Why does health care reform have to mean spending more on health care? We already spend much more per person than any other country. We in America practice an exorbitantly expensive style of medicine. We have de-emphasized the trusting relationship between patient and physician while over-using technology, drugs and devices in large part fostered by the Congress via its control over the Medicare payment schedule. Instead of addressing the more complex situation of the way we practice medicine in this country and its causes, our political class has chosen to focus on the results of our excessive spending, insurance costs. There are solutions to this problem; we can as a nation cover all Americans for a lesser percentage of gross domestic product that is more in-line with that of other developed countries. This would have a salutary effect on our economy. We can correct our health care system if we understand the flaws and realistically correct them.
Major Flaws in our Health Care System
• Medicare’s payment schedule, which as the largest insurer drives the industry, has chronically under-funded the doctor-patient relationship and over-funded technology, drugs and devices, and is responsible for a profound negative effect on the practice of medicine in the United States.
The under-funding of the time patients and physicians can carefully review the issues has caused a decrease in preventative care and poor management of the chronically ill.
• More and more use of expensive technology without evidence of superiority over existing, less costly methods takes advantage of lucrative quirks in the Medicare payment schedule. Some examples are proton accelerators for prostate cancer and the use of cardiac stents in patients whose conditions are just as easily managed with medication.
• There is no nationwide, consistent system of oversight by qualified experts
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delivered. One expert after another has said that inappropriate care is the 42
biggest culprit in out-of-control costs - estimated at over $700 billion per year.
• Cardiopulmonary resuscitation (CPR) is automatically performed unless a
“Do Not Resuscitate Order” is written. CPR by default began in the 1960s when the typical hospital population was much younger. Today that population is much older, yet we spend billions a year on CPR, mostly on end-of-life patients who have no chance of survival and who suffer from the procedure.
• Hospital and physician administrative costs have become nearly unmanageable due to the number of staff needed to handle the wide range of insurance plans because of state mandates and many employers providing a multitude of different coverages. The same is true for the insurance companies themselves. All those costs are passed on and contribute to ever-burgeoning healthcare expenses.
• Device and drug company advertising directly to the public helps promote an increasing sense of consumerism. Patients and their families have a virtual smorgasbord of drugs, devices, and procedures, all attractively packaged in the ads, that they can demand whether they'd be of any benefit or not. Unfortunately, many physicians are loathe saying no to them.
• Presently government programs, Medicare and Medicaid, are being subsidized by the privately insured. We have not created a system whereby each generation pays for most of its own health care. The present system of depending on younger citizens to fund the health care of the elderly is, because of demographic changes, no longer sustainable.
The problems in our healthcare system have become so complicated and intertwined that remedies involving huge additional spending are not the solution. The objective should be to care for all our citizens at a reasonable rate that brings the percentage of gross domestic product spent on health care more in line with that of other industrialized countries, thus increasing our global competitiveness. If the following recommendations are adopted, these goals would be realized.
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Recommendation 1: Specific Actions by Congress
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The original intent of these acts was to
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give patients more voice in their care and the ability to refuse even beneficial treatment, protect the disabled, and prevent hospital emergency rooms from turning away patients because of a lack of ability to pay. Frequently these acts have morphed into a license to receive care or treatment, whether it is beneficial or not. This has caused many thoughtful physicians who have the best interests of their patients at heart of having to concern themselves about the possibility of legal action. Alternatively there are physicians who knowingly or unknowingly deliver non-beneficial care because the treatments and procedures are handsomely reimbursed by third parties. Amending these laws to include a phrase such as “within the boundaries of acceptable medical standards” would have a dramatic impact on the way we practice medicine in the United States.
The medical profession would have to collaborate on difficult cases, exercise more judgment, individualize decisions on each patient, and work to decrease non-beneficial inappropriate care. Importantly, patients and physicians would have to dialogue regarding the rationality of their medical plans. Thus Congress would be actively endorsing recommendations 2 & 3.
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Create a separately
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chartered, independent federal agency – like the Federal Reserve System – that would be a central clearinghouse for our entire health care industry – public and private. I would call it a “Healthcare Bank” which would, like the Federal Reserve System regarding monetary policy, insulate health care from the politics of Congress. The Healthcare Bank would coordinate and perform many tasks now done by insurers and healthcare providers. It would not only simplify the system and make it more uniform, it would decrease administrative costs to the tune of billions of dollars a year. At the same time it would maintain our present mix of private and governmental insurers.
The Healthcare Bank would:
1. Convene a biannual meeting of representatives from all insurance entities and the national peer review panel (see Recommendation 3) to define five 44
standardized national insurance packages. The lowest cost plans 1 & 2
would cover all essential appropriate medical services and would be available to all with no exclusions for preexisting conditions. Plan 2 would be the government equivalent of plan 1, federally funded and covering the poor and uninsured, thus eliminating Medicaid. As medical costs decreased the number of uninsured would decrease and the accrued savings would be more than adequate to roll in coverage for the remaining uninsured. At the other end of the scale, plan 5 would be considerably more expensive and include extras such as podiatry, massage, health club memberships, plastic surgery, etc. Plans 3&4 would be successive gradations between plans 1-2& 5. This would replace the present thousands of plans funded by third party payers and thus save many billions in administrative costs. Insurers would compete by lowering costs and by initiating innovative programs such as weight, diabetes and blood pressure control, home health services for the elderly, etc. Co-pays and minor outpatient costs could be paid via health savings accounts with contributions by the federal government for those in plan 2. These health savings accounts would accumulate funds tax free with yearly contributions so that by the time of retirement most health care would be funded by these accounts. Medicare would then be available for catastrophic coverage. Any monies remaining after the demise of the individual would be inheritable.
The Bank would also ensure that all insurers, public and private, adequately fund hospital and nursing home care thus eliminating cost shifting. This would preclude the need for hospitals and nursing homes to stress often unnecessary, non-beneficial technological and procedural care to maintain solvency.
2. Determine fees so that physicians and patients would have adequate time to thoroughly discuss the medical issues at hand, at least ½ hour per outpatient visit, and allow primary care physicians to visit their patients when hospitalized. To meet the immediate primary care shortage, internal medicine sub-specialists would be recruited to also provide primary care.
3. Establish a central computer system through which all billing and payments takes place and through which all insurers are paid.
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4. Maintain an electronic medical record system for the entire nation with multi-layered safeguards to insure privacy.
5. Require that all hospitals, nursing homes, other health providers and insurance entities (public and private) adjust their computer programs so that all could interface with the bank’s computers, with the proper privacy safeguards. The bank would charge a small fee for each transaction which would cover the costs for initiating and maintaining these electronic services without consuming additional federal funds.
6. Fund The National Institutes of Health (our major national research endeavor) by collecting monies from all insurers, governmental and private, in proportion to the percentage of the population covered by each. This type of research is an investment for the future and should be funded by all carriers, not just the federal government.
7. Require all drug and device companies to fund their clinical research through the National Institutes of Health which would oversee the experimental design and the results, thus removing the conflicts of interest that exist in the present system. The Healthcare Bank would collect and distribute the funds. This would eliminate the need for a proposed expensive new bureaucracy, a Healthcare Comparative Effectiveness Research Institute, because information would be developed prospectively rather than retrospectively at no cost to the government.
8. Fund graduate medical education (residencies & fellowships) through funding from all carriers in proportion to their market share and make payments directly to the educational entities. This would ensure that post graduate physician training is primarily a training experience.
9. Pay the salaries and staff of the expanded peer review committees (see Recommendation 3).
10. Be funded by fees paid by all carriers in proportion to their market share.
The Healthcare Bank, like the Federal Reserve, would report to Congress on a fixed schedule.
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11. Promote additional training for nurses (probably three year in-hospital programs) to rectify the present and predicted future severe nursing shortage. Nurses are the foundation of any health care system and will be especially needed as our population ages.
12. Require all hospitals to use an updated admission form, see Appendix, described in Recommendation 2.
Recommendation 2: A New Style of Hospital Admission Form While noble in their intent, Advance Directives have proven to be ineffective. Only about 20% of Americans have executed an advance directive and only about half of these have discussed their wishes with their physician. Without one, most hospitals and nursing homes assume that the patient wishes every conceivable means of medical therapy, even if inappropriate for that particular patient.
Another problem with advance directives is that it asks the person to make a decision about what type of care would be wanted at some time in the future.
However, one could not possibly know what the clinical situation will be at that time.
1. This new style of hospital admission form (Appendix 1), to be completed within a reasonable time frame after each hospital admission, would serve as a fresh and timely advance directive. Because admission to a hospital is an extremely stressful time for the patient and family, the medical team can facilitate the completion of an up-to-date advanced directive, helping the patient/family make rational decisions about which therapies are indicated and among them those that are not wanted. During the discussion about the form the physician can clarify the fact that only beneficial care can be administered. These discussions help create a mutual understanding between the patient/family and the medical team regarding a rational care plan based on medical knowledge adapted for that particular individual.
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2. The form would also create a timely appeal mechanism to resolve any disagreement between the patient/family and the medical team. The appeal team would consist of two doctors and a nurse, in effect an expanded peer review committee (see Recommendation 3).
3. Using this form would eliminate cardiopulmonary resuscitation (CPR) by default – that is performing CPR whether it would benefit the patient or not. CPR - the restarting of heartbeat and breathing - was first developed in the early 1960s, before Medicare, when the hospital patient population was much younger. So it was reasonable to be initiated automatically whenever there was a cardiac arrest because the patients had a more reasonable chance of survival and recovery. However, the hospital population is now much older and many are in an end-of-life situation.
Despite this change in demographics the custom still remains to attempt CPR automatically, even in patients with end-stage disease despite great discomfit to the dying patient. This occurs unless a specific order is written to avoid the procedure. The new admission form would correct this problem by making cardiopulmonary resuscitation an ordered event to be used in the appropriate circumstance. This would save many thousands of patients a great deal of discomfort and preserve billions of dollars of resources.
Recommendation 3: Expanded Peer Review Committees (two physicians & a nurse)
No healthcare system, universal or otherwise, can be efficient, cost effective, and truly serve the best interests of patients without peer review. That is - consistent, uniform, organized oversight by senior physicians and nurses with knowledge and experience in the practice of medicine and patient/family support. This would take the form of expanded peer review committees organized at the local and national level created through Congressional action through the recommended amendments to The Patient Self Determination Act, The Americans with Disabilities Act and the Emergency Medical & Labor Act described in Recommendation 1.
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Expanded peer review would be by medically trained professionals who understand the need to asses every situation based on its own individual characteristics. It will also be the key to addressing the issues that have made our healthcare system so dysfunctional. Issues like ICU and coronary artery stent overuse, inappropriate transferring of nursing home patients to hospitals even though they cannot benefit from hospital based care, and many other situations would be addressed by these peer review committees. Withholding care that is of no value is NOT rationing, but in reality is just the opposite. When resources are conserved and used wisely and appropriately, rationing will not be necessary, and every patient can be treated as a unique individual with unique needs without regard to cost.
Expanded peer review committees would be in every area in the country. These committees would have no financial affiliation with the various institutions. They would have the power to cease payment (after initial discussion) for care that offers no benefit to the patient, and mediate disagreements between admitting physicians and families over options for care.
These appointments would be salaried; therefore committee members would have no financial interest in their decisions (the basic flaw in managed care).
These salaries would be paid for by a consortium of all insurers through the Healthcare Bank.
A national committee also composed of senior physicians and nurses would oversee the entire system for the nation. National appointments would be similar to those of The Federal Reserve Bank. Local committee nominations would follow guidelines established by the national committee.
The peer review committees would ensure that the Congressional amendments to the above mentioned acts are indeed in effect and that national standards be created. This would alleviate the discrepancies in care so well documented by the Dartmouth Atlas of Healthcare.
Many physicians would object to the system, thinking that it would interfere with their autonomy and could threaten their income. Many others, however, would embrace it for three reasons:
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1. It would reintroduce the primacy of the patient-doctor relationship for all physicians. It would save more than enough resources so that we as a nation could provide universal coverage while simultaneously decreasing our total health care costs, thus greatly improving our economy.
2. It would provide support for the physicians who truly try to do their best for their patients, but now have to concern themselves with legal and economic issues.
3. It would rightfully place physicians at the core of healthcare reform to deal with excessive costs, lack of care for millions of our citizens, the public's dissatisfaction with the system and our less than stellar health outcomes compared to other developed nations.
Importantly, expanded peer review committees through their power to withhold payment for inappropriate care would send a powerful message that this sort of medical practice would no longer be acceptable. It would not take long before we saw a significant drop in billing for useless technological procedures and treatments. As a result, healthcare costs would plummet by billions of dollars.
Summary
These three reforms to our health care system – Congressional action inserting language in existing acts so that only medically reasonable treatments are delivered, creating a Healthcare Bank, a new style of hospital admission form, and a system of expanded peer review committees - would ensure excellent care for all our citizens while significantly lowering our health care costs.
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New Hospital Admission Form
Appropriate Care Hospital Admission Form
Name __________________________ Med. Record #___________________
D.O.B. _________________________ Date __________________________
1. Is Patient capable of decision making: Yes ( ) No ( ) If No, who is responsible? Next of Kin/ guardian: ___________________
phone________________
2. Cardiopulmonary Resuscitation (CPR) is ordered on this patient: Yes ( ) No ( ) Place the following restrictions on CPR. DO NOT DO THE FOLLOWING: ( ) intubation ( ) chest compression ( ) resuscitation drugs ( ) cardioversion 3. When thought to be in an end of life situation by the medical team, I want to receive palliative care and consider placement in hospice: Yes ( ) No ( ) If No, the appropriate care I want is: ________________________________________
5. Other therapies this patient has chosen to refuse even though medically indicated are: 5. Other Stipulations or Concerns:
This form serves as a guide for physicians to carry out the wishes of the patient. There is a hospital physician team responsible for oversight of appropriate care, whose goal is to help define beneficial care appropriate for the patient (the benefit to the patient significantly exceeds the risks). An expanded peer review care committee is available for the patient should conflict arise.
Physician Signature __________________________
Patient Signature ___________________________
Witness Signature ___________________________
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Section 3 – Essays from my Blog
This is a collection of essays from my blog,
www.drkennethfisher.blogspot.com divided into three parts. Part A and Part B
provide the reader insights into the fundamental problems with today’s health care system and the flaws in the new health care reform law, The Patient Protection and Affordable Care Act. Part C deals with what steps are necessary to create universal coverage for all Americans and importantly, at a cost that will improve not harm our national economy.
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Part A: Problems with Today’s System
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Can Medical Ethics Taken to the Extreme be Detrimental?
I believe it can. Here’s a recent example.
An 18-month old child with a rare and always fatal disease had been on life support in a Texas hospital for five months. The Texas physicians, with the agreement of the hospital ethics committee wanted to discontinue life support because the child had no chance of recovery. His death was imminent and certain.
Texas has a Futility Law that provides for a limited time period before the hospital, with the agreement of the ethics committee, can discontinue all but supportive care. His mother wanted life support continued and with the help of others, appealed to the courts to prevent the Texas Futility Law from being activated in this case. The child died before the judge’s final ruling.
Dr. Robert D. Truog, Professor of Medical Ethics and Anesthesia (pediatrics) Harvard Medical Schoo