Let's Improve everyone's health without spending more money!

Washington State Medical Association (WSMA) supports the Washington State Health Benefits Exchange

2012-01-18T14:35:00.000-08:00

The Washington State Medical Association (WSMA) has announced support for the Governor’s requested legislation on the Washington State Health Benefits Exchange (SB 6178/HB 2319), authorized by the Affordable Care Act. WSMA testimony before the Senate Health & Long-Term Care Committee and the House Health Care and Wellness Committee made the following points:

·         The WSMA supports an Exchange that promotes the purchase of health insurance, ensures administrative simplification, ensures patients have access to local providers, provides coverage for key benefits and promotes the viability of physicians and their medical practices.
·         Qualified Health Plans - Any decisions to expand Qualified Health Plan standards should be analyzed carefully with mindfulness towards barriers that can limit access to affordable health coverage.
·         Market Rules - The exchange must be stable and sustainable. Market rules imposed should keep an eye on affordability for patients and the viability of medical practices.
·         Powers of the Exchange Board and the Office of Insurance Commissioner (OIC) - In regulating the Exchange, the Board must be responsive to the interests and needs of Washington’s physicians and consumers. Policies that drive payment rates down to Medicaid levels will jeopardize access to care.
·         Washington High Risk Insurance Pool - WSMA supports operation of the WSHIP for patients who are most vulnerable. Consideration should be given towards keeping it open past January 1, 2014.

In my view, this common sense input is important advice to heed that will make our Washington State Health Benefits Exchange strong, sustainable and useful.

Announcement from Larry Thompson, Director of the Whatcom Alliance for Health Care Access

2012-01-06T11:26:00.000-08:00

A momentous accomplishment for our community that will go a log way to assist in our work to build a safe, efficient and effective Accountable Care Organization for Whatcom County.

"I am pleased to announce that the Center for Medicare Services (CMS) has recommended the Whatcom Alliance for Health Care Access (WAHA) for award of funds under the Care Transitions program (Project Impact). There are conditions on this award which have not yet been shared with us. We are scheduled to review these conditions by phone with CMS on January 17.

This is a multi-year award which carries with it up to $5.7 million to reimburse us for the cost of assisting patients to make safe transitions between care settings.

As you can appreciate, this is one key piece of several funding awards we must secure to fully implement the vision called for in our Phase I ACO work. On the other hand, the scale of the award relative to the current WAHA budget will present us all with stewardship and management challenges.

I would like to take this opportunity to thank our many community partners in this venture without whom this effort is merely a shell. As well, please join me in thanking our staff, especially Elya Moore, whose hard work and inspiration led to this success.

Larry Thompson"

3 Principles that can bring us together for meaningful healthcare reform

2011-12-19T14:43:00.000-08:00

The usual discussion about health care reform often resembles a food fight in middle school. Insults pass for argument, and facts get ignored or selectively presented only when they bolster one's opinion. What would it look like if we talked about what we all truly care about. Could we have a different discussion?

When I have discussed this issue with others in my community, there are 3 important principles that seem to ring true with most of us.

First, we need to invest in "us" and the future we want to build. If we envision America as a successful land of opportunity, it means that we need a healthy workforce, able to compete and healthy students able to learn new skills. Our investment now in an equitable system that allows that to happen is simply a requirement needed to make it so! This future will not happen by accident, and our failure to act now will doom our next generation to a future much different than we would like for them.

Secondly, we must end waste! It makes no sense to spend money on treatments that do not heal, or on complicated paper work that drives up costs. Fraud must be eliminated. Research on how to improve care must be supported, and the public should see the benefits!

Finally, we need to end cost shifting, and share the burden fairly. Medical pricing today makes no sense. The cash paying person is charged the most. Hospitals overcharge for some things to pay for what is not covered. Some people get a tax break on insurance and some do not. A healthy society needs every one to be covered, and the cost must be affordable for all, or our society will remain broken and care will remain out of reach for many.

A Twitter Debate about Health Care reform

2011-11-25T13:25:00.000-08:00

I had an interesting experience after I used Twitter to note and lament the resignation of CMS Director Dr. Donald Berwick. Craig Casey, an insurance agent in San Diego, sent several "tweets"disparaging Dr. Berwick and taking issue with"Obamacare". It is impossible for me to tweet an adequate reply to Craig, so I am using this column to reply point by point:
20+ million more on Medicaid equals Dr. shortage in / or rationing. you have elderly relatives Dave?
This statement assumes that these folks were not receiving care before, and that suddenly they will now show up! The reality is, however, that they have been seen for expensive and uncoordinated care in emergency rooms, and for complications due to no consistent primary care access. Obamacare will shift that to early primary care, and yes, we will need more folks to provide that care as things change.
Quoting his own comments about #Healthcare #rationing, he committed political suicide, no assassination. Good bye Obamacareite. Actually, Dr. Berwick has been a tireless advocate of safety in health care as head of the Institute for Health Care Improvement, and he has always focused on the patient and how we need to work together to achieve better outcomes of care. This work takes study and organization, which has caused him to step on a few toes in the insurance industry and elsewhere. This has lead to pressure by republicans in Congress to make his confirmation impossible. He should be proud of who his enemies are. Organized medicine has supported him completely.
The cost curve was bent upwards, health #insurance rates have jumped 20% since #Obamacare was passed UNaffordable care act. This is just not true. Insurance rates have been going up at an astronomical rate for years. The Employer Health Benefits Survey by the Kaiser Family Foundation, which specializes in health care issues, found that health insurance premiums have jumped by 9 percent in 2011. Drew Altman, president and CEO of Kaiser, said that the premium increase was not because of Obamacare but that the Obamacare law accounted for 1 to 2 percentage points. He noted, “It reflects the costs of covering young adults up to 26 years of age under their parents’ policies" and also "the costs of providing prevention benefits without cost-sharing". We can actually expect cost savings later from these measures!
Not when their reimbursement rates are being cut by the false promises of coverage via #Obamacare. This makes no sense to me. There is a problem at present due to the fact that Medicare rates are due to decrease 27%, because of the flawed update formula from years past, but that has nothing to do with Obamacare.
Since you And Berwick brought it up, MedPAC, IPAB, & CER. #Rationing equals #deathpanels. disprove it then. This is nutty talk. The reality is that we ration care now, and always have, by ability to pay. Even people with insurance are now often having trouble affording care. If we don't start paying for health care based on quality instead of volume, and work together to organize and provide services that we all need for a healthy and productive society, more of us will be priced out of needed care ever year. That is not an outcome that we can afford.

Dr. Donald Berwick Resigns as Head of CMS

2011-11-23T14:21:00.000-08:00

Donald Berwick, MD, a tireless advocate for patient safety in health care, has decided to resign his post as administrator of the Centers for Medicare and Medicaid Services (CMS), effective December 2. I am very sorry to see him go.

Dr. Berwick will have served only 17 months in the post. President Obama nominated Dr. Berwick, who was head of the Institute for Healthcare Improvement, for the CMS post in April 2010, a move that was hailed by diverse groups such as the American College of Physicians, the American Academy of Family Physicians, AARP, Walmart, and Consumers Union. Inspite ofthis broad based support, President Obama found that GOP opponents were blocking his Senate confirmation, as part of their all out strategy to stop health care reform. This caused the president to install Dr. Berwick as CMS administrator through a "pocket" appointment while the Senate was in recess, a special appointment that is set to expire by law at the end of 2011. Dr. Berwick was renominated in January 2011, but he still faced implacable opposition from Senate Republicans. His resignation, therefore, comes as no surprise.

According to news reports, Dr. Berwick told the staff of the Department of Health and Human Services in an email, that he had "bittersweet emotions", and that although their work was challenging and incomplete, that "we are now well on our way to achieving a whole new level of security and quality for healthcare in America."

Amen. I hope so. Thank you, Dr. Berwick, for your leadership.

How to not save money while providing healthcare!

2011-10-03T14:37:00.000-07:00

As of October 1st, the State of Washington has decided to "save money" on Medicaid (DSHS) medical care payments, by allowing maximum of three “non-emergency” visits to emergency departments each year. They have drawn up a list of more than 700 diagnoses as “non-emergent” that include such surprising symptoms as chest pain, abdominal pain, miscarriage and breathing problems, and the decision affects all Medicaid patients, including children.

Now all of us want to save money on rising health care costs, and if some is wasted in the emergency department, it makes good sense to try and reduce the waste, but this plan is ridiculous! People who go to the emergency department often do so because they have no regular physician or other alternative and they do not know where else to go. The "savings" the state thinks they will get will actually be a cost to the hospital who is not paid, and that will simply drive up costs for the rest of us. Limiting access to people in pain, having trouble breathing or having a miscarriage, without providing an alternative, is dangerous, unethical and wrong.

The Washington State state chapter of the American College of Emergency Physicians (WA-ACEP) has filed suit to void this action by our state Health Care Authority. Their action follows an unsatisfactory effort to work with the Health Care Authority before filing suit.

Any effort to save money in medical care must also address patient safety, effectiveness, timeliness, efficiency, equity and the needs of the patient. This action by the State of Washington fails on all levels!

We should be ashamed. We should be angry.

2011-08-31T20:22:00.000-07:00

What kind of a country do we want to be?

For some time now, we have been learning about the steady decline in the welfare of children in the United States. 20% of children now live in poverty, schools are often failing them, health care has been difficult to access, immunizations are down, families are stressed, and now we are informed in an extensive new study that the newborn death rate in the United States is now higher than in 40 other countries including Malaysia, Cuba and Poland. Our previous ranking was 29.

The great tragedy here is that many of these deaths can be prevented, with improved access to appropriate medical care, leadership for effective public health education, prenatal care and parental education and support.

Access to basic health care for all needs to begin first with our children. And it is the responsibility of all of us to step in, when parents are unable to. Yes, this is a moral issue, but also in our general self interest. The well being of today's children determines our future.

Our society is pursuing a self destructive course by failing to provide all of our children with access to good health, education and a nurturing environment to grow up in, while at the same time we indebt them by failing to pay our bills. We should be ashamed. We should be angry. This is why we need health care for all in this country. This is not the rich against the poor. All of us in these United States of America must compete against the world. There is no valid reason why our children should be handicapped in their start in life compared to those in Malaysia, Cuba and Poland. There is no good way to spin this.

WE'RE NUMBER 41! WE'RE NUMBER 41! Does that sound right to you? And we pay more than anywhere else.

These are the countries where a baby has a better chance of living in the first critical months of life:

Luxembourg
San Marino
Iceland
Japan
Singapore
Slovenia
Sweden
Andorra
Cyprus
Czech Republic
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Monaco
Norway
Spain
Australia
Austria
Belgium
Estonia
Israel
Netherlands
New Zealand
Portugal
Switzerland
Brunei Darussalam
Canada
Croatia
Cuba
Hungary
Lithuania
Poland
Republic of Korea
United Kingdom
Malaysia
Malta
Serbia
Slovakia
Chile
Latvia
Montenegro

Healthcare is changing in Whatcom County – be a part of it

2011-06-24T08:19:00.000-07:00

Free Community Forum - Help guide our new direction.
Friday, June 24, 2011,12 -6 PM, Christ the King Community Church, 4173 Meridian, Bellingham, WA

Click here for complete information

Bending the Cost Curve

2011-06-10T09:17:00.000-07:00

In the continuing debate about the budget crisis and health care reform many partisans continue to miss the fact that the process of healthcare and how we pay for needs to change, if we are going to affect the actual cost of care. For example, the State of Massachusetts has now officially endorsed a complete move away from fee-for-service and towards an ACO-like delivery system and financial reform. Blue Cross Blue Shield is the dominant payer in that State and has developed the model in the link to pay ACO-like groups of providers.

This is complicated stuff that is not susceptible to opinionated sound bites, and that is why the talking heads and politicians do not often address this issue, but it is critical to understand! If you are interested, you can check out 1 year of research on this model’s effect on cost and quality here:

Blue Cross Blue Shield Massachusetts Report Click Here

The results are very promising! This is how we "bend the cost curve" and this is an example of the needed change that I have been talking about!

The Character Assasination of Dr. Don Berwick

2011-03-14T12:05:00.001-07:00

Dr Don Berwick, one of the most highly qualified administrators ever nominated for public office, is about to be sacrificed on the altar of politics. Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, recently told reporters that he has discussed Berwick's nomination with Republican senators and they plan to oppose Berwick under any circumstances. “Republicans won,” he said about the nomination.

Trouble is, I don't remember hearing about any fight.

Tom Curry, Executive Director and CEO of the Washington State Medical Association wrote in his March 14th Monday Memo to physician members that:

This is one of those instances where it would be better to fight and lose (while defending one’s view of the underlying reform legislation) than “duck and cover”.

I agree. This deserves to be a fight - a big fight - a loud fight. Dr Berwick is a world leader in understanding the problems of quality and inefficiency in US healthcare. It is an area of study and learning that he has dedicated his life to. His nomination is supported by all of organized medicine. Why? Because physicians know the quality of his work and the seriousness of our problems. The barrier to his confirmation is, interests that profit from our current mess are going all out to scare people and paint Don Berwick as a radical who wants to ration their health care. Consider the website donberwick.com. This site is a project of The Heartland Institute, who according to sourcewatch is "a frequent ally of, and funded by, the tobacco industry" who "now refuses to publicly disclose who its corporate and foundation funders are". They are also known to have been funded in the past by the tobacco, oil and gas industry as well as the infamous Koch Brothers.

Do we want shadowy, secretly funded pressure groups paid for by big business to make our decisions for us, before debate occurs, or do we want a full discussion in the light of day? This is disgusting. Our legislators need to hear from us now.

Healthcare and YOU

2011-03-03T10:43:00.000-08:00

Sorry to say, but when it comes to understanding health care reform, our media have done a woeful job of keeping us informed and the general public remains very confused and unenlightened. For example, recent studies demonstrate that many Americans who believe they understand how the law works are actually thoroughly misinformed, and some are not even aware it is still in effect.A poll released by the Kaiser Family Foundation at the end of February found that about 20 percent of people wrongly believe that the law ended when Republicans in the House of Representatives voted to repeal it earlier this year, and 26 percent replied that they didn’t know if it was still the law or not! Well, it is.

What is a person to do if they would like to get a cogent, accurate understanding of the new law, without the partisan bias and media spin? Fortunately, there are now some good choices! A new site, called HealthCare and You.org avoids the heated politics behind the legislation and focuses instead on what the plan means for consumers. People who log on to the site can slect their state, age group, and circumstances to find a personal and customized explanation of the law’s provisions, with a timeline indications when portions of the law will take effect.The site has been developed by a coalition of groups t hat includes the American Academy of Family Physicians (AAFP), the AARP, the American Medical Association, the American Nurses Association; the Catholic Health Association; the National Community Pharmacists Association; the American College of Physicians; and the American Cancer Society Cancer Action Network. Check it out!

Want to find out what actual coverage options are available to you right now? Remember HealthCare.gov

The Best Care Anywhere

2011-02-22T13:48:00.000-08:00

I recently had an interesting encounter with a long time friend and colleague who left his private practice of family medicine and started work for the Veterans Health Administration in one of their new community primary care centers. "How's it going", I asked. "Are you happy in your new position?" I believe that his answer to me is something that everyone needs to hear.

My friend explained that the uncompensated hours he used to spend in his private practice dealing with administrative issues, multiple insurance requests, and conflicting drug formularies are now a thing of the past. "Unlike my life in private practice, my time is now completely devoted to the care of my patients, and collaboration within the practice on how to make our care better. I have scheduled time throughout the day to catch up on needed paper work and administrative duties, and we also have planned collaboration sessions with other VA health care professionals to learn and plan our team work for patient care".

The VA, once maligned in previous generations, has been quietly at work, transforming itself into what many now believe is the the highest-quality healthcare provider in the United States. They have done this by emphasizing access to primary care, creating health care teams that learn how to coordinate their care, and paying attention to the scientific evidence of what does and does not work for patient benefit. As a result, our United States Veterans Health Administration has become the only fully functioning, evidence-based healthcare system in the entire country.

Unfortunately the transformative changes in the VA are impossible to duplicate in our current private system, because of the way our current system is set up. As a doctor who works on healthcare improvement issues everyday in the real world, I have learned that the biggest barriers I face are insurance companies and the lack of planning and coordination among those who work in healthcare.

So, what are the lessons for us who struggle outside of the VA system as we plan for healthcare reform? For me, the answer seems clear:

Personal medical home - use this full service , primary care model as the template to deliver and organize our care
Payment reform - value the doctor's time and reward quality instead of volume
Use information technology - in a systematic and intelligent way to track care, identify outcomes and interact with our patients
Plan intelligently - so that needed access to care is available
Allow doctors time - for the planning and care coordination that is so necessary to improve their care and so undervalued today.

A great book to learn more about the change in the United States Veterans Health Administration and how it compares to our overall health care system is Best Care Anywhere: Why VA Health Care is Better Than Yours, by Phillip Longman.

How to Rate the New Health Care Changes

2011-01-02T08:05:00.000-08:00

The Affordable Care Act contains a series of provisions that are phasing in, as scheduled, until the final period of complete implementation in 2014. Now, with the advent of 2011, several provisions take effect which start to change things for all of us. I give each change a "thumbs up" or "thumbs down" rating below.

• New rule for tax-free savings accounts. If you have an HSA, like I do, so called non-prescription "over-the-counter drugs" that are not actually prescribed by a doctor are no longer eligible to be paid from that account. This is the kind of rule that might look good to a bureaucrat, but to me it is ridiculous. People now will be calling for prescriptions for their Tylenol, resulting in wasted time and money by all of us. Instead of saving money, this will be a fiasco. Thumbs down!

• Health-insurance companies “medical loss ratio”. Plans will now be required to spend at least 80 to 85 percent of the premium for actual medical care and quality improvements for patients, instead of administrative costs. Those that fail to do so will be required to issue a rebate to their customers beginning in 2012. The US Department of Health and Human Services says on www.HealthCare.gov that this will protect up to 74.8 million insured Americans from unreasonable rate increases. Last year, in 2010, we saw large increases from insurance companies who were attempting to pad their revenue before this provision took place. Thumbs up!

• Closing the Medicare drug coverage “doughnut hole.” Drug companies are now required to provide a 50 percent discount on brand-name prescription drugs to Medicare recipients who fall into the coverage gap in the Part D drug plans. Also, federal subsidies will be phased in for generic prescriptions in the Part D coverage gap. This gap will be progressively be closed over the next 10 years. It would be better to require competitive bidding by these companies, but this is a step in the right direction. Thumbs up!

• Medicare bonus for Primary-care physicians and general surgeons. These doctors will receive a 10 percent bonus payment for treating Medicare patients, which should help to encourage better access, although it is not enough, in my opinion to make much of a difference. Thumbs up!

• Preventive care for Medicare recipients. In a big change of philosophy, seniors will now be able to get free preventive services that include annual checkups and personalized prevention plans. No more waivers! Thumbs up!

• Medicare Advantage changes. Medicare recipients are eligible each year to choose private insurance companies for their care, a system called Medicare Advantage. We have all seen the adds! In the past, these plans were eligible for payments that were higher than ordinary Medicare, and these costs were born by increased premiums for all Medicare beneficiaries. Now, Medicare Advantage payments will be tapered down over the next few years to eliminate this subsidy. The new law has already resulted in higher premiums for many Medicare Advantage plans, but it prohibits these plans from raising cost-sharing requirements higher than what is required under traditional Medicare. Thumbs up!

• Center for Medicare and Medicaid Innovation. This center is already up and running and has launched multiple initiatives to test new ways of delivering care to patients that reduce costs and maintain or improve quality. One idea is an Accountable Care Organization (ACO), which is a new entity in which health-care providers can work together to contract for and manage care. Work is already under way here in Whatcom County to try and build such a system! Thumbs up!

• Community Based Care Transitions Program. One of the most expensive problems in health care, that also is a sign of poor quality is the readmission of discharged patients to the hospital right after they are sent home. This program seeks to improve care for seniors after they leave the hospital, by coordinating care and connecting patients back to services in their communities. Thumbs up!

• Medicaid incentives for prevention of chronic disease. The plan includes grants for states to help begin support services for Medicaid (low-income) recipients to cope with chronic problems, such as tobacco use, weight control, and various health conditions. Thumbs up!

All in all, things are slowly moving in the right direction. More details here: http://www.healthcare.gov/law/timeline/index.html

Act now to maintain access to your doctor if Medicare payment rates go down

2010-11-01T13:47:00.000-07:00

For some time now, people covered by Medicare have been having an increasingly difficult time finding primary care physicians who will accept them into their practice. This has been a problem due to the fact that low Medicare rates of payment make it very difficult for primary care doctors to be financially successful. Now, there is a danger that this access problem might become a full fledged crisis around the nation.

On December 1, 2010 Medicare rates for physicians are scheduled to decrease by more than 23%, and then, on January 1, 2011, rates are scheduled to go down another 7%. This is not because of health care reform, but rather is due to Medicare's sustainable growth rate (SGR) formula, which automatically pays doctors less if the use of medical services paid for goes up, in order to "balance the budget". Congress has avoided fixing this problem, and now, with a likely Republican majority in one or both houses of the new Congress pledging no new spending, it is very possible that nothing will be done to rectify the situation.

Is there anything that you or a loved one on Medicare can do to maintain future primary care access if this happens? Fortunately, yes there is! Look into signing up with a Medicare Advantage plan that your doctor accepts which contracts directly with physicians to provide care for Medicare patients. These plans often work in creative ways with physicians to enhance primary care coverage, and save money by screening and treating early to reduce costs. In my medical group, Family Care Network, we contract with four MA plans, and we ask all new patients to sign up with one of those in order to become a patient with us. Open enrollment for choosing a new Medicare Advantage plan begins November 15, 2010. A good approach is to ask your doctor's office what plans they work with, and then visit an independent Medicare insurance agency to review your options and pick the plan that is right for you!

10 big health reform changes yet to come

2010-09-24T14:58:00.000-07:00

Yesterday marked a major milestone in our progress to create a high-performing health care system for the United States. Provisions in the Affordable Care Act have now taken effect, such as the requirement for insurance plans to allow young adults to join or stay on their parents' plan until age 26, and a ban on insurance plans' practice of "rescinding" coverage after individuals get sick.

There are additional health care reforms are coming in the next months and years that I am looking forward to. These are designed to improve how our care is organized, delivered, and paid for. Here are 10 big changes yet to come:

1. Health Insurance Exchanges and New Market Rules
Health insurance exchanges will give us the ability to compare and choose among health plans, while setting the rules for fair competition.
2. New Nonprofit Plan Choices
Innovative, nonprofit cooperatives have transformed health care delivery into mission-driven, patient-centered, and value-enhancing systems that are accountable to patients and consumers.
3. Health Plans will be required to meet minimum medical loss ratios and requests for Insurance Premium Increases will be reviewed.

4. New changes to encourage primary Care and disease prevention
These include increased primary care payment rates under Medicare and Medicaid, preventive services without patient cost-sharing, and support of community and employer prevention and wellness programs. The act also increases funding for community health centers and the National Health Service Corps. These provisions start to focus our health system on primary care, encourages doctors o enter primary care specialties and get us ready for more fundamental payment reforms.
5. Stimulate Innovation
The Accountable Care Act establishes a Center for Medicare and Medicaid Innovation, which will allow us to test innovative payment methods for the personal medical home. Medicare reimbursement rates are decreased by 1 percent for hospitals that have high rates of readmission for certain conditions. Individual states will be allowed to test integrating Medicare and Medicaid-covered health services provided to the poor on Medicare.
6. Accountable Care Organizations
These are collections of health care providers that can formally assume responsibility for the cost and quality of health care given to a defined group of patients. Research has shown that ACOs have the potential to reduce growth in health care costs and improve patient outcomes by introducing incentives for efficient use of resources and encouraging greater coordination of care.
7. Independent Payment Advisory Board
This board has authority to identify areas of waste and opportunities for improving the quality of care for Medicare beneficiaries. The board’s recommendations will take effect in years when Medicare costs are projected to exceed predetermined rate-of-increase targets—unless Congress passes legislation to override those recommendations, in which case Congress would be responsible for achieving the same level of savings.
8. Quality Improvement and Public Reporting
The law requires public reporting of physician quality and patient experience through a "Physician Compare" Web site for Medicare beneficiaries. It also makes Medicare data available for pooling with data on provider performance from other payers—an important step toward creation of an all-payer provider performance database. (Privacy will be protected.) Reports by health plan will be available to the public.
9. Medicare Private Plan Competition
Plans must compete on value, quality and service, and will no longer receive extra funds.
10. A Tax on High-Premium Health Insurance Plans
The new law imposes a 40 percent excise tax on health plans with premiums in excess of $10,200 for individual policies and $27,500 for families, to take effect in 2018. This will be adjusted in case of unexpected increases in medical costs prior to 2018.

A Great Opportunity to Discuss Progress in Health Care

2010-08-27T14:50:00.000-07:00

The origin of tour word for doctor comes from the Latin word doceō, which means "I teach". We have recently been living through an explosion in medical knowledge, and for this reason, the doctors of the Whatcom County Medical Society are proud to present an event every fall that seeks to communicate with our patients around these developments. The Mini-Medical School is presented by Medical Society members on current topics of interest or controversy in medicine. Beyond physicians sharing information, these presentations offer an opportunity to talk with physicians about how they think about health and disease, how they analyze problems and how they apply science in their work. I hope that we have a great turnout. Here is this years schedule!

Wednesday, September 8 “Food Sensitivity: allergies, intolerances and strong convictions”

Dr. Kevin Dooms, Bellingham Asthma, Allergy and Immunology

Wednesday, September 15 “Health Care Reform: what’s in it for me?”

Dr. David Lynch, Family Care Network

Wednesday, September 22 “Whatcom CSI: fact and fiction of death investigation

Dr. Gary Goldfogel, Whatcom County Medical Examiner

Wednesday, September 29 “The Evidence is Clear: surgery is the most effective treatment for obesity and diabetes”

Dr. Walter Medlin, PeaceHealth Medical Group

Wednesday, October 6 “Cancer: the art and science of diagnosis and treatment”

Drs. Ian Thompson and William Hall, Northwest Radiation Oncology Associates

Wednesday, October 13 “Vaccine-preventable diseases and vaccines: how safe and how effective?”

Dr. Greg Stern, Whatcom County Health Department

All lectures are free to the public and will be held 7:00—8:30 p.m. at St. Luke’s Health Education Center, 3333 Squalicum Parkway, Bellingham, WA

Information: call (360) 676-7630 or email: wcms@hinet.org

The right man for the job has Bellingham and Whatcom County connections

2010-07-07T08:53:00.000-07:00

The White House has announced that President Obama will bypass the nomination process of the United States Senate in order to make a recess appointment of Dr. Donald Berwick to be the head of the Centers for Medicare & Medicaid Services (CMS). This is due to the fact that the White House has been unable to even get a hearing scheduled by the Senate, much less go through the process.

I believe that this nomination is of great importance, and it signals that the administration is serious about moving forward on creative and needed health care reform. Dr. Berwick has been universally praised by a wide spectrum of health care leaders as the best man for this job. President Obama has chosen a strong advocate for a patient-centered health-care system to be in charge of much of health-care reform. This is a very good thing!

There are three aspects of health-care reform that must be considered simultaneously if we are to achieve real reform - cost, access and quality. Cost and access have both proven to be politically polarized topics. Quality, however, should be what unites us all, and that is the experience that Dr. Berwick brings to the table. Dr. Berwick has done more than anyone champion quality and his organization, the Institute for Healthcare Improvement (IHI), is famous among physicians for catalyzing health-care providers around how to improve their care and decrease error. This should not be an ideological issue. Unfortunately, the radical right has already pounced on this announcement, and referred to Berwick as a "radical". This is a tragedy. If Dr. Berwick is a radical, it is because he favors that health care reform must revolve around thechoices, preferences and desires of patients, and not insurance companies. That truly would be a radical change from what we have today. He elevates the needs of patients above insurance companies, government or medical providers.

It has been my privilege to work with Dr. Berwick right here in Bellingham and Whatcom County. The Pursuing Perfection project began in 2001, when Family Care Network and St. Joseph Hospital worked with other community partners to reorganize their work around the patients that we serve. We were one of13 locations in the US and Europe to focus on fundamental improvement in patient care throughout the health care system, and Dr. Berwick traveled to meet with us as a part of the involvement of IHI. He is the real deal.

If a man like Dr. Don Berwick cannot find a smooth confirmation because of political polarization, then no leaders can. That means that the best people will continue to ignore the call of public service, since an unimpeachable record of achievement will be less important than political ideology. What a shame. No, what a tragedy.

A Creative and Welcome Development

2010-05-31T10:16:00.000-07:00

The State of Washington has just announced the creation of the Washington Health Program, which is a non-subsidized version of the Basic Health Program (BHP). Like the Basic Health Program, the new offering is administered by the Washington State Health Care Authority (HCA).

This is a creative and welcome development! Washington residents currently have few, if any, affordable options for health care coverage. Right now, there are more than 100,000 people on the BHP waiting list, who cannot enroll due to a lack of funding by the state. The Washington Health plan will provide folks with a more affordable option designed for basic, no frills medical care coverage. The new program provides essentially the same benefits as the BHP, but with no subsidy and no cost to the state. Enrollees pay the entire premium, plus a small amount for administrative costs.

The HCA is contracting with Community Health Plan (CHP) of Washington to provide the coverage. The plan lowers the purchase cost by including a cap on annual costs. Enrollees having the option of choosing a $75,000 or $100,000 expense cap in health care coverage per year. According to past experience, less than 2% of BHP enrollees accumulated $75,000 or more total cost in 2009.

Some details from the HCA:
· Premiums are to be as low as $100 per month.
· A 35 year-old could expect to pay between $125 and $183 depending on their location and the coverage options they select.
· Washington Health is available to any state resident who is not enrolled in the BHP, Medicaid, or eligible for Medicare.
· It is designed for low income people, but there are no income limitations. It is available statewide.
· Community Health Plan (CHP) is contracted mainly with federally qualified community clinics, and there are few private primary care physician in their network.
· Coverage is expected to begin July 1 and applications are being taken now through the Washington Health website at www.washingtonhealth.hca.wa.gov. Applications can also be requested toll-free at 1-800-660-9840.

The Dawn of a New Day - 5 BIG wins in the Health Care reform Act

2010-03-25T10:56:00.000-07:00

1. Health insurance companies will not be able to discriminate against you because you have a pre-existing condition.

The problem has been that millions of adults and children have been denied insurance specifically because they have a medical condition. The Kaiser Family Foundation says that 21 percent of people who apply for health insurance on their own get turned down, or charged a higher price or offered a plan that does not cover their pre-existing condition. This will stop!

2. Young adults will be able to keep their parents' insurance until age 26.

The health care reform legislation requires insurance companies to allow dependent children to stay on their parents' insurance policies until age 26. The children can't have jobs that offer insurance, and they must be claimed as dependents on their parents' taxes.

Currently dependents get booted off Mom and Dad's health insurance much earlier than this, depending on the state they live in, sometimes as early as age 19. This will stop!

3. You will be eligible for a subsidy to buy insurance if you make less than $88,000 per year for a family of four.

Starting in 2014, the health care reform bill provides subsidies for people who don't get insurance from their employers and therefore have to buy it on their own. The amount of the subsidy will computed based on your income, whether you're single or have a family, your age, and where you live. For example:

• A 40-year old making $30,000 a year in a medium-cost area of the country will get an $850 subsidy toward buying a policy, which should cost about $3,500, according to a Kaiser Family Foundation subsidy calculator.

• A 40-year-old in the same city who has a family of four and is making $60,000 will get a $4,220 subsidy toward a policy that costs $9,435.

You can estimate your own subsidy by using this Kaiser subsidy calculator.

4. If your employer does not offer insurance, that might change!

Starting in 2014, if your company employs more than 50 people, it will be required to offer you a health plan that covers at least 60 percent of your overall health costs, or the company will be fined $750 per year per full-time worker. That fine could increase to $2,000 if the reconciliation act passes.

5. Health care reform has major benefits for senior citizens!

The AARP reports that health care legislation does important things for seniors:

It gives people on Medicare new access to free preventive services such as screenings for cancer and diabetes.
It will decrease and then, by 2020 it will close the "doughnut hole," Part-D drug payment gap where Medicare stops paying once a senior has spent more than $2,830 on prescription drugs and resumes when the individual's out-of-pocket spending has reached about $4,550.
Spending for Medicare beneficiaries is budgeted to increase 2 percent each year.

Surprise! People favor passage of health reform

2010-03-23T18:07:00.000-07:00

A telephone survey of 1,005 adults was conducted by the Gallup organization on March 22, the day after Congress enacted health reform legislation. The margin error is 4 percentage points. The results show that "More Americans call Congress' passage of a healthcare reform bill "a good thing" (49%) than call it "a bad thing" (40%). Reaction is predictably partisan, with independents evenly divided.

In my opinion, when folks really get to understand how this bill will interrupt our endless cycle of cost increase and non coverage, that support will continue to increase!

Gallup concludes, "Passage of healthcare reform was a clear political victory for President Obama and his allies in Congress. While it also pleases most of his Democratic base nationwide, it is met with greater ambivalence among independents and with considerable antipathy among Republicans. Whether these groups' views on the issue harden or soften in the coming months could be crucial to how healthcare reform factors into this year's midterm elections. Given that initial public reaction to Sunday's vote is more positive than recent public opinion about passing a healthcare reform bill, it appears some softening has already occurred."

On the first day that health reform becomes law

2010-03-21T08:49:00.000-07:00

The United States House of Representatives is poised to take an historic vote today on whether or not to implement health care reform. You will often hear opponents say that the bill does "not take effect" until 2014, but actually, there are many improvements that will occur right away. This is a good time to reflect on what this vote could mean for all of us.

On the first day that health reform becomes law:

· Annual caps on coverage will be eliminated
· Rescisions - the practice of dumping people even if they have paid their premiums – will be eliminated
· Pre-existing conditions for children will be eliminated, followed later by the elimination of all pre-existing conditions
· Parents will be allowed to have their children on their health insurance policy until age 26
· The "Donut Hole" Medicare Part D drug coverage gap will be decreased with a $250 rebate

In short, in addition to expanding coverage, reducing the deficit and helping to decrease costs, there is a lot other immediate benefits to like in this new bill. We need to encourage our representatives not to blink, and to take this momentous step for all of our citizens.

Guess which country in the graph below has the worst health care statistics

2010-02-22T20:23:00.000-08:00

You will often here the opponents of health care reform say that costs are increasing all over the world, and not just here at home. As the graph above makes clear, the costs of US health care are rising much faster than anywhere on the planet. In 2009, health insurance companies made their largest profits in history, and still dealt out staggering premium increases. And after all of this. some people are still scared of some government regulation? We are a nation of suckers!

We can do this

2010-02-05T12:02:00.000-08:00

The US Center for Medicare and Medicaid Services has just reported that U.S. health spending reached $2.5 trillion in 2009, and that health care's share of the economy grew 1.1 percentage points to 17.3 percent. This is the largest one-year increase in health care spending since the federal government began keeping track in 1960. Where I work, our insurance asked for a 35% rate increase to maintain our employee coverage for one more year. The same thing happened to my wife's family business this year. This experience has been repeated all over the country.

These findings underscore the fact that we are all experiencing an unprecedented "Tax" on the cost of our health care, except instead of coming from the government, it is being imposed by the insurance industry, who simply pass along their cost of paying for our dysfunctional system, while they also charge us for lobbying our Congressional representatives to stop needed reform. This is sick.

It is time to become outraged! The need for comprehensive health care reform to rein in unsustainable spending growth has never been more clear. The increasing burden on American families, businesses, and our state and local governments cannot be sustained.

What can we do now? Is there anything that might attract bipartisan support? Assuming that the minority party is willing to also work on this, I think that implementing a few modest steps now would help tremendously:

Require that all be covered, with subsidy for the poor, and real penalties for those who opt out.
Eliminate pre-existing conditions and have true community rating.
Establish an online health plan marketplace in each state where plans can compete on benefits, service and price. Allow national plans to compete, but do not eliminate local plans.
Monitor quality results by plan, and publish the results for all to consider when purchasing.
Allow everyone to have an income tax deduction for their plan costs (not just employer plans) up to a certain annual cost.
Enact reasonable tort reform legislation that actually directs most of the money to those who are injured.
Require payment reform for care delivery, that incentivises provision of primary care, and encourages doctors and hospitals to provide the best care (not the most expensive), and are aware of and held accountable for their quality of care results.

We can do this, but only if our law makers work together and stop playing gotcha like middle school students. Actually, I apologize to the middle school students. They would do a better job.

"We have met the enemy, and he is us!", Pogo

2009-12-30T05:36:00.000-08:00

The US House and the Senate have both passed health care reform bills, and it is now up to the Conference Committee to craft a compromise bill that must then be passed by each legislative body. If a bill is ultimately signed into law by President Obama, we are likely to hear years of arguments as to whether or not this bill is a good or bad thing for our nation.

What likely will not be debated, however, is our corrupt and sclerotic political system that has produced these bills. Instead of honest debate, and collaboration about how to solve a problem, we have been treated to our representatives cynically selling their votes for this bill in order to to "buy votes back home" from local voters who continue to fall for this kind of nonsense. Want examples? Here are just a few:

Senator Ben Nelson, D-Neb., has insisted that the federal government promise to pick up the full cost of Medicaid expansion in his state, costing about $100 million over 10 years, paid for by the residents of other states. In addition, he insisted that a private, physician-owned hospital being built in Bellevue, Neb., be able to get referrals from doctors who own it, which according to new regulations will be illegal throughout the rest of the country.

Senator Christoper Dodd, D-Conn., procured $100 million dollars for construction of a hospital at a public university in his state.

Senator Patrick Leahy, D-Vt., negotiated $600 million in additional Medicaid benefits for his state over 10 years. Massachusetts is getting $500 million in Medicaid help for similar reasons, all paid for by those of us in other states.

Senator Mary Landrieu, D-La., extracted an extra $300 million in special funds for a new "Louisiana Purchase."

Senator Joe Lieberman, I-Conn.,along with most Republicans, has just taken the insurance money and tried to stop everything those lobbyists do not want.

Longshoremen union supporters of Democrats were exempted from most of a new tax on high-value health insurance plans, as were electrical linemen, police officers, firefighters, emergency first responders and workers in construction, mining, forestry, fishing and certain agriculture jobs.

As citizens can vote these people out of office any time we want, and yet we do not. We can insist on ethical behavior, but we do not. Yes, these bills are a complicated mess in many ways, although probably the best that we can do for now.

The problem is us. When we continue to re-elect corrupt, cynical politicians, who buy our votes with our own money, we get exactly what we deserve. So far, they have not been able to underestimate us.

All I want for Christmas!

2009-12-10T17:27:00.000-08:00

The Cost of Dying, 60 Minutes, November 22, 2009

2009-11-22T23:29:00.000-08:00

60 Minutes presented an outstanding program that tells the story in human terms about how our country manages to waste so much money while not properly caring for those we love at the end of life. If you missed the program, take 14 minutes of your time to watch this outstanding piece of excellent TV journalism.

The Cost of Dying, CBS TV 60 Minutes, November 22, 2009

Two News Stories that Help to Make It Clear Why We Need Comprehensive Health Care Reform

2009-11-09T09:05:00.000-08:00

Big insurers spend much less on medical care than previously reported

Dow Jones Newswire reports that a US Senate Commerce Committee investigation found that the six largest US health insurers spent less on medical care than what industry officials estimated. Of the total amount received in premiums by the companies in the individual insurance market, 74 cents of every dollar were spent on medical care, according to a review of publicly available of data on industry earnings. Meanwhile, America's Health Insurance Plans estimated that the industry spent an average of 87 cents of every premium dollar on medical care. Click Here for Complete Story

HMOs planning large 2010 premium increases despite strong 3Q earnings.

Forbes Magazine notes that although "most of the major managed-care companies" have announced strong 3Q results, the message "during this earnings season is that HMOs are focused on rebuilding margins, even if it makes insurance even less affordable." Goldman Sachs analyst Matthew Borsch "calls it 'the highest pricing trend in years.' The premium increases he's seeing are in the neighborhood of 13 to 15 percent for next year." Analysts say HMOs are concentrating on making up for operating profit margins, which "reached zero last year for the industry as whole." Moreover, the companies not only want recompense for the "higher costs" they incurred this year from COBRA, they must "cover rising ordinary medical costs that show no signs of slowing down." Barclays analyst Joshua Raskin predicts overall health spending in 2010 will "climb 9 percent."

Click here for the complete story

The bill is HR 3962, the Affordable Health Care for America Act

2009-11-03T07:48:00.000-08:00

The Whatcom Alliance for Health Care Access is a long time community health care study group that I participate in, which is dedicated to improving access and quality of care in Whatcom County, Washington. It is composed of citizens from all walks of life and segments of society. On November 2, 2009, they reviewed HR 3962 and released their findings. What follows is my edited version of their conclusions.

General Comments on the Bill

• This is a very comprehensive reform package that lays the ground work for providing changes and incentives to the delivery system that will reduce waste and improve outcomes overtime.
• Strong, thoughtful approach to Medicare payment reform that will result in implementation of recommendations over time
• Recognition and inclusion of reform initiatives. Specifics include a focus on wellness and prevention, expanding support for primary care training, creating opportunities for state and community level pilot projects and innovations and recognition of the importance of consumer engagement in reducing costs and improving outcomes.

Specific Comments Relative to Principles of Reform

1. Need to provide coverage and care for all people at all times regardless of age, employment status, economic circumstances and preexisting conditions
• Bill effectively addresses underwriting issues relative to age, health status and pre-existing conditions and creates level playing field for public and private market
• Bill provides options for all individuals (including low income) and most businesses to access affordable and in some cases subsidized health coverage through the exchange or through Medicare or Medicaid

2. Need to improve patient outcomes and reduce waste through improved care coordination, and a focus on primary care and preventive care.
• Emphasis on reduction of waste and fraud throughout bill including provisions in Medicare and Medicaid changes are seen as addressing this issue
• Reform elements throughout bill to increase primary care training including expanding residency options seen as positive
• Medical home recognition and including support of medical home pilot programs and shared decision making seen as effective
• Elimination of co-payments and deductibles for preventive services in Medicare and Medicare supports access to preventive care
• Grant program to help small employers to strengthen workplace wellness programs and support of community preventive services grants seen as important steps.

3. Need to assure consumer choice of providers and public and private plans
• Addressed through establishment of exchange and creation of a self sustaining public option.

4. Need to simplify the system (insurance administration, etc.) so that it is user friendly (understandable and transparent to consumers.)
• Creating level playing field in terms of underwriting and enactment of administrative simplification to reduce paperwork, standardize transactions and improve transparency seen as important step forward

5. Need to control costs and improve quality of care by reforming the payment system so that it rewards results and not activity and holds providers accountable for outcomes not procedures.
• Increased payments for primary care under Medicaid important step
• Addressing of Medicare payment rates based on geography and geographic variations in health spending through IOM studies with provisions for adopting recommendations is needed for cost control and quality improvement in Medicare
• Provisions for Center for Medicare and Medicaid Innovation creation and empowerment, creation of Accountable Care Organization program and Comparative Effectiveness Research Agency all needed to identify quality measures, provide the science to implement evidence based care and provide the incentives for the delivery system to implement those changes
• Changes to Medicare Advantage plans seen as supporting this principle

Some Persisting Questions and Issues

1. Affordability will be an ongoing challenge that needs to be monitored and addressed. How will that be handled?
2. What role will the public options play in health reform proposals to drive innovation?
3. Is financing adequate and sustainable?

A Sad Irony

2009-10-22T07:31:00.000-07:00

Senate Democrats lost a key vote October 21st on a $247 billion dollar measure to avoid decreased Medicare reimbursement payments to doctors over the next 10 years. This would not have been an increase, but would have simply kept them at the same level they are now. The proposal was blocked in a 47-to-53 vote and thirteen Democrats broke with their party's leadership to join a unanimous Republican opposition.

Why is this a big deal? Well, the irony of this vote is that is that we may be passing health care reform to expand care availability to the general public, while decreasing access for Medicare patients to needed primary care if this vote stands.

This measure had been separated from broader proposals to overhaul the nation's health care system, because it is a separate problem that predates health care reform proposals. Under the current formula, Congress balances the Medicare budget by decreasing doctors payments to compensate for increased utilization by the public. Primary care is hit particularly hard, since those doctors have high office overhead costs that must be paid. A 21% cut is planned for January 1st, and 10% cuts are foreseen every year thereafter. Since doctors are already limiting access for Medicare patients due to existing low payments, it does not take a genius to understand that this payment decrease will be a catastrophe for Medicare patients. How sad that 53 members of the United States Senate either do not to understand that, or cynically do not care.

What doctors think about health care reform

2009-09-28T12:42:00.000-07:00

What do doctors think about proposed health care reform? The voices of physicians in the current debate have beenalmost exclusively from national physicians’ groups and societies, and little has been known about "the doctor in the trenches" and how they view things. A recent study the The New England Journal of Medicine sheds new light on this issue.

Turns out that a majority of physicians (62.9%) support reform that includes both a public andprivate plan options. 27.3% support reform offering only private options.

Read the entire article here

One reason medical care is so expensive: We All pay a Hidden Tax

2009-09-23T09:07:00.000-07:00

Those of us who currently have private health insurance pay a "hidden tax", included in our premiums, to pay for costs incurred by those without coverage. A new study now calculates that cost to be $1,017.00 per family in 2008, which is in addition to the actual taxes paid to support Medicaid and other government programs.

In 2008, the uninsured received $116 billion worth of care from hospitals, doctors, and other providers, which was usually provided for emergencies that could no longer be ignored. Those costs had to be paid for somehow, and they were covered in the following ways:

On average, the uninsured themselves paid for more 37 percent of the total costs of the care they received.
Government programs and charities, paid for another 26 percent of that care.
The rest, approximately $42.7 billion in 2008, was unpaid (So called "uncompensated care").

To cover the rest of this "uncompensated care", the cost was shifted to private insurers by charging more for health services. These charges then result in the higher premiums we all pay. In 2008 the extra charge for family health care coverage was $1,017.00 and for a single person was $368.00.

The next time you here someone bemoan "increased taxes" to pay for health care reform, remember the truth. We need to get rid of the tax we already bear, and substitute a planned system that actually gets people in for needed care before things fall apart, thereby saving us all money.

Click here to read a full copy of the report.

Do we wish to be the only rich nation in the world that lets a 32-year-old woman die because she can’t get health insurance? Is that really us?

2009-09-13T10:43:00.000-07:00

"Nikki was a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance." Nicholas Kristof tells the true story of Nikki White in an Op-Ed column in the New York Times on September 13, 2009.

The story of Nikki White graphically explains what is wrong with our current system, and why health care reform is so desperately needed. After she lost her job and health insurance, Nikki tried everything to get medical care, but no insurance company would accept her. As Kristof explains, "She spent months painfully writing letters to anyone she thought might be able to help. She fought tenaciously for her life.

Finally, Nikki collapsed at her home in Tennessee and was rushed to a hospital emergency room, which was then required to treat her without payment until her condition stabilized. Since money was no longer an issue, the hospital performed 25 emergency surgeries on Nikki, and she spent six months in critical care."

Here is the irony - “When Nikki showed up at the emergency room, she received the best of care, and the hospital spent hundreds of thousands of dollars on her,” said her step-father, “But that’s not when she needed the care.”

By then it was too late. In 2006, Nikki White died at age 32. Her doctor, Amylyn Crawford, said, “Nikki didn’t die from lupus, Nikki died from complications of the failing American health care system.”

Access to early, appropriate health care is something that any of us can loose without warning. We need reform. I do not want to live in the only rich nation in the world that lets anybody die because they can’t get health insurance.

Click here to read the entire article by Nicholas Kristof.

How American Health Care Killed My Father

2009-09-06T12:07:00.000-07:00

That is the provocative title of an article by David Goldhill in the September, 2009 issue of The Atlantic monthly magazine. After the needless death of his father, Goldhill began a personal exploration of the health-care industry. He found that for years it has delivered poor service and irregular quality with an astonishingly high cost. It is a system, he argues, that is not worth preserving in anything like its current form, and he believes that the timid health-care reform now being contemplated will not fix it. His insights as a non-health care professional business executive, who looks at things from a business point of view, are profound, and I encourage everyone to read the article. You understanding of the compelling need for change will be enhanced.

So, if change is needed, what is the experts prescription for change, in a nutshell? In a September 6, 2009 article from the The Brookings Institution a group of 10 health care policy experts detail a set of concrete, feasible steps to revamp the system to control cost and improve saftey and quality. The plan, “Bending the Curve: Effective Steps to Address Long-Term Health Care Spending Growth,” focuses on reducing the growth of health care spending, while also improving quality.

Their strategy consists of four interrelated pillars:

First, we all need better information and tools to be more effective in getting the right care.
Second, payments to health care providers should reward improvement in quality and reductions in cost growth, while emphasizing disease prevention and coordination of care.
Third, health insurance markets must be reformed and government subsidies restructured to create competition and improve incentives around value improvement rather than risk selection. This will require all to be covered in some way.
Fourth, people need support for improving their health and lowering overall health care costs, including incentives for achieving measurable health goals.

The report is well worth a read, in order to understand each of the pillars. Only by being informed on the issues so we know what is really being suggested can we cut through the claims of those trying to derail needed change. You can get a copy of this report by clicking on this text.

The emotion you are feeling is “Frustration”

2009-08-20T10:13:00.000-07:00

Are you frustrated with our current health care system? Does health care reform address your frustration?

Let's get real! Here is a run down on what people are frustrated about, and what the facts are about proposed reform!

Frustration: I can lose my insurance if I am out of work or my company cannot afford the benefit.
Frustration: I may not be covered due to a pre-existing condition, even though I have insurance. They can decide not to pay after I get sick!
Reform includes health coverage for all US citizens regardless of age, employment, wealth or pre-existing conditions.
Frustration: I can't find a primary care doctor to be my partner to focus on prevention, health and coordination.
Reform includes support for primary care, in order to train more specialists in this area to meet this need.
Frustration: I do not have a choice of who I see with my current insurance.
Reform includes assurance that you will have a choice of plans, providers and hospital, both public or private plan.
Frustration: The system is so complicated, I do not understand my insurance, and there is so much paper work.
Reform includes simplified regulations and uniform rules for you and your doctor, so that it is user friendly and understandable.
Frustration: Costs keep going up too fast! I struggle to meet my share of the bills.
Reform includes a change in the rules of the game, in order to help you get the best care the first time with the best quality results. This can lead to better care and lower costs for all of us.
Frustration: We are losing jobs because of the high cost of American products due to expensive insurance, and this makes me worry I may lose my job.
Reform will take away the extra costs that insurers must pay for those who are not covered. America will become more competitive.

All of us will benefit from reform. Even those of us who have good coverage right now. We need to get real. We need to do this.

2009-08-17T13:54:00.000-07:00

Thanks to David Horsey at the Seattle Post Intelligencer for today's commentary in the form of this cartoon.

Originally published on Sunday, August 16, 2009 in the Seattle PI.

Ugly Spectacle Endangers Reform

2009-08-15T10:19:00.001-07:00

During the 2008 presidential campaign, Nobel Prize winning journalist and economist Paul Krugman warned that upon assuming office, President Obama would face “an unending procession of wild charges and fake scandals, dutifully given credence by major media organizations that somehow can’t bring themselves to declare the accusations unequivocally false.” In his column in the New York Times, Krugman now asks, "So, how’s it going?"

Sad to say, Krugman has hit the nail on the head, and the scurrilous attacks on the president over health care have no relationship to anything he is actually doing or proposing.

Take for example the claim that health care reform will create “death panels” (according to Sarah Palin) that will send the elderly off to an early grave. It’s a complete fabrication. Grossly and maliciously untrue. The provision actually provides that Medicare will pay for end-of-life counseling requested by the patient was initially introduced by Senator Isakson, a Republican from Georgia. No one screamed at him about this, and he continues to say that it’s “nuts” to claim that it has anything to do with euthanasia. Before this current campaign, some of the current peddlers of the euthanasia smear, (for example, Mr. Gingrich and Mrs. Palin) were both on the record as being supporters of “advance directives” for medical care in the event that you are incapacitated or comatose. Not only that, but legislation to establish the Part D Medicare drug program during the Bush Presidency also established counseling for advance directives. No false outrage was seen at that time.

The smear continues to spread, and I am saddened to see that so-called moderate Republicans, such as Senator Grassley, (R) Iowa, have endorsed the lie. As Krugman notes, "his role in the health care debate has been flat-out despicable". Senator Grassley claims that Senator Ted Kennedy’s brain tumor would not have been treated properly in other countries because they prefer to “spend money on people who can contribute more to the economy.” This week, Grassley told an audience that “you have every right to fear,” that we “should not have a government-run plan to decide when to pull the plug on grandma.”

Right now the politics of opposition are an ugly spectacle. When the distorted paranoia of some worried citizens is cynically manipulated by Republicans and special interest groups to fuel the mistrust with out right lies, is a very worrisome trend.

Those of us who support reform also need to tap into our sense of passion and outrage. Passion to achieve a family doctor for every family, lower cost, freedom to choose and coverage for all Americans, and outrage at the lies and fear-mongering that are being used to block that goal.

Now is not the time to shrink from the debate.

PolitiFact.com is A Place to Find out the Truth!

2009-08-13T13:46:00.000-07:00

www.PolitiFact.com is a project of the St. Petersburg Times, the same newspaper that won the Pulitzer Prize for outstanding coverage of the 2008 presidential election.

This web site is the place for you to check the truth about claims made in the US health care debate. Reporters and editors from the Times fact-check statements by members of Congress, the White House, lobbyists and interest groups and then rate them on the "Truth-O-Meter". Amazing! Someone in the press doing actual journalism. The ratings range from "Pants on Fire" (recent winner Sarah Palin) all the way to "True". Check out these recent "Pants on Fire" rulings and enjoy yourself.

Report from a Town Hall Meeting, Mt. Vernon, Washington

2009-08-09T11:56:00.000-07:00

The news had been full of reports of angry crowds with rude and obnoxious behavior, harassing members of Congress who were attempting to discuss health care reform with constituents, so it was with a little trepidation that I set out for the 2nd of 3 meetings hosted by Congressman Rick Larsen for Washington's 2nd Congressional District. Could the normally respectful and open minded people I live and work with behave this way? Turns out, I need not have worried!

So many people came to the meeting that the large auditorium was completely filled, and a crowd of thousands spilled over into the outside lawn. Speakers were set up so that all could hear, and Larsen made a point of coming out on to the lawn area to take questions. Congressman Larsen treated everyone with patience and respect. Oh, to be sure, there were some who seemed bent on stoking ill will, such as the guy who had a picture of the President defaced to look like Hitler. These folks were far outnumbered by those who came to listen and have true dialog, and when the Congressman singled out the picture of President Obama as Hitler, to say it was not reflective of true and honest criticism and debate, there was a loud and prolonged applause from 90% of those in attendance. To those who complained that the house bill was rushed through by people who did not understand it, he made it clear that he had read the entire bill, and had a copy with him to refer to if there were specific questions. And the questions did come!

One of the most interesting things I learned at this meeting is how confused and misinformed some worried people are about the truth contained in the recent bill passed by the House of Representatives. For example, one woman thought that payment for care would be limited to $5,000. The Congressman explained that no, this figure was a cap on expenses for her to be responsible for, and not a limit on benefits. Another thought that illegal aliens would be covered, and was told that they are explicitly not covered by this bill. There were many other examples.

Larsen made it clear that he is not approaching reform as an ideolog, but rather, he wants to accomplish practical change by keeping the following principles in mind:

Ban discrimination for pre-existing conditions, age and gender;
Don't try to fix what isn't broken. If people have insurance and doctors they like, they should be able to keep them;
Eliminate fraud, waste and abuse in government health programs;
Invest in prevention and pay for quality of care, not quantity of tests;
And get reform that works for Washington State.

He particularly took pains to explain that Washington state currently is penalized for providing higher-quality, lower-cost care by Medicare because reimbursement rates are so low that many local doctors do not accept Medicare patients. Under the original health care reform bill introduced in the House, this problem was not fixed, and was expanded, so that the same unfair, wasteful reimbursement policies would have been expanded from Medicare to the public insurance option. As he said, "What good is an insurance card if you can't find a doctor who will treat you?" That was his reason for opposing the "public plan" option as presented. To improve this situation, Larsen has worked with colleagues from Washington and other states with the same problem to secure an agreement with House leadership to agree to reform Medicare payments, reward high-quality, cost-efficient care and remedy geographic disparities that hurt access to care for local patients.

All in all, I was very impressed. Congressman Larsen should be commended for working hard on our behalf, with clear principles of reform. He is obviously very knowledgeable and energized about this issue. Residents of our area should be commended for their attention and respectfulness of the town hall process. I was glad that I went.

One disappointment I do have is with our local newspaper, The Bellingham Herald. I could not find a report of our local meeting, but there were 2 articles with old news about how meetings are being disrupted. What a missed opportunity by our media to set the record straight!

$ The cost of Health Care reform

2009-08-06T20:18:00.000-07:00

You've probably heard it said by critics that health reform will cost taxpayers at least a trillion dollars. This sounds scary, which is the intent of the critics, but it turns out not to be true!

The quoted figure is not a trillion dollars a year, but rather a trillion dollars over 10 years. On a yearly basis, the cost equals approximately $140 billion dollars. To put this in perspective, the Part D Medicare Drug plan passed during the Bush presidency is about 600 billion dollars for drugs alone.

$140 billion dollars a year still overstates the cost, however. That is because other parts of the reform plan result in savings for Medicare, such as the reduction of subsidies to private insurers, reform of payment rates for doctors and a decrease in payments to hospitals for providing "free care" to the uninsured. When all of this is taken into account, the net increase in government spending for health care will likely be about $100 billion a year, which is a one-time increase equal to less than 1 percent of US national income, which has historically grown at an average annual rate of 2.5 percent every year.

While criticizing, right wing critics have stood against ideas to improve care and lower costs. For example, a plan to fund research which gives doctors, patients and health plans better information on what works and what doesn't, Republican critics have claimed a sinister plot to have the government decide what treatments you will get. Using this kind of perverted logic, a proposal that Medicare pay for counseling on end-of-life care is transformed into a secret plan for mass euthanasia of the elderly. There are many other examples.

Please, don't take hysterical criticism at face value. The truth is more complicated, but also reassuring.

What's In It for Me? What are our obligations to each other?

2009-08-02T11:13:00.000-07:00

As what passes for a health care debate rages all around us, I have come to realize that between the polarized extremes there exists a very important group of people who are the key to what will happen this fall, and that is the large group of Americans who have health insurance and who are worried they may lose advantages in any reform. All of the noise in our media is an attempt to reach this group, who are likely asking, "What's in it for me"?

I believe that those who currently have health insurance and good access to medical care would be well advised to support proposed health care reform for the following reasons:

They may lose their insurance coverage! Right now, 14,000 insured people lose their coverage every day when they lose their job or the employer cannot continue to afford benefits, and that number is expected to increase greatly with current trends.
Business can't afford the increasing costs! Under the current system, costs are expected to double during the next 10 years.
Young people are priced out of the system! Those looking for work at the beginning of their careers are most likely to get jobs without benefits, leaving them uncovered and raising the cost for all others.
Insurance often does not work when you need it, even if you have it! The for profit system is full of people who work hard to "ration your care" by figuring out how not to pay for things.
The payment system must be reformed! Our current mess of a non system is caused by the payment incentive and lack of incentives we now have.
Quality is often lacking! A sad and poorly understood fact is that even people with good insurance get the recommended care they should have only about 1/4 of the time. The care is not organized in a way that allows most doctors to manage their patients the best way possible.
They may lose their doctor! Very few medical students are going in to the primary care disciplines, due primarily to the fact that they cannot afford to. Retiring family doctors are not being replaced. Reform which supports primary care is crucial to attracting the best and brightest into primary care.

When all is said and done, however, thinking just about ourselves misses one of the most important reasons for reform. Perhaps the most important thing to consider is, what are our obligations to each other? Our entire American society is engaged in global competition with all the countries on earth for the innovations, jobs, products and benefits of the world to come. We must have a society with well educated, healthy and productive citizens to secure the benefits of the future. Our companies need a level playing field that does not saddle them with the unequal and exorbitant costs of a failed system.

If the the future is scary to you, it is really not because of the risk of changing, but because we might not change. Don't be fooled.

The Party's Over

2009-07-18T09:04:00.000-07:00

Up until now, we have seen some superficial co-operation among disparate interests over needed healthcare reform, but now the wheels seem to be coming of the bus. Republicans, conservative groups and some business organizations have begun accelerating efforts to derail legislation, by calling the Democratic proposals costly and dangerous experiments in "government-run" health care. Their main goal is to slow down the pace of the legislation in Congress in the hope of fomenting wider opposition. Sen. Jim DeMint (R-S.C.) has been quoted in the Washington Post as saying, "If we're able to stop Obama on this, it will be his Waterloo." "It will break him."

What we are talking about, of course, is regulation of the market, and figuring out how to cover all of our citizens. That is not "government-run" health care. In the many countries of Europe, for example, very few of them "run" the health care system, Great Britain being the notable exception. By trotting out their tired old stereotypes, I think that conservative activists are discrediting their cause, and depriving us of a real debate on substance.

The fact is that we already do have one "government-run" health care program", and that is Medicare. I will be the first to tell you that it does have faults, but it is highly rated by those it serves, and it is quite efficient in it's management, far more so that private plans are. So much for the evil, clumsy government.

We already have a dysfunctional healthcare mess for which we spend more than anyone else on the planet. The money we waste may not be a government tax, but we are paying it every time we buy a product made by a US firm or pay your insurance premium.

New US Surgeon General Choice Says a Lot!

2009-07-14T08:41:00.000-07:00

President Obama has finally announced his choice for surgeon general, and it is Dr. Regina Benjamin, a 52-year-old family physician who has spent most of her career practicing in a Gulf Coast clinic in Alabama. She graduated from Xavier University of Louisiana in 1979, attended Morehouse School of Medicine from 1980 to 1982, and received a doctor of medicine degree from the University of Alabama at Birmingham in 1984. She completed residency training in family Medicine at the Medical Center of Central Georgia in 1987, where her medical training was paid for by the National Health Service Corps, under which medical students promise to work in areas with few doctors in exchange for free tuition. She has also earned a master's in business administration in 1991 from Tulane University.

I am hopeful that President Obama's choice of Dr. Benjamin is a clear indication of the direction he wants to take in health care reform. The fact that he chose a family physician, and not a corporate bureaucrat or medical school academician seems to say a lot about what he values!

Mayo Clinic Principles of Health Care reform

2009-07-12T20:29:00.000-07:00

I had an interesting experience this week when my friend, retired pathologist Dr. Bob Gibb, asked me to sit in with him on a group telephone call among alumni physicians trained at the Mayo Clinic. It seems that Mayo has decided to try and play a "convener role" in our national discussion of health policy, and this phone conference was part of an effort to spread their message and get the word out about what they believe is central to true health care reform. They have also developed a web site for the Mayo Health Policy Center.

On the call I learned that Mayo has 4 cornerstone principles that they believe must be included for meanigful reform:

Creating Value - do we actually improve health in a measurable way?
Coordinated Care - Mayo is an example of working together and not in silos
Payment Reform - provide incentives to coordinate care, improve outcomes and enhance patient decision making
Health Insurance for All- essential in order to share risk, and improve the health of entire populations.

Although they have nailed 4 needed elements, I would add two more principles that I believe are also essential for us here in the United States:

Choice - people want a choice of doctors, plans and hospitals when possible
Access -the Massachusetts experience makes it clear that "insurance for all" is a hollow accomplishment without enough primary care doctors to provide access to care!

During the call, there was a discussion of the thought behind the Mayo cornerstones which noted that they support the personal medical home as a way of achieving the principles, they do not believe that simply expanding Medicare is rational, since it does not address value, coordination and payment reform, and they do support some pilot projects to sort out the various ideas of how to manage the needed change.

Steven Pearlstein noted in a recent Washington Post article, "If we really want to fix America's overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine, individually and collectively. Everything else -- mandate or no mandate, the tax treatment of health benefits, whether there's a "public plan" to compete against private health insurers -- is just tinkering at the margin." I could not agree more. In order to get there, however, we will need to pay physicians differently to coordinate care, and measure results. For this reason, payment reform is the most critical first step. Indeed, the results we are seeing today are just what our payment system is designed to produce! The American College of Physicians (ACP) 2006 report actually predicts the imminent collapse of primary care in the United States, due to the inadequate and dysfunctional payment policies of the government and other third party payers.

We have an historic opportunity to change course. Thanks to the Mayo Clinic for weighing in!

How Does The Patient-Centered Medical Home Transform Health Care Delivery?

2009-06-26T08:49:00.000-07:00

Can Patient-Centered Medical Homes Transform Health Care Delivery? The answer is clearly yes, and that is a point I have tried to emphasize, but I often get asked by those less familiar with the subject, how does this really make a difference?

The basic idea in a nutshell is that in order to be effective and add value, health reform must deliver a new delivery system built on a solid foundation of primary care. There are two barriers to this happening:

We are losing primary care providers, and very few new doctors are in the pipeline to replace them
The way primary care doctors are paid is inadequate and dysfunctional, so that they are not paid for the work that patients truly need and want them to do.

The medical home is an approach to primary care organized around the relationship between the patient and their personal physician. It is is primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” It has now been endorsed by important, independent health care think tanks, such as the Commonwealth Fund.

In 2007, four primary care specialty societies, representing more than 300,000 primary care specialists, issued a joint description of the Principles of the Patient-Centered Medical Home:

A personal physician;
A whole-person orientation;
Safe and high-quality care (e.g., evidence-based medicine, appropriate use of health information technology);
Enhanced access to care; (e.g., phone visits, secure web visits, group visits with appropriate use of health information technology);
payment that recognizes the added value provided to patients and insurers who have a patient-centered medical home.

Today, few Americans say they have a source of care with these features, but I am proud to say that my medical group, Family Care Network, has made wonderful progress to become a full fledged Patient-Centered Medical Home for our patients. We now know what works. There is no excuse to delay. If we do not move forward in this effort, we will continue to reap the whirlwind of spiraling costs and plummeting value. Primary Care will disappear. Now is the time.

We are witnessing a Battle for the Soul of American Medicine

2009-06-04T09:34:00.000-07:00

The title of this column is a direct quote from an insightful article in the New Yorker magazine, June 1, 2009, page 36, written by Dr. Atul Gwande, entitled "The Cost Conundrum, What a Texas town can teach us about health care". Read this article!

"Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems."

AMEN.

So Who Opposses Health Care Refrom These Days?

2009-05-31T16:22:00.000-07:00

The news has recently contained several stories which note that many prior opponents of health care reform are now "working together" in common purpose to help bring needed change. At the same time, we are now starting to see anti-reform television advertisements that warn against "any form of government-run health care". The most widely available ads come from an organization that is calling itself "Conservatives for Patients' Rights ". If you believe in Santa and the Tooth Fairy, you might also think that a group of citizens spontaneously got together to educate the the reat of us, but the reality turns out to be far different! Conservatives for Patient's Rights is bankrolled and founded by a guy with a past named Rick Scott, best known for heading a company that paid the the largest health care fraud settlement in US history. Scott was a healthcare executive who grew Columbia Hospital Corp. from two El Paso hospitals in 1988 into the nation's largest investor-owned hospital chain and the world's largest healthcare company.

Columbia later merged with HCA, and Scott was forced out in 1997. Subsequently, a government investigation into HCA resulted in HCA paying $1.7 billion dollars in civil and criminal charges to settle the largest health care fraud settlement in US history, but Scott was not charged individually. He now owns a controlling interest in Discovery Health, and is the Chair of a chain of an urgent care center chain in Florida known as Solantic Corp.

As you watch the adds bankrolled by Scott and his Conservatives for Patient's Rights, you will notice broad statements that really have nothing to say about what is being proposed now for the US. Instead, he strives to create fear of change and rails against the "nanny state" "taking choice out of health care" and other vague notions, while quoting folks from Canada or the UK about problems they perceive in their countries' systems. You would never know to watch these ads that the proposals by the current administration adhere to the 4 pillars of reform that Mr. Scott advocates, which include choice, competition, accountability and responsibility . He forgot to mention equity, effectiveness, affordability and universality, however.

Take care as you watch these ads! Ask who paid for them, where they come from and what the sponsors have to gain by blocking meaningful reform. As President G.W. Bush once tried to say, "Fool me once, shame on you, fool me twice, shame on me!"

A Practical Approach to Health Insurance reform

2009-05-25T14:49:00.000-07:00

When it comes to change on a national level, new ideas and needed reform proposals often come from the states. Maybe that will now happen with health care insurance reform.

On May 18, the Whatcom County Medical Society hosted a presentation by Washington State Insurance Commissioner Mike Kreidler, who accepted our invitation to speak to us about his innovative and practical plan for health insurance reform in Washington State, known as the Guaranteed Health Benefit Plan. As insurance commissioner, Kreidler has developed a wealth of knowledge, that includes experience running a health insurance company when KPS Health Plans were put into receivership. He has clearly put his experience to good use in the design of this plan.

Commissioner Kreidler’s Guaranteed Health Benefit Plan would provide health care coverage for all Washington residents up to age 65, by virtue of residency in the state for one year, while it also preserves the individual's freedom of choice to pick the plan they want. Keidler described how it would work:

All residents get catastrophic coverage for health care costs exceeding $10,000 a year.
Limited preventive care is covered, which includes an annual checkup, immunizations and age-appropriate cancer screenings.
Funding comes from a payroll tax, shared by the worker and employer.
Consumers and employers can choose additional coverage for other care from any insurance plan serving the state, and costs will be much less, since the roulette wheel of catastrophic cost has been removed.
All insurance "customer service" – both catastrophic and routine, is provided by the private insurers.
For expenses in excess of $10,000, the insurance company pays at their contracted rates, and deals with the state for the payment to them
Individuals with no coverage of any kind are at leas covered for some preventive care, and all "catastrphic" care that exceeds $10,0000.

Commissioner Kreidler's approach is refreshing and very interesting. He builds on the structure we have now, while the plan causes minimal disruption to the existing system, extends coverage to all without mandates, and yet still respects choice in the system. It is a way to get moving on this important issue now. As he noted in his talk, all advanced countries have migrated to their own health care systems by building conservatively on the unique features of their pre-existing systems, and it is unlikely that we will have reform as a "big bang" event.

After his talk, Commissioner Kreidler left to fly to Washington, DC for talks with key legislators there. As the health care debate continues, I think that his is a welcome voice for common sense. and a practical choice to help people quickly!

You can get details about the plan by clicking here.

PM Bellingham Discussion on KGMI

2009-05-13T11:24:00.000-07:00

I had a very stimulating conversation about health care and our need for reform on the PM Bellingham radio program, hosted on KGMI radio by Jacqueline Cartier and Ken Mann. They asked great questions, and gave refreshing insight from a younger person's perspective

PM Bellingham Radio Program Link Click Here

Healthcare US Cost-to-Value Ratio Punishes Business

2009-04-06T14:06:00.000-07:00

Each year, the CEOs of major US companies gather for the Business Roundtable, where they discuss serious issues affecting business. So what are they talking about during the worst economic crisis in generations? Health care! And their consensus is that our "dismal state of health care" affects our global competitiveness and the national economy. Their conclusion is based on the cost-to-value ratio that compares the dollar amount spent on health care in the US with the value received for that care. When comparing the dollar amount spent to the health of the citizenry, the roundtable findings show:

$2.4 trillion a year is spent on health care in the US
On a per-capita basis, that’s $1,928 per person for 2006
$1,928 per capita is 250% more than any other nation spends
On a cost-to-value basis, the US is 23 points behind its five top economic competitors (Canada, France, Germany, Japan, and the United Kingdom)
The governments of these five nations play a bigger role in their healthcare systems than the US does, although each nation operates on a different healthcare system
The US is 46 points behind its closest emerging competitors (Brazil, China, and India).

I may sound like a broken record, but our health care problems are not just about cost. We are definitely not getting value received!

Have we reached the tipping point in Health Care Reform?

2009-03-23T08:41:00.000-07:00

Just maybe! This interesting article from "The Medicaid Front Page", makes the case. Time will tell!

http://www.medicaidfrontpage.com/2009/03/us-healthcare-and-reform.html

What does the Nation Think about Health Care Reform?

2009-03-19T11:18:00.000-07:00

In December, the Presidential Transition Team invited Americans to host and participate in health care community discussions, and the employees and staff of Family Care Network were a part of that process. The idea was to for small, local gatherings to discuss health care, identify what's broken, suggest ideas to fix it and submit responses to the Transition Team for analysis of the nations feedback.

On March 5, Health and Human Services issued a special report of the community discussion outcomes. Over 9,000 Americans in 50 states and Washington, DC signed up to host a forum and 3,276 group reports were submitted to the Transition Teams special website (www.change.gov ).

The report shows that America’s concerns and views are very similar to the discussion that we had here at Family Care Network. Concerns focused on access to health insurance, rising premiums and high drug costs, and the “broken” health system, with poor access to primary care, and lack of affordability. Also of concern was being “under insurable,” medical mistakes and the system not being “for them.” Of the groups reporting cost of health care concerns, 28% focused on health insurance premiums and another 28% focused on the overall cost of the system.

The solutions suggested by the reporting groups highlighted the need for a system that is fair (36%), patient centered and choice oriented (19%), simple and efficient (17%), and comprehensive (15%). Fairness was a very common theme, and our current "system" was perceived to be quite "unfair". Some respondent groups said that health care should be considered a basic right, not a privilege and many felt the system should insure all Americans.

The analysis of responses found there were no significant differences in opinion based on rural or city location, region of the country, average income or employment status. The only exception noted was that those who represented the health care field expressed more concerns with provider shortages, the lack of a “system,” inadequate research, payment rates, medical malpractice, inefficiency of the system, and inadequate treatment of mental health.

If you are interested in reviewing the detailed report visit: www.healthreform.gov.

The need has never been greater

2009-02-12T08:45:00.000-08:00

My grandfather was a physician in general practice at the beginning of the last century, before the Flexner Report revolutionized medical training and brought medical education into the scientific age. His office was in the bottom of the family home. My grandmother would open the door, folks would come in, and the agenda was whatever was on the mind of the person who came. There was no phone interuption (there were no phones!), record keeping was easy (20 years on one 3 by 5 card), and most modern therapies had not yet been invented.

Today, many physicians in primary care continue to practice in the same basic style as my grandfather. They wait in their office to see what comes, and are only paid for this visit "piece work". It is as if the telephone was never invented, much less the Internet! They do not manage their patient panel in such a way as to improve their overall care, because they do not have the tools to know how the group is doing, and indeed, they may not even have thought about it.

Recently, Dr. Kevin Grumbach, professor and chair of the Department of Family and Community Medicine at the University of California, San Francisco, has renewed the call for a thorough "Revitalization of Primary Care". He correctly notes that the traditional model of primary care has not been very well supported by payers, purchasers or government agencies, and that people are turning away from it. In a recent article, he is quoted as saying, "This model of 19th-century practice -- of the doctor in the office and patients coming in -- is not going to work in the 21st century. We have come to the proverbial fork in the road." He identifies physician payment reform as one of the first steps we must take in revitalizing primary care, to provide the personal medical home. This is the work that we have been engaged in at Family Care Network.

Dr. Grumbach notes that the worsening shortage of primary care physicians is fueling "medical homelessness," which leaves patients without adequate access to primary care services and patient-centered medical homes. This is particularly tragic, since the ratio of primary care doctors to the population is the only statistic that has ever been shown to correlate with both improved health care quality and decreased cost of care. We must change now. The need has never been greater.

Flight of the Doctors

2009-01-07T12:45:00.000-08:00

Jason Hwang has noted the recent, dreary evidence that primary care doctors are disappearing from the scene, and he correctly writes about the need "to encourage business models that reduce paperwork and red tape, while rewarding lifelong wellness care – the core tenet of primary care medicine."

I have written a comment on his blog, however, since I believe that he misses the importance of having independent primary care as a needed protection for patients.

Read more here: Flight of the Doctors by Jason Hwang

What does the Election of Barack Obama Really Mean for Health Care

2008-11-05T19:24:00.000-08:00

We have chosen Barack Obama as our next President! This means that his proposal for how to reform health care will certainly set the tone for our discussion about how to improve quality, cut rising costs and extend medical coverage to about 45 million additional Americans.

Since any proposal must be submited to Congress, it is reasonable to assume that elements of Obama's proposal may well be modified, but at the core of his proposal are principles that would change health care delivery and coverage in the U.S.

The cornerstones of Obama's plan are:

Expand Medicaid eligibility to include greater numbers of the uninsured
Mandate coverage for children
Create a national exchange where uninsured folks can purchase a public or private policy;
Provide subsidies to lower-income individuals and small businesses to help defray the cost of purchasing insurance; and,
Tax medium and large-size employers that decline to provide their employees with health insurance.

Of crucial importance in all of this is the need for us to remember that quality of care, and value for the money we spend, must be improved dramatically for any plan to be truly successful. Obama has chosen great advisers who understand this, but there is great danger that economic concerns could drive attention into only cost cutting steps, without insuring that we adequately pay for improved access and provision of primary care services. We could do the most to improve access and quality, while simultaneously lowering costs, by supporting legislation requiring all plans to provide payment for the personal medical home. Simply expanding programs like Medicaid, without this type of reform, will fail, since they do not pay primary care physician adequately for providing the care!

We have discussed the specific benfits of the personal medical home previously, and it is important to remember in a time of scarce resources, that by supporting the provision of primary care first, we are supporting the only thing that has ever been shown to be associated with both improved quality and decreased cost of medical care! Although well intentioned, throwing more money at our current health care mess will be bound to dissapoint us, by making more people eligable for the dysfunctional, and unorganized type of care that is currently bankrupting us.

McCain and Obama Health Plan Proposals, a Family Doctors View

2008-09-22T07:06:00.000-07:00

How likely is it that the presidential election of 2008 will help provide clarity about our US national health policy? American health care continues to careen along like an ongoing train wreck, with very high prices, access problems, and inconsistent quality of service. In spite of this fact, however, there has been very little media attention to proposed plans for its reform by the two leading presidential candidates. At present, American health care costs amount to 15 percent of our national GDP, and we yet we have one sixth of our population that is left uncovered at any given time. Most of the developed countries that we like to compare ourselves to have an organized approach to delivering care, spend less than half of the GDP percentage we do, and they still manage to cover all of their populations and show far better national health outcomes than we have in the United States.

It may surprise some to know that payment in American health care is not driven not by health issues but rather by lobbyists. Physician incomes derive from how much they use procedures and high technology which benefit large firms that effectively lobby Washington. This distorts the supply of physician types, and means that primary care physicians, the bedrock of care everywhere else in the world, are paid the least. Consequently, their numbers are plummeting. Preventive care to keep people well and screen for disease is not a priority for most insurance companies, because they often see their paying clients shift between companies year by year, and most costs of chronic disease are born by the federal Medicare program, and not the private companies. Thirty percent of our American costs go to administer thousands of separate insurance schemes whose rules seem to change by the day, while most developed countries spend only 5 to 8 percent on administration. We are getting a raw deal, even if we have insurance coverage.

Much like the high price of oil, the extreme costs of American health care act as a general tax on the economy. We can’t afford the wasteful health care we have now, and with an aging population, we won’t be able to in the future. Where’s the money going to come from? I believe that as we try to answer that question, we need to also ask ourselves what we believe health care is really for? Should we continue to provide the vast majority of big pharmaceutical company profits, and pay 30 percent of our budget to insurance companies to administratively deny health care, or should we be focused on expanding coverage, providing access and improving quality?

The issue can seem completed. Understanding the difference between employer- mandated private and public plans versus tax exclusion of employer health insurance by refundable tax credits do not seem inspire the citizenry. In the media, sound bites all to often replace informed debate, when health care is mentioned at all.

In spite of all this, the upcoming election offers those of us in the US electorate us a chance to weigh in on the direction of our national health care policy, since there are major differences between the McCain and Obama plans that have implications for almost every American. Yet the political will for change, in the teeth of opposition from a gigantic medical industrial complex, is simply not yet there. A nation, which spends twice as much money per person as anywhere else in the world, but can only produce health statistics equal to Cuba and Lithuania, requires reform. But sadly, the plans of each presidential candidate are unlikely to survive lobbyist opposition, if the population remains uninformed and uninvolved. Let’s look at the plans!

John McCain's Vision for Health Care Reform

The McCain plan addresses a current major inequality in present day health insurance, which is that we have tax deductions only for employer paid insurance. If you are a business, you can create health care insurance to cover all your health care costs, which the government will then take off your income in order to reduce your taxes. McCain’s plan would replace employer insurance with a tax credit of $2,500 for individuals, $5,000 for families. The uninsured would get tax credits to buy health insurance, and market competition would lead to better, more substantial coverage. In addition, McCain proposes that Medicare shift from fee for service to “bundled” services paid at a fixed fee. The candidate and his advisors tout this plan as one that will let market forces fix health care, as plan compete. Unfortunately, market solutions have not recently worked very well in other arenas! Consider the current meltdown of our unregulated mortgage market, with the failure of Fannie Mae, Freddy Mac, Bear Stearns, Lehman Brothers and Indy Mac Bank, which has resulted in the drying up of needed credit for worthy businesses.

Under the McCain plan, what can you expect your $2,500 tax deduction to buy? If you are a young and healthy person, you will likely be able to get coverage with a large deductible. If you have a chronic condition, however, you will not be an attractive person for a company to take on. The medical insurance companies will still be unregulated, and we can expect that they will try to cherry pick their customers in order to “insure” only those without existing medical problems. Unlike real insurance, where you insure everybody so that the healthy help cover the unlucky and unhealthy; the McCain plan would create coverage for the uninsured only in theory. If you become injured or chronically ill, you’ll likely be stuck.

Obama Plan for a Healthy America

Senator Obama’s health care plan builds on the existing employer paid, private system that is now in existence. Employers will be required to offer private insurance or pay a federal tax that will be used to fund care for those who do not have access to insurance through their employer. Obama also envisions a new government health plan, “similar to what members of Congress give themselves”, and a new “insurance exchange” where those who can’t buy group health insurance will have access to affordable plans. The “cherry picking” to avoid sick patients with preexisting conditions would be outlawed. There is no “mandate” in the Obama plan that forces everyone to get insurance, except that children must have coverage. The Obama campaign believes that so many people are uninsured mainly due to the fact that insurance is unaffordable, and that people will buy reasonably priced plans if they are offered them. He and his advisors advocate that we focus intently on improving the quality of our care, and not just on reducing the cost.

Let’s hope that these issues get discussed honestly in the upcoming debates.

Patient Centered Medical Home Purchaser Guide is Now Available

2008-08-01T16:29:00.000-07:00

The Patient-Centered Primary Care Collaborative, or PCPCC, has unveiled a purchaser guide to encourage large buyers of health care to adopt the patient-centered medical home as part of their health care plans. The guide explains how health care purchasers can readily make the patient-centered medical home a cornerstone of their health care plans. The guide represents the first time health care professionals, health care plans and consumers have all collaborated on a purchasing document, and this gives the booklet a multisided perspective that other guides lack. It correlates well with the joint principles of the patient-centered medical home adopted by the AAFP, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association.

The guide can be downloaded free of charge and used by any group interested. It can even be "private labeled" as part of a groups existing effort! Use this tool!

Senator Obama proposes "The Quality Cure"

2008-07-23T10:00:00.000-07:00

Potential voters in November are starting to pay more attention to what the leading presidential candidates have to say about how to reform our health care system. In a new article from the New York Times magazine, David Cutler responds to the principles underlying Senator Barack Obama's proposals. Cutler basically says that the US should focus on improving the quality of care rather than on reducing our consumption of it. Rather than pay less, they want to pay more wisely, and encourage health-care providers to do more of what they should and less of what is wasteful by building proper incentives into the system. Chief among these ideas is to support the personal medical home, which we have been writing about in this blog, and to continue the role of our private health care insurers, but with oversight and regulation that promotes these aims. In my opinion, this is the right direction, and voters have a clear choice in November.

2008 Health System Scorecard Shows No Improvement

2008-07-17T12:37:00.000-07:00

Alas! The Commonwealth Fund Commission on a High Performance Health System released its first health system scorecard two years ago, and found that the United States fell far short of benchmarks for access, quality, efficiency, and other key measures of health system performance. Now, two years have gone by, and the 2008 edition of the scorecard paints an even bleaker picture. Instead of organizing around change for improvement, supporting the ability of primary care to provide a personal medical home and holding insurance companies accountable to help improve care, congress has gone through their annual dithering about how much to lower doctor rates, insurance plans have continued to cherry pick low risk subscribers, and the number of primary care doctors has continued to dwindle. It is no surprise that we have gone from bad to worse! Our system is perfectly designed to get these results.

The United States scored an average of 65 out of a possible 100 across 37 indicators— below the overall score in the 2006 report, which was already abysmal! The U.S. health system is on the road to a train wreck. Of greatest concern, access to health care has significantly declined. As of 2007, more than 75 million adults—42 percent of all adults ages 19 to 64—were either uninsured during the year or poorly insured, up from 35 percent in 2003. At the same time, the U.S. did not keep pace with gains in health outcomes achieved by the leading countries. The U.S. now ranks last out of 19 countries on a measure of mortality amenable to medical care, falling from 15th as other countries raised the bar on performance. Up to 101,000 fewer people would die prematurely if the U.S. could achieve leading, benchmark country rates.

The U.S. spends twice per person what other major industrialized countries spend on health care, and our costs continue to rise faster than income, while our quality results continue to plummet. We will soon have $1 of every $5 of national income going toward health care. We should expect a better return on this investment. We should be outraged.

Who really pays for health care?

2008-03-27T22:11:00.000-07:00

The best article I have ever seen to explain this complicated subject!

By Ezekiel J. Emanuel and Victor R. Fuchs
March 27, 2008
For The Chicago Tribune

Who really pays for health care in the United States?

Americans believe employers pay the bulk of workers' premiums, government pays for Medicare, Medicaid and the State Children's Health Insurance Program and individuals pay some premiums as well as deductibles and co-pays. This is wrong. Business, government and individuals do not share the financial responsibility for health coverage. Individuals bear the full cost of health care through lower wages and taxes.

Employers like to say—and often believe—that they pay for health care. They complain that the huge increases in health-care costs are coming out of their bottom lines—as if costs come out of profits. Union leaders also like to have their members think that health benefits are a bonus on top of wages and that the leadership is negotiating hard to get them the free benefit.

Employers sponsor health insurance for the majority of Americans, but that is not the same as employers bearing the cost for workers' health insurance. Wages and fringe benefits, such as health insurance, are simply components of overall worker compensation. When employers provide health insurance to workers, they may define the benefits, select the health plan to manage the benefits and collect the funds to pay the health plan, but they do not bear the ultimate cost. What is labeled as employers' contribution to the health-insurance premium is really paid for by employees through lower wages and take-home pay.

Looking at the facts

This cost-wage trade-off is usually well hidden from employers and workers, but many studies show that it is a painful reality for average Americans. For instance, over the last 30 years, health-insurance premiums have increased by 300 percent after adjustment for inflation. During that time, after-tax corporate profits per employee have increased 200 percent, while workers' average hourly earnings, adjusted for inflation, decreased by 4 percent. Rather than coming out of corporate profits, the increasing cost of health care has resulted in relatively flat wages for 30 years.

To illustrate, consider Wal-Mart Stores Inc. and Safeway Inc. Wal-Mart, a non-unionized retail giant, is notorious for skimpy health benefits. From 2004 through 2006, its after-tax profits averaged 1.9 percent of sales. Safeway, a highly unionized supermarket chain, offers generous health benefits that cost more than 2 percent of sales. But in 2004 through 2006, its after-tax profits averaged 1.8 percent of sales, virtually the same as Wal-Mart. The difference between Wal-Mart and Safeway in the provision of health benefits is not found in the companies' profits.

Another way to see this is to compare the change in workers' wages with the change in health-care costs. Why were the mid-1990s such good economic times for average Americans? Between 1994 and 1999, the growth in health-care costs was low and therefore wages went up. But from 1988 to 1991 and 2001 to 2004, health-care costs went up rapidly, sending wages down.

What about Medicare, Medicaid and SCHIP? The government's funds for health care don't come from governors, senators, representatives or the president. When government pays for increases in health-care costs, it taxes current citizens, borrows—asking future taxpayers to foot the bill—or reduces other state services that benefit citizens. Health-care costs are now the single largest state expenditure, exceeding even education. Recently, as costs for Medicaid and other government health-care programs have increased faster than tax receipts, states have resorted to cutting the funds for education, forcing the substantial recent rise in tuition and fees for state colleges. Middle-class families, falling victim to rising health-care costs, are finding it harder to pay for their children's education.

Time to get serious

So, what does the trade-off mean?

First, Americans need to forget about the myth of a free lunch. Workers are not getting something from employers while paying nothing. They are paying for their health insurance, including the premiums supposedly contributed by their employers.

Second, to help the struggling middle class, we need to get health-care costs under control. There is no way to have a sustained rise in middle-class incomes without restraining the growth in health-care expenditures. Similarly, if we want government to invest in better primary education and more affordable colleges we need to find a way to hold down the cost of health care. We are robbing our children to pay for medicine.

We need to rewrite the social contract in America. We need to get employers out of providing health insurance. It is one of the most inefficient ways to get people covered, and it impedes efforts to keep costs down.

Instead, we need to provide all Americans with a standard benefits package regardless of their income, employment status, health status or age. This will provide Americans invaluable peace of mind, defuse labor-management conflict and get people to focus on value and determining whether more health care is worth the added costs.

Keeping costs sane

How do we get health-care costs under control? We need to eliminate the overuse of medical tests and treatments. For instance, studies have shown that doctors perform more than twice as many Caesarean sections in Miami and Fresno, Calif., as in Minneapolis, even after taking into account the differences among patients—with no improvement in the health of mothers or babies. Similarly, many studies show that more hospitalizations, use of specialists and frequent tests do not lead to improved survival rates or quality of life—just much higher costs. Further we need to use cost-effective medical care when there are options. This is obvious for prescribing generic drugs rather than similar brand-name drugs, but it is also true for tests and treatments. Most important, patients with chronic conditions such as diabetes, heart failure and emphysema account for 70 percent of health-care costs. We need more coordinated care with fewer specialists involved to keep these patients taking their medications, adhering to their diets and other treatments, and staying out of hospitals where costs are high.

Achieving these changes will not be easy, but three policy changes will set the necessary foundation. First, an Institute for Technology and Outcomes Assessment is critical to collecting information comparing the effectiveness and costs of different medical interventions. That data will allow doctors to choose the most effective treatments. Second, we need a crash program to institute electronic medical records. Today, only 15 percent of doctors and 25 percent of hospitals have computerized records. The government has to provide financial incentives and mandate that within five years all doctors and hospitals have interoperable electronic medical records.

Finally, we need to change how we pay doctors and hospitals. Most doctors are paid fee-for-services, that is they get money for doing more tests and procedures and not for coordinating care and ensuring high quality medical care. Doctors need to be paid on the basis of performance and patient outcomes.

Controlling health-care costs is not easy, but for average Americans it is the only way to sustainably increase wages. And if we do it right, it will actually improve the quality of health care.

Dr. Ezekiel J. Emanuel is chair of the department of bioethics at The Clinical Center of the National Institutes of Health. Victor R. Fuchs is a professor of economics (emeritus) at Stanford University.

Senate Hearing Links Physician Payment Rates to Primary Care Shortage

2008-02-21T08:24:00.000-08:00

Several witnesses testified before a Senate committee on Feb. 12th that our nation's health care system continues to undervalue primary care services, and that this is leading to a skewed physician payment structure that is rapidly creating a shortage of primary care physicians throughout the nation.

Amazingly, although he agrees with and understands the data, the governments spokesman on this issue reaches an illogical conclusion, however. "When I say primary care services are undervalued, that does not mean that just increasing the prices paid to primary care is the solution," said Bruce Steinwald, director of health care for the United States Government Accountability Office, or GAO, during testimony before the Senate Health Education, Labor and Pensions Committee. "As you are well aware, we face unsustainable trends in the Medicare program and in the health care system as a whole. And, just as payment incentives are misaligned in primary care, they are misaligned in specialty medicine as well."

Yes, that is all true, I guess, but retaining primary care physicians will involve paying them more!

Medicare operates under a fee-for-service system, which rewards doctors based on the volume of services they provide. Medicare is the prime example of "how the system undervalues primary care services," and this discourages medical school students from pursuing a career in the primary care field, and causesthose in practice to restrict who they will see and retire early. These payment disparities have been exacerbated by technological improvements that allow subspecialists to provide more procedure type services in a shorter period of time, which leads them to an increase in payments and income, making these specialities more attractive career options for medical school students. In contrast, primary care physicians rely primarily on face to face time during office visits for their income. This means their ony option to be "more efficient" is to reduce time with their patients, which leads to rushed care and compromised quality.

I agree with the director, when he said, "This undervaluing of primary care services appears to be counter productive given the vast literature describing the relationship between health care costs and quality".

Medical Home Accredidation Process Now in Place

2008-01-25T16:03:00.000-08:00

The Patient Centered Medical Home is a medical practice that facilitates a partnership between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by information technology, health information exchange and other means to assure that patients get the indicated care at the time and in the way that they need and want it, in a culturally appropriate manner.

The concept of the personal Medical Home reflects input from the American College of Physicians (ACP), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA).

Now the National Committee for Quality Assurance (NCQA) has released standards for patient-centered medical homes. This means that health care providers and purchasers now have a means to recognize these practices and assess the add value added to patient care.

At present, few physician offices in primary care specialties, would likely qualify for recognition as a patient-centered medical home under the new NCQA standards. In spite of this fact, however, there is ample evidence that the availability of primary care is crucial to quality health care outcome, and more efficient care. The irony is that primary care is rapidly disappearing from the health care scene, since it not not nurtured and properly paid for.

There is widespread agreement that primary care is in crisis. Medical students often do not choose to practice primary care medicine. Existing doctors are often overwhelmed and patients aren't satisfied. Insurers say they are disappointed with its cost and quality.

The Patient Centered Medical home provides a way to change the status quo by enabling physicians to provide comprehensive primary care through stronger partnerships with their patients. Those that choose to integrate elements of this new model into their practices now have a mechanism to prove this distinction to patients and insurers. In order for these enhanced services to be sustainable, however, this designation must be recognized and rewarded by payers.

I ask all insurers to quickly develop products that support this effort. The time is now. We do not need another set of expectations for primary care physicians that are unfunded.

Why does an organized approach to health care matter ?

2008-01-22T08:44:00.000-08:00

In a recently reported study in the journal Health Affairs, supported by The Commonwealth Fund, researchers at the London School of Hygiene and Tropical Medicine determined that the United States ranked last among 19 industrialized countries on a measure of preventable deaths.

The study, "Measuring the Health of Nations: Updating an Earlier Analysis," compared rates of "amenable mortality" before age 75. This means death from causes that are preventable with timely and effective health care. Other nations improved dramatically between the two study periods, 1997-98 and 2002-03, while the U.S. improved only slightly on the measure. Previously, the U.S. had ranked 15th among the 19 countries.

This measure of preventable deaths is a valuable indicator of health system performance, because it measures what we care about most, namely, is our health care effective? The measures include causes such as appendicitis and hypertension, as well as illnesses that can be detected early with effective screenings, such as cervical or colon cancer.

The authors state that if the U.S. had achieved the average rate of the three top-performing countries, there would have been 101,000 fewer deaths annually by the end of the study period. The top performing countries were France, Japan, and Australia, all of which have various forms of organized, universal coverage for their populations.

How do people in different countries view their health care ? How do their opinions compare to those in the US?

2007-11-01T11:42:00.000-07:00

As we debate how to achieve an improved health care system for the United States, the opponents of change often raise the specter of "socialized medicine", and invoke stories about the horrible care and service in other countries. What has been lacking in this discussion is, how do the residents of the United States and other countries actually feel themselves about their experiences within their respective health care systems?

A new seven-nation survey has just been released by The Commonwealth Fund. It shows that U.S. adults were the most likely to say they experienced medical errors, more likely to report they went without care because of the cost, and more likely to feel the health care system needs to be rebuilt completely. The results, are published in the journal Health Affairs.

The article, Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007 , also shows that U.S. adults have the highest out-of-pocket costs and the greatest difficulty paying for needed medical care.

The survey was conducted among 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. One-third of U.S. adults surveyed called for rebuilding the system, and this was the highest rate of any country surveyed. In addition to cost concerns, the experiences of U.S. patients indicated more fragmented and inefficient care in the U.S., including medical record and test delays.

Commonwealth Fund Senior Vice President Cathy Schoen, the lead author of the study, said "Patients in the U.S. are frustrated by high costs and a complicated health care system,".

The survey also examined the experiences of adults who have a "medical home", which was defined in this study as a regular source of care that is accessible and helps coordinate their care. Across all seven countries, only about half to 60 percent of the adults reported having such a relationship with a health care provider. In each of the countries in the survey, those adults who did have a medical home reported a significantly more positive care experience.

Food for thought as we discuss how to improve our system!

Is there a Health Plan proposal that stands out in the Presidential Race? I think so!

2007-10-30T06:03:00.000-07:00

On October 23, 2007 , Democratic Presidential Candidate Sen. Joseph R. Biden Jr. of Delaware unveiled a health care plan that would provide health insurance for all children, provide more coverage options for adults, and focus on disease prevention and modernizing the nation's health care system.

Biden's plan would permit uninsured Americans to buy into an insurance program similar to the one that provides health care benefits to federal employees and members of Congress. People would pay on a sliding scale based on income. Biden's proposal would continue the Medicare program, and inaddition, allow people between the ages of 55 and 64 to buy into the Medicare program, with the federal government providing a subsidy to low-income individuals.

The State Children's Health Insurance Program (SCHIP) would be expanded to children in families with incomes of 300 percent of the federal poverty level or below. This equates to $61,950 for a family of four, and coverage to children in the family would be extended to at least age 21. Biden's plan also would have the federal government "reinsure" 75 percent of the cost of catastrophic health costs for cases exceeding $50,000 per individual, in order to help keep the cost of the commercial plans low.

Senator Biden has said that if he is elected, he would convene a meeting, within the first 90 days of his administration, with all players involved in health care, in hopes of making coverage both universal and affordable. "Getting this done will require the kind of experience and leadership that comes from years of success corralling bipartisan support for numerous issues," he said. "I have that experience and it will prove invaluable when I am president."

Here are some other important elements of Biden's plan:

Eliminate co-payments for physicals, vaccinations, vision and hearing screenings, and preventative dental checkups for children of all income levels.
Prohibit employers and insurers from collecting or using genetic discrimination when making decisions about hiring or providing health care coverage, including the cost of a policy.
Invest at least $1 billion yearly to help hospitals, physicians, and other health care providers move to electronic health records systems.
Add 100,000 new nurses to the workforce in the next five years and establish scholarship and loan repayment programs to encourage people to join the public health workforce.

After reviewing all of the plan proposals from the Democratic and Republican candidates for president that have so far been released, this plan seems like the best to me! It combines the strengths of our private insurance system with intelligent government subsidy for those who need it. It also encourages access to needed types of primary care in order to improve quality and decrease cost. It addresses a growing problem of older adults not yet able to join Medicare, ensures treatment for children, and covers the large group of younger adults who are ignored by most other proposals. Most importantly, this plan avoids the "false choice" between pouring more money into our dysfunctional current system, or going to a government take over of health care. It is an intelligent middle way, that includes important reforms along with intelligent funding.

One of my adult daughters has given money to the Biden campaign based on her support of this proposal, and I hope this plan receives a great deal of attention and debate!

Click here to read more from the Biden Campaign

There is One Politician Telling the Truth about Health Care

2007-06-12T19:46:00.000-07:00

Although our political landscape is littered with candidates who are ducking the issue, or speaking in platitudes, there is one courageous politician who is telling the truth about the need for health care reform in the United States, and I heard him speak on June 11, 2007.

Physician and former Oregon Governor John Kitzhaber is the founder of The Archimedes Movement, which is committed to creating opportunities for meaningful engagement about health care reform. He gave the keynote address here in Bellingham, Washington, at a community forum sponsored by the Whatcom Alliance for Health Care Access, which works locally to help obtain access to needed health care in our community.

His message was that fundamental change is needed to fix America’s “broken” health-care system, and he made the case forcefully, and then outlined what needs to be done.

Kitzhaber is promoting legislation introduced in the Oregon legislature that would restructure his state’s health-care system to provide universal care. “The responsibility to fix the health-care system does not belong to someone on the other side of the country,” Kitzhaber said. “It belongs to us.”

Kitzhaber, who is a physician, focused on the broader problems in American health care, including the pending financial crisis that will peak after millions of retiring members of the baby boom generation will seek benefits.

He also spoke of the “coverage gap” in the current system — the estimated 50 million Americans who do not receive health benefits through work and don’t qualify for Medicare or Medicaid. These uninsured individuals typically do not receive preventive care and then often end up later in emergency rooms, which adds huge unnecessary costs to the system that are shifted to those who do pay for health care, Kitzhaber noted. At the same time, many of these folks are working individuals who are taxed to pay for the health care provided to others by the federal government, who are on Medicaid or Medicare, in spite of the fact that they themselves cannot afford their own care.

“It’s a huge hidden tax that adds enormous costs,” Kitzhaber said. “It makes no sense as a business model and it makes no sense as social policy.”

Kitzhaber said there needs to be a serious discussion on the national level about fixing the system, and that time is running out. SB 27 introduced in Salem is a way to get the issue on the national stage, so that congress must address it. He pointed to Oregon’s 1989 attempt to gain authority over how it administers federal health-care funds as an example of a state forcing a national discussion on the issue. Information about the current bill is available at WeCanDoBetter.org.

Although much of the talk focused on the finances of health care, I was pleased that Dr. Kitzhaber pointed out that we will not solve the problem if we do not reform how health care is delivered. We must emphasize the parts of health care that we already know confer the most benefit, such as primary care, education, health screening and chronic disease management, while empowering people to make choices that fit with their own values. Currently, our "system" favors paying for the expensive and the technological care which is often at the end of life, while trying to save money by limiting peoples access to the most valuable benefits. “It makes no sense as a business model and it makes no sense as social policy.”

"The ability to fix the U.S. healthcare system does not belong to someone else. It belongs to us. If we're not willing to do it for ourselves we can do it for our children and grandchildren."

AMEN

You can learn more and sign up to help at WeCanDoBetter.org .

A CHANGE IN THE FACE OF MEDICINE

2007-05-08T11:34:00.000-07:00

This article was written by family physician David H. Hopper MD, from Princeton, WV, upon the occaision of his premature withdrawal from Family Medicine practice. It is an eloguent testimonial to something that is happening all over the United States. The article appeared in the Bluefield Daily Telegraph.

A CHANGE IN THE FACE OF MEDICINE

Change is always difficult, yet as it says in the Bible, Ecclesiastes 3:1 “There is an appointed time for everything. And there is a time for every event under heaven.” After almost 30 years of serving the people of Princeton and the surrounding region, change took place in the lives of many in this community with my closing of Total Life Family Practice.

This decision was not an easy one, for my partner and I have enjoyed many good years caring for our patients through this practice. However, despite the governor’s logo, we are no longer “open for business.” With this closure over a dozen jobs have been lost and many thousands have lost their family doctors.

The demands of the practice of medicine are continuing to grow. Managing piles of paperwork, dealing with drug formulary and insurance issues, meeting rising overhead with inadequate reimbursement from Medicare, Medicaid and insurance companies, paying high WV malpractice insurance premiums and handling numerous other issues make private practice increasingly difficult. These problems are nationwide, but seem to be even worse here in WV.

Over the years 8 physicians came and left the practice, all of whom moved out of state. Recruiting and retaining doctors became increasingly hard. It became progressively harder to take time off to follow other callings such as my medical mission trips to Sudan or other misfortunate places. Finally I made the extremely tough decision to close my practice.

My decision was an individual one and certainly does not apply to all primary care doctors, but it is one that seems to be increasingly common. The private practice of family medicine has become less and less appealing. The joy of long term patient care relationships, the fulfillment of knowing that you had been able to manage multiple problems which would have required visits to numerous specialists, and the pleasure caring for the children of children you delivered is still available to the family doctor. However the stress of the system, which has persistently undervalued primary care services, has led shrinking percentage of new graduates to enter these fields.

In a recent issue of CA: A Cancer Journal for Clinicians, Dr. Richard Wender, President of the American Cancer Society said: “Adultswith a primary care physician as their personal physician are19% less likely to die prematurely than individuals who utilizea specialist as their personal physician.” And “Despite the striking evidence of the critical role played byprimary care clinicians in the cancer fight, the future of primarycare services in the United States is uncertain. Several highprofile publications have questioned whether we are facing ‘theend of primary care.’ ”

Change will continue to take place in American healthcare, and it must. However it is sad to see the most personal aspect of the healthcare system die off. Be thankful for your family doctor, and support a system that allows whole person medicine to survive.

Joint Principles of the Patient-Centered Medical Home, agreed upon by the AAFP and the ACP

2007-02-19T15:39:00.000-08:00

American Academy of Family Physicians

American College of Physicians

Joint Principles of the Patient-Centered Medical Home

July 2006

Introduction

The American Academy of Family Physicians and the American College of Physicians have developed proposals for improving care of patients through a patient-centered practice model called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006). Similarly the American Academy of Pediatrics has proposed a medical home for children and adolescents with special needs.

AAFP and ACP offer these joint principles that describe the elements of the patient-centered, physician-guided medical home.

Principles

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; end of life care.

Care is coordinated and/or integrated across all domains of the health care system (hospitals, home health agencies, nursing homes, consultants and other components of the complex health care system), facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it.

Quality and safety are hallmarks of the medical home:

▪ Evidence-based medicine and clinical decision-support tools guide decision making

▪ Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.

▪ Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met

▪ Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication

· Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.

Enhanced access to care through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and office staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

· It should reflect the value of physician and non-physician staff work that falls outside of the face-to-face visit associated with patient-centered care management.

· It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.

· It should support adoption and use of health information technology for quality improvement;

· It should support provision of enhanced communication access such as secure e-mail and telephone consultation;

· It should recognize the value of physician work associated with remote monitoring of clinical data using technology.

· It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).

· It should recognize case mix differences in the patient population being treated within the practice.

· It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.

· It should allow for additional payments for achieving measurable and continuous quality improvements.

Why Doesn't My Doctor's Office Take My New Insurance Plan?

2007-02-03T11:46:00.000-08:00

Many people who get medical insurance through their employer have had the experience of the plan being changed by their employer from year to year. Usually the employer does this to save money on the premiums that they pay on behalf of the employee, and any other considerations are of a very secondary importance. This can be frustrating to employees, however, who may find that their personal physician either does not accept the new insurance, or is not a "preferred provider", which means that they will have to pay more for their care. Why don't doctors take every insurance? Here is a recent story that I am familiar with here in the Northwest.

A prominent employer was recently purchased by a new parent company, which made the decision to change the employee medical plan as part of cost savings measures. This medical plan they chose was not very active in the area, and so the plan gave the employer a very inexpensive price to try and "buy their business" and get a foothold in the community. Trouble was, very few doctors in the community had signed up with that plan. The local doctors were not consulted as to why they did not participate, and the employees of the company were not involved in the decision. It probably never even occurred to the company officials that their action might affect others in the community. Either that, or they did not care.

Suddenly, doctors were confronted with hundreds of their long time clients who presented their plan and asked for the office to sign a contract with their new insurance. It turns out that the doctors offices had not signed up with this company on purpose, due to the way the plan did business. Anxious to learn if things might have changed, one doctors group undertook a survey of medical practices in other areas that were already working with the plan. They learned that working with this plan was a disaster. Here are some of the specific problems they uncovered:

Doctors offices were forced to call customer service lines that were almost always busy, making it difficult to ask questions and get assistance
Customer service would frequently "transfer" calls which then became disconnected, starting the cycle of trying to get through again.
Customer service would frequently say they are going to reprocess a claim that was "lost" but then it would not happen
Most customer service calls are handled from India or Jamaica, by individuals who could not make a decision or really help. Often there is a lack of understanding from the person due to language barriers.
Payments for doctors services were artificially low, and grouped services together, only paying for one of them
Large, multispecialty clinics that could profit from expensive tests and procedures signed up and could afford the losses in primary care because they were able to make it up on their high ticket items, but the primary care clinics could not make it pay
The company's corporate practices often drove a wedge between the patient and the physician on several levels such as:

Inefficient claims process that loses claims but insists they were never billed and then blames the doctors office to the patient who complains
Requirements for multiple pre-authorization requests from the doctors office, even for routine care, but then hours are wasted trying to get through. An example is the requirement that the doctors office call them when a patient is in the hospital or is diagnosed as being pregnant. If this is not done "right away" then the later claim for care will not be paid

The plan created a business climate in the area that reduced medical insurance plan availability, since the other plans could not compete with the artificially low prices

Some states have already enacted legislation against this company because of some of their "predatory" business practices

The particular group in question decided once again not to participate with the plan, because to do so would jeopardize their own business and encourage employers to choose the plan. They do try to help their patients, however, by submitting a bill to the insurance company on behalf of the patient. If the claim is not paid, they then transfer it to the patient who gets to deal with their company directly to try and work things out.

Behavior like this from insurance companies is one reason why we have 50% less medical school graduates choosing to go into family medicine than we had when I made that choice in 1975. I believe that employers and citizens need to be more aware of how their choices affect the health care delivery system that they depend on for their care. Our health care "system' is a mess, precisely because of nonsense like this.

What Care Enhancement Services justify enhanced payment ?

2006-12-17T17:17:00.000-08:00

In my last post, we discussed the orientation and philosophy of the personal medical home, as advocated by the American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP). A reasonable question to ask is, what exactly is being done by the doctor and staff that justifies enhanced payment to the physicians office? What are the services that do not fall into the usual payment for an office visit?

Recently, my medical group entered into a pioneering contract with a Medicare Advantage insurance company to hammer out these details as part of a new Medicare Advantage plan. Here is what we came up with:

Personal Medical Home Care Enhancement Services

• Maintain the patient's "personal medical home" electronic health care record, which includes an updated medication list, problem list, and records of all care provided and summaries of care received outside the family physician's office.

• Systematically remind members of covered preventive screening services.

• Apply the Wagner Chronic Care Model of pre-planned office visits to provide medical care for chronic conditions. This model includes the following:

1. A registry system for chronic conditions including but not limited to congestive heart failure and high-risk diabetes, that allows the medical team to identify patients with chronic conditions, assure that the needed care is delivered, and recall the patients for the regular follow-up care necessary for their condition.

2. Software for decision support, available in the room at the time of care. Family Care Network has invested in computerized software that provides evidence-based guidelines for care in the room for patient and health professionals to utilize at the time of services. This software also allows health professionals to link on the web to medical library services from the exam room.

3. The use of clear patient-friendly tools to enable patients to understand their chronic conditions and the actions necessary for them to achieve optimal health.

4. The use of clinical staff to support the patient in self-managing and telephone support, depending on the patient's needs.

• Provide regular quality reports (as agreed) for the insurance companies patients.

• Conduct an annual risk assessment for each member at which time the member's chronic medical problems are identified, reviewed and updated.

• Maintain the patient-doctor health care relationship between office visits by using telephone care and the Doc InTouch secure web messaging system when appropriate. This will enable more frequent interactions with the health care team to facilitate patient self-management.

These "deliverables" for the insurance company are value added work that is in addition to what is normally expected. Taken together, these measures provide a concrete framework that allows for much better patient management, and patient outcomes. If this approach was emulated nationally, it would go a long way to improve our national health care scorecard, and at the same time dramatically improve the financial health of family physician offices.

The Medicare Crisis, National in Scope, Local in Impact

2006-11-28T14:01:00.000-08:00

Medicare was founded in 1965 to help cover the costs associated with health care for older Americans and those with certain disabilities. Since that time it has evolved into one of the most needed and important programs in U.S. Government history. Unforunately, however, as our nation’s health care system now braces for a Medicare Population explosion, caused by the Baby Boom Generation aging into Medicare, primary care medicine finds itself on the verge of collapse due to drastically insufficient Medicare reimbursement.

Some Medicare beneficiaries have already felt this on a personal level, as they have had difficulty finding a family doctor for their primary care needs. This is due to the fact that Medicare funding for the services provided by family physicians often does not cover the actual cost to the doctor of providing that care! In fact, according to a 2006 report from the American College of Physicians, "Primary care is on the verge of collapse. Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy". The report further notes that the key contributor to the problem they describe is the "inadequate and dysfunctional payment policies" of the government and insurance companies. "Unless immediate and comprehensive reforms are implemented by Congress and CMS (Medicare), primary care - the backbone of the U.S. healthcare system - will collapse," concludes the report. "The consequences will be higher costs and lower quality as patients find themselves in a confusing, fragmented, over-specialized system in which no one physician accepts responsibility for their care, and no one physician is accountable to them for the quality of care provided."

The problem described in this report is very familiar to your family doctor, and all of us here in my practice at Family Care Network (FCN). A Family Medicine practice is really a small business which simply cannot remain viable if revenue does not exceed expense. If the current inadequate and dysfunctional Medicare payment policies continue, and with the Medicare population about to increase dramatically, doctors will have no choice but to close their practice to Medicare patients. It is simply not possible for physicians to subsidize the care of so many without becoming economically non-viable. This is a terrible prospect, at the very time when the need will be the greatest! I believe that this is unacceptable, and that is why I am sharing this information about steps we are taking in my medical group, The Family Care Network Solution.

Family Care Network (FCN) has been working diligently to bring this crisis to the attention of our elected officials. While we sincerely hope that our State and Federal Governments will eventually address this crisis on both a national and local level, we have taken a position that FCN must seek out a more immediate solution to ensure our long term viability for survival.

FCN has developed a long term strategic plan for Medicare which we believe will enable us to:

1. Remain in Practice.
2. Continue practicing family medicine according to the Personal Medical Home model of health care as advocated by the American Academy of Family Physicians (AAFP) (see next page).
3. Continue providing care for our existing Medicare Patients.
4. Care for existing patients who become Medicare eligible.
5. Accept new Medicare patients into our practice (beginning in 2007).

The central component to the FCN Medicare Strategy is partnering ONLY with Medicare insurance companies that recognize the critical role played by family medicine in the overall health care system, and choosing ONLY insurance partners that financially support the "Personal Medical Home" as advocated by the AAFP and ACP.

We realize that patients have different needs and preferences when it comes to their Medicare health insurance. As such, FCN will provide our patients with access to multiple Medicare insurance plan options. We also recognize how confusing Medicare insurance has become and therefore FCN will provide insurance counseling services at no cost to our patients. Licensed insurance professionals well versed in all of the various Medicare insurance plans accepted by FCN, will be on-hand to help you understand your options and enroll in the Medicare insurance plan that is best suited to your personal needs.

Finally, FCN believes that healthy communication correlates directly to healthy patients. FCN requires that all Medicare insurance company partners provide internet connectivity between patient and provider via the DocInTouch web messaging program, at no cost to the patient. DocInTouch is a secure internet-based service that enables patients and physicians to communicate efficiently and effectively, and this type of functionality is part of the personal medical home concept.

The Personal Medical Home

All physicians and staff at FCN firmly embrace and support the Personal Medical Home model of health care advocated by the American Academy of Family Physicians (AAFP). FCN supports the Personal Medical Home in the following ways:

1. The physician makes a commitment to the patient to know them as a person, and to provide ongoing, continuity of care for illness and injury, as well as medical planning and advice for screening for illnesses and maintenance of good health.
2. Our office team shares this commitment, assisting the physician in providing hospital care, home care and consultation when needed.
3. Maintain accurate medical records for the care delivered and provide patient education using current technology.
4. Maintain patient registries for certain chronic diseases (Diabetes, Congestive Heart Failure) in order to study, monitor and improve the adequacy of their care, as well as to seek out patients who have not received needed care.
5. Provide planned chronic care visits for diabetes and other appropriate conditions, so that needed information is present for treatment and education at the time of the visit.
6. Integrate patient feedback to improve the performance of the practice.
7. Implement the “New Model of Family Medicine” described in the Future of Family Medicine Report, including secure web messaging.

As we communicate with our patients about these changes, we are letting them know that we greatly appreciate their continued support and patronage. Providing their Personal Medical Home is something that we take very seriously and we remain fully committed to providing the absolute best primary care medicine possible. We recognize that re-evaluating Medicare insurance needs involves significant effort, time and stress. We hope that they understand the challenge we are currently facing, but with stheir support we are confident that we will overcome this challenge, together.

How the US Health Care System falls short, and what to do about it!

2006-11-27T14:12:00.000-08:00

When most people in the public at large think about our health care situation in the United States, it is usually with regard to the high cost of health insurance premiums. Quality is assumed by most people to be present. Assessment of quality in the US was recently undertaken by the Commonwealth Fund Commission on a High Performance Health System, which has now summarized their results as the National Scorecard on U.S. Health System Performance. This is the first-ever comprehensive assessment of health care outcomes, quality, access, efficiency, and equity in one report. It is no surprise to me that the finding ofthis report show that America's health system falls far short of what we need, especially considering that the US pays more per capita than any other nation on earth.

Across 37 indicators of performance, the U.S. achieves an overall score of 66 out of a possible 100 when comparing actual performance to achievable benchmarks, or a "D+". The following graph shows the score for the US in the major areas observed.

Click Graph to Enlarge

These results clearly show that not only is cost a problem, and not only do we have about 45 million people who are not covered, but our results for the money spent fall far short of what is needed and achieveable.

I have included a link to the report in this blog, but I believe that the messages from the Scorecard are clear:

Preventive and primary care quality deficiencies undermine outcomes for patients and contribute to inefficiencies that raise the cost of care. These deficiencies are to be expected in a system that chronically underfunds primary care, and does not pay doctors for proven primary care strategies such as electronic medical records, chronic disease registries, telephone management followup, web messaging and quality benchmarks. Universal coverage and participation are essential to improve quality and efficiency, as well as access to needed care.
Quality and efficiency can be improved together, and we must look for improvements that yield both results. Failure to coordinate care for patients over the course of treatment put patients at risk and raise the cost of care. This is especially acute with patients who do not have a "Personal medical home". Policies that facilitate and promote linking providers and information about care will be essential for productivity, safety, and quality gains. Financial incentives posed by the fee-for-service system of payment as currently designed undermine efforts to improve preventive and primary care, manage chronic conditions, and coordinate care. We need to devise payment incentives to reward more effective and efficient care, with a focus on value. Research and investment in data systems are important keys to progress. Investment in, and implementation of, electronic medical records and modern health information technology in physician offices and hospitals is low—leaving physicians and other providers without useful tools to ensure reliable high quality care. By emphasizing adequate payment for primary care, savings can be generated from more efficient use of expensive resources including more effective care in the community to control chronic disease and assure patients timely access to primary care. The challenge is finding ways to re-channel these savings into investments in improved coverage and system capacity to improve performance in the future.

Setting national goals for improvement based on best achieved rates is likely to be an effective method to motivate change and move the overall distribution to higher levels.
Our health system needs to focus on improving health outcomes for people over the course of their lives, as they move from place to place and from one site of care to another. This requires a degree of organization and coordination that we currently lack. It also requires that each person have a "personal medical home" with a primary care physician office team.

This Scorecard is a snap shot of the vital signs of our health system. It is not a pretty picture! Our rising costs and deteriorating coverage require leadership to transform the health system.

I say, let's start by adequately funding all primary care, so that we begin with the basics - adequate access for early care, chronic disease care and preventive care. This personal medical home, supported by state of the art medical records, can then be the organizing central point for improving communication and reforming the health care system.

How to Lower the Cost AND Improve the Quality of our Health Care

2006-11-24T11:47:00.000-08:00

One of my favorite and most useful resources for understanding the complexity and variation in our United States health care "system" is the Dartmouth Atlas of Health Care.

One of the most fascinating observations made as a result of this ongoing study was published in 2004 (Health Affairs, 10.1377/hlthaff.w4.184 Copyright © 2004 by Project HOPE ). The authors, Katherine Baicker and Amitabh Chandra studied the relationship between Medicare Spending, the type of physician workforce, and beneficiary's quality of care. The results were astounding, and showed that only one parameter correlated with improved quality and decreased cost, and that was the ratio of family physicians to the general population.

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These results confirm what has also noted all over the world, which is that high functioning health care systems have a high ratio of primary care doctors as part of the physician work force. The authors also looked at the affect of the ratio of more narrowly focused specialist physicians on cost and quality.

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The data clearly show that as the ratio of narrowly focused specialist doctors increases relative to the general population, cost goes up and overall quality actually worsens!

How can this be? It seems counter intuitive to many people that more specialists would result in lower quality of care. Based on my years of practice experience, I believe these results are accurate, and that the results are due to several factors:
1.) When family physicians are in short supply, needed primary care services, that should be the foundation of all that we do, are not received by many people who have their first contact with specialists .
2.) When family physicians are in short supply, they are forced into a mode of seeing patients more quickly than is desirable, which I believe lowers the quality and the patient satisfaction. Costs go up because it is easier to simply order the expensive tests that drive up costs than it is to do a detailed history and physical exam before planning workup.
3.) Due to their training and focus, narrowly trained specialists sometimes bring high risk and high expense habits to bear in situations where a less aggressive approach might be preferable.
These doctors are a valuable and needed part of our care delivery system, but they do not specialize in first access health care, screening and helping us to stay well.

The authors looked at other factors, but did not observe any other clear relationships. Data on nurses, for example, did not show a change with a changing ratio to population.

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So what does this mean for health care reform? To me, the implications are clear, and aggressive action is required. Health insurers and the federal government need to begin immediately to implement policies that nurture the provision of primary care.

Unfortunately, the current state of affairs is bleak. The American College of Physicians (ACP) has issued a 2006 report that predicts the imminent collapse of primary care in the United States, due to the inadequate and dysfunctional payment policies of the government and other third party payers. Most government payment programs do not even cover the overhead cost of doctors to provide primary care, and the situation is getting worse! Medicare, for example, is scheduled to decrease payments by 5.1% as of January, 2007. Fewer and fewer medical students are choosing to pursue family medicine or other primary care as a career option, because they know they can make more money at less personal risk by going into a high tech, limited specialty. Many existing primary care doctors are near retirement and will soon be out of the workforce. And all of this is happening at the very time we will experience a large jump in Medicare age patients needing primary care services.

The Medicare situation is due to the way payments to doctors are calculated. Medicare Part "B" was established to cover doctors visits. As care has become more technical and complex, new services have been added into the pot for coverage. Now, in addition to doctors visits, Par "B" also covers out patient surgery, CT scans, MRI scans, nuclear medicine and other high tech wonders. This then results in Medicare Part "B" spending "too much money", and payment reductions for everyone are then put in place. Primary care office visits get cut back, in spite of the fact that payment is already too low.

If we began a national policy of enhancing the ability of family physicians to provide excellent primary care, it would need to start by decoupling primary care payment from the rest of payment for health care. This would encourage the development of what the American Academy of Family Physicians (AAFP) calls the "personal medical home", a place where they know your name and each of us knows we can go for care and referral. Payment to primary care practices needs to be enough to cover overhead, build state of the art infrastructure to incorporate electronic medical records, support advanced management strategies and let the doctors make a reasonable profit. This will attract doctors to family medicine at the time we need them most! The data are clear. We need to nurture and encourage the only part of our current health care "system" that is already demonstrating a clear relationship to increased quality and lower cost.

Should Health Care be a Right in the United States?

2006-11-23T11:28:00.000-08:00

The United States is very unusual among the industrialized nations of the world, because we are the only country in that group which does not recognize access to health care as a fundamental right of citizenship. How can this be? Why have we evolved in a different direction?

Do you believe that health care should be a right in our country? I do. Some time ago, I submitted an essay to the NPR Radio series, "This I Believe" about my thoughts on this topic. So far, they have not chosen to broadcast my entry, so I include it here.

This I Believe

I was working outdoors in a small courtyard, next to a village school, as a volunteer doctor in El Salvador, when I met an old gentleman who had come to see me. He came accompanied by his daughter, who explained that her father had lost most of his hearing over the last several years, and they had not had the money to have him checked. I finished taking his history, and began my exam, only to find that both of his ears were completely blocked by massive amounts of ear wax. Although the job was difficult, I was finally able to get all of the wax removed, and the joy on his face testified to the miracle he had experienced of being able to hear again. In my lifetime of work as a family physician, I have had many other experiences where the lives of people have been fundamentally changed by receiving needed medical care. I have also seen people whose lives have been changed for the worse when needed care was not available.

I believe that in today’s modern United States, access to medical care must be considered a fundamental right. If the United States of America was founded today, this would be acknowledged in our constitution.

Our founders wrote in the Declaration of Independence:

“ that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

I believe that 1776 it did not occur to the signers of the Declaration to name medical care as a right, because it barely existed and was not very effective. Rich and poor Americans alike found themselves in the same boat. One in five children died before reaching a year of age, infections and accidents were the leading causes of mortality, and the average age of death was in the early 40s. Indeed, George Washington himself, the founder of our country, died at home from the complications of a strep throat.

Today, our country is much different place. As a family doctor, I have seen first hand how prompt treatment of illness and injury can have life saving and life changing consequences. I have seen how care of chronic illness can prevent disability and premature death, and how screening tests allow us to find and treat early illness to affect a cure. I have witnessed children who became seriously ill due to lack of available treatment or immunizations, and adults who have died from stroke or heart attack because of untreated hypertension. I have seen emergency rooms full of people in crisis with problems that should have been care for in the community long before. In all of these cases, the persons’ ability to exercise their right to “Life, Liberty and the pursuit of Happiness” was taken away by the lack of needed health care.

The Declaration of Independence noted in 1776 that “Governments are instituted among Men” to secure our rights. I believe that health care has now become a basic right, and that it is now time for our government to secure this right for all of us to basic medical care.

This I Believe.