Successful healthcare reform is critical to the well-being of our nation. Who has the answers? As a rural family physician, I keep shouting in vain that they are backing the trailer up to the wrong barn. Reform proposals utilizing creative accounting keep conjuring up healthcare expenditure savings where they don’t exist, and even is we could attain this mythological information technology utopia, it will be mere cough medicine for our healthcare system’s pneumonia. It scares me to think that healthcare reform is being guided by myths.

Myths: Evidence based medicine, technology, Electronic Medical Records (EMR), quality improvement, universal healthcare coverage.

All these good concepts will prove incapable of solving our healthcare crisis. The fundamental flaw behind the proposals of presidents, politicians, pundits, policy makers and physicians is the notion that universal access to quality evidence based, measurable, mistake free medicine can prevent illness and death, cure the unhealthy and provide a safety net to save us if we fall from health. No one wants to hear the truth: the safety net at its best is riddled with holes. Policy makers are trying to assemble a toy on Christmas Eve without instructions, but even worse, they are operating under the assumption that this toy is supposed to fly rather than simply roll along the ground.

The major public health breakthroughs in order of decreasing benefit remain clean water, immunizations and antibiotics (overused and abused). If we cured all cancer it would increase the average American life span by only a year. Of course we should strive for the prevention and cure of cancer and availability of medications, but healthcare reform should place the highest priority on the doctor patient relationship.

No matter what we do, people will continue to suffer from illness; people will continue to die prematurely; tragedies will continue to occur at nearly the same rate as they occur today, but we cannot accept the public perception that healthcare doesn’t care.

Evidence based medicine is just a fancy term for what doctors have been doing already, using the best available evidence to make medical decisions. Giving it a name falsely implies that now we should practice based on fact rather than whatever we were doing before. That fact is that evidence based or not, half of what we believe to be scientifically proven will be proven wrong in five years. The fact is medicine is based on opinion, not fact. What percentage of human physiology, diagnosis, treatment and cure of illness do we know? 95%? 85%? Despite the fact that we may have cracked the human genome code, try 10% and you’d be closer to the truth. Surprised? Ask a doctor how does acupuncture work? How many lives per year do we save by PSA screening? (Answer: not enough.) Ask the woman who did everything right -annual exams, monthly self breast exams, regular mammograms, surgery and chemotherapy, but is dying of breast cancer.

To make a reform policy based on Evidence Based Medicine and expect it to improve our nation’s health or save money is like telling the hitters on the hapless 2008 Colorado Rockies to keep their eye on the ball. Good advice, but likely not innovative enough to win the Rockies a pennant in 2009?

Injecting billions of dollars for a health information technology utopia is like giving a big Christmas bonus for every shareholder of health information technology vendors, perhaps stimulating the economy, but failing to remedy the main problems within the healthcare system. The Obama stimulus package may speed development of health IT, enabling us to reduce inefficiency in finding and using health information, but the real problems such as our gross primary care shortage and deleterious incentives bred by our third party payer system remain immune to IT fixes.

EMR will be even more disappointing than it will be costly. What we eventually gain in efficiency, we will lose immediately in up coding. Doctors charge fees based on the amount of data supposedly gathered and processed during the visit. EMR makes it easier for doctors to document more data allowing for higher charges. Higher reimbursement for the same care may sound good for doctors but it’s bad for healthcare reform. EMR will result in check box medicine, three page notes (If you printed it out on paper) for 12 minute office visits and higher levels of office charges. The number of harmful mistakes due to lack of EMR is grossly overestimated. Sixty-five percent of patients seen in my clinic are relatively healthy, and I should be able to keep their records on 5 x 7 index cards. EMR may eliminate the need to flip through obese paper charts to find information, but it does not represent healthcare reform. Healthcare reform should eliminate the need for EMR.

My review of inpatient medical records reveals that roughly three out of every four sheets of paper seems to be placed in the chart to make it hard to find the useful information. Privacy statements, multiple copies of demographics sheets that contain the insurance carrier identification, copies of orders justifying the tests performed, consents for treatment and other useless papers clutter the chart. Notes in the outpatient chart originally served only as a reminder of what occurred during the visit. Instead the chart has become legal defense. If it is not written in the chart, the doctor did not consider, examine, ask or explain. The office notes have also evolved into justification for payment from insurance companies, Medicare and Medicaid. No longer do we tolerate succinct notes reading, “Strep throat. Penicillin. $4.” Perhaps we should. EMR professes to be healthcare salvation, like the amazing clean up machine that Dr. Seuss’s Cat in the Hat uses after he trashes the house. EMR may be progress, but it isn’t healthcare reform. The need for EMR is but the symptom of a trashed house.

Quality improvement mandates will not fix the problem. We can have either quality care, or the guarantee of quality care. We cannot have both. Medicine is such a cumbersome art to quantify, mandates to do so will use up so many resources proving and guaranteeing quality care, we won’t have enough resources left to care for people when the baby boomers hit the hospital doors. Hospitals should strive to continue to educate themselves and improve the quality of care, but the notion that a multitude of quality improvement initiatives will save five million lives per year is healthcare refantasy- not reform. The patient centered medical home is a good concept, but should physicians get paid extra for providing patient friendly ready access to quality care? Should your mechanic charge extra to fix your car on the day you need it? The American Academy of Family Physicians should encourage physicians to make their offices medical homes, but do not expect to solve our healthcare crisis by requiring doctors to document and prove quality care.

No matter how you spin it, we have one pile of money to take care of 300 million Americans. Universal healthcare coverage merely rearranges the piles, like rearranging the deck chairs on the Titanic. Having the wealthier pay higher healthcare costs to compensate for those who cannot pay, or having everyone pay higher premiums or funding it all through taxpayer dollars merely shifts the piles of money around. True healthcare reform must drastically reduce the cost of delivering care, so we can make the pile of money smaller. As our current massive luxurious healthcare system sinks to the ocean floor shall we start lining up deck chairs and assign seats by annual income? Now is the time for a whole lot of lifeboats- a whole lot of family physicians.

The river of time and nature

True healthcare reform must start with the simple realization that except for isolated lifesaving triumphs, all of healthcare is but a few stones thrown into the cruel and unforgiving river of time and nature. The tragedy would not be in the futility in attempting to dam that river. The tragedy would be to continue to sap our economy and still allow people to feel lost, alone, abandoned, hopeless and without even a rudder to choose their course down this river. The solution must mostly comfort and guide people on their voyage for a bargain price.

Fortunately the real goal should simply be to enable every American easy access to a caring human being who has a reasonable grasp of that 10% of medical knowledge to help guide that person through the system, through the river of time and nature. To at least place a hand on every person’s shoulder and say, “I don’t know what is going to happen, but I am going to do my very best to utilize all we know to help you. You will not be forgotten or lost in the shuffle. You will not be abandoned because of your inability to pay. I may make an honest mistake, but I will treat you as I would treat my own family.” Can’t we simply improve that access to our current system with improved healthcare coverage for the indigent, and subsidies for the lower class? Any rancher knows it is nearly impossible to herd 20 cows into a livestock trailer sitting in the middle of a pasture. Five, ten or even twenty cowboys cannot get the job done. It will be just as futile to try to herd 300 million Americans into such a healthcare system with five, ten or a thousand rules, incentives or subsidies. Perhaps I’m not smart enough to solve the healthcare crisis, but I know this, take a bucket of grain and one cowboy can lead the whole herd where he wants ‘em. Where do we want ‘em? Primary care.

The solution: An army of family physicians

We need an army of family physicians working with physician assistants and nurse practitioners. We will need the specialists to make this the greatest healthcare system in the world, but the family physician is ideally suited to save the American people from our broken system. I would generalize and choose all primary care physicians for the job, but family physicians have the advantage of being able to care for the whole family. They can do a quick free ear check on a child when mom comes in for her obstetric check. Family physicians can care for more for less.

We need a primary care based system, and any reform plan that attempts to rely on information technology and does not create a primary care dominant system will fail without question. How do we accomplish this? I believe it is a better incentive strategy to eliminate debt for newly trained family physicians than to spend federal dollars paying them more for services the rest of their careers. Make family physicians and their physician’s assistants and family nurse practitioners and possibly all primary care providers exempt from malpractice lawsuits. Absurd? Military physicians are exempt from malpractice suits and they are the physicians likely to care for the President of the United States. Drastic yes, but malpractice suits are an ineffective way of regulating physicians. Besides let’s face it, we are in a crisis situation here. Let the state board of Medical Examiners and the American Board of Family Medicine regulate and police the profession. Is lack of a monetary consolation to a victim of malpractice any more criminal than our current system where thousands of people feel lost and abandoned by the system every day? Politically impossible? Maybe, but is it really? What is the budgetary cost of such a move? $0.00. What are the risks? None really. What are the benefits? More physicians choosing to go into family medicine and primary care, helping to solve our primary care shortage.

Insurance should be for hospital care and specialty care. Primary outpatient care should be financed totally separately from inpatient and specialty care. You don’t buy insurance to cover oil changes on your car. People ideally should save in Health Savings accounts and pay directly for inevitable healthcare expenses. Enough family physicians can care for the majority of America’s health needs without Medicare, Medicaid or insurance. Family physicians won’t get rich, but they will have security and something they no longer enjoy- job satisfaction. Without malpractice threat they would no longer have to pay $20,000 per year for malpractice insurance. Without the hassle of third party payers, physicians could drastically reduce their overhead and administrative waste. They would continue to take care of the indigent for free, but now with an attitude of altruism rather than frustration. The new generation of family physicians is out there. I have seen them rotate through our clinic. They study in our schools and universities. They spend their vacations in third world countries where they feel they can help more human beings. Idealistic and bright, they burn with the desire to make a difference, one patient at a time, but without change, we surely will extinguish their flame with debt and all that distracts them from their patients.

Of course there is a lot more to successful healthcare reform. Preventive care will need to be encouraged if third party payers are no longer covering routine health maintenance. The problem of high drug costs can be solved. Primary care physicians in impoverished locations cannot be made to shoulder the brunt of the burden of indigent care. How do you address the problem of people trying to save money by avoiding necessary tests and treatment? But these are all problems with attainable solutions. The outlook is bright if we can expose the myths and clearly see what is real and important. Technology can help, but it is not our panacea. A variation of universal healthcare coverage demands consideration, but no matter what the solution, we must become primary care based and fulfill our fundamental obligation to take care of each other, young and old, rich and poor.

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43 Responses for “Mythology and Healthcare Reform”

  1. twa says:

    I can’t even play along with this. As someone who believes that we should be committed to excellence in medicine, this post, inasmuch as I believe it represents a lot of physicians out there, is distressing. More “trust me – I’m a doctor,don’t try to quantify what I do, don’t try to differentiate between me and my colleagues, its more art than science, one patient at a time … blah blah blah”. Yes people will always get sick, some no matter what. But we know how to effectively treat and prevent a tremendous amount of common conditions. And yet many patients don’t even get the most basic of recommended care. There are systems in this country (and even more in other countries) that do provide better care and produce better outcomes for a population. Much of this is due to the systemic nature of the care – systems that support the physicians ability to provide excellent care. And many of these systems are in fact primary care based. But primary care physicians alone are not going to save health care. Systems that effectively coordinate care across conditions and providers, systems that provide the right incentives and pay for the right things. Systems that effectively make use of technology to make care more cost effective and higher quality. We should strive to learn from and build on these systems. A failure to effectively create and implement standards for quality is at the root of a wasteful and ineffective health system. Yes primary care is important. But it is not THE answer. Let’s quit dreaming about what could be if we could just go back to 1950 – and lets look forward and build on the tools and knowledge we have in 2009.

  2. Deron S. says:

    The only thing we can agree on these days is the fact that we can’t agree on what real reform looks like. I still don’t think anyone is getting to the true core of the problem though: we have too many healthcare transactions taking place. Too many patients being referred for unnecessary testing, too many patients needing care for conditions they could have prevented if they maintained healthier lifestyles, too many unnecessary physician/insurance company communications, etc.
    Do we really want to redesign a system around an increasingly sick population, or do we want to look for ways to change the personal and societal factors that are making us sicker? We can have 6 million new PCPs and a wonderful new nationwide HIT system, but the need for those things would be far less pressing if people took more responsibility for their health and the health of their children.
    Are there greedy physicians and greedy insurance companies and greedy HIT vendors and greedy drug companies out there? Sure there are. But there is no better way to reduce their impact on our healthcare system than to reduce the demand for their services.
    Are we avoiding this because we feel that it will be more difficult to change ourselves than to change the system around us?

  3. J. F. Sucher, MD FACS says:

    This diatribe is filled with so many problems that I need to take them on one by one. But with respect to Dr. Uyemura I will start with agreeing to one single point.
    1. “We need a primary care based system, and any reform plan that attempts to rely on information technology and does not create a primary care dominant system will fail without question”.
    - I agree. This really is a no brainer. The U.S. healthcare system needs to push for improved primary care. But its not enough to simply offer society something that it refuses to use. One large problem is that our culture lacks the desire to actually participate in preventative medicine. This is where we could make a huge impact, but it will take decades to realize its benefits.
    Now on to what I don’t agree with:
    2. “That fact is that evidence based or not, half of what we believe to be scientifically proven will be proven wrong in five years. The fact is medicine is based on opinion, not fact.”
    -Really? 50% of scientifically proven evidence will be proven wrong in five years? Please give me a source for this statistic. But rather, please retract this unsound statement. Additionally, much of medicine is based on fact. NOT opinion. You have no sound footing to say such statements. Medicine is a practice that deals in statistical probabilities. This is true. But those statistics are factual.
    3. “What we eventually gain in efficiency, we will lose immediately in up coding. EMR makes it easier for doctors to document more data allowing for higher charges.”
    -First, it is well known that efficiencies are lost in dealing with EMR/EHR/etc. Second, you imply that the medical profession is not coding correctly, and that we will now “up code(ing)”. Professionally this is offensive, and suggests that the reason for EMRs is simply about billing.
    4. “EMR will result in check box medicine, three page notes (If you printed it out on paper) for 12 minute office visits and higher levels of office charges.”
    - Not withstanding that many EMRs lack the ability to generate appropriately readable documents, the fact is the EMR has nothing to do with “check box medicine”. EMR is a tool. How you evaluate your patients has nothing to do with how you document the visit. EMR can however help you remember to do something (such as check the PSA this visit), when you otherwise may have overlooked it.
    5. “The number of harmful mistakes due to lack of EMR is grossly overestimated.”
    -Again, I ask you for data to support this. The number of harmful mistakes in a hospital setting is alarmingly high, with a significant amount of objective data to support this claim. This has nothing to do with “lack of EMR”, but is a statement that simply tells us that we live in a healthcare profession that is troubled by mistakes that can be reduced. EMR is one tool that may help reduce the risk of errors. It may also introduce new errors (which has been documented in the literature).
    6. “Sixty-five percent of patients seen in my clinic are relatively healthy, and I should be able to keep their records on 5 x 7 index cards.”
    -Great. 100% of my patients are extra-ordinarily ill. That has nothing to do with how my records should be kept. Having you keep your 5X7 cards will do nothing for your patient should they end up in the hospital with an acute illness. It also doesn’t help the patient when you send them to see an endocrinolgosist with their blood sugar isn’t being controlled by traditional steps. It doesn’t help the patient when they want have to fill out all of your office forms after they have filled out a myriad of other forms for other providers of care. Keeping your 5X7 cards is akin to me keeping a teletype and refusing to use a telephone. Its OK to use technology. Granted, it comes with potential pitfalls, understanding how to use it and when is the key.
    7. “My review of inpatient medical records reveals that roughly three out of every four sheets of paper seems to be placed in the chart to make it hard to find the useful information.”
    -This problem has nothing to do with your argument. But, it is a pro for EMR. You will never see the other 3 pieces of paper should you use a well built EMR.
    8. “…the chart has become legal defense. If it is not written in the chart, the doctor did not consider, examine, ask or explain. The office notes have also evolved into justification for payment from insurance companies, Medicare and Medicaid.”
    -Yes this is true. But it is also true that the illegible scribble of many physicians has not promoted the understanding of what happened during a hospital admission when it is necessary to review such records.
    9. “The American Academy of Family Physicians should encourage physicians to make their offices medical homes, but do not expect to solve our healthcare crisis by requiring doctors to document and prove quality care.”
    -Now this is a biggy. It is abundantly clear that we as a medical profession need to do everything that we can to prove quality of care. To not do so is simply shortsighted. You are implying that we just continue on with a naive trust that everything that we as physicians do is just fine. This line of though in intolerable.
    10. “Fortunately the real goal should simply be to enable every American easy access to a caring human being who has a reasonable grasp of that 10% of medical knowledge to help guide that person through the system, through the river of time and nature.”
    -I want to commend you for your passion, empathy and caring. However, this is not the “real goal”. The “real goal” is to improve the deliver of healthcare in so much as we attempt to provide higher quality of care WITH compassion. EMRs won’t do it. I agree. Healthcare IT won’t do it. I agree. But fuzzy statements and guides “through the river of time and nature” is a bit over the top.
    11. “Make family physicians and their physician’s assistants and family nurse practitioners and possibly all primary care providers exempt from malpractice lawsuits. Absurd? Military physicians are exempt from malpractice suits and they are the physicians likely to care for the President of the United States.”
    -Yes, this is absurd. First, why should PCPs get some kind of special ticket? We have a medical jurisprudence system in the U.S.. I may not like it, and you may not like it.. but it is what it is. It is based on providing a means by which patients retain the right to reasonable medical care. The reality is that there are a number of less than optimal physicians out there and they should be sued. BTW, the President of the U.S. is rarely if ever seen by a military doctor.
    OK… I’m stopping at 11 points.
    I think that you should re-calibrate your thought process. We are all very upset with the healthcare system. We are all working extremely hard and getting paid less. We are all facing the fears of dealing with the legal system. We are all tired and drained from dealing with the extra-ordinarily broken business of medicine. But none of these has anything to do with investing in HealthCare IT. I don’t doubt for a minute that there will be a giant waste of money lost in this “stimulus” package. But I do know that there needs to be a concerted effort in the developement of better Healthcare IT that can help us practice medicine better.
    JFS

  4. David MD says:

    Wow. I can feel your frustration and I’m very sorry. Before medical school I did a BS Elect Engr/Comp Sci and I worked in industry doing both hardware design and software work. During my freshman year in college I was part of an NSF grant programming an EMR. The point is that I am very much into technology but that puts me in a position where I concur with your opinion that the EMRs are much too complicated and that most of your patients you could keep their record on a 5 x 7 index card if the goal was for treatment reasons only and not 1) defensive medicine and 2) billing codes. Yet it is useful to have the 5 x 7 index card worth of information in electronic form. I currently do some consulting in EMR development.
    Regarding health care there needs to be much more focus on helping people have healthier lifestyles. New York Mayor Mike Bloomberg has much done work in this direction and the work he did in New York City should be emulated nationwide for he got the teen smoking rate down to 8.5% compared with 21% nationwide and formely in New York City and got 200,000 adults (20% of the adult smokers) to quit smoking. Studies show that 70% of adults want to quit smoking so making his plan nationwide would do so very, very much for the health of the nation. Helping people with obesity and getting exercise is also extremely important and New York State is implementing an “Obesity Tax” of 18% on sugar soft drinks (but not diet soft drinks). As you know it is very hard to change patient lifestyle but by using market forces we can do much to help them. Corn (and thus high fructose corn syrup) is subsidized by the government for about $2 billion per year. We need to have subsidies (and increased WIC/food stamp allotments) for fruits and vegetables.
    According to a significant study that I have cited earlier, 12% of health care resources (about $300 billion of last years $2.6 trillion health care budget) are consumed by smokers who have known for 45 years that smoking is bad for them for smoking is in cigarette packs. Another study done in 1995 date demonstrated that 7% and 2.4% of health care resources are consumed by obesity and lack of exercise respectively. This had undoubtedly gone up in the past 13 years since obesity is on the rise. But this comes to another $240 billion of the national health care budget consumed. By having smokers no longer have the health care resources they consume subsidized by taxpayers so that they pay them themselves we have plenty of money to take care of the uninsured. Moreover, along with banning smoking in public places, increasing prices of cigarettes help people to quit smoking (and stop teens from starting).
    Yet another category of ill health is environment including air and water pollution and lead paint. Having polluters pay for the health costs they incur and inducing them through market forces to clean up the pollution can also significantly improve health care.
    While I won’t use the phrase “Evidence Based Medicine” is is important to recognize the regional variations in health care as documented by the Dartmouth Atlas (The Mayo Clinic consumes far fewer resources to treat patients than the Boston area for example) and also documented by The Agency for Healthcare Research and Quality (AHRQ) which also documents which are unnecessary procedures and tests. CMS and AHRQ needs to be doing more studies which show which devices are efficacious and have their budgets for this purpose significantly increased.
    See http://content.nejm.org/cgi/content/full/357/12/1221
    We Can Do Better — Improving the Health of the American People
    http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1308416
    State estimates of total medical expenditures attributable to cigarette smoking, 1993.
    L S Miller, X Zhang, D P Rice, and W Max
    http://www.ncbi.nlm.nih.gov/pubmed/10593542?dopt=Abstract (study about obesity and lack of exercise costs).
    for more details.

  5. twa says:

    Thank you Dr. Sucher. Your 11 points are spot on in my humble lay-person opinion. You and other physicians such as yourself restore my faith in the profession. I was so angry after reading this post that I couldn’t type straight.

  6. Debt Free @ says:

    If you are finding yourself at the end of your rope financially, if you have a heavy burden of debt on your shoulders and are looking for a debt elimination system, the first thing you must understand is that debt elimination system is not a debt consolidation system.

  7. The good doctor says the “solution” for our ills is “an army of primary care physicians,”
    Not a myth-filled system brimming with half-baked and half-assed rules and conditions.
    I agree, but how do we recruit this army, from where and whence will it come,
    And what wii be the incentives, and who will be willing to pay the right sum,
    To compensate for the current shortage of desperately needed primary clinicians.

  8. Dr. Pandey says:

    Monte,
    I agree with you on most of the points. I did an article on the heathcare solution at http://blogs.biproinc.com/healthcare/?p=485
    Granted the site audience a bit smaller than this place..but that is besides the point.
    What I beleive in is that solution lies into doing so many things tegether..such as education, training, quality, business practice, insurance, policy, wellness etc. I am in healthcare consulting business and I can tell you this..that unless people open up for change it will not bite only the common person but will also hurt those who are currently protecting the system – just like the financial market.
    rgds
    ravi
    http://www.biproinc.com/healthcare_service.html

  9. PT says:

    Thank you for this post. While I think you downplay the potential benefits of EMR in coordinating care, it’s wonderful to hear someone speak with enough humility to admit that we’re not going to just suddenly meet all of our healthcare desires by swiping at political straw men like “evidence based medicine”, and “rooting out waste & fraud”. Noble goals, but way overhyped in terms of savings.
    Two statements I thought were particularly good…
    “The fact is medicine is based on opinion, not fact. What percentage of human physiology, diagnosis, treatment and cure of illness do we know? 95%? 85%? Despite the fact that we may have cracked the human genome code, try 10% and you’d be closer to the truth.”
    Exactly why it’s a god awful idea to create some Gov’t agency to tell doctors what treatments they must give for what symptoms. I’d prefer relying on my doctor’s discretion rather than someone I’ve never met who’s been appointed by some politician.
    “Insurance should be for hospital care and specialty care. Primary outpatient care should be financed totally separately from inpatient and specialty care. You don’t buy insurance to cover oil changes on your car.”
    By definition a large part of what we call insurance is in no way shape or form insurance. By definition, insurance boils down to coverage “in case stuff happens”. Routine care by definition is not insurable – what we have now is a system that forces pre-payment for routine services, in addition to providing insurance. What reason do we have to bundle an oil change with an engine overhaul? Yes, changing your oil can prevent having to have an overhaul, but that doesn’t make payments you make to guarantee yourself an oil change in the future insurance. I think it makes sense to unbundle certain items, to make catastrophic coverage available people who can’t afford a plan with A-Z coverage. Why should someone buy a plan that covers things like knee replacements? Furthermore, silly minimum coverage mandates such as dental coverage just make premiums unaffordable for a larger number of people.

  10. Govindan says:

    Enough food for thought……..it was interesting analogy.

  11. Peter says:

    “True healthcare reform must drastically reduce the cost of delivering care, so we can make the pile of money smaller.”
    That won’t happen when billings and prices drive profit. It will happen when hosptials are not profit centers but cost centers, where their innovation to cut costs is rewarded, not passed on to the insurance industry.
    “We need an army of family physicians working with physician assistants and nurse practitioners.”
    “I believe it is a better incentive strategy to eliminate debt for newly trained family physicians…”
    That is a national goal not possible with the present system that has no one persuing or funding national goals. Giving rich and poor medical students incentives to chose primary care is fine, but let’s also get something in return – more PCPs working in shortage, poor and remote areas.
    “Insurance should be for hospital care and specialty care.”
    How would retaining the same system we have now solve our cost/access problems? Insurance companies don’t force hosptials to cut costs, they pass them on. I’m not afraid of not paying my PCP, I’m, afraid of trying to pay the bills I get from a hospital. I get tired of the car/healthare analogy, they just doesn’t go together.
    “Without malpractice threat they would no longer have to pay $20,000 per year for malpractice insurance.”
    Sorry, but everyone should be held accountable. But getting healthcare under a national system where health bills would not be part of the settlement would get settlement awards and premiums reduced.
    “Without the hassle of third party payers, physicians could drastically reduce their overhead and administrative waste.”
    If they had one payor, the government, with one set of rules they would also reduce overhead and admin. costs.
    “They would continue to take care of the indigent for free, but now with an attitude of altruism rather than frustration.” “Primary care physicians in impoverished locations cannot be made to shoulder the brunt of the burden of indigent care.”
    Two contradictory statements. No reason to work for free for any patient, anywhere. Under a national plan you’d get paid for treating everyone.
    “How do you address the problem of people trying to save money by avoiding necessary tests and treatment?”
    By not always comparing healthcare to car insurance. Under a national plan all care would be paid for so there would be no finanical barriers.
    All of what you want is more achievable under a national, government run, single-pay system. We can also legislate policy for preventative progams at the same time as we reform healthcare – one does not have to happen before the other. Everyone agrees we should prevent sickness but to do that we need to change habits – that will involve taxes for bad behavior to fund incentives for good behavior and to fund sickness from bad behavior – you’ll need to convince Americans, mostly corporate America, that taxes can be good.

  12. bev M.D. says:

    My thought after reading the post and comments:
    “We have met the enemy and he is us.”

  13. PT says:

    Peter: “That won’t happen when billings and prices drive profit. It will happen when hospitals are not profit centers but cost centers, where their innovation to cut costs is rewarded, not passed on to the insurance industry.”
    Um, how exactly are you going reward cost cutting without profits?

  14. Nate says:

    2. “That fact is that evidence based or not, half of what we believe to be scientifically proven will be proven wrong in five years. The fact is medicine is based on opinion, not fact.”
    Are stints good or bad, are we doing angioplasty this year or not? VIOXX is out or is it back for some? I grew up being told to drink lots of milk it’s good for my bones but the last time I went to the doctor he told me milk was for baby cows. Statistics change as you gather more information. To believe stats are forever set and factual is a scary opinion to hear from a doctor. Didn’t the “stats” use to support bleeding patients with leeches?
    “Second, you imply that the medical profession is not coding correctly, and that we will now “up code(ing)”. Professionally this is offensive”
    As the person who pays the bills physicians generate allow me to remove the implication and clearly state as a fact you do not bill correctly, you presently upcode at an obscene level and only my investment in technology to catch you and the threat of me requesting medical records to support your charges, which you seldom have, prevents you from doing it more. More disconcerting is the naivety required to think that as soon as EMRs become standard someone won’t release software guiding doctors on what extra work to do to support upcoding. There are already seminars held all over the country teaching providers and their staff how to “maximize” their billing. An electronic widget that flashes a message to ask this question and get an extra $10 could be written in hours. Heck I might start on one after work today.
    4. 24 hour nurse lines and websites already use check box medicine, the guidelines are hierarchal, check the box and move on, how are providers going to be immune to this?
    7. How are you going to submit legal consents in court off an EMR? Your asking for a whole lot of new laws to overturn decades of court cases if you think a check box on your EMR is going to fly as proof of consent or notification.
    In regards to the effects insurance has there was a chart done using CMS data that showed in the early 60s Americans paid for over 50% of their care OOP. Today that is below 18%. Majority of Americans have minimal expenses each year, to insure these is the most inefficient way possible to finance them. We could save 10-20% of those expenses tomorrow by eliminating first dollar coverage. I have never seen an explanation, besides increasing carrier profits and government taxes, that justifies this change in society.
    “That won’t happen when billings and prices drive profit. It will happen when hosptials are not profit centers but cost centers, where their innovation to cut costs is rewarded, not passed on to the insurance industry.”
    We tried this, called them HMOs, and the public would not tolerate them and the limits they placed on consumption. See the point above, once individuals became detached from the cost payors and payees went to war. You will never be able to legislate an equilibrium between the two. Only when it is the patients dollar being spent will profit, either insurer or provider, not be a major driver of decisions.
    “How would retaining the same system we have now solve our cost/access problems? Insurance companies don’t force hosptials to cut costs, they pass them on. I’m not afraid of not paying my PCP, I’m, afraid of trying to pay the bills I get from a hospital. I get tired of the car/healthare analogy, they just doesn’t go together.”
    The system we have now is the result of HMO Act 1973, AWP laws, denied care lawsuits, and 51 governments trying to appear like they are doing something about the problem. Why don’t we start by asking what 3 decades of reform has accomplished? Insurance is not a good or bad thing, it’s just a mechanism for transferring risk, what you oppose is how it has been utilized and implemented in the past, and this was done by the politicians your now asking to solve the problem. What your really saying without knowing it is lets get rid of the politicians and the way they use insurance. Taking the politics out of the system wherever possible is the best start any plan can make. Why do you tire of the car analogy, it is very applicable. Just like an actuary can tell you how many times an 18 year old male with a b average will get in an accident an actuary can tell you how likely you are to get cancer and the cost associated with it. Do you have a problem with Life Insurance and the death tables? There all in the same, the problem is when politicians and society force insurance to act in a manner that is not insurance. I can insure you from large hospital bills due to cancer or a heart attack; I can’t insure your personal decision to go to the doctor for your runny nose or annual check up. I could insure your annual check or your semi annual dental cleaning but that has all the common sense of insuring an oil change or empty gas tank.
    “If they had one payor, the government, with one set of rules they would also reduce overhead and admin. costs.”
    Then why is Medicare not more efficient? You can save a penny by making all the rules the same but if you lose a nickel because all the rules are the same what have you accomplished? All government plans lose almost as much to fraud and waste as it cost to administer private plans. This is what skimping on administration gets you, no checks and balances, no safe guards, and an open pocket book to be picked.
    “No reason to work for free for any patient, anywhere. Under a national plan you’d get paid for treating everyone.”
    You won’t get paid enough to treat anyone but you will get paid something for everyone, what a deal.
    “Under a national plan all care would be paid for so there would be no finanical barriers.”
    How do you address the larger problem of people getting care that is unnecessary and wasteful? Do you know how much Medicare use to pay for elderly patients getting their nails clipped?
    It must be great being progressive Peter and never having to worry about the consequences of your actions. Take well fare for example, your great people because you took the poor and moved them all into prison like towers for free or minimal cost to them. The results of 2000 poor people with little to no employment living on top of each other and the resulting crime and drug problems was not foreseeable, who could have guessed that would happen. Most of your ideas on healthcare reform suffer the same shortsightedness. When you think you have a solution you need to go 3-4 steps down the road and see what the reaction and consequences will be.
    What was so wrong with American Healthcare circa 1960? We can still have the medical advances without tossing out the rest of the system like we did. Why not look at what worked so well and try to go back to it instead of pretneding we are all so smart we can predict the future?

  15. More family physicians would be a plus, but I think the key issue is equitable access to whatever health care people may need. That means a universal-access, single-payer system.
    As to the myth of “universal access to quality evidence based, measurable, mistake free medicine (that)can prevent illness and death, cure the unhealthy and provide a safety net to save us if we fall from health” – maybe some people in their teens and twenties subscribe to this myth? I’m not personally aware of anyone who does. No one with any knowledge of health care, or even simply much experience of life, could possibly believe in such a thing.
    Americans don’t want a health care Santa. We’re just fed up with the health care corporate profiteers.

  16. NVQ says:

    Very interested analogy

  17. AnnR says:

    I think a lot of this EMR discord comes from a “us vs them” mentality. The days of the doctor hanging out his/her shingle may be over.
    I’d rather that my army of primary care providers, the one I see this afternoon after I call this morning when I have a sudden problem, had more than just a 3 X 5 card on my history.
    They probably haven’t ever seen me before. Maybe it’d be useful for them to know what my last blood work looked like or what drugs I’m taking. Heck, even if I get in with my regular doctor, I’m not willing to trust that she remembers every little medical thing about me.
    I think the EMR move frightens the medical profession for two reasons. The first is that small offices bear a large expense. The second is that high priced specialists know that the next step will be to start running comprehensive data operations on their services and that this will result in less reimbursement for treatments that aren’t worth much but are high-tech or new.
    It’s a shame because the small PCP would benefit from diminishing the draw of specialists from the health spending pool, but it does appear that EMR effort unite otherwise divided areas of medicine.

  18. Simply too much here to digest completely, but certainly well thought out discussion. I will address one point only though..time is short.
    The concern that EHR/EMR only supports up-coding and promulgates check-box medicine has some basis in truth with our current reimbursement system and overhead cost crunch..certainly with primary care. As has been stated previously in THCB, in our current E&M/CPT system, the only method for financial growth and sustainability is to see more…translate–>to make sure you code efficiently for shorter visits and do away with longhand notes (ie check-box). As such until preventive care, disease management and procedural/imaging efficiency are used (at least in part) as indicators for reimbursement, then the HIT system may be lost for its true benefits. If however such an approach to care and reimbursement is to be included in reform, then EHR/EMR etc. will be mandatory to assure its success and efficiency. But I would agree that on its own, without a global vision, then it may not be money well spent.

  19. rbar says:

    Although I mostly disagree with Dr. Uyemura, I do think that he stresses two or three important points that are often overlooked:
    (1) Many in the US (that includes people outsides the HC system and patients, but unfortunately some doctors as well) have unrealistic expectations regarding medical care. A bit more humility would be appropriate re. mankind’s limited medical knowledge – and that includes also our modest amounts of good evidence, as long as one is talking about really solid (class A/RCT) evidence.
    But that does not mean at all one should not try to effectively use the limited evidence we have and promote the use of EBM (and thereby I rather end up in Dr. Sucher’s camp).
    (2) I also think that Dr. Uyemura is right when he states that medicine is not an exact science, but that the diagnostic process involves complicated, largely unquantifiable judgment calls. He also believes that “an honest mistake” may be part of medical care.
    Similarly, that does not mean that we (as physicians) should not try our best in terms of quality improvement (both on the individual and system level).
    However, our current legal system focusses on “reasonable care”, which is a highly doubtful concept since there are almost always medical experts that – with the facile backing of retrospect analysis and, often, subspecialty knowledge – testify that any care effort with a bad outcome was not reasonable/substandard. Any doctor who provides a reasonable effort (documenting a reasonable history, exam, analysis and plan) should be protected from being called “negligent”. (It is a different question whether a doctor whose career is riddled with bad judgments is competent … but that would be for the boards to determine, not jury trials.)
    (3) With regards to EMR, I do think that they are an unavoidable improvement (in terms of safety/accessibility and in terms of stopping duplicate exams, provided that they are truly interconnected), but I would say that they are marginal for healthcare reform. I have read, on this blog, a lot of unrealistic expectations re. the impact of EHR implemantation.

  20. Peter says:

    “Um, how exactly are you going reward cost cutting without profits?”
    Reducing waste creates dollars, those dollars can be distributed in pay raises, bonuses and/or additional services to patients.
    “and clearly state as a fact you do not bill correctly, you presently upcode at an obscene level”
    Just wondering how this works down to the premium payer? I guess the uninsured are yet screwed again when they don’t have the “investment in technology” to catch it on their bills.
    “Then why is Medicare not more efficient?”
    http://www.thehealthcareblog.com/the_health_care_blog/2006/06/policy_why_medi.html
    “All government plans lose almost as much to fraud and waste as it cost to administer private plans.”
    um, then how does every single-pay country provide healthcare at about 1/2 our cost?
    “We tried this, called them HMOs, and the public would not tolerate them and the limits they placed on consumption.”
    Well if we assume that is true, that was then, this is now. Seems conspicuous consumption (from debt) has taken a back seat, at least for a while. People (other than Wall Street) are also realizing there is no free lunch and are seeing their healthcare benefits disappear or be reduced, or cost more. But I’ll give you, we may not be hurting enough yet in healthcare for there to be enough of a push for real reform – but it will come.
    “You won’t get paid enough to treat anyone but you will get paid something for everyone, what a deal.”
    That’s not what I said, and that’s not what is happening in single-pay countries.
    “How do you address the larger problem of people getting care that is unnecessary and wasteful?”
    Well you certainly don’t reward over utilization with profits as we do now. You create budgets that everyone is forced to adhere to.
    “Do you know how much Medicare use to pay for elderly patients getting their nails clipped?”
    No I don’t, do you? I’m not sure if foot care can be classified as healthcare? I know with the elderly foot care is very important, especially those with diabetes. But with single-pay non-covered services are defined.
    “your great people because you took the poor and moved them all into prison like towers for free or minimal cost to them. The results of 2000 poor people with little to no employment living on top of each other and the resulting crime and drug problems was not foreseeable,”
    Nate, not my choice but we now know that was the wrong policy, that came about because no one wanted poor people (especially blacks) living in THEIR neighborhood. So we created black ghettos. We now know what works better (de-segregation) and that is housing the poor in successful neighborhoods. Care to have a poor (black) person living next door to you?
    “instead of pretneding we are all so smart we can predict the future?”
    Looks like the future is 20% GDP for healthcare if we don’t do something other than pass costs onto premium payers with HDHP plans.

  21. pbnesbitt says:

    As a former executive in a worker’s compensation managed care system, I have a few thoughts regarding US health care and solutions to the problems of rising costs and limiting health care. When we created the new managed care system, we tried to create an alliance between providers, payers, and patients. We were committed to a non-adversarial system with the belief that we could improve patient care while lowering costs. The results were anticipated but non the less somewhat surprising, an overall reduction in medical costs ranging between 35 and 50 percent net, after subtraction of management costs.
    I have tried to provide a brief synopsis of the system below. I see no reason why the system described wouldn’t scale up.
    The 10 simple rules for a Successful Health Care System
    1. There are three parties in health care systems: patients, providers, and payers. They must all be satisfied with their roles and the benefits if a system is to work effectively. When they are not satisfied, it creates friction and that costs money.
    2. Doctors and health care providers are the providers of care and all those in good standing should be invited to join the system. They are the final arbiters of care should be making all decisions regarding the care of their patients. They should not require prior approval from anyone except their patients.
    3. In order to participate in the system, health care providers must agree to follow a simple set of universal treatment guidelines. A prime example is, “Be sparing in the use of tests and studies unless indicated by clinical findings.” Providers who fail to follow the guidelines are removed from the system.
    4. Doctors and providers must be paid promptly and fairly for their services. All medical reports and bills are submitted electronically to care coordinators.
    5. All patients have a right to appropriate health care. But most patients lack the knowledge to effectively manage their own care. A rational system requires care coordination and management to ensure that patient care follows the agreed upon guidelines and is appropriate.
    6. Care coordinators are independent of providers and payers. They are, however, responsible to each party. Their primary responsibility is to see that patients receive appropriate care; their secondary responsibilities are to the providers and payers. Providers should be paid promptly for all services rendered and payer’s money should not be wasted.
    7. Care coordinators manage care through computer programs that evaluate care against the universal guidelines and medical bills against agreements. Provider failure to follow guidelines initiates a discussion with the care coordinators who will try to resolve differences. Medical bills are automatically adjusted.
    8. When necessary, care coordinators discuss care with patients.
    9. Payers must promptly pay all medical bills submitted by the care coordinators.
    10. Any personal injury or malpractice claims go to arbitration and are defended by the care coordinators.
    This system worked effectively with multiple employers with tens of thousands of employees each. Given the success of this program in reducing costs while increasing the satisfaction of all parties, it should certainly be considered when evaluating new health care initiatives.

  22. Nate says:

    Peter you just don’t grasp facts or choose to ignore them, either way debate with you is fruitless.
    You link to Maggie, who has no understanding of insurance, to support your case that Medicare is not less efficient then the left believes? She has as many factual errors in her writing as you do and is just as unlikely to admit to them no matter how clear the proof.
    What she fails to mention in her first couple paragraphs is the enrollment in HMOs during the period profits increased. It is highly dishonest to discuss profits in absolute dollars in a fluctuating market. It’s like crying about oil company profits when the market doubles in size, apparently liberals expect an insurance company to make $X no matter if they have 1 million members or 10 million members. Comparing one year to another is also hazardous as trends take a couple years to develop, a change in accounting or regulatory reserves could skew one years numbers pretty bad. Carriers also go through soft markets where they lose billions in fierce pricing battles, you can’t ignore those periods and only look at hard market times then complain about the profit.
    Maggie’s article, like most of her writing, is full of guesses and insinuations from someone with no experience in the business. It doesn’t cost 5% to enrollee people, Medicare has a documented fraud rate, from GOA and CMS studies, around 10% compared to 2-3% in private insurance. These are all facts that she never bothers to learn, she just makes up beliefs based on what she is trying to sell.
    Liberals claim private insurance spend 20% of their premium on overhead, this is over stated but even using your numbers 20% of $3500 is $700 a year for overhead, this includes state premium tax and compliance with federal and state laws.
    Medicare spends around 5-6% when you include CMS and congressional expenses used to manage it, at an average cost of $6600 that is $396. Your also getting a fraction of the benefits, you didn’t have Rx till 2006 and you still don’t have dental and vision. Medicare also has its problems with Fraud and abuse, 10% of $6600 is $660. $660 plus $396 is $1056. Where’s the improvement Peter? Why should we pay $356 more per enrollee per year?
    For facts about Medicare cost instead of Maggieisms read INSIDE THE BLACK BOX OF ADMINISTRATIVE COSTS by Kenneth E. Thorpe
    And
    Medicare’s Hidden Administrative Costs:
    A Comparison of Medicare and the Private Sector
    (Based in Part on a Technical Paper by Mark Litow of Milliman, Inc.)
    Take another 10 minutes and read the 2007 and 2008 HSS PERM results if you doubt the fraud and abuse problem.
    “um, then how does every single-pay country provide healthcare at about 1/2 our cost?”
    Rationing! Lower provider reimbursement and lower consumption.
    Is this the type of system you want?; http://news.yahoo.com/s/ap/20090204/ap_on_re_as/as_japan_medical_care_denied
    “TOKYO – A 69-year-old Japanese man injured in a traffic accident died after paramedics spent more than an hour negotiating with 14 hospitals before one admitted him, a fire department official said Wednesday. The man, whose bicycle collided with a motorcycle in the western city of Itami, waited at the scene in an ambulance because the hospitals said they could not accept him, citing a lack of specialists, equipment, beds and staff, according to Mitsuhisa Ikemoto.” It was the latest in a string of recent cases in Japan in which patients were denied treatment, underscoring the country’s health care woes that include a shortage of doctors. More than 14,000 emergency patients were rejected at least three times by Japanese hospitals before getting treatment in 2007, according to the latest government survey. In the worst case, a woman in her 70s with a breathing problem was rejected 49 times in Tokyo.
    If we rejected people at the ER our cost would be lower to, dead patients consume very little care, except in Medicare where dead patients and doctors still mange to stay busy somehow. Further I’m really sick of progressives and liberals comparing “our” system to Europe. We don’t have “our” system we have 50 states, if you where to take out the states ran by liberals “our” system wouldn’t look nearly so bad. It’s MA, NY, and other reformed states that drive our cost. If people with your mentality would stop screwing things up “our” system wouldn’t be so expensive.
    “But I’ll give you, we may not be hurting enough yet in healthcare for there to be enough of a push for real reform – but it will come.”
    “We” are not hurting, YOU are hurting, go to Iowa and the Midwest and the South, we don’t spend $12,000 a year for family coverage. We control our spending, it’s YOU who has a problem that YOU are trying to solve by getting the rest of us to pay for it. As far as we are concerned MA and NY can take their HC system and shove off, the rest of us will do just fine without you. And save a fortune in the process.
    “Nate, not my choice but we now know that was the wrong policy”
    And we know now Ted Kennedy’s HMO Act of 1973 was the wrong policy, and we know now the new deal was the wrong policy during the great depression, and we know now the government forcing banks to make loans to people with poor credit was the wrong policy, notice a trend here Peter? It’s almost like politicians have a really long track record of being wrong, they get very wealthy doing it but it almost always screws us. Ted Kennedy alone has a 30 year career being 100% wrong on Healthcare, yet there he is at the front of your train, you suckers just never learn.
    “Care to have a poor (black) person living next door to you?”
    I have them on 2-3 sides of me thank you, I am surrounded by housing projects. We have a nice mix of brown, black, and white poor out here though, we don’t like to discriminate.

  23. rbar says:

    Nate,
    I am not sure whether I understand you correctly. Are you really comparing admin. cost for medicare with private insurance based on total abolute admin. cost per enrolled individual, instead of administrative costs per volume of care/HC dollars spent? (And BTW, where is this 10% MC fraud rate coming from, I’d be interested if that is a real number/official estimate?).
    And if you have to rely on anecdotes to support your arguments, don’t you realize that this does not contribute to a meaningful discussion that you say you support? Or do you want for example this
    http://www.newser.com/archive-us-news/1N1-121F0DDCD841CEF0/video-shows-woman-dying-on-brooklyn-hospital-floor.html
    for an answer?

  24. Monte Uyemura says:

    I need to clarify. Technology, EMR, quality improvement and evidence based medicine are not bad. They are progress with pro’s and cons. Granted I emphasized the disadvantages in my discussion to make the point that these are myths as far as healthcare reform. Healthcare reform must transform our system into a primary care dominant system.
    I don’t doubt EMR is more efficient. In fact our hospital has purchased a system and we are in transition. To say that it will result in upcoding is not offensive to our profession. My partners and I, I believe code lower than we are allowed by the complex billing system. I believe as a whole we will charge more 99214′s with EMR. It is actually a vote of confidence to our profession when I say EMR will not improve significantly the quality of care, because despite our “archaic” record system I believe the majority of physicians try to do what’s best for their patients and if health information is not immediately available, they take the time to find it. I know some don’t. The argument will be how much EMR improves quality. The answer will determine how many doctors have not been looking for information that wasn’t immediately available. I hope for the sake of the reputation of our profession that it doesn’t help too drastically. No doubt EMR and health IT will make things easier for doctors once they figure out how to use it, but is it money well spent? You could buy every doctor a Mercedes Benz to drive to work, but would we show up to work earlier?
    I admit, exempting primary care physicians from malpractice suit sounds a little more ridiculous than the concept of giving loan forgiveness to doctors going into underserved areas. (Our nation is underserved in primary care) But as we are borrowing from my children to spend billions for health IT, that was the cheapest way I could think of to move towards a primary care based system. As a rural family physician, I feel strongly what is NOT healthcare reform, but I’m willing to concede others may have a better way to make us primary care based.
    The biggest point I must clarify. I do not advocate physicians abandon quality improvement. In everything, life, medicine we must continue to try and improve. It is time to retire when a doctor no longer wants to improve. I am opposed to a barage of government mandated quality improvement initiatives, and maybe it’s because I think I know better what needs improving than the government, and that is open for debate. However I am positive, it will not solve our healthcare crisis.
    Monte Uyemura, MD

  25. Nate says:

    “I admit, exempting primary care physicians from malpractice suit sounds a little more ridiculous”
    It’s not a ridiculous concept at all, there are ridiculous ways you can achieve it though. Just carte blanch exempting them would be silly but a logical solution would be to clarify the legal expectations of primary care doctors, this should be done for all doctors. Right now a large number of malpractice suits are based on the outcome not the treatment. A Doctor can do everything right, still have a bad outcome and get sued.
    It should be codified that if a doctor follows and documents acceptable treatment plans they can not be sued.
    This could be the catalyst for implementing and funding EMR. If a doctor can save 10K per year on their malpractice insurance that frees up the money for them to purchase EMR software. Insurers would offer the substantial discount to any provider utilizing EMR to document compliance with the new malpractice immunity laws.
    Granted it doesn’t satisfy progressives’ desire to spend billions of tax payors dollars but it does reduce insurance company income so they should like that. I would also trust the purchasing decisions of physicians actually using the software to determine who prevails in the EMR market then politicians picking the winners of the sweepstake.
    If we want providers to embrace EMR it needs to benefit them not be regulated on them, they have proven very adept the past 3 decades at finding loop holes when they don’t like something. Instead of spending billions fighting them make it to their advantage to get on board.

  26. Peter says:

    “and we know now the government forcing banks to make loans to people with poor credit was the wrong policy,”
    http://www.slate.com/id/2204583/pagenum/all/

  27. Peter says:

    “We” are not hurting, YOU are hurting, go to Iowa and the Midwest and the South, we don’t spend $12,000 a year for family coverage.”
    http://www.nchc.org/facts/cost.shtml
    From the above article: “A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.”
    And this from Iowa: http://www.iowaforhealthcare.org/press-releases/2007/12/12/health-care-costs-threaten-iowa-farm-and-ranch-families.html
    And this for Iowa:
    http://www.familiesusa.org/resources/newsroom/press-releases/2008-press-releases/health-care-premiums-rose-39.html

  28. twa says:

    “The answer will determine how many doctors have not been looking for information that wasn’t immediately available. I hope for the sake of the reputation of our profession that it doesn’t help too drastically.”
    I hope for the sake of patients that it helps dramatically.
    Having said that I recognize that at the individual physcian level the efficacy of the EMR/technology may seem limited. But within the context of systems of care I can’t believe, nor does the evidence support, the notion that it is ineffective. Quite the opposite. I’m sure you take good care of your patients. I’m sure that 100% of physicians graduated in the top 10% of their class. I’m sure that the reasons our health outcomes (on factors amenable to health care interventions) are so pathetic is because every other physician practices exactly the same way you do.
    I don’t mean that to sound insulting. I’m just trying to make the point that we have to move beyond looking at health care as simply the interaction between one doctor and one patient repeated over and over.

  29. Nate says:

    need to work with us Peter, what are you trying to say? You link to NCHC.org but don’t say why. To support my point take a gander at;
    http://www.statehealthfacts.org/comparetable.jsp?ind=271&cat=5&sub=67&yr=61&typ=4
    Employer Based Health Premiums / Family coverage
    Rank/Employee Contribution/Employer Contribution/Total
    50 Nevada $2,144 $7,602 $9,746
    43 Iowa $2,638 $7,913 $10,550
    5 Massachusetts $3,073 $9,218 $12,290
    Now lets look at Health Spending
    1 Utah $3,972
    2 Arizona $4,103
    3 Idaho $4,444
    4 New Mexico $4,471
    5 Nevada $4,569
    48 New York $6,535
    49 Maine $6,540
    50 Massachusetts $6,683
    51 District of Columbia $8,295
    Notice any trends? Seems states ran by Liberals have a crisis of cost and spending, the rest of us have a crisis of you trying to get us to pay for your failures.

  30. Peter says:

    Nate, see also
    Wyoming (R) – 12,087
    North Carolina (D) – 10,950
    Hawaii (D) – 9,426
    Are you saying Repiblicans keep their citizens healthier?
    “You link to NCHC.org but don’t say why.”
    You didn’t read this in my post? So how’s Iowa so great? You said “We arn’t hurting, there’s a lot of hurt out there, as per my links.
    “A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses”

  31. Nate says:

    Surveys by leftest organizations campaigning for “reform” are propganda not facts. We are not going to reform our healthcare system based on propoganda. We already elected a President based on sound bites and look at the joke that has already turned into.
    Surveys are for highschool girls questioning their popularity or determining what you want for dinner. Red America can afford our healthcare system, what we can’t afford is the boondoggle blue america has turned their systems into. It appears Utah’s cost is already on par with the rest of the world, why do they need to change anything? Maybe MA and NY should be looking to UT for advice instead of Europe?

  32. Thanks for the breath of fresh air; being on the front lines daily with patients speaks volumes for the need of an army of primary care docs in all sectors- public, private from all walks of life. There is a critical shortage.
    We also need to focus on health- and prevention of illness- if we are ever going to be able to keep the U.S Health Care Titanic from sinking.
    This shift will take every one of us outside our comfort zones but will be the life preserver that this health care system needs.
    All the fancy technology will mean nothing when Medicare costs deplete our Social Security reserves and truly bankrupt our nation.
    I’m all for technology, efficiency and sound electronic records, but this is all “icing on the cake”; let’s regroup and get back to basics. Primary care needs to play a crucial role in this process of integratng wellness, prevention and early intervention.
    Thanks for listening.

  33. Lon Marshall says:

    I am a marriage & family therapist. I am the owner of a small group practice. Just two or three comments from a mental health practitioner’s point of view.
    I prefer to collaborate with primary care physicians versus psychiatrists (specialists). My experience with primary care docs is that they take time to talk with the patients and seem to have better bedside manner in general than psychiatrists, as strange as that may sound. I have heard that 70% of anti-depression prescriptions are written by primary care physicians.
    There is evidence in my field that what helps the patient most is the resources the patient brings into the office (eg. hope, faith, family etc.) followed by the “doctor-patient relationship”. These two things count for far more than, technology, expert knowledge or technique. The “doctor” that best knows how to use these two things will help the most people, in my business. I imagine there is a lot of crossover.
    I like the common sense approach of Dr. Uyemura. Some of the best interventions come from a minimalist perspective.

  34. dave says:

    I beleive in preventitive health but not universal health care. We need to get healthier by exercising more and eating better. To many fast food places especially in California where I live.

  35. M. Chee says:

    Thanks Dr. Uyemura for your assessment of the broken health care system. We definitely to increase our focus on recruiting more primary care physicians who can go out and take ofto care for hardworking Americans- where the syringe meets the skin so to speak. But I must say, however, that I disagree with you on the minutiae with regards to several of your other points. Reform that works will require facets of every subjectthe topics you touched on. Although you make excellent points about the difficulties in each arena, the fact remains that change will come in all of them. I invite you, Dr. Uyemura, and anyone else interested in having a voice during this historic moment to visit http://www.fairmanagedcare.org and sign up to become a member. We are an emerging national grassroots movement focused on changing the debate about health care costs and holding managed care companies responsible for their behavior.

  36. Donald says:

    This is a good discussion. It would be of value to think of yourselves not as physicians, but as consumers of health care. Being too much on the other side blinds. Consumer demand has guided much, always will. Indeed was it not consumer demand for freedom that guided the colonies to form a union?
    So…where will you go, what will you do when you are sick, want answers? To seargeant XYZ in the army of Family Docs? Unlikely. If you could remove one obstacle, it is surely known where you would go. Remove the overcrowding..and a bit of the chaos..and you would go to the ED (ER). There you will have an answer for what affects you (no pneumonia, no pulm embolus, no acute mi, no cva, etc) in short order. We as physicians need to wake up. We are now a technologically intensive service sector, and it behooves us to augment the place we already have — where services and technologies are provided at one site, and (relatively) efficiently (compared to the rest of the system). Emergency Departments are diagnostic centers that cut time out of the process of discovering etiologies, and starting treatment. Instead of imagining something that cannot be in our lifetimes…how about…..unclogging the EDs by removing the back end hold ups, preferential treatment of elective surgeries, etc. Then make these currently available centers of a large portion of care, the center of more care….from which appropriate referrals can be made.

  37. There’s merits to modernizing healthcare IT. Increasing communication efficiency by digitizing medical records can bring cost down. The question is will the cost savings truly be pass on to consumers?

  38. K Walsh says:

    The health insurance companies have played a major role in our current healthcare crisis. These companies make huge profits and their CEOs make millions, while the rest of us, workers and employers alike, face skyrocketing healthcare costs, impossible bureaucracy, and life-threatening insurance denials.
    THE FACTS: HEALTH INSURANCE COMPANY PROFITS IN 2007:
    1. UnitedHealth Group — $ 4.654 BILLION. UnitedHealth Group owns Oxford, PacifiCare, IBA, AmeriChoice, Evercare, Ovations, MAMSI and Ingenix, a healthcare data company
    2. WellPoint — $ 3.345 BILLION. Wellpoint owns BLUES across the US, including Anthem Blue Cross Blue Shield, Blue Cross Blue Shield of Georgia, Blue Cross Blue Shield of Wisconsin, Empire HealthChoice Assurance, Healthy Alliance, and many others
    3. Aetna Inc. — $ 1.831 BILLION
    4. CIGNA Corp — $ 1.115 BILLION
    5. Humana Inc. — $ 834 million
    6. Coventry Health Care — $626 million. Coventry owns Altius, Carelink, Group Health Plan, HealthAmerica, OmniCare, WellPath, others
    7. Health Net — $ 194 million
    The huge insurance company profits—BILLIONS EACH YEAR—could be used to provide quality healthcare for millions of people. We need to get the insurance companies OUT of healthcare, so patients can receive the care they need and physicians can be paid adequately for their work.
    The only way that we all will have affordable, quality care is to get the insurance companies OUT of healthcare! We can no longer tolerate a healthcare system where those without medical expertise or genuine interest in our patients’ health have absolute control, and where profits are made by denying care.
    FOR MORE INFORMATION, SEE: http://www.insurancecompanyrules.org/learn_more/the_roster/

  39. MD as HELL says:

    If you all were not abusing the term “insurance” you would experience instant clarity in your thinking. No one has “insurance” anymore. Medicare is not insurance. Medicaid is not insurance. Hmo, PPO, blah, blah, blah…NOT INSURANCE. Insurance is a contract…If A happens then B is paid. No denials in real insurance. But healthcare plans can deny payment, because there is no contract.
    As for all the profits someone wants to loot, they would not exist if the government was taking in the premiums. There would be a huge deficit and less care.

  40. I AGREE says:

    By Wayne Barrett Tuesday, Jul 3 2001
    Most of Bill Thompson’s “financial consulting” clients are not revealed on his Board of Ed disclosure forms. The most disturbing one that Thompson did list, however, was Managed Healthcare Systems Inc., where he earned a total of $65,000 in 1997 and 1998, according to his tax returns. A black-owned HMO whose principals worked at the highest levels of the Reagan administration, the company is shrouded in scandal.
    Last year, New York Attorney General Eliot Spitzer forced the MHS, which specializes in recruiting Medicaid recipients for its HMO, to repay the state $2 million for Medicaid services that patients never received. Spitzer also put Jean Moise Millien, the director of an MHS clinic, in jail for up to three years after he pled guilty to stealing $275,000 from Medicaid. Spitzer’s press release revealed that MHS knew for years that Millien’s clinic, Stuyvesant Heights Medical Group, was largely run by “unsupervised physician’s assistants and nurse practitioners” and that patients “were consistently complaining that they were having difficulty getting services.”
    Yet, said Spitzer, the company “failed to take corrective action or properly oversee its subcontractor.” MHS portrayed itself as “a victim” of the clinic when they settled with Spitzer.
    The State Health Department also revoked Millien’s physician’s assistant license in November 2000, finding that he’d run the clinic since 1991—four years before the MHS contract began—without on-site supervision by a licensed M.D. The Department also found that the clinic corporation had been dissolved by state officials for tax delinquency reasons in 1994 and that Millien had a prior criminal record. Spitzer said a doctor from Pennsylvania came to the clinic once a week “to sign charts” for a while, but “eventually stopped coming altogether.”
    An MHS affiliate left a similar trail of complaints in Pennsylvania—where it became the subject of Philadelphia Inquirerexposés in 1996 and 1997, before and during Thompson’s employment. According to one study, it was three times as likely to refuse to pay for days of hospital care as the state’s next most stingy HMO. The “focus of six special state and federal audits” and a onetime target of a Pennsylvania grand jury, according to the Inquirer,the company took a reported $119 million in profits and executive bonuses from its Pennsylvania Medicaid work alone in the early ’90s, making it the “most profitable HMO” in the state.
    Anthony Welters, the principal owner of AmeriChoice, the Virginia-based parent of MHS, was a top Reagan transportation official, gave $20,000 to Pennsylvania GOP governor Tom Ridge, and has given over $56,000 in recent years to Republican candidates and committees across the country. Clarence Thomas is the godfather of one of his children. Thelma Duggin, another top executive, worked in the Reagan White House and at the Republican National Committee under Lee Atwater, the engineer of the Willie Horton campaign.
    Thompson said he’d known Welters and Duggin since 1992, when they started trying to do business in Brooklyn, and that he “bumped into Tony” in 1997 and Welters offered him a consulting job that started that June. Charged with “reaching out and helping them obtain business,” Thompson said he “spoke to community organizations.” Though he says he “never visited an MHS clinic”—including the Stuyvesant Heights one near his home—he insists that MHS is “a good company.” While Thompson’s tax returns indicate that AmeriChoice paid him $35,000 in 1998, his disclosure forms report no income from the company.

  41. What's Changed says:

    Chicken Gate Returns
    The 101 Dumbest Moments In Business 2003 EDITION Whiffed pitch No. 6: blatant stereotyping. By Mark Athitakis April 1, 2003 (Business 2.0)– GRAND PRIZE WINNER, DUMBEST MOMENT OF 2002 Which leads to the question, Who is Chicken Man? & Why were whole fried chickens selected?
    In September, insurance company AmeriChoice brings trucks to blighted neighborhoods in New York City and gives away coupons for “free chickens” as an incentive for the underprivileged to switch their Medicare coverage. New York state senator Carl Kruger files a complaint with the state attorney general. The 101 Dumbest Moments In Business 2003 EDITION – April 1, 2003 Apr 1, 2003 … Just don’t tell him about the “Chinese health balls.” ….. In September, insurance company AmeriChoice brings trucks to blighted … New York state senator Carl Kruger files a complaint with the state attorney general….. Falling on his sword, Welch announces he’ll give up most of the perks,…2009 and 2010 $120,000 from your tax dollars.
    Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools. These checks came from AmeriChoice Health and on the surface seems like fine gifts. Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind in order to promote its share or induce its share of the market place. This is not allowed as a use of your taxpayers dollars, yet it happens.What does it really cost the City of Philadelphia to receive this money? Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that? PS… Did the Mayor send for Chicken Man or was he approached by Chicken Man? The Mystery Widens! Can Chicken Man save the Liabraries?
    CEO of AmeriChoice Health Bolts.. Was that Chicken Man? John J. Kirchner – Director, Operations John Kirchner joined Healthfirst in May 2010 with over 25 years experience in health care management. Mr. Kirchner’s background includes responsibility for health plan P&L, strategic planning and operations, and government and regulatory affairs. Mr. Kirchner will be responsible for supporting all aspects of NJ health plan operations. Prior to joining Healthfirst, Mr. Kirchner held a variety of positions at AmeriChoice of New Jersey serving as President from 2007 through 2009.
    Will this mystery man or woman or chicken ever be caught? Will the “secret eggs” given out to housing authority officers Clinics, Doctors and whoever, make it into through that crispy crust prepared by their Home Office Line Chefs?. Will the Doctors who collected all those extra eggs for sharing thier patients recipes with the Home Office Line Chefs ever really be rewarded? Will the Great Head Chef Chicken Man or whomever that directed and approved all to avoid, overlook the rules, laws and regulations Menu, ever be really compensated for their true worth or will Salmonella remain the dish served for Medicare and Mediciad Industry.
    PS Is the Chicken Man a Blues Brothers Wanna B??? HEALTH INSURANCE COMPANY PROFITS IN 2007:A Whole lot Of Chicken
    UnitedHealth Group — $ 4.654 BILLION. UnitedHealth Group owns Oxford, PacifiCare, IBA, AmeriChoice, Evercare, Ovations, MAMSI and Ingenix, a healthcare data company ans a lot of others.

  42. Complaince? says:

    8:53 am July 29, 2010
    MEDICARE FRAUD, MEDICADE FRAUD, AND KICKBACKS AND BRIBES BUSINESS AS USUAL,INSIDER INFORMATION GIVEN. 9B BS ONE THING BUT WHAT ABOUT YOUR “HANDS OFF POLICY” BY THE DOJ AND CMS AND HHS, AND WHY NO INVESTAGATIONS OR AUDITS TO CONFIRM AND HELP?
    WHAT ABOUT “TAXPAYERS TO PREVENT AND STOP FRAUD INTEREST FOR MEDICARE AND MEDICADE” WHAT ABOUT WILLIS AND WILKINS BEING FIRED FOR NOT WANTING TO BREAK THE HEALTH FRAUD LAWS?
    NJ CEPA CLAIM FILED……..FALSE CLAIM DECISION UNDER APPEAL AND FILED….. WHERE IS ANY HELP FROM YOUR DEPARTMENT?
    The U.S. District Court for the District of New Jersey dismissed May 13 a qui tam action alleging violations of the False Claims Act (FCA) by United Health Group and its subsidiaries. According to the court, the complaint failed to state a claim upon which relief could be granted under the FCA. Relator Charles Wilkins began employment with United Health Group and its subsidiary AmeriChoice in October 2007 as a sales representative. Relator Darryl Willis began employment with United Health Group and AmeriChoice in 2007 as the general manager for Medicare/Medicaid marketing and sales.
    In their qui tam complaint, relators allege 11 violations of Medicare and Medicaid regulations. The United States declined to intervene in the case and the relators filed an amended complaint that stated one federal count—violation of 31 U.S.C. § 3729(a)(1)-(3)—and nine state law counts. United Health moved to dismiss under Fed. R. Civ. P. 12(b)(6), arguing relators failed to plead the elements of a “false certification” claim, they failed to plead any anti-kickback violations, and failed to adequately plead a conspiracy. Relators alleged that because United Health entered into a contract expressly certifying that it agreed with all “terms and conditions of payment,” they made a false claim when they submitted claims despite any one of the 11 purported regulatory violations alleged in the amended complaint. Rejecting relators’ express false certification claim, the court found “[not once in the Amended Complaint have Relators identified even a single claim for payment to the Government.”The court also held relators’ implied false certification claim failed. According to the court, relators argued that because United Health agreed to comply with all CMS regulations when it contracted to become a prescription drug plan sponsor, and because at times it was in violation of some regulations, it therefore committed fraud each time it submitted a claim for payment. The court found such a theory of liability overly broad. “If Relators' theory were correct, the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,” the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government's payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and [t]hey have not done so.” Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
    United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).
    FCA claim alleging aggressive marketing tactics by health plan provider dismissed
    Publication: Health Law Week
    Date: Friday, June 4 2010
    The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans — including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.
    The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator’s false certification claim. The relators’ theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants’ motion to dismiss was granted.
    Source: Health Law Week, 06/04/2010
    Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement.

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