The Price Is Basically Right


Recently, President-Elect Trump selected Rep. Tom Price, MD to lead the Department of Health and Human Services.  Suffice it to say, this signals Mr. Trumps’ resolve and commitment to definitively repealing and replacing.  Dr. Price has already sunk his teeth into health care reform, having proposed alternative healthcare solutions in every Congressional session since 2009.  As a physician myself, I am delighted at the prospect of having another doctor at the helm of HHS. The last physician to lead HHS was Louis Sullivan, MD as part of the administration of George H.W. Bush.  Having a physician, who can understand the needs of physicians and patients, representing both in health policy decision making at the federal level gives everyone the best chance for meaningful and successful health care reform. 

Dr. Price is a third generation physician and a retired orthopedic surgeon with experience in clinical practice and academia before being elected to the U.S. House of Representatives.  At his core, he has been a fierce critic of Obamacare.  Dr. Prices’ most frequent objection to the ACA is the fact it hinders the ability of patients and physicians to be in control of medical decision making and puts the government squarely between doctors and patients.  Amen! He understands the subtle distinction that while expanding coverage may provide insurance, it is in no way akin to delivering patients unfettered access to health care. 

As I fend off increasing government regulations in my quest for survival as an independent physician, Dr. Price (and Seema Verma – Mr. Slavitts’ replacement at CMS) seem like an oasis in the desert.  Below are some basic tenets of the Price Plan, The Empowering Patients First Act. 

  1. Tax credits so individuals may buy insurance on the private market. It starts at $1,200 a year and increases with age, but is not adjusted for income. People on Medicaid, Medicare, and Tricare, could opt to buy private insurance and receive this tax credit.
  2. Expansion of health savings accounts, which allows people to save pre-tax money which can be used to pay for premiums, copayments, and deductibles.
  3. Individuals with existing medical conditions cannot be denied coverage if they had continuous insurance for 18 months before selecting a new policy. This continuous coverage provision incentivizes individuals to purchase insurance while young in the hope of creating a long-term insurance pool, (something Obamacare has been unable to accomplish.)
  4. Federal money would be given to individual States to create high-risk pools. These are government-run health plans for people with existing medical conditions who cannot obtain affordable health insurance on the private market. Price has suggested using $3 billion in funding for high risk pools—which comes to $1 billion a year.  This approach carries some inherent risk because cost predictions may underestimate reality.  Critics say high-risk pools have been tried in as many as 34 states and largely failed because they were routinely underfunded. It is possible the annual cost of high risk pools at closer to $2.5 billion a year. Fine, make sure we fund this adequately this time.
  5. Balance billing could be allowed, which evens the playing field for physicians and patients alike.  It would offset the exorbitant “facility fee” hospitals are allowed and independent offices are forbidden to charge.  Allowing physicians leeway on reimbursement could significantly alter the dismal trend of physicians leaving clinical medicine in droves. 

Dr. Price has criticized “government takeover of healthcare.”  I agree with him wholeheartedly.  His socially conservative stances have angered many; he is pro-life, votes against insurance coverage for women’s health issues, additional funding of CHIP (Children’s Health Insurance Plan), and LGBT issues.  However, the more I struggle to stay afloat in independent practice, the less these differences of opinion actually matter.  Sylvia Burwell and I probably agree on Womens, LGBT, and childrens’ health issues, but my bleeding heart, ironically, has worsened my chance for survival in a career I love.  Reality is what brought this very liberal physician to advocate a different approach to healthcare reform. 

Dr. Price recently stated, “Premiums have gone up, not down. Many Americans lost the health coverage they were told time and time again by the President that they could keep. Choices are fewer.”  He is correct.  Choice for all of us has evaporated from the system in many small rural areas suffering from physician shortages already. Frustration at the overwhelming increases in insurance premiums is palpable everywhere in this country.  Maybe it is time to give Dr. Price and Seema Verma a chance.  There will be many compromises as in all things, but allowing physicians and patients more control over their lives and livelihoods is a revolution worth celebrating. 

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28 replies »

  1. Allan, I agree this is a concern for all of us. Every system will have cracks and those of us will take on the special cases because that is what we do and will continue to do.

  2. Talk about mythology. If you keep pushing/forcing us to use useless technology, we are going to exit and there will be nothing left . You go on and on about why healthcare is so expensive and technology is a monstrous unnecessary part of increasing cost. You focus immediately on the physicians assuming global risk because we are the low hanging fruit.

    Let’s just turn that around. I am willing to accept risk when EVERY CEO of EVERY insurance company and IT company involved in healthcare accepts risk for the same income I make. Once you guys are not getting rich off our backs for contributing NOTHING tangible and necessary to healthcare, then and only then, will I listen to what I should do.

    I am a primary care doc in an underserved area; I save lives EVERY single day just by being in my office. We are an ER, urgent care, and clinic all rolled into one depending on what day you visit. Hell is going to freeze over before a guy who can write code on a computer tells me what risk I NEED to assume. You do not know what works. I do. I KNOW what keeps people alive and healthy as do many physicians on here. We are tired of being told what we should and should not do by those who have NO idea what they are talking about. Your comments are insulting and offensive.

    Do you realize your entire IT industry is “not medically necessary?” How about we eliminate all IT and just let doctors be doctors. Go pick on another group of people.

  3. Steve – I AM often struggling to afford food, shelter, and clothing. We do without many things to survive and keep our standard of living as low as possible to try and save for four college educations.

    All people have priorities. I talked to three families today on Medicaid insurance who would LOVE to have this option of insurance physicians would accept. How about speech therapists, OT, and physical therapists. The waitlist at the local hospital (the only place accepting Medicaid for these services) is over 12 months long. This is proper care for children?

    Many families would prioritize affording this so their children would have a better chance. Right now, they have NO options and NO choice. If it’s not important to a family, then that is fine.

    My Medicaid families are bright, motivated, work hard at jobs or work hard at finishing their educations and they do everything they can to provide their children a chance. Most would jump at the option to purchase something (even with a small copay) to provide their children better healthcare. Why can we not give them an option? They are human being and deserve better than what we have now.

  4. 2healthguru writes, “Physicians MUST assume global risk ”

    If that is what you want you will quickly learn the words ‘not medically necessary’.

  5. Most people have less than $1000 in savings. Where is the HSA money going to come from? People in the lower income brackets are already having to decide if they can feed their children and afford food, shelter and housing. Now you will force them to use HSAs, so that money will need to come from somewhere. So, if you couple an HSA with a catastrophic plan, say a $10k deductible, where is that $10k for the HSA going to come from? Are you claiming that the presence of an HSA will make people turn in to savers? Seems unlikely. Much more likely is that this just functions like we have in the past. If you have a good job or make decent money, you get health insurance. Other wise you just go bare and declare bankruptcy if you have some big bills.

    “Patients parents making less than 50K will put money into those if there is incentive to do so and save on taxes.”

    The average income tax rate paid by those under $50k is 4%, and the president elect has suggested that people earning under $50k should pay no taxes. What incentives and which taxes are you reducing to fund HSAs?

  6. Paul, where else than healthcare does the supply side get to set price? First we had UCR – usual, customary and ‘reasonable’. The reasonable part was a statistical determination of ‘prevailing’ fees. The floor was a relentless uptrend until certain efforts were designed to moderate the medical portion of CPI.

    Same story on the hospital side. First cost plus, then solely cost, then DRGs, MDCs, ASCs, followed by global and then service tiered per diems and case rates (i.e, bundles). The results? ‘Provider inputs’ (costs), coupled with the collective failed efforts of health plans to materially manage clinical risk, have delivered onto ‘Caesar’ the obscenely ‘unaffordable’ and relentless rise in both commercial premiums and Medicare costs. Just watch as the comprehensive and value added benefits offered by Medicare Advantage plans (over-funded I might add) continue to push costs to beneficiaries via increasing copays, and deductibles. We’ve seen this dance before. The attack on comprehensive benefits vs. ‘defined [capped] contribution plans’ to arrive at ‘vouchercare’ (a charade of mythical consumer directed health plans) handwriting is on the wall. PriceWatch and TrumpCare have no new ideas. Only tired and recycled Heritage and AEI talking points.

    There is much culpability of ALL parties to the healthcare borg. RUC, RBRVS and conversion factors all contribute to the relentless tweaking of a failed, do more to earn more burning platform.

    We know what works. Physicians MUST assume global risk (and NOT exit to concierge or membership models as defacto ‘HMO-lite’ versions with NO system risk other than PCP services), then pivot hospitals to ‘cost centers’ vs. the current predominant revenue center DNA, and finally engage patients/members in material shared decision making while leveraging best practices in technology.

    Just to be clear your solution is no solution. More Ayn Rand free market fairy mythology; and Lasik and plastic (i.e., cosmetic, elective) surgery a false equivalency, imj.

  7. Phochfeld, I can’t predict the future nor do I know what Dr. Al-Agba’s solutions are other than what she has written and almost all if not all of that is leading in the right direction. You are suggesting something that theoretically seems to be great, but we already know it doesn’t work.

    Think of the grocery store where all are considered to be in the same pool contributing the same amount to the store. Now think of the lines where the top grade beef and lobster are and look at the lines and the empty bins.

    Rationing always occurs no matter what system is utilized. Therefore it is best to get the right sized shoe on the right foot. One size fits all doesn’t work very well.

  8. Niran, I think almost everyone is concerned about high risk patients and not losing insurance when they become ill. Unfortunately every system will have cracks that people fall through, more so now because the ACA moved us in the wrong direction. Therefore, we have to focus on the bulk of the population as healthcare costs will come down tremendously if all the incentives are aligned in the right direction. That means many of those that are problematic today will not be as problematic in the future. The special cases need to be managed outside of the normal marketplace and then integrated into it. Subsidies are ideal for that type of situation.

  9. I almost suggested he join us…. that would make my day… Dr. Nelson, we would love to have your input and expertise!

  10. I actually answered #1 up above and did not think it was necessary to answer it a second time. Actually balance billing will allow us to be paid adequately for our time in all honesty. I would like to spend more time with my patients, make enough to feed my kids and have a home, and continue to enjoy my job. Balance billing in primary care is the same as the “facility fee” is for the hospitals except they are charging $100-300 on top of the visit charge.

    Now as for the HSA, many of my patients love their HSA plans. It frees them up to pay for things out of pocket. For instance, I had a Medicaid family the other day, where both parents are working and the mother has an HSA. I prescribed something that was unlikely to be covered by insurance (like Zyrtec or Claritin) and pharmacies tell patients they are not allowed to pay cash for something if they have Medicaid (not true) so then they simply are not given that particular medication. This mom said she would have no problem paying out of pocket at the pharmacy because she could be reimbursed for it. Her child could use her HSA in spite of being on Medicaid.

    Patients parents making less than 50K will put money into those if there is incentive to do so and save on taxes. I have dozens of teachers families who are on Medicaid with one stay at home parent. Most have 3-5 children. They are more than capable of making decisions about HSA’s especially if their employers make contributions also.

    As for high risk pools, this suggestion is difficult for me to place into a framework. It appears when tried before in many states it was underfunded. I am not sure it would work if funded properly. Finally the continuous coverage provision provides better incentive than Obamacare did to purchase insurance. So now I have answered #1, #2, #3, quasi #4. I think we need to be open minded as a group instead of just lamenting change.

  11. ??? Didn’t say that. Do you dispute that being able to balance bill will mean we docs will make more money? Probably not given the above. So just exactly how do physicians end up making more money when we are talking about tax credits in the 3k range and what kind of insurance will they have? HSAs? How many of your patients making under 50 k are going to be able to put money in those? For the 50% of people spending 3% of our health care money this will work fine. How will it work for those with chronic illnesses or for the big impact diagnoses requiring big outlays for a year or two?

    What you are designing is a system not much different than what we had before Obamacare. Wealthier people, and those with good jobs, can afford good insurance and everyone else does without.

    Finally, is it telling that out of all my questions the only one to which you respond is #5? Do you really have no answers to the others? Trump and Price won, so there is a good chance we end up with something like this. I am hoping someone can explain how this will really work, and who wins and who loses. Bringing back failures like high risk pools and telling me they will really work this time w/o having any explanation at all is not reassuring.

  12. Oh, how I have missed your Peter-isms. Basically, the tax credit incentivizes purchase of decent insurance a physician will accept thereby allowing a poorer individual to find a care provider instead of having “amazing” free coverage and NO doctor.

    Not one practice where I live is accepting new Medicaid patients. Not ONE! This is terrible with no end in sight. Patients pulled off my waitlist after six months have conditions like I see in third world medicine. To have such limited access to medical care while having insurance is an abomination in this country. We must change it and allow patients the freedom of choice. 65% of my Medicaid families own their homes. Many drive nice cars, take lavish vacations, and attend private schools. Many are self employed, with one stay at home parent, and would love the freedom to choose decent insurance plan. If a patient is destitute obviously their healthcare responsibility should be different.

  13. Barry, I agree with your concerns. I hoped you would comment on the high risk pools as I felt equivocal about if they could or would work with “adequate” funding. Maybe they won’t. As to the balance billing, I was thinking about primary care akin to the facility fee that surgeons, specialists, and hospitals are allowed to charge. Basically, something to help level the playing field. Facility fees either should be eliminated or PCPs allowed to balance bill.

  14. Steve, why does having enough money to feed my children bother you so much? I should be able to afford food, shelter, clothing, health insurance, and student loan payments while working as a physician. Another 10k lower and I will qualify for Medicaid myself. Seriously? You begrudge me that? Why?

  15. “1. Tax credits so individuals may buy insurance on the private market. It starts at $1,200 a year and increases with age, but is not adjusted for income. People on Medicaid, Medicare, and Tricare, could opt to buy private insurance and receive this tax credit.”

    I’m interested in how the nuts and bolts of this will work.

    So a Medicaid recipient, restricted by income & assets to qualify for Medicaid, can buy health insurance for $1200? Would this be a family or an individual? Could you direct us to a plan that can be had for $1200? Or is the $1200 for a 2 year old and a 25 year old would get how much?

  16. 1) The tax credits are being set so low that people won’t be able to buy anything but very high deductible insurance. Conservatives have spent the last few years complaining about the high deductibles with the cheaper plans in Obamacare making them useless for people in the lower income groups. How will this plan change that? Doesn’t look lie it does.

    2) Again, great for those making good incomes. What happens to the bottom 50%?

    3) What happens to those with a prolonged illness or lose their jobs for other reasons of longer than 18 months?

    4) As everyone else has pointed out, if these had worked, we would not have needed Obamacare. You should also be aware that the affordability of these plans varied greatly from state to state. (Fun math fact. $3 billion is 0.1% of $3 trillion, total health spending in 2014)

    5) Ahhhh. I can make more money.

    6) Seema Verma had the benefit of ACA monies to make her reforms. It is too early to tell if they are successful or not. What should make us think she can initiate reforms that will cut costs and still provide access absent ACA monies?


  17. Excellent post. Agreed. Once physicians gave up the power to price their services as they saw fit…..replacing that with a government sponsored committee to set prices (CMS)…..doctors were screwed and so were patients (eventually). Giving docs freedom to balance bill….and patients to accept or reject the priced service we will be better off; as seen in lasik pricing and plastic surgery pricing.

  18. “There needs to be special rules”

    No ,no, no. No “rules.” That’s Gubmint regulation. The “Free Market” solves ALL problems.

  19. I believe Dr. Al-Agba is overly focused on the trees and is missing the forest. Today, two-thirds of every health care dollar is directly or indirectly taxpayer money. Per-capita we, the taxpayer already spends more on health care than every every other country in the world. None of the above suggestions are going to substantively control TOTAL cost. Let me go through his list.
    1) Tax credits only diverts cost onto the taxpayer, without doing anything about total cost.
    2) HSA’s work only for wealthy people. All people will still need health insurance because a single significant illness will wipe out their savings in a heartbeat.
    3) Continuous coverage is crucial. In an ideal, everybody would be able to sustain coverage all the time, but we all know that there will be millions who, at some time, will not be able to afford the premiums, and go naked for a short while, after which they will be forced into the high risk pools. See (4) below.
    4) High risk pools are just another way to make the taxpayer contribute more. This is simply another way that Insurance companies will be able to avoid high risk individuals, which is how they make their money.
    5) Balance billing, as I understand it, will allow providers to get around the only mechanism that Medicare has to control costs which is by controlling allowable reimbursement. This will make total cost go in the wrong direction.

    The necessary but NOT sufficient first step in addressing our health care conundrum is to, first, admit that we are all paying for everybody, then put everybody in the same risk pool and, finally, pay for it publicly. Then we will have the leverage to control the drivers on cost such as insurance company chaos, the cost of drugs and devices, and the dwindling supply of primary care providers, among others.

  20. Uniformly available “health insurance,” although a component of the COMMON GOOD for all citizens, will never become efficient without a concurrent strategy to improve the availability and accessibility of Primary Healthcare for each citizen. This is not possible without a nationally sanctioned and locally driven strategy, community by community. Mobilizing local institutions, by broadly sanctioned support, is most likely the only means to nationally solve the adversity problems that support the over-all availability and accessibility barriers within our nation’s health care. These barriers persisting over time, eventually cause the inefficiency and high cost of our nation’s healthcare. The Design Principles for managing a Common-Pool Resource (as in the portion of our GDP dedicated to healthcare) are known. The political-science economists have been studying, world-wide, these issues for 50 years. The results are well defined. We only lack the will to do it. Our nation’s economy cannot sustain the burden of our nation’s excessive cost of healthcare. Rationing is on the horizon without down-loading the current Paradigm Paralysis gripping our nation’s healthcare. Nobel Prize winner, 2009, Elinor Ostrom and her many colleagues have it right. Today’s the day to, at least, start thinking about it.

  21. The weakest link by far in the Price proposal is high risk pool financing. Prior to the ACA, 35 states plus the District of Columbia offered high risk pools while 15 states did not. Those high risk pools never served more than 200,000 people altogether and they didn’t do a very good job for many of them. Experts estimated at the time that at least four to five million people needed high risk pool coverage which probably would have cost $60-$100 billion per year less whatever could be extracted in premiums from those who needed the coverage. The Price high risk financing proposal is a joke plain and simple.

    The second problematic issue is balance billing. This sounds like a reasonable concept for primary care as a balance bill would often be less than $100 and rarely more than several hundred dollars. For surgeons, however, it could easily be thousands of dollars. Then there is the issue of balance billing for care that must be delivered under emergency conditions.

    Radiologists, anesthesiologists, pathologists and emergency medicine doctors often deliberately refuse to join any insurance networks because they know patients have no role in choosing them and they want the ability to present very high bills for their services. There needs to be special rules that govern billing for care that must be delivered under emergency conditions including a genuine meeting of the minds on price before services are rendered. If there is no meeting of the minds, the contract and the bill should be unenforceable and just shoving a financial responsibility form in front of the patient to be signed in the hospital should be considered signing under duress or undue influence so it won’t count.