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POLICY: The times they are a changin’?

By THOMAS R.LEITH

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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MichelleMarcRickTom LeithBarry Carol Recent comment authors
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Tom Leith
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Tom Leith

> What’s the clerk at Wal-Mart supposed to do? Unionize. 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… Read more »

Rick
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Rick

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… Read more »

Michelle
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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… Read more »

Marc
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“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.”

Barry,
You’ve got one volunteer here!

Rick
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Rick

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… Read more »

Tom Leith
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Tom Leith

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… Read more »

Barry Carol
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Barry Carol

“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… Read more »

Steve Beller, Ph.D
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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… Read more »

jason d
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jason d

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… Read more »

Steve Beller, Ph.D
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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.