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Health Policy

Say Farewell to the Family Doctor?

Remember the solo family doctor? In in some places, as noted in this Wall Street Journal/Smart Money article, it has become increasingly likely that she’s collecting a paycheck from a large regional hospital—and practicing medicine according to the hospital’s strict playbook.

Nationwide at least one in six doctors—more than 150,000—now works as an employee of a hospital system. And with about half of recent medical school graduates deciding to work for hospitals and many established doctors looking to unload their practices amid the tough economic climate, what was a trickle of change has turned into a torrent. Jim Pizzo, a Chicago-area hospital consultant, says the blistering pace of these mergers is leading some colleagues to joke that there are two types of physicians today: “Those employed by hospitals and those about to be.”

Is this trend (if there is enough evidence to suggest a real trend) problematic, or at the very least what are its upsides and downsides for patients?

Whether they wear suits or scrubs, many physicians think they’re doing the right thing. Hospital executives say they’re adapting to the rapid evolution of the health care business, while physicians, worn thin running businesses during the recession, are drawn to the safety of a salary and regular hours as well as the appeal of not having to deal with many other administrative issues small business owners have to work through, such as the hassles of office space and tenancy, benefits packages, and of course the question of access to costly medical equipment.

What’s less clear is how the fever to buy up local doctors’ offices will affect the paper-gowned patients caught in the middle, with many saying they’ve already seen costs rise or treatment choices dwindle. Consumer advocates say the demise of the neighborhood doctor could turn out to be as big a change for medicine as anything happening at the national level with health care reform. “The story of how well these collaborations will actually work, day after day, hasn’t been written yet,” says Roland Goertz, president of the American Academy of Family Physicians. Read more…

The Rigors of Treating the Patient in Chief

No patient gets closer medical attention than the president of the United States. Wherever he goes, a doctor, nurse or paramedic trails a few footsteps behind, ready for any medical need. It is the ultimate in concierge medicine.

For the president’s doctor, it is a little different, as detailed in this New York Times article. The job of White House physician combines professional responsibility with the glamour and trappings of proximity to history. The White House medical office is only a few steps from the Oval Office, and the doctor has automatic access to the president’s living quarters.

A medical staff member stays overnight in the White House. When the president travels, the doctor rides in a limousine near the head of the motorcade. Jet lag and stress make the job one of near-constant fatigue, shadowed by dread of assassination attempts.

Now a recent holder of the job, Dr. Connie Mariano, has written an account of her nine-year tenure under three presidents, Bill Clinton and both George Bushes. The book, The White House Doctor: My Patients Were Presidents — a Memoir, is one of just a handful of autobiographical accounts by presidential physicians.

Dr. Mariano’s story is an inspiring one. The daughter of a Navy steward, she was the first Filipino-American of either sex to rise to rear admiral, and the first woman in the military to become the White House physician. Read more…

Why Parents Fear the Needle

Last month MCNtalk raised the question of paranoia around the issue of vaccinations in Vaccinations and Autism: Junk Science Isn’t a Victimless Crime. As a follow-up to this issue—with its very serious public health implications—MCNtalk is exploring the issue further.

This article in the New York Times looks at why the public would be so receptive and responsive to the results of one very limited study, noting “[it’s] because the public’s underlying fear of vaccines goes much deeper than a single paper. Until officials realize that, and learn how to counter such deep-seated concerns, the paranoia — and the public-health risk it poses — will remain.” Read more…

Excessive weight of U.S. population costs $270 billion annually

People who are overweight or obese are costing the country $270 billion annually in increased medical costs and high rates of disability and mortality, according to the latest estimates.

The study, released Jan. 10 by the Society of Actuaries, analyzed increased medical costs and loss of economic productivity resulting from excess mortality and disability. Researchers found that obesity cost the U.S. economy $198 billion in 2009, and excess medical costs of the overweight population were $72 billion.

“There is substantial evidence that overweight and obesity are becoming worldwide epidemics and are having negative impacts on health and mortality,” said study co-author Donald Behan, PhD, an independent consulting actuary.

An overweight person is defined as having a body mass index of 25 to 29.9, and an obese person has a body mass index of 30 or more.

As Doctors Age, Worries About Their Abilities Grow

Per this article in the New York Times, an aging population has many implications. It’s important to note that one-third of the nation’s physicians are over 65, and that proportion is expected to rise. Many doctors, of course, retain their skills and sharpness of mind into their 70s and beyond. And the type of work a physician performs makes a difference: A 2006 study found that in complicated operations, patients’ mortality rates were higher when the surgeon was 60 or older, though there was no difference between younger and older doctors in routine operations.

Patient advocates note that commercial pilots, who are also responsible for the safety of others, must retire at age 65 and must undergo physical and mental exams every six months starting at 40. Yet “the profession of medicine has never really had an organized way to measure physician competency,” said Diane Pinakiewicz, president of the nonprofit National Patient Safety Foundation. “We need to be systematically and comprehensively evaluating physicians on some sort of periodic basis.”

Some experts are calling for regular cognitive and physical screening once doctors reach 65 or 70, and a small cadre of hospitals have instituted screening for older physicians. Some specialty boards already require physicians to renew their certification every 7 to 10 years and have toughened recertification requirements.

What would screening entail? The answer to that question is unclear. Some doubt that a single type of exam can be used to assess the performance of doctors from a variety of specialties. “More research is needed for us to define what combination of cognitive and motor issues are important,” said Dr. Stuart Green, a member of the ethics committee of the American Academy of Orthopaedic Surgeons. Read more…

Coupons for Patients, but Higher Bills for Insurers

The brilliant brand name drug marketers, per this New York Times article,  have found a simple way to undermine the consumer incentives in place to encourage use of generics: cover the co-pay differentials that patients would otherwise need to pay, and sock the big difference in cost to the carrier and therefore to the employer or ratepayers and ultimately others in the plan.

This is one more example of the inherent flaws in a health care system where the consumer is not paying in any direct way for the choices that they or their doctors are making. If the cost of a particular drug were somehow felt by the patient, and there were two choices—one expensive and one less so—the consumer would make some of their own cost benefit decisions and in many cases, select the less costly alternative.

The problem outlined by these practices can and should be dealt with either legislatively—by prohibiting incentives to patients designed to undermine plan designs— or by the plans themselves, deciding to not cover such drugs absent an effective appeals process.

How Valid Are Pain Validity Tests?

Sprained ankle

We recently ran across an article citing a company that has reportedly devised a test to determine if pain is real. Here is the article, “Pain Validity Test Gets 30 Workers’ Compensation Claimants Back to Work Immediately.”

Here is the company that offers the test: http://veritassupporttesting.com. We have no experience with the test and would welcome comments from those who have reviewed or used it. It sounds like an interesting concept, but whether it meets scientific and clinical scrutiny is not clear to us.

Health Spending and the Aftermath of Economic Crisis

Given the widespread debate around health care (and its financing) reform, it’s important to understand the current status of health care finance and how it fits into the larger economy. How has the largest economic crisis in 80 years impact the situation? In 2009, per this New York Times article, health care accounted for a larger share of a smaller economy — a record 17.6 percent of the total economic output in 2009, according to a Federal government report issued earlier this month.

The nation spent $2.5 trillion on health care in 2009, for an average of $8,086 a person, and the recession had a profound influence. The share of the economy devoted to health care rose one percentage point in 2009, the largest one-year increase in a half-century of record-keeping.

The economy contracted while health spending continued to grow. Yet Many consumers decreased their use of health care goods and services.

What are the implications for health care reform? That question is widely debated. Senator Orrin Hatch (R, Utah) in line to be the senior Republican on the Finance Committee, said the new health care law could lead to “crushing increases in health costs and premiums.” By contrast, the chief medicare actuary, Richard S. Foster, has estimated that the new law will lead to an increase of only nine-tenths of 1 percent in national health spending over 10 years.  Read more…

Repealing Health Care Reform Is the Real Job Killer

We have been watching the pundits and partisans discuss, argue and scream about health care reform. What continues to baffle us is the ability of a number of big lies to dominate discussion, and for the topic to have become a proxy on Obama. Here is a very interesting column in the New York Times on the subject.  

The topic is too complex to dissect here but let’s address just one argument raised against change and cited by the new speaker Boehner: That health care reform is a job killer. From a recent interview on NBC:

You have to understand that in my opinion Obamacare is the biggest job killer we have in America today. It’s a weight over every employer that we have. Thereby requiring them to hold back their willingness to hire people. Secondly, I believe that Obamacare will ruin the best health care delivery system in the world. And then thirdly, I think it’ll bankrupt our country. On September 24th, when we rolled out our Pledge to America, we made clear that we wanted to repeal Obamacare. We are going to do what we said we were going to do.  Read more…

Let’s deal with some real on-the-ground experience – our own at MCN. When the founder of MCN first bought his own insurance as an individual physician in 1982, he does not remember it. This suggests that the purchase was a non-event, like insuring a car or a home.

Fast forward to 2010 and the company is annually faced with double digit increases for the same level of coverage, not unlike other companies. And the company benefits from group rates, unlike individuals who routinely face much higher increases, largely because the pools they are part of are skewed towards the sicker and higher care consumers.

Employees who leave the company are faced with COBRA expenses that are considerable and burdensome, if they choose to be covered and do not have other options. We also find ourselves increasingly cautious about adding staff. Obviously hiring decisions are complex, but the tangible cost of insurance is one further barrier to adding staff.

From a common sense and policy standpoint, we have always wondered why it is the business of an employer to provide health care for employees. It is not the employer’s job to feed, house or educated the children of employees. That is what a pay check is for. All of the above are necessities, but only one seems to be an employer cost. If everyone was employed and covered, I suppose it would be a non-issue, but that is not the case. Those employers who provide health coverage need to compete against those who do not, and this is not a fair competition in many cases, especially when in the same sector such as hospitality.

We would prefer to see in increase in taxes applicable to ALL businesses and employees — including small businesses — contributing to a system that covers all. The ability to have and pay for health care is not an option. Those who by virtue of true poverty or stupidity do not have access to coverage do not get denied care. The cost is shifted to the rest of us. A system depending upon involuntary cost shifting is not charity, it is inefficient and unfair to all.

 
Those who truly maintain their views that the Government has no place in health care I assume will be willing to burn their VA Health and Medicare cards or disavow those systems when and if they become eligible. A significant portion of the US Health spend is already government based, so it is a bit late to keep government out of it. Government involvement is not radical or unproven, but rather is the mode or some variant thereof, in many of the most robust world economies, including Canada, Australia and Germany, among others.

A claim made by those who support job creation – who doesn’t? — is that entrepreneurship is good. How does this relate to health care reform, however? What is the likelihood that an individual will leave the comfort of a secure job with health coverage for the immediate financial uncertainty of their own business — and how is this impacted by the burden of providing individual health care for the entrepreneur’s family?

This very real uncertainty as much as any other reason is why the status quo (which is not really a status quo, but rather a relentlessly increasing and unsustainable burden) is why innovation and job creation are being killed.

And a core issue that no current proposals appear to meaningfully address is the continued increase of health as a portion of GDP (17.6% in 2009) and the absence of normal market forces that come into play with most purchases. By this I refer to the buyer and the consumer being de-linked.

Witness drug companies waiving copayments on expensive drugs that get charged to the carriers (from another article in the New York Times), and witness our own behaviors that rarely involves asking — when it comes to health — “how much is it?” and shopping for alternatives.

Imagine going shopping and filling your cart in a store with no prices, and you have US health-care today. The “free marketers” who make up the health care industry decry and condemn allowing the true buyers of care – insurance companies, employers and government — when these entities suggest that they may use their purchasing power to impact price and consumption.

Our current view of patients and doctors knowing what is ‘right” while staying blind, indifferent to, or directly benefiting from the cost paid by others is not working.

Rather than reflexively engage in partisan bickering on the topic, let’s look at the reality of what we are now seeing in our businesses and lives and those of our families and neighbors – as we review our options going forward. David M. Cutler, Otto Eckstein Professor of Applied Economics, Harvard University, and a Senior Fellow at the Center for American Progress, notes that: “The imminent effort in the House of Representatives to repeal health care reform is a major step in the wrong direction if promoting economic recovery is job one.”