Sunday, October 18, 2009

Response to "Solution" (too big for comments!)

The writer here has some good ideas. Some need modification in ways that I may not be able to suggest.

However after have spent my career in both academic medicine and private practice and doing some high risk surgical procedures some things mentioned are difficult to achieve.

1. In regard to malpractice:
The only sensible solution which is most likely not attainable given the casino like malpractice environment in which we live is a panel of physicians each of whom is in the same field of medicine as is the defendant or accused doctor. There are physicians who will not be swayed by the fact that the accused is a peer of theirs, a friend etc. This panel will determine whether or not there was an act of malpractice.

Why is this not attainable? There is a lot of money involved in these cases. Even the defendant’s attorney is paid pretty good fees by the defendant’s malpractice insurance company. Then there is the injured party’s attorney who may be paid for his work by the hour or perhaps he/she will be paid 1/3 to 1/2 of any award that the injured party is given. Lastly there are the expert witnesses. These are physicians who advertise their services in the journals which attorney’s read. These self proclaimed expert witnesses advertise that they will testify for either side of a case. That is for or against the accused physician. These fees run into the thousands of dollars. There is a lot of money involved here and these above described professionals will not give up that part of their income without a big fight. Unfortunately these people have a great deal of say in legislating changes in malpractice law.

2. In regard to the member owned health organization
if a physician’s peers and patient evaluation determine the pay and whether or not a given physician should be fired the easiest thing for a hired physician to do is pick easy cases, cases with a high probability of success and refer the more difficult cases to an outside physician. Why should such a physician go through the stress of operating on poor risk patients and risking his career. The administration of the MOHOM non profit or not will want those cases done in his MOHMO. Again there is money involved.

3. Then there is the problem an MOHO may have with diagnostic procedures.
Is a physician ordering too many? Was that test essential? Again what is the nature of his patient load. Example: a child falls off of his bicycle hits his head on the curb, he acts a little dopey. Is there bleeding into or onto his brain---do we do an MRI for 1500 dollars? Maybe we ought to simply wait to see what happens. Does the child clear up or does he rapidly go into a coma with irreversible brain damage that could have be been prevented with prompt surgical intervention--- here we may be back to malpractice problems. Well the child clears up so was the MRI justified? To the child’s mother and father it certainly was justified. To a green eyeshade types NO. Additionally the administrator of the MOHMO may criticize the expenditure for the MRI . This would be especially true if the MRI result was normal. Also does the MOHMO own the MRI machine or are the patients referred outside of the MOHMO? Essentially who gets that 1500 dollars?

4. There are some very certain things that must be done and can be done. We must cover pre existing conditions, we must allow transportability of an insurance policy across state lines and perhaps across national boundaries, we must allow insurance companies to sell policies across state lines in order to increase insurance company competition.

5. Lastly one way or another we must help cover families that have continuing crushing medical bills for a member of their family. Such as an individual that will need expensive medication and other treatments for as long as the member lives. This expenditure will interfere with other children in the family such as their education. The psychological effect upon such a family of say having to spend 20% of their income for such care indefinitely is devastating. They live close to penury and in a depression for most of their lives. That’s wrong. Making it a deductable item for the income tax is not an answer, the money still goes out and only a small portion is realized by a tax saving.

This along with changing the regulation of the insurance companies must be done and it can be done. Beyond that we must be very careful. I spent one year working in Italy which has socialized medicine. Believe me it’s not good.

I have offered very little in the way of solutions but we must not allow the unemployables, the poorly educated ones who unfortunately make up the membership of the congress ruin what we have. I believe that the insurance companies ought to be freed up for us to determine what they can do and what they cannot or will not do for us. Of course they plan to make a profit, but making a profit makes for efficiency in distinction to what I saw and experienced in socialized Italy.

We can do these things and more if only the social engineers in Washington D.C. really had our interests at heart but they don’t.

In a socialized system the individual means nothing it is the group that is important. We are edging this way. Thus with a sick non contributing member of society, say a man who pushed a rife across Europe, through Korea, his son fought in Vietnam, his grandchildren are in Iraq and Afganistan, his wife worked and paid taxes her whole working life as did he---why bother ???
We can do better we always have.

Alan S. Freemond


Solution Author said...

Thank you for your response, Alan, now let me offer counterpoints.

1) I realize that the entrenched interests of the Trial Lawyers are what have forestalled tort reform up to now, and perhaps it is a naive dream to think it can be overturned, but for this I turn to the favorite trick of the 'community organizer'. Incrementalism. In order to accomplished the desired environment we do not need 'comprehensive tort reform', merely targeted exemption for the proposed non profits. If they are as successful as conversion to employer provided health care was in 1953, when the nation went from 9% coverage to 60% coverage in ONE YEAR, then tort reform will be a fait accompli. Dream Big!

Solution Author said...

2) This is part and parcel of working out the details of how a MOHO would function. Members should not tolerate such "cherry picking". Doctors in the organization might team to solve particularly difficult issues, but the team would not long protect a staffer who was substandard. A physician in a MOHO will not be in a position to pick and choose his patients, nor should 'referrals' be required except in the most extraordinary circumstances. This is a feature of the current system that works to undermine doctor/patient relationships - and inflating costs in the process. With money as the motivator, MOHOs will not long tolerate referals that come out of their operating budget (do you seriously think a subscribing customer will tolerate being fobbed off on an outside doctor AND paying for it?).

Solution Author said...

3) Level of service is another issue to be resolved in crafting the details of how a MOHO should function. Some standards will be required and this will have to be a collaborative decision determined by both the doctors and their subscribers. It is, in essence, the rationing that everyone likes to talk about when throwing bombs at the other side. For my part, if a cost benefit decision is going to be made, I don't want an insurance company making the decision (the current system), and I sure as hell don't want the Government making the decision (the proposed legislation) That should be a decision my doctor and I make. If, as a subscriber, I wish to support my doctor and take a step beyond the norm for the MOHO there is always MY OWN health spending account. I believe that these points of equilibrium of cost and benefit will always be shifting with the consensus of all of the elements of a MOHO, doctor, administration and subscriber. Also, your example is one of trauma, thus a risk item, not health care and would likely be more in the realm of insurance and traditional ER operations.
MOHOs may have a wide variation of competencies which will be determined by the demands and resources of their subscribers. Some may own MRI's if they have sufficient need, but I suspect that most will purchase this from an outside vendor. It is also possible that a second tier of service organizations, subscribed to by the MOHOs, might be ways to efficiently provide such specialized and technical services. Such exceptional services may also require that a patient co-pay some percentage from his health spending account, which creates a financial incentive for the patient to ensure that the service is medically necessary, not an emotional luxury (this also takes the doctor off the hook :-).

One observation - with the close scrutiny of costs the proposed system would engender, this should place significant downward pressure on MRI providers, etc. Look to the Lasik surgery services for a model of how known costs and competition can provide the best service at the lowest price...

Solution Author said...

4 & 5) I agree with all your statements regarding insurance, but consider this. Since policies are individually owned under the proposed system and presumably purchased before anything that would qualify as a 'condition', no such thing as a 'pre-existing condition' can exist. This is a byproduct of the current insurance system tied to employers instead of persons. If a 'condition' develops, it is the permanent responsibility of the insurer (that's why they call it RISK). Of course, this will require regulation to prevent insurers from fraudulently ducking out on their end of the deal, and will likely require rules regarding premium manipulation and the like as well. The down side is, we are where we are, and we can hardly expect that any of those who currently have 'conditions' and no coverage have any chance of paying for them or getting someone else to do so. Preexisting conditions are the Achilles Heel of the current system and the most daunting obstacle to progress towards something better. I don't have a specific notion of how this can be accomplished, but I have to think if we were to absorb this as part of the current Medicaid it would still be cheaper than what is being foisted off on us by the current administration. Anybody else have an Idea on how to handle this?

A. Dearborn Citizen said...

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