The world is not going to end. We witnessed a revolution earlier this week. The people have spoken and they chose the anti-establishment, street smart, government shrinking candidate who bucks the status quo. We find ourselves in uncharted territory, with an unpredictable President-elect, who has unclear plans for healthcare. Here is what we do know. Mr. Trump is a successful entrepreneur. Forbes describes the entrepreneurship pathway as having no clear story line, but a “sense of chaos, hectic decision making, and moments of great fear and doubt.” Improving our broken healthcare system will involve decision making in the face of great uncertainty. Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job.
Mr. Trump won over the white working-class individuals in small rural areas. Sluggish economic recovery in these areas played a significant role in his unanticipated victory. It is these disenchanted individuals watching the American Dream slip through their fingers who voted for Mr. Trump. Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats. 25% of the population lives in rural areas yet only 10% of the physicians practice in there. Physicians are leaving the system in droves, closing their patient panels, and not keeping up with demand, thereby threatening patient access in these isolated locales.
Independent practices have a better chance of survival than they did just a few short days ago. Do not sit idle. My son, who is in the second grade, was asked to write down his thoughts on this election. “If Hilary Clinton is elected, I will die.” His teacher insisted he use facts to back up his dramatic statement. “If Hilary Clinton becomes President, she will close my mom’s clinic, we will not have enough money for food, and I will die.” While this is not exactly the conversation that took place over family dinner, my son did understand healthcare would change dramatically following this election. You should have seen him on election night when the network called Pennsylvania for Trump, but that is another story for another day. Private practice physicians must seize this opportunity to be involved in the “make things great again” conversation.
Hillarycare was a known entity with a foregone conclusion. Trumpcare remains a bit of an unknown. His “plan” for healthcare was revealed a little more than a week ago, ironically, at Valley Forge. It encompasses dropping the insurance mandate and allowing purchase across state lines, making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions. The blank canvas is full of possibilities, which is markedly better than the universal health care plan we could have been facing had the outcome of the election been different.
Every clever “fix” for healthcare so far has had unforeseen adverse consequences. Providing marketplaces for consumers to shop for insurance did not improve health; instead, it padded the pockets of insurance company CEO’s, lobbyists, and administrators with special interests. The statistics on rising insurance premiums could not have been released at a better time to facilitate a Trump victory. I am overjoyed at the possibility disingenuous CMS employees and lobbyists for the American College of Physicians could be out of jobs. As for MACRA, I hope it goes down with the Affordable Care Act ship altogether. Physicians want to practice at the top of their skill set, without needless oversight by administrators telling us what is “best practice.”
The system Mr. Trump is inheriting is full of obstacles. Patients are disgruntled about paying exorbitant premiums they can ill afford. Even Bill Clinton chimed in, “The costs are going up, coverage is going down, it’s the craziest thing in the world.” Maybe not the craziest thing. I say a man getting elected to the White House without having any previous political or military experience while most of the polls were predicting his loss is fairly extraordinary.
Admittedly, there are no easy solutions. My best advice is for him to familiarize himself with the game, the players, the field, and the score, and then develop his own blueprint for healthcare. Most importantly, get back to the basics. One hundred years ago healthcare started with fundamentals: the physician, the patient, a stethoscope, and a conversation. People were arguably as healthy then as they are today give or take a few communicable diseases. Additional thoughts are below:
- Invest and innovate, especially in primary care. We are cost-effective and knowledgeable.
- Stop penalizing physicians who do not use Electronic Health Records. Physicians are doing two hours of paperwork for every one hour of patient care and hiring ancillary staff to support this unnecessary infrastructure. Let me care for my patients and do my job. Give me control.
- Shrink or Decentralize the Centers for Medicare and Medicaid bureaucracy. None of these people are practicing health care providers. Why are they in charge of 18% of the GDP, when they know little of practice on the front lines?
- Encourage innovation and competition amongst insurance companies. If you want a low deductible, your children covered until they are 26, and exemption from pre-existing conditions, then pay for it. If you want only catastrophic coverage, and pay for routine maintenance as you go, then pay less and save the extra money to go on a cruise.
- Redefine high “quality.” Reward physicians when they spend more time with patients, are more accessible, and able to prevent expensive hospital admissions and readmissions. Eliminate patient satisfaction scores, immunization rate scores, and outdated HEDIS measure goals.
- Require Medicaid recipients to contribute to their health insurance, on a sliding income-based scale. Require small copays for insurance plans including Medicare and Medicaid. Even a small personal investment ($3) for a visit has been shown to increase value in the eyes of the consumer.
- Allow Medicare to negotiate with drug companies. Pharmaceutical companies have been getting fat and happy while Americans have just been getting fatter and more ill.
Our problems in health care have little to do with the patients or the physicians; rather it has to do with corruption of our administrators and nonessential healthcare players. Beware of the snake oil salesmen touting their latest “solution” for the health care conundrum; instead, look to physicians with boots on the ground caring for real patients to provide tangible answers.
Niran al-Agba is a physician in Washington State.
Categories: Uncategorized
“Give me control.”
That was a funny line in this article.
“Give me control, for I am a doctor, damn it.”
That would have been a more entertaining collection of words for that moment.
You have no say in your professional life. Talk to the Medical Assistants. They will feel your pain. While the RNs laugh.
Pipe down and get back to work. I think I see someone from the American College of Hospital Executives coming.
John, you’d better look up the definition of risk. Just as Trump thought the definition of “sacrifice” was building structures and making money.
Scam artists risk going to jail for using other peoples money. Are they “entrepreneurs”?
We should start calling these things Peterisms.
You’re arguing Trump isn’t an entrepreneur?
HINT: Some (not all) entrepreneurs find ways to take risks USING OTHER PEOPLES MONEY.
Gregg, you write, “dis-organized medicine failed”.
Did it really fail or was it wildly successful, so successful that we ended up curing and treating more and more patients which caused unexpected budgetary problems? If those patients had died like they did before , those budgetary problems would not exist. From my vantage point what you call dis-organized medicine initially escaped much of the bureaucracy and created all these things you talk about including the replacement of human parts, diagnostic testing that didn’t require cutting the patient open, cures for some cancers control of others, less and less invasive cardiac procedures saving and extending life, etc. None of this was expected in the earlier years. The bureaucracy built upon itself creating all sorts of nutty things including the ACA which is now imploding,
If time permitted I would comment further on the rest of what you said, but as before I think the point has been made that you have your own point of view and that point of view may not be as good as you assume it to be.
Gregg, you are correct physicians have been too passive when it came to driving change in healthcare. It is time we stand up, fight, and be the change we wish to see. Not every idea is going to work, but the larger point is clinicians actually practicing medicine with real patients should be involved since we are greatly affected.
Sorry! No intent to offend. I’ve been in direct delivery of care, though not as a clinician since the mid 70s after graduating from UCLA School of Public Health with and MPH in behavioral sciences and community health – which the rest of the country is just now catching up with in 2016 due to the triple aim and population health narrative.
I wholly agree the ‘healthcare conundrum’ we’ve ‘co-created’, and yes I mean all of us from the AMA to ABMS, the litany of member specialty societies, state medical boards and the economic turf carved out via the credentialing process and enforced by hospital medical staff privileging practices, the entire hospital administration profession, and so-called managed care to the copy cat equivalents on the allied or ancillary health side. We created an excessively hierarchical ecosystem which is imploding of its own internal weight and complexity.
I was a pioneer in the PRA (Physician’s Recognition Award) Category I CME program world, and a certified California Medical Association surveyor (under the mentorship of Stanley Skillicorn, MD) well before its adoption by state medical boards as a condition of re-licensure. Back then, it was truly about focused education after ‘medical audits’ (peer generated criteria for quality care by specialty) determined ‘gaps’ in what should happen vs. what was actually evidenced in the medical record. We assumed the light touch of voluntary CME to be both reasonable and appropriate ‘intervention’ to less than optimal or evidenced based care.
As I see it, dis-organized medicine failed due in part towards its tendancy to ‘circle the wagons and shoot in’ via an apparent addiction to the internecine warfare of cognitives v proceduralists and other geo-political credentialling practices. It failed to ‘own’ the organization and dispersion of mission critical healthcare assets from hospitals, to ambulatory surgical centers and the litany of diagnostic imaging and therapeutic centers (lithotripsy, radiotherapy, etc.) which migrated away from and competed with traditionally controlled hospital operations. The exit was compelling from efficiency, access, governance and investment thesis perspectives. Yet, in the fee-for-service world, expanding access often meant bench-marking price to inpatient equivalents and generally adding to the nation’s healthcare tab. The efficiencies did not return a benefit to the community though it typically enriched the physician partners. Any hospital volume declines by the emergence of this usually un-welcomed (unless it was a JV) competition were offset by hospital charge master price increases which added the double wammie of induced excess capacity and aggregate total cost increases.
The independent practice association (IPA) introduced as a means for ‘mainstream’ medicine to participate in and ‘craft’ the emerging prominence of the Health Maintenance Organization (HMO) model and their lighter footprint PPOs as the took over as the predominant financing and delivery model of ‘U.S. Healthcare Inc’. The theory was as more untethered practices were drawn together by an increasing volume of shared patients, it would drive the need for practice integration, greater care coordination collegiality, the requires healthIT spine, core management services support (MSO), group purchasing including supplies and professional liability insurance, etc. In other words, ‘cowboy medicine’ would give rise to ‘pit crews’ in the words of Atul Gawande. The ‘integration’ (clinical, financial and legal) would be incremental, scalable and driven by the gravity of mission and culture essential for an emerging group practice, ergo the term ‘GPWW’ (group practice without walls) emerged for a while. This all went south beginning with the aggressive ‘roll-up’ strategy that converted sleepy community based HMOs to for-profit operators that lost sight of their community benefit (DNA) obligations and shifted to an ‘EPS’ (earnings per share) culture which was all about profit growth.
This collapsed as we all know. Some may remember the meteoric rise of Maxicare and its national expansion via HealthAmerica (a house of cards) which drove what was a promising model of engaging private practices in California into Chapter 11 Bankruptcy.
In my view docs have a super duty to take control of the healthcareborg they have been culpable in co-creating. We have a house of cards that is imploding as we speak. Yet this sense of ‘learned helplessness’ must start with them. I have said repeatedly the ‘exits’ from this mess into direct practice and even concierge medicine is a rational response to an irrational system.
So if we have any discourse here, it need be with what works and not just for the low hanging fruit rather easy to pick off, but what leads to a sustainable healthcare financing and delivery ecosystem. I’d say the first step in that direction is for hospitals to be seen as ‘cost centers’ (as in the Kaiser Permanente – including Group Health – California models) and NOT the ‘revenue centers’ model fueled by fee-for-services that has produced the armies of clipboards hounding you and your peers, let alone their multi-million dollar salaries even at so-called ‘non-profit’ 501c3 health systems.
Again, thanks for piece!
Gregg
Peter we can both say whatever we want, but the proof is provided by those that are willing to continue to invest in projects Donald Trump is involved with. They don’t invest when they think they will lose money.
Do you think most businesses are self funded? That is what it sounds like. Businesses fail all the time and investors recognize that though those inexperienced in business don’t.
If I remember correctly McDonalds original secretary accepted stock in that hamburger company rather than full payment for services. She owned one of the mega mansions in Palm Beach Florida. You probably would think of her as smart. But, had McDonald’s failed you probably would call McDonald a theif and a liar because his secretary would never have been paid.
We need people like you to provide your services, but one would never invest in a person that could not understand risk and reward.
“One doesn’t create a great company without the risk of failure.”
Definition of “entrepreneur”: a person who organizes and operates a business or businesses, taking on greater than normal financial risks in order to do so.
Definition of Trump:
https://www.bloomberg.com/view/articles/2016-09-26/how-trump-rides-on-waves-of-other-people-s-money
“‘Mr. Trump is a successful entrepreneur.’ Really? I suppose if serial bankruptcies…”
Bankruptcy laws have changed through the years, but I think it worthwhile to state that Abraham Lincoln could have gone bankrupt if he lived under today’s laws. He kept paying his debts off and to my understanding never fully pain them.
But I need not point to an almost bankrupt President when I can point to several others.
Jefferson
Grant
McKinley
Not only Presidents were surrounded by debt , industrialists were as well.
Henry Ford’s early company went bankrupt.
Then again for those of you still members of the Mickey Mouse Club, yes, Walt Disney went bankrupt.
One doesn’t create a great company without the risk of failure. That is capitalism. The bad companies disappear and the good companies survive. In fact many of our richest and most productive citizens have failed once or more before their genius created companies that we recognize as huge successes. Some who are afraid of failure have to remember that unless one faces failure one can almost never face that fantastic success.
In Israel where the population is only a bit more than 8 million we see a large number of start up companies that fail. However, failure in Israel doesn’t have the negative impact it has elsewhere. If the logic is good people will loan to those failures again and again because those are the ones moving the world forward. That is why in the world Israel, having a population of only 8,000,000, is number three in patents while most of the rest of the world of 7.4 billion is far behind.
Gregg, maybe later I will deal with some of your other points, but I think you get the idea that these quick responses appealing to emotion don’t lend themselves to an accurate portrayal of an individual even if personally satisfying.
Steve- I am still working on who the WE is exactly. Insurance companies and drug companies should do it because the government should follow the pathway of other countries and negotiate, negotiate, negotiate. There is no incentive to negotiate right now. Pfizer knows Medicare will pay full price for their drugs right now. What if that was in jeopardy ie if your price does not come down, then we will not cover your drug at all. Neither party understands the inside issues of practicing medicine. This is where the WE comes in and we put together individuals from all backgrounds with an interest in healthcare and formulate plans.
Listen, if I could make the same amount of money seeing 15 instead of 20+ patients per day, I will jump at the chance. You are right some will try to keep doing what they are doing, but patients will see the difference and likely vote with their feet. If life is more manageable for physicians, there will be more of us instead of so many running like their hair is on fire.
“Nope. They don’t want to compete. ”
Of course they don’t want to compete and neither does any large company with market share. That is one of the problems with Obama and the ACA. He and the ACA like to deal with large corporations. The ACA reduces competition in all areas including hospitals, insurers and physicians. The left likes to set prices and micro manage. That generally leads to less competition. Under the present rules and regulations it is very hard for new entrants into the ACA’s health insurance realm.
If you think that the interference of the ACA is minimal where health insurers are concerned then you better reread the bill. New entrants face too many obstacles. Therefore, when one says they are going to increase competition that means ridding ourselves from some of the rules and regulations of the ACA.
As before I am not going to comment on some of your other ideas because your glibness continues even though it appears the naiveté you claim to exist in others seems tightly held by you. “Nope” with your follow up explanation clearly demonstrates how you miss the point.
Nope. They don’t want to compete. Most of our states have been dominated by one, two or three insurers for years. Now, states are eliminating any regulatory barriers that exist, and insurers still aren’t coming. Alternatively, if insurers wanted to compete, they could simply start up in a new state. Hasn’t been happening. The costs involved in starting up are stopping them, not regulations.(Doctors should inherently know this. Most of us give volume discounts to larger insurers. Actually, they just pay us less and we accept it. When a new carrier comes along and they have very few patients we don’t accept lower payments from them. IOW, insurers can offer whatever kind of lower premiums they want, but they can only do that if they can get providers to participate. We aren’t going to participate with a new provider until they have a proven track record of being able to pay on time.)
Perhaps the best example of this is Medicare Advantage. Insurers with MA operate under the same rules. What we still see with MA is that insurers avoid working in the same markets. Granted, in the markets where they do overlap costs tend to be a bit lower.
What people on the right should also acknowledge is that in the exchanges insurers can, if they want, compete. It has been a pretty mixed bag so far. I would say there is not good evidence that we know how to get insurance companies to compete, and when placed in positions where they can do so, the results have been mixed. Just glibly saying you are going to “encourage” competition is meaningless. Really, I am pretty well grounded in economics and math, but I think you need to read more and understand how markets are currently (and historically) shaped.
Niran- Who is this we that will do all of this negotiating? Why would insurance companies do that? Drug companies? Why aren’t hospitals and insurance companies already negotiating for the lowest prices they can get? (The one area where we could do this easily is with Medicare, but that is a special interest issue. Neither party is interested in changing it. Either party could have done so years ago if they wanted.) Sorry, this all comes of as wishful thinking unless you actually have some plan, some means to accomplish it.
As to your other ideas, I think they have merit. Of course, what will really happen when you pay more per patient is that many people will keep saying the same number of people to increase income. Not sure how you guard against that or maybe we don’t want to do so. My preferred idea, would be to have a freeze on payments to specialists while shifting increases to PCPs.
Yes, but you do not work in a private clinic, which has vastly different challenges than either of those you face. Encouraging competition in insurance does have a basis in reality. Whether or not those pieces are put into play, depends on what this administration does.
As to how we invest in primary care and where the money is going to come from… we negotiate savings in other areas ie insurance companies, government bureaucrats, and negotiation with drug companies to start. There are likely numerous other places to find significant savings. The money saved from a variety of interventions creates a pool of money to “invest” in primary care clinicians. Listen, I am not asking for more money. I am asking for more money per patient to see fewer patients and in turn do a better job with them. As the quality of care improves, the need for specialty care decreases. Also, charging a premium on access to specialists that is “unnecessary” as well as “unnecessary” ER visits are things that should be disincentivized in a variety of ways. Solutions are going to take “thinking outside the box.” My thoughts may not be revolutionary, but what do we have to lose by changing course? Things are clearly worse than they were before Obamacare and as of Jan 1, MACRA is going to kick off Dr-exit, the consequences from which will take years to recover from.
Yep. Bankruptcies do not disqualify one from being a successful entrepreneur. His tolerance for ambiguity is one of his best assets, no matter which side of the aisle you are on. The risk does NOT require everyone buys in and participates. We have survived for many generations without that. You have clearly swallowed that idea of the left, hook, line and sinker. You had me interested until you went the Adelade route. Mostashari has no idea what those of us on the front lines are doing.
Look, my bias is that I am the owner of a private practice in existence for 46 years. I have been voted one the top physicians in the county for seven years running. I know healthcare for children and I am good at it. These are my opinions based on my experience and direct observations over the last 16 years. More than 7 physicians are retiring in this county at the end of the year, they are young, far younger than retirement age. There is a looming crisis on the horizon, no one is talking about. There will be NO physicians at the rate we are going except in large cities, which will be catastrophic.
Those suffering in small rural areas are the ones who overwhelmingly spoke for change.
Now, you are a tech person. It appears you are an entrepreneur yourself. You believe in your heart of hearts, it makes health care better. I am afraid it does not, especially as things stand now. Not where I practice and not for what I do in primary care.
You can insult my opinion, but these are my thoughts based on my experience practicing medicine. I do not cherry pick patients and accept every patient with significant congenital defects and chromosomal disorders sent my way. These children can become very sick at times and we can handle 95% of what comes our way. That takes time, effort, and fortitude as well as a “tolerance for ambiguity.”
Money should be spent on allowing us to actually do our job; which means spending enough time with patients to save lives. Technology may have a place in hospitals or large institutions, it is NOT required or even preferable for me to do my job. When someone in the tech world actually understands what I really do every day in my office with patients, then they will GET it. But so far, it helps bureaucrats collect data and that is of no consequence to me.
Oh my! Where to start on the TrumpCare ‘faith based’ hologram which you seem to have swallowed in whole?
‘Mr. Trump is a successful entrepreneur.’
Really? I suppose if serial bankruptcies and forced bailouts including a record near billion dollar annual operating loss constitutes ‘success’. Had he not ‘owned’ the banks, his failing roll of the dice real estate house of cards would have erased his entire net worth. Gulp! Some successful entrepreneur, and that’s before TrumpU, AirTrump and a line of failed extensions of his brand. Who knows what other stories might be revealed by his allegedly ‘under audit’ tax returns?
‘Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job. ‘
Nowhere in evidence is this man’s ‘tolerance for ambiguity’ evident. What we do know is quite to the contrary, i.e., how thin skinned and undisciplined he is and how quick he is to draw and fire his wrath at others with little to no self awareness nor concern with the disproportionate power advantage he possesses especially when attacking women, other minorities and those with considerable less standing than he. Hardly a skill set for a competent CEO.
On TrumpCare:
‘It encompasses dropping the insurance mandate and allowing purchase across state lines, making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions.’
The socialization of risk REQUIRES everyone to be in the pool less adverse selection drives an underwriting death spiral. Eliminating the American Enterprise Institute recommended and market driven policy of the individual mandate is both naive and foolish – though institutional amnesia as to its origins seems to have set in.
New wine in the same old bottle:
Health savings accounts (HSAs) and thus voucher equivaents including block grants to the states are not point of purchase empowerment plays driving a consumer directed care revolution that will tame the rapacious appetite of an over-engineered, physicians ‘purchase order driven’ zeigeist that equates to a ‘do more to earn more’ incentives disproportionately fueling specialty or niche market waste, fraud and abuse. Your exempting physicians from the problem seems a little ‘tone deaf’, and make no mistake we ‘patients’ do play a variably modest to material role in the healthcare conundrum as well.
Selling across state lines is upside mythology. Lets assume the law of large numbers prevails in terms of best pricing practices. An out of state plan is more often than not nowhere near critical mass in a specific and ‘adjacent’ marketplace to argue for or extract ‘most favored nations’ rate’ (best price). These are tired and now recycled Republican talking points under the guide of choice, freedom and independence. What this really means is I have the right to buy ‘junk insurance’ – so-called mini-meds which look attractive from a premium standpoint but provide little to no coverage in the event I need serious attention. The wrap around catastrophic solution is mythical too as well.
The empowerment of primary care physicians is also a solution but perhaps not in the generic manner you suggest: ‘Invest and innovate, especially in primary care. We are cost-effective and knowledgeable.’ Direct practices, retainer medicine or membership based models like Qliance in your state have real promise but ONLY if the assume additional risk for downstream exposure a la IoraHealth or more recently PCP empowerment via Aledade ACO business models.
I have developed many provider networks including a 250,000 member equivalent Primary Care IPA with a global (hospital, physician and ancillary) risk (including drugs) percent of premium download @85% from both commercial carriers and Medicare Advantage contractors. We capped and empowered the PCPs as prudent resource managers and traffickers into the specialty and sub-specialty domain via office training, detailed and current provider directories and immersive PCP engagement into the critical role they play via referrals and hospitalization. We even capitated via sub-capitation higher cost specialty services (orthopedics, oncology, cardiology, urology, general surgery, etc). Bottom-line, we failed and went BK. Primaries sandbagged to protect their total income returns and more often than not shifted the liability to buckets of their specialty partners. There were many issues underlying this tendency and ultimate demise, but holding out primary care physicians as an on the come innovative solution calls the question via what business model? I suspect you line up on the dis-intermediation side of concierge medicine – a cherry picking practice at best.
I completely agree with you on empowering Medicare to negotiate direct and on behalf of some 54 million beneficiaries vs. deleveraging their aggregate market power via a series of PDPs under Part D. I wrote about this advocating on behalf of Proposition 61 in California (which unfortunately couldn’t spend like the drunken sailors at PhRMA: and this failed): https://yesonprop61.wordpress.com/2016/10/17/yes-on-proposition-61-the-california-drug-price-relief-act/ and the deconstruction of the ‘NO’ narrative: https://yesonprop61.wordpress.com/no-on-prop-61/
The most informed claim you make is: ‘Admittedly, there are no easy solutions.’ Agree, but lets get honest about what works and then develop the political chops to get it done.
Gregg Masters
@2healthguru
Your comment saying insurers“ don’t want to compete, they want to make money” suggested that Niran was a naive child. I recognize and believe Niran does as well that competition has been reduced by those on the left so I straightened out your thinking process and told you how competition works. One doesn’t get much competition when government sets too many parameters like was done by the ACA.
You now agree with the basics of competition something you didn’t understand before or aternativley you worded your statement on competition in a very poor fashion that demonstrates one who doesn’t have a firm handle on economic principles and how they have been discarded by the ACA legislation.
“Glib?” Not maybe, but absolute. Before complaining about being tired of talking points learn what they are. The ACA along with other regulations place all sorts of restrictions on insurers that discourage new entrants into the marketplace. New entrants would increase competition.
“In a competitive environment ”
Sure. Hope you know the old economist joke that ends with “assume a can opener”. You have just assumed one. Most health care markets are dominated by relatively few insurance companies. IF, and that is a big if, we actually had a competitive environment, what you said would be true. In fact, we don’t. In some ideal economic model, you are correct. In reality, not the case. As I noted, states have already tried to encourage insurance companies to enter their state to compete. Has not worked. Glib? Maybe, but mostly I am tired of talking points that have no basis in reality.
Invest in primary care. I agree with this, but again, how is this going to happen? You just put the GOP in charge. Where is the money going to come from? This is not about accepting the election and moving on. This is about having been in health care for 45 years in some form or another and paying attention. You can’t just glibly assert that we will invest in primary care without considering where that capital will come from.
BTW, I work at both a CAH AND a level one trauma center. I have to deal with the issues facing both.
“Trumpland: Where hate and ignorance is popular again.”
Peter most of the hate I have been hearing seems to come from you.
Pesto maybe you could tell us how you paid for health coverage before the ACA and after the ACA and what you would prefer without it?
Uh, no doctor got any subsidy from Ocare. Govt had 8 years to correct the financial meltdown sequalae and craft a healthcare bill. Instead we got a health insurance bill/monstrosity forced down our throats filled with goodies for pharm, insurance companies, etc and when the money ran out they all bailed. Face it, Obama has been a failure top to bottom, and the nation has repudiated his legacy.
We the peasants changed the face of the republic. We were sliding towards destruction. Us po’ white trash (I’m really Hispanic and Irish) don’t know nuffin and should go die.
You spew the hate that you accuse us of having. You are the delusional one.
Anyone working for critical access hospital (costs of which are paid by the government) is going to like big government. It literally sustains you. Your bias is exactly opposite to mine. Investing in primary care IS the answer because it avoids other higher expenses in the long run. Allan already handled the market competition issue below quite well. I’m not sure age is an issue, but I am likely younger than you are. I agree with Allan that you sound angry and glib in your comments; the election is over. Accept it and move on. No one is going to run around closing CAH’s, those are necessary to healthcare infrastructure in this country.
“Encourage competition among insurance companies? How old are you? Do you have any idea how naive this is? They don’t want to compete, they want to make money.”
I’m sure Niran can answer this herself better than I, but when I read this I wondered how much you understood about the marketplace.
In a competitive environment if insurers aren’t competitive they don’t make money. If cost is an issue then insurers competing with one another will attempt to underprice one another. It may not be their choice to compete, but in a competitive market they either compete or die. Competition causes prices to fall towards their marginal levels.
I would make a few other comments, but based upon the time and your glib statements I don’t think it is worth it. This example should be sufficient enought to note the errors in your logic and understanding..
Sorry. You have Trump. You don’t get to have anything you put on your list. What you will get is some effort to allow sales of insurance across state lines. This is already allowed. In the 6 states that have passed laws encouraging sales across state lines, no insurance companies have come to participate. If you are really a doctor, and if you have ever really run a practice, you should understand why. Next, you will get block grants for Medicaid, which will really just be cuts in Medicaid money, then giving it to the state. You will also get HSAs, great for people who make lots of money. Not os great for those who don’t.
As to your list, a few ideas are good. Invest in primary care? Who is going to do that? Not the insurance companies. Again, if you really are a doctor you know that already. Guess that leaves the government, but then you don’t seem to want govt involvement. How is this going to work?
Encourage competition among insurance companies? How old are you? Do you have any idea how naive this is? They don’t want to compete, they want to make money.
#2 is fine. However, at some point someone is going to ask you to prove that what you are doing actually works. Better figure out how to measure what you do. If I were in charge I would drop requirements that you use EHRs, just require that you show what you are doing is effective and leave it up to you to figure out how to do that.
#5 Good. Also, please show us that this results in better outcomes for your patients.
#6. True, especially when buying non-health care related goods. When it comes to health care, this has been shown to stop people from getting drugs they should take and screening they should have. Read up on Value based insurance. We should probably be making some stuff free, some stuff really cheap and other stuff expensive.
#7-Good idea.
#3- Not sure where you are going here. I assume you know that Medicare administration costs less than that for private insurance. (Dont bother bringing up the Avik Roy nonsense. Anyone smart enough to get an MD can figure out why he is wrong.) If you are saying Medicare has too much say in what we do, I guess I get this, but need to be more specific.
BTW, I work at a 25 bed critical access hospital in the hinterlands as well as a level one trauma center. What is your plan to pay for healthcare for those poor in rural areas, especially since poverty is mor common in rural areas?
There are so many rules and regulations out there that I will bet all or almost all have done something that could be cosidered criminal in their lifetimes. I don’t know of many promotors and builders that havensn’t been investigated. They too frequently have to deal with government officials frequently Democratic so one should expect to be investigated hanging out with those types. Trump actually hung out with Hillary and that scares me because she is the quintessential crook along with being a treasoness liar.
By the way I read some of your 560 and I am sure there are a few that might have been true, but I saw a whole bunch of mistatements from the trash you seem to indulge in. We can throw mud at each of the candidates, but at the end of the day the candidate most likely needing pardoning and likely will be pardoned is Hillary Clinton. If she is pardoned I expect a lot of others to be pardoned as well leaving all the lower level Clintonites available for prosecution. If this is done as I predict ask yourself why so many had to be pardoned.
Bobby- while I was born during the time Nixon was being pardoned, (so not all that knowledgeable) I wholeheartedly agree with the rest of your post after that. In this case, we do not have consequences yet, only perceived ones. Let’s relax and see what happens.
Who’s, the exchanges? How much did subsidies go up to compensate?
I find it puzzling (but not really) that those speaking the loudest against Obamacare are the ones who don’t have it, need it, and don’t buy through it. This fight is not about what coverage we all need and can afford, but what ideology of failure the right wants.
They went up, 1. because premiums were set too low ( optimistic blunder) to reflect that the buy-in enforcement for young/healthy’s would actually work.
2. Because the Obamacare risk group was a group by itself with nothing to blunt the never-could-afford-insurance-before sick group who needed it and still do – I’m betting a lot in those remote, underserved rural regions you say you care so much about.
“How is this any different than 2000?”
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THIS is how it differs, in terms of consequences:
https://medium.com/@BobbyGvegas/i-alone-can-solve-8a4b5fe1ff47#.go3fweru9
How is this any different than 2000? I lived with the disappointment my guy lost when “really” he won. Maybe you would prefer “not enough people spoke outside of California and New York for her.” Any way you slice it, this is the result. The electoral college allowed Penn, MI, Ohio, and WI decide this election. Insurance premiums went up by 30% in Penn, maybe that had something to do with his victory? It would be very interesting to superimpose the map of insurance premium increases, over the surprising states that turned red after years of blue. I haven’t seen that yet, but would find it fascinating. Regardless, it is time to move forward looking at the glass half full. That is how life works.
The primary care system was arguably less broken than before MU and EHR mandates. We CAN go back to the paper system and fee for service, but maybe that is not where the country is headed. Paper is cheap, efficient, and very effective. Getting a 10 page note for an ear infection seen elsewhere with a bunch of junk on it is not as helpful as my 20 line dictation diagnosing the same thing. In 10 seconds or less, I can glance and see what the exam findings were and what medication was used. That is real efficiency. Fee for service is like anything else, a specific payment for a service rendered. The reason it became uncontrollable is due to third party payers “paying” for everything. Why are massages, acupuncture, and other non life-saving treatments covered by third party payers now? When a consumer is not paying directly for that service, it encourages wasteful spending. Why be careful when “it is covered” anyway? I will try to go point by point.
1) you do not need EHR for population health. You WANT it for this purpose. People get flu shots the same way they have for the last 25 years. In addition, the insurance companies call my patients directly and remind them. Third party payers have databases and should use them plus hire the extra staff to do the legwork.
2) The system is “wasteful” because we do not have enough care continuity. This is one of the largest issues we have. When patients only see me for a decade, very few tests are duplicated. Also, once you have trained your patient or parent, they utilize fewer services because they know its ok to stay home on Sunday night when their child has a fever. It is a partnership between me and my patient. Receiving one on one care from ONE person with an occasional specialist thrown in here or there empowers consumers to be comfortable making these decisions. CONTINUITY will decrease spending considerably.
3) When one has Continuity, the physician already knows the patients meds, allergies, conditions at the point of care. In the elderly, the physicians involved could coordinate like they always did, fax a dictation on 1 page and it gets added to the chart. Better yet, give the patient a memory stick and have them print it out and hand it to their primary care doc directly. Now maybe some physicians actually love their EMR systems. Fine, they can keep them. Eliminate the mandate for EMR’s for all of us. Add documentation flexibility.
4) As far as access, this could be handled many ways. Yes, someone can print out your note and had it to you. It could be put on your “device” within a few days after being seen. When I send a patient to a specialist, I have them take a picture of the dictation note that is most important for that appointment. Recently, we could not get digital xrays transferred to the ortho appointment. I had the mother take a picture on her cell phone of both views. While it is a bit rudimentary, it was effective and helpful for the specialist.
Although I have written some rebuttal to your points, we really want the same things. We just look at the solution differently. I do not know one physician who really enjoys working with electronic records. It is a pain in the neck. Physicians are supposed to look and talk to patients, not be typing on a computer. It goes against everything we were trained to do and believe. For some reason, physicians keep going along with the changes as if we have no choice. My soapbox is that we do have a choice. While you might not agree how important continuity is, mull over it for a while. It is the way to solve many of our care quality and cost problems.
I am asking for ‘flexibility’ in the documentation methods for physicians and dropping the mandate. Larger conglomerate institutions can afford expensive technology. I cannot. Why close my small clinic down, when it provides a significant contribution to the community by keeping children safe and healthy?
As far as “the people have spoken”, (which seems to bother you)
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Only because it’s BS. ~25% of voters “have spoken” for Trump. Moreover, Clinton’s popular vote plurality continues to grow, and is now reported at about 1.8 million more aggregate votes than The Donald’s. So, it seems that of those who bothered to “speak” at the ballot box, Trump was not their first choice. That he was nonetheless elected owes to structural Constitutional mechanics more than national popular will.
The only mandate I mentioned was the misguided EHR requirement. I do not think there has been a mandate for the Republicans since 1984 when I was 10. I remember the entire country was almost completely red. In my mind, a true mandate would be considerably different than the results we saw Tuesday night. As far as “the people have spoken”, (which seems to bother you), those people who showed up and voted have chosen a new leader in accordance with the representative democracy in which we live. Neither you or I can do very much about that. We need to embrace change and move forward.
Allan, yes early on I thought I might be in trouble for writing this article, but figured I would ride it out and stick to the central point, which is the world is not going to end. Moving to Canada does not solve the American Healthcare problem. It is time to roll up our sleeves, get to work, and innovate. I suspect there will be some “outside the box” ideas coming down the pipeline.
You know, both of those are intriguing ideas. Tricare Standard works that way with indemnity method if the provider is out of network. Patients just bring in the check and sign it over. It is effective and the consumer understands what “they are spending” so to speak. Anything that encourages ownership of individual health and wellness is a good thing for healthcare overall. Medi-buck type vouchers also helps quantify things more accurately for the consumer. Right now, some Medicaid families tend to over utilize because it is no cost to them. ie, they can email me at night, I will tell them to walk in the next morning at 9am and they still go to the ER for a simple immunization reaction. Patients paying out of pocket are less likely to do these sorts of things. Thank you for reading.
Thanks, Niran, for your thoughtful piece.
I keep thinking that the root cause of all our problems is third party payors.
These cause all of us to believe we are dealing with Santa.
As far as I can see the only ways to get around this problem is to have either have indemnity-type insurance* or to subsidize with Medi-Buck type vouchers.
*Claims money is paid to the patient first and he/she reimburses the provider.
As usual Allan you look at this with Republican blinders. Trump is being investigated for fraud and has a history of being named in federal lawsuits.
What would you say if a Democrat had said half the things Trump said during the campaign?
560 false things Trump said during the campaign.
https://www.thestar.com/news/world/uselection/2016/11/04/donald-trump-the-unauthorized-database-of-false-things.html
Trumpland: Where hate and ignorance is popular again.