Posts Tagged ‘healthcare reform’

The monthly newsletter came from my medical specialty society.  There was an article on how much doctors are being paid, pointing out that in 2009 doctors in my specialty experienced an increase in average income of between 7-12 percent, though specialists in general saw a decrease of about 4 percent.

In a down economy with a lot of people hurting and roughly 10 percent unemployment, doctors have been relatively spared from financial pain. As the deficit commission looks into ways to cut costs, reducing payments to doctors will be considered.  I suspect physician organizations will aggressively fight such cuts, pointing out that potential cuts in Medicare would hurt patients.

I don’t want to see patients hurt, but the patriotic side of me says that we doctors shouldn’t be completely spared from the effects of a down economy that is causing our patients to suffer.

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Make sure you check out the Getting Better Health Care Radio Program on webtalkradio.net. My latest interview is with Dr. Nancy Oriol, founder of the award winning Family Van program in Boston. She tells us about the barriers to accessing our health care system and how reaching out to the community can help reduce those barriers.

Want to reduce your health care costs? Don’t miss my interview with Dr. Cynthia Koelker, author of 101 Ways to Save Money on Healthcare.   She tells us how we can save money on preventive care, including information on which screening tests we need and which we don’t.

The previous show with David Coates talks about the politics of making needed changes in our health care system.

Another show not to be missed is the interview with Dr. Sandra Kweder, Deputy Director of the Office of New Drugs in the FDA’s Center for Drug Evaluation and Research.  She explains what the FDA does to assure that marketed drug products are effective and safe.

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Doctor patient communication

The Archives of Internal Medicine reports that communication between doctors and patients isn’t always what it should be.  The study of 89 hospitalized patients found:

  • Of the 73% of patients who thought there was 1 main physician, only 18% could name the physician
  • Only 67% of the physicians thought patients knew their names
  • Only 57% of patients knew their diagnosis
  • Only 21% of physicians said they always provided explanations of some kind
  • 90% of patients getting a new medication said they were never told about any side effects

The researchers concluded that steps to improve patient-physician communication should be identified and implemented.  Boy, is that an understatement!

To start, perhaps doctors could leave each patient a business card with the doctor’s name on the card.  That would help patients know their doctors’ names.  Even better, have a line on the card where the diagnosis could be written.  I’d include the doctor’s cell phone and e-mail address to help enhance communication between the doctor and the patient and their family.  And perhaps the doctor ought to have a checklist of things to do so that whenever a new prescription is given, the patient is given a written explanation about the medication, including the potential side effects to look out for.

Of course it would help for every patient to be given the opportunity to give their doctor feedback through a system like www.DrScore.com to identify these kinds of problems and solutions to them ASAP.  A “Please give me feedback at http://www.DrScore.com” would be a nice addition to that business card.

We are so invested in improving medical care, with billions and billions of dollars going to the development of new treatments that may someday help someone.  Just a little common sense and some inexpensive solutions could be done right now to enhance the care that most patients receive.

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Campaign finance legislation failed to pass the Senate today.  Last year, U.S. Senators Chuck Grassley (R-IA) and Herb Kohl (D-WI) introduced legislation to require drug companies to publicly report money they give to doctors over $100 every year.

This is a wonderful idea. Greater transparency helps everyone.  At DrScore, this is a focus of our beliefs about U.S. medicine. Doctors have nothing to fear and much to gain from transparency, whether we talk about patient satisfaction scores or pharmaceutical company support. The last thing we doctors need to do is to raise suspicions by fighting efforts to improve transparency.

In fact, physicians should lead the way in support of more transparency.  Not only should we be supporting the Grassley/Kohl measure, but  we should encourage Congress to expand the measure to include payments to politicians and their campaign funds.  Senator Grassley hit the nail on the head when he said, “The goal of our legislation is to lay it all out, make the information available for everyone to see, and let people make their own judgments about what the relationships mean or don’t mean.  If something’s wrong, then exposure will help to correct it.  Like Justice Brandeis said almost a century ago, ‘sunshine is the best disinfectant.’”

This applies to both physicians and politicians.  I hope we find that politicians are as ethical as physicians are.  If so, the public will be well served.

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On Getting Better Health Care, physician Cynthia Koelker, M.D., describes practical ways people can lower their health care costs right now.

Koelker is author of the book 101 Ways to Save Money on Health Care.

We don’t need government to legislate health care reform to lower costs if we take some personal responsibility. Click here to listen to the show.

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I was invited by a small group of medical students to speak to them about “managed care.” This group of students meets regularly for discussions of general topics. They kept hearing about managed care and about health care reform, and they felt like they didn’t understand any of it.

I hope I didn’t commit a sin talking to naïve medical students about the business of medicine so early in their training. This is normally a time that their heads are stuffed with facts about biochemistry, physiology, pathology and microbiology, not practical stuff like the vagaries of our insurance system.

The students had identified a very nice article about managed care and its many variations for us to discuss (Sekhri NK. Managed care: the US experience. Bull World Health Organ. 2000;78(6):830-44). My favorite line in that paper was ‘‘if you have seen one managed care plan, you have seen one managed care.” The complications of the payment systems for health care are extraordinary.

With the people of Massachusetts sounding a resounding “No!” for the current health care reform plans, it’s clear something different, something for which there is greater consensus, is needed.

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The U.S. Preventive Services Task Force (USPSTF) — a quasi-governmental, independent panel of experts in primary care and prevention charged with systematically reviewing the evidence of effectiveness and developing recommendations for preventive health services — just created a whole lot of hoopla by changing their mammography screening recommendations. They made the changes in an environment politically charged by the ongoing health care reform debate and raised the ire of some patient advocates.

The USPSTF is a trustworthy, conservative body that focuses on evidence, not politics. However, the decisions the USPSTF makes, certainly in this case, can have massive political implications. As a researcher who once studied the health screening and prevention needs of patients, I used the venerated guidelines set by the USPSTF as the criterion for assessing these needs. As a dermatologist, I’m familiar with USPSTF recommendations largely because of what they DON’T recommend: skin cancer screening.

Among dermatologists — doctors who see skin cancer every day — there is widespread support for skin cancer screening. The USPSTF, which focuses on scientific evidence, sees no proven net benefit and does not recommend routine skin cancer screening, much to the chagrin of most dermatologists. However, I trust their judgment. The USPSTF doesn’t support politically expedient skin cancer screening, because the evidence to support routine skin cancer screening is lacking.

The USPSTF has my trust, but many others don’t share that view. Listening to the debate over the change in mammography screening recommendations, I hear emotional and quasi-scientific rants about the horrors of the new mammography recommendation and how the lives of women are being totally discounted by the Task Force. I’m sure the Task Force carefully considered those lives. The specific evidence for how many lives are saved by routine mammography screening for women in the 40-50 year age range is roughly one life saved for every 2,000 women screened. And I am sure the USPSTF weighed that benefit against the risks of screening. What are those risks of screening? There are false positive tests that can result in morbidity and scarring from the resulting biopsies, as well as a profound emotional toll brought on by being told, “you have an abnormal mammogram.”

Those who view the changed USPSTF mammography screening recommendation through the lens of the health care reform debate magnify the noise surrounding the scientific controversy with allegations that a quasi-governmental body is deciding the future of women’s health and making recommendations to ration care away from women while callously ignoring the lives of our mothers, sisters and daughters who will die needlessly. They say this proves that the last thing we need now is more government involvement in American health care. I’m not so paranoid.

The Task Force didn’t ignore women’s lives. On the contrary, it carefully weighed the risks and benefits to women. The Task Force didn’t ration care. On the contrary, while the Task Force didn’t recommend routine mammography for women in their 40s, the Task Force did recommend that the decision to have mammography “should be an individual one and take into account patient context, including the patient’s values regarding specific benefits and harms.”

And that, to my ear, is a good thing. Patients should be empowered to make individual decisions based on the best evidence and on their own unique situations and preferences. The concept of patient-centered care and greater involvement of patients in their own health care underlies both the USPSTF recommendations and everything that I have advocated about patient satisfaction and feedback through DrScore.com.

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One of the great ironies of our health care system are copayment assistance programs.  Such programs seem like a wonderful way to help patients obtain access to modern medical treatments.  But as was pointed out in NPR’s This American Life show on health care reform, there’s a “dark side” to these programs.

Here’s how they work. Let’s say a company comes out with a new drug, and they set a price of $800 for a month’s supply. The insurer may cover much of the cost of the drug,  but because the drug is so much more expensive than other options, the insurer puts the drug on “tier 3,” requiring patients to pay 20 percent of the cost. In this example, that’s $160 per month, nearly $2,000 per year, which is a considerable sum of money. Some patients either can’t or won’t pay that much, so to help patients get better access to the drug, the company may offer a rebate or coupon program that cuts the cost of the co-payment from $160 to something far more affordable, perhaps just $10 or $20/month.

This sounds like a great way to help patients, but unfortunately, it is also a great way to game the system and keep the costs of drugs high. The purpose of co-payments is to create some incentive for patients to choose a lower cost product, but the co-payment assistance cards insulate patients from the cost of the drug, so they may choose the higher priced drug even though its benefits may be marginal in relation to the much higher cost. This allows the drug company to continue charging the insurer a very high price, and there is little pressure from the patient to provide lower costs drugs.

Insurers ask patients to pay for a part of the cost in order that patients consider the financial cost of using the biologic. If drug companies are permitted to eliminate the co-payment that insurers have in place, the drug company no longer has to compete on price.

A similar phenomenon happens when doctors see patients without charging co-payments for the visits. The doctor may feel that they are just being nice to patients by not charging the co-payment. But these co-payments have a central place in helping regulate patients’ use of doctors’ services. Doctors can reasonably see a patient without charging the patient (or the insurer) anything if the doctor wants to help the patient out. Taking payments from insurers without trying to collect the co-payment is somewhat dubious and sometimes illegal.

Years ago, while still in training, I went to see a dentist for a regular check-up and to address a minor problem. It was a very rainy day, and I was able to get in right away due to a cancellation. Understanding that I was a student, the dentist offered me a very reasonable, low price for his services. Upon finding out that I was insured, he said I didn’t need to worry about the bill at all, and that he would happily take care of everything directly with the insurer. Almost certainly, he billed the insurer far more than he offered to bill me directly. Insurance doesn’t just insulate the purchasers of services from the cost of the service; the doctors who provide the service have little compunction about charging unseen, third party insurance corporations whatever the doctor can, while many doctors wouldn’t directly charge the patient such a high price.

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National Public Radio’s “This American Life” is a wonderful program, and I was excited to see that they were going to cover health care reform in two episodes. I downloaded them as podcasts — you can too at http://www.thisamericanlife.org/Radio_Archive.aspx, episodes 391 and 392.  

Last Saturday, I finally had a chance to listen to Part Two while driving home from a medical meeting. This episode of “This American Life” provides the clearest and most rational explanation of the high cost of health care that I’ve heard on any medium. The show was well balanced toward insurance companies, doctors and drug companies, yet it made clear how our system is screwed up and how it got that way.  If you get the chance, listen to this program. You will come away better educated on the whole debate.

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