Monday, December 20, 2010

Conversation with a Health Care Leader: the past and future of health reform with Dr. Susan Rudd Bailey

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Today we talked with Susan Rudd Bailey, MD who is the President of the nation's largest state medical society about the genesis of federal health reform and what she expects for the future.  This nationally known leader of the Texas Medical Association is candid in her discussion of the role that physicians and patients play in determining the ultimate outcome of the recent federal health regulation.  She also discusses the implications of the flawed funding mechanism for Medicare -- the so called "SGR".

Thursday, December 16, 2010

Is Obamacare unconstitutional?

Is Obamacare unconstitutional?  That's the question we address today on  Darren Whitehurst and Dan Finch from the Texas Medical Association join us today to discuss the Virginia federal judge ruling that the health reform bill is unconstitutional.  What does it mean?  And what effect is it going to have on the upcoming session of Congress?

Tuesday, December 7, 2010

End of Life: What to expect, what it will cost, and what you can do about it

When anyone brings up the idea of end of life care, you are thrown a political football. Yet, the failure to have these discussions with your loved ones creates an expensive and emotional mess.

I can't tell you the number of times I've been sitting at a table with friends and this issue has surfaced with almost unanimous consent: they all want to die with minimal terminal intervention.

Then why do we spend the majority of our Medicare health care expenditures on end of life interventions?

The answer is probably one of political correctness and emotional attachment -- both of which can cloud the decision making process.

This is making the assumption that we could even make the right decision if we wanted to.

Case in point: my father.

Seven years ago when my father was 83 years old he casually asked me to feel a "knot in his belly" on one of my trips to his cattle ranch deep in central Texas.

And, even as a dermatologist, I could tell that he had a pulsatile mass about the size of a navel orange under that cutaneous organ by the same name.

And sure enough, after a trip to the VA medical center, a sonogram and a CT scan, we correctly determined that he had an abdominal aortic aneurysm. And, without intervention, it most certainly would be his death sentence.

So we talked.

I think this is the first of many steps in dealing with elderly parents and end of life decisions. He wanted to know how serious was the surgery, would there be a risk he would end up disabled in the nursing home, or would it change his lifestyle?

As an octogenarian rancher who feeds cows every day, drinks a pot of black coffee, and has smoked at least a half-a-pack of Winston's since WWII, these were certainly concerns.

So we made a decision: no surgery.

If it ruptured and he died an instantaneous death then that would be the way he would leave our world.

We took this opportunity to also discuss asset management of his household possessions, land, cattle, and bank accounts so that my mother would not be a bankrupt widow in the event of an end of life event for either of them.

Time passed and my father lived in constant fear that the rupture could come at any moment.

Fast forward two years: I was attending a medical meeting in Austin, Texas and my father calls at 7 a.m. This is not his normal routine so I was immediately concerned.

He quickly told me that he was having abdominal pain, pain in his legs, and was feeling dizzy. He was rupturing his aneurysm.

I told him to get in the car with my 80 year old mother and drive straight to Providence Hospital in Waco -- 90 miles away.

I was hoping I could temper the dangerous caravan of my mother's driving by calling ahead and warning the emergency room. Within 20 minutes of his arrival we had confirmed that he was dissecting his aneurysm and death or surgery was imminent.

So, we talked.

The doctor suggested surgery and since he had made it to the ER, I encouraged him that he needed to give it a try -- my mother was concerned about the cost. (She is very frugal).

So he had the surgery, was in the ICU for four hours, and checked out back to home in 5 days. That was five years ago.

Now my 90 year old father still feeds and takes care of the ranch, drinks a pot of black coffee every day, and yes, still smokes a half-a-pack of Winstons. Very happy, very productive. No other health complaints.

So did we make the right decision 7 years ago when we agreed not to pursue treatment?

To our family, it was the right decision at the time. So when people make statements that make it sound like end of life care is easy, they are dead wrong. It never is.

But, there are probably some lessons here that we can learn from.

First, you must have the "discussion." It is imperative that you talk to your parents or older loved ones early -- while they still have all of their faculties and can participate in the decision making process.

These discussions are never easy. But it puts the wishes and desires of the parent in concert with those of the siblings. My discussion was easy with my parents, and my sister and I get along so well that there was really no differences of opinion. But it doesn't always work out that way.

You most certainly should formalize a living will. This puts pen to paper and makes the end of life time event easier because there is less opportunity for confusion on what was decided during the "discussion."

And finally, everyone needs to consider the financial impact of any end of life decision. This time is almost always the most expensive health care experience for any patient.

It is not uncommon for spouses to be left bankrupt with years of bills to pay There is also the issue of sitters, home nursing, and medications that also can feed the final costs of someones life.

The government has gotten much stricter on families using their own assets to manage the end of life -- even if it will be detrimental to the surviving spouse. So don't think you can just "transfer assets" into your kids accounts and that will satisfy the requirements to get the nursing home expenses paid for by the state (Medicaid).

You should enlist the help of a knowledgable attorney on all of these end of life decisions. That information can go a long way to making it more understandable for all the parties involved and that the older person's wishes are maintained.

Unfortunately there is no book in the mainstream press on how to deal with elderly parents like we have with pregnancy (such as: What to Expect when You are Expecting).

So, everyone has to write their own conclusion.

- Posted using BlogPress from my iPad

Location:Wolf Island, Galapagos, Ecuador

Friday, December 3, 2010

Texas Dermatology supports the National Psoriasis Walk

The Health Care Cold War: Will ACO's Bring Down The Wall?

Although there are no sounds of B-52's flying at low altitudes above the hospital, there are salvos nonetheless between the partners in health care as the positioning of providers in the ACO marketplace starts to crystallize.

ACO's, or accountable care organizations, are the product of one of the Obamacare beta solutions for controlling health care costs and improving outcomes.

My friend Dan Finch at the Texas Medical Association compared them to unicorns: no one's ever seen one but you'll recognize it when you do.

I'm not sure he's completely correct, there are a few of these organizations forming around the country. One in Chicago offers to produce great data on the utility of the delivery mechanism though the jury is still out on whether it will net positive results for patients.

These new entities can be formed really by anyone -- that is, anyone brave enough to pioneer the business model. The risks are great because of the capital requirements to protect the integrity of the captitated payment system which is really the heart of the organization.

Capitation is an ugly word in health care financing probably because of the almost unanimous negative consequences of the insurance models funded in this manner in the 90's.

Everyone then left with a bad taste in their mouth.

Insurance companies couldn't rein in physicians and hospitals to control costs and patients never bought into the model that prevented them from using a infinite amount of resources in their own health care.

So why would it be different now?

The argument is mostly supported not by the change in patient expectations or the robust IT infrastructure that we have in this century, but rather by the necessity to control costs. That argument unfortunately will drive the business principles that formulate these new organizations.

The definition of a "cold war" must include the word "protectionism." Certainly the world saw the escalation in missile batteries and nuclear warheads until Reagan was successful in "tearing down that wall."

But, pardon the reckless use of the 1988-presidential-debate line: Mr. Obama you are no Reagan.

Why am I so pessimistic these ACO's will find a place in this market space?

First is the lack of a unified national standard concerning our information technology infrastructure. There is currently no data sharing among providers outside of their own controlled groups (you can thank another federal stature for the difficulty here: read HIPPA).

And although a standard can be created and implemented, there is still the fact that many of the ground war health care practitioners (the primary care physicians) are still not active users of this technology. Current estimates put this at somewhere around 30% tops.

And with the cost of implementation of an electronic health record setup in a physician's office near $40K it will be some time before we see widespread adoption of EMR's.

Then there is the issue of exactly what we will measure to insure that quality care is being delivered. These so called "measures" of quality are still undergoing national debate and peer review. They're close to getting the numbers right. The question is whether physicians and patients will buy in.

And finally there is the nasty issue of "gain sharing." This is where you reward the parties for achieving the goals of delivering high quality care in an efficient manner.

Paying physicians is particularly difficult because of a myriad of other federal statues relating to anti-trust and kick back regulations.

Some groups, particularly hospitals, believe that the answer to this issue is direct employment of physicians. But this business model is challenging in that not only must a hospital control the diverse interests of a multi-specialty group of physicians, but it also has to morph the health care of individual patients to fit a cost savings model.

Both of these groups are not historically responsive to direction by a third party.

Then you have the difficult problem that hospitals are funded by actually admitting patients and providing care. In the ACO model the profits only come from keeping patient's healthy and OUT OF THE HOSPITAL.

Now sure, business models can change. But hospitals will have to recognize and be able to adapt to this change in a swift and controlled manner to insure that they remain profitable and can continue their mission.

Oh lest I forget one other very important party to the ACO equation: the people who pay for health care services.

Whether these ACO's are created as a hospital-based entity or along the traditional insurance model, at the end of the day both the government and American business expect to pay less for health care services in the future.

So for the ACO model to be successful it actually has to have a declining net revenue line.

It is this money line that has everyone so concerned and lining up to protect their own interests.

Hospitals are arguing for a hospital-centric model so they can control the dollar at the end of the day. Physicians are either jumping on board with the hospital groups or they are lobbying for measures to protect their private practice.

Patient groups are seeing that there could be limitations on both who they can see for care and where they can go. This loss of autonomy in the doctor-patient relationship will be very hard for most patients to swallow.

Insurance companies and business groups don't trust hospitals, physicians, or patients to work to control costs in the health care economy. So they are lobbying for strong protective measures to insure that ACO's don't get out of the normal reserve requirements to sell an insurance product.

ACO's hold the promise of ending the cold war.

If all of the parties could work together on a fair and balanced model that puts the patient first in the decision making process, it could offer an opportunity for success.

But for now all of the parties are building up their arms to protect their own interests, or they are being overwhelmed by a well funded adversary.

Virtually every hospital is "creating an ACO" and physician's practices are being gobbled up health care systems.

I applaud the idea of collaboration and use of IT to improve the health experience for patients. Today, though, I'm not too confident that the current attempt at tearing down the wall will work.

- Posted using BlogPress from my iPad

Location:Quito, Ecuador