Friday, May 15, 2009

How ObamaCare will affect your doctor

At the heart of President Barack Obama's health-care plan is an insurance program funded by taxpayers, administered by Washington, and open to everyone. Modeled on Medicare, this "public option" will soon become the single dominant health plan, which is its political purpose. It will restructure the practice of medicine in the process.

Republicans and Democrats agree that the government's Medicare scheme for compensating doctors is deeply flawed. Yet Mr. Obama's plan for a centrally managed government insurance program exacerbates Medicare's problems by redistributing even more income away from lower-paid primary care providers and misaligning doctors' financial incentives.

Like Medicare, the "public option" will control spending by using its purchasing clout and political leverage to dictate low prices to doctors. (Medicare pays doctors 20% to 30% less than private plans, on average.) While the public option is meant for the uninsured, employers will realize it's easier -- and cheaper -- to move employees into the government plan than continue workplace coverage.

The Lewin Group, a health-care policy research and consulting firm, estimates that enrollment in the public option will reach 131 million people if it's open to everyone and pays Medicare rates, as many expect. Fully two-thirds of the privately insured will move out of or lose coverage. As patients shift to a lower-paying government plan, doctors' incomes will decline by as much as 15% to 20% depending on their specialty.

Physician income declines will be accompanied by regulations that will make practicing medicine more costly, creating a double whammy of lower revenue and higher practice costs, especially for primary-care doctors who generally operate busy practices and work on thinner margins. For example, doctors will face expenses to deploy pricey electronic prescribing tools and computerized health records that are mandated under the Obama plan. For most doctors these capital costs won't be fully covered by the subsidies provided by the plan.

Government insurance programs also shift compliance costs directly onto doctors by encumbering them with rules requiring expensive staffing and documentation. It's a way for government health programs like Medicare to control charges. The rules are backed up with threats of arbitrary probes targeting documentation infractions. There will also be disproportionate fines, giving doctors and hospitals reason to overspend on their back offices to avoid reprisals.

The 60% of doctors who are self-employed will be hardest hit. That includes specialists, such as dermatologists and surgeons, who see a lot of private patients. But it also includes tens of thousands of primary-care doctors, the very physicians the Obama administration says need the most help.

Doctors will consolidate into larger practices to spread overhead costs, and they'll cram more patients into tight schedules to make up in volume what's lost in margin. Visits will be shortened and new appointments harder to secure. It already takes on average 18 days to get an initial appointment with an internist, according to the American Medical Association, and as many as 30 days for specialists like obstetricians and neurologists.

Right or wrong, more doctors will close their practices to new patients, especially patients carrying lower paying insurance such as Medicaid. Some doctors will opt out of the system entirely, going "cash only." If too many doctors take this route the government could step in -- as in Canada, for example -- to effectively outlaw private-only medical practice.

These changes are superimposed on a payment system where compensation often bears no connection to clinical outcomes. Medicare provides all the wrong incentives. Its charge-based system pays doctors more for delivering more care, meaning incomes rise as medical problems persist and decline when illness resolves.

So how should we reform our broken health-care system? Rather than redistribute physician income as a way to subsidize an expansion of government control, Mr. Obama should fix the payment system to align incentives with improved care. After years of working on this problem, Medicare has only a few token demonstration programs to show for its efforts. Medicare's failure underscores why an inherently local undertaking like a medical practice is badly managed by a remote and political bureaucracy.

But while Medicare has stumbled with these efforts, private health plans have made notable progress on similar payment reforms. Private plans are more likely to lead payment reform efforts because they have more motivation than Medicare to use pay as a way to achieve better outcomes.

Private plans already pay doctors more than Medicare because they compete to attract higher quality providers into their networks. This gives them every incentive, as well as added leverage, to reward good clinicians while penalizing or excluding bad ones. A recent report by PriceWaterhouse Coopers that examined 10 of the nation's largest commercial health plans found that eight had implemented performance-based pay measures for doctors. All 10 plans are expanding efforts to monitor quality improvement at the provider level.

Among the promising examples of private innovation in health-care delivery: In Pennsylvania, the Geisinger Clinic's "warranty" program, where providers take financial responsibility for the entire episode of care; or the experience of the Blue Cross Blue Shield plans in Pennsylvania, Michigan and Virginia, where doctors are paid more for delivering better outcomes.

There are plenty of alternatives to Mr. Obama's plan that expand coverage to the uninsured, give them the chance to buy private coverage like Congress enjoys, and limit government management over what are inherently personal transactions between doctors and patients.

Rep. Nydia Velazquez (D., N.Y.) has introduced a bipartisan measure, the Small Business Cooperative for Healthcare Options to Improve Coverage for Employees (Choice) Act of 2009, that would make it cheaper and easier for small employers to offer health insurance. Mr. Obama would also get bipartisan compromise on premium support for people priced out of insurance to give them a wider range of choices. This could be modeled after the Medicare drug benefit, which relies on competition between private plans to increase choices and hold down costs. It could be funded, in part, through tax credits targeted to lower-income Americans.

There are also measures available that could fix structural flaws in our delivery system and make coverage more affordable without top-down controls set in Washington. The surest way to intensify flaws in the delivery of health care is to extend a Medicare-like "public option" into more corners of the private market. More government control of doctors and their reimbursement schemes will only create more problems.


Big waste of money on crooked NHS doctors

Family doctors accused of misconduct are being suspended for up to four years and at a cost of up to £900,000, according to figures revealed by the NHS under the Freedom of Information Act.

Primary care trusts in England disclosed that 134 GPs have been suspended over the last three years. The trusts pay 90 per cent of the doctors’ salaries during suspension, costing the NHS £8.2 million.

Norman Lamb, health spokesman for the Liberal Democrats, described the costs as scandalous. “They involve a huge waste of public money and show that the system of pursuing allegations against doctors is failing,” he told The Guardian.

GPs suspected of misconduct are suspended by their primary care trust or by the General Medical Council, which regulates doctors. Trusts handle less serious cases and must seek approval if they last longer than six months. John Canning, of the British Medical Association, said that the disciplinary system can be “quite slow” to ensure that both sides have time to prepare. “But even bearing that in mind, too many cases take too long,” he said.

David Stout, director of the PCT Network, said that the speed of the system coulod be frustrating. “Some of the delays are excessive, very costly and benefit nobody.”

The trust for Haringey, north London, spent £1.4 million in the last three years on three GPs who were suspended. Newham, east London, spent £1.1 million on seven suspended doctors since 2006.


Canadian Health Care: A Killer

A Cure Worse Than the Disease

Canada's health care system too often proves a death sentence for cancer patients. Emily Morley got some very bad news in March 2006. Her cancer had spread, the doctor informed the 67-year-old Canadian. She would need to see an oncologist. Then Morley got some really bad news: She'd have to wait several months before she could get an appointment. Only after her family raised a ruckus, calling the local paper and starting a petition to demand she get care, did the government get her a specialist. Then, it was more bad news: Morley had only three months to live.

At least she had time to put her affairs in order. Had her family not intervened, noted provincial lawmaker Don McMorris, it is quite likely that Emily Morley may have died before even seeing an oncologist for the first time. But that's how a single-payer, or universal, health care system works (so to speak). Even the very ill routinely hurry up and wait.

Alarmingly, Congress is gearing up to reform American health care along Canadian lines and proponents are trying to take a short-cut to get there. According to former Medicaid director Dennis Smith, proponents of a government-run health system are hoping to enact a bill by by-passing the usual, lengthy bipartisan review process.

The goal of any reform, supposedly, would be to trigger competition between government-run health care and currently existing private health insurance plans. Yet, Smith warns, the government will inevitably tilt the playing field to favor its own plan, running private coverage out of business. Americans could be left with a single, government-run health plan a la Canada's.

So lets take a look at what such a system means for our northern neighbors. As Sally Pipes, president of the Pacific Research Institute and a former Canadian citizen, recently told Congress, today some 750,000 Canadians are on a wait-list for medical procedures. Further, 3.2 million (out of a population of 32 million) are waiting for a chance to see their primary-care physician. Once a PCP diagnoses a problem, Canadians must keep on waiting 17.3 weeks on average before they can see a specialist.

Why? The Canadian government controls costs by rationing care, Pipes explained. Canada ranks 14th out of 25 [Organization for Economic Co-operation and Development] countries in MRI machines, and 19th out of 26 countries in CT scanners. Long wait times and lack of equipment force many to seek care in the United States.

Take Member of Parliament Belinda Stronach. She strongly supports Canada's health care system. But where did she go when she was diagnosed with cancer in 2007? To California, where she paid for treatment out-of-pocket.

Then there was a mother in Calgary, Alberta, who had to be flown to Great Falls, Mont., to deliver her quadruplets. This relatively small American city had better facilities than any hospital in the wealthy province of Alberta.

Our current system is far from perfect, of course. Millions of Americans lack health insurance, prompting many to put off seeing a doctor until a small, treatable problem has become a larger, more threatening condition. But the answer isn't to try and cover everyone through a single-payer system.

We'd be better off changing how the federal tax code treats health insurance (which, illogically enough in our 21st century economy, ties it to our jobs). Such a change would foster genuine competition among insurers by allowing Americans to shop for the coverage that suits them best in an open market. Current policy provides unlimited tax breaks for health coverage provided through employers. Meanwhile, Americans who want to buy their own insurance must do so with after-tax dollars. Few can afford to do that, especially since insurers are more interested in competing for big group coverage (more lives, more money) rather than individual or family-based coverage.

Lawmakers could change this, and even provide vouchers or other forms of direct assistance to help poorer Americans buy private plans they would own and control. This would also make insurance portable when people change jobs.

Maintaining our standard of care is critical. There's a reason Canadians fly south for treatment: Our system, for all its flaws, provides superior quality and access to care. Lets ensure that policymakers, in their understandable zeal to reform health care, dont make changes that weaken the entire system.


No comments: