Uncategorized

Mythology and Healthcare Reform

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.

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as:

43
Leave a Reply

43 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
27 Comment authors
Complaince?What's ChangedI AGREEMD as HELLK Walsh Recent comment authors
newest oldest most voted
Complaince?
Guest
Complaince?

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… Read more »

What's Changed
Guest
What's Changed

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… Read more »

I AGREE
Guest
I AGREE

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… Read more »

MD as HELL
Guest
MD as HELL

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.

K Walsh
Guest
K Walsh

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… Read more »

KevinM @ medical coders
Guest

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?

Donald
Guest
Donald

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… Read more »

M. Chee
Guest
M. Chee

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.… Read more »

dave
Guest

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.

Lon Marshall
Guest

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… Read more »

Dr Mary Zennett
Guest

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… Read more »

Nate
Guest
Nate

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… Read more »

Peter
Guest
Peter

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”

Nate
Guest
Nate

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… Read more »

twa
Guest
twa

“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… Read more »