Thursday, May 14, 2009

Obama's Health Care Reform: Let the Games Begin


Can you feel the love? Cupid ran out of arrows in Washington, D.C. this week. On Monday, several medical industry groups including physicians met at the White House for a health care reform love fest. For as long as I’ve been a physician, the pharmaceutical industry, insurance companies, hospitals, physicians and medical device makers all viewed medical reform as a disease that needed to be vanquished. This week, these erstwhile reform antagonists are sitting around Obama’s campfire in a Kumbaya moment. These health care stakeholders pledged to reduce health care spending (read: their income) 1.5% annually over the next 10 years. What happened? Were they drugged or hypnotized? Is there a secret deal that we don’t know about? Did they drink the Obama Kool-Aide that has intoxicated much of the nation? Did they hear an inspiring sermon at their church services this past Sunday and were inspired to do the right thing for America?

The correct answer, of course, is none of the above. These medical interest groups are savvy survivors and are feigning cooperation with their eyes wide open. They have calculated that it would be a clumsy strategy to oppose the president at this early phase. In particular, the pharmaceutical industry, so often demonized in congress and in the press, needs to buff its image now before it is given a scarlet letter and ostracized. These groups have even suggested cooperation with comparative effectiveness research, which could substantially reduce their profits. These medical industries want a seat at the reform table so they can influence a process that might otherwise dismantle them.

The president has joined hands with this medical coalition because he needs them. These reform adversaries, with their tons of money and influence, could sink the ship before it even leaves port. Harry and Louise, the hokey and effective media campaign that helped to deflate the Clintons’ health care reform effort, will seem like a pea shooter compared to the weapons that medical special interest groups are prepared to wield today. The Kabuki dance we witnessed at the White House this week can quickly evolve into a hostile conflict.

Both sides will stay at the campfire for now. This is the domestic version of realpolitik, the policy of dealing with unsavory governments if it serves our national interest. Everyone knows the game here. They will all sing from the same hymnal as long as it serves their interests. Soon, however, interests will diverge and fissures will develop. Accusations will replace amity. The peace pipe will be exchanged for a lead pipe. Each side will stridently argue that if the other side prevails, then the health care system will be ruined.

For the moment, we are to believe that the romance is real. But, this love won’t last. Soon, arrows will fly and they won’t be coming from Cupid’s bow.

21 comments:

Ashok V. Daftary, MD, FACP. said...

How right you are . As a "primary care" Internist,Health Affairs just informed me that I contribute approximately $68,000 of scut uncompensated labor every year to support these greedy clowns.
Uncompensated physician labor in this country contributes $21-30 billion yearly to a private health industry

Michael Kirsch, M.D. said...

Consider all of the players in the medical arena. Which ones are truly on the patients' side?

Anonymous said...

THE HEALTH INSURANCE INDUSTRY HAS TAKEN BACK THEIR ‘PROMISE TO CONTROL COSTS. It would affect their profits. . .

Read about it here: http://www.nytimes.com/2009/05/15/health/policy/15health.html?_r=2&partner=rssnyt&emc=rss

It’s what we’ve known all along: we can't trust the insurance industry with health care reform.

Only a single-payer approach to healthcare reform will end the inhumanity of our failed healthcare insurance system, where profits are more important than patients’ health, and where people die because of it.Our fight for equal access to healthcare for all is about democracy, human rights, civil rights, and basic human decency.

Michael Kirsch, M.D. said...

My posting predicted that the 'love wouldn't last', but the speed of the annulment is impressive. My fear of single-payer is that we will end up with medical mediocrity in exchange for universal access. Where do you get better service, Federal Express or the Division of Motor Vehicles? I agree that we should be suspicious of the insurance companies. The pursuit of profit is not inherently evil. Every player in the game - including the public - has an angle and an agenda. I'm not sure that anyone at the table is pure.

Anonymous said...

A national study of nearly 900 U.S. physicians and medical group administrators found that physicians spent on average 142 hours annually interacting with health plans, at an annual cost to physician practices of $31 billion, or $68,274 on average per physician, per year.

Key Findings:

• Physicians, on average, spent 142.3 hours per year interacting with health plans, or 3.0 hours per week and 2.7 physician work weeks per year. Primary care physicians spent significantly more time (164.9 hours per year) than medical specialists (123.7 hours) or surgical specialists (100.3 hours).
• Nursing staff spent an additional 23 weeks per year per physician interacting with health plans, while clerical staff spent 44 weeks and senior administrators spent 2.6 weeks doing so.
• Compared with other interactions, physicians, on average, spent more time dealing with formularies (78.2 hours for primary care doctors, for example), and the least on submitting or reviewing health plan quality data (1.9 hours annually for all physicians).

Converted into dollars, practices spent an average of $68,274 per physician per year interacting with health plans; primary care practices spent $64,859 annually per physician, nearly one-third of the income, plus benefits, of the typical primary care physician.

The Bottom Line:

Although health plans claim to have reduced the administrative burden they place on physicians, evidence shows that the average physician spends nearly three weeks a year interacting with plans, at an estimated annual cost to practices of $31 billion. Primary care physicians, especially those in small practices, spend larger amounts of time interacting with plans than those in other specialties.

Citation:

L. P. Casalino, S. Nicholson, D. N. Gans et al., "What Does It Cost Physician Practices to Interact with Health Insurance Plans?" Health Affairs Web Exclusive, May 14, 2009, w533-w543. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.4.w533

Michael Kirsch, M.D. said...

As a physician, I do not need a study to inform me what I experience every day in practice. Spending time on medication formulary issues is torture. However, it is constitutionally permissible since it is cruel but not unusual. I agree that it is an enormous waste of time and money and drains office morale. My frustration, however, is not sufficient for me to advocate for a single-payer system. Medicare is a model of a single payer and has its own mountain of useless paperwork and bureaucratic morass to wade through. Physicians are opting out of Medicare or pursuing concierge practices to escape its onerous requirements and ever diminishing reimbursements. I agree with the anonymous commenter above that my profession is aching for deserved relief on this issue. What other profession has to hire a separate staff just to figure out what we should be paid?

Anonymous said...

There are two main arguments in favor of single payer health care.

THE MORAL ETHICAL ARGUMENT

The first is the ethical moral argument. Health insurance companies make their profit by denying health care to sick people. That is immoral and unethical.

THE ECONOMIC ARGUMENT

The second compelling argument is economic. Our current system of for-profit corporate health insurance has created an unbearable economic burden on the nation.

There are over 100 separate health insurance companies operating under different sets of rules creating a huge 30 % administrative overhead. For comparison, administrative overhead for Medicare is only 2%.

By converting to a single payer system, we immediately save 300 billion dollars in administrative overhead. Medicare is a 40 year example of a successful single payer system which has an administrative overhead of 2%, not 30%.

As a nation, we are now paying twice what other countries pay for health care, yet we do not have universal health coverage here in the US. 50 million Americans are without healthcare and 87 million Americans without health insurance at some point in the past 2 years. Almost half the bankruptcies currently filed in the United States are because of medical bills.

Despite the costs we pay, the United States ranks LAST on a list of 19 industrialized nations in preventable deaths, and 29th of 37 in infant mortality. The World Health Organization ranks the US at 72nd for healthcare accessibility and efficiency. We can no longer maintain the status quo for the ways we currently provide and pay for health care.

WHY WE DON'T HAVE SINGLE PAYER NOW

These two arguments in favor of a single payer heath insurance system (moral and economic) are so compelling, that one must conclude the only reason we don't have single payer now is because of lack of representative government. The obvious conclusion is that our government does not serve the people who elected them. Rather, our elected government officials serve the special interests of the health insurance industry and other corporations who make massive campaign contributions.

Michael Kirsch, M.D. said...

I do not agree with your comment, "Health insurance companies make their profit by denying health care to sick people." Do supermarkets earn their profit by denying food to those who need it? Are construction companies obligated to solve homelessness? I agree that the current system has inequities and variations in care that demand reform. I also agree, and have posted repeatedly, that we are wasting billions of dollars in excessive medical care. These two facts are inarguable. The dispute is over the best path to pursue to reach the objective. Single payer, your solution, addresses many deficiencies but could be a cure much worse than the disease. If we had single payer with universal access and mediocre medical quality, would you be satisfied?

Anonymous said...

Everyone is wrong.
Medicare and all the other medical insurance companies should be completely abolished!

How can you call medical insurance market competitive when it is dominated by less than a dozen insurers?

Medical care should be delivered for cash in order to reduce costs.

Imagine a patient coming to see a doctor who quotes him a price of $150+ for an eye exam. The patient will not accept this highway robbery. He'll say, here is $30, take it or leave it. :-) COSTS DOWN!!!

750,000 physicians competing against each other over pricing of their services will bring the costs down and offer truly universal coverage.

Also, it is of no secret that physicians price their services according to the Medicare RVUs. Just like a pharmaceutical company, a physician (at a minimum!) expects to be paid according to the government-set standard.
Excuse me, but Medicare effectively creates a price floor for physician and pharmaceutical compensation. This is fraud, because government has in effect created a trust with physicians and pharmaceutical companies.

In a free market, the price floor for a good or service is determined by the consumer's demand for that service at the quoted price.

I hardly think most people would be willing to pay $150 to see a doctor for a derm exam.

Single-payer system will lower the standard of care in US, for sure. No government can predict how to price the market. Soviet Union, anyone? 70-year experiment in the making.

Also, do you think Canadians/English/Japanese/Swiss doctors and economists are dumber than their American counterparts? But they cannot make their systems rival that of US in terms of quality of service. Decades of government pricing models for healthcare brought nothing but a decline in the quality of service and availability of treatments.

All medical insurance should be eliminated. Doctors will with time agree to lower CASH fees in order to protect their practices. Consumers will benefit immediately.

Also, I am sure that at least 10% of the physicians will immediately defect from the herd and form consumer advocate groups that will advise on whether a particular physician service is reasonably priced and whether a doctor is taking advantage of a patient by sending him for an MRI over a minor headache.

Abolish Medicare and all the look-alikes. Make people pay for regular/chronic care and allow catastrophic insurance option with a high deductible.

Michael Kirsch, M.D. said...

While I do not endorse abolishing medical insurance entirely,the high deductible feature is worthy of consideration. When patients have some 'skin in the game', they are much more discriminating about their physicians' recommendations. When patients bear some financial responsibility, they will not automatically acquiesce to their doctors' casual suggestions to proceed with an MRI for back pain or a colonoscopy after a day of constipation. Conversely, when medical care is on someone else's tab, then neither the doctor nor the patient have any incentive to proceed conservatively. This is similar to businessmen who dine out on the company's expense account. I suspect that they order much differently than if they were paying the bill personally.

Anonymous said...

The high-feature deductible is already available. If I am not mistaken, there are undercover insurance policies available to physicians with high-deductibles and low premiums. General population of course has no access to such policies :-) Doctors are preying on people's ignorance and Congress lawyers are milking physicians for their greed.

I liked the observation of Ben Stein: "Everyone in this country pays homage to the free market, but no one wants to work for free market wages." :-)

Anonymous said...

In Minnesota, where every major health insurer now offers high-deductible plans, nearly half a million enrollees, or 10 percent are now covered by such insurance.

That's created an explosion in demand for price information - which used to be treated like industry secrets. Now, law requires clinics and hospitals to give an estimate whenever a patient asks for it.

Last year, overall medical spending in Minnesota grew at just 6 percent, the smallest increase in a decade, according to the Department of Health. At companies that switched to HSA-type plans, the slowdown was even more dramatic, with some reporting actual drops in medical spending.

For Jeff Palumbo of Grant, Minn., the epiphany came this year when he took his son in for ringworm. Palumbo had just switched to his employer's high-deductible plan. Despite multiple phone calls to his clinic and his insurer to ask the price of a doctor visit, he kept getting the same maddening answer: It depends. Finally, someone told him it would cost at least $85. When Palumbo ended up getting billed $125 for the visit - "For seven minutes!" - he called to complain.

Next time, he said, he'll go to a MinuteClinic. (It charges $59 for ringworm.) Despite the frustrations, Palumbo likes his control over spending. "It makes you ask more questions," he said.

Anonymous said...

Again, from Ben Stein:

You get rich by working in fields in which you can fix your wages, preferably with the government’s help. These include law, where you need a license to practice, and thereby can lift yourself out of working for free-market wages. (Everyone in this country pays homage to the free market, but no one wants to work for free-market wages.) They also include medicine, where a far more difficult license is required, and where desperate patients will pay almost anything to look and feel good. They also include accounting at the C.P.A. level.

Anonymous said...

To all the doctors that want a single-payer option:

Again, from Ben Stein:
"You do not get rich by a lifetime of work in any field in which there are government price caps on earnings."

The ignorance among physicians about economics is staggering.
Good luck greedy lazy disorganized physicians!

For some reason, Congress does institute price controls on lawyers, even though legal services are next to a necessity in American society.

Good luck to the new and recent graduates :-)

Anonymous said...

correction to the previous post:

For some reason, Congress does NOT institute price controls on lawyers, even though legal services are next to a necessity in American society.

Anonymous said...

should be read by every patient

http://www.jpands.org/vol11no4/gervais.pdf

Anonymous said...

And this:

http://www.jpands.org/vol14no2/kurisko.pdf

Anonymous said...

I see the owner of the site got scared over his salary and is not replying to my comments.

Another lying limousine liberal who wants to brand himself with this site into the next Atul Gawanade.

Michael Kirsch, M.D. said...

If I were really scared, then I wouldn't be anonymous.

Anonymous said...

then reply!!!!!!

Leonard Okoth said...
This comment has been removed by a blog administrator.

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