Tuesday, June 20, 2017

Costs vs Care

The below op-ed ran in the New York Times yesterday and amassed over 1500 comments that validated much of what the author mentions with regards to the history of how the Medical Industrial Complex became just that.

This comment resonated with me with regards to some of the many issues that have led to this:
As a RN for over 35 years I have watched the decline of quality in healthcare spiral downward - cause: continued unbridled greed in management. Staff is always first to be cut, billing audits are not taken seriously when overbilled charges exceed DRG so go to stop loss extra payments, and make sure the stockholders, upper management and BIG Pharm reap any "profits".
We seriously need more input with the hard and soft sciences that make up the practice of medicine, not the management. Why do we need MARKETING in healthcare? How many BILLIONS are sqandered trying to claim one company surpasses another?
Until we focus on the practice of medicine and get serious about the excess waste of management and artificial "R&D" costs, same downward spiral.
I am 100% for EQUITABLE Universal Healthcare for Americans, WAKE UP quit being ignorant about "socialism". Healthcare is in a realm of its own and should be treated as such, not just another greeder opp.

But what alarmed me is that this article is in fact another way of promoting an agenda that includes the new rage of "concierge," medicine, and another about how to "skirt state regulations?"

As always the truth in medicine is buried deep in the documents you sign before ever walking in the door. These same papers shoved at families or individuals in crisis by those whom we have placed in an immense position of trust and faith. Two positions they don't extend to us in any regard.

As this comment provides:

Ms Chapin, you forget that those of us lucky enough to have insurance and doctors, to be able to pay even the co-pays of medications, or who have had surgeries or hospitalizations are all experts in the field.

To write about fixing our health care mess without addressing costs, particularly of perscription drugs, is ridiculous. President Obama correctly described the problem when he explained that the for-profit healthcare industry now represents one fifth of our economy. Still, we have to start some place. How about banning the advertising of perscription drugs which is a significant part of the cost of "bringing them to market"? How about price controls on any vital life saving drug R&D subsidized by government or foundation money? Is this country just too corrupt to manage to do any of this? Is that the underlying assumption of your very limited premise? One thing we can all agree on is that what we have now is not sustainable.

And lastly I share this:

We've had "tort reform" in Oklahoma, Jack, for several years now. You almost can't sue a doctor or dentist, not unless you start out rich enough to pay for legal representation, evidence gathering, and much more before there's any court hearing at all. Lawyers can't take cases on contingency. And if you lose a malpractice case as a plaintiff, you have to pay for all the lawyers of the medical corporation or insurance corporation as well as your own. In short, you will be ruined financially for the rest of your life, most likely. So people don't sue, no matter what they suffer, except in very few cases indeed. I surely wouldn't. Especially considering that most of the time, the doctor or dentist and their insurers win the cases anyway. Have costs declined here? Not one bit. Is medical care more accessible? Not at all. Are doctors and dentists happier? Certainly, as are insurance companies. Are patients better off? No. As we say down here, not hardly. If you want a nice little present for doctors and insurers, then tort reform is for you. But if you think anyone else will benefit, think again, because we won't.

So blame the Insurers but in reality is a much more complex system that is about money. And as I read the comments by the Physicians it almost always mentioned that fact and not the absurd costs, the role of big Pharma and how the failure to provide a cross section of care regardless of the type of insurance the patient carried seemed to be ignored if not mentioned unless of course in the context of how they lose money.

As these comment mentions:
I recall listening to the radio news back i n '69 or '70 and something the announcer said has stuck in my mind ever since. He quoted a statement made by the president of the AMA at their annual meeting who said during his keynote speech that "any doctor making less than one hundred thousand dollars by their third year in practice wasn't doing their job." Keep in mind the year this statement was made if you're wondering about the amount being so small. Also keep in mind that this was his definition of quality care.
By 1980, many small medical insurers had bailed, by the early 90’s, nearly all. Early-on, non-profit HMOs were an experiment to build large inclusive groups to spread the risk as much as possible, so the lower premiums would cover costs. These non-profits had a medical loss ratio of around 6 percent, meaning that for every premium dollar only six cents was lost, and did not go to pay medical-related benefits.

The inability to get a more universal population was not achieved, and these HMOs largely disappeared to be replaced large stock-based HMOs, which catered to corporations with large groups, with higher premiums for individuals and small groups. This has worked well for the HMOs, their investors and corporations, but not entrepreneurs, small businesses, non-profits, and the self-employed.

I wrote Senator-elect Al Franken and explained to him the plus 20% MLR’s of HMO’s compared to our single-payer systems: Medicare, Medicaid and the VA., which had held an MLR of around 1.7% for years, before limited privatization doubled it. I suggested capping MLR’s, only because single-payer-for-all was DOA in 2008 to Republicans and the controlling neo-liberals. A 20% cap passed.

The fact is investors making money on primary care premiums is immoral. It totals hundreds of billions of dollars per year. It is illegal in the rest of the industrialized world, who employ pluralistic-universal systems, where stock insurance is only for non-primary care, upgraded hospitalization, etc.
But I also want to include this Physicians comment which is equally relevant:
Today in my practice I saw 5 medicare patients who fell over the weekend and their shoulder/knee hurt. The kind of thing your mom would put ice on and send you out to play after 5 minutes. Their cost: ZERO. Why? They insured their copay, so no reason not to go to the doctor. In the hospital I have a 90 year old from a nursing home with Alzheimers who hasn't spoken in years, and the family insists on "doing everything." And a 40 year old who stopped his seizure meds "just because" and ran into a huge problem.

This is where our healthcare dollars go. The payer MUST be between the patient and doctor because both sides abuse the system. A single-payer does nothing to change this unless we decide it does. Americans are not ready for health reform because it would mandate saying NO to fruitless care, NO to unnecessary tests, NO to treating bad choices.
Most of us have had good health coverage because we take care of ourselves and consider our options, and make healthcare a priority.

Americans need to be told NO the way Canadians and Europeans are IF we want 'universal' coverage. And asking the wealthier to foot the bill to continue the present system of unlimited everything is not an acceptable nor functional answer.

We spend more than any nation that offers public option and they have better results. And the supposition by the author that market innovations will not lower costs as long as there is a profit motive. Why should America try to reinvent the wheel when we have successful models to choose from in other advanced countries such as Germany, Japan, France, the U.K., and Singapore? All these countries have slightly different systems but the way they keep their costs lower than our costs is by putting ceilings on prices, both pharmaceuticals and medical procedures. This is from 2013:

OECD average - 3463
US - 8713
UK - 3235
France - 4124
Australia (similar obesity) - 3966
Germany - 4919
Denmark - 4553
The Netherlands - 5131
Canada - 4361
Israel - 2128
Switzerland (Highly regulated private insurance) - 6325

But the author also mangles facts with regards to Kaiser and their model for care and the NHS but those crazy facts have no business here and again there is like any op-ed an  agenda or the the "take it from the source" reality. 

The reality is that medical care is akin to national defense and we are on the front line battling a force that is immense and diverse with its own demands and needs. We have been losing for decades and the current bill being secretly passed in Congress is all one needs to know that no one has our interests at heart, so don't expect a transplant.


How Did Health Care Get to Be Such a Mess?


By CHRISTY FORD CHAPIN
THE NEW YORK TIMES
JUNE 19, 2017


The problem with American health care is not the care. It’s the insurance.

Both parties have stumbled to enact comprehensive health care reform because they insist on patching up a rickety, malfunctioning model. The insurance company model drives up prices and fragments care. Rather than rejecting this jerry-built structure, the Democrats’ Obamacare legislation simply added a cracked support beam or two. The Republican bill will knock those out to focus on spackling other dilapidated parts of the system.

An alternative structure can be found in the early decades of the 20th century, when the medical marketplace offered a variety of models. Unions, businesses, consumer cooperatives and ethnic and African-American mutual aid societies had diverse ways of organizing and paying for medical care.

Physicians established a particularly elegant model: the prepaid doctor group. Unlike today’s physician practices, these groups usually staffed a variety of specialists, including general practitioners, surgeons and obstetricians. Patients received integrated care in one location, with group physicians from across specialties meeting regularly to review treatment options for their chronically ill or hard-to-treat patients.

Individuals and families paid a monthly fee, not to an insurance company but directly to the physician group. This system held down costs. Physicians typically earned a base salary plus a percentage of the group’s quarterly profits, so they lacked incentive to either ration care, which would lose them paying patients, or provide unnecessary care.

This contrasts with current examples of such financing arrangements. Where physicians earn a preset salary — for example, in Kaiser Permanente plans or in the British National Health Service — patients frequently complain about rationed or delayed care. When physicians are paid on a fee-for-service basis, for every service or procedure they provide — as they are under the insurance company model — then care is oversupplied. In these systems, costs escalate quickly.

Unfortunately, the leaders of the American Medical Association saw early health care models — union welfare funds, prepaid physician groups — as a threat. A.M.A. members sat on state licensing boards, so they could revoke the licenses of physicians who joined these “alternative” plans. A.M.A. officials likewise saw to it that recalcitrant physicians had their hospital admitting privileges rescinded.

The A.M.A. was also busy working to prevent government intervention in the medical field. Persistent federal efforts to reform health care began during the 1930s. After World War II, President Harry Truman proposed a universal health care system, and archival evidence suggests that policy makers hoped to build the program around prepaid physician groups.

A.M.A. officials decided that the best way to keep the government out of their industry was to design a private sector model: the insurance company model.

In this system, insurance companies would pay physicians using fee-for-service compensation. Insurers would pay for services even though they lacked the ability to control their supply. Moreover, the A.M.A. forbade insurers from supervising physician work and from financing multispecialty practices, which they feared might develop into medical corporations.

With the insurance company model, the A.M.A. could fight off Truman’s plan for universal care and, over the next decade, oppose more moderate reforms offered during the Eisenhower years.

Through each legislative battle, physicians and their new allies, insurers, argued that federal health care funding was unnecessary because they were expanding insurance coverage. Indeed, because of the perceived threat of reform, insurers weathered rapidly rising medical costs and unfavorable financial conditions to expand coverage from about a quarter of the population in 1945 to about 80 percent in 1965.

But private interests failed to cover a sufficient number of the elderly. Consequently, Congress stepped in to create Medicare in 1965. The private health care sector had far more capacity to manage a large, complex program than did the government, so Medicare was designed around the insurance company model. Insurers, moreover, were tasked with helping administer the program, acting as intermediaries between the government and service providers.

With Medicare, the demand for health services increased and medical costs became a national crisis. To constrain rising prices, insurers gradually introduced cost containment procedures and incrementally claimed supervisory authority over doctors. Soon they were reviewing their medical work, standardizing treatment blueprints tied to reimbursements and shaping the practice of medicine.

It’s easy to see the challenge of real reform: To actually bring down costs, legislators must roll back regulations to allow market innovation outside the insurance company model.

In some places, doctors are already trying their hand at practices similar to prepaid physician groups, as in concierge medicine experiments like the Atlas MD plan, a physician cooperative in Wichita, Kan. These plans must be able to skirt state insurance regulations and other laws, such as those prohibiting physicians from owning their own diagnostic facilities.

Both Democrats and Republicans could learn from this lost history of health care innovation.

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