Like at least tens of other Americans, I spent virtually the entire day today listening carefully to what might be billed as The Great Bi-Partisan Healthcare Summit of 2010. Calling this leadership discussion a “summit” is particularly apt; there seems little doubt that the tone and nature of political discourse will now head straight downhill. My own suspicion is that it’ll reach the bottom faster than any skier at the Winter Olympics in Vancouver.
CNN, Fox and The Daily Show will rehash the main talking points of the two parties ad nauseum over the next day or two, so I will restrict my own comments to a few things that seemed particularly interesting or noteworthy.(see Note 1) Most of these will are bound to be glossed over in the regular media.
1. In a summit that was supposed to be all about bi-partisanship, commonality, and/or suggested “compromise by starting over”, the President (and everyone else in the room) completely ignored the fact that one person there had already drafted a bi-partisan bill: Senator Ron Wyden (D-Oregon). Co-drafted with Senator Robert Bennett (R-Utah), the Wyden-Bennett “Healthy Americans Act”, was scored by the Congressional Budget Office and Joint Committee on Taxation as being “roughly budget neutral in 2014”. Along the way it would provide private health insurance coverage for 99% of Americans, eliminate the headache and inefficiency of having health insurance coverage tied to employment, establish basic levels of coverage based upon benchmarks already present in the private sector, and allow complete portability of healthcare coverage. But apparently it wasn’t worth talking about.
While Senator Wyden was in the room for the entire time, you wouldn’t have known it unless you stayed for the last few minutes of actual discussion. He was allowed to speak for roughly five minutes, and merely suggested that he had some bipartisan ”ideas” that he’d be talking with attendees about in private after the meeting.
In a meeting where the Democrats are calling for “immediate action” and the Republicans are asking for a new approach based upon private-sector insurance, it ranks somewhere between shameful and criminal that no one breathed a word regarding the very existence of this alternative legislation. Despite its impressively bi-partisan origins, in July of 2009 President Obama refused to support the proposal, calling it too “radical” for the country. That alone should make the Republicans want to bring it up, if only to criticize the President’s lack of leadership. The least that everyone could have done is talked about whether anyone thought that it might be a viable alternative to the overstuffed legilsation already on the table.
2. In roughly the middle of the discussion, Senator Kent Conrad brought up an interesting statistic about the utilization of Medicare services. He noted that about 5% of Medicare beneficiaries account for nearly half of all Medicare expenditures – a percentage demonstrated by the figure below. Most of these individuals have one or more chronic diseases, are on multiple medications and are probably seeing a variety of primary and specialty care providers. Senator Conrad’s point was that this high incidence of cost and “polypharmacy” illustrated the need for “providers to better coordinate their care”.
This graph is taken from this CBO publication.
When government legislators and regulators talk about “coordinated care” in the United States, it’s generally a code phrase for second-guessing providers, cooking up more “guidelines of care”, and then punishing doctors when those bureaucratic guidelines are not followed. But with this much money at stake, I have a simple suggestion that I do not think has yet been proposed or systematically implemented nationwide. (To tell the truth, I can’t vouch for the fact that it’s never been discussed before. But if it has not already been tried, I hereby humbly offer the idea to the Federal government of the United States of America in exchange for only one-tenth of one percent of any savings that might be derived from its use.)
With only 10% of the beneficiary population generating a full 61.5% of all Medicare costs, it should be a relatively simple to identify the vast majority of these patients by statistical analysis. They will for example, probably fall into a certain age range, have one or more chronic conditions, be prescribed multiple medications and so on. The care of such patients typically takes an enormous amount of time and effort to manage successfully. Because the Federal government’s complex, expensive and poorly conceived method of payment does not tend to reward doctors for taking their time, nor for thinking about how a given patient might be better managed, most doctors cannot afford to see many of these patients.(see Note 2) If they do, they must either give them short shrift, go broke, or work like animals seeing hundreds of other patients in order to make up the financial deficit. It shouldn’t the slightest bit surprising that many, if not most, primary care providers and specialists have a difficult time coordinating care and caring for these folks.
Since this is the case, instead of turning the entire healthcare system upside down with elaborate Federal programs, why not implement a far simpler solution that does not appear in the President’s health plan? Carve out this population and have them assigned to the care of a relatively small number of “complex Medicare patient” specialists. Since most people are already familiar with the idea of intensive care specialists in hospitals, I’ll call them “outpatient intensive care doctors”. These would be ordinary physicians trained in internal medicine (since virtually all of the patients will be elderly), but whose entire practice would consist of complex Medicare patients. Regular medical practices would be required to refer all patients meeting the “Medicare complex patient criteria” to an outpatient intensive care practice.
Virtually all of patient visits with outpatient intensivists would be longer than average and billable with a high level of complexity. This will allow these doctors to survive financially. This is in marked contrast to their high volume colleagues who have to take on complex cases in addition to twenty other patients each day. The outpatient intensivist’s primary mission is to minimize the number of complications for patients under their care, and ensure that their care is highly monitored and coordinated. They are free to refer to any specialist and obtain any tests and consultations that their judgment may deem necessary.
If the use of outpatient intensivists can’t reduce the cost associated with the top 10% of costly Medicare patients, it’s a good bet that nothing can without of overt rationing. In that case we should quit kidding ourselves about the utility of “guidelines”, “pay-for-performance” and similar gimmicks, and simply get out our wallets and resource rationing coupons.
3. Perhaps the most amusing moment of the meeting took place when physician and Senator Tom Coburn (R-OK) brought up the topic of finding and punishing truly fraudulent Medicare providers. This is something you’d think that this topic would be old hat to the Democratic summiteers. The President’s initiative proposes no less than fourteen new government programs and initiatives to “crack down on waste, fraud and abuse”. The Senate original reform bill itself refers to “fraud” some 85 times as reported here. In contrast, Mr. Coburn suggested a supremely simple intervention: using undercover Medicare agents as “undercover patients”. These “patients” would be in an ideal position to know if suspected fraudulent providers are mis-using their Medicare coverage, offering kick-backs, selling defective equipment or otherwise engaging in truly criminal activity.
The immediate response of the President and other Democrats to this simple proposal was that of utter surprise. It was obvious that no one had ever suggested such a thing to them before – despite the fact that they had just spent over a year acquiring expertise on fixing healthcare and “carefully listening to Republican proposals”. It’s not often that one gets to see the most powerful leader in the free world flummoxed by such a simple and (probably) inexpensive, highly effective concept.
4. There is one final topic of interest I’ll comment upon, given that this nationally broadcast session was supposed to give Americans “the story” as presented by each side. It was supposed to allow them to decide which, if either, side was more compelling.
These were the incidents in which the supposed “facts” presented by each side were in dispute. The first time was between the President and Senator Lamar Alexander (R-TN). These two gentlemen spent some time arguing about whether the Congressional Budget Office (CBO) had said that the Democratic plan would raise private insurance premiums, or lower them. The second time was when Representative Paul Ryan (R-WI) quoted a truly impressive array of CBOish figures which (he said) demonstrated that the Democratic healthcare proposals utilized so much accounting sleight-of-hand that it amounted to a Ponzi scheme. This was immediately contradicted by one of the Democratic representatives present, who was also supposedly referring to the CBO “gold standard”.
I will readily admit that I am not an expert on the CBO’s reports and government accounting. I doubt that most people are. However if our Leaders are going to get together for a seven hour nationally televised meeting and claim to use CBO reports to call each other liars, can’t they bring a referee? How much trouble could it possibly be to whip out a cell phone, call the CBO and ask them to send someone over to tell the American public who’s right? Do our nation’s highest elected officials wish to remain ignorant and uninformed about the financial realities of American healthcare and their own “reform” proposals forever?
Hmmm. I was afraid of that. This is why we’re on the road to Hellth.
There are lots of other ways in which the cost of American healthcare can easily be reduced by hundreds of billions of dollars each year. I have discussed many of them in my book, “Overhauling the Healthcare Machine”, and will touch on more of them in future posts.
I think that it goes without saying that none of our Leaders mentioned any of them. I seriously doubt that they either know of them, or have given them any thought whatesoever.
Note 1: As pointed out in my last post, this summit will be the major healthcare headline only until this coming Monday. At that point I predict that virtually all of the media’s attention will be devoted to the “Crisis in Medicare”, as the 21% reduction in gross Medicare compensation to physicians takes effect. A rational economic entities, doctors and clinics will be forced to turn away or delay scheduling Medicare patients because it costs more to see than healthcare providers will receive in compensation. The resulting chaos and media circus will result in many calls for “immediate action” on the Presidents’ healthcare reform proposal to resolve this healthcare emergency.
Note 2: The method of calculating what healthcare providers in the United States are paid for their services is called the “resource-based relative value system”, or “RBRVS” for short. Have no fear – this monstrosity will be the subject of future posts, as it figures prominently in wasting huge amounts of time and money for patients, taxpayers and healthcare providers alike.