Adam Graham-Silverman, The Fiscal Times, Author at �鶹Ů�� Health News

Health Care: Run On It or Against It?

Adam Graham-Silverman, The Fiscal Times — Fri, 08 Oct 2010 00:30:00 +0000

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Republicans think they have a winning issue in health care reform, calling for its repeal and slamming the new law as big government gone haywire-even before most of its provisions have taken effect. A new poll suggests it’s not so clear-cut, and some Democrats seem to agree.

Case in point: Sen. Russ Feingold, who’s running on his vote for the health care bills that President Obama signed in March. His new TV ad touts his support for new law and warns his GOP opponent, Ron Johnson: “hands off my health care.” Johnson has his own ad, claiming that Feingold went against his state’s wishes when he voted for the health care bills.

It’s a roll of the dice for Feingold, who’s trailing in the polls. A new Pew Research/National Journal poll shows that 35 percent of voters say they’re less likely to support a candidate who backed the new law, while 36 percent say they’re more likely to support a health care backer. While a large majority of Republicans say they’re less likely to vote for a pro-health care candidate, a large majority of Democrats say the opposite. Among independents, 29 percent said they’d be more likely to vote for someone who supported the new law, while 37 percent said they’d be less likely to do so. A Washington Post poll also out this week shows a similar divide.

But then there are the 25 percent who said they would make no difference at all in how they voted.

“Repeal and replace” has been a health care mantra for Republican candidates almost since the law was signed. But what that means is open to speculation. The House GOP’s Pledge to America says: “we will immediately take action to repeal this law.” In its place, the pledge suggests medical liability aka tort reform, expansion of tax-exempt health savings accounts and allowing people to buy insurance across state lines, but offers few other specifics.

It’s not that Republicans think that the law is all bad. Republican Rep. Cathy McMorris Rodgers of Washington state recently conceded to CNN’s Candy Crowley that the GOP plan would keep two popular provisions: Allowing children up to age 26 to stay on their parents’ insurance; and prohibiting denial of insurance based on a pre-existing condition. Everything else, she said, is up for debate.

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Price Fixing And Kickbacks Sully Medical Supply Business

Adam Graham-Silverman, The Fiscal Times — Wed, 07 Jul 2010 17:24:48 +0000

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With all the provisions in the new health care law to curve, it seems that Congress left a couple things out: the price of medical supplies and measuring cost-effectiveness in clinical research.

Supplies ranging from gloves and gauze to drugs and machinery are the second-largest expense for hospitals. Since the mid-1980s, the purchasing companies that have a near monopoly on providing these supplies have been allowed to take payments from manufacturers. That means that the manufacturers can pay suppliers to pick their products, and that hospitals have little choice but to accept the prices and products they’re offered. The chances for price control have only worsened since 1996, when the suppliers got an exemption from antitrust rules. But fixing this scheme was not part of the health care reform conversation.

A new article in lays out the scheme – and its impacts – exhaustively. “It’s a system that has stifled innovation and kept lifesaving medical devices off the market,” writes Editor Mariah Blake.

The suppliers, known as group purchasing organizations, or GPOs, were created in the 1970s to negotiate on hospitals’ behalf. But in 1986 they started charging manufacturers, instead of hospitals, to fund their operations. To deter kickback schemes, payments that made up more than 3 percent of sales were supposed to be reported, but by 2002, “GPOs were collecting upfront payments of up to $3 million from suppliers in return for awarding sales contracts, not to mention a large share of revenues,” Blake writes. One supplier paid a GPO 94 percent of its sales.

GPOs say they save hospitals money by bundling supplies and using their size to negotiate good deals. But the . One medical company crunched seven years of data and found that GPO prices were heavily inflated. “The idea of hospitals outsourcing oversight of their supply budgets may seem hard to fathom,” Blake writes. “But the price of medical supplies is not always transparent.”

Another area the law overlooks: cost comparisons in research on clinical effectiveness. Among its many research projects, establishes an institute to conduct and prioritize research that compares clinical effectiveness of various devices and services. But it precludes looking at cost-effectiveness analyses, according to a from Mathematica Policy Research and the Center for Studying Health System Change. The funds, some $600 million a year raised from a fee on insurance that runs from 2013 to 2019, can’t be used to calculate “quality-adjusted life years,” a stat used to judge the value of a procedure. And the results can’t be taken as mandates or guidelines for payment and coverage.

All of this nervousness about what the researchers can and can’t do stems from the controversy over “death panels” and new mammography guidelines that came up last summer during the health care debate. “Such information on marginal cost-effectiveness has proven meaningful in public efforts in which the citizens accept the legitimacy of restricting access because of cost considerations; but the recent debate suggests the U.S. public is not ready,” the authors write. It also serves to remind that the success of the new law now depends on anonymous officials, not politicians and the public. This research institute will be run by a board that includes drug and device makers, raising questions about conflicts of interest. As in a recent column, “[T]he implementation period brings a dangerous asymmetry: The public quiets down, as people think action has been taken, but the lobbyists mount up.”

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Health Care Model Faces Hurdles On Quality and Cost

Adam Graham-Silverman, The Fiscal Times — Fri, 25 Jun 2010 15:19:00 +0000

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Physician Scott Eden’s primary care practice is a model for the reforms that President Obama is hoping to unleash with the health care legislation he signed this year. Eden’s Annapolis, Md., office has added an online medical record system and adopted new procedures to oversee and coordinate his patients’ care. That, in turn, has allowed him to shift clerical work and basic patient interactions to new staff he’s added.

As a result, he says he now sees three to five more patients each day, and no longer brings home the unreturned phone messages and unfilled prescription orders that had kept him working until 11 p.m. “I can actually do things for patients that I was not able to do,” Eden said.

The practice is part of a two-year pilot project funded by insurance giant CareFirst that has helped change its relationships with patients, largely by paying the doctors to provide additional care and examinations that go uncompensated under existing insurance plans. Eden and his partners suspect that their new model has kept patients healthier by actively managing treatment and pushing routine preventive testing, and cut costs by heading off emergency room visits and defensive referrals to specialists.

But this patient-centered experiment in Maryland faces a bumpy road. Once the CareFirst funding runs out at the end of this year, these innovations may not be sustainable. Unless they can get paid for these services, the doctors say they may not be able to continue checking up on a patient’s diabetes or inoculations, or visit with patients via e-mail. “I’ll do that to a certain extent, but I’ve got to go see the next patient in the next room to meet overhead,” said Patricia Czapp, another doctor in Eden’s office. “It all goes away,” she said of the extra services.

The U.S. spent $2.5 trillion last year on health care, or nearly 18 percent of the gross domestic product, according to government figures. Health care spending, including the government’s Medicare and Medicaid programs, has consistently grown at a faster pace than the economy as a whole since the 1960s, a major cause of alarm among government leaders attempting to deal with the long-term deficit.

The doctors say they can’t adopt a new approach without major changes in the dominant payment structure, in which reimbursements from private insurance and Medicare are based on procedures and not time spent or difficulty of a case. And while there are under way across the country to streamline and better coordinate medical services, experts say there are few incentives in the new health care overhaul law to promote the Annapolis model, and not enough research to justify it yet.

“If you want to look at it skeptically, well, this is a way to boost payments to primary care physicians, which intuitively could lead to savings elsewhere in the system, but there is not a lot of strong evidence that the savings are there,” said Stephen Zuckerman, a health economist at the Urban Institute, a Washington think tank.

Bending the Curve

During the health care debate, Obama argued that slowing the depends on steering the industry to adopt more cost-efficient methods such as computerizing medical records, coordinating services and referrals and boosting prevention to cut down on emergency room and prescription drug costs. The law authorizes to test models and .

In the current system, care is often fragmented by medical specialty, paid by procedures, not outcomes, and lacking communication between practitioners. At the same time, everyone agrees that primary care is and ill-prepared to handle the 30 million new patients that will be added to the insurance rolls as a result of the new law. “They spend a lot of their day doing stuff that somebody else ought to be doing that they don’t find particularly rewarding or challenging,” said Paul Grundy, who is head of IBM’s health care transformation projects. At the same time, heavy caseloads and relatively low pay have caused a looming shortage -35,000-44,000 by 2025.

So the Annapolis doctors are trying one new model, the “patient-centered medical home,” the profession’s term for practices that expand communication and access to doctors, manage chronic conditions and adopt a team-based approach to care that includes primary doctors as well as nurses and medical assistants.

At the Annapolis practice, where five primary care doctors manage about 12,500 patients, electronic record-keeping is central to the entire system. Doctors and staff can enter vital signs and notes into tablet PCs, which contain patients’ histories, appointments, prescriptions, even digital versions of x-rays. It gives the doctors easy access to information to discuss with patients, and prompts them about prescription refills or preventive tests such as a colonoscopy. (One study found that providers writing electronic prescriptions were seven times less likely to make errors than those doing it by hand.) Patients can see their records and get prompts for appointments and tests through the Internet, so they have access to the same information and can see blood test results, for example, as soon as the doctor does.

Under the old model, the practice, which is owned by Anne Arundel Health System, was productivity-driven, meaning that more patients and more procedures meant more pay. Under that model, Czapp said, she might have had five minutes to deal with a patient’s vision problems, chest pain and knee pain-a recipe for multiple referrals to specialists amid a fear of getting sued for missing something. “What am I doing at that point?” she asked. “I’m a waitress. I’m not doing anything.” Now, a patient can come in for nearly any kind of care on the day they call-or maybe they correspond via secure e-mail through the record system. The office phones allow emergency access to a doctor 24 hours a day. If someone comes in for a sinus infection but is due for a pap smear, Czapp says she can take care of it on the spot. “You start reacting to patient requests a little differently,” she said.

As employers begin to demand more for their money from insurers, CareFirst officials think this approach will save money and promote better health. CareFirst pays the practice a management fee for each of its patients and reimburses for preventive tests, e-visits and other uncovered services.

Robert Morales, a patient of Czapp’s, came into the office in February 2009 after a fall with a broken knee and saw the benefits firsthand. Staff quickly pulled up his records, called in a specialist and had him in a cast and on his way within an hour. “When you have an emergency and you go around to a medical center bingo! You don’t have to fill out all those stupid forms, with the same information every time,” said Morales, 73, a retired lawyer who lives in nearby Crofton. He regularly looks at his records online to check appointments and lab results. “I don’t have that kind of relationship with my urologist, who’s a first-rate man, but he’s not wired this way,” he said.

The Jury is Out

Despite the anecdotal evidence, however, substantial data has yet to emerge showing that this model saves money or lives. A two-year published earlier this month trying to adopt these changes, but found no evidence of better health, and in some cases found that patients thought their care got worse. The study did not look at cost, nor were the doctors given any financial incentives to change, though some got technical assistance. Terry McGeeney, the head of TransforMED, which funded the nationwide study and is the lead doctors’ group supporting the model, said it was nonetheless helpful to see what works and show the challenges involved. “The project is really set up as a learning map,” he said. But the lack of evidence has kept insurers from changing the way they pay, and kept large employers from pushing for it as well, said Zuckerman of the Urban Institute.

The medical community has yet to reach consensus on the best way to manage and pay for the health-home model. While the new health care law favors strengthening building blocks of the system like prevention and care coordination, it doesn’t give this model any special consideration. Medicare will now cover some prevention and coordination services. “I think at this point there certainly isn’t anything in the bill that would move to widespread adoption of the patient-centered medical home in Medicare or Medicaid,” Zuckerman said.

And most primary care is provided by small offices that aren’t connected to a larger health system and can’t afford a huge change in their practice model. “The biggest impediment is still the independent small practices,” said McGeeney. “They are so busy from dawn to dusk, seeing patients, trying to stay afloat, that they’re maybe not as engaged in this whole national movement as they should be.”

The health-home idea is gaining traction in some places, however, and several trials in specific settings have shown success. One pilot in Pennsylvania showed a 7 percent drop in spending, 20 percent fewer hospital admissions and many practices being able to see more patients. “The bottleneck is really psychosocial,” said Grundy, a leading proponent of the medical home model. He believes that the country’s already past the tipping point toward adopting the model on a large scale.

For doctors like Czapp, it would mark a move back toward what she was promised in med school that primary care would be-a close connection and active relationship with patients.

“We were all hot to be doctors like that, but because it was never valued and never affordable, we never got there,” she said. “We need to value what primary care is doing to keep somebody out of the hospital, out of the operating room, out of the emergency room,” she said. “Until you start recognizing the value of that and reimbursing it, you can’t change this machine, which is specialty-driven, procedure-driven and fragmented.”

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Two Tiered Medical Care for Haves and Have Nots

Adam Graham-Silverman, The Fiscal Times — Wed, 19 May 2010 00:30:00 +0000

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Not long after Cynthia Thek gave birth, her gynecologist opened a new practice in Englewood, N.J. Gone was the traditional waiting room, replaced by a reception area with spa-like ambience. Instead of a hospital gown, patients got a plush bathrobe. “It’s a beautiful space. The staff is superfriendly. You don’t feel rushed by the doctor or even the staff,” Thek, 32, explained recently. “However, [the doctor] also stopped accepting any insurance.”

Thek stuck with her doctor, , for one post-delivery visit, paying $250, about half of which her insurance reimbursed. But when she learned that care for her next pregnancy would run $8,000 to $10,000, much of it not reimbursable, she decided to look for a new OB-GYN.

A small but growing number of physicians are pursuing Dr. Ashton’s approach: abandoning traditional insurance-based practice to offer VIP treatment, including more time with patients, in return for upfront fees. In one common setup, often called concierge or retainer-based medicine, a primary care doctor charges an annual fee ranging from $1,000 to $20,000 just to get in the door. When doctors shift to this model they can cull their patient loads, selecting only those who can foot the bill. The services they provide often include a deluxe annual physical, 24-hour direct cell phone access to a doctor and escorts on visits to specialists. Some doctors still accept insurance and Medicare and bill normally for routine care. Others, like Dr. Ashton, opt out of that system in order to charge what the market will bear. Ashton did not respond to requests for comment.

The Haves, The Have-Nots

Doctors say the concierge system makes life much easier for them and assures better care to their remaining patients. “At the end of the day, you can look yourself in the mirror and you know that you did a good job with the patients you saw,” said Dr. , a Boca Raton, Fla., physician who cut his roster of patients from 3,500 to fewer than 400 five years ago. “You couldn’t do that seeing 40 or 45 senior citizens a day in the past.” While that may be true for the doctor and remaining patients, it’s not always easy for the thousands who didn’t or couldn’t pay, and who had to find a new doctor. Some health care experts view this as an ominous trend that could exacerbate socioeconomic disparity in the health care system in light of a . They say this development could be especially troublesome once the adds millions of Americans to the health insurance rolls and sends them looking for doctors. “Doctors love it. But in fact, from a societal point of view it’s a tragedy,” said Dr. Richard Cooper, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

The health care legislation recently signed by President Barack Obama is aimed at lowering costs and adding insurance coverage for more than 30 million people starting in 2014, including 16 million new Medicaid and Children’s Health Insurance Program members. But it does not account for the of 35,000 to 44,000 new primary care doctors, nurses practitioners and physician assistants that are choosing alternate disciplines because of , , a and a compared with medical specialists.

The Doctor Is Out

A 2009 survey of general practitioners by the American Academy of Family Physicians showed that 42 percent were not accepting new Medicaid patients. 65 million Americans are already living in areas the government has deemed short of primary care practitioners. And they’re not the only ones dropping out of the system. Recently, Walgreens and two other pharmacies in Seattle, Wash., decided to deny coverage to new Medicaid patients because of low reimbursements. And in a shocking move by one of the most revered hospitals in the country, The Mayo Clinic shuttered its Medicaid facility in Phoenix, Ariz., because it was losing too much money.

Dr. Marc Siegel fired a warning shot about the doctor dearth in an last April. “With more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have,” he said. He cited a 2008 report by the Medicare Payment Advisory Commission stating that 28 percent of Medicare beneficiaries had trouble finding a primary care physician; another survey that year by the Texas Medical Association found that only 38 percent of primary care doctors in Texas took new Medicare patients. Texas is not alone, as more and more physicians try to find acceptable ways to practice medicine without feeling like they’re being exploited.

Top-Of-The-Line Care For Top-Of-The-Market Fees

Concierge-style medicine is one way that overloaded doctors have chosen to respond. The American Academy of Private Physicians, the trade group representing the concierge care movement, says more than 1,000 doctors have gone this route. By another measure, 1.2 percent of respondents to AAFP’s survey say they practice concierge, boutique or retainer medicine.

While fee-for-service, or “private,” doctors have long existed, primary care doctors began converting to the concierge model about 15 years ago. Companies came along to help doctors set up these practices and handle the administration. The largest, MDVIP, has more than 380 doctors. (This rise of high-cost medical services was accompanied by low-cost programs aimed at the poor or uninsured.)

In 2002, MDVIP attracted the attention of several Democratic members of Congress, who were essentially charging seniors for services that Medicare already provided at established rates. That would be illegal. In a letter and subsequent documents, Health and Human Services secretary Tommy Thompson said that this model was fine so long as the fee was for services that were not covered by Medicare. With the exception of , in which a concierge-style doctor in Minnesota paid more than $50,000 to settle a claim that he violated his agreement with Medicare, HHS has left these doctors alone.

But many doctors say that while the current system is not sustainable, drastic cuts in patient load are ultimately misguided. “It’s a short-term solution to say, ‘I’m going to cherry pick some people who can pay me a concierge fee,'” said , an internist at Boston Medical Center. “The majority of us think it’s an unethical and ultimately selfish way to practice medicine.”

Dr. John Goldberg, an internist in the Kansas City area, said he could hardly ask a patient who can barely pay for medication to pay a fee for his care. Juggling many sick patients is just part of a day’s work, he said. “I worked in three or four people [Monday] that didn’t have an appointment Friday when we closed the office,” Goldberg said. “They’re not paying a premium; that’s just the right thing to do.”

The American Medical Association says there’s with concierge-type of arrangements. However, its ethics manual cautions that they “not be promoted as a promise for more or better diagnostic and therapeutic services.” That puts concierge doctors, particularly those who offer traditional service as well, in the awkward position of trying to promise patients that they’re getting something for the extra money while telling the rest they’re not giving up any medical services.

Of course some concierge doctors do say they provide services, not necessarily better care. “What I sell my patients is a better day,” said Dr. Marcy Zwelling, head of AAPP and a concierge doctor near Long Beach, Calif., who shed most of her 3,000 patients. “Do I think that sitting in a waiting room is bad care? No, but it’s probably a waste of time. I don’t think people die because they don’t have what we do. But do I think my patients live longer? I know they do.” There are no peer-reviewed studies of the health benefits of this approach. MDVIP cites showing lower hospitalization rates for Medicare patients who are in concierge practices compared with those who are not. suggests that the pool of concierge subscribers is less black and Hispanic, and has fewer chronic illnesses, like diabetes, than the general patient population.

Changing By Default, Not Design?

Doctors who have adopted this approach say the current system has forced them into it. To break even with reimbursements from Medicare and private insurance, Dr. Susan Wilder said she used to be able to spend no more than 8 minutes with each patient. “You’re forced into a situation of seeing more and more patients in less and less time, and the patients are more and more complex, and the administrative costs go higher and higher,” said Wilder, who converted her suburban Phoenix practice to a hybrid in which some patients pay a concierge fee while others do not. Wilder said her longstanding patients know that they get quality care no matter what. “I don’t think they needed any reassurance. I’m not going to dumb myself down to take care of my routine patients,” she said.

Reznick, the Boca Raton doctor, said he tried everything to keep his practice afloat. But he couldn’t manage. He now charges an annual fee of $1,800 as well as small payments for office visits.

Like all the concierge doctors interviewed for this story, Reznick found other doctors to take the patients who did not join his program, and kept very ill patients as well as some who could not pay.

Groups that support concierge physicians say the cost about $4 per day in most cases is not prohibitive, and that it comes down to a question of choice in the marketplace. “People go to McDonald’s; people go to Burger King, you know,” said Zwelling. “It’s a choice.” Darin Engelhardt, the president of MDVIP, said that most physicians who convert are on the verge of leaving medicine altogether, so it’s not accurate to say that every conversion means one less doctor in the market. To the contrary, the success of MDVIP’s financial model will lure doctors back to general practice, he said.

“On the experienced physician side, we extend the careers of primary care physicians,” he said. “And as far as younger physicians go, we’ve created a model that can prove that primary care can in fact be viable again.”

But for Thek, who quickly found a new OB-GYN who does accept her insurance, it was not worth the price. “I feel like I get the same level of care at the new practice,” she said, “minus the spa-like office and the plush bathrobe.”

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Health Care: Run On It or Against It?

Adam Graham-Silverman, The Fiscal Times — Fri, 08 Oct 2010 00:30:00 +0000

This story comes from our partner

But then there are the 25 percent who said they would make no difference at all in how they voted.

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Price Fixing And Kickbacks Sully Medical Supply Business

Adam Graham-Silverman, The Fiscal Times — Wed, 07 Jul 2010 17:24:48 +0000

This story comes from our partner

With all the provisions in the new health care law to curve, it seems that Congress left a couple things out: the price of medical supplies and measuring cost-effectiveness in clinical research.

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Health Care Model Faces Hurdles On Quality and Cost

Adam Graham-Silverman, The Fiscal Times — Fri, 25 Jun 2010 15:19:00 +0000

This story comes from our partner

Bending the Curve

The Jury is Out

For doctors like Czapp, it would mark a move back toward what she was promised in med school that primary care would be-a close connection and active relationship with patients.

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Two Tiered Medical Care for Haves and Have Nots

Adam Graham-Silverman, The Fiscal Times — Wed, 19 May 2010 00:30:00 +0000

This story comes from our partner

The Haves, The Have-Nots

The Doctor Is Out

Top-Of-The-Line Care For Top-Of-The-Market Fees

Changing By Default, Not Design?

Reznick, the Boca Raton doctor, said he tried everything to keep his practice afloat. But he couldn’t manage. He now charges an annual fee of $1,800 as well as small payments for office visits.

Like all the concierge doctors interviewed for this story, Reznick found other doctors to take the patients who did not join his program, and kept very ill patients as well as some who could not pay.

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