"docdano. com Live" Protesting in Wisconsin: Is Obamacare at the root of the debate?

I spoke last night to a group of young physicians at a venue across the street from the Wisconsin State Capitol at the height of the protest against the state government.

Amid the drum beats and screams of union organizers chanting how workers' rights would be eternally devastated because of the loss of collective bargaining, I lectured to a group of resident physicians on the benefits that await patients with the explosion in health care technology.

The root of the problem centers around a state, like almost all in the country, that is saddled with loss of tax revenues due to the downturn in the economy. This has resulted in massive budget deficits and hard choices.

Many states including Wisconsin have ushered in a flurry of Republicans who ran on campaigns of no new taxes, the need to cut waste and spending, and more state's rights.

So that's what the Republican Governor did from day one in office.

He first attempted to limit spending on education to trim the budget, but because of collective bargaining the negotiation of this type of decrease in the state spending was not palatable to the unions.

It didn't matter, really, because the Republicans had the votes to pass it anyway.

But instead of voting on this budgetary issue, the Democrats chose to flee to the land of Obama in Illinois to prevent the state legislature from reaching the critical number of votes to make a quorum.

For three weeks this stalled the debate and decision on the issue, until the Republicans decided to pull out the budget issues (which require the quorum) and vote instead on non-budgetary items - like collective bargaining.

So this lead to more protests.

I literally visited with hundreds of people in Wisconsin over the past week and different opinions abound from every direction.

Clearly if you are a member of the "haves" then you have no desire to give up a benefit.

That's normal.

One person told me that his daughter is a unionized teacher and she pays a whopping $23 a month for health care insurance with no deductible. Even if you factor in that there might be some requirements for her to see certain physicians in network or limitations on formulary and specialist access, this is still a bargain.

He went on tell me that the Governor's proposal would have raised this to $123 per month. I don't know if these numbers are accurate, but the change in benefit structure certainly spurred part of the protest that had national attention.

If you've read this blog before, you know that I'm not a fan of the Obamacare bill. And I think you are seeing in Wisconsin one end of the spectrum of the problems with the bill.

Let me show you why.

To pay for the extra benefits offered under the bill (like no pre-existing illness exclusion, limitations on the right of rescission of insurance if you're too sick to be in the plan, or extended coverage for children), then there will have to be either more money (read tax dollars or higher premiums) or a decline in benefits for those that are members of the "haves."

It's really that simple.

State governments who have been charged with implementing many of the provisions of the federal health care bill don't have the ability to print money or sell treasury bonds. Their only source of revenue is tax dollars.

A significant part of Obama's plan was to provide health insurance for "all Americans." And, unfortunately, a large number of the uninsured were to be covered with the under funded, limited access Medicaid system -- much of which is paid for by the states.

Finding revenue for Medicaid means that other state funded services - like education, or health benefits for teachers - have to be cut and shifted.

That is the only possible way to fund insurance for the "have nots."

I've been derided for one of my statements in the past, but I stand by it: the Obamacare health regulation was the largest transfer of wealth in American history.

So the union supported President now finds himself supporting the union backed protesters who are fighting against changes in state government that would be used to pay for the health care bill that he (and the unions) supported.

Wisconsin is only a microcosm of what is happening in every state that is now grappling with implementing the federal health legislation in a time of budget crisis.

It is an expensive bill, and now we are starting to pay the price.

I'm a big fan of expanding health care access and coverage for the "have nots." A country like the United States should be ashamed for having citizens that don't have access to quality health care. I'm just not a supporter of the big, expensive, inefficient and over-reaching federal health care bill that was passed last year.

Let's face it: the bill cost the taxpayers almost $1 trillion.

The payment for the bill is due now.

And lest you think that non-government workers will get a free ride and this is just an issue for state employees - it will filter down to every American.

As health plans shift to include the new benefits, pay the taxes and fees that are now required by the IRS, and see declining membership due to employees shifting to government subsidized insurance products there will no doubt either be an increase in your health care premiums or a reduction in your benefits.

The problem is that for many insured Americans there is no union to fight for your corporate benefits.

It will be left up to you.

One Wisconsin young man told me that maybe the Republicans should have left Congress when the health care bill was passed.

I reminded him that democracy doesn't work this way. We elect people to represent us and sometimes we win, and sometimes we lose.

I think the Obamacare bill is failure, but I believe strongly that we can keep what's good and fix what's broken. We just have to continue the debate, make compromises, and yes, probably make some sacrifices.

So it probably won't be the last protest I'll attend. Maybe next time I'll get to carry a sign...I'm not much of a drum beater.


- Posted using BlogPress from my iPad

Location:State Capitol, Madison, Wisconsin

Groupon: Are coupons really the right answer for health care?

I'm always fascinated by new technology and particularly ways social media works in our world.

So it was natural for me to sign up for Groupon.com, the internet based deal program that works with local vendors to offer special coupons and discounts for products or services.

Sometimes these deals are just incredible - from 50% off food products to half price golf to yoga for $19 per month rather than $140.

But what about using coupons for health care services?

Sounds odd, I know, but this has been a common practice for years with aesthetic services and cosmetic procedures or treatments.

It's not uncommon at all to see deals for "free Botox" or discounts on micro-dermabrasion or chemical peels.

But would you be influenced by a coupon for "free prostate exam" or "buy one get one free mammogram"?  Or would you just think that provider was weird?

It may sounds strange, but actually this happens every day.

It's hidden behind the cloak and dagger world of the pharmaceutical sample closet.

For years the drug sample has been the easiest tease to entice patients to try a different medication.  Sometimes they are very helpful -- a difficult medication to use (like an unusual dispenser for a spray on product), unusual side effects ("try it before you buy it"), or most commonly the patient has no money and they leave with a bag full of free drugs.

But these are certainly short term solutions and may or may not lead to a patient actually buying the product.

It's no surprise that most of the samples in the closet are for chronic medications -- not for something you have to take for a week or less.

But the interesting invasion into the sample closet has been the coupon.

Now not quite "groupon-like," coupons are now available for almost all name brand, non-generic medications -- particularly if they are early in their evolution of release.

This is how it usually works:  you decide you want to prescribe a new anti-hypertensive (an expensive way to say blood pressure medication).  Compared to a generic medicine which might fall under the $4 per month Walmart plan, this medication might be $300 per month.

But, there might be some advantages:  lower incidence of side effects, easier dosing regimen, or maybe its more effective.  There usually is a real medical reason despite what some Washington pundits might say.

Newer drugs usually work better.

But, nevertheless it costs $300. That's roughly half of some people's Social Security check.

Now with insurance this medication would be a lot cheaper (for the patient) but it is very likely that it would not fall under the "preferred plan" of their prescription drug coverage.

That means that it would likely cause a higher co-pay such as $50 as opposed to $5.

This is where the pharmaceutical coupons come into play.  Now, instead of advertisement laden boxes of pills, the sample closet is full of boxes full of coupons or discount cards.

Patients are asked to call a 1-800 number to activate the card, "register" (which means the company collects information on the patient, disease, and provider), and then the card can be used to off set part of the extra cost related to use of the expensive medication.

These cards usually function as "discount cards."  That is, they will provide either a certain reduction in your copay amount, or they will fix the total cost of medication at a certain point.

Most of the cards require you have insurance to use them.  There is no free lunch here, and the drug companies themselves don't want to be out the total cost of the drug, only part of their margin.

Sometimes there are limits on the amount of benefit you can receive.  The card may only be good for three refills, or it may be unlimited.  You want to make sure you check this carefully before you continue to refill your medication.

Pharmacies as rule don't like to deal with these cards.  Much like grocery stores don't like to deal with coupons.

There is an extra step for them, possibly some activation required on their part and certainly they have to carry additional float, in addition to your insurance, before they will get paid.

What's fascinating to me is that these provide a direct incentive to use a more expensive medication.

Now, as I've outlined here, there are some benefits of these cards.  But let's face it, these are expensive medications -- there is no free lunch.

It's the incentive that seems bizarre.  Physicians and hospitals are forbidden from discounting co-pays, not collecting deductibles, or for offering covered services for less than the contracted amount in most insurance contracts.

There have been several lawsuits already between rival health care systems in communities where one hospital might write off co-pays or deductibles to entice patients to choose their facility over the competitor.

This might be like a patient knowing that regardless if he has Blue Cross Blue Shield insurance, for example, they could choose either emergency room -- because the cost would be the same to them.

Patients with high deductible insurance plans are particularly susceptible to this type of gaming.  The catch is that the hospital is able to collect enough money on the subsequent procedure or test to offset the loss of the deductible.

The problem is for the insurance company and the other insured patients that are on the policy.

It removes the incentive to stay within network and comply with the contract that makes indemnity insurance work in the first place.

Everyone has to play by the same rules.

So why do pharmaceutical companies get to use these discount cards?

I'm not sure I can answer that question, but I hope I've been able to shed some light on these type of cards and discounts.

In some situations they may be very helpful.  If you require an expensive medication, particularly one that is new, be sure to ask your physician if the company offers any type of discount card.

If not, then asked them for a lower priced, generic alternative.

Otherwise, just be aware that these cards can get you established on an expensive medicine for you only to find out that the benefits were temporary.

Also be careful if the company is going to send you a rebate.  This puts the risk on you for collecting the money.

So although not quite Groupon.com type coupons, there are some discounts available for expensive medications.

You just may have to shop around and be an educated consumer-patient.

Your private health information: Could it end up on YouTube?

Ok, imagine this.

You take a video of your little girl's soccer practice with your iPhone. Within moments it's posted on YouTube for the grandparents to see.

Minutes later search engines called spiders begin to crawl across the data set of images on your upload. Face recognition technology identifies a face on the video and, with some assistance from the geo-tagging of the built in GPS metadata that accompanied the upload, gets a general location of where the video was made.

It determines that your child has other photos posted on Flickr and also a photo in the local newspaper. Now it associates a name with the face. The name might be associated with a Facebook account.

Maybe there's an article that mentions a parent. The data discovery evolution continues continually attributing identifying information. The parent's information is exhaustive, but most importantly it contains an address.

From a face on a cell phone video, a sexual predator might discover the home and contact information for your child.

All searchable by keyword: soccer, girl, Facebook, my home town.

Scary.

Its easy to see the danger the internet can pose to children. We all know that. From Net Nanny to Web Watcher there are software and web packages that purport to protect our children.

They are good. But not perfect.

Health information interconnectivity is considered the holy grail of disease management.

In fact, most experts, including me, feel that without a robust means of health care providers sharing information we can never achieve the cost and quality metrics required for optimal health care delivery.

Especially as we enter the world of the ACO - accountable care organizations - where multiple providers may very well be paid to manage the health care of an individual patient, it will be essential to share information.

Cost savings will be dependent on reducing duplicated tests, encouraging patients to fill needed prescriptions for their diabetes or hypertension, or reminding and scheduling patients for preventative health measures like mammograms or a colonoscopy.

And patients will like it.

Can you imagine a doctor visit for an elderly patient where medicines are continually updated including whether they were even filled at the pharmacy?

We have that now in our office and many physicians subscribe to pharmacy data information that can help us know what medications patients are using.

In addition many offices and emergency rooms have access to claims data for some insured patients.

What does this tell you? Well, for one thing, it can report what you have filed on your health insurance as a recent claim including diagnosis codes for illnesses, visits to other emergency rooms or health providers, and procedures you may have had.

It certainly isn't perfect - the coding has to be right and it's stale (often not being updated for months) - but it provides a snapshot of the health care services that you received which in a pinch can provide a physician with some idea of your medical background.

Some insurers will also report medical allergies to round out the picture.

But the problem here is that all the information is fragmented. There are multiple sources, many that are not up-to-date or recent, and they are on many different databases.

The word thrown out a lot by governments and policy gurus is "data warehousing." This would be a central repository of all the available information that could be accessed securely and updated.

The benefits could be great: better managed health care for individuals and populations. Maybe less visits to the emergency rooms for diabetics, fewer readmissions to the hospital for patients with congestive heart failure, and less unnecessary tests for patients with chronic diseases.

The concept of disease case management might be able to lower cost and improve quality. A value statement that would be hard for anyone to argue with.

But are our privacy rules robust enough to protect our patients?

That's really the question.

So imagine these scenarios.

A school district during a new hire review of a teacher discover that she's taken antidepressants in the past. Would this be a good employee to hire?

A drug company does a database query for men with erectile dysfunction as a diagnosis code and who have been prescribed Viagra. They are sent emails and junk mail advertising a new little blue pill.

Your company hires a consultant to lower health insurance costs for your employees. They sell a product that searches the web and ranks future applicants on past health care costs and usage and provides a score. With a high score an applicant doesn't get an interview.

You file a disability claim on your short term disability plan. Your insurance company, by finding your face on a YouTube video and attributing a name, sees that you can play on a YMCA flag football team. See the problem here?

You could write hundreds of these scenarios. Does it mean that we have to shut down interconnectivity and data sharing of sensitive health information?

No. We can't afford too.

We must continue to move the ball forward to achieve quality and cost improvement.

We have no other option.

But it does raise the concern that as we get more and more data on the web, and more and more sophisticated in our processing power, there will be big problems with patient's privacy.

The best thing that could happen would be a systematic process -- where everyone works together -- to create a unified secure database with strong patient protection rules, including who can access the data and how it can be used.

For now we are left with a fragmented system where companies and governments are creating their own plan and their own data warehouses. All of these will have their own rules, security, data, and problems.

So am I scared of posting something on Facebook?

Absolutely not.

Do I think someday someone will be posting the status of my high blood pressure?

Absolutely.



- Posted using BlogPress from my iPad

Location:Dallas, Texas

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.


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Location:Quito, Ecuador