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Now With the Elections Over, We Can Focus on Health Care – A View from the Trenches

By Brian L. Grant, MD

Pundits are debating the meaning of the recent election results. I believe that to some degree the election is a mandate to continue to address our out-of-control health care system and an endorsement by the  electorate to continue to develop and deploy the Affordable Care Act – aka ObamaCare.

Coming at health care as a physician, patient, employer, taxpayer and medical director of a company whose business it is to review medical claims for appropriateness of treatment and utilization – I believe I have both skin in the game and a deep perspective on the problems we face.

Long ago during residency, during my medical rotation, I concluded that so much of care was of little value in providing quality or quantity of life to those whose days were numbered. Those providing the treatment were unable or unwilling to ask the tough questions that would limit care in hopeless situations. Governed by good intentions, physicians were and still are largely expected to treat with little moderation. This decision is supported by the economic rewards of treatment, encouragement by the hospitals they work in, and a fear that denying treatment or moderating the testing provided might expose them to litigation.

I wondered how many people would choose the care received if the system were somehow different, such as their paying directly for care of having the money available for some other use. I continue to ask this question today, while recognizing that many would abuse this choice, denying necessary preventive care to themselves or their children if given the option of diverting their health care spending to another cause.

But absent external controls on utilization and consumption – overuse and unnecessary care is common, and according to some, represents some 750 billion dollars annually, or about 25% of our health spend! This would suggest that we stand to gain far more from curbing spending and utilization than we do from discounting it.

And since patients and their families are largely shielded via insurance from the economic impact of treatment, they lack interest or incentive in invoking the economic self-interest that governs all of us in our non-medical personal spending behaviors, when we are not spending directly for our care.

Third party payments also mean that the costs of treatment are not responsive to competition, since everything is expected to be paid for at whatever price may be charged. Third party surrogates including insurance carriers, bill reviewers, and companies such as MCN whose work aims to control excessive and unnecessary costs are attacked by stakeholders including patients, providers, drug manufacturers, device manufacturers and hospitals when limits or denials are suggested or imposed.

As an employer, I have experienced annual increases well into the double digits in proposed premiums for our staff, only curbed by increasing co-payments, deductibles and some of the premium increases to the employees. This means less income for staff as their personal health spend increases – a trend common across the economy. The rate of increase has appeared to curb a bit over the past two years, perhaps in response to the reforms underway that improve the structure of the system by spreading risks to a wider population of insured individuals.

I grudgingly accept the need to provide coverage for employees, all the while wondering why this is the case. Staff do not receive company-paid housing, food or education; they get a paycheck to pay for some, and we all pay taxes to pay for other universal needs such as education. Why is healthcare a unique outlier by being tied to employment? How do we as a society rationally defend employer-based health-care given the outcome? The consequences are well-known.

They include most notably the lack of paid insurance for dependents and spouses under most employer plans,  total lack of coverage for many working people whose jobs don’t provide coverage, the unemployed, students, and those who are self-employed and either can’t afford care or choose to gamble by not buying coverage. Since hospitals do not turn away patients needing emergency care, those without coverage are either forced into economically dire straits if they have any money left over to pay, or the rest of us pay for their care via cost-shifting by these institutions to those who can and do pay. This results in higher premiums for those with insurance and the employers paying for them.

In a nation that extols the virtues of small business and entrepreneurs, how many men and women who might take the risk to strike out on their own are deterred from doing so because they can’t afford the high cost of individual health care, especially if they or a member of their family has preexisting risk that makes insurance unavailable or unaffordable. One would think that those who claim to champion a creative economy would insist upon health care being available and affordable to all. Yet by and large this was and is not the case.

As a patient and physician, I have had the opportunity to consume and provide care and see hospital bills that were extraordinary in their complexity and impenetrability, including excesses in line item charges, and inclusion of items that were not necessary in a particular case but dispensed to all patients admitted as standing orders. If you have the occasion to be hospitalized, call and ask for the multi-page actual bill submitted to your carrier rather than the several line summary they send you describing what was billed, what was paid, what was discounted and what you owe as a balance. It will be an eye-opener!

As a taxpayer I am aware of the massive multi-trillion dollar size of the US system, representing about 18% of our GDP or around a third more than those of other industrialized nations that have better public health metrics including infant mortality and life-spans. This excess spending decreases our national productivity and imposes burdens on all, and riches on a few.

Reasonable people can and should debate the details and the specifics; but like defense spending, entitlements and other massive expenses – health-care should be debated and addressed with data, not ideology! Those who believe that continuing the system with minor alterations are advocating the structural equivalent to putting lipstick on a pig. Concluding that this will somehow lead to meaningful change is either naive or willfully deceptive.

I struggle with the concept of personal freedom vs. personal responsibility, the role of government and who should pay for choices. Others do as well. Thus the debates on public health and safety, lifestyles, chronic illness and self-determined behaviors and how much the government should regulate what we do, how we consume and who should pay for these choices. Many entries in MCNTalk have addressed these topics that include obesity, tobacco, vaccinations, and those who question if and how these should be regulated and who should pay. Again one can debate the details and the ideology, but we can’t escape the expensive outcomes for individuals and society.

Democracy is a participatory sport in a game with real consequences for all. We wish our legislators well, thank them for their service and will be there loudly exercising our freedom along with them in the coming years.

Health Reform: A Matter of Life and Death

Access to insurance is a matter of life and death for some.

In this poignant New York Times column, “A Possibly Fatal Mistake,” Nicolas Kristof tells the sad story of his childhood and college friend, Scott Androes, who made a bad choice and may pay with his life.

That choice was not purchasing health insurance when he was marginally employed and realistically able to do so. For Scott, like many Americans, the thought of buying an individual policy in a high risk market seemed too expensive and unnecessary.

But after months of warning signs and a trip to the emergency room later, Scott realized how costly taking that risk would be. This year, he was diagnosed with metastatic prostate cancer and a treatment plan that is upwards of $550,000. It would appear that his days are numbered.

In his piece, Kristof compassionately writes about the bigger picture of this issue and how health care reform and politics play a major role in individual stories like his friends. He characterizes one presidential candidate’s philosophy, opposed to most of the health care reform proposals, as seeing this outcome:

“…as I understand it, is that this is a tragic but necessary byproduct of requiring Americans to take personal responsibility for their lives. They need to understand that mistakes have consequences. That’s why, he the candidate, would repeal Obamacare and leave people like Scott to pay the price for their irresponsibility.”

Kristof goes on to say:

“To me, that seems ineffably harsh. We all make mistakes, and a humane government tries to compensate for our misjudgments. That’s why highways have guard rails, why drivers must wear seat belts, why police officers pull over speeders, why we have fire codes. In other modern countries, Scott would have been insured, and his cancer would have been much more likely to be detected in time for effective treatment. Is that a nanny state? No, it’s a civilized one.”

The key point that Kristof makes is how crucial it is to put our partisan bias aside and consider the millions of U.S. citizens who are currently affected by our broken health care system. Which presidential candidate will actually work to fix and prevent stories like this after the election?

“So as you watch the presidential debates, as you listen to those campaign ads, remember that what is at stake is not so much the success of one politician or another. The real impact of the election will be felt in the lives of men and women around the country… Our choices this election come too late for Scott, although I hope that my friend from tiny Silverton, Ore., who somehow beat the odds so many times already in his life, will also beat this cancer. The election has the potential to help save the lives of many others who don’t have insurance.” Read more…

 

 

Study: Brain Exercises Don’t Improve Cognition

A recent article in Time concludes “getting a good night’s sleep, excercise, and eating right” are more likely to “maximize a brain’s potential” than a computer game. The interesting thing about this is that neuroscientists can’t agree. Some believe these games can alter the dopamine receptors, which would theoretically aid in learning and cognitive functions, while others believe the phrase “practice makes perfect” better describes the improvement, and  does not carry over to cognitive functions.

Kaiser Permanente’s Visions of a Healthcare “Farmer’s Market”

Kaiser

A nonprofit system, salaried doctors on staff, an ambitious electronic health records system, but most importantly the idea of competition based on health outcomes rather than price are just a few things that make Kaiser Permanente an unconventional HMO provider.

Read the entire Forbes article.

Benefit for Uninsured May Still Pose Hurtle

With the passage of health reform, we are now seeing frequent reports of its shortcomings. The new legislation still relies upon a private insurance market and the expectation that individuals will buy insurance or suffer penalty. People, especially those with lower incomes, will behave rationally and in what they perceive to be their economic interests. This many for some include preserving scarce cash today, and not focusing on an uncertain and expensive need for future health care. Rather than argue that people should behave responsibly and address future health issues with insurance, this article, from April 20 in the NY Times, and the individuals describes speaks for itself.

“Wellness” – A Word I dislike

The New York Times Magazine of April 18 carried this article that addresses one of my pet peeves – the abuse of our beautiful language. Actually the article is too kind to the word, focusing on the first use and evolution of the term. What benefit is there to a word that has a perfectly fine equivalent called – health?

Wellness has become a buzzword and a marketing term to promote all sorts of expensive maneuvers and services, often in the workplace, to improve the health of individuals, often involving incentives, paid consultants and the like. I have yet to see a scholarly report that establishes the effectiveness of such programs and their cost benefit. I believe it most likely that those who wish to be healthy need no external incentive or program, and are already taking care of themselves, and those who can’t or won’t engage in healthy choices in their lives are unlikely to be significantly persuaded by a workplace program.

How many people are in the dark about what it takes to be healthy, especially adults in the workforce?

A Remedy for Troubled Doctors

Physicians from time to time have issues impacting their ability to practice. Many of these issues are temporary, relating to health or substance abuse, skill deficiencies and other matters. Others may become permanent. At MCN in the course of credentialing consultants, we review cases where regulatory action has taken place. This Wall Street Journal article describes one program’s approach to assessment and remediation of physicians who have practice issues leading to regulatory action in California.

The Nothing Cure

By Matthew Herper and Robert Langreth, From Forbes Magazine, Issue Date March 29, 2010

Instead of ignoring the placebo effect, doctors should try to enhance it, says a Harvard Medical School professor.

This interesting discussion on the placebo effect is worth a read. The presence of the placebo effect is well-known and generally accepted in medicine, though it may be frequently argued as to when it is taking place or not – especially when one’s own treatment is being questioned.

From a policy standpoint, a legitimate question is whether those treatments that have a significant placebo component are ethical to the degree there may be conscious deception on the part of the practitioner – on behalf of helping their patient. In addition, should third parties such as insurance or government be asked and expected to pay for placebo interventions?

Welcome to MCNtalk – a discussion group for you

MCNtalk, which has existed for many years as an email broadcast, is being converted into a blog. Advantages include the ability for prior articles to be stored, indexed and accessed by readers, as well as a robust ability to include many features and full user control of how or if they receive notifications of new postings or comments.

In addition, this blog will be readily available on the web for subscribers and non-subscribers alike.

It is a work in progress and we hope to add many enhancements over time.

The address is http://www.mcntalk.com

Your comments and ideas are welcome as well as requests to add a particular site or blog to the featured list. We also welcome links to articles of interest, or even your own idea pieces.

Our goal is to present articles of interest and potential relevance to those who deal with medical issues in claims management, disability, injury and related legal and administrative issues, as well as those who have a general interest in health-care issues. I am linking to blogs that focus on health care politics but we will do our best to steer clear of partisan and acutely political matters. We recognize that our readership is diverse and that there is no shortage of good sources for thoughtful comments, reflections and positions on current political issues.

This does not mean that the occasional article will not be controversial, and we welcome divergent comments. Inclusion of a particular article does not necessarily imply agreement with the stated position by MCN or it’s staff.

The original MCNTalk email list will be used for periodic reminders about the blog and recent articles. But we encourage direct subscription via the button on the upper left, which will provide immediate notice of new postings. You may change your subscription preferences or unsubscribe at any time.

We welcome comments but they should be signed, courteous and relevant to the posting. We will tread gently into the world of comments and initially screen them before posting, perhaps opening them up to non-screened postings for repeat commentators or all.

If you have ideas or thoughts about making MCNTalk more effective and relevant – send them to us at MCNTalk@mcn.com.

Thank you.

Brian L. Grant, MD
Chairman and Medical Director