Monday, July 27, 2009

Healthcare Reform or Deform?

Healthcare reform has hit yet another hurdle recently. Now Congress will be unable to reach any consensus or pass any bill by the autumn recess in August. They will not even be able to pass a bill saying that they will pass a healthcare bill when they return from recess. There are already so many things wrong with this. The first is why Congress even gets a recess. Does the President get a recess? Why is it that the executive branch is the only branch without a recess? How do things get done during the recess if our government was designed to work with checks and balances? Who is doing the checking and balancing of the executive branch during the recess? Shoe elves that come out of the closet at night? Separate from the issue of healthcare reform, there should be no recess for Congress. Given all the benefits they reap from their position, as well as the infinite reelection possibilities, they should work their asses off for their constituencies. My healthcare premiums will only go up during the recess. Joe the Plumber’s premiums will only go up during the recess. And yet it is not important enough for Congress to stay in session to begin to work on what will no doubt be a lengthy and protracted reform. It literally will take an act of war to bring Congress back to session.

The President has stated that he uses the Cleveland Clinic and the Mayo Clinic (the Minnesota flagship, I believe he is referencing) as models for his ideal healthcare setup. These are places where you get comprehensive care that is structured slightly differently than your ordinary community hospital, or even many of your tertiary care hospitals. You get specialty care from the beginning, and of course, you get the latest and greatest that medicine has to offer. Now who would not want this kind of care? And for everyone who wants that kind of care, who would want to actually pay for it? What the President does not state is that these are also teaching institutions. There are enormous differences between your vanilla hospital and a teaching hospital. Firstly, teaching hospitals do have the latest and greatest medicine have to offer, though community hospitals are not far behind anymore. But because teaching hospitals are supposed to train physicians, they also order and perform far more tests. It does not seem that way on an individual basis, but just five extra tests per patient over a year is a lot of money. Is that really a big deal if you are getting the best medical care, though? I would not think so, if I were the one getting the care. It’s like being at a bar and splitting the bar tab among your friends. It works out great if you are the one drinking the most and sucks when all you’ve had is Miller Lite when everyone is doing shots. Someone is paying for all these extra tests—everyone, regardless of whether or not you are the one getting them done.

The second difference is that teaching hospitals are such large entities that they have physicians on staff. That is to say, the physicians are salaried with bonus potential. Of course there can be private physicians with rounding privileges as well, but at the Mayo and Cleveland Clinics I would bet there are few if any private physicians. This means that physician reimbursement is reduced. Among the specialties in medicine, private physicians earn more than academic/teaching physicians. The ironic exception is the family physician and internist, who do better selling their practices to a hospital. So while it would be nice to a structured comprehensive system like the Mayo Clinic, it would require physician reimbursement to be reduced dramatically, since there far far more private physicians than academic ones. President Obama will not say this because he knows that he will wholly lose the support of physicians around the country. The AMA (American Medical Association) is predominately made up of non-private physicians, and their support of his plan fails to represent the opinion of the bulk of physicians. You may say that physicians make too much money, and I would agree with you if you were referring to twenty years ago, but not for today (see one of my prior posts). The analogous plan would be to create a new system for comprehensive specialized education that results in teacher salaries being cut nearly in half. The teachers would most certainly be outraged. Would the public be any more sympathetic to them than to physicians?

The major source of money loss in healthcare is testing. Everyone agrees on that. The vast disagreement is why there is so much testing. Some say it is because physicians are tricked or bribed into ordering ore tests. Some say it is out of fear of malpractice suits. Some say it is because there is less time to actually talk and examine a patient. And some say it is because physicians have gotten dumber. I think everyone is right. I think much should be done to rein in malpractice suits. Much should also be done to reduce extraneous testing. If it is not curbed, future generations of physicians will be trained into doing the exact things physicians are doing today. But these methods are unlikely to reduce costs because as a broad stroke reform method, it will likely hurt just as many patients as patients it saves from wasting money. There will always be exceptions to the preauthorization rules. And making physicians jump through more hoops will only delay diagnoses and ultimately treatment. It will only add another layer of red tape. What really needs to be done it is reduce the cost of the tests. In medicine, there is dissociation between the test requester and the test administrator. Hospitals that also run labs and imaging studies base much of their rates relative the private rates of freestanding lab and imaging centers. Does it really cost a thousand dollars to run an MRI? Of course it does not. Not even if you factor in the cost of the machine, which is very expensive. Does it cost two hundred dollars to run a basic metabolic panel? Of course it does not. This is where the money in healthcare is predominately going. Physicians in high earning specialties do not make their money from seeing patients and being on call. They make their money in the business of medicine. They own an endoscopy unit. They run a cardiac stress testing laboratory. They make a pittance on the procedure and interpretation of the test, but make a killing on the sale of the tracer, the use of a sterile room, the oxygen that is administered by nasal cannula. This is where the money is. Reducing the costs of tests even ten percent would generate enormous savings. But it is not to be, since it will encroach and confound the President’s position on businesses, especially in the current economic crisis.

Another thing the President stated was that the healthcare that would become available to the uninsured would be the same as that available to Congressmen today. He did mention that the insurance Congressmen enjoy is a tiered system. But he did not elaborate further, and for good reason. Like all insurances, the insurance available to Congressmen is tiered, meaning that you can determine how much coverage you wish to buy. You can decide how much your copays for physician visits will be, how much you pay to have a CT scan, how much you pay per inpatient hospital day, and how much you pay for out of network services. If you want a lower premium, you can accept fifty dollar copays and pay the bulk of out of network services. This is likely what the low income Americans targeted for coverage will get. But if you make good money and have a pension, say, like a Congressman, you can get much better coverage with lower copays, no referral requirements, and third tier medications for fifteen dollars. Suddenly the healthcare reform plan is not so appealing. But if you hide that fact by misleading people into thinking they will have the same coverage as Senator Ted Kennedy, then you can garner tremendous support.

If the President has his way, then the game of chicken will surely begin. There are many physicians who have stated that they simply cannot or will not practice in such an oppressive climate for medicine. So we will see if they are serious. If they are, there will be an even greater shortfall of physicians, especially primary care physicians, to see the fifty million newly insured patients, let alone the existing insured population. Then there really will be savings because there will not be anyone left to order “unnecessary” tests. And even if they do flinch and remain practicing in medicine, there will be fewer and fewer physicians entering medicine such that over time a critical shortfall will still develop. Perhaps in time it may be alleviated by physician extenders such as physician assistants and nurse practitioners, but then they really will not be physician extenders anymore. They will be the primary healthcare providers. And if you believe they have the same training and knowledge as physicians then you have nothing to worry about. But if it turns out they do not, there is going to be a lot of trouble.