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When I was growing up the economy was terrible. The recession of the 1970s (with effects lasting until 1983) was characterized by both high unemployment and high inflation, leading to the presidency of Jimmy Carter and subsequently the presidency of Ronald Reagan. The last 30 years have been characterized by economic growth but at the expense of an increase in the wealth of the top 10% of the population and a concomitant decrease in the incomes of the bottom 50%. When this trend began, those who were the recipients of the increase were unapologetic in the display of their wealth, with Madonna’s Material Girl becoming an anthem of sorts. Acquiring wealth and displaying it was encouraged.

When I entered medical school in the 1980s, although it was understood that we would do well financially, financial incentives were not supposed to influence our decision making. Doctors made money but making money was not what being a doctor was about. We were told by our mentors to do the right thing by the patient and the money would follow. We were not guaranteed entry into the top 1%.

Today the top 1% of American households make more than $380,000 (US). As you can see from this survey, this level  income is easily within the reach of most non-primary care specialists. As chronicled by Atul Gwande, in ways subtle and not -so-subtle, physicians are able to influence patients (consumers?) to purchase health care such that today THEY ARE THE 1 PERCENT.

I have my own set of thoughts regarding the discussions of wealth redistribution, progressive taxation, and the value to society of certain types of work as measured by income. I (probably selfishly) believe that physicians deserve to be valued by society. I worry that physicians (like Wall Street executives) confuse income with value to society. I discussed the spectacle of Michael Jackson’s life previously but really had convinced myself that this was a “one-of” episode. Conrad Murray and his obsession with money and willingness to (allegedly) commit murder to maintain a client was an aberration, right?

Today’s news brings more evidence that physicians are willing to be participants in harming people in exchange for money. Reported by Bloomberg and picked up by the AP, the market for stealing solid organs for transplant has moved from an urban legend status to reality:

[B]rokers use deception, violence and coercion to buy kidneys from impoverished people, mainly in underdeveloped countries, and then sell them to critically ill patients in more-affluent nations. The middlemen form alliances with doctors in leading hospitals who do these transplants for a fee, no questions asked.

Although the real bad guys are the gangs who kidnap the potential donors, the article lets the doctors off VERY EASY. In describing one transplant evaluation:

They took him to Metropolitano Hospital, where kidney specialist Gustavo Salvador sat down with Yafimau. Salvador, who did his medical training at Central University of Ecuador, says Yafimau showed him the document saying he wanted to donate a kidney.

“If someone comes to me and says, ‘I come to voluntarily say that I want to donate,’ then that’s as far as we go,” says Salvador, sitting in an office adorned with Salvador Dali prints. “I can’t investigate the life of the person. That’s not my job.”

Salvador says he was paid $800, his normal fee for referring a patient to a surgeon.

This scandal is not, for the most part, American in origin in the traditional sense. I do believe we have some culpability. First, in the same way those who trained the pilots who flew on 9/11 should have asked about the purpose of the training, our Graduate Medical Education system trains physicians with little to no discussion of manpower needs and ultimate outcome of training. If we train an excess of transplant surgeons they are going to have to practice somewhere and their skill set is limited. Our training should reflect manpower needs. Second, medicine as a commodity leads to poor decision making on the part of the physician and on the part of the patient. Third, physicians apparently need a set of rules imposed to prevent them from behaving badly. It was the Nazi atrocities that led to the reform of research ethics. What is it going to take to reform the ethics of clinical practice?

Bob Bowman has sent me the rest of his thoughts about my post regarding the Family Medicine’s role in the health care delivery system and I will share these with you (with a little commentary from me):

We started with “all he saw was a family practice doctor” – this was a comment that could have been made any time in the past 80 years. For the first twenty of those years medical educators such as Osler, Flexner, and various deans would defend the general practitioner as essential and of great value. The medical education leadership began with a perspective that was predominantly generalist and steadily transitioned to physicians more focused on subspecialty, hospital, and research areas.

 One of the consequences of separations between types of physicians was the somewhat derogatory term LMD or Local MD. Town versus gown is another descriptive phrase for the competitive situation although in more recent decades, both town and gown physicians have been losing out. Control of accreditation, training, exclusive markets, health policy influences, associations, and journals has moved steadily toward physicians born, raised, educated, trained, and practicing in top concentrations. Over 70% of US physicians or more arise from about 25% of the population.

Josh Freeman has done a lot of work on this. He points out that not only are physicians-in-training overwhelmingly from caucasian families but also 15.7% of students had one or more parents who was a physician and 24.1% more had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…”  Bob goes on to point out:

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I am training for the marathon here in Mobile and this is the end of my first 60 mile week. Although I don’t define myself as a runner, I guess running 60 miles in a week would be dumb for a non-runner. Here in Mobile,we  runners can pursue our avocation outside almost every day of the year. I am further blessed by living just north of a large, antebellum cemetary (Magnolia Cemetary) where a circuit is about 1.8 miles or, put another way, it takes 2 1/2 laps over 45 minutes to run 5 miles

Running for several hours gives one a lot of reflecting time. While running today I reflected on being called a socialist by our medical students for pointing out that the Democrats had won the election and would probably dictate changes in health care policy (being right doesn’t make one especially popular) and the results of the cloture vote which proved my point. After that my thoughts turned to the cemetary and the monuments contained within. Many of the private graves have clustered dates which coincide with outbreaks of yellow fever or influenza but my attention today was drawn to the monuments  with labels such as Woodmen of the World, Watermen’s Association, and Fire Department Association among others .These were put up by benevolent societies.

In an article about benevolent societies at the turn of the last century, C. A. Spencer identifies these as “any local voluntary or incorporated non-profit association organized with or without capital stock providing mutual assistance for its members in the form of services or payments.” These organizations were designed to offer protection to their members at cost with the organizations constitution specifying the benefits to be provided such as sickness, disability, burial, and occasionally survivor. The as many (if not all of the members) belonged to the labor class, services usually provided by family members and servants to upper class folks were provided by the society which was an incentive for membership. These services included “watching” the sick and providing a physician who was kept on retainer. The members when not sick got to (and still get to) wear some great costumes and have a lot of fun. For example, the Mobile (Alabama) Turner’s Association celebrated the thirtieth anniversary of its founding in 1868, according to the Mobile Daily Register, with a parade, an address, and a song and dance exercise followed by fireworks.  As white workers became more prosperous, their societies tended to become less important to the provision of services (they were able to pay cash or their workplace provided doctors) but because of the economic precariousness of blacks in the early 20th century (most men were laborers), their societies were more likely to have survived. Interestingly, some of these societies have evolved into insurance companies.

Benevolent Societies were an important way to aggregate resources among African-Americans, recent immigrants, and members of common crafts (particularly if there was an element of physical risk). They became less important to the provision of healthcare in the 1950’s with the rise of employer based insurance and government-funded coverage to the poor and the elderly in the 1960’s. Perhaps if we all still had a vested interest in our own health as well as that of our immediate neighbor-in-the-funnny-hat then the debate over paying for health care reform would be a little more civil.

Dr Jeff Terry has written another letter to the editor of the Mobile paper regarding the lack of attention that alternatives to the Democrats proposed health care reform (such as HR 3400) have received. Aside from the obvious (the Republicans had 6 years to do something and what they managed to accomplish was to give a $2,000,000,000 gift to Pharma) there’s the question of whether the alternative proposal has any merit.

As mentioned before, Kaiser Family Foundation has put together a nifty comparison of all of the Health Reform proposals. Dr Terry asks what the Democrats want to accomplish. I would say that President Obama lays it out quite specifically:

The President has indicated that comprehensive health reform should:
• Reduce long-term growth of health care costs for businesses and government.
• Protect families from bankruptcy or debt because of health care costs.
• Guarantee choice of doctors and health plans.
• Invest in prevention and wellness.
• Improve patient safety and quality care.
• Assure affordable, quality health coverage for all Americans.
• Maintain coverage when you change or lose your job.
• End barriers to coverage for people with pre-existing medical conditions.
• The plan must put the country on a clear path to cover all Americans.

HR 3400 Overview

Allow people who purchase coverage in the individual market to deduct the cost of premiums from their income taxes. Provide refundable tax credits to individuals and families with incomes below 300% FPL to purchase insurance in the individual market. Establish Association Health Plans and Individual Membership Associations through which employers and individuals can purchase coverage. Implement state high risk pools or reinsurance programs to provide coverage for people with pre-existing health conditions. Require states to provide coverage to 90% of children with family incomes below 200% FPL as a condition for expanding child eligibility to 300% FPL, and require states to provide vouchers to children eligible for Medicaid and CHIP, to be used to purchase private insurance.

Or, Kaiser has a tool that will generate a side-by-side comparison. By doing that, you can see that HR 3400 has no requirement for individuals to have coverage. Permit employers to automatically enroll individuals in the lowest cost group health plan as long as they can opt out of coverage (which will lead to high deductibles for low wage employess and lessen coverage). Barriers to pre-existing illnesses and injury are not reduced. Medicare fraud is the only example of wasteful healthcare spending covered and it prohibits comparative effectiveness research from being used to deny coverage of a health care service under a Federal health care program and require the Federal Coordinating Council for Comparative Effectiveness Research to present research findings to relevant specialty organizations before publicly releasing them (this will almost certainly increase costs).

Dr Terry feels that Representative Price has a proposal “which offers real reform measures that put patients back in control of their health care and their lives”. I would argue that what it offers is more subsidies for the wealthy, less accountability for physicians, and less coverage for Americans. I hope Dr Terry will take a look at the Kaiser website.

Better Homes & G copyAmericans like to believe they have the best health care system in the world. They certainly seem to believe that access to specialist physicians and high end technology is important in maintaining the “quality” of the health care delivery system. Little by little, the word is getting out that more is not necessarily better and almost certainly is often worse. The most egregious example of this is Michael Jackson’s death which was ruled a homicide, allegedly perpetrated by his personal cardiologist. Turns out that having a cardiologist attending you 24/7/365 may not be a good thing. On a more mundane note, NPR decided to look into this and has posted an in-depth look at health care variation that is very well done. The key points of this report are that 1) Americans are the same no matter where you go (despite the belief of some folks that we’re made differently), 2) doctors influence patient choices when determining among choices of equally appropriate healthcare, and 3) money and payment structure influences doctors. This is not rocket science but the fact that it took Alix Spiegel 20 minutes to explain may mean it is more difficult for the average person to grasp than I might believe (and then again, I suspect the NPR demographic may not be average anyway). NPR quotes the Dartmouth Atlas data that suggests almost 1/3 of all healthcare costs are for procedures that are not helpful and may be harmful.

Why is this important to Alabama? The talk of “Health Care Reform” has morphed into “Health Insurance Reform” and now has morphed again into “Covering the Uninsured with Private Health Insurance.” In 2008, Blue Cross of Alabama reported $4,000,000,000 in premium collection. Most of this business, as I understand it, was done with companies who use Blue Cross of Alabama to administer their plan. They have no risk (the companies put money into the plan and take money out) but they take a percentage of the money (8%) and get to hold the premium in the bank (drawing interest) until it is needed. It would seem that they do better as more money is spent on health care, necessary or not. I certainly hope that someone pressures them to look at the payment structure and outcomes, not just  Alabamians’ satisfaction with their product.

Two observations on health care delivery. One from a trip to Montgomery and another from a trip to Mayo’s Barber Shop. The hair cut was yesterday. One of my fellow customers was speaking of the cancer treatment received by a family member. Although we have a comprehensive cancer center in Mobile (the Mitchel Cancer Institute) with world class physicians treating the disease in question, my barbershop buddy chose to go to a competing concern (The Cancer Treatment Centers of America). This was likely prompted by the advertisements on television (in 1996, they were sued for being overly aggressive and their commercials are still worrisome), the promise of “holistic” care, and the fact that Blue Cross of Alabama would pay for the care. Turns out, the differences between our local comprehensive cancer center and the CTCA include the aggresive approach of CTCA, the presence of shareholders and the profit motive. An article in Business Week follows a patient who maxes out her $1,000,000 policy limits but is very happy with her care. It seems that some of what they sell is “hope”. The second difference is that CTCA will likely not treat uninsured cancer sufferers from Mobile Alabama as is required of the local cancer center (as CTCA requires $125,000 up front and reserves of $250,000 prior to starting treatment). What for-profit healthcare concerns may be selling to their shareholders is the ability to generate a lot of charges posted to each patient’s insurance policy.

My trip to Montgomery was to attend a board meeting of the Alabama Academy of Family Physicians. I have known most of these “Family Docs” for over 10 years. They have fought for many of the programs that now exist to get folks who might consider practice in rural Alabama into medical school. The group has seemed beaten down the past couple of times we’ve met. Partly this is because Blue Cross of Alabama, our single payor, has raised the codes billed by Family Docs by 20% over the past 19 year whereas the codes billed by our “partialist” colleagues have been raised over 300%. Also, it is because they would NEVER consider limiting access by making someone take out a mortgage to see if their diabetes/hypertension/arthritis would benefit from the care of their hometown physician.

The system that has evolved over the past 60 years requires a lot of overpayment from some areas to allow care to be provided at some level to all who presented for care. For-profit organizations such as CTCA take money away from communities such as ours. If they had demonstrably better outcomes and if care were available without such cost shifting, it might be justifiable. Unfortunately, the outcomes aren’t easily researched (try googling “outcomes” and “cancer centers” and getting unbiased information) and paying for indigent care is still not easily done in places like Mobile. I’m still waiting to see Congress solve this one.

Tomorrow, we’ll see what happens with what could be a disaster of epic proportions. Alabama Medicaid, whose travails regarding inadequate funding have been well documented, may go completely broke at midnight tonight. At odds are the Governor who is unable to generate an acceptable revenue stream in the general funds to cover a required match for Medicaid dollars (the feds contribute $3 for every $1 we put up), and both the Bush administration and the Obama administration who are unwilling to accept the state’s definition of “match” as being an actual match. As chronicled by the Birmingham news earlier this year, the hospitals actually put a bit of money ($800 million) to try to head off the disaster but the governor and the feds (both Democrat and Republican) don’t see eye to eye on whether the funding source is actual or is a little bit too evanescent (i.e. will exist only to draw down federal dollars).

In 2004 the seeds of the crisis were planted when the state was unwilling to consider a switch from intragovernmental transfers (no real dollars placed, one time resources used) to another method of matching funds that CMS found more acceptable. It was the hospitals, through the Alabama Hospital Association, that put together what they thought was a formula to get around the problems identified by CMS in Alabama’s previous scheme.  

Although unable to give particulars, Commissioner Steckel’s impression of the problem, as presented to the legislature, is as follows: 

“Simply put, the federal government has changed the rules on how hospitals calculate costs, particularly in how they define uncompensated care.”

In her budget presentation this year, Commissioner Steckel pointed out what Medicaid does in Alabama

  • 20%, or nearly 1 million Alabama citizens are eligible for some type of Medicaid coverage
  • Nearly half of all births, or approximately 30,000 births each year, are paid for by Medicaid.
  • 38% of Alabama’s children depend on Medicaid for healthcare coverage.
  • 12.8% of Alabama’s elderly residents are Medicaid eligible.
  • 71% of the nursing home residents in participating facilities are Medicaid eligible.
  • More than 14,000 elderly and disabled individuals participate in one of six home and community-based waivers;
  • Medicaid pays for over 7 million prescriptions a year.

Governor Riley went back up to D. C. earlier this week  to try to rectify the situation. I guess we find out tomorrow whether that misunderstanding was settled and these services can continue or not.

Frank deGruy, the Chairman of Family Medicine at the University of Colorado, came to Mobile as a visiting professor last week. Prior to his arrival, he sent me some of his reflections on the healthcare system as it is now and where his vision is on where it should (will?) go which I have posted here. The references in .pdf are only available to folks within the USA system but can be obtained through most libraries. Very interesting reading.

I have been out recruiting residents, providing direct patient care, and assisting in a rewrite of the hospital bylaws so I have been unavailable to comment on the President’s speech. For those of you that watched, you no doubt noted the “shout out” given to Alabama. Turns out that “government” is the only viable competitor to Blue Cross because no one else is able to compete. Although the Republican gubernatorial candidates see the evil had of communism, I can’t help but think competition would be healthy. Blue Cross sells their policies to  businesses by offering virtually unlimited access to employees. They then try to manipulate physicians into making decisions in Blue Cross’s economic interest. Consumers, then, are encouraged to seek unlimited health care and providers are encouraged to put barriers in their way. Not the incentives that will “bend the curve“, or even give me a warm fuzzy feeling.

On this Labor Day I sit in one of the richest countries of the world. I make more money than 98% of the American workers. My peer group (American physicians) makes that or above. Yet, when I watched a  physician on a Fox News clip talk about health reform today, I got the impresion he had just come in from panhandling. In addition, the blame-the-patient nature of his proposed solutions made me long for the days when we believed in demons and humors as causes of illness…at least then the individuals were not to be blamed. Rather than blather on, I refer you to the Health Affairs article from 2004 which identifies increases in cost per disease treated as the major contributor to health care cost increases for most diseases. For some diseases such as treatment of depression, that increase in cost leads to improved wellbeing and increased productivity. 

In short, let’s all agree to deliver high quality care and not milk the system as happens in some places. If we redirect the money currently spent, we can give better care to more people for less cost. No where are “tax breaks” mentioned in my medical texts as a treatment option. Regarding my overweight patients, my bet is that between good medical care and changes in the built environment and improved peer influence, people who need to lose weight will. Meanwhile, we physicians need remember (ironically) the “Fat Man’s laws” and stop blaming the patients for a flawed system that is much more our creation than theirs.

Also, physicians who are on television probably shouldn’t claim poverty.