Saturday, December 21, 2013
WHY AREN'T DOCTORS INVOLVED IN HEALTH REFORM--ACTUALLY WE ARE, BUT NO ONE LISTENS TO US
As I was watching CNN news recently, I noted in the headlines different ways Obamacare is failing. Current problems discussed were the customers’ sticker shock of high deductible plans (up to $12,700 for families), the president blaming the insurance companies for having substandard plans, and the people blaming the president for losing their current insurance.
One patient even complained, “My new health care plan tripled in price, and now, it is like having a third loan to deal with, including my car and home loan.” A vicious cycle of blame between Washington, health insurance companies, and the patients is quickly demoralizing this nation and simply increasing costs with more administrative regulations.
And we need answers.
Surprisingly, in all of this, doctors were not even mentioned. As if doctors do not know the intricacies of how the health care system works. As if doctors are not there for their patients 24 hours per day, ordering tests or doing procedures that can benefit a patient’s well-being. As if doctors are not dealing with denials from the insurance companies on a daily basis, losing valuable hours to menial paperwork that could be spent caring for our country’s sick.
Doctors have a duty to care for their patients and are the engines that put health care into motion. They yearn to maintain that physician-patient relationship that is important to the care of our patients. Unfortunately, doctors are not being directly involved in the health care reform debate despite being on the front lines of care. They have an opportunity to provide valuable insight into the day-to-day operations of this health care machine.
Would you want to fly in a plane with no input from a pilot? Or design a curriculum without a teacher’s input? These “insider” insights are essential to health care in order to exact true change and improve health care for everyone to enjoy. Unless we embrace this idea and look to doctors to help solve these dilemmas, we will be doomed with increasing prices, more talking heads on TV blaming others, and dysfunctional insurance companies, all who have never spent a minute shadowing a doctor, yet claiming to know all the answers.
The current law and regulations being implemented under Obamacare will ultimately lead to sicker patients and low quality care for three reasons:
First, older doctors will retire early fed up with the system. These older doctors feel that the loss of a patient-physician relationship and the burdensome regulations (ie. paperwork) will choke off their ability to provide good care. In addition, their expenses are increasing with these new regulations. Add in the projected cuts in reimbursement up to 26%, and their livelihood will be threatened. These cuts could force these doctors out of practice or force them to stop seeing Medicare patients simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already.
Second, young smart minds will no longer enter the field due to rising debt (average $250,000 after medical school) and severe cuts in reimbursement (yearly threats of 26% cuts to reimbursement). If young college students realize that they cannot provide for a family despite going to school and training for 14 years, deferring income for all those years, and then being slapped with a $250,000 medical school bill, they will turn to different professions.
Third, current younger doctors will become more demoralized with administration and lawmakers dictating how they provide care. They will feel as if they are increasingly being treated as machines, expecting to provide great care such as answering patient calls at 2am, working 24 hours shifts, doing more procedures for less, and filling out more and more paperwork, all with the threat of getting sued if they don’t perform without making a mistake. This will produce a high burnout rate and poorer care.
These doctors went into medicine to feel a healthy bond between themselves and their patients. They enjoy talking and spending time with them in the office. Unfortunately, with all the unnecessary documentation regulations and time restraints, doctors are losing the bond that is so critical for care. For those doctors who choose to stay in the field of medicine, many of them will instead elect to practice concierge medicine, taking the insurance company out of the equation and attempting to maintain the physician-patient relationship.
There are numerous articles out there that show concierge medicine is growing. With current doctors feeling demoralized and younger students afraid to enter the field, this will create a massive shortage of doctors and threaten the health of our citizens.
Having said all this, I as a doctor do not want this to happen. I went into medicine as a calling to help others and take this role seriously. I longed for the idea of sitting down and talking with my patients, sharing stories with them, not on the clock, and without cumbersome, slow computers and administrators documenting every move I make. I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this.
Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input. We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works. But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws.
I would now like to outline below a few of these ideas that would lead to better and more affordable care.
The first idea involves making costs and reimbursement more simplified and transparent. These changes would help clarify misconceptions about doctor’s pay. Leaders need to stop attacking doctors for how much they earn because they do not really know how it works. In all other professions, one gets paid what the bill says. If a handyman comes in to fix your sink and charges $80, you pay him $80. If you seek a lawyer, and he says he charges $250/hour and he works 4 hours for you, you owe him $1000.
Unfortunately, the medical billing is unique, confusing, and wrong. The charges (bills) that patients see in the mail are not what doctors get paid. These are inflated numbers derived from contracts between hospitals or groups and insurance companies. A recent New York Times article headlines read “As Hospital Prices Soar, a Stitch Costs $500.” Sadly, these inflated numbers have nothing to do with what the doctor gets paid. In fact, those bills do not go to the doctor at all, but rather to the hospital.
When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid, depending on the patient’s insurance, utilize a fee schedule. This schedule consists of thousands of codes that give dollar amounts for individual procedures or clinic visits. Each code has a dollar figure to determine how much to reimburse that doctor. This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare. This can range from 80% to 180% of Medicare depending on the insurance carrier.
If a patient has Medicare, however, one can see exactly what that doctor will get paid based on the code for that procedure, test, or office visit (CPT code) by using the fee schedule. This is often called the “allowable charge” in patient’s bills. The revenue the doctor receives is in fact this fee and is set no matter how much the hospital or doctor chooses to charge.
To complicate matters, there are usually two different charges in a patient’s bill: a “professional” charge from the doctor, and a “facility or hospital” charge.
First, the doctor only collects a fraction of the “professional charge.” This is the charge for the doctors’ services (e.g. office visit vs. procedure vs. MRI interpretation). The doctor only receives a fraction of this “professional charge” because this is reduced by the fee schedule to the appropriate amount. Remember, charges and what the doctor actually gets paid are very different in medicine. The doctor does not collect any of the hospital charge as this charge goes to the hospital. After all of this, a doctor gets paid only a small fraction of this “professional charge” because these allowable charges do not include overhead expenses the practice incurs (which can range from 30 to 60%).
This situation I describe above is not understood by our leaders as verified in this video of President Obama discussing foot amputations in diabetics. President Obama claimed that surgeons get paid “30, 40, 50 thousand dollars” for a foot amputation. Looking at the Medicare Fee schedule, CPT code 28805 states that the surgeon would get paid $738.90, which is the fee before his expenses are considered. This $738.90 needs to cover his office space, staffing, medical liability, and years of training to have the privilege of performing this life saving operation. Thus, the doctor actually gets paid 1.4% ($738.90/$50,000) of what President Obama claimed he got paid. Our leaders are clearly confused and have no right attacking physicians’ reimbursement.
Another example of confusing costs of medical treatment hits closer to home as my own mother presented to the ER with sudden blurry vision a few weeks ago. Concerned for serious causes for this symptom, several tests were run to rule out causes such as stroke or tumor. Thankfully, her diagnosis was nothing life threatening and is recovering. She then received the following bill two weeks later in the mail explaining her charges. I have attached a copy of the bill.
She was shocked at how high the charges were and could not decipher this bill. Referring to my explanations above, under “professional/physician charges,” it “appears” a physician gets paid $450.00 to interpret a CT head and $580.00 to interpret a MRI of the brain. As I described above, this is far from the truth. Looking at the fee schedule, code 70450, a CT head would pay a doctor $29 for a Medicare patient. This is far different than the $450 shown on the bill. In fact, it is only 6% of what the bill states! Likewise, an MRI brain, code 70558, would pay a radiologist $109. Way off from the charge of $580. There are other inflated fees for the hospital as you can see in this bill totaling over $11,000, but these are not related to a doctor’s compensation.
This clearly illustrates that doctors payment systems are confusing for patients and creates much anxiety when trying to decipher a bill in the mail. It is apparently even confusing to lawmakers and the president who are trying to modify reimbursement yet do not know how doctors get paid. Even though a stitch may cost $500, the doctor got paid $28 dollars to read a complex CT scan of the brain. We need real costs to health care, not inflated charges from hospitals. This needs to be addressed so patients and lawmakers can understand where doctors are coming from and realize that doctors are getting paid much less than meets the eye.
In addition to the above explanation, doctors do not get paid for talking on the phone to patients or other doctors, writing prescriptions, or ordering lab work or radiology tests. This is simply work we do to allow patients to get the best care and do not charge hourly fees for this work. We do this work in between seeing patients in the office.
Further, if we drive to the hospital in the middle of the night to perform a procedure, we get paid the same and we do not charge extra. Doctors do not collect whatever they want for clinic visits or procedures; this is all determined by the fee schedule explained above. In addition, if one procedure takes longer than average or is more complex, a doctor does not collect more for that procedure unlike other professions that are paid hourly. The fee is pre-determined by the Medicare fee schedule no matter how sick the patient is. This is clearly different among other professions which charge an hourly rate.
In addition, if there is a follow up call or letter after the procedure, this is all part of the one fee and no additional fees are billed. If that patient calls at 9pm that night with a health complaint or the patient arrives 30 minutes late to an appointment, there is not an increased charge (ie. we do not get paid more). I am not stating that hourly rate work like how lawyers get paid is flawed or wrong; I am simply stating it is very different and sometimes this contrast is not noticed. Do I speak with patients at 9pm and do I spend the extra 30 minutes helping patients get the quality care they deserve?
Of course, I willingly do this because I went into medicine to help those in need and I get satisfaction from this. I do worry, however, that this may not continue to be the case for all doctors if reimbursement models are not modified and doctors’ fees are not corrected for inflation and practice expenses. They simply will not bring in enough revenue to cover their expenses. Again, doctors’ fees have been declining, are not secure (please read about the SGR formula), and do not adjust for inflation. Solutions involve making costs and charges more transparent and realizing the true (not inflated) costs and benefits of medical devices, services, and materials. With actual costs (not inflated charges) being available and transparent, patients would be given choices and autonomy about their health.
The vehicle for this would be health savings accounts (which I will describe in more detail below), which would allow patients to use their own money with their doctor’s advice to decide on what care is best for them. This would increase competition amongst providers, lower prices, and offer more choice and involvement in their care.
The second idea involves tort reform. We as doctors have a calling to help patients. But, as we all are human, mistakes can happen. It is very important that patients who are injured by mistakes be compensated in a way that the law is supposed to provide. However, the point of law is to provide reliable decision-making that can sort good health care from bad health care. Instead, currently, it is run ad hoc jury by jury with no set standards. The system currently favors a doctor if in fact something was done wrongly or it may favor a patient even if no mistake was made. This unreliability leads to defensive medicine, ordering tests and procedures just to prove that you did something, or excessively documenting trivial facts to prove you looked at everything. The estimates for defensive medicine has been estimated up to $200 billion per year. The current laws neglect both the patient and the doctor and drives up costs with administrative and attorney fees.
Here is an example of the evolution of defensive medicine. If a family physician determines a patient’s headache is likely due to tension and there are no warning signs for something serious, the doctor may choose not to order a CT scan and have the patient follow up if symptoms do not improve. Rarely, a tumor or bleeding in the brain could present in such a way despite a normal clinical evaluation by the doctor. If that patient ends up having a tumor or bleeding, they can sue the doctor for not ordering the CT scan earlier. In turn, that doctor doesn’t want that to ever happen again, even though he did everything right by using his clinical knowledge to determine nothing serious was likely going on.
Thus, he will order CTs on everyone simply to avoid a frivolous lawsuit even though he knows that the CT will be normal. This exponentially increases costs as doctors across the thousands of hospitals in America follow suit not only for headaches but for other common ailments. No, doctors cannot play God and know every outcome with the thousands of patients they see yearly. But they are very good at using their knowledge and training to determine if someone is sick and likely needs further immediate attention or not.
Having said that, if the doctor did do something wrong, the patient is still taken advantage of with the current tort system. Thirty-nine percent of cases take three years to settle and 60 cents on the dollar are used for lawyer fees and administrative costs. Patients definitely deserve to be compensated for poor health care and this current system fails them.
The answer to this rests in health care courts described by Common Good Chair Philip K. Howard. He states that expert judges without juries would determine what is good versus bad care. This would provide consistent standards of what is required in certain health care situations. It would benefit patients because they would not spend three years dealing with the jury system nor pay trial lawyers 60 cents on the dollar for a case they may not even win. And it would benefit physicians because they could act on their best professional judgment without being scared of being liable when they did nothing wrong. It would let us do our jobs without being smothered by lawyers looking over our shoulder, yet provide patients with fair consistent rulings in cases of being wronged.
By creating clear standards of care, health care courts will allow judges to dispose of weak and invalid claims quickly after filing, while also disincentivizing doctors and insurers from defending cases in which they are clearly at fault.
The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs. This could be accomplished with health savings accounts. These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status. With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services. This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones.
In order for these accounts to work well though, hospitals’ and doctors’ prices need to be more transparent and reflect true costs so patients know what they are buying. Currently, that is impossible. Hospital and doctor bills make little sense, are falsely inflated (as described above), and do not reflect true costs, leaving patients confused about real costs to their health. When a patient hurts his or her knee, goes to the doctor, and the doctor orders an expensive MRI, there is no mention of costs. The patient’s insurance “covers” the MRI, making the costs a non-issue for that patient. There is no incentive to try ice, physical therapy, and rest before delving into an expensive MRI.
If the actual price was known for that MRI, patients could know what they are “buying.” This price would be significantly less than the inflated charges because prices would be required to be transparent. True prices would be published and patients could shop for MRI scanners just as they would for any other service. This would thus allow patients control over how they spend their health care dollars.
In the same light, during the last six months of our lives, we spend up to 50% of our own total lifetime health care dollars. In America, when patients are extremely sick and brought into the hospital, everything in our medical repertoire is used to keep them alive. Costs can be up to $10,000 per day of ICU care not including other aggressive measures.
Unfortunately, patients may not know these costs. With patient funded health savings accounts, patients would have more of a role in their own care, and could decide based on a doctor’s recommendation the best course of action, considering the patient’s prognosis, benefits, risks, and costs. Of course, families always have input into their loved ones health near the end of his or her life and can decide how aggressive they wish to be while talking with their team of doctors.
However, the way it is being done is likely wrong. Doctors are not bringing up hospice to patients early enough. Instead, many families with their loved ones are faced spending their last months in an ICU, hooked up to breathing tubes, only prolonging the inevitable. Patients’ and their families are being deprived of spending that time at home in a more comfortable setting. Quality of life is not being brought up, only quantity. An article in the Washington Postaddresses these end of life issues extremely well, entitled “An unrealistic view of death, through a doctor’s eyes.”
It states that modern medicine may be doing more to complicate end of life issues, rather than improve it. The article also states that people think death is a failure of modern medicine rather than simply life’s natural conclusion. I am not saying that every patient in an ICU needs hospice brought up. Each patient in unique and families should decide based on their values and wishes. A previously healthy 28 year old involved in a car wreck who remains in an ICU may need months in an ICU to recover and would benefit from this long hospitalization.
However, a 90-year-old patient with other medical problems such as heart failure and kidney disease in the ICU with a new diagnosis of a terminal cancer may benefit from a talk with hospice. Every human being is unique in their health needs and I feel families and doctors need to be more open about goals of care at the end of life An interesting article details some of these issues, entitled “How Doctors Die.”
It basically points out that most doctors choose less, not more, care at the end of their life because they personally witness the limits to human medicine action. It illustrates that there is not always an answer or a cure and that doing nothing is sometimes the best care available. All in all, more patient ownership of end of life costs utilizing their health savings accounts combined with frank discussions with their doctors about these end of life issues would definitely lower health care costs and even help families cope with difficult illnesses.
The final suggestion involves preventing chronic illnesses that end up costing Americans a lot as they age. We are very good at treating complex medical problems with patients who are very sick, but not very good at reducing medical costs through preventative medicine. We are very good at bringing a new state of the art drug used to thin the blood to the market, but bad at actually preventing the reason for needing that drug in the first place!
In fact, 50% of our health care dollars ($623 billion) are spent on the sickest 5% of patients (30 million) in America. Interestingly, the top 1% of health care “spenders” accounted for 20% of the total health care expenditures in America. These are usually patients with multiple chronic medical conditions such as obesity, diabetes, kidney and heart disease. Studies often quote Americans as spending a lot on health care, yet being ranked lower than most other countries on health care outcomes. This is the reason these stats make sense. We spend a lot on patients who are very sick and can prolong their life, but do little to prevent them from getting sick.
Recently, Sanjay Gupta summed up the solution to this paradox very well in a CNN article. He basically states that increased access to health care with Obamacare would not improve our health outcomes. Rather, patients taking ownership of their own health and holding themselves accountable will promote a healthier America. Eating better, exercising more, and reducing stress can go a long way. It would also reduce the likelihood of developing these expensive chronic medical conditions, which drive costs higher.
In conclusion, I feel that Capitol Hill needs input from doctors working in the front lines to discuss our issues so that the best reform possible can be made. Doctors experience all of the above issues on a daily basis and have insight that politicians cannot observe since they do not spend time in doctor’s offices or hospitals. These are a few issues that would help our deserving patients get the best care and restore that critical relationship we need with our patients.
I believe that by empowering patients more in the health care system through health savings accounts, reforming our tort laws, making costs more transparent, being more realistic about end of life issues, and living healthier, we can come a long way. I hope we can work together with lawmakers to create a system that can benefit everyone.
Matthew Moeller is a gastroenteroloigst.