.

The final problem I'll write about in this post has to do with the mindset of americans. I'm going write a synopsis of a story I read on another blog, I'm sorry I don't remember where I read it so I can't link to it. The story tells of a young woman with medicaid that came into an ER after a car accident. The doctor tells the man she came with that they'll need to get a head ct scan. At first he was hesitant worrying about the cost. The Dr. tells him there is no need to worry that it will all be picked up by medicaid. The man stops and says, "Oh, in that case can you just scan her whole body to make sure nothing else is wrong?" The story is an illustration of americans mentalitly when it comes to "free" stuff. There is already entirely too much waste in healthcare. Just wait untill people have no vested interest in what's happening. How in the world will the government control waste at the patient level? It can't. Creating waste is strike three, and yoooouuuuurrre out.

We have a flawed system, and there is no doubt that reform needs to be made, but not this way. Competition drives innovation and lower costs, not a government mandated monopoly with limited funds. It'd be nice to live in a utopia where people didn't abuse systems and we all went to the Dr. on an appropriate basis, but we don't live in that world. We live in a world of waste and excess This plan won't help that, it will make it worse.

Alot of people have championed this cause because they think our country has a problem with availability of healthcare. Our system has many flaws, but availability is not one. Between charity care, free clinics, medicaid/medicare and emtala laws, healthcare is available at the very least on an emergency basis to everyone. Also, please don't get too involved in the "sharing the wealth mentality." America was founded on the idea that hard work will pay off. It's against everything that america stands for to penalize someone because they make too much money. Or to penalize people that have worked hard and earned more money than most people. If it were you being taxed at a 50 or 60% clip would it be fair then? We need to wait for a better plan. This healthcare bill is no better than the flawed economic stimulus plan that overspent borrowed money. It's financially irresponsible.

I hope all of you will at the very least read the bill and understand it's merits and demerits and tell your representatives that this isn't the plan to fix healthcare. Write them, even if you'll be reported to obama. I refuse to let such a flawed plan completely sink healthcare, and potentially my job into a dark abyss.