Tag Archives: Obamacare

On Healthcare Costs

“Monday Musings” for Monday August 19, 2013

Volume III, No. 31/124

healthcare_costs_cropped

Health Care Reform

 By Assad Meymandi, MD, PhD, DLFAPA*

With Obamacare looming to take effect in 2014, and opponents dismembering it limb by limb, we thought another essay on American healthcare is in order. To begin, American healthcare is the costliest in the world, yet quality is patchy and millions are uninsured. Incentives both for patients and suppliers need urgent treatment. The cost of healthcare in one state of Indiana is more than the entire country of India. America spends twice as much per person on health care as Swedes do. Yet there are over 50 million uninsured and many more underinsured. We are spending 16%, soon to be 17% of gross domestic product (GDP) on health care, the most expensive in the world. Literally billions of words have been written since the Truman administration attempted health care reform. Surely, billions more words will be written before we arrive at a satisfactory solution. Meantime, here are some practical and simple suggestions to ward off the current crisis.

1)    Number one money guzzler is obesity. Obesity causes diabetes, cardiovascular disease, hypertension, musculoskeletal problems, back pain, and stroke. The cost of cardiac bypass is $16,000 to $18,000. The cost of back surgery, ninety percent related to obesity, is in the tens of billions of dollars. If we could prevent even a small percentage of people from becoming obese, we could drastically reduce medical expense. We need preventive measures and ought to offer incentives to encourage healthy eating and exercise.

2)    Reimbursement issue: The system encourages oftentimes unneeded procedures and very expensive lab tests and scans. The system does not pay for process and thinking medicine. This flawed system drives the doctors to spend less time with their patients. I do know that with the inflation- adjusted rates, primary care physicians are receiving one-third less pay today than they did 20 years ago.

3)    Government mandated single payer may be the answer. But look at the examples of Canada and England. It takes as long as three years to get elective surgery in their system. That is not consistent with the temperament of freedom seeking Americans.

4)    For-profit driven health care companies should be banned. The middle man and health care insurance companies/venders are poisonous. The dollars that should go to patient care go to pay the salaries, bonuses and backdated stock options of the company’s chief executive officers and their staffs. Convicted William McGuire of United Healthcare and many others like him are examples of these unwelcome middle-man-intruders in medicine.

5)    Waste, repetitious expensive lab work and million dollar work-ups are commonplace in medicine. The primary cause, besides financial incentives of the sinister “more-lab-work-you-do, the-more-fees-you-collect”, is the practice of defensive medicine. We need some comprehensive tort reform to keep physicians from over-ordering. The fear of malpractice litigation does indeed lead the doctors to order tests that may not be necessary to the patient’s care, resulting in billions of dollars of needless expenditure.

6)    There is no question that there are a few bad apples in the barrel. The holy house of medicine does have contaminants. There are a few physicians who go into medicine for anticipated financial rewards, but they are not very many. Remember in the 1970’s, insertion of Swan Ganz catheter in pulmonary arteries was the rage in medicine. Cardiologists were suing their pulmonologist colleagues as to whose practice domain insertion of the catheter belonged. We have had reports of unethical behavior in the ranks of cardiothoracic surgeons scaring patients to submit to procedures such as bypass operation and insertion of stents for which there was no indication. But these unethical doctors are very few. The overwhelming majority of physicians consider medicine a calling and their sacred profession a priesthood. But we do need to keep a closer eye on the few bad apples, thus requiring us to strengthen the States’ Medical Boards.

7)    Finally, in order to reduce cost, we must emphasize and preach the gospel of prevention. Recently in a health related meeting with several people, among them Lanier Cansler, former Secretary, NC Health and Human Services, I asked what percentage of the Department’s budget is spent on prevention. It is an astonishing 5 to 7%. I believe we should approach this issue with thoughtful planning, but a revolutionary attitude. We must effectively combat the unwelcome and dangerous epidemic of obesity. But first, we physicians, nurses and members of healthcare providers, including US Surgeon General, the country’s highest ranking medical doctor, ought to combat obesity.

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 *The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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On the Cost of Healthcare, continued

Monday Musings for Monday April 29, 2013

Volume III, No. 16/119

(Editor’s Note: This week’s Monday Musings is written by pulmonologist Dr. Theodore R Kunstling, Medical Director, Duke Raleigh Hospital, Raleigh NC).

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OBAMACARE – YEAR  THREE

By Ted Kunstling, MD

The Patient Protection and Affordable Care Act (PPACA) signed by President Obama on March 23, 2010 seeks to achieve at least two major objectives: extending health insurance coverage to millions of uninsured Americans and controlling the rise of health care costs in the United States. How has the PPACA affected health care professionals so far?

Most health care providers agree that our current system of payment is broken, while most voters covered by employer or government- provided insurance remain satisfied with their own access to care, if not their increasing out-of-pocket expenses. The health care policy debate has been transformed by politicians into one of pitting increased access to care against controlling costs and reducing the role of the government in society. The Republican-controlled N.C. legislature has refused to allow expansion of Medicaid coverage to 500,000 uninsured placing financial stresses on hospitals which had counted on these funds to offset Medicare reductions. A serious viable alternative to ObamaCare has yet to be proposed.

Meanwhile, inevitably, the world of healthcare providers is undergoing radical transformation. Congress has mandated “meaningful use” of electronic medical records (EMR), before their value has been convincingly demonstrated. Local hospitals, beginning with Duke University Health System, are all adapting the Epic EMR at a total cost sure to exceed $1 billion. Value Based Purchasing will tie reimbursement to the results of publically reported patient safety and satisfaction data. The staggering costs of complying with these mandates are driving physicians to become employees of large hospital- centered entities which possess the capital and administrative expertise necessary to survive. As debates rage, private practice is being supplanted by centralized control of the medical profession by the government and large private entities, goals they have long sought as necessary to achieve control of costs.

Thus, physicians are rapidly entering a brave new world. Their masters in the new system have different values from those traditionally held by medical professionals. Return on investment rather than community need determines which services are offered and where facilities are located. Patients, astutely defined as “sufferers” by Robertson Davies in his novel, The Cunning Man, are regarded as customers.  Entertainment and service companies such as Disney and Southwest Airlines become role models for serving our customers. The teachings of the giants of medicine, such as Osler and Stead, seem drowned out by advertising. Physicians are issued new sets of values, are instructed what words may or may not be used in medical records, and are scripted in how to speak to their patients.

The future is uncertain, but a consensus is growing that renewed leadership by physicians will be essential if a way is to be found to expand access to care and create greater value at the same time. Hospitals such as Duke Raleigh have begun to prepare their medical leaders with the skills and knowledge necessary for them to have a seat at the table, to contribute meaningfully to ‘the pool of common knowledge.’

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*Assad Meymandi, MD, PhD, DLFAPA is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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On the Cost of Healthcare

Monday Musings for Monday April 22, 2013

Volume III, No. 15 /118

(Editor’s Note: Much has been said and written about the 2000 plus pages of ‘Obamacare’ which I have recently finished reading.  It is a boring document written in arcane language with abundant legalese absurdities and bureaucratic banalities. We are devoting two ‘MM’s to bring some clarity to the matter, since 2014 will be the year much of the law will take effect. Today’s column are some thoughts about what will help, and next week Dr.Ted Kunstling, a pulmonologist and Medical Director, Duke Raleigh Hospital, will continue with his reflections).

Health Care Reform (Part I)

By Assad Meymandi, MD, PhD, DLFAPA*

Socratic elenchus and Aristotelian entelechy are elegant, and the prose of Plato, is lyrical and beautiful. All three in their discourse ask ‘Who are you? What do you do?’ ‘Are you and your lives making any difference?’ I apply the same to health care in America. What are we, what do we do? And what we are doing is making any difference? American healthcare is the costliest in the world, yet quality is patchy and millions are uninsured. Incentives both for patients and suppliers need urgent treatment. The cost of healthcare in one state of Indiana is more than the entire country of India. America spends twice as much per person on health care as Swedes do. Yet there are over 50 million uninsured and many more under-insured. We are spending 17%, soon to be 20% of gross domestic product (GDP) on health care, the most expensive in the world. Literally, billions of words have been written since the Truman administration attempted health care reform. Surely, billions more words will be written before we arrive at a satisfactory solution. Meantime, here are some practical and simple suggestions to ward off the current crisis.

1)    Number one money guzzler is obesity. Obesity causes diabetes, cardiovascular disease, hypertension, musculoskeletal problems, back   pain, and stroke.  The cost of cardiac bypass is $18,000 to $20,000. The cost of back surgery, ninety percent related to obesity, is in the tens of billions. If we could prevent even a small percentage of people from becoming obese, we could drastically reduce medical expense. We need preventive measure and offer incentive to healthy eating and exercise.

2)    Reimbursement issue:  The system encourages doing procedures and very expensive lab tests and scans. The system does not pay for process and thinking medicine. This flawed system drives the doctors to spend less time with their patients. I do know that inflation adjusted, primary care physicians are receiving one third less pay today than they did 20 years ago.

3)    Government mandated single payer may be the answer. But look at Canada and England. It takes as long as three years to get elective surgery. That is not consistent with the temperament of freedom seeking Americans.

4)    For-profit driven health care companies should be banned. The middle man and health care insurance companies/venders are poisonous. The dollars that should go to patient care go to pay the salaries, bonuses and backdated stock options of the company’s chief executive officers and their staffs. Convicted Richard Scrushy of Health South and William McGuire of United Healthcare and many others like him are examples of these unwelcome middle-man-intruders in medicine.

5)    Waste, repetitious expensive lab work, million- dollar work- ups are common place in medicine. The primary cause, besides financial incentive of the sinister “more-lab-work-you-do, the-more-fees-you-collect”, is the practice of defensive medicine. We need some comprehensive tort reform to keep physicians from over ordering. The fear of malpractice litigation does indeed lead the doctors to order tests that may not be necessary to the patient’s care, resulting in billions of dollars of needless expenditure.

6)    There is no question that there are a few bad apples in the barrel. The holy house of medicine does have contaminants. There are a few physicians who go into medicine for anticipated financial rewards, but they are not very many. For most, doctors consider medicine a calling, and their sacred profession, a priesthood. But we do need to keep a closer eye on the few bad apples, thus requiring us to strengthen the NC Medical Board.

7)    Finally, In order to reduce cost, we must emphasize and preach the gospel of prevention. Recently in a health related meeting with several people, among them Lanier Cansler, Secretary, NC Health and Human Services, I asked what percentage of the Department’s budget is spent on prevention. It is an astonishing 5% to 7%. I believe we should approach this issue with thoughtful planning, but a revolutionary attitude. We must effectively combat the unwelcome and dangerous epidemic of obesity.

dad_sig_pic

 *The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012).He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

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