Tiers of U.S. Healthcare

A recent U.S. presidential-candidate debate included proposals on Medicare-for-all, care for illegal immigrants and private insurance: supposedly a three tier system. Exactly which existing tiers would be removed, which would be funded and how would the budget for care work?

Consider the layer cake of U.S. healthcare, as it exists. Start at the top where little figures of a bride and groom might stand. That is the highly-privileged care provided to members of Congress and many government employees (“Cadillac” health plans with a large percent government subsidized plus pre-tax perks). That insurance provides good care (not as good as the care in the French system, but pretty good).

The next tier is the “CEO” or “rich guy” healthcare. They have so much money they don’t need insurance. They just buy what they want at big name hospitals with private suites staffed by nicely dressed doctors in suits and young nurses with little pointed hats. The motto is “whatever you want”. CT scans of everything happen at least once a year and heart tests proceed just because “you can’t be too careful”. And, heavens, the food you like is on your diet. Rating of care: poor.

The next tier is a hodgepodge of layers or “options” offered by many insurance companies like Blue Cross, UnitedHealthcare, Aetna etc. These are mostly provided through an employer group plan. And, sometimes purchased individually at a higher cost if the person is part-time or retired before age 65. Some plans have high deductibles and high co-pays that financially make care difficult to obtain. Some closed panels of providers limit where a person can obtain care and limit the options for moving or travel. The insurance companies scrape off 15% of the icing (administrative fees). Rating of care: fair to good.

Next is the Medicare tier divided into several layers including Medicare with a supplement (fee-for-service) and Medicare Advantage (per-capita). Rating of care is good with a plus for lower cost compared to the higher layers. Unfortunately, Medicare does not negotiate drug prices according to laws supported by drug companies. Rating of care: good.

Next are decorations of socialized medicine. These include the Veterans Administration, Indian Health Service and various levels of military healthcare (Tricare). Rating of care: good.

Next is Medicaid. A State run and federally supported insurance for the poor. It is limited by budgets and willing providers. Rating of care: fair if you qualify, but many who need care don’t qualify for a variety of reasons.

Finally, the bottom layer. The layer for those with no insurance and no funds. All States require emergency rooms to provide care to “stabilize” a mental or physical illness. Anyone can obtain health care in the U.S. based on this nearly insane model where people wait until they are really sick to receive care in the most expensive setting. The bills, which none in this layer can pay, are astronomical and serve only to further bankrupt the unfortunate. Rating of care: poor with no connection to a primary care provider or mental health follow-up.

In conclusion, the recent superficial debate about healthcare seems to hinge on hot-button issues like rich insurance companies, greedy drug companies and desperate immigrants who become sick. Of course healthcare costs money — only a politician would say otherwise. The healthcare system we have or will have is exactly what we plan.

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Medicare For All — what does that mean?

Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.

There are two major versions of Medicare: Standard and Advantage.

Medicare Standard

  1. It sets the allowed price for hospital and medical provider services
  2. It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.

Medicare Advantage

  1. Limits participants to one insurance company or organization
  2. Has lower premiums
  3. Wraps Medicare and a supplement together

What about Medicare For All

  1. What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.

The Choices

This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?

☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐   Profits for drug companies limited to 5%

All covered medications available for $10/month
☐ All approved hospital days available for $400/day

☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐  0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe

☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service

☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals
(5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget

☐ Ongoing and up-to-date quality measurements on all services
No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)

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Privatize the VA? Pay more for less.

free-vector-veterans-administration_089530_Veterans_Administration

Should the US privatize the Veterans Administration hospitals and clinics?  Let’s put the assumptions in the question on the table:

  • Bureaucracy is bad
  • US health care is good
  • The US is in continuous war
  • Treating the wounded is too expensive

This blog is about healthcare, not geopolitics, yet the temptation to see war as a disease is difficult ignore.  Let’s not go there.  Instead, compare the VA system with the proposed replacement.

VA Healthcare Private US Healthcare
  • Lower drug prices due to negotiation by the system
  • Expertise with PTSD, alcoholism, tobaccoism, drug addiction, low income, amputations and poor literacy.
  • Group sessions with people having a military background
  • Funding is always in doubt
  • Managed as a system, although management is only fair.
  • World healthcare rank is unknown, but is likely better than the US as a whole.
  • High drug prices due to lack of negotiation at the system level
  • Primary care is unequipped to deal with social and psychiatric problems (not in the usual five-minute visit that is profitable)
  • Group treatments with people who might dislike the military.
  • No limits on costs and profits
  • Highly influenced by the biggest lobbying efforts in the US
  • Not managed as a system
  • World healthcare rank is 26th.

Would a veteran actually want private healthcare?  Perhaps veterans living a long distance from a VA facility would choose private care.  But, if VA facilities are close who would want to enter a private system that is hugely expensive, not focused on war injuries, poorly managed, and has low quality ratings?

The real answer to the initial question is that private US healthcare needs to improve tremendously.  If and when that happens then the need for the VA would naturally disappear.  And, by the way, less war would help.

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US Healthcare — a foolish consistency

foolishconsistency

Ralph Waldo Emerson is not usually associated with healthcare.  However, his famous quote about consistency may apply.  The US healthcare system seems to be quite consistent, in a bad way.

The Perspective section of the September 7, 2017 edition of the New England Journal of Medicine featured an opinion article by Eric Schneider and David Squires.  The essence of the article is to point out the US healthcare system has a lot of potential, receives lots of money, discovers great treatments and has some institutions that really deliver good care.  The authors suggest with a change in focus US healthcare could be number one in the world.  Yet, it is not.  And, it maintains a poor rating CONSISTENTLY.

The authors state key strategies for improving healthcare:

  1. Timely access to care (preventive, acute and chronic)
  2. Delivery of evidence-based and appropriate care services.

They note several things that stand in the way of delivering care of any type:

  1. Cost of care (US is number one)
  2. Administrative burden (US is number one)
  3. Disparities in the delivery of care (US rates very high)

In any large US city the profusion of stand-alone emergency rooms is testament to the failed notion of high-cost rescue treatment rather than low-cost prevention or ongoing monitoring and early intervention.   The US tends to invest in high-cost drugs, treatments and surgeries and under-invests in primary care and social services.  The failure to adjust the focus of healthcare efforts has become a financial train wreck.

The authors of the above article present four prescriptions for US healthcare:

  1. Improve access to care
  2. Increase investment in primary care
  3. Reduce the administrative burden
  4. Make healthcare more equitable, so all people can receive good healthcare

However, those lofty goals require something else.  The US must stop the foolish consistency of accepting poor health care, of paying too much for healthcare and believing great inventions automatically lead to great healthcare.

Perhaps the Emerson quote is too painful.  An Albert Einstein quote may be better:

“The world we have created is a product of our thinking;  it cannot  be changed without changing our thinking.”

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Physician Shortage — no end in sight


The above chart is from data just released from the National Resident Matching Program.  This is about doctors who completed medical school and now according to their preferences are matched with training programs in various specialties.  This is for the first year of residency, but it should be noted physicians may branch out to other specialties later in training.  Internal medicine is a good example since those physicians branch out to later be general internists, hospitalists, cardiologists, pulmonologists, gastroenterologists, diabetologists, and nephrologists among others.

The point of this chart is to show how the shortfall in US physicians is being filled by foreign physicians.   The foreign physicians are good doctors, in fact, some of the best in the countries they come from.

The obvious question is WHAT IS WRONG WITH THE US PHYSICIAN TRAINING PROGRAM?  It obviously is not keeping up with demand.  Thousands of US students desperately want to go to medical school, but there is no place for them.  Certainly, cost is a definite issue — many who would like to go to medical school just can’t secure the funding or don’t want to go into debt for hundreds of thousands of dollars.  So, the inadequacy of US medical training is resolved from afar.

Other countries, like the UK, solve this problem by offering aspiring doctors the funds to go to medical school in exchange for becoming a specified type of doctor and practicing (for a number of years) in a specified location.  It seems to work.

Attracting good doctors from other parts of the world sounds attractive but it’s not so nice for those other countries losing the doctors.  The US has a significant physician shortage which is getting worse.  Since the US does not have a healthcare system it is not possible to respond to the shortage.  The free market system fills the lucrative specialties in the nice locations leaving the non-urban communities to go without or hopefully attract a foreign medical doctor.  In many rural communities there are no US trained physicians.

US healthcare quality is at the bottom of industrialized countries.   Access to healthcare declines in large part due to a shortage of providers.  Since there is no organized healthcare system no resolution is in sight.  It’s staggering to realize even Cuba has more doctors per capita than the US.  The discussion and legislation so hotly debated currently seems oblivious to the shortage of physicians for which insurance is no solution.

 

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Healthcare Standstill — poor prognosis

So, what’s the problem with US healthcare?  What’s the fix?  What’s the medication for the ailing health system?

Start over.  Begin again.  Throw out the mess.

Usually, complicated problems are solved incrementally by finding each small problem and fixing each one until the huge problem is resolved.  This approach has failed healthcare in the United States.  The evidence is overwhelming.

  • rising cost
  • declining health
  • inability to train enough workers
  • high infant mortality
  • inability to control drug costs
  • focus on cost instead of health
  • fragmented improvement efforts

THE UNDERLYING PROBLEM IS THE US DOES NOT HAVE A HEALTHCARE SYSTEM:  NO SYSTEM TO CORRECT, NO SYSTEM TO MEASURE, NO GOALS TO MEET, NOBODY WHO IS ACCOUNTABLE.

The measure of a healthcare system is an average.  It’s not whether one guy is cured from leukemia but whether the average baby survives, the average citizen can get a doctor appointment, can purchase medications, and can have surgery if needed.

Sadly, if you are a legislator every problem looks like a financial problem — you can pay more or pay less.  You tried the first option so now you want to try the second option.

Supply and demand economics does work  But, it just has to be applied the correct way.  If the salary paid to a lawmaker is dependent on improving health in the country then the economic theory would work fine.  It does not work fine when complicated treatments are marketed to a population with low health literacy (and that includes the President and Congress past and present).

The reason Medicare-for-all seems so appealing is because it is a system.  Perhaps it’s not as good as the systems in other countries, but it’s the system we know.  It’s time to stop complaining about cost and complexity.  DO SOMETHING and KEEP IT SIMPLE.

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Deprescribe — too many medications

bottle_of_medsMany patients take too many medications which leads to unnecessary side effects, drug interactions and high cost.  Yet physicians sometimes fight just to get patients to take necessary medications.  Two examples:

  1. Provider:  How many medications are you taking?
    Patient:  Including vitamins I think fifteen.
    Provider:  What? I only have two medications on my list.
    Patient:  I restarted all the medications I was taking before you hospitalized me plus all the new prescriptions from when I left the hospital and I added some vitamins.
  2. Patient:  I stopped that medication because I thought it was causing my hair to fall out.
    Provider:  Your heart medication does not cause hair to fall out.  And, even if it did you could die without it.

The medications you take should be reviewed at each visit so you and the provider consider which are truly needed and why.  The provider who gives the patient a prescription is responsible to make sure there is no interaction or duplication with ongoing treatment.  Yes, that means cardiologists and dentists also.  A proactive patient should simply ask, “Is that new medication compatible with all of my existing medications and does it replace one of the existing medications?

The highest risk situation for evaluation of medications happens when alternate providers become involved.  Like a hospital doctor, an ER doctor or a specialist.  They tend to add medications without fully considering the existing medications, often thinking the primary provider will resolve any drug issues — too bad when a fill-in primary provider steps into the mix.

An article in the Washington Post January 28, 2017 by Dr. Ranit Mishori advises the following questions for providers and patients to consider together about medications:

● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?

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