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Healthcare quality and affordability crisis and possiblesolutions
I am a family physician who practiced from 1988-2000 while also volunteering at amedical ministry clinic for the indigent that I co-founded with a minister. I started avery successful software company named e-MDs that sells electronic medical recordsto help clinicians deliver superior and more cost effective care by following bestclinical practice at the point of care. I feel I am in the unique position as a priorpracticing physician, then medical software designer to understand the problems andpossible solutions to this multifaceted problem. It is possible to dramatically improvequality of care while simultaneously saving billions in healthcare costs anddistributing income to primary care physicians and specialists in a more equitablemanner. This plan requires a huge shift in the way we provide healthcare today, but thebenefits are enormous. There will be some casualties, but improving the systemoften requires sacrifice at first. I will briefly describe what I know would solve ourcountries' runaway costs in healthcare as a percent of GDP, while providing universalaccess and superior quality. This is a gross simplification of a complex problem.Briefly the major problems in U.S. healthcare today are as follows:1)Costs increasing much faster than inflation without any demonstrableimprovement in quality or access.2)Higher costs = lower affordability and more Americans going 'bare'.3)Lack of standards in information systems and lack of adoption of EMRsprevents accurate tracking of quality of care benchmarks to justify "pay forperformance" and accountability.4)A reimbursement system that favors 'volume' over quality in the primary caresetting and a system that rewards intervention/procedures (cutting) ratherthan thinking (cognitive care).
5)
Improper balance of primary care to specialty care. In countries with theWHO's highest quality ratings like Spain and Italy, the ratio of primary careproviders to specialists is 3 to 1. In the U.S., that ratio is reversed and thedisparity in incomes is accelerating causing a mass exodus of primary carephysicians.
6)
Mass marketing of ineffective, sometimes dangerous remedies, to desperatepatients that decide to seek care outside traditional healthcare. These 'quack'treatments and charlatan health care providers have sprung up as patientsseek more affordable care or respond to the promise of a cure. There is nostandardization or oversight; so many patients are defrauded while certainfringe alternative practitioners become rich off of their deception.
7)
Malpractice costs remain a significant problem. Reforms only temporarilyalleviate the strain before clever trial lawyers figure out a different angle. Thiscould partially be remedied by moving malpractice to a federalized system(out of states hands) and using a panel of true 'peers' instead of lay juries thatact upon emotion and ingrained prejudices instead the scientific facts.
8)
Insurance companies. There are so many, with so many differentrequirements and payment policies, that it is estimated that 30 to 40% of every healthcare dollar is spent on administrative paperwork rather thanactual medical care. Their mandate is to make profits for their corporateshareholders. As long as their incentives are aligned with making profits andby extension, withholding services, they cannot be expected to provider
 
stellar care or hold patient information in confidence – regardless of legislationlike HIPAA. One of the first things that must go is a for profit health insuranceindustry.
9)
Big business derives enormous profits from the inefficiencies of the system -from hospitals to health IT businesses like Cerner, IBM and EPIC to name but afew. What is best and most cost effective for patient care is often ignored infavor of an established, yet archaic, proprietary system. The reason for this issimple - these costs are passed onto the government and private payers. Freemarket controls are inefficient in a complex system that excludespatients/consumers from easy comparison shopping for their healthcaredollars.Corollary problems outside of the medical system that contribute to costs includetaxpayer subsidization of poor health habits and practices. High fat, calorie densefoods are preferred by the indigent because they pack the most calories per buck.Until and unless government somehow rewards healthier eating (perhaps thrusubsidy of fruits and vegetables and tax on high fat foods), poor eating habits willcontinue to contribute to otherwise preventable diabetes, cancer and heart disease.I will provide an outline of the solution and the rationale for why it would work. Thereare, by the way, many phases to a complete and successful transition in ourhealthcare system. We could achieve the greatest and most respected healthcaresystem in the world. Instead, today we are laughed at by other countries for thewaste, inefficiency, inequality and runaway costs of our healthcare system. It is truethat timeliness, access for a privileged few and tertiary care are unsurpassed in theworld, but these alone are not enough - especially when it is possible to retain thislevel of quality and open up healthcare to those who need it most.
The solution starts
with moving to a single payer system. That payer should be theU.S. government, although it could work with a select few high quality regionalpayers as agents of the government. To prevent overwhelming current resources, toachieve consumer and physician buy-in, and to meet most American's expectationsof timely, state of the art healthcare, a two tiered system would be optimal. By that,I mean basic, universal healthcare for basic medical services and generic medicationsfor everyone with the ability for employed persons to purchase additional services ata discounted rate. For the affluent, a sizeable luxury tax could help subsidize theircare and the care of employed individuals.  There are many challenges to implementing such a model.
1)
It would be necessary to massively expand primary care access. Aggressiveexpansion of the PA (Physician Assistant) and CNP (Certified NursePractitioner) programs would be required to ramp up for the addition of 48million people to the insured healthcare population while also expanding therole, authority and compensation of good, board certified primary carephysicians.
2)
Changes to cumbersome insurance data collection and reporting would beneeded. We must move off of RVUs and ICD-CPT as a reimbursementmethodology. Newer, codified and clinically relevant data models exists thatgreatly simplify a grossly over complicated and broken system (the AMA willfight this as it eliminates the need for their cash cow - CPT)
3)
Malpractice must be addressed to better control costs and eliminate thetendency for physicians to practice expensive and potentially dangerous
 
defensive medicine. Uniformity in malpractice laws must be applied on anational level. States must abdicate this role.4)Genomics will provide an incredible opportunity to tailor therapeutic optionsand research disease markers across populations, but that kind of informationwill be far too valuable and dangerous to ever be allowed into the hands of third party payers. The danger of this is so great that genomics cannotbecome part of a standardized medical record until safeguards are in place toassure patient maintenance of ownership and absolute security of thatinformation.
5)
Reimbursement to healthcare providers must be fair and equitable (which it isnot today – specialists largely call the shots and primary care physicians arebecoming extinct). In return for a fairer payment system, medical care MUSTbe tied to quality of care indices. There is no accountability today, and thislack of accountability is the single greatest travesty I hear when doctors andhealthcare pundits brag that we have the best healthcare system in the world. This can be rectified, but it will require universal adoption of an easy to useelectronic medical record that captures granular medical information in aformat that allows for anonymous aggregated and local quality reporting whilesafeguarding patient identity. This would also help us identify bioterrorismattacks earlier, provide more cost effective research, testing of drug therapiesand more accurate outcomes tracking. The list of benefits is almost endless.CMS is already well into a pilot that explores tying reimbursement toaccountability.
The method by which this works is called adjusted risk capitation. Thecapitation or HMO model failed in the past because there were no good tools to accurately capture and report risk severity and quality of care.That is now possible with the right EMR and clinical data model. Thisreimbursement model is in trial today with CMS, but the health datacapture tools remain mired in the ICD-9/CPT world. Adjusted risk capitation, done correctly, eliminates payment discrepancies betweenspecialists and primary care, provides for measurable higher quality of care and creates incentives to deliver higher quality of care by rewarding medical providers who provide that higher standard of care.
Realizing no one formula will satisfy everyone, a reasonable compromise thattakes into account the extra training required to become a clinician or surgeoncould be as simple as subsidizing the medical education of doctors thruresidency and then applying a base salary based on specialty plus a ‘bonus’for demonstrating measurable higher quality. Also, to make this work,physicians would need to be employed and their overhead covered by theemployer – most likely the government. To get and keep the best and thebrightest, salaries would have to be competitive with the private sector. Thesalary would need to correlate with work effort - # patients seen per day andafter hours with a rapidly diminishing rate after a certain threshold of patientswas exceeded. The reason for this is simple. Some doctors see 80 patientsper day. They are providing terrible quality of care, yet being rewarded forthe extra volume.A base salary for a board certified primary care physician, adjusted forinflation, ideally would be between $125,000 to $150,000 per year with abonus as high as 100% for demonstrating superior quality. Quality could onlybe reasonably accurately measured if doctors used an electronic health recordsystem. Surgeons would get the same base plus a multiplier and thismultiplier might be based on additional years of training or society’sdetermination of a particular specialties’ contribution to society. An actuarial
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ਟੁਟਪੈਣਾ ji

All the points mentioned above are indeed for better US healthcare which is not in a very good shape right now but I doubt the possibility of the AMA to take over the ICD-CPT.

reply03 / 25 / 2012
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