The Healthcare Reform Quote of the Day

From Jerry Pournelle:

[B]efore we deliver another 15% of the GDP to Obama’s management team, would it not be better to wait a bit to see how well his present policies work? It’s not clear that the management team understands the economy, but they have certainly been given more power over it than any American government has ever had. Obama says that if we don’t do his health care reform soon, we never will. I question that. If what the Obama team is doing works, Obama will surely not lose popularity, and there will be far more support for the notion of turning this knotty problems over to a team that has successfully managed economic recovery. What’s the great hurry?

Good question.

Robbing Peter to pay Paul

Or to be more precise, robbing the young and yet-unborn generations of Americans to pay for healthcare for the current crop:

President Barack Obama on Tuesday proposed budget rules that would allow Congress to borrow tens of billions of dollars and put the nation deeper in debt to jump-start the administration’s emerging health care overhaul.

…

It would carve out about $2.5 trillion worth of exemptions for Obama’s priorities over the next decade. His health care reform plan also would get a green light to run big deficits in its early years.

This is madness.

We don’t need more doctors

So says Clayton M. Christensen, co-author of The Innovator’s Prescription: A Disruptive Solution for Health Care.  Clinics manned by nurse practitioners will save healthcare:

MinuteClinic, the largest chain of such retail clinics, records average patient satisfaction scores of 4.9 out of 5, while providing care that is 32 to 47 percent below the cost of primary care physicians. While the rest of the health care system only delivers about 55 percent of recommended care, MinuteClinic staff demonstrated 99.15 percent adherence to clinical guidelines in a study involving over 50,000 visits.

I guess the retail clinics run by CVS that have shut down didn’t get the memo on this.  Nor did the increasing number of Medicare patients who can’t find a primary care physician.

Healthcare Players Promise Big Savings

From Rich Lowery at National Review Online:

Groups like America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America — key players in defeating Hillary Care in 1994 — sent Obama a letter voluntarily offering to control costs. They can’t spell out with specificity how they’ll conjure up $2 trillion in savings during the next decade, but that’s beside the point.

Does this mean the members of groups like America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America have been overcharging something on the order of $2 trillion over the last decade?  If they knew how to save such a vast sum of money, why didn’t they mention it before?  Lowery continues:

Groups that could be expected to resist the further nationalization of health care are shouldering their way to the bargaining table in the hopes of protecting themselves from the worst of legislation they consider inevitable. For a president who made a cottage industry of hope during his campaign, Obama is benefiting from rank fear in his dealings with potentially recalcitrant business interests, from Chrysler’s secured creditors to the health-care industry — get on board or get run over.

While I don’t support most of the President’s healthcare reforms, in fairness it should be noted that inevitable legislation is a response to rising healthcare costs; the decline of primary care; and less and less coverage via higher copays, prior authorizations for prescription drugs, precertifications for imaging studies, or simple refusals to pay for needed procedures even after the patient and their employer have funneled a fortune in insurance premiums to a health insurance company that simply wants to keep the money and not provide service.

Much of the socialist reform the Obama administration is implementing — yes, folks, it’s socialism; deal with it — is a reaction to failures of capitalism.  I’m a believer in the free market and I hate to see the administration dismantle American capitalism.  But something like this was bound to happen in an America where industries fail to deliver, whether it’s affordable healthcare or a fuel-efficient automobile.  And, of course, the executives of failed companies are not merely rewarded for failure but lavished with riches for it.

The creep — now more of a brisk walk — of socialism is not the disease, per se.  It’s an opportunistic infection.  Modern America’s dysfunctional pseudo-capitalism is where the true pathology lies.

Is this company trying to extort money from doctors?, Part 2

The May 4, 2009 Tennessean has a story on Health Research Insights.  An excerpt:

Health Research Insights, the Franklin-based company that sent the letter, is riding a wave of interest among self-insured employers intent on examining bills from physicians and other providers for what could be overpayment errors.

For employers including Cookeville, Tenn., trucking company Averitt Inc., which hired HRI, it is all part of a push to control rising health-care costs while fulfilling obligations to ensure that their health plan dollars are spent wisely.

But doctors such as Hill question HRI’s techniques, suggesting that the approach seems to assume wrongdoing took place after studying payment data that doesn’t necessarily take into account all the details of a particular patient’s case.

“You should check the medical records before you accuse somebody of fraudulent billing,” said Hill, who responded two weeks later by providing records to show that his billings were accurate.

Others defend HRI’s practices and say it and other similar companies have a role in making sure health-care dollars are spent appropriately.

I’m pretty sure the “others” who defend HRI’s practices are people who don’t have a problem with physicians and hospitals being targets of intimidation by a company that doesn’t bother to look at medical records — the only way to confirm or deny that even the possibility of fraud or overpayment has occured — if it means more money in their pockets.  This sounds like something the Tennessee Attorney General might look into.

Identity Theft Red Flags Rule Delayed

The Federal Trade Commission has decided to allow medical practices until August 1st, rather than the original target date of May 1st, to implement identity theft prevention programs, according to AAFP News Now.  At least the creep of government overregulation of medicine has been slowed a bit.  Better than nothing, but not by much.

It’s just the flu, people!

Not to diminish the potential complications of the illness and with no disrespect to those who have lost loved ones as a result of it, but…it’s just the damned flu, folks!  And a mild strain of the flu at that.  Does putting the name “swine” in front of it and having the news media give it round the clock coverage make it somehow worse?  Some perspective here: In the last 24 hours 109 Americans have been killed in car accidents.  Another 109 will die in the next 24 hours.  On average, 109 Americans die in car crashes every day of the year.  Where are the news stories on the Bad Driver Pandemic?

In a typical flu season, hundreds of thousands of people worldwide die from complications related to the disease.  One flu death is one too many and reasonable precautions against the swine flu should be taken, but the context of this statistic seriously suggests that the impact from the swine flu problem is, from a dispassionate epidemiological perspective, trivial.

Two “probable” cases of swine flu at a local school has resulted in every school in the county being shut down for days.  Today at lunch, I noticed the restaurants were full of happy, healthy teenagers.  Instead of congregating at school, they were congregating in restaurants.  While I doubt these young people are immune to the swine flu, they do appear to be immune to the swine flu hysteria that has gripped the media, the World Health Organization, and any number of local, state, and national politicians who now have an excuse to appear concerned and authoritative in front of television cameras.

Let’s define our terms

For me, saying “This was written by Thomas Sowell” is usually sufficient for me to conclude that the article or book in question is required reading, utterly brilliant, and eminently quotable.  And this piece is all that.  Some excerpts:

Insurance is not medical care. Indeed, health care is not the same as medical care. Countries with universal health care do not have more or better medical care.

…

Those who think in terms of talking points, instead of trying to understand realities, make much of the fact that some countries with government-controlled medical care have longer life expectancies than that in the United States.

That is where the difference between health care and medical care comes in. Medical care is what doctors can do for you. Health care includes what you do for yourself – such as diet, exercise, and lifestyle.

…

Even for things that take longer to do you in – obesity, alcohol, cholesterol, tobacco – doctors can tell you what to do or not do, but whether you follow their advice or not is what determines the outcome.

Americans tend to be more obese, consume more drugs, and have more homicides. None of that is going to change with “universal health care” because it isn’t health care. It is medical care.

Paradigm Lost

Medical Economics reports that CVS is shutting down 89 of its retail clinics in the coming months.  While the economic downturn is the likely suspect, the fact that American patients increasingly need health care for multiple chronic problems and not minute clinics or walk-in clinics is doubtless a contributing factor.

Identity theft and medical practices

Effective May 1st, medical offices will be required to have in place an identity theft prevention program.  Is there really any reason for having this?  No.  There was also never a plague of patient confidentiality violations, but that didn’t stop HIPAA.  When the government has a solution, little details like the non-existence of the problem are simply ignored.

Fortunately, the American Academy of Family Physicians has resources in place to help medical offices deal with this latest (but by no stretch of the imagination last) unnecessary bureacratic intrusion into the art and science of medicine.  This link to the AAFP’s Identity Theft Red Flags Rule page is a good place to start.  The “meat and potatoes” of this nonsense can be found here.  To really get to the bottom line, the AAFP has developed this one page Red Flag Rule table in Microsoft Word format that can be downloaded and printed and will probably answer as a serviceable plan for most practices.

More potholes on the road to digital medical records

Brandon Glenn at Modern Medicine talks about a problem inherent in Google’s PHR (Personal Health Record):

Google’s PHR problems apparently stem from their reliance on coding data to describe patients’ medical conditions in the PHRs. Health IT leaders from Google and Beth Israel Deaconess Hospital (where deBronkart, the patient, receives treatment) say PHRs are a new technology and “will improve as more precise coding language is adopted in the coming years.”

This reminds me of a “kicked back” claim I once received on a urinalysis I’d obtained on a patient.  I’d used code 788.1 (Dysuria).  Somehow, what the third party-payor got was 798.1 (Instantaneous Death).  Of course, even when this sort of data entry error doesn’t occur, there’s still a lot of coding nonsense out there.  Glenn concludes that this “doesn’t bode too well for the federal government’s stated goal that all American citizens have an electronic health record by 2014.”  No, it doesn’t.  Worse still, unrealistic government-mandated electronic record compliance mandates will incentivize many physicians to opt out of Medicare.

And Dr. Wes discusses another problem related to the lack of electronic record interoperability: The Health Information Legacy Problem:

“While every one’s talking about developing a fully-integrated nationwide electronic medical record, no one give a damn about the old systems that exist out there. They’re not worth supporting. No one cares about the data they contain, even though for the doctor, they contain critical documentation about patient’s prior health care and are vital documentation to prevent litigation.

…

“So I ask you, when the government decides on a single electronic medical record system that suits their needs and is all-encompassing, what’s going to happen to all the data on the other systems?”

Physicians’ notoriously illegible handwriting notwithstanding, paper and ink does have the virtue of being “interoperable.”  But these technical problems with medical health information technology (HIT) are no problem at all to HIT vendors who simply want to sell their products whether they are practical or not.  Nor is it a problem for politicians who have never had careers as practicing physicians, hospital administrators, or information technologists.  It’s easy to be boundlessly optimistic about the solution when you are utterly clueless about the problem.

Is this company trying to extort money from doctors?

Here is a story  from American Medical News about a company that is sending out letters requesting repayment for “overpaid” claims, many of them several years old:

When Snellville, Ga., internist Joel Fine, MD, read a note from a company called Health Research Insights, he thought it sounded a little bit like a chain letter — vaguely threatening, insistent on a quick response, with few details.

The letter, addressed “Dear Health Care Professional,” accused Dr. Fine of upcoding four claims for treating Georgia-Pacific employees. The earliest dated back to February 2005. “Of course, I was offended,” Dr. Fine said.

HRI’s letter offered him two choices: pay $347 to “immediately settle this issue” or send complete records proving he did not incorrectly bill for the visits in question. The letter warned that if Dr. Fine did not pay HRI or contact them with records to prove his innocence, his case could be turned over to federal authorities.

…

Since late last year, thousands of doctors in Georgia and Tennessee have received letters from HRI similar to Dr. Fine’s. The Indiana State Medical Assn. says it has received a warning from HRI that it will start collection efforts in that state.

Like health plans, HRI identifies physicians it believes are above the norm in the number of high-level codes they submit and targets them for recoupments. Unlike health plans, however, HRI does not analyze individual medical records along with the claims.

It uses, by the company’s own description, an algorithm to determine the amount of upcoding and overpayment — then demands that the physicians produce the medical records and other paperwork to fight the claim.

…

HRI’s chief executive officer, Theodore Perry, PhD, wouldn’t talk to American Medical News. But the company’s Web page describes its business as authorized under ERISA.

…

Health care attorneys and experts in ERISA law said doctors who receive the type of letter Dr. Fine received from HRI should think twice before just sending a check.

“The reality is you don’t even have to talk with these people,” said Michael F. Schaff, an attorney who specializes in health care and contracting with the firm Wilentz, Goldman & Spitzer in Woodbridge, N.J.

“Until they show they have some type of authority, they’re bluffing,” he said. “This comes out of the blue saying, ‘You owe us X amount of dollars.’ To me, that’s extortion.”

Both Blue Cross Blue Shield of Tennessee and Blue Cross Blue Shield of Georgia have sent out letters denying any complicity with HRI’s attempts at getting money from physicians.  So who and what are Health Research Insights, Inc.?  According to their website, Theodore L. Perry, Ph.D., Johnny E. Gore, M.D., and Charles L. Polatsek, M.B.A. are the company’s “founding partners.”  According to this website, they are also the entire company.  The HRI website lists the following address and phone number:

Health Research Insights, Inc.
P.O. Box 682467
Franklin, TN, 37068-2467
Recovery 615-916-4480

The MANTA website has other contact information:

Health Research Insights, Inc
381 Riverside Dr, Ste 300
Franklin, TN 37064-8934
Contact Phone: 615-224-0240

This website has yet another address and a fax number:

Health Research Insights, Inc.
1120 Holiday CT, Ste 4
Franklin, TN 37067-1302
Phone 615-224-0240
Fax 615-224-0241

The fax number given to Dr. Fine in the letter he received from HRI was 615-263-0196.

The Tennessee Medical Association (link requires TMA member log in) warns: “The TMA Legal Department says letters from Health Research Insights (HRI) demanding overpayment recoupment may not be based on prior review of clinical records.”

Big Brother says, “Take your medicine.”

 

Did I remember to take my Victory lisinopril?

The Daily Mail out of Britain, the most suveilled Western nation on Earth, has a story about a plan to monitor patient drug compliance:

Microchips in pills could soon allow doctors to find out whether a patient has taken their medication.

The digestible sensors, just 1mm wide, would mean GPs and surgeons could monitor patients outside the hospital or surgery.

Developers say the technology could be particularly useful for psychiatric or elderly patients who rely on a complicated regime of drugs – and are at risk if they miss a dose or take it at the wrong time.

It could also be used for the chronically ill, such as people with heart disease, to establish whether costly drugs are working or whether they are causing potentially dangerous side effects.

The sensors could even remind women to take the Pill if they forget.

The ‘intelligent’ medicine works by activating a harmless electric charge when drugs are digested by the stomach.

This charge is picked up by a sensing patch on the patients’ stomach or back, which records the time and date that the pill is digested. It also measures heart rate, motion and breathing patterns.

The information is transmitted to a patient’s mobile phone and then to the internet using wireless technology, to give a complete picture of their health and the impact of their drugs.

Doctors and carers can view this information on secure web pages or have the information sent to their mobile phones.

YOUR ILLNESS WILL BE EXTERMINATED!!!

In Touch Technologies’ remote presence robotic system, known as the RP-7, has already found its way into hospitals.  The Cult of Skaro was unavailable for comment.

EHRs: The Road to Serfdom?

While I’ve been skeptical about the cost-effectiveness and readiness of EMR/EHR technology, Dr. R. Wayne Porter or Terrell, Texas sees something more sinister:

The Electronic Health Record is a Trojan Horse which will open the gates to an invading army of bureaucrats and central planners and give them the tools with which to enslave us. Using it they will track every physician’s practice and compare it to their mandates (which is what “guidelines” will become). Dissidents will be punished. Those who fail to conform will be dropped from insurance company and medicare panels and/or have their licenses revoked. We must reject this poisonous “gift” and resist every effort to implement such a system, not only for ourselves, but for the sake of our patients, the citizens of this Country, who will be ensnared as well.

Why do we lie meekly still as, one by one, the threads of third party and State control are fastened over us? They are not yet so numerous that we cannot break free of them. Do we fear the loss of our comfortable lifestyles or our position and prestige (whatever may be left of it)? We have only to stand up and cry “Enough!” and they will be forced to scatter like cockroaches in the glare of the light.

That’s a pretty strong indictment.  I think EMR/EHR technology will produce cost savings, fewer errors, and better patient care…some day.  The technology is not ready.  But when it is ready, physicians should embrace it more than fear it.

As for third party and State control, are there large numbers of American patients who are burning their Medicare and private insurance cards out of frustration with third party-payors denying treatment and overriding physician decision-making?  This would seem to be a far greater source of both patient and physician dissatisfaction with the third party-payor system than whether one’s office notes are on sheets of paper or in a hard drive.  Everyone seems to hate health insurance companies, but is that hatred taking the form of large numbers of patients telling them that they will no longer pay their premiums?  We may one day see such a backlash, but not anytime soon.  For now, patients by and large seem to find it equitable or at least tolerable to pay enormous monthly insurance premiums to health insurance companies that will often deny coverage and stick them with the bill.  It is the unwillingness of the vast majority of patients to pay for their own health care that empowers both the state and private third party-payors.

If physicians stand up and cry “Enough!” will they will be forced to scatter like cockroaches in the glare of the light?  Since only 4% of American physicians currently use fully operation electronic records systems, it sounds like physicians have already cried “Enough!” yet the cockroaches seem undisturbed.

The coming end of the drug rep era

American Medical News reports Doctors increasingly close doors to drug reps, while pharma cuts ranks and Mass. bans drug- and device-makers’ gifts to doctors and forces pay disclosures.  From the latter article:

The new regulations implement a state law enacted last year and bar industry gifts such as pens, notepads and food in physician offices. The restrictions are meant to reduce health care costs…

I’m sure we will eventually see the cost of prescription drugs come down.  I just think it will be because the pharmaceutical industry — or what is eventually left of it — will stop spending hundreds of millions of dollars of R & D money per new drug when they know they won’t be able to market the drug and recoup their investment.  But it’s nice to know that our national nightmare of 99 cent drug rep pens is finally coming to an end.

Lies, damn lies, and statistics, Part 2

Keith Hennessey, former Assistant to the U.S. President for Economic Policy and former Director of the U.S. National Economic Council, deconstructs those 46 million Americans who don’t have health insurance.  He finds few people who fit the stereotype of patients in desperate need of health care who cannot afford it.

Reason’s Nick Gillespie talked about this last year.  And this doctor was talking about in back in 2005.

Are office visits undervalued as compared with procedures?

The Virtual Patient thinks so:

Our health care system is built upside down today and that is the reason for excessive costs. Insurance companies are willing to pay for expensive procedures at the same time they are reducing the amount paid for office visits to doctors.

…

I am convinced that paying doctors twice as much as is currently allowed for office consultation and evaluation would drastically reduce medical costs…

This echoes the words of Dr. Jennifer Frank writing in Family Practice Management back in 2007:

As a family physician, I have the opportunity to save the lives of my patients every day. For example, helping patients with diabetes to lower their A1Cs, take their medication, stop smoking, start exercising, control their blood pressure or a host of other primary, secondary and tertiary prevention measures keeps patients from ever getting to the ICU in Mary’s condition. Yet this type of “life saving” is not appreciated and glorified in the same way as critical care. It is much more exciting to see a critically ill patient saved from the brink of death than to see a primary care physician initiate aspirin chemoprophylaxis. The U.S. medical community is just as enamored with highly specialized, resource-intensive medicine as is the audience of “ER.”

While it is a strength of our health care system that we can perform interventions that save critically ill patients, it is a failure of our system that the majority of our training and spending is focused on high-tech interventions for a few patients rather than preventive care that would aid thousands more. For example, screening for and preventing the complications of hyperlipidemia is often not reimbursable, but the cardiac catheterization five years later to evaluate and treat coronary artery disease is highly reimbursable. It seems our system is set up to reward failure – the failure to prevent disease.

As I noted before, preventive medicine is often not very cost effective.  But The Virtual Patient and Dr. Frank’s points are well taken.  You get what you pay for and what we pay for in American medicine is high tech procedures not low tech — and low cost — cognitive skills.  But I don’t think this will last indefinitely.  The increasing requirement for prior authorization for and not infrequent rejection of expensive imaging studies like MRIs and the common refusal by insurance companies and pharmacy benefit management companies to pay for non-generic drugs is a sort of tacit admission that our health care system is too enamored with high tech, high cost solutions to problems for which cheaper alternatives exist.

With no disrespect to the procedural subspecialties and the good work they do, the health care pendulum will eventually swing back — and is perhaps already starting to swing back — to primary care.

A sucker’s game?

Three insurance prior authorizations in the last week and the results:

• MRI of the upper extremity for persistent pain: DENIED.
• Overnight supplemental oxygen for hypoxia due to status asthmaticus: DENIED.
• Viagra for sexual dysfunction: APPROVED.

All of these patients have private insurance that they and/or their employers pay for so it will be there when they need it.  At a time when Newsweek can run a cover story entitled “We Are All Socialists Now” and the American President tells business leaders that his administration is all that stands between them and the pitchforks, if I were in charge of a private insurance company I would be doing my damnest to demonstrate how well the private sector works.

HHS secretary nominee says primary care docs need a raise

James Arvantes at AAFP News Now reports:

Kansas Gov. Kathleen Sebelius told a Senate committee last week that if confirmed as secretary of  [Health and Human Services], she would work to change Medicare’s payment policies to increase the number of primary care physicians.

…

Sebelius, who testified before the Senate Health, Education, Labor and Pensions, or HELP, Committee, here on March 31 as part of her confirmation process, called for “refocusing the payment incentives so that primary care becomes a much more lucrative profession.” There are relatively few health care professionals in preventive medicine compared with the number of subspecialists, said Sebelius, adding “if we focus on prevention and wellness, we will not need as many (sub)specialists.”

While it’s nice to hear someone (potentially) in a position of authority in health care singing the praises of primary care, it may be premature to pop open the champagne.

For starters, it would be encouraging to hear her say that decreasing the burdens of paperwork, malpractice insurance, and third party-payor interference in health care decisions is critical to rejuvenating primary care.  While increasing Medicare payments to PCPs is nice, the fact is that Medicare has an unfunded liability as of 2008 of $36.3 trillion (as tabulated using a 75 year horizon) or $85.9 trillion (using an infinite horizon).  At some point we have to make it less expensiveto practice medicine and not simply make it more “lucrative.”  The payment structure for physicians in general, and primary care physicians in particular, needs to reduce inefficiency, not simply accommodate it.

As far as Medicare being the driving force in any plan to increase primary care physician pay, no one should ignore what has happened at the various banks and private (or once-private) companies that accepted government bailout money.  Their “rescue” by the government turned out to be more of a Faustian bargain.  Don’t think for a minute that government largess will come without strings attached.  Some of those strings are attached already.

Another problem is that Governor Sebelius appears to have drunk the preventive medicine Kool Aid.  While preventive medicine has its place, it is a rather mixed bag with regard to cost effectiveness.  The primary care community should use extreme caution with trying to marry the ideas of primary care, preventive medicine, and lower health care costs in the minds of either the public or politicians.  Primary care and cost effectiveness are often found together; preventive medicine is not always (and probably not usually) the mechanism by which the former leads to the latter.

It’s good news that America seems to be slowly waking up to the fact that primary care has tremendous value and that as a result of allowing it to deteriorate for a generation we have a health care system that is now falling to pieces.  But the primary care community’s response to this should not be one of mindless elation that at last we are being recognized for how valuable our profession is.  Primary care has a long road to travel to get back to the forefront of American medicine.  The journey seems to be getting underway, but there are many obstacles to overcome and pitfalls to avoid.