Healthcare Reform: Is Anyone Listening?

In recent years, as a medical director in a large hospital system, I have seen and written about so many abuses of our present healthcare system that I have just about given up, saying it’s no use. Just in case someone might be interested, keep reading for a list of what I’ve found:

1. Scores of uninsured patients coming to the emergency room with problems for which they had delayed seeking treatment because they had neither insurance coverage nor financial means to self-pay—leading to costly care and morbid outcomes which could have been prevented by timely intervention.

2. Adverse events, too often sentinel events, from medication errors that could have been avoided had there been a system whereby a primary care physician monitored the patients care and medications.

3. A plethora of medically unnecessary diagnostic testing—laboratory, radiological, nuclear imaging; and medically unnecessary overutilization of ancillary service—home health nursing, physical therapy, durable medical equipment.

4. Blatant disregard by attending and consulting physicians for appropriate utilization of acute inpatient hospital care.

5. Reduction of reimbursement to primary care physicians—the very caregiver who is in a position to control unnecessary costs and utilization, and to oversee quality of care.

6. A reluctance of graduating physicians to enter primary care training, because of the reimbursement issue, and instead pursue monetary rewarding specialities.

7. Unreasonable denial of benefits by insurance carriers in order to increase profit margins.

8. Health insurance carriers refusing coverage and/or requiring exorbitant deductibles for covering select groups (cherry-picking) thereby shifting costs of medical care to tax supported federally funded entities.

9. Referrals of patients by physicians to entities, such as Day Surgery Units, Specialty Hospitals, Imaging Centers, Physical Therapy, Home Health Agencies, IV Therapy Companies in which the referring physician has a financial interest or from which the referring physician receives a stipend, often in a disguised form, in return for referrals.

10, Ineffective peer review programs by healthcare organizations that seldom adequately address performance issues or gross quality issues.

11. Joint venture relationships between physicians and hospitals that manage to circumvent statutory requirements for transparency and reward physician-partners for admission referrals.

Opponents of any form of a single-payer healthcare system often refer to the complaints that arise from systems in other countries, such as England and Canada regarding delays in receiving treatment. If statistics from those countries are analyzed, the only delays in those countries are cases where there is no emergency or urgency. There might be inconvenience from waiting times but neither patient satisfaction nor overall outcome of care is found to be affected.

A continuation of the status quo system—a system where more is better whether or not it is medically necessary—regardless how it’s tweaked, will not work. Our present healthcare system is such that if the cost escalates, insurance carriers, even tax supported federally funded programs, Medicare and Medicaid, simply raise the premiums, the co-pays and deductibles, thus forcing the consumer to pay for the run-away increases. Incentives for providers to provide more services for financial gain, with third parties paying for the cost, has to be removed before any reform will work.

The real test of effectiveness of any healthcare reform effort will be whether or not our lawmakers are brave enough, and will be kept knowledgeable enough, to ignore lobbyists paid by special interest organizations and whether they will recognize wherein the problem lies.

http://www.charlesclarknovels.com

Medical Home

A term you will hear used frequently in the months to come is "Medical Home." The concept of a medical home is already being developed in a few of the major medical centers in the nation and has been shown to correct many of the deficiencies in our present healthcare system . Briefly it comprises all elements of health care, for the most part under one roof. A sort of "one-stop-shopping" approach to the delivery of medical care. If the concept--as it now exists in some centers--is analyzed carefully, it can be seen that it might well be the answer to reform of the deplorable healthcare system we now have in place--a system that we can blame on no one but ourselves.

To understand the potential of a "Medical Home" we need to take a look at health care in years past: How did our present system evolve? What is the root cause of its deterioration into the costliest among the industrialized nations of the world and that produces the worst outcome of care?

For the moment, envision what medical care was like immediately following WW II, about the time antibiotics came on the scene. Most people had a family doctor that they turned to for whatever ailment that arose. The family doc managed most illnesses with the tools available. He/she often did surgical procedures, delivered babies, treated broken bones, and even provided much of the psycho-social counseling of that era. The family physician was always available, accessible--a quasi-member of his patient's family--and never appeared to be obsessed with financial reward for his services.

As time passed, more specialization emerged: specialists in surgery, orthopedics, internal medicine subcategories, to name a few. Their presence in every community of any size provided the primary care physician, the family doctor, a referral source for complex problems. Quality of care, as measured by today's standards, improved remarkably with the arrival of more specialists, but at the same time the cost of care escalated.

Next came the federally funded Medicare and Medicaid programs and the beginning of the spiraling growth of private insurance. Blue Cross/Blue Shield led the pack. The insurance industry grew by leaps and bounds. This was followed by the "Managed Care" concept--the HMOs and Preferred Provider Organizations, and multple variant systems--structured to capture as many of the health care dollars as possible. These embryonic sub-systems of the 1990s as well as those of today have focused on profit margins, often using denial of benefits to achieve operating profits. Unfortunately most have neglected to impose adequate quality control measures as they have grown. 

Now, add to the hodgepodge of super-specialists, primary care physicians, insurance payers, the various reimbursement systems, and the multiple other healthcare providers that are competing for a share of the healthcare dollar--Hospitals, Nursing Homes, Day Surgery Units, Imaging Centers, Laboratories, Home Health Organizations, Rehab Centers, Specialty Hospitals--and you have our present fragmented system. It is the most costly per capita and has produced the worst outcome among idustrialized nations and leaves millions uninsured or underinsured.

So, what happens? Cost of care escalates out of control, quality of care deteriorates, greed drives providers to reach for more and more of the medical care dollars, some by performing medically unnecessary procedures and diagnostic testing, and others by having a financial interest in entities to which they refer. Consumers demand more care, whether or not medically necessary. Insurance companies simply smile when the cost and abuse increases: they raise the premiums, co-pays, and deductibles to cover the increase in skyrocketing cost, and take their management percent to the bank. 

Not eveyone can afford the costly health insurance even if it is available. It's not unusual for a family to have to allocate 50% of their expendable income either for healthcare insurance or for the staggering medical care expenses that they face if they don't have coverage. So often the only alternative is to choose bankruptcy.

How would a so-called "Medical Home" concept gives us a healthcare system that leaves no one behind, that contains overall cost, and improves the quality of care? The "Medical Home" model--an example is the Mayo Clinic in Rochester, Minnesota--is a comprehensive integrated concept that assigns patients a lead doctor, a primary care physician, who coordinates all of the patients care. This includes referrals for diagnostic testing, referrals to specialists, and referrals to ancillary facilities. The key to the success of health delivery systems, such as the integrated "Medical Home" model is simply this: Accountability. Every patient of the totally integrated system has access to needed healthcare: preventive care, emergency-urgency needs, treatment of crippling chronic disease, and necessary mental health care. Every treating provider--physicians, qualified medical provider, ancillary facilities--is held accountable for appropriate care, from the standpoint of quality, medical necessity, and cost.

Regarding reimbursement, an essential element for comprehensive healthcare is adequate compensation for the front-line primary care physicians who are in a postion to provide necessary preventive care and oversee referrals to competent secondary providers. Almost daily I hear stories of the difficulty people have in finding primary care physicians--family practice physicians and internist. Many of these sorely needed physicians are dropping out of practice or pursuing other medical fields. There has been a significant drop in the number of young physicians entering primary practice training programs. This must be corrected by adequate compensation for these doctors who will play such an important role in overseeing utilization and quality in integrated "Medical Home" concept or in any plan that's adopted to reform our healthcare system.

Another essential element that will insure quality of care as well as appropriate cost and outcome is the Electronic Medical Record (EMR)--it should be made available to all providers involved in the care of any specific patient, assuring transparency in the continuum of care by all caregivers. 

Is any system that conforms to the above description of a "Medical Home" attainable? Of course it is; but only if payers, consumers, and all providers buy-in to the concept, have input in developing criteria for medical necessity of care, and if our lawmakers refuse to yield to lobbyists for the greedy special interest groups who have produced the present national healthcare disaster and who advocate a continuation of the status-quo system.

Charles Clark, Sr., M.D.

www.charlesclarknovels.com

A Hoosier Problem

I've been thrown out of a lot of places in my lifetime, most of the time for reasons that I am not very proud of. But the recent ablation of my comment on the blog: Senator Delph [Rep, Ind]: Illegal Immigration Costs Hoosiers 'Millions' Annually on Health Care, Education makes me proud that I am a human rightist. I don't resent at all having my opinion deleted from the blog praising the tunnel-vision senator. I've reproduced my comment below for the benefit of anyone who might navigate through my website. I have the distinct impression that removing my comment is typical of many similar acts of deception that we've seen recently by our leaders in congress. Acts that have been responsible for the economic crisis, the healthcare disaster, and the management of the immigration crisis that we are seeing today. Read below and let me know you're thoughts.

Sure, take their education opportunities away. Let the children turn to gangs, turn to sexual exploitation, and turn to be drug-runners in order to survive. We don’t mind paying for the consequences of those social tragedies, do we?

Instead of helping these sojourners in our communities become good, self-sufficient, tax-paying citizens, let’s just grind them down, raid the workplaces, tear children away from their parents, put the family breadwinners in detention camps. And by all means let’s withhold health care. What have they done to deserve it? Not by being construction workers, housekeepers, restaurant workers, or engaging in countless other labor intensive jobs for the purpose of providing for their families and to make our lives more comfortable.

Senator Delph needs to ask Tim Kennedy of the Indiana Hospital Association if he has ever heard of the EMTALA law. If any of the illegal immigrants in Indiana are denied basic, outpatient health care they turn to emergency rooms where, by law, they can’t be turned away, and the cost of care does skyrocket. The same applies also to the millions of uninsured and underinsured “legals” in every community in the nation. The cost far exceeds the cost of health care for the “illegals”, most of whom are afraid to present themselves any place where they might be discovered and labeled as criminals.

I submit that Senator Delph consider focusing on the crisis issues of today–the economic disaster and the deteriorating healthcare system.

charlesclarknovels

www.charlesclarknovels.com

October 15th, 2008 at 11:29 pms

Health Care Reform 2009

At some point in time–hopefully before the Social Security System becomes bankrupt–our lawmakers and leaders have to accept the stark reality that a continuation of the same healthcare system that we have been accustomed to in the past is NOT going to work in the years ahead. The system must be totally reformed--restructured in a way that incentives for providers to provide more and more service, whether or not it is medically necessary, have to be removed. Reimbursement must be denied for referral of patients by physicians to entities in which they, the physician-providers, have a financial interest: entities such as laboratories, imaging centers, day surgery units, hospitals, home health agencies; or to entities from which a physician receives a stipend in return for referrals. Joint ventures between hospitals and physicians must be scrutinized thoroughly and should always be transparent insofar as the public is concerned.

If the cost of health care is ever to be contained, the concept that more is better must be abandoned. Likewise, the health insurance industry must abandon the policy of ignoring over-utilization of services by healthcare providers and subsequently raising the premiums, deductibles, and co-pays--to be paid by the insured--when the cost of health care escalates from the medically unnecessary over-utilization of services. The health insurance industry should be mandated to focus on appropriate utilization and quality, instead of on loss ratios.

Basic Healthcare is a right of every person in this country and it should be affordable, available, and accessible. No one should be left uncovered. There should be no denial of benefits based on pre-existing conditions. If anyone is economically underprivileged, healthcare should be available through special federally funded programs. Individuals who elect to avail themselves of unlimited services over and above Basic Healthcare--without concern for whether or not those services are medically necessary--should be privileged to purchase health insurance for that purpose, without compomising the cost of federally funded Basic Healthcare for every resident in the United States.

How do you define Basic Healthcare? It should be rich in practice guidelines for all health care providers to follow in their care of patients, and its structure should reflect a consensus of input from all providers--physicians, hospitals, ancillary free-standing entities, nurses, and ancillary service providers, all of which must be held accountable for the expenditure of the taxpayers' health care dollars.

Is any political candidate or lawmaker brave enough to ignore the overpaid lobbyists and make those changes? If not our broken healthcare system is doomed to self-destruction.

Medication Error Cover-up

On Wednesday, September 24, 2008, one of the Corpus Christi local television stations reported a news item of significant community interest. The Christus Spohn Shoreline Hospital, a part of the giant not-for-profit Christus Health System, was the site of a major medication error event: Eleven patients had been given doses of a cardiac medication by mistake instead of an innocuous drug ordered for some digestive disorder. There were two reports--on the 6:00 pm news and again on the 10:00 pm news. The report stated that the error had been confirmed, but the hospital officials had no comment other than to say they were looking into the occurrence. 

There has been absolutely no comment by any other news media and no comment or explanation by the Christus Spohn Hospital officials since. Isn't the public entitled to know: What were the drugs that were administered in error? What adverse effects could these drugs have produced? Was there any morbidity as a result of this error? What measures have been taken to assure that similar errors do not happen again?

The focus of concern by the hospital industry and the Joint Commission for the months and years ahead stresses the need for transparency and for patient safety . Can either goal be achieved with cover-up like we're seeing here with this occurrence?

A few weeks ago a medication error occurred in the same hospital system that received nationwide publicity--wrong dose of Heparin given to several newborn infants. It is understandable that the hospital would not want another life-threatening error to receive similar notoriety.

But the mystery still stands. How did the hospital manage to pull off the cover-up? And how often does cover-up occur?