April 17, 2010

Healthcare Reform: What does it mean for you?

It’s been several weeks since the passage of healthcare bill and the dust has not even remotely begun to settle.  The rancorous debate is over.  What’s left now is to figure out what it will do to and for the American system of health care.  It has been said over and over by talking heads on TV that the American health system as we know it is gone.  I am afraid that is true, for better or for worse.  The effects will not all be immediate but they will be huge.

Whether or not you think the bill is good, bad or ulgy depends on where you sit now in your healthcare situation.  If you are already on some sort of state or federal program that costs you nothing, then not much has changed for you.  If you are employed and have employer based insurance, or retired with the same type of insurance, your costs or your employer’s costs are going to go up. If you work but either do not have insurance from your employer or cannot afford to buy insurance, then you are in luck as you will have the opportunity to get insurance cheaper than you could before.  If you are in a medicare advantage program, your plan is going to be squeezed financially rather significantly and ultimately you will feel it either in the pocketbook or your services covered or both.  If you are 26 or younger and did not have insurance, you can now be covered under your parent’s policy up to age 26.  If you are an employer of 50 people or more, you are in big trouble as the bill is going to be huge for health insurance.  Know this, there is no such thing as FREE HEALTHCARE under this new bill.  It will cost something to someone somewhere.

To try to help put a finer point on all this, let’s go through some of what we do know.  What we don’t know now, we won’t know until the chips fall.  In any government program this big, the law of unintended consequences will be significant in nature and extent.  It put a smile on my face when I learned that congress passed a bill that takes away some of their own health benefits.[i]  Obviously they had no idea what they were voting on or they would have taken that part out, or at least enhanced it for themselves. 

So, without further adieu, what do we know?

1.       Up to 32 million people who do not have insurance will now have options they didn’t have before.[ii] So what does that mean?  Those 32 million are comprised of three basic groups[iii].  Many of these benefits may not kick in for several years.

a.       Group one are those who are unable to afford insurance due to cost or due to previously existing conditions, or who once they developed an issue, were then tossed out of the plan due to high usage or meeting lifetime caps.  In general their health problems have worsened over the years due to neglect.  Once they have insurance they will want to use it and will require significant resources to correct those problems

b.       Group two are those who require subsidies in order to afford insurance.  This group tends to have a lot of health issues as well.

c.       The third group is the generally young and healthy who have made an economic decision not to purchase insurance coverage.

                                                               i.      Of those 3 large groups, two of them will need significant health interventions.

                                                             ii.      The above measures will raise the percentage of covered people from 83% to 95%[iv], at a cost of nearly $1 trillion, that’s with a “T”.  Does anyone even know what a trillion is? Take a look at this link for an illustration of it… http://www.pagetutor.com/trillion/index.html

2.       Dependent children will be able to remain on their parents until age 26, unless they have employer related insurance.  No reference needed, common knowledge. Begins in 6 months or so.

3.       You cannot be denied insurance because of prior conditions and no more waiting periods until benefits kick in. Additionally, you cannot be booted due to health claims, AND there is no lifetime limit to what the insurance company has to spend on your care.[v]  Many of these items do not kick in until 2014.

4.       Childrens coverage under Medicaid is being expanded.[vi] To review fiscal issues ignored by congress for this, see this footnote. [vii]

5.       The famous medicare pastry product, otherwise known as the “donut hole”, is going to begin shrinking.  I believe the hole is $2500 deep, and this year the feds will send you a check for $250 to help with that.  By the time we get to 2020 the donut hole will be gone, eaten up by the black hole known as the federal government. [viii]

6.       Insurance exchanges, whatever that is, will be set up for those who cannot afford insurance, and subsidies will be given depending on income and family size.

As you can see, many of these reforms look rather appetizing to the individual.  The bigger issues being debated now revolve around paying for all this.  The CBO (congressional budget office) takes a different view than does either congress or the White House on the estimates on costs of healthcare reform.[ix]

At this point I would like to leave the debate as to how this will shake out to the pundits, policy wonks and economists in Washington, DC.  Truthfully I don’t think anyone really knows, outside of God Almighty, how this is going to shake out. 

Now, if you will permit, I’d like to give you my perspective on all this.  If you like you can stop reading here and read all the references I have included below, and spend some time sorting out for yourself what you think it means.  I have been asked numerous times in the last several weeks what I make of all this. So here goes.  Keep in mind this now evolves into an opinion piece.  Feel free to disagree, even vehemently, but please be nice about it. 

I believe that the US has the greatest health care system in the world.  Where is it that sick children from other countries with life threatening conditions go for treatment? Where do heads of state from elsewhere go for treatment of serious illness? Rhetorical questions all, with the obvious answer being the USA.  Do we have issues that need addressing? Absolutely. I don’t think we need to throw the baby out with the bath water, but I am afraid that is what we may have done. 

Adding 32 million healthcare consumers into a system without increasing the supply of doctors is going to cause supply and demand problems. [x] [xi] Note that the references for this are several years old, before anyone knew that healthcare reform was coming.  Do not misunderstand me, many of those 32 million need healthcare. They do get it in emergency situations as it is illegal for hospital emergency rooms to refuse care due to finances.  Nor do doctors turn people away in true emergencies for financial reasons. 

Adding 32 million to an underserved nation is akin to putting The Country Lunchbox in downtown Seattle and asking them to fix lunch for all of Seattle.  They can fix lunch, they can serve to their capacity, but if you want lunch in Seattle, you are going to have to wait.  Your turn will eventually come, but you may be a bit hungry in the meantime. 

Primary care medicine is in a shortage situation for many reasons. The American Medical Assoc. and the  Council on Graduate Medical Education have been screwing up estimates for physician needs for the last 100 years. Currently the American health system rewards doctors who do procedures over doctors who think without doing procedures.   Specialists do think, but their financial rewards come from the procedures they perform.  As a result of significant education debt, most medical school graduates migrate to the higher paying specialties.  Primary care is at the bottom of the financial rung, and some specialists can make two to five times what primary care makes.  So if you come out of medical school with $100,000 in debt or more, which is not uncommon, you are going to want to make more money in order to pay that off.  I am digressing a bit, but wanted to give you some perspective.  Personally I love primary care, but I do wish the feds and insurance companies valued what I do a bit more.

As a result of this primary care shortage, people are going to see some real consequences. With the influx of new patients needing care and now armed with the insurance to help them out, everyone is going to have to wait longer to get appointments.  Primary care docs like me will do our best to accommodate the needs, but in order to maintain sanity we will only be able to see so many people in a day and still have some energy to go home and engage our families.

I predict several things may happen as a result of all this.  It will become harder and harder to find a primary care doctor that will accept you as a patient.  That is a reality right now. It may become harder as the feds and states lower reimbursement for primary care.  The cost of delivering primary care is increasing for many reasons.  This will drive many private primary care doctors out of private practice.  This will cause many private offices to close.  Those doctors will either relocate somewhere else where you aren’t, or they will become employed by hospitals or larger physician organizations.  Additionally, as the shortage worsens, community health centers, like Valley View Health Center, will most likely become larger and larger in their own efforts to meet the increased needs.  Or, your doctor may opt out of insurance altogether and operate on a cash basis only.

Your “doctor” may turn out to be a nurse or physician assistant.  Nurse practioners and physician assistants are playing a greater role in the delivery of primary care.   These healthcare providers are also known as “midlevel” providers.  They can do an excellent job with most issues, but their training is nowhere near that of primary care physicians.  This is not sour grapes, it’s just the reality.   Nurse practitioners, particularly, would likely object to that statement, but seven years of training does not equal eleven years of training. And keep in mind this is an opinion piece. I have worked with a physician assistant for the past 14 years and would not have been able to deliver the care we have at Riffe Medical Center, Inc. without Ann Morgan, PA-C.  She is nothing short of fantastic.

The feds and states are going to struggle to provide what the health reform bill has promised.  Preventive care is going to become a priority now that someone is willing to pay for it.  By the way, that “someone” is you, the taxpayer.  Medical knowledge is rapidly advancing, and with each advance, Americans want to take advantage of the new technology. New technology is expensive.  There will come a day when rationing will occur.  Oregon has been doing that for years.  It goes on to some degree now in the form of “prior authorizations” which is the insurance company’s effort to make it harder for you to get the fancy MRI you want.  It will be available, but may only be available if you have the means to pay for it out of pocket.

Which leads us to another issue.  When resources become strained and there is not enough money to fund the mandates, health care will devolve into care for the haves and for the have nots. The have nots will be left to the community clinics, the hospital owned clinics, and perhaps some large physician organizations.  The haves will go to doctors who specifically cater to those who can pay for the personalized care and for the extended amount of time those doctors can give you.  In the have not system, doctors, and midlevels, will be vastly overworked, and unfortunately the quality of health care will likely suffer.  When there is not enough money to pay for our current levels of care, we will become like the Canadian system with long wait times for surgery, etc.   What we take for granted now will become a thing of the past.  Immediate referrals to specialists for your urgent condition will have to be dealt with in other manners.  The MRI for your knee may have to wait. Subsequently, possible surgery will have to wait as well.  You can live with your knee problems, it’s not life threatening, but the days of quick fixes may be gone.

So what can you do about this? If it hasn’t become obvious by now, YOU need to take control of YOUR health.  There will soon come a day when doctors are paid according to how healthy their patients are.  When that day comes, your doctor may decide to drop you as a patient because you are noncompliant with his or her suggestions for your health, and as a result he or she is penalized financially for your bad health.  Now is the time to take your health conditions seriously.  Now is the time to realize that you may pay a higher insurance premium because you smoke, or you are overweight, or you have diabetes, or your cholesterol is too high due to your eating habits or any number of other vices you may have.  If the money to take care of you is limited in the future, anything you can do now to improve your health status is going to benefit you.  Of course, those measures will benefit you in any scenario, but if you don’t deal with them now, you may be penalized financially later for not taking care of it.

With the huge influx of new patients flooding into the system, how and where health care is delivered will change.  Currently the routine is that an issue pops up and you call your doctor and make an appointment and you are seen in the office. In the future you may have a virtual online visit, or a phone visit, or a phone visit with a nurse, or perhaps your insurance will have a panel of nurses you can call for advice without seeing or consulting your doctor.  You may not be able to get in to be seen, but you will have some contact with the healthcare system.  (At this point, I’d like to pause for some shameless self-promotion.  Not many of you have taken advantage of Riffe Medical Center, Inc’s capability for online virtual office visits.  We have offered these for several years now at www.riffemedicalcenter.com .  It costs $40 on a credit card and can save you an office visit which may reduce the need to miss school or work.  This is acceptable for many minor problems, such as bladder infections, minor skin rashes, colds, sinusitis, bronchitis, etc.  This is NOT acceptable for abdominal pain or chest pain or impending death or other urgent situations.  So, check it out and give it a try.  End of shameless self-promotion. Your insurance may or may not reimburse you.)

Much has been written in the national medical press about the idea of a “Medical Home”.  The idea is that your family doctor coordinates all your care, ensures you have access to emergency care, etc etc.  I thought that’s what I have been doing all along, but apparently not. In the medical home scenario, you also have access to diabetes counseling, nutritional counseling, chronic disease coordination, etc etc. all under one roof. This is a nice idea, but it costs lots of money to hire all the staff.  There was one study that spent $1.8 million dollars to implement a medical home.  At the end of the year and a half study, they were thrilled to report that their vaccination rate for the pneumonia shot rocketed from 35% to 45%.  Woo hoo!  $1.8 mill for an additional 300 pneumonia shots.  I am sorry but I don’t have a reference for you, so you’ll have to take my word for it. Give me half that money and I can increase the vaccine rate quite a bit more than that.

The cost of health care is ridiculously high.  Medical bills are one of the leading causes of bankruptcy.[xii]  Most people think that doctors take most of the money spent in the US, but physician fees only constitute about 21% of all costs.  Hospitals take up 30%, medicines 10% and the rest split among other things. [xiii]   As a nation we spend about $2.3 TRILLION on healthcare (our economy is a $13 trillion dollar engine, or was before the recession/depression). Stunning I know, see the link as to what a trillion dollars is. The vast majority of that is spent on the last 6 months of life.  As money dwindles to care for increasing numbers of people, rationing will kick in, make no mistake.