$ The cost of Health Care reform

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?

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

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!

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

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?

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

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?

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

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

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