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Friday, August 07, 2009

Heathcare Reform And Why You Should Care

Any meaningful debate about healthcare must start with an honest and candid dialogue and address the hard issues such as (1) one's right to healthcare and the level of thereof, (2) rationing of healthcare services and prescription drugs, (3) litigation and tort reform,(4) waste in the healthcare system, (5) health care delivery options and last but not least (6) how to pay for healthcare reform?

Liberals are pushing for a public option which seems suspiciously like a trojan horse for nationalization, a one-payer system. President Obama denies this is the objective but some influential members of congress have a decidedly different point of view. Watch the video of Barney Frank; both his intent and desired outcome are clear.

Significantly expanding coverage without reforming health-care delivery is "a recipe for failure," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change in Washington, D.C. "You won't be able to sustain the expanded coverage because it will just bankrupt us."

Spending on health care this year is projected to reach $2.5 trillion, or 17.6 percent of the U.S. gross domestic product, according to a Kaiser Family Foundation analysis of Medicare and Medicaid data. That's up from 7.2 percent in 1970, and by 2018 it could swell to one-fifth of the GDP, which is a measure of all goods and services produced in the United States.

Meanwhile, a worsening shortage of primary-care providers and rising demand for certain specialists will continue to strain the system, perhaps creating long waits for appointments. The following video shows the breakdown in overall healthcare costs.

Should American citizens and illegals have a right to health care?
Neither the US Constitution nor the Bill of Rights assert any such right. Healthcare coverage for those who can not pay is another entitlement program and we need to call it that. Now many conservatives are under the impression that entitlement programs benefit only the poor but that concept is dead wrong- the middle class and the rich get their entitlements just like the poor, it's just that their entitlements come with better labels. Welfare, food stamps, Medicaid and similar state programs are seen as entitlements to the poor (which they are) but Medicare and Social Security are viewed as rights by the middle and upper classes - a return of what they paid into the system- this is only partly true and a small part at that. Unfortunately the math and facts do not support this argument. Agriculture and other specific sector subsidies and investment tax deductions and loopholes are not viewed by the middle and upper classes as entitlements but in reality they are no different from welfare transfer payments made to the poor.

My own view is that taxpayer funded health care should be provided at basic levels but not full health care. It is disingenuous and dishonest to pretend that everyone should have a right to the best health care that money can buy whether or not they can afford it. And the lowest level should be for illegals, such as emergency care. As a nation, we need to find a political stasis for benefits and coverage being offered under healtcare reform.

Rationing of healthcare services and prescription drugs:
Let's face it, healthcare is rationed today; it is just largely adjudicated by the free market. A profound conundrum and one of the immutable laws of economics is that you can control prices and supply of commodities and services but you cannot control both at the same time in a free market economy. To think that the system can suddenly provide health care services to 47 million additional people (who knows what the real number is) that are currently not insured and not have longer wait times, does not make common sense - can anyone say rationing? And notice I said those who are not insured- everyone of those 47 million have access to emergency health care today which is paid for by health care providers, by tax payers and those of us who pay for health insurance and/or pay directly for health care. So when and if healthcare reform is enacted and regardless of whether there is a public option or some sort of non-profit co-ops, healthcare rationing will continue and you can bet it will get worse.

Litigation and tort reform:
At one of his town hall meetings, President Obama said he was "not comfortable with artificial caps on litigation". In addition to the cost of defensive medicine, medical malpractice insurance which is driven largely by punitive damages, runs in many cases as much as the doctors' salaries.

Below are excerpts from an article published by UMHS.

The high cost of malpractice insurance for some medical specialties affects not only how many doctors are entering the field of obstetrics and gynecology, but also where they offer their widely needed obstetric, prenatal and gynecological care, according to new University of Michigan Health System research.

Their study, published in the June issue of the journal Obstetrics & Gynecology, gives a foreboding prognosis for the supply of doctors specializing in the field because of the rising costs of malpractice premiums.

“The high cost of malpractice premiums is beginning to lead providers to drop or reduce obstetrical services. Our study presented evidence that high malpractice premiums affect where new obstetricians are locating and it may affect the supply in the future,” says Scott B. Ransom, D.O., M.B.A., M.P.H., associate professor of obstetrics and gynecology at the U-M Medical School and of health management and policy at the U-M School of Public Health, and the senior author of the paper.
“Something has to be done about the skyrocketing cost of malpractice premiums in our field,” says Ransom, also the director of women's health and gynecology at the Ann Arbor VA Healthcare Center and director of the U-M Program for Healthcare Improvement and Leadership Development. “We are going to lose some of the best and brightest young doctors who otherwise might enter this field, and we are going to face shortages in many areas of the country if something isn't done.”

Malpractice insurance premiums vary widely from state to state. Florida is the highest-premium state, with an average 2004 premium of more than $195,000, followed by Nevada, Michigan, the District of Columbia, Ohio, Massachusetts, West Virginia, Connecticut, Illinois and New York. Many areas of the country, especially around major metropolitan areas, are experiencing large increases in the average costs of premiums. Between 2003 and 2004, Dade County in Florida, which includes the city of Miami, went from $249,000 to $277,000, an increase of about 11 percent.

In that same period, Cook County in Illinois, which includes Chicago , jumped about 67 percent from $138,000 to more than $230,000. Wayne County in Michigan , which includes Detroit, went up 18 percent, from almost $164,000 to nearly $194,000.

As you can imagine the underlying reasons for the high cost of medical malpractice insurance premiums are varied and complicated but there is little doubt that outrageous jury awards (punitive damages) are the major factor. In other words, if punitive awards were capped at some reasonable amount, the cost of every one's healthcare would be significantly reduced. Naturally most attorneys are opposed to any attempt to reform tort laws since this is how they get rich. I personally believe you could take at least 20% of cost out of the entire healthcare system and still pay 100% of compensatory damages and punitive damages with reasonable caps. Changes to the legal system would also be required to eliminate the wasteful spending on defensive medicine. Case in point- several years ago when I went to the emerency room at a local hospital and the attending physician admitted me to a room for a couple of days for tests and examinations. I gave my vital medical information to the nurse in the emergency room, in the private room and later on at two different occassions for tests/procedures. When later I suggested to the doctor that the hosptial could benefit from my services to improve it's efficiency, he said the problem was not a lack of systems understanding on part of the hospital but lawyers- you mean his/her life was at stake on you only asked one time?

Waste in the healthcare system:
Records automation and more efficient healthcare delivery systems can significantly reduce waste in the system. However, here is an important point to remember in a macro-economic environment- one person's waste is another person's income. Automation of records and tests/procedures eliminates some one's job. However, it is possible to gain more efficiency than actual cost reductions, in other words cost avoidance.

Healthcare Delivery Options:

Models of Healthcare Delivery
A NextGen Tutorials in Medicine Article published in association with the New England Journal of Medicine.

There is no perfect healthcare delivery system for a country. Some models seem to work better than others but each has its own advantages and drawbacks. Broadly, healthcare delivery models could be classified under tiered system or diffuse system.

The tiered system is made up of regionalized systems of healthcare delivery divided into Primary care, Secondary care and Tertiary care. Such a pyramidal system is more common in UK and in HMOs (Health Maintenance Organizations) in US.

Primary care
Refers to the activities concerned with prevention and treatment of common medical problems in outpatient setting. Care is delivered by primary care practitioners (PCPs) in the US or general practitioners (GPs) in the UK. A PCP could be responsible for 2000-3000 patients and is responsible for managing patient's overall care.
Secondary care
Concerns with treatment of disorders requiring specialist opinion or hospitalization. The patients are usually referred from Primary care and the physicians are affiliated to a hospital or a group practice.
Tertiary care
Provides medical and/or surgical management of complex disorders in an inpatient setting and usually requiring collaboration between multiple specialties. These are super-specialized standalone hospitals or specialty departments in a multi-specialty hospital.
In the diffuse system there is no such division. In this system patients can directly approach specialists without consulting GPs or PCPs first. The boundaries between GPs, internists, family practitioners and pediatricians are blurred. Many internal medicine specialists provide primary care, many family practitioners provide secondary care. However, some centers have designated "hospitalists" for inpatient care.

The diffuse system is the relatively more common in United States. It is a diamond type of system with most hospitals providing a mix of multi-specialty secondary and tertiary services. The stress is on getting the latest technology and advanced clinical care closer to home.

Models of healthcare delivery
In the late 19th and early 20th centuries, contract doctors existed in many parts of United States. Large organizations and philanthropic societies employed physicians under salaries or capitated (fixed pre-payment) contracts. In a capitated system, providers are paid a fixed amount per patient per month regardless of the quantum of services utilized. This slowly lost popularity due to increasing competition for contracts and price wars.

In the later half of 20th century, fee-for-service was the dominant model of healthcare delivery. The physicians were affiliated with a hospital as staff members and had admitting privileges. They wielded considerable power since they could chose to admit to the hospital of their choice. They were not employed by the hospital and the specialists were dependant on a referral network of physicians affiliated with the same hospital or a different group.

In a group practice, a number of physicians, usually from multiple specialties, come together to setup a group practice. Some of the senior physicians have ownership stake in the practice. Most of other physicians are compensated through a mix of salary and bonuses. The practice bills the insurance plans or the patients on a fee-for-service basis. The group practices try to coordinate care amongst physicians in the practice.

Community health centers were the earliest alternative to fee-for-service setups. They managed health of entire community rather focusing just on walk in patients. These took the form of neighborhood health centers, homeless clinics or clinics for immigrants providing a mix of clinical and public health services.

HMOs originated when large cooperatives or public sector employers started taking onus of delivering care for their members for a nominal fee. They evolved Health Insurance Plans where the employers paid a fixed amount per employee to the healthcare provider bringing together financing and delivery of care into one entity. This prepaid model of care was renamed HMOs which subsequently evolved into network HMOs.

An HMO which provides full services from primary to tertiary care is known as a Vertically Integrated HMO. It owns a health plan and either owns or has contracts with group practices or hospitals.

Some physicians may form groups or associations just for the purpose of negotiating and administering contracts. Independent Practice Associations (IPA) were formed when insurance companies, hospitals or local governments started contracting with individual fee-for-service physicians, office based physician group practices. The IPA is responsible for the network of physicians which is not linked to the HMOs plan. In some arrangements, physicians can contract with different HMOs or IPAs. A variance to this structure is Integrated Medical Group (IMG) in which physicians are employees rather than owners of their practices. IPAs and IMGs could also provide care under capitated system, assuming the financial risk of providing care.

IPAs, IMGs and HMOs operate in a largely similar structure; however, the "Virtual Integrated" groups enter into contracts for provision of all services putting them in contrast with the Vertically intergrated HMOs.

A POS (Point of Service) plan gives the HMO plan members to get healthcare services from physicians who are not on the HMO's provider panel. Usually they are required to pay higher co-pay for such services unlike in HMO where they would have paid the whole amount.

PPO (Preferred Provider Organization) plans differ from HMOs in the way they compensate their panel providers. The contracts are based on fee for service payments unlike HMOs limiting the financial risk to physicians and hospitals. The PPOs are able to negotiate reduced rates with providers in return of the increased availability of patient pool.

With the introduction of HMO model, the HMOs controlled the patient base through contracts removing physician's admitting discretion to their choice of hospital. This has given hospital administrator better position in the power equation. According to recent data, PPOs are becoming popular over HMO plans.

The other important systems are Medicare, Medicaid and governmental health programs. The Employers and Medicare beneficiaries pay into the federal Medicare program fund during their employment for subsequent coverage. The healthcare service provider they visit bills the insurer which gets its payment from Medicare. Under the Medicaid program, the Medicaid enrollee gets coverage from the program and the provider bills the payor, which gets payment from Medicaid program.

The Veterans Affairs, Department of Defense and Indian health service directly provide service to covered individuals since they act both as a payor and provider.

Integrated systems
Group practices: They may or may not contract with HMOs. Management Services Organizations (MSOs) are specialized agencies for the management of physician practices. Sometimes they also act as the source of capital. MSO services could include billing, claim processing, administration, contract management, utilization management, quality control. MSOs could also own the assets related to practice such as office space, equipment, support staff. Sometimes MSOs buy out physician practices using outside funding and becomes a Physician Practice Management company.

Physician Hospital organization: A PHO is formed to exert greater negotiation power against MCOs. They are a type of arrangement between physicians and hospitals and are usually affiliated with one hospital. They can directly contract with employers too.

Integrated Delivery Systems (IDS): IDS are the strategic arrangements between hospitals, physicians and insurers to provide full spectrum of healthcare services to a given population. Managed care organizations contract with IDS instead of each of different players. Larger size of IDS can facilitate investment in capital expenditure.

Employer driven payment systems
Employer provides health insurance to individuals who seek care from provider which bills a payor or insurer. In the case of large employer which is self insured, the bills would come back to the employer and payor combination. In such cases the insurance companies usually act as ASOs (Administrative Service Organization) for the employers providing administrative support.

For individuals who are ineligible for group insurance, individual policies are available. In this system, the individuals who are self employed or on individual policies seek coverage from an insurer which reimburses the providers providing service to the individuals.

In United States, the healthcare administration is largely outside the governmental control. This leaves hospital capacity regulation, residency seat allocation and coordination of care amongst primary, secondary and tertiary centers in the hands of private entities. The physician groups control the policy, occupational standards and entry requirements for licensing. So their professional interests and favor for technology and inpatient capacity also led to expansion of hospital facilities. Over the last few decades, the healthcare has increasingly been delivered at hospitals rather than physician offices. With emerging consumer driven healthcare models and advanced surgical techniques, there is a gradual shift towards Ambulatory Clinics. This will introduce newer models of healthcare delivery

How to pay for the healthcare reform:
President Obama seems to suggest that much of the estimated $1 trillion cost of healthcare reform will come from drug manufacturers and health insurance companies and from cutting waste out of the system. The top 13 health insurance companies last year made about 5% profits on their revenues and if you took all the profits from the health insurance and drug companies it would total only about 3% of the total cost of healthcare today, not to mention the $1 trillion of additional estimated cost of healthcare reform. And you have heard much about the drug companies offering a few hundred million but this is pennies compared to the $1 trillion price tag of healthcare reform. Cutting waste from the system will be like "the millions of jobs that are supposed to be saved", no one will be able to measure it. In my opinion any efficiency savings actually acheived will be more than offset by the increased cost of government bureauarcy in overseeing healthcare reform. Take a look at the healthcare reform organization chart on the home page of congressman Kevin Brady, R, Texas and you will get the picture.

Unless we borrow or print the money, the $1 trillion dollar cost of healthcare reform will be passed to the consumer through higher taxes, insurance premiums or to businesses who in turn will pass the costs back to consumers in the form of increased prices of goods and services - either that or we get reduced healthcare services. There is no other way. My guess is that it will be some of all of the above.


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