HCCD Report Maryland 20817

Health Care Community Discussion
Bethesda, MD

Summary of discussion is followed by a list of individual comments made for each discussion point.

1. NON UNIVERSAL ACCESS (NUA) to health care is the number one problem and soft  (non-direct patient care costs) costs are the number one fiscal problem both of which in aggregate cause significant quality problems.

(Quality) NUA means that 26 million US citizens are not able to get care.  This means that they are not getting their health maintenance (vaccines, cancer screening—mammography/bowel/prostate—high blood pressure—lipid checks)

(Quality)  NUA means that that patients use the ER system as the only access method, which dilutes ER quality

NUA means that patients have to find new docs and employers have to find new plans yearly or bi-yearly as a means to cut costs which decreases quality due to poor continuity of care.

NUA means that patients hurt by the medical system are not taken care of by the medical system and thus increase the need for medical malpractice claims as a way for these patients to receive care for health care induced medical problems.

NUA is a moral and social justice problem because as a wealthy country with 33% of world GDP we should provide universal care to our total population otherwise our other political choices are selfish.

High SOFT costs:  40% of Health Care GDP goes to insurance companies, administrative costs (which are extensive -to deal with a complicated insurance payment system that generally defaults to non- or under payment requiring additional efforts to recover proper payments), and legal system costs. Interestingly, if the “soft costs” were eliminated, this 40% of the total health care costs (16 % GDP) would provide funding for coverage of our 10% (26 million) uninsured population.  We could provide total health maintenance; we could hire and employ more nurses and physicians so that patient contact hours could increase.  We think that patient and physician satisfaction would increase with increasing contact time and quality would also be positively affected because the physicians would have the time to do comprehensive care.

Physician salaries are not the source of high medical costs.  The average primary care physician with 7 years post college education and 10 to 15 years experience is making less that the person selling contracts for pavement work in the small business represented in our group discussion.  We cannot recruit and maintain the caliber of physicians when pay is low, time with patients is short, and decisions are pre-determined by insurance flow charts.  The level of responsibility and expertise needs to be compensated.  Some doctors would take pay cut for more time off.

Additional points listed under discussion point #1:

• Inequitable distribution of limited health care resources
• Decision making about resource allocation often not based on medical science/health care needs.
• Companies nickel and dime the cost of coverage
• CEOs/Leadership base health care decisions on personal experiences
• Incentives for insurance companies
• Method analysis used by insurance companies in the renewal process
• Lack of true education for the insured on how to get the most from their insurance.  Providers purposefully keep patients in the dark
• Insurance administrative burden
• Cost:  no way to understand or to congtrol the cost
• Personal education and personal responsibility i.e. eating/exercise/smoking/drinking choices
• Health insurance companies are in the business of fixing their bottom line – more than maintaining health.
• Hierarchy in decision making about access to health care
• Inadequate primary care
• Nurse practitioners should be used
• Continuity
• Catastrophic illness should not bankrupt anybody
• Problems in expectations
• Costs are hidden

1. Health care provider quality

Increase physician contact time with patients by one adding more supervised nurse practitioners to do health maintenance screening.  NOTE nurse practitioners cannot be un-supervised and each note and order should be co-signed.  We have seen examples in the VA and Military systems (number one uses of these providers) where these practitioners are utilized without adequate oversight at a cost to quality.

Train more physicians so that we have sufficient numbers to take care of the surge in patients.

The current malpractice system adversely drives health care costs.  Some malpractice fees are exorbitant, and more importantly, some medical decisions are driven by a “what needs to be done to avoid being sued” mentality.  A different way of identifying poor medical care and an effective way of getting rid of “bad” doctors is needed.  It will cost a million dollars for a hospital to get rid of a bad doctor.  So instead, they are not removed, and this places the unknowing patient at risk. 

Cap legal fees for physician discharge costs from group and hospital practices (take 1 million dollars to get rid of a “bad doc”).  State board maintenance of credentials is not effective.

Additional points listed under discussion point #2:

• Quality will improve immensely if we can get lawyers out of the system
• Education is essential
• Most pick Dr.s by word of mouth
• Quality is affected by the number of nurses and number of doctors
• Quality is first consideration, but large company plans have been used successfully
• Internet somewhat useful
• Malpractice is not the best method to address performance
• Proactive management of performance is not rewarded
• Large systems will not increase quality of care
• Pay for performance is not the solution – the metric is hard, but let outcomes change malpractice rates or reimbursement?
• NEED to redesign the performance process

2. COSTS

Use a HYBRED (universal coverage and choice coverage) by expanding a single payer universal access system.  Some of the group expressed the thought that we have a very diverse population and the likelihood of satisfying the needs by a “one-size fits all” approach was very low. An example would be that all patient can have the option of basic coverage with ability to sue for malpractice but caps are provided for lawyer and recovery fees from the government.  The system might model the PHS Indian Health service or VA systems.  The VA system does not have high soft costs and uses government purchases of costly medical items and provides care at a 40% discounted rate.  It does not make sense to have 40% of the health care dollar go to Insurance companies.

As the economic crisis evolves spending money on infrastructure so increasing health costs maybe a way to employ Americans and transition our economy from an industrial base to a service (including health care) base.

Patients need a carrot…maybe use tax system to give pts a tax cut if they have certain good parameters and have appropriate cancer screening weight, exercise smoking cessation etc.

Maybe give small companies a tax cut if they have every employee enrolled in a medical care plan - like depreciation.

Maybe add more doctors and nurse and play for it our of homeland security funds and these docs/nurses could be recalled for national disaster needs.

Need to be careful to have competition and profit motivations so that system does not become complacent.

Additional points listed under discussion point #3:

• Health care companies base payment processing on algorhythms – no human sees or touches the claim.  A patient is forced to persist and nag health care companies to resolve issues, but may not know how to effectively ask or make inquiries.
• Even though we have insurance, we are always unsure of the out of pocket costs and have no way to plan.  We often receive bills months later.
• Establish a safety net and make it portable
• Pre-existing conditions – pregnancy, epilepsy, or other – exclude the most needy

Additional points listed under discussion point #4:

• Regardless of how health care is paid for, alternatives (i.e. competitive) are always valuable
• Would the best doctors participate in insurance exchange?
• Private options are necessary:  An essential component of America is the freedom to choose what a person buys and that should include health care

Additional points listed under discussion point #5:

• Employer should be OUT of the health care equation – there is an inherent moral/ethical dilemma when the employer is involved
• Gov’t should pay – let employers pay for retirement
• Employment based health care can mandate some health screening, but this should not bar anyone from insurance

Additional points listed under discussion point #6:

• Preventive medicine is used if it is normalized in society.  Expected use at schools and places of work would increase useage.  Media helps too – use the “Couric Effect”.

Additional points listed under discussion point #7:

• Increase number of nurses and community health workers (i.e. Indian Health Service model)
• Give tax incentives for key indicators
• Increase number of gyms and recreational facilities
• Increase access to health care for for preventive services
• Smoke free bars and restaurants etc.
• Planning for bike paths and running and walking trails
• Mandate screening tests as part of insurance, but not allow this to affect a persons policy.

General comments: the current health care system does not have the right “carrots and sticks”.  There is a disconnect between what drives costs and what constitutes quality health care and health maintenance.

General agreement that what is needed is an improvement in access and quality, but that “reform” could mean decreased services to decrease costs.  This would not be the right model!