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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.
- It sets the allowed price for hospital and medical provider services
- It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.
- Limits participants to one insurance company or organization
- Has lower premiums
- Wraps Medicare and a supplement together
What about Medicare For All
- 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.
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)
The people in the United States pay more for drugs than any other country. And, they pay more to universities to do drug research than other countries. In a nutshell, it is due to a lack of regulation in the U.S.
Drug companies constantly complain regulations are hurting profits. Now it appears without enough regulation drug companies are hurting sick patients. As big pharma points out, it’s all legal. Basically, big pharma points a finger at the US Congress for not imposing restrictions common in the rest of the world. Sounds like a circular argument!
Between the two articles linked above and this author’s experience here are the reasons:
- Abuse of patent laws
- Driving small drug companies and generic companies out of business with frivolous but highly expensive suits.
- Release of a similar drug before a patent expires and manipulating doctors and patients to change to the new drug suggesting the similar drug is “MUCH” better (evergreening).
- Paying new drug makers to delay marketing their competitive drug (pay-to-delay). While at the same time asking for a fast track through the FDA approval process.
- Claiming a new drug is novel when by any reasonable standard it is not (asthma inhalers are a good example).
- Coupling devices to drugs to double the difficulty for competition (like insulin pumps).
- Failing to pay their fair share of basic drug research, funded by the US government instead.
- Happily doing “inversion” deals to move headquarters to other countries to evade US taxes — into the very countries that strongly regulate drug company profits.
- Voluntarily limiting profits in many countries due to the threat of regulation, but failing to offer the same deal to the US.
- Lobbying successfully to prevent Medicare (a larger health program than the NHS in the UK) from negotiating prices as the UK has done for many years.
- Blackmailing patients to pay for old drugs at exorbitant prices because generic companies are afraid to compete (pricing because-they-can, oral beclomethasone is one example).
- Preventing drugs from other countries to be sold across borders because of unfounded safety concerns (crocodile tears).
- Actively avoiding drug comparison research — forcing others to do that type of research after the drug is already marketed.
- Doing cancer drug research with endpoints (such as tumor size) rather than life expectancy. 85% of cancer drugs now have no connection to the most basic expectation of patients, to live longer.
- The WSJ review of 40 drugs administered in physicians offices: 39 cost less in the UK, 37 cost less in Norway and 28 cost less in Ontario Canada. The price gouging in the US certainly suggests racketeering.
- Drug company profits are 17% in the US and 7% elsewhere.
- Actively avoid cost-effectiveness research — prescribers don’t know whether a new drug is better or worse than old drugs except by what is told to them by marketing. (Unlike the UK drug system which is strongly linked to cost-effectiveness)
- Drug companies hide special deals with large customers so other customers have no idea of the low end of the price spectrum. The companies are so large that a lone US State can not leverage deals needed to lower prices like countries can.
Perhaps I have missed some other corrupt practice or unethical behavior, there are just so many. This mess needs to be cleaned up! At very least the US Congress needs to institute controls similar to other countries. Feel free to send this blog to your congressional representative — with a copy of your drug bills!
Moderate fitness is the most powerful treatment to prevent disease. And, moderate fitness is easy to obtain. Just walk 20 minutes a day. People get very little extra benefit from more exercise than that! The graph shows moderate fitness lowers your risk of death by about two thirds — and the extra years you get will have better quality.
The benefit of moderate fitness exceeds that of not having the following conditions:
- high blood pressure
- high cholesterol
- family history of heart disease
So what worries you more? Being a couch potato or having any of those conditions? The couch potato is the worst. This is not to say you should continue smoking — it means you need to BOTH exercise AND stop smoking.
The average American watches 5 hours of TV per day and many think the lack of activity it causes increases the death rate. Just skip one TV show and walk instead to reverse the trend.
A good primary care provider should ask you about your level of exercise and fitness at every visit. A lack of fitness is the most severe health problem in the United States. Health providers almost always check you blood pressure when in fact your level of activity is more important — let’s keep this in perspective.
Here is an absolutely wonderful YouTube video about fitness:
It’s difficult to understand how one person coming to the U.S. with Ebola constitutes a crisis. The 75,000 patients per year that die of hospital acquired infections looks more like a crisis. The 443,000 deaths per year related to smoking is clearly a crisis. CNN and Fox news seem to be able to stir panic with constant “we’re all going to die” mentality. The most helpful suggestion from the media is to quarantine Texas.
Helene Cooper of the New York Times was featured on PBS 10/19/2014. She recently returned from a reporting trip to Liberia where she concluded Liberians show less panic than people in the U.S. She attributes this to Liberian’s having a better understanding of how the disease is transmitted. The observation rings true since most US news reporting does not attempt to educate, just analyze incomplete information. When this is all over congress will owe CDC director Dr. Thomas Frieden a massive apology for their rabid questioning … do they ever apologize?
The disease is transmitted by bodily fluids, usually by touching a person (see picture) with symptoms (vomiting, diarrhea and fever) or touching their secretions. In Liberia the population avoids touching each other. But, the real risk is for healthcare workers — because people with symptoms go to the hospital. The patient who came from Liberia with the disease died in a Dallas hospital but his fiancé and other people he lived with did not get sick! It is the nurses who are at risk and two of them (so far) have contracted the illness.
It’s good to hear the U.S. military is erecting mobile hospitals in West Africa — hopefully more countries will help.
Ambulatory Surgery Centers (ASC) are adept at hiding problems. Just try to find death rates, numbers of transfers to hospitals, organ punctures, and surgical procedures required to correct errors. Nope — you won’t find those crucial bits of data for public view. Here is a link to statistics collected for “internal” review: Quality Reporting Program.
As with most health care entities the public expression of “quality” is “certification” — which means an outside reviewer thinks the organization has the right programs and procedures so nothing stands in the way of quality care. Likewise, nothing usually stands in the way of a student getting an A+ on a test — but A+ is not always the grade. As Confucius says: “there are always greater and lesser”.
So, as a patient, what should you look for; what questions should you ask?
- Is the ASC certified? If not, find another ASC.
- How many patients does the surgeon treat at the ASC — expect at least 10 per week.
- How often does the surgeon do the procedure you need at the ASC — expect at least 10 per month.
- Will you be sedated? — if so, make sure an anesthesiologist or nurse anesthetist will be monitoring you while sedated — if not — find a different ASC.
- How close is a hospital if you have one of those serious complications listed in the consent-for-surgery form? If an ambulance would take more than 10 minutes to get you to the hospital consider another ASC.
- If you have severe heart or lung problems (like a history of congestive heart failure or COPD) consider having your procedure at a hospital rather than at an ASC.
- Ask if a pre-op check list, like the one the World Health Organization recommends, is used for all surgeries — if not, quality is a questionable. If the surgeons says they don’t need a check list find a different surgeon. Keep this in perspective — every airplane pilot must follow a pre-flight checklist, is your surgery any less important?
- The person that comes with you needs to write down what the surgeons says after the procedure. Patients who have been sedated, even if they seem fully awake, will have impaired memory for many hours. Have the person with you write down what was found at surgery — what is the diagnosis and what are the specific instructions.
- Absolutely avoid late afternoon surgery — because you will be shipped to the hospital for minor complications — the ASC will close and they don’t have staff to provide care after closing.
Doctors are unhappy because the medical world is not what they expected (or dreamed about).
An essay in the Wall Street Journal today “Why Doctors Are Sick of Their Profession?” describes the feelings of many doctors. What are those feelings? What do they mean?
Most physicians cope very well and are quite successful in society. Clearly, they do not have a psychiatric disorder as a group. Yet, the WSJ article lists certain symptoms. These are feelings of:
frustration, failed aspirations, malaise, worthless sacrifice, loss of control, conspiracy of lawmakers and insurance companies, devalued work, and recurrent intrusions of unpleasant thoughts. Lawyers (the scum of the earth) make more money than they do. And, oppression is keeping them from doing things the “right way”.
If a patient complains of those symptoms the diagnosis would be: depression with underlying obsessive-compulsive and narcissistic traits. For doctors it may just be the world is not what they expected when they started 15 years of training. The job is basically good and it’s too late to start over.
Is money an issue? If a distraught patient says their anxiety has nothing to do with a “recent divorce” … it really has everything to do with the divorce. If a doctor say it “has nothing to do with money” … it’s the money.
As a group doctors have a huge capacity for delayed gratification. They go through difficult years of training by thinking it will get better later — the salary will go up, all the testing will stop, professors will go away, long hours will improve, and no one will question their decisions. Welcome to the real world: stagnant salaries, maintenance of certification tests, professors who set evidence based guidelines, long hours and insurance companies that question decisions.
Medical training is mostly to blame. It’s too long, often unfocused, minimizes teamwork and shuns consistency. The fight for doctors to follow evidence based guidelines is undermined by the constant drum beat of “cook book medicine”. In fact, most medical treatment is by the book — a stunning revelation to most. If physician expectations were better managed during training the dissatisfaction after training would not be an issue.
Many employees find their job the least stressful part of the day. Stressed physicians need to focus on their job of diagnosis and treatment — it is very rewarding. Extraneous worries can drive you crazy.
Accountable care organizations reduce physician stress by focusing physicians on the job of taking care of patients while business professionals manage the business. Perhaps increasing the structure of medical care is the solution for physicians, not the enemy.
Medication mistakes are common. A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%. The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.
The study is biased by assuming all the errors are caused by patients — not the providers. The authors point to patient problems of low health literacy and a poor facility with numbers. Illegible instructions, poor communication skills, excessive complexity of medical regimens, conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.
Even a simple phone call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.
The article conclusion is to apply more effort to find those high risk patients. Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take. The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.