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.
Categories: Uncategorized
8:53 am July 29, 2010
MEDICARE FRAUD, MEDICADE FRAUD, AND KICKBACKS AND BRIBES BUSINESS AS USUAL,INSIDER INFORMATION GIVEN. 9B BS ONE THING BUT WHAT ABOUT YOUR “HANDS OFF POLICY” BY THE DOJ AND CMS AND HHS, AND WHY NO INVESTAGATIONS OR AUDITS TO CONFIRM AND HELP?
WHAT ABOUT “TAXPAYERS TO PREVENT AND STOP FRAUD INTEREST FOR MEDICARE AND MEDICADE” WHAT ABOUT WILLIS AND WILKINS BEING FIRED FOR NOT WANTING TO BREAK THE HEALTH FRAUD LAWS?
NJ CEPA CLAIM FILED……..FALSE CLAIM DECISION UNDER APPEAL AND FILED….. WHERE IS ANY HELP FROM YOUR DEPARTMENT?
The U.S. District Court for the District of New Jersey dismissed May 13 a qui tam action alleging violations of the False Claims Act (FCA) by United Health Group and its subsidiaries. According to the court, the complaint failed to state a claim upon which relief could be granted under the FCA. Relator Charles Wilkins began employment with United Health Group and its subsidiary AmeriChoice in October 2007 as a sales representative. Relator Darryl Willis began employment with United Health Group and AmeriChoice in 2007 as the general manager for Medicare/Medicaid marketing and sales.
In their qui tam complaint, relators allege 11 violations of Medicare and Medicaid regulations. The United States declined to intervene in the case and the relators filed an amended complaint that stated one federal count—violation of 31 U.S.C. § 3729(a)(1)-(3)—and nine state law counts. United Health moved to dismiss under Fed. R. Civ. P. 12(b)(6), arguing relators failed to plead the elements of a “false certification” claim, they failed to plead any anti-kickback violations, and failed to adequately plead a conspiracy. Relators alleged that because United Health entered into a contract expressly certifying that it agreed with all “terms and conditions of payment,” they made a false claim when they submitted claims despite any one of the 11 purported regulatory violations alleged in the amended complaint. Rejecting relators’ express false certification claim, the court found “[not once in the Amended Complaint have Relators identified even a single claim for payment to the Government.”The court also held relators’ implied false certification claim failed. According to the court, relators argued that because United Health agreed to comply with all CMS regulations when it contracted to become a prescription drug plan sponsor, and because at times it was in violation of some regulations, it therefore committed fraud each time it submitted a claim for payment. The court found such a theory of liability overly broad. “If Relators’ theory were correct, the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,” the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government’s payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and [t]hey have not done so.” Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).
FCA claim alleging aggressive marketing tactics by health plan provider dismissed
Publication: Health Law Week
Date: Friday, June 4 2010
The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans — including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.
The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator’s false certification claim. The relators’ theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants’ motion to dismiss was granted.
Source: Health Law Week, 06/04/2010
Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement.
Chicken Gate Returns
The 101 Dumbest Moments In Business 2003 EDITION Whiffed pitch No. 6: blatant stereotyping. By Mark Athitakis April 1, 2003 (Business 2.0)– GRAND PRIZE WINNER, DUMBEST MOMENT OF 2002 Which leads to the question, Who is Chicken Man? & Why were whole fried chickens selected?
In September, insurance company AmeriChoice brings trucks to blighted neighborhoods in New York City and gives away coupons for “free chickens” as an incentive for the underprivileged to switch their Medicare coverage. New York state senator Carl Kruger files a complaint with the state attorney general. The 101 Dumbest Moments In Business 2003 EDITION – April 1, 2003 Apr 1, 2003 … Just don’t tell him about the “Chinese health balls.” ….. In September, insurance company AmeriChoice brings trucks to blighted … New York state senator Carl Kruger files a complaint with the state attorney general….. Falling on his sword, Welch announces he’ll give up most of the perks,…2009 and 2010 $120,000 from your tax dollars.
Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools. These checks came from AmeriChoice Health and on the surface seems like fine gifts. Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind in order to promote its share or induce its share of the market place. This is not allowed as a use of your taxpayers dollars, yet it happens.What does it really cost the City of Philadelphia to receive this money? Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that? PS… Did the Mayor send for Chicken Man or was he approached by Chicken Man? The Mystery Widens! Can Chicken Man save the Liabraries?
CEO of AmeriChoice Health Bolts.. Was that Chicken Man? John J. Kirchner – Director, Operations John Kirchner joined Healthfirst in May 2010 with over 25 years experience in health care management. Mr. Kirchner’s background includes responsibility for health plan P&L, strategic planning and operations, and government and regulatory affairs. Mr. Kirchner will be responsible for supporting all aspects of NJ health plan operations. Prior to joining Healthfirst, Mr. Kirchner held a variety of positions at AmeriChoice of New Jersey serving as President from 2007 through 2009.
Will this mystery man or woman or chicken ever be caught? Will the “secret eggs” given out to housing authority officers Clinics, Doctors and whoever, make it into through that crispy crust prepared by their Home Office Line Chefs?. Will the Doctors who collected all those extra eggs for sharing thier patients recipes with the Home Office Line Chefs ever really be rewarded? Will the Great Head Chef Chicken Man or whomever that directed and approved all to avoid, overlook the rules, laws and regulations Menu, ever be really compensated for their true worth or will Salmonella remain the dish served for Medicare and Mediciad Industry.
PS Is the Chicken Man a Blues Brothers Wanna B??? HEALTH INSURANCE COMPANY PROFITS IN 2007:A Whole lot Of Chicken
UnitedHealth Group — $ 4.654 BILLION. UnitedHealth Group owns Oxford, PacifiCare, IBA, AmeriChoice, Evercare, Ovations, MAMSI and Ingenix, a healthcare data company ans a lot of others.
By Wayne Barrett Tuesday, Jul 3 2001
Most of Bill Thompson’s “financial consulting” clients are not revealed on his Board of Ed disclosure forms. The most disturbing one that Thompson did list, however, was Managed Healthcare Systems Inc., where he earned a total of $65,000 in 1997 and 1998, according to his tax returns. A black-owned HMO whose principals worked at the highest levels of the Reagan administration, the company is shrouded in scandal.
Last year, New York Attorney General Eliot Spitzer forced the MHS, which specializes in recruiting Medicaid recipients for its HMO, to repay the state $2 million for Medicaid services that patients never received. Spitzer also put Jean Moise Millien, the director of an MHS clinic, in jail for up to three years after he pled guilty to stealing $275,000 from Medicaid. Spitzer’s press release revealed that MHS knew for years that Millien’s clinic, Stuyvesant Heights Medical Group, was largely run by “unsupervised physician’s assistants and nurse practitioners” and that patients “were consistently complaining that they were having difficulty getting services.”
Yet, said Spitzer, the company “failed to take corrective action or properly oversee its subcontractor.” MHS portrayed itself as “a victim” of the clinic when they settled with Spitzer.
The State Health Department also revoked Millien’s physician’s assistant license in November 2000, finding that he’d run the clinic since 1991—four years before the MHS contract began—without on-site supervision by a licensed M.D. The Department also found that the clinic corporation had been dissolved by state officials for tax delinquency reasons in 1994 and that Millien had a prior criminal record. Spitzer said a doctor from Pennsylvania came to the clinic once a week “to sign charts” for a while, but “eventually stopped coming altogether.”
An MHS affiliate left a similar trail of complaints in Pennsylvania—where it became the subject of Philadelphia Inquirerexposés in 1996 and 1997, before and during Thompson’s employment. According to one study, it was three times as likely to refuse to pay for days of hospital care as the state’s next most stingy HMO. The “focus of six special state and federal audits” and a onetime target of a Pennsylvania grand jury, according to the Inquirer,the company took a reported $119 million in profits and executive bonuses from its Pennsylvania Medicaid work alone in the early ’90s, making it the “most profitable HMO” in the state.
Anthony Welters, the principal owner of AmeriChoice, the Virginia-based parent of MHS, was a top Reagan transportation official, gave $20,000 to Pennsylvania GOP governor Tom Ridge, and has given over $56,000 in recent years to Republican candidates and committees across the country. Clarence Thomas is the godfather of one of his children. Thelma Duggin, another top executive, worked in the Reagan White House and at the Republican National Committee under Lee Atwater, the engineer of the Willie Horton campaign.
Thompson said he’d known Welters and Duggin since 1992, when they started trying to do business in Brooklyn, and that he “bumped into Tony” in 1997 and Welters offered him a consulting job that started that June. Charged with “reaching out and helping them obtain business,” Thompson said he “spoke to community organizations.” Though he says he “never visited an MHS clinic”—including the Stuyvesant Heights one near his home—he insists that MHS is “a good company.” While Thompson’s tax returns indicate that AmeriChoice paid him $35,000 in 1998, his disclosure forms report no income from the company.
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.
The health insurance companies have played a major role in our current healthcare crisis. These companies make huge profits and their CEOs make millions, while the rest of us, workers and employers alike, face skyrocketing healthcare costs, impossible bureaucracy, and life-threatening insurance denials.
THE FACTS: HEALTH INSURANCE COMPANY PROFITS IN 2007:
1. UnitedHealth Group — $ 4.654 BILLION. UnitedHealth Group owns Oxford, PacifiCare, IBA, AmeriChoice, Evercare, Ovations, MAMSI and Ingenix, a healthcare data company
2. WellPoint — $ 3.345 BILLION. Wellpoint owns BLUES across the US, including Anthem Blue Cross Blue Shield, Blue Cross Blue Shield of Georgia, Blue Cross Blue Shield of Wisconsin, Empire HealthChoice Assurance, Healthy Alliance, and many others
3. Aetna Inc. — $ 1.831 BILLION
4. CIGNA Corp — $ 1.115 BILLION
5. Humana Inc. — $ 834 million
6. Coventry Health Care — $626 million. Coventry owns Altius, Carelink, Group Health Plan, HealthAmerica, OmniCare, WellPath, others
7. Health Net — $ 194 million
The huge insurance company profits—BILLIONS EACH YEAR—could be used to provide quality healthcare for millions of people. We need to get the insurance companies OUT of healthcare, so patients can receive the care they need and physicians can be paid adequately for their work.
The only way that we all will have affordable, quality care is to get the insurance companies OUT of healthcare! We can no longer tolerate a healthcare system where those without medical expertise or genuine interest in our patients’ health have absolute control, and where profits are made by denying care.
FOR MORE INFORMATION, SEE: http://www.insurancecompanyrules.org/learn_more/the_roster/
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?
This is a good discussion. It would be of value to think of yourselves not as physicians, but as consumers of health care. Being too much on the other side blinds. Consumer demand has guided much, always will. Indeed was it not consumer demand for freedom that guided the colonies to form a union?
So…where will you go, what will you do when you are sick, want answers? To seargeant XYZ in the army of Family Docs? Unlikely. If you could remove one obstacle, it is surely known where you would go. Remove the overcrowding..and a bit of the chaos..and you would go to the ED (ER). There you will have an answer for what affects you (no pneumonia, no pulm embolus, no acute mi, no cva, etc) in short order. We as physicians need to wake up. We are now a technologically intensive service sector, and it behooves us to augment the place we already have — where services and technologies are provided at one site, and (relatively) efficiently (compared to the rest of the system). Emergency Departments are diagnostic centers that cut time out of the process of discovering etiologies, and starting treatment. Instead of imagining something that cannot be in our lifetimes…how about…..unclogging the EDs by removing the back end hold ups, preferential treatment of elective surgeries, etc. Then make these currently available centers of a large portion of care, the center of more care….from which appropriate referrals can be made.
Thanks Dr. Uyemura for your assessment of the broken health care system. We definitely to increase our focus on recruiting more primary care physicians who can go out and take ofto care for hardworking Americans- where the syringe meets the skin so to speak. But I must say, however, that I disagree with you on the minutiae with regards to several of your other points. Reform that works will require facets of every subjectthe topics you touched on. Although you make excellent points about the difficulties in each arena, the fact remains that change will come in all of them. I invite you, Dr. Uyemura, and anyone else interested in having a voice during this historic moment to visit http://www.fairmanagedcare.org and sign up to become a member. We are an emerging national grassroots movement focused on changing the debate about health care costs and holding managed care companies responsible for their behavior.
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.
I am a marriage & family therapist. I am the owner of a small group practice. Just two or three comments from a mental health practitioner’s point of view.
I prefer to collaborate with primary care physicians versus psychiatrists (specialists). My experience with primary care docs is that they take time to talk with the patients and seem to have better bedside manner in general than psychiatrists, as strange as that may sound. I have heard that 70% of anti-depression prescriptions are written by primary care physicians.
There is evidence in my field that what helps the patient most is the resources the patient brings into the office (eg. hope, faith, family etc.) followed by the “doctor-patient relationship”. These two things count for far more than, technology, expert knowledge or technique. The “doctor” that best knows how to use these two things will help the most people, in my business. I imagine there is a lot of crossover.
I like the common sense approach of Dr. Uyemura. Some of the best interventions come from a minimalist perspective.
Thanks for the breath of fresh air; being on the front lines daily with patients speaks volumes for the need of an army of primary care docs in all sectors- public, private from all walks of life. There is a critical shortage.
We also need to focus on health- and prevention of illness- if we are ever going to be able to keep the U.S Health Care Titanic from sinking.
This shift will take every one of us outside our comfort zones but will be the life preserver that this health care system needs.
All the fancy technology will mean nothing when Medicare costs deplete our Social Security reserves and truly bankrupt our nation.
I’m all for technology, efficiency and sound electronic records, but this is all “icing on the cake”; let’s regroup and get back to basics. Primary care needs to play a crucial role in this process of integratng wellness, prevention and early intervention.
Thanks for listening.
Surveys by leftest organizations campaigning for “reform” are propganda not facts. We are not going to reform our healthcare system based on propoganda. We already elected a President based on sound bites and look at the joke that has already turned into.
Surveys are for highschool girls questioning their popularity or determining what you want for dinner. Red America can afford our healthcare system, what we can’t afford is the boondoggle blue america has turned their systems into. It appears Utah’s cost is already on par with the rest of the world, why do they need to change anything? Maybe MA and NY should be looking to UT for advice instead of Europe?
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”
need to work with us Peter, what are you trying to say? You link to NCHC.org but don’t say why. To support my point take a gander at;
http://www.statehealthfacts.org/comparetable.jsp?ind=271&cat=5&sub=67&yr=61&typ=4
Employer Based Health Premiums / Family coverage
Rank/Employee Contribution/Employer Contribution/Total
50 Nevada $2,144 $7,602 $9,746
43 Iowa $2,638 $7,913 $10,550
5 Massachusetts $3,073 $9,218 $12,290
Now lets look at Health Spending
1 Utah $3,972
2 Arizona $4,103
3 Idaho $4,444
4 New Mexico $4,471
5 Nevada $4,569
48 New York $6,535
49 Maine $6,540
50 Massachusetts $6,683
51 District of Columbia $8,295
Notice any trends? Seems states ran by Liberals have a crisis of cost and spending, the rest of us have a crisis of you trying to get us to pay for your failures.
“The answer will determine how many doctors have not been looking for information that wasn’t immediately available. I hope for the sake of the reputation of our profession that it doesn’t help too drastically.”
I hope for the sake of patients that it helps dramatically.
Having said that I recognize that at the individual physcian level the efficacy of the EMR/technology may seem limited. But within the context of systems of care I can’t believe, nor does the evidence support, the notion that it is ineffective. Quite the opposite. I’m sure you take good care of your patients. I’m sure that 100% of physicians graduated in the top 10% of their class. I’m sure that the reasons our health outcomes (on factors amenable to health care interventions) are so pathetic is because every other physician practices exactly the same way you do.
I don’t mean that to sound insulting. I’m just trying to make the point that we have to move beyond looking at health care as simply the interaction between one doctor and one patient repeated over and over.
“Is this the type of system you want?”
http://www.washingtonpost.com/wp-dyn/content/article/2006/06/14/AR2006061402166.html
http://www.newsweek.com/id/33435
“We” are not hurting, YOU are hurting, go to Iowa and the Midwest and the South, we don’t spend $12,000 a year for family coverage.”
http://www.nchc.org/facts/cost.shtml
From the above article: “A survey of Iowa consumers found that in order to cope with rising health insurance costs, 86 percent said they had cut back on how much they could save, and 44 percent said that they have cut back on food and heating expenses.”
And this from Iowa: http://www.iowaforhealthcare.org/press-releases/2007/12/12/health-care-costs-threaten-iowa-farm-and-ranch-families.html
And this for Iowa:
http://www.familiesusa.org/resources/newsroom/press-releases/2008-press-releases/health-care-premiums-rose-39.html
“and we know now the government forcing banks to make loans to people with poor credit was the wrong policy,”
http://www.slate.com/id/2204583/pagenum/all/
“I admit, exempting primary care physicians from malpractice suit sounds a little more ridiculous”
It’s not a ridiculous concept at all, there are ridiculous ways you can achieve it though. Just carte blanch exempting them would be silly but a logical solution would be to clarify the legal expectations of primary care doctors, this should be done for all doctors. Right now a large number of malpractice suits are based on the outcome not the treatment. A Doctor can do everything right, still have a bad outcome and get sued.
It should be codified that if a doctor follows and documents acceptable treatment plans they can not be sued.
This could be the catalyst for implementing and funding EMR. If a doctor can save 10K per year on their malpractice insurance that frees up the money for them to purchase EMR software. Insurers would offer the substantial discount to any provider utilizing EMR to document compliance with the new malpractice immunity laws.
Granted it doesn’t satisfy progressives’ desire to spend billions of tax payors dollars but it does reduce insurance company income so they should like that. I would also trust the purchasing decisions of physicians actually using the software to determine who prevails in the EMR market then politicians picking the winners of the sweepstake.
If we want providers to embrace EMR it needs to benefit them not be regulated on them, they have proven very adept the past 3 decades at finding loop holes when they don’t like something. Instead of spending billions fighting them make it to their advantage to get on board.
I need to clarify. Technology, EMR, quality improvement and evidence based medicine are not bad. They are progress with pro’s and cons. Granted I emphasized the disadvantages in my discussion to make the point that these are myths as far as healthcare reform. Healthcare reform must transform our system into a primary care dominant system.
I don’t doubt EMR is more efficient. In fact our hospital has purchased a system and we are in transition. To say that it will result in upcoding is not offensive to our profession. My partners and I, I believe code lower than we are allowed by the complex billing system. I believe as a whole we will charge more 99214’s with EMR. It is actually a vote of confidence to our profession when I say EMR will not improve significantly the quality of care, because despite our “archaic” record system I believe the majority of physicians try to do what’s best for their patients and if health information is not immediately available, they take the time to find it. I know some don’t. The argument will be how much EMR improves quality. The answer will determine how many doctors have not been looking for information that wasn’t immediately available. I hope for the sake of the reputation of our profession that it doesn’t help too drastically. No doubt EMR and health IT will make things easier for doctors once they figure out how to use it, but is it money well spent? You could buy every doctor a Mercedes Benz to drive to work, but would we show up to work earlier?
I admit, exempting primary care physicians from malpractice suit sounds a little more ridiculous than the concept of giving loan forgiveness to doctors going into underserved areas. (Our nation is underserved in primary care) But as we are borrowing from my children to spend billions for health IT, that was the cheapest way I could think of to move towards a primary care based system. As a rural family physician, I feel strongly what is NOT healthcare reform, but I’m willing to concede others may have a better way to make us primary care based.
The biggest point I must clarify. I do not advocate physicians abandon quality improvement. In everything, life, medicine we must continue to try and improve. It is time to retire when a doctor no longer wants to improve. I am opposed to a barage of government mandated quality improvement initiatives, and maybe it’s because I think I know better what needs improving than the government, and that is open for debate. However I am positive, it will not solve our healthcare crisis.
Monte Uyemura, MD
Nate,
I am not sure whether I understand you correctly. Are you really comparing admin. cost for medicare with private insurance based on total abolute admin. cost per enrolled individual, instead of administrative costs per volume of care/HC dollars spent? (And BTW, where is this 10% MC fraud rate coming from, I’d be interested if that is a real number/official estimate?).
And if you have to rely on anecdotes to support your arguments, don’t you realize that this does not contribute to a meaningful discussion that you say you support? Or do you want for example this
http://www.newser.com/archive-us-news/1N1-121F0DDCD841CEF0/video-shows-woman-dying-on-brooklyn-hospital-floor.html
for an answer?
Peter you just don’t grasp facts or choose to ignore them, either way debate with you is fruitless.
You link to Maggie, who has no understanding of insurance, to support your case that Medicare is not less efficient then the left believes? She has as many factual errors in her writing as you do and is just as unlikely to admit to them no matter how clear the proof.
What she fails to mention in her first couple paragraphs is the enrollment in HMOs during the period profits increased. It is highly dishonest to discuss profits in absolute dollars in a fluctuating market. It’s like crying about oil company profits when the market doubles in size, apparently liberals expect an insurance company to make $X no matter if they have 1 million members or 10 million members. Comparing one year to another is also hazardous as trends take a couple years to develop, a change in accounting or regulatory reserves could skew one years numbers pretty bad. Carriers also go through soft markets where they lose billions in fierce pricing battles, you can’t ignore those periods and only look at hard market times then complain about the profit.
Maggie’s article, like most of her writing, is full of guesses and insinuations from someone with no experience in the business. It doesn’t cost 5% to enrollee people, Medicare has a documented fraud rate, from GOA and CMS studies, around 10% compared to 2-3% in private insurance. These are all facts that she never bothers to learn, she just makes up beliefs based on what she is trying to sell.
Liberals claim private insurance spend 20% of their premium on overhead, this is over stated but even using your numbers 20% of $3500 is $700 a year for overhead, this includes state premium tax and compliance with federal and state laws.
Medicare spends around 5-6% when you include CMS and congressional expenses used to manage it, at an average cost of $6600 that is $396. Your also getting a fraction of the benefits, you didn’t have Rx till 2006 and you still don’t have dental and vision. Medicare also has its problems with Fraud and abuse, 10% of $6600 is $660. $660 plus $396 is $1056. Where’s the improvement Peter? Why should we pay $356 more per enrollee per year?
For facts about Medicare cost instead of Maggieisms read INSIDE THE BLACK BOX OF ADMINISTRATIVE COSTS by Kenneth E. Thorpe
And
Medicare’s Hidden Administrative Costs:
A Comparison of Medicare and the Private Sector
(Based in Part on a Technical Paper by Mark Litow of Milliman, Inc.)
Take another 10 minutes and read the 2007 and 2008 HSS PERM results if you doubt the fraud and abuse problem.
“um, then how does every single-pay country provide healthcare at about 1/2 our cost?”
Rationing! Lower provider reimbursement and lower consumption.
Is this the type of system you want?; http://news.yahoo.com/s/ap/20090204/ap_on_re_as/as_japan_medical_care_denied
“TOKYO – A 69-year-old Japanese man injured in a traffic accident died after paramedics spent more than an hour negotiating with 14 hospitals before one admitted him, a fire department official said Wednesday. The man, whose bicycle collided with a motorcycle in the western city of Itami, waited at the scene in an ambulance because the hospitals said they could not accept him, citing a lack of specialists, equipment, beds and staff, according to Mitsuhisa Ikemoto.” It was the latest in a string of recent cases in Japan in which patients were denied treatment, underscoring the country’s health care woes that include a shortage of doctors. More than 14,000 emergency patients were rejected at least three times by Japanese hospitals before getting treatment in 2007, according to the latest government survey. In the worst case, a woman in her 70s with a breathing problem was rejected 49 times in Tokyo.
If we rejected people at the ER our cost would be lower to, dead patients consume very little care, except in Medicare where dead patients and doctors still mange to stay busy somehow. Further I’m really sick of progressives and liberals comparing “our” system to Europe. We don’t have “our” system we have 50 states, if you where to take out the states ran by liberals “our” system wouldn’t look nearly so bad. It’s MA, NY, and other reformed states that drive our cost. If people with your mentality would stop screwing things up “our” system wouldn’t be so expensive.
“But I’ll give you, we may not be hurting enough yet in healthcare for there to be enough of a push for real reform – but it will come.”
“We” are not hurting, YOU are hurting, go to Iowa and the Midwest and the South, we don’t spend $12,000 a year for family coverage. We control our spending, it’s YOU who has a problem that YOU are trying to solve by getting the rest of us to pay for it. As far as we are concerned MA and NY can take their HC system and shove off, the rest of us will do just fine without you. And save a fortune in the process.
“Nate, not my choice but we now know that was the wrong policy”
And we know now Ted Kennedy’s HMO Act of 1973 was the wrong policy, and we know now the new deal was the wrong policy during the great depression, and we know now the government forcing banks to make loans to people with poor credit was the wrong policy, notice a trend here Peter? It’s almost like politicians have a really long track record of being wrong, they get very wealthy doing it but it almost always screws us. Ted Kennedy alone has a 30 year career being 100% wrong on Healthcare, yet there he is at the front of your train, you suckers just never learn.
“Care to have a poor (black) person living next door to you?”
I have them on 2-3 sides of me thank you, I am surrounded by housing projects. We have a nice mix of brown, black, and white poor out here though, we don’t like to discriminate.
As a former executive in a worker’s compensation managed care system, I have a few thoughts regarding US health care and solutions to the problems of rising costs and limiting health care. When we created the new managed care system, we tried to create an alliance between providers, payers, and patients. We were committed to a non-adversarial system with the belief that we could improve patient care while lowering costs. The results were anticipated but non the less somewhat surprising, an overall reduction in medical costs ranging between 35 and 50 percent net, after subtraction of management costs.
I have tried to provide a brief synopsis of the system below. I see no reason why the system described wouldn’t scale up.
The 10 simple rules for a Successful Health Care System
1. There are three parties in health care systems: patients, providers, and payers. They must all be satisfied with their roles and the benefits if a system is to work effectively. When they are not satisfied, it creates friction and that costs money.
2. Doctors and health care providers are the providers of care and all those in good standing should be invited to join the system. They are the final arbiters of care should be making all decisions regarding the care of their patients. They should not require prior approval from anyone except their patients.
3. In order to participate in the system, health care providers must agree to follow a simple set of universal treatment guidelines. A prime example is, “Be sparing in the use of tests and studies unless indicated by clinical findings.” Providers who fail to follow the guidelines are removed from the system.
4. Doctors and providers must be paid promptly and fairly for their services. All medical reports and bills are submitted electronically to care coordinators.
5. All patients have a right to appropriate health care. But most patients lack the knowledge to effectively manage their own care. A rational system requires care coordination and management to ensure that patient care follows the agreed upon guidelines and is appropriate.
6. Care coordinators are independent of providers and payers. They are, however, responsible to each party. Their primary responsibility is to see that patients receive appropriate care; their secondary responsibilities are to the providers and payers. Providers should be paid promptly for all services rendered and payer’s money should not be wasted.
7. Care coordinators manage care through computer programs that evaluate care against the universal guidelines and medical bills against agreements. Provider failure to follow guidelines initiates a discussion with the care coordinators who will try to resolve differences. Medical bills are automatically adjusted.
8. When necessary, care coordinators discuss care with patients.
9. Payers must promptly pay all medical bills submitted by the care coordinators.
10. Any personal injury or malpractice claims go to arbitration and are defended by the care coordinators.
This system worked effectively with multiple employers with tens of thousands of employees each. Given the success of this program in reducing costs while increasing the satisfaction of all parties, it should certainly be considered when evaluating new health care initiatives.
“Um, how exactly are you going reward cost cutting without profits?”
Reducing waste creates dollars, those dollars can be distributed in pay raises, bonuses and/or additional services to patients.
“and clearly state as a fact you do not bill correctly, you presently upcode at an obscene level”
Just wondering how this works down to the premium payer? I guess the uninsured are yet screwed again when they don’t have the “investment in technology” to catch it on their bills.
“Then why is Medicare not more efficient?”
https://thehealthcareblog.com/the_health_care_blog/2006/06/policy_why_medi.html
“All government plans lose almost as much to fraud and waste as it cost to administer private plans.”
um, then how does every single-pay country provide healthcare at about 1/2 our cost?
“We tried this, called them HMOs, and the public would not tolerate them and the limits they placed on consumption.”
Well if we assume that is true, that was then, this is now. Seems conspicuous consumption (from debt) has taken a back seat, at least for a while. People (other than Wall Street) are also realizing there is no free lunch and are seeing their healthcare benefits disappear or be reduced, or cost more. But I’ll give you, we may not be hurting enough yet in healthcare for there to be enough of a push for real reform – but it will come.
“You won’t get paid enough to treat anyone but you will get paid something for everyone, what a deal.”
That’s not what I said, and that’s not what is happening in single-pay countries.
“How do you address the larger problem of people getting care that is unnecessary and wasteful?”
Well you certainly don’t reward over utilization with profits as we do now. You create budgets that everyone is forced to adhere to.
“Do you know how much Medicare use to pay for elderly patients getting their nails clipped?”
No I don’t, do you? I’m not sure if foot care can be classified as healthcare? I know with the elderly foot care is very important, especially those with diabetes. But with single-pay non-covered services are defined.
“your great people because you took the poor and moved them all into prison like towers for free or minimal cost to them. The results of 2000 poor people with little to no employment living on top of each other and the resulting crime and drug problems was not foreseeable,”
Nate, not my choice but we now know that was the wrong policy, that came about because no one wanted poor people (especially blacks) living in THEIR neighborhood. So we created black ghettos. We now know what works better (de-segregation) and that is housing the poor in successful neighborhoods. Care to have a poor (black) person living next door to you?
“instead of pretneding we are all so smart we can predict the future?”
Looks like the future is 20% GDP for healthcare if we don’t do something other than pass costs onto premium payers with HDHP plans.
Although I mostly disagree with Dr. Uyemura, I do think that he stresses two or three important points that are often overlooked:
(1) Many in the US (that includes people outsides the HC system and patients, but unfortunately some doctors as well) have unrealistic expectations regarding medical care. A bit more humility would be appropriate re. mankind’s limited medical knowledge – and that includes also our modest amounts of good evidence, as long as one is talking about really solid (class A/RCT) evidence.
But that does not mean at all one should not try to effectively use the limited evidence we have and promote the use of EBM (and thereby I rather end up in Dr. Sucher’s camp).
(2) I also think that Dr. Uyemura is right when he states that medicine is not an exact science, but that the diagnostic process involves complicated, largely unquantifiable judgment calls. He also believes that “an honest mistake” may be part of medical care.
Similarly, that does not mean that we (as physicians) should not try our best in terms of quality improvement (both on the individual and system level).
However, our current legal system focusses on “reasonable care”, which is a highly doubtful concept since there are almost always medical experts that – with the facile backing of retrospect analysis and, often, subspecialty knowledge – testify that any care effort with a bad outcome was not reasonable/substandard. Any doctor who provides a reasonable effort (documenting a reasonable history, exam, analysis and plan) should be protected from being called “negligent”. (It is a different question whether a doctor whose career is riddled with bad judgments is competent … but that would be for the boards to determine, not jury trials.)
(3) With regards to EMR, I do think that they are an unavoidable improvement (in terms of safety/accessibility and in terms of stopping duplicate exams, provided that they are truly interconnected), but I would say that they are marginal for healthcare reform. I have read, on this blog, a lot of unrealistic expectations re. the impact of EHR implemantation.
Simply too much here to digest completely, but certainly well thought out discussion. I will address one point only though..time is short.
The concern that EHR/EMR only supports up-coding and promulgates check-box medicine has some basis in truth with our current reimbursement system and overhead cost crunch..certainly with primary care. As has been stated previously in THCB, in our current E&M/CPT system, the only method for financial growth and sustainability is to see more…translate–>to make sure you code efficiently for shorter visits and do away with longhand notes (ie check-box). As such until preventive care, disease management and procedural/imaging efficiency are used (at least in part) as indicators for reimbursement, then the HIT system may be lost for its true benefits. If however such an approach to care and reimbursement is to be included in reform, then EHR/EMR etc. will be mandatory to assure its success and efficiency. But I would agree that on its own, without a global vision, then it may not be money well spent.
I think a lot of this EMR discord comes from a “us vs them” mentality. The days of the doctor hanging out his/her shingle may be over.
I’d rather that my army of primary care providers, the one I see this afternoon after I call this