Micro-Practice

A new kind of clinician is emerging in America. One whose practice is smaller, higher-tech, and more under the control of the physician than health plans. The Washington Post explains:

The waiting room of Ramona Seidel's family medicine practice is empty, and she works hard to keep it that way.

After several years in a traditional suburban group practice that blended pediatrics and family medicine, Seidel quit to start her own micro-practice in Annapolis: a low-overhead, high-tech office that gives her more control over how she treats patients and more time to spend with them. She's happier. Her patients are happier. And she's pretty convinced they are healthier having a physician who knows them well.

The micro-practice model is being advocated for by the Institute for Health Improvement, which states that a successful micro-practice will "(1) have as its primary purpose a focus on the patient—a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement of care—a commitment to process improvement; and (3) routinely measure its patterns of performance, 'feed back' the data, and make changes based on the data."

There are clear upsides for the patient and the physician with this model. But with a shrinking supply of primary care physicians it may not take off as quickly as some would like. Still, it's a move in the more compassionate direction.

How it Works for the Underinsured

Part IV in Trudy Lieberman's series on how the health reform platforms of the Presidential candidates will work for Americans published today in the Columbia Journalism Review.

Today, we follow the story of Kevin Smith, who is insured through his wife's employer, Arkansas State University. The Smiths (Kevin, his wife, and four kids) have an 80/20 health plan (insurance pays 80%; the family covers the other 20%). He and his family are considered underinsured - meaning their health insurance doesn't cover all of their needed care. They have accumulated about $7,000 of medical debt in the past year.

How would they fare under the candidates' plans?

Under McCain's Plan
McCain’s health proposals are geared toward encouraging employers like Arkansas State University to drop health insurance for their employees and encourage them to use tax credits to buy policies in the individual market. McCain would also require those with employer-based insurance to pay income taxes on the value of those benefits, perhaps another inducement to move into the individual market. For starters, though, Smith’s asthma most likely makes him uninsurable if he buys on his own.

Assuming he could qualify medically, a comparable family policy currently sold by Arkansas Blue Cross Blue Shield costs about $5800. If he used the $5000 credit to buy such a policy, he might pay only $800 in premiums and save some money this year. Since this policy, like the one from Arkansas State, requires 20 percent coinsurance, he would still find himself with out-of-pocket expenses and a stack of bills. The under-insurance problem would not disappear, and down the road, there are other risks of switching. As Smith and his wife get older, the $5000 credit buys less coverage because premiums in the individual market increase with a person’s age. They could end up paying far more in premiums than if they stayed with their employer plan.

Under Obama's Plan
Because Obama’s proposals are so vague, it’s hard to say whether the Smiths would benefit. Early on, Obama said that his proposed public plan would be available to small businesses and individuals without access to employer-based coverage or public plans. That seems to indicate he wouldn’t be eligible for any kind of new public insurance option like those being promoted by Obama surrogates; that is, barring some huge legislative breakthrough that lets everyone buy into a Medicare-like plan that might offer cheaper premiums and comprehensive benefits—in short, a better deal than private insurance, whether provided by employers or bought individually.

On the trail, Obama has promised that he has the secret sauce to lower insurance premiums by $2500 for a typical family. That implies his proposed cost control measures—health IT, requiring hospitals to publicly report on costs and quality, and better management of chronic conditions—will actually keep medical costs from rising.

So, they'll most likely stay uninsured.

Harry and Louise are Back

The ad campaign that sank the Clinton health care plan is back - this time in favor of reform.

http://www.harryandlouisereturn.com/

We'll keep blogging about health reform. Send us your comments, or tell us your story by emailing us.

Healthcare and the Election

Part III in the health care reform series featured in the Columbia Journalism Review published today. Reporter Judy Lieberman introduces us to Annette Murph, 54, who cannot work due to medical problems and so cannot afford health care insurance. "What irony!" Lieberman writes of Murph's situation. "The American way of health care forces those with serious medical problems to battle an inhospitable system that, at times, seems designed to keep them from getting care rather than meeting their medical needs."

Here is a summary of the medical situation facing Annette Murph:

• She got high blood pressure and arthritis when she was 28—from her mother and grandmother.
• Nine years ago, doctors diagnosed diabetes—her parents, cousins, and uncles all had the disease.
• Her thyroid gland is abnormal, and she has had two heart attacks; two first cousins died young from heart attacks.
• Two years ago she underwent knee replacement surgery (which was unsuccessful), and can no longer work as a buffet attendant at one of the casinos that line the Mississippi River not far from her home.

Her financial situation isn't much better:

• Since she left her job, she has accumulated over $15,000 in unpaid medical bills.
• Although Social Security disability payments qualify her for Medicare, there is a two-year wait for coverage, and she still has six months to go.
• She can't  get continuous coverage under Medicaid because her $758 monthly income is too high. In Arkansas, a single person can make no more than $108.33 a month to qualify for that program.
• Murph turned to Medicaid’s program for the medically needy—less than ideal for someone who needs regular care. Every three months she must re-qualify for coverage. If she doesn’t qualify again, she pays her bills out of pocket.

Ok, so how does she fare under the Presidential candidates' health plans, especially given that the candidates aren't talking much about people like Annette who fall through the cracks? According to Lieberman:

Under McCain's Plan
McCain’s $2500 tax credit to buy a policy wouldn’t do Murph much good: she lacks the money to pay for the rest of the premium, and she wouldn’t qualify anyway. No carrier would take her on. She wouldn’t qualify for his still-vague guaranteed access plan, but it probably wouldn’t help her either. She would be unable to pay the inevitably high premiums, and she wouldn’t qualify for subsidies since she already qualifies for Medicare and Medicaid. Getting benefits from those programs often disqualifies people from state high risk pools, and the McCain proposal might work the same way. In sum, his plan wouldn’t hurt her but it wouldn’t help much, either.

Under Obama’s Plan
Obama and his surrogates have pushed a strategy that builds on the preexisting “public-private partnership”—citizens can get coverage from an employer, buy their own, or go to a public program. Murph is already in the public part, which would probably make her ineligible for his proposed public program for people without access to employer coverage or other public programs. ... Obama calls for expanding Medicaid, a move that could help her get continuous benefits while avoiding the onerous “spend down” process. But an expansion would take lots of money from both the federal and state governments, and state Medicaid budgets are perennially tight. The test of Obama’s commitment to greater coverage will come in the expansion of federal programs, while maybe even compressing the waiting period for Medicare for those getting Social Security disability payments. If the public programs don’t expand to catch more people or make things easier for those already enrolled, those like Annette Murph will still be in the same fix.

What do the Candidates' Plans Mean for You?

Though there has been plenty of reporting about the Presidential candidates' health reform plans, how much do we really understand about what the John McCain or Barack Obama plans will mean for individuals and families? Making it clear is a mantle taken up by Columbia Journalism Review reporter Trudy Lieberman, who has begun a series looking at real people and the candidates' plans:

So far, mainstream media coverage of health care during the campaign has been characterized by stenographic reporting—simply transcribing what the candidates say, buzz words and all. Blogosphere coverage has trended the opposite direction—way too much wonk talk, angels dancing on the head of a pin-type stuff.

What have been missing are the people stories. Exactly how will all these economic and political calculations and pronouncements affect those who struggle daily to fill their prescriptions, find a competent doctor, or pay their medical bills? These are the people whose stories the media have yet to tell.

Lieberman's first stop was Helena, Arkansas, where she noted "how little [the residents] knew about the coming health care battle being waged in their name." She concludes that by telling the personal stories of how these policy decisions will affect people "it will not only be more interesting, but it will help people evaluate the ad messages, the special interest spiels, the propaganda, and the demagoguery that will surely come."

In her second piece she details how Helena's head jailer and his diabetic son would fare under the Obama and McCain plans. Her analysis:

Neither father nor son would fare well under McCain’s proposals. Bell the elder would have to pay taxes on the value of his health insurance benefits. Economists argue that removing the tax exclusion for employer-provided benefits is a move toward equity, since the exclusion now favors highly paid people who get rich benefits. Equity or not, Bell would have to find the money to pay the extra taxes on an income that hardly covers the essentials. In exchange, he would get a $2500 tax credit to buy his own coverage, as an incentive to leave the county’s health plan.

...

Bell the younger would have the same problem. Even with the $2500 tax credit and additional federal subsidies, most likely he would still be uninsured. His diabetes makes him uninsurable. McCain proposes putting people like him in a special high risk pool for the sickest of the sick, where premiums would be sky-high and benefits may be limited. Without an income to pay the premiums required by the high risk pool, or very generous subsidies, it’s hard to see how this would be much of an option. Bottom line: James Bell IV would still have troubled getting needed care.

And under the Obama plan:

Neither father nor son would be required to buy insurance. The elder Bell could keep his coverage, which will probably get more expensive. Although Obama has promised that he would lower the cost of premiums by $2500 for the typical family, health analysts dispute whether this is achievable. Obama talks of a public plan option: Medicare-like coverage that people could choose instead of buying from commercial carriers. Whether this option will be cheaper depends on who provides the coverage.

If the government offers the benefits, as it does for Medicare, it’s possible that Bell’s premiums and other out-of-pocket expenses could be lower. There would also be a uniform comprehensive benefit package. If private insurers, with their high marketing and administrative costs, offer the benefits, then it’s not clear which option would be preferable. Too much is unknown, and, as the Democratic Party’s platform notes, all this will be thrashed out in the legislative process anyway.

The Plastic in Our Bottles

A new FDA report finds that bisphenol, the chemical used to harden plastics, is safe. Even the European Union Commission agrees.

At least 10 states, including California, are currently considering bills to restrict the use of this chemical, especially in products for babies. The chemical is similar to estrogen and does leech from the containers into food and beverages. But it seems there's some official consensus that it's safe, which means that the amount of this chemical we are ingesting is less than what would be needed to do harm.

Find out more about the chemical, and other facts about plastic here. Most manufacturers offer products free of bisphenol, including Toys R Us and most baby bottle manufacturers. Check the packaging on the products if you're unsure.

We support the level of public debate and research debate that's going on about this chemical. We believe that far too little is known about the amount and levels of chemicals in the products we all use everyday. In fact, we were staunch advocates for the Safe Cosmetics bill in California, which strengthens consumer protections regarding chemicals in cosmetics. We're also advocating for the restrictions on the chemicals in baby products. And because there are such large gaps in understanding the effects of environmental contaminants on human health, we supported the passage of the Biomonitoring bill, which has established a formal mechanism for measuring toxic chemicals in people.

Compassion in Medicine

It's been out for about four years now, but the book bears mentioning. Medicine and Compassion is good for anyone - caregiver or not - but there's a lot in it that can bring into our awareness the truth of our lives.

One of the most powerful sentiments in the book is the reminder that we are all "waiting in line to die." How does that truth change the way we interact with patients, with each other?

Digging Out of Medical Debt

The Wall Street Journal posts an article today about getting out of medical debt. You'll need a subscription to access the full article, but we'd like to summarize a few of the tips:

• Negotiate - "Believe it or not, medical care is negotiable," the Journal writes. And it is. If you are uninsured or under-insured call your doctor's office or hospital to let them know and ask to work out a lower price. Typically, you can reduce your bill by up to half.
• Ask for a payment plan - Most hospitals and doctors offices will set you up on a payment plan so that your finances don't take a huge hit, and you won't typically get charged interest. "Just make sure to keep in close contact with the billing department," the Journal cautions. "Once a payment plan is in place. Many hospitals have computer systems that push buckets of unpaid bills into collection after a certain date ... so [you] will need a human to override the software program."
• Seek help - You're not in this alone. Hospitals have access to government funds (or their own charity care funds) to help cover the cost of caring for those without adequate insurance. Call the hospital and let them know your situation. Talk to the hospital's financial counselor and fill out a charity care application. You can also contact the Patient Advocate Foundation to secure additional help with paying your bills.

Medical Road Rage

We've all seen it in the movies and on television: The brilliant, highly-experienced and tenacious chief surgeon berates the residents, interns, nurses - just about anyone - in the hospital for every offense, imagined or real. The surgeon gets away with this behavior because, well, s/he is brilliant, highly-experienced, and tenacious. More important, s/he brings in patients.

They are stereotyped as the playground bullies of the medical field, which is what makes this drama such rich fodder for the entertainment industry. Maggie Mahar posts an informative exploration today of the cultural divide in medicine between the doctors who "perform procedures" and those who "practice cognitive medicine."

Is there a difference between surgeons and other doctors in terms of their ability to act compassionately? It's a question that may never get answered, but something is starting to happen in the medical field to curb this kind of behavior. Namely, disciplining doctors. Take this case, reported on in The Boston Globe:

During an operation at a Salem hospital last summer, an orthopedic surgeon, frustrated by a pair of scissors that wouldn't cut, threw them and narrowly missed a nurse.

In many hospitals, outbursts from a top surgeon who generates significant revenue or a star researcher who wins huge grants often have been tolerated. But in this instance, North Shore Medical Center disciplined the doctor who threw scissors and required mandatory team training for all operating room staff under a recent policy requiring physicians to treat their colleagues with "civility and respect."

The article goes on to point out that The Joint Commission is for the first time is requiring all hospitals, nursing homes, and other health care facilities to adopt "zero-tolerance" policies by Jan. 1, including codes of conduct, ways to encourage staff to report bad behavior, and a process for helping and, if necessary, disciplining offenders.

We're Ready

Yet another public opinion poll has confirmed that the nation is ready for health care reform.

• Nine out of 10 people surveyed said the presidential candidates should propose reforms that would improve the quality of health care, ensure that all Americans have affordable care, and reduce the number of uninsured.
• Eight in 10 people said they supported efforts to improve health care performance, access, quality and cost. For example, one in three said their doctors ordered tests that had already been done or recommended unnecessary treatment.
• Most of the people surveyed expressed frustration with the way their health care was managed. For instance, 47 percent said their health care was poorly coordinated; this lack of coordination included not being informed about test results and having to make several calls to get the results.
• Nine of 10 people said it was important that they have one place or one doctor responsible for their primary care and coordination of all their care. And, nine of 10 wanted easier access to their medical records.

Our own Health Security Index shows the same readiness:

• The number one concern regarding health security is affordability - and from 2007 to 2008 there was a 50 percent jump in the number of respondents that cited affordable health care for all as the single most important challenge facing the nation today.
• Democrats (34%), Republicans (32%), and Independents (39%) similarly recognize affordability as the most important health care challenge.
• The uninsured are more than three times as likely to have to choose between basic necessities, like rent and groceries, and health care.
• Across all political parties, respondents showed surprising agreement on reform measures that support health insurance choice and tax credits for the poor.

So if the nation is ready, why aren't we making progress? It's no longer a question of political will, but of priorities. Vying for attention with health care reform are the Iraq War and the economy. Only by telling our nation's leaders that you want health care reform to remain a priority will we be able to affect real change. Send in a letter or an email to your local representatives and keep the focus strong.