|
|
| |
|
Community For Better Health Care
|
| |
Medical Gluttony
Current
Issue: (previous
issue) (past issue)
|
Much of patient Gluttony is seen as expected service.
|
|
Physicians have been
ineffective in pointing out the significant costs of health care that
are submerged into medical practices. Patients expect health care as
their right. However, where does the right come from and where does it
proceed? Patients today receive mostly free care. They pay a small
fraction of the cost of being seen, almost none of the cost of the
laboratory and x-rays they demand; and this seems to expand the
appetite for "more 'n more" courtesies that are not
understood as costs. For physicians to even mention them as costs is
considered greed on the part of the physician. What are the
unappreciated and unrecognized subtleties of excessive health care
consumption?
For their own
convenience, patients make demands such as having the doctor phone
their prescriptions to the pharmacist in order to have ready when they
arrived at the pharmacy. Seemingly an obvious small service rendered
for their convenience. Any amount of explanation or comment would only
be interpreted as insensitive or uncaring. Most patients do not
understand the cost of time since they no longer pay for the
physician's time. To make the point in terms the patient could most
likely understand, after one such request when I was several minutes
into the appointment, I placed the call to his pharmacy on the speaker
telephone so the patient could hear the menus and the time taken to
navigate those menus. While waiting to be transferred to the
pharmacist, I completed my examination and explained the diagnosis and
the treatment plan. At the conclusion of the 20-minute appointment and
also the writing of the prescriptions, I pressed the speaker button to
disconnect the phone from the pharmacist waiting list since I knew that
20 minutes is frequently not enough time to phone in a prescription (I
was still on hold with the automated voice saying there was only one
other customer ahead of me). I got up, gave him the written
prescriptions, and led him out the door explaining we were already 10
minutes into the next patient's appointment. As I shook his hand, I
pointed out that his HMO pays about half the office call charge; now he
could obviously see that to ask for a personalized call-in prescription
(as patients frequently do) was like requesting a second full office
visit time for half the value of one office visit. Therefore, we would
no longer be able to honor phone-in prescription requests; he would
have to use the paper prescriptions or the electronic prescriptions
available at the time of service. I'm still not sure if the doubling of
costs for half the revenue was understood. But it certainly was not
appreciated.
In another instance, a
patient presented himself at our window during a busy schedule wanting
all his prescriptions of the previous week re-written for a mail order
pharmacy that allows three-months supply rather than one month at the
local pharmacy. So, standing at my counter, after pulling his chart, I
rewrote all his prescriptions that had been for a 30-day supply with
eleven refills to a 90-day supply and 9 months of refills. I had tried
to talk him into using the mail order pharmacy the previous week. This
patient again did not comprehend that taking ten minutes or half an
appointment was an inordinate cost expected as a courtesy and an
affront to the other patients having to wait longer. When unions are
rebelling to a 10 percent cut in wages during the current recession,
these patients have no realization of the 50 percent cut in the
doctor's wages for their 20-minute appointments, now up to 30 minutes.
Last week, a patient
wanted his prescriptions on a "fax in" form that others
normally bring with them from their mail order pharmacies in order to
expedite faxing in their prescriptions. Only this patient did not have
the forms. He reminded my front desk manager that she could call his
mail order drug plan and request the forms and then I could complete
them. It took my office manager 20 minutes to navigate the mail order
pharmacy phone menus to finally get the appropriate forms that the
patient had left at his home. I had to rewrite the prescriptions on the
requested form and my office then faxed them along with his credit card
number to his mail order pharmacy. He occupied the check-in/check-out
counter at my front desk for about 35 minutes in addition to about 5
minutes of my duplicated work.
Would government
medicine be more efficient in the practice situations? Experience to
date would not support such a view. Physicians were the most efficient
and cost effective when they did their own x-rays, lab work, and other
procedures in their offices. These have slowly been driven out by
mandates, some of which have actually prevented physicians from doing
their own laboratory work and basic x-rays. Most of the arguments have
centered on the premise that the physician is incentivised to excessive
utilization when in fact they are more efficient in their utilization.
Studies have shown that doctors who send their patients to the Lab,
X-ray or ECG facility order far more Lab tests, ECGs and CXRs than the
internist, cardiologist or the chest physician who do their own Lab,
ECG and CXR. Furthermore, the Lab, ECG and X-Ray facilities charge at
least twice what a private office charges.
More industries are
going through the "lean" revolution these days, some by force
of bankruptcy and some by having a culture of "lean
manufacturing" or "lean marketing" that are being put
through greater challenges during our economic downturn. The most
cost-efficient hospitals of the mid-twentieth century were the
physician-owned hospitals. During my medical student preceptorship in a
rural community where the three physicians owned their own hospital,
surgical unit, pharmacy, and office building, they were considerably
cheaper than the surrounding community hospitals. When they did their
yearly cost analysis, they seldom found a reason to increase any
hospital charges to the level of the surrounding community since, in
their estimation, they were making adequate profit.
Today, physicians have
very little control over hospital, x-ray, lab or pharmaceutical
charges. However, in their practice they have little choice but to
utilize hospitals, labs, x-ray facilities and pharmacies. Patients
still tell me that the physicians control the hospitals. No amount of
data will convince most patients otherwise. The only answer will be an
integrated health plan outside the arena of government medicine in the
open medical market place, which doesn't exist today. If health care
could be restored to the open market place, this would be the most
ruthless way to reduce charges and all costs. That would also put the
patient and his physician in full control. This would require a very
disruptive innovation. Almost all of the current players, whether
hospitals, physicians, or health insurance plans, would resist and even
fight such a change. Stay tuned.
Medical Gluttony thrives in Government and
Health Insurance Programs.
Gluttony
Disappears with Appropriate Deductibles and Co-payments on Every
Service.
subscribe
|
Previous
Issue: (current
issue) (past issue)
|
Health Insurance for outpatient doctor's visits
compared to cash.
|
|
WSJ BLOG: by Robert Berry, MD: Another way for healthcare
May14, 2009
Before we cede over all
control of our healthcare dollars to the federal government under the
naive illusion that it will somehow control costs, improve care, and
expand access, it would be worth discussing other options that actually
have proven to reduce costs while allowing average citizens to control
most of their own healthcare dollars and decisions.
Except for catastrophic
injuries and illnesses, doctors' outpatient fees are affordable for the
vast majority of Americans. There
is no reason to have insurance pay physicians for outpatient visits -
these bills can be settled directly at the time of service or on a
retainer basis on terms acceptable to patient and doctor (rather than
the one-sided arrangement that now exists with insurers and
physicians). Charges at my
direct-pay primary care medical practice run anywhere from an oil
change to a brake job - neither of which any American in their right
mind would purchase insurance for.
As a result, my annual overhead is about $120,000 or about
$200,000 a year less than that of physicians who accept insurance
(according to data reported by the Medical Group Management
Association).
Dr. Brian Forrest,
another insurance-free doctor, has lower overhead than I do. In a June 2007 Family
Practice Management article entitled, "Breaking Even on 4
Visits Per Day," he reports his annual overhead at roughly $80,000
- just 2/3rds of mine and almost a quarter of a million dollars less
than that of the average family physician in this country who bills
insurance. His average
charge per patient visit including his time, labs, and equipment is
$82.
If all primary care
outpatient visits were settled directly rather than through insurance,
the nation would save about $75 billion a year. It would be even more if
outpatient visits to all physicians were paid directly. This might not sound like a lot
in Washington terms, but it should be noted that the total amount paid
to physicians is only about $350 billion per year. Perhaps as much as 1/3rd
of the payment to physicians is wasted settling relatively small
outpatient claims that could be paid without insurance.
Paying doctors directly
for their services has other benefits besides reducing cost. It has been said, "he who
pays the piper calls the tune."
In a single payer system, doctors work for the government, not
the patient, and the interests of the two don't necessarily coincide. When patients pay directly, physicians have to compete on quality
and price, forcing them to be accountable for the value they provide. When doctors compete, patients
win.
Direct payment also
forces patients to become more involved in determining how their
outpatient dollars are spent, thus reducing unnecessary care. More money would then be
available to pay doctors rather than overhead, making medicine more
financially attractive to current physicians (who are considering
retiring) and bright college students who having many options other
than healthcare from which to choose.
Single payer will
reduce the number of doctors for the future. Who will want to put up with
hassles and low pay when most physicians could do better in other
careers? The physicians
who would remain would either be disgruntled from having their careers
commandeered by the government or be readily compliant with government
edicts. Single payer will
produce a no win situation for doctors, patients, and our economy. When doctors don't compete, we
all lose (except government bureaucrats). . .
Medical Gluttony thrives in Government and
Health Insurance Programs.
It
Disappears with Appropriate Deductibles, Co-payments or Cash on
outpatient Services.
|
Past
Issue: (current
issue) (previous
issue)
|
Entitlement Madness by John Goodman, PhD
|
|
As of last year's
report, Social Security and Medicare had an unfunded liability in
excess of $100 trillion (see
Table I), about 6 ½ times the size of the entire economy. This is
the excess of promises we have made over and above expected taxes and
premiums. To avoid draconian benefit cuts or tax increase in future
years we would need to have that $100 trillion in the bank, earning
interest today. But of course we do not. (Although it is of small
comfort, Jagadeesh Gokhale has shown that our European trading partners
are in even worse shape.)
These obligations are
especially important in light of the enormous increase in unfunded
liability and cash flow deficits that are about to be added. Currently,
about 100 million people depend on Medicare and Medicaid for their
health care. Under President Obama's new health reform plan, an
additional 100 million or so could be enrolled in public and
quasi-public plans with the entitlement guarantee that their premiums
will not exceed 10% of family income.
The $100 trillion
figure is based on looking indefinitely into the future. (For reasons
we have explained before a
shorter time horizon gives misleading estimates.) Yet a different way
of accounting is to use the method private companies and state and
local governments now have to use. If we halted these programs
tomorrow, collecting no more taxes and allowing no more benefit
accruals, how much do we owe people for benefits they have already
earned? Answer: $52 trillion. Read
the entire blog . . .
MedicalTuesday has always recommended that the
only way to save Medicare is to index it for longevity as Social
Security started to do. Since longevity has increased from 62 years
when social security started to 77 years today, this indexing must be
gradual over a long time. Social Security has only reached an indexing
level of 67 years. Adding an additional 100 million Americans to these
benefits, that must be paid for by working Americans, is sheer lunacy.
The Big Government advocates are criticizing our Health Care as costing
too much at 17 percent of GDP. Why do we want to push it to 25 percent
of GDP? Aren't we headed in the wrong direction for fiscal
responsibility?
Medical Gluttony thrives in Government and
Health Insurance Programs.
Gluttony
is controlled with Appropriate Deductibles and Co-payments on Every
Service.
top
|
|
For other issues, please visit our archives. We
invite you to sign up for this
biweekly newsletter.
|
|
|