POLICY: The times they are a changin’?


I am not quite sure what to make of this. In this past Sunday’s (18-Jun-2006) edition of the St. Louis (my fair city) Post Dispatch on Page 1, above the fold, was a story headlined  Is your doctor paid to keep you healthy? Probably Not.

Typically, physicians get paid only when their patients receive care, and more complex care often brings bigger paychecks. At the same time, doctors complain that paltry payments for office visits force them to rush through checkups instead of educating patients about their illnesses, medications and healthy living – all of which might lower future medical bills.

It’s a system that gives doctors little financial incentive to keep patients well. And, experts say, it might be contributing to dangerous, unnecessary care as well as high medical bills.

So, the writer (Mary Jo Feldstein) has got the problem identified. Good. The rest of the story is about three things:

  1. Medicare Advantage (“like” an HMO)
  2. Disease Management & Care Coordination
  3. Essence, a Medicare Advantage plan owned by a big medical group here in St. Louis

The article speaks glowingly about “better quality at a lower cost”, acknowledges in passing that Medicare Advantage beneficiaries all go to doctors chosen by the plan, but then (get this) does not dwell on the restriction of “choice”. This is uncharacteristic of this newspaper. Wow. Oh, and Maggie Mahar’s book gets yet another plug in the article. I thought she’d like to know that.Then on the front page of today’s (22-Jun-2006) WSJ, above the fold is a story (sub req’d) about how the New York State Medicaid department has discovered Disease Management. In a deal struck between the state and Mount Sinai Hospital, their outpatient clinics were designated “Diagnostic and Treatment Centers” which brought higher Medicaid reimbursements. In return Mount Sinai runs a DM program around CHF, and the state’s total Medicaid payments to Mount Sinai Hospital have fallen. But this is evidently OK with the hospital: they have been running at 95% capacity, and would much rather have a bed filled by (say) a commercially-insured ortho patient than by a Medicaid CHF patient. Evidently things are working as expected. The government of New York State has begun to pay docs to keep patients — OK, they’re not healthy. Healthier. Or at least out of the hospital and more functional.So? With attitudes towards the loss of “choice” changing evidently among patients and (significantly) the press, and with a new apparent willingness to pay doctors and allied pros to think and talk to and teach patients, maybe — just maybe the stage is being set for a resurgence of `70s idealistic Managed Care Organizations. Toss in a handful of transparency, shake it up a bit, let it marinate a few years and it could be we have an environment where the Enthoven Plan doesn’t look so revolutionary. Or scary.

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10 replies »

  1. > What’s the clerk at Wal-Mart supposed to do?
    This has its problems too, of course. But unions could partially de-couple health insurance from employment for people in an “un-reformed” healthcare finance world, it could help identify the best docs & hospitals in any world. In an Enthoven-ish world the need for the former function would be obviated, but the latter would still exist.
    The Wal-Mart clerk could also talk to his neighbor the medical billing clerk and ask for guidance. Or her brother in law the engineer. Or the lawyer at church. There is more to our society than the federal government.
    But I think they ought to unionize.

  2. Michelle, some excellent points, and some great food for thought in what you posted here. But I want to challenge you just a little bit. You cite a lot of valuable experience in your background — clinician, administrator, etc. I have to believe that your experience and wherewithal have much to do with your success. What’s the clerk at Wal-Mart supposed to do? “Get educated” isn’t an answer because if education were either valued by or otherwise expected from such a person, they wouldn’t be a clerk at Wal-Mart in the first place. And there’s more people with modest levels of education than there are people with high levels of education.

  3. I have been in the medical field for many years as a clinician, adminstrator, and at one point, as a hospitalized patient with no health insurance, and let me say, I did much better negotiating on my own than the insurance companies have done.
    If you look at the big picture, doctors cannot unionize and their salaries have decreased by 40% in the past 10 years and will continue to decrease in the years to come. Premiums are increasing, insurance companies are getting more and more into the “deny procedures now and ask questions later” and the pharma companies have bigger pensions than ever (as do the insurance companies). So where is our healthcare going? Well, the “best and the brightest” are not going into medicine anymore. So what should we do as consumers? I recently published a book on how to save money in healthcare called “Healthcare for Less.” This book is based on my experiences and other peoples’ experiences on what really works! Keep in mind that most doctors go into the field because they was to help people and we as consumers need to try to keep the good doctors working and get the bad doctor out! How do we do that? By being more educated consumers. We are a democracy, we have choices, and we need to make sure we are making the right choices in terms of our healthcare. So read the book, if you want to make the right choices in healthcare for yourself, and help that doctor help you! If you don’t believe me, go onto http://www.amazon.com and read the reviews….

  4. “I haven’t noticed consumers volunteering to either give up the tax advantages currently afforded employer provided healthcare or accept systematic rationing of expensive end of life care via QALY metrics.”

    You’ve got one volunteer here!

  5. Barry, you’re a man after my own heart. Our problems may be medical and financial, but those are only the symptoms. It’s a cultural dysfunction that we view healthcare as an infinite resource, when it’s not. And no one wants to hear “no” when they want service, because that’s seen as rationing, particularly with end-of-life issues.
    If that’s not what we all actually believe, it’s at least the way the narrative goes for the media/political/interest-group continuum. So we make only incremental progress on reforms, and the sheer bulk of our economy allows us to carry on for a time with the ultimately unsustainable bad habit of rationing based on the individual’s ability to pay, when we ought to be embracing some system of QALYs, and other ways of saying “no.”
    So how do you change a culture? I couldn’t say, but Matthew has said it before, and he’s right: it’s going to take something catastrophic, and we ain’t there yet. Kinda like a drunk that needs to hit his bottom before he decides to get on the wagon.

  6. Steve Beller writes:
    > I believe there’s a real risk in states without a
    > state-risk pool for the kind of scenario Jason
    > describes. After all, it’s only “good business.”
    Not in any system described by the two articles I have referenced. It’ll probably get you jail time. What “list” Jason thinks somebody will be knocked-off of is a mystery to me. Maybe he’ll come back and tell us in detail how this might work: Medicare Advantage plan categorically refuses to serve eligible beneficiary.
    I think he’s bloviating and ignoring the larger point: at least some patients will tolerate managed care, at least some of the press think better care is a fair trade against total freedom of choice, and at least New York State has discovered the value of having patients spend a little time with a doc or nurse or whomever without being cut, irradiated, probed, or whatever.

  7. “If we’re a compassionate country, then we should be, at bare minimum, demanding universal coverage. If we’re not, then why care about the needs of our neighbors? Just take care of “me and mine” … After all, we could never be in their boat!”
    I’m pretty confident that most people would say that we are a compassionate country, and, of course, there should be universal coverage. The problem is getting from here to there in a real world of finite resources. We clearly cannot afford a blank check approach that would give everything to everyone with no deductibles or co-pays forever. The question then is, how much can we afford to spend on healthcare as a percentage of GDP, and what steps are each of the stakeholder groups prepared to make to reduce costs and improve efficiency throughout the system?
    I have not seen doctors or hospitals embrace either pricing transparency or express a willingness to develop quality and performance metrics that would be useful to patients and infomediaries.
    I haven’t heard trial lawyers express any support for health courts that could reduce the cost of medical litigation and the defensive medicine that accompanies it.
    I haven’t noticed consumers volunteering to either give up the tax advantages currently afforded employer provided healthcare or accept systematic rationing of expensive end of life care via QALY metrics.
    I haven’t noticed much pricing restraint from either Big Pharma or Biotech Pharma in pricing patent protected drugs, especially some of the new cancer drugs coming to market at enormous cost to the system.
    While insurers are starting to take some limited steps toward disclosing what they actually pay doctors, hospitals, labs, imaging centers, etc. for services, tests and procedures, I’m sure they could do a lot more a lot sooner if they really wanted to.
    We can talk about compassion and universal coverage until we’re blue in the face, but until the major stakeholder groups come forward with some meaningful ideas that require some sacrifice from THEM, they have no credibility.
    It’s too bad, because we are likely to move toward a solution born out of crisis after the next Presidential election cycle. When that happens, the interest groups will probably look back and ask why didn’t we get together and resolve this problem sensibly when we had the chance?

  8. From my understanding, in a state like NY (and several others), there’s a state-risk pool, which means people with pre-existing conditions cannot be singled out and given higher premiums. That’s good news for older and sicker folks, but it means the young and healthy have to pay more than in other states.
    Is this a better system? Depends who you ask.
    I believe there’s a real risk in states without a state-risk pool for the kind of scenario Jason describes. After all, it’s only “good business.”
    Where does ethics come into play? Can American Political Capitalism be socially responsible? What about individual responsibility?
    The economic solutions such as HSA and HDHP do not address these thorny issues, and can even make matter worse for certain groups.
    I guess we just have to look at ourselves in the mirror and ask: “What kind of people are we? Are we a country that cares about its citizens, or a bunch of individuals and families that focus on ‘survival of the economically fittest?’
    In other words, we should have started our search for a path to healthcare reform by asking, “What really matters to us as a people?”
    If we’re a compassionate country, then we should be, at bare minimum, demanding universal coverage. If we’re not, then why care about the needs of our neighbors? Just take care of “me and mine” … After all, we could never be in their boat!

  9. The biggest determinant of patient health is not what the doctor does, its the patient’s pre-existing disease status.
    If I was a doctor who operated under the model proposed in the link, this is what I would do:
    1) Have all prospective patients complete a detailed questonnaire about their health status.
    2) Automaticalyl knock off the list anybody who has a chronic condition like diabetes, heart disease, obesity, etc.
    This would allow me to take only healthy patients, and I would make a shitload of money because I wouldnt have to spend any money taking care of them.
    This system would also hugely benefit pediatricians, because in general kids are much healthier than older senior citizens with many chronic ailments.
    Geriatrics would hate this program, because 100% of their patient population consists of older people, most of whom have chronic debilitating illness.

  10. There is hope! Many things are moving the right direction. But we should remain vigilant since all this good stuff is barely scratching the surface of what needs to be done. For example, few complete disease management programs are implemented and they all lack important components. So, while all this recent news is encouraging, it should all be kelp in perspective: Our country has barely begun to take the first few baby steps toward solving the healthcare crisis! And (sadly) those tiny steps are leaps ahead of where we’ve been.