Will Giving Doctors More Money to Coordinate Care Pay Off?

By JULIE APPLEBY
July 14, 2008

States, the federal government and private insurers are experimenting with an idea to cut costs and make patients happier: Paying primary-care doctors extra money to oversee and coordinate patients’ care.

The pay boost rewards doctors who reshape their practices to recreate an era when a trusted family physician helped patients through hospitalizations, coordinated specialist care and provided routine screenings. Such efforts may save money by reducing hospitalizations, ER visits and disease.

Dubbed “medical homes,” the concept is a modern twist on an idea first promoted in the 1960s. Under most pilot projects being tested, primary-care doctors who have established medical homes will receive additional fees ranging from just a few dollars a month per patient to more than $35,000 a year per doctor from states, Medicare or other insurers.

Medicare this year will choose eight states to test whether paying primary-care doctors more per month to treat patients with chronic illnesses in medical home settings results in better care and lower costs than traditional practices.

The concept aims to change rushed doctor’s appointments and fragmented specialist care by creating patient care “teams,” which could include nurse practitioners, nutritionists or other medical staff. Medical homes also offer longer office hours, electronic medical records and same-day appointments.

The idea is that patients would turn to a trusted adviser, either the doctor or another team member, for preventive and routine care and rely on that person to help coordinate needed screenings, specialist visits and other care, says Terry McGeeney, head of TransforMED, a subsidiary of the American Academy of Family Physicians that helps doctors create such practices.

While health maintenance organizations and managed care companies aimed for such coordination, many didn’t pay doctors adequately for it, instead rewarding them financially for restricting care, says McGeeney. Under medical homes, he says, doctors won’t prevent patients from seeing specialists or ordering tests.

It’s not clear how well such plans will work. North Carolina saved $231 million in 2002-03 by setting up medical homes in its Medicaid program.

Joseph Antos, an economist at the conservative American Enterprise Institute, says no one argues with the goal, but: “If all we’re doing is rearranging the deck chairs on the medical Titanic, and spending more money, that’s clearly not something we want to do.”

The idea appeals to doctors such as Joseph Mambu, who set up his Pennsylvania practice as a medical home. They recreate “the old-fashioned doctor who has the time to get to know you,” he says. “This is our last, best hope to save primary care.”

Copyright © 2008 ABC News Internet Ventures

Study leads to debates on mandates

By Kay Lazar
Globe Staff / July 8, 2008

A long-awaited report concludes that 12 cents of every $1 paid for health insurance in Massachusetts goes toward 26 state-mandated benefits, from maternity and mental healthcare to infertility and diabetes services.

Graphic Estimated spending on mandated benefits
Statewide, the price tag is $1.3 billion a year, says the report released yesterday by the Division of Health Care Finance and Policy. It was commissioned in 2006 as part of the state’s near-universal health insurance law.

Insurers and small business groups said the findings show that mandates are helping to drive up costs, making coverage unaffordable as many businesses and workers struggle. The business groups said the mandates translate to roughly $1,300 annually per employee in a family healthcare plan.

But some mandates are also required under federal law, the report said, meaning that employers would have to offer those benefits even if the state mandates were not in place. Excluding such benefits, the report concludes that the cost of the state’s mandates would be no higher than $687 million a year, or roughly 6 cents of every $1 paid for health insurance.

State lawmakers are now considering proposals that could require employers to add more benefits, including expanded mental healthcare coverage.

“It’s getting harder and harder for both employees and employers to pay healthcare costs,” said Dr. Marylou Buyse, president of the Massachusetts Association of Health Plans, which represents most of the state’s health insurers.

“We believe there should be a moratorium on all new mandates until healthcare costs rise at the same rate as general inflation,” she said. “Right now, healthcare costs are about two to three times the rate of inflation.”

The report’s authors reviewed health studies about the various mandates and estimated that most of them are cost-effective. But they suggested that regulators may consider removing some that are not considered the standard of care, such as bone marrow transplants for treatment of breast cancer. The report also noted that just five of the mandates - maternity, mental health, home health, preventive care for children, and infertility services - account for 80 percent of the total cost of the mandated benefits.

Advocates for universal health coverage said these conclusions show that regulators and lawmakers are not going to be able to wring significant cost savings from slashing existing benefits.

“Healthcare costs are going to require serious grappling of root causes of cost inflation, which are not these mandated benefits,” said Brian Rosman, research director at Health Care for All, a nonprofit that lobbies for affordable healthcare and pushed for the state’s 2006 landmark health insurance overhaul.

The law included a moratorium on adding mandated health benefits until the state published a report detailing the costs of existing mandates. The report released yesterday effectively lifts that moratorium.

The report did not calculate the cost of mandatory prescription drug coverage, which is being phased in this year.

Small business owners say that that mandate alone is likely to boost costs by another 3 to 4 percent.

“Legislators think companies are all big businesses who can afford to pay, and that’s not true,” said Bill Vernon, state director of the National Federation of Independent Business, which represents small business owners.

Vernon said small business owners are bearing the brunt of the state mandates because most larger companies are exempt from state insurance rules under federal law.

He said healthcare costs are typically the second- or third-largest employer expense and that mandates make it tough for small companies to tailor their coverage to the benefits that would most help their employees.

“Perhaps the employees want something else, like higher pay or more 401K contributions,” he said. “It’s the [lack of] flexibility that really irritates small business owners.”

By RAHUL K. PARIKH, M.D.
Published: June 10, 2008

It wasn’t the boy I had a problem with. It was his mother.
 
We had met a few months earlier, when I gave her 14-year-old son a diagnosis of mild asthma. I didn’t mind her tough questions, but her tone of voice put me on edge. She seemed suspicious, almost angry. Still, in the end I decided she was just a smart, assertive parent, and I let it go.
 
This time, she was more confrontational. She complained she had been “forced” to bring in her son for a physical because his school needed a doctor’s clearance before he could play sports. What kind of racket did we doctors have with schools? Why did she have to bring in her son when she knew he was healthy? I was taking her money for doing this?

I bit my tongue and tried to tell her why I thought they belonged here. Yes, he was probably very healthy. But an annual checkup could help him learn to take charge of his own health as he grew up, and it would give me a chance to encourage healthy choices and to get a good sense his emotional health during these challenging years. Finally, I pointed out, he was due for a tetanus booster.

She was unimpressed. “I don’t believe in preventive care,” she said. “I’ll treat him for tetanus if he needs it.”

The rest of the visit went more smoothly, mainly because Mom left the room so I could examine her son. But before they left, she again accused me of taking her money, saying I hadn’t done anything different from their previous visits. Before I could reply, her son politely confirmed that this visit had been more comprehensive.

I have had my share of difficult patients and parents. But putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son. I wasn’t sure I wanted to do it again.

I considered my options. I could be stoic, do my job and keep the boy in my practice. I could call his mother and ask her to keep her opinions to herself so I could focus on her son, though my instincts told me that this wouldn’t stop her. Finally, I could decline to see her son, and therefore her, ever again. In other words, fire my patient.

The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.

By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff.

Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.

But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. Obviously, I couldn’t just abandon them. Yet like a lot of legal jargon, the word “abandonment” is open to interpretation. I decided it meant that as long as I wasn’t leaving anyone out to dry with a serious, immediate medical problem, that I gave a patient reasonable notice and provided options about where to continue getting care, I was within my rights.

I thought about our conversation on the tetanus booster, when the mother said she didn’t believe in preventive care. I’m a pediatrician — prevention is in my DNA. If I accepted her view, I’d be compromising my conscience and my professional ethics. I couldn’t do that.

I wrote a letter addressed to my patient’s mother and sent by certified mail. I kept it brief: “Sometimes, a patient or family and doctor aren’t compatible. … Therefore, I will be dismissing you from my practice.” I went on to advise them how they could get a new pediatrician and told them that until they found a new doctor, I would continue to care for her child’s mild asthma.

Two weeks later, I received notice that they had gotten it. The child had signed for it, which made me feel bad because I didn’t have anything against him. Checking his chart, I saw that his mother had chosen a new pediatrician, a colleague of mine. They hadn’t seen him yet.

I considered telling my colleague about my experience. Perhaps warning him so he could remember to take extra care would help get them off to a better start. On the other hand, perhaps I would unfairly bias him against this child and his mother.

I decided to keep quiet. After all, it could have just been me. 

Rahul K. Parikh is a physician in Walnut Creek, Calif. He writes about medicine for Salon.

Check other readers comments:  http://community.nytimes.com/article/comments/2008/06/10/health/views/10case.html

The Democratic Presidential Candidates participated in the first online only debate.  They weighed in on such issues as Iraq, education and healthcare. 

Yahoo! News asked users who they would vote for after seeing the online debate. Only a fraction of those who watched debate footage voted — more than a million people watched debate clips, but only 15%, or about 160,000 people, voted. That’s not so different from the low-turnout rates we usually see in actual elections.

 How do you feel about the candidates view on the state of healthcare and their plan to resolve the issue of the uninsured?

http://debates.news.yahoo.com/

Hopefully, we’ll have the opportunity to see the Republican mashup debate soon. 

Now before you read into the title, listen to what I have to say.  I read an article in the New Times dated: August 17, 2000 called: “Global Warming Could Worsen Allergies, Study Finds”   (http://www.nytimes.com/library/national/science/081700sci-environ-climate.html)

First of all, the article basically states the theory that as carbon dioxide increases; pollen should increase as a result of Global Warming.

Here are some excerpts from the article I found interesting…

“The ubiquitous weed makes nearly twice as much pollen now as it did 100 years ago and will likely double its production again over the coming century with predicted increases in carbon dioxide levels, the Agriculture Department study suggests.”

“A laboratory study done by USDA in 1998 and 1999 found that ragweed pollen counts went from 5.5 grams per plant at carbon-dioxide levels that existed in 1900 to 10 grams at current levels. At predicted CO2 levels in the year 2100, the pollen count would reach 20 grams per plant.”

“The USDA researchers expanded their ragweed study this summer by planting the weed in controlled conditions outdoors in Maryland.”

Plants that were set out in Baltimore, where it is hotter and carbon-dioxide levels are higher than outside the city, are growing significantly faster than at a rural site, said Lewis Ziska, a plant physiologist who is leading the research.  “The ones that are growing in the city are bigger and have more pollen, on the order of a third bigger,” Ziska said.

As you can see, according to the research of the Agriculture Department, ragweed makes more pollen today than it did 100 years ago.

The problem I have with this research is who was counting particulates in the air from pollen 100 years ago.  We are talking about 1907.  We just started flying airplanes within the past 60 years.  So how can they base this evidence as factual, when the data is going to be skewed based upon the change in technology.  This is not proof of a ragweed problem or of Global Warming.

The assumption for the increase is said to be caused by Global Warming.  The assumption is based upon research done in the laboratory.  How can a lab truly represent a “GLOBAL” event?  How can this be replicated? 

I realize that plants were set in Baltimore and found that they grew bigger than in the rural areas.  There are many factors that could contribute to their growth than just because there was more carbon dioxide.  Some of those factors can be related to elevation, average temperature, average moisture, precipitation distributions, average wind affects, location to direct sunlight, soil conditions, etc.  None of these things were talked about in the article, so you wonder if they were considered in laboratory.  I also wonder how the plants were cared for during this period of time.  The study states that it was conducted in a “Controlled Environment”, but I thought the environment was anything but controlled.

Now I realize that this is just a news article and we probably only got part of the truth - being that this is the News!!  But as soon as someone mentions key words such as “Global Warming” it becomes BIG NEWS and fact.

My point is that we should not take everything as fact.  There is not sufficient proof here for a growing health issue with allergies contributed by Global Warming.  I wonder if they considered conditions such as the fact that there is more wind generated in a city by passing traffic, wind tunnel effects from buildings, people walking on sidewalks, etc than in rural areas.  Thus, pollen may be naturally forced to increase into the atmosphere because of these daily events rather than Global Warming.

The federal government has made a disaster of Medicare, so why would anyone want them to manage health care! With the introduction of Medicare’s Part D prescription drug benefit, many seniors are paying more for their prescriptions than before this “benefit” went into effect. At 88 years old, my mother takes two prescriptions. Her total cost for these medicines was approximately $30.00 per month. Under forced enrollment in Medicare Part D her out of pocket expense is now $71.79 per month! There is always a huge price tag that comes with any government mandated program and I, for one, do not believe you get what you pay for when the federal government is involved. The members of the Congress and Senate have opted out of participation in Medicare and Social Security. Do you really want to put your healthcare coverage options in the hands of those that would never use it for themselves?

A high deductible health plan along with a health savings account makes the most sense for millions of consumers. With pre-tax contributions, non taxable investment earnings and year to year rollover, how can anyone go wrong? It’s not a case of use or lose it! Several years ago I had a primary care physician that had a medical practice in Canada, which has “socialized medicine”. Prior to meeting him I innocently thought that it would be great to have programs like that in the US. He quickly changed my mind when he told me about all of the problems that he encountered with the program. That was why he relocated to the US. He wanted the freedom to practice medicine the way he was taught and not have the government tell him what he could and could not do with his patients. When voting in this next election keep in mind that politicians, just like Michael Moore’s movie “Sicko”, never tell both sides of the story. We do not want to have universal health insurance forced upon us!

Guest post by the GoHealth Insurance Research Team

The State Children’s Health Insurance Program — better known as SCHIP — was created by Congress in 1997. It was designed to provide health coverage for uninsured children through a combination of state and Federal funds.

The $40 billion originally budgeted for SCHIP runs out this year. Congress now must re-authorize the program and determine how much more money will be spent. That issue has become the subject of a fierce debate — how much should be re-invested into SCHIP?

In President Bush’s budget proposal to Congress back in February of 2007, he allotted $5 billion for SCHIP over the next 5 years. That number was rejected by many lawmakers, who want to spend $50 to $75 billion and further expand the program. President Bush has since added $10 billion to his proposal, but it’s still well shy of what the opposition is demanding.

The Bush administration maintains the SCHIP program should be restricted to provide coverage for uninsured children in families with incomes of up to 200% of the federal poverty level. But many states have already been given the Federal go-ahead to extend SCHIP coverage to uninsured parents — a factor that’s contributed to the program’s budget shortfall. Now that the money is running out, the White House wants to cut off coverage for adults completely.

They want to restrict SCHIP eligibility because they see the expansion as a move toward universal healthcare. President Bush was quoted in the Los Angeles Times, saying Democrats are pushing SCHIP expansion because they want “to take incremental steps down the path to government-run healthcare for every American.”

Republicans tend to support a market reform — rather than universal healthcare — to make private health coverage more accessible. They argue that increased competition would drive prices down and make health plans for children more affordable for families with incomes above 200% of the poverty level.

It’s true that many Democrats are exploring the idea of universal healthcare for all Americans. But even politicians who don’t support universal healthcare have raised an important argument in favor of expanding SCHIP coverage to adults: when parents get coverage, it increases the chance they’ll enroll their children, too. When Mark McClellan was the administrator of the Centers for Medicare and Medicaid Services, he authorized grants to 13 states to extend the SCHIP coverage to parents.

“In support of that approach, there is no question that covering kids with their parents is more efficient overall. It’s a better way to provide coverage than to have separate plans for kids and parents,” explained McClellan.

Another concern of restricting SCHIP eligibility is that many children could lose coverage — especially if they’re above the 200% poverty level.

The question isn’t if SCHIP will be re-authorized or not. It’s whether eligibility will be restricted or expanded.

Who do you think should SCHIP cover?

Sources

Alonso-Zaldivar, Ricardo. Bush Criticizes Children’s Health Plan.
Los Angeles Times. June 28, 2007. http://www.latimes.com/news/nationworld/politics/la-na-kids28jun28,1,3165586.story?ctrack=1&cset=true

Freking, Kevin. States, Feds Split on Kids’ Health Insurance.
USA Today. June 18, 2007.

http://www.usatoday.com/news/health/2007-06-18-kidsinsurance_n.htm

Pear, Robert. A Battle Over Expansion of Children’s Insurance. The New York Times. July 9, 2007. http://www.nytimes.com/2007/07/09/washington/09child.html

SCHIP Waivers Allowing States To Expand Coverage To Adults Break From Bush Administration’s Position, Lawmakers Say. Medical News Today. June 25, 2007. http://www.medicalnewstoday.com/medicalnews.php?newsid=74982

Who would benefit from mandated health insurance? This is a major question moving through the health care delivery system. An unusual coalition that includes some of the largest companies: PepsiCo, General Mills, Pacific Gas and Electric. Wm. Wrigley Jr. Co. and The Kroger Co. was formed in California to launch a political campaign calling for medical insurance to be expanded to everyone.

The coalition also includes insures and drug firms that probably would benefit from mandated health insurance: Aetna, Blue Shield of California, Cigna Healthcare, Eli Lilly and Co. and PacificCare.

Who would benefit for Mandated Health Insurance, more importantly who would it hurt? Should we require all individuals to obtain health insurance?

Leslie Wines, writer for Market Watch, penned this article on President Bush call for a reform of the tax code to create a standard deduction for all Americans with Health Insurance.

“The reform would end a disparity that forces persons who pay for their own insurance to pay more taxes than those who are insured through their jobs, he said.

“Today, the tax code unfairly penalizes people who do not get health insurance through their job,” Bush said in his weekly ratio address. “If you buy health insurance on your own, you pay much more after taxes than if you get it through your job.” Read the address.

“I proposed to end this unfair bias in the tax code by creating a standard tax deduction for every American who has health insurance,” Bush said.

Bush said that, for example, every family that has health insurance could get a $15,000 deduction on their taxes. Such a deduction could also apply to payroll taxes, so that even those who pay no income taxes would benefit.

“Americans deserve a level playing field,” he said.” If you’re self-employed, a farmer, a rancher, or an employee at a small business who buys health insurance on your own, you should get the same tax advantage as those who get their health insurance through their job at a big business.”

The president said that health care costs are rising twice as fast as wages, making it difficult for working families to afford coverage.

“These rising costs also make it harder for small businesses to offer health coverage to their employees,” he said. “We must address these rising costs so that more Americans can afford basic private health insurance.”

“Bush said he has been speaking with citizens about health care reform and next week will visit a Tennessee to speak with people who do not have access to basic affordable health insurance.”

What are we missing here? It sounds good. The uninsured numbers are forcast in the 47 - 50 million range. Would this help the uninsured. Where do we get the dollars to fund this tax deduction? Do we cut Medicare and Medicaid?