Daily Healthy: integrated care

A Citizen's Amendment to RyanCare

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There are <a href="http://acasignups.net/sites/default/files/2016_total_coverage_pie_chart.jpg" target="_blank">approximately</a> 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare exchanges. There are another 14 million or so who could be buying insurance on the individual market, but choose not to buy anything. This puts the total individual market at about 10% of Americans. Half of those are, or are eligible to be, heavily subsided through Obamacare (including those huge deductibles). The other 5% are facing the full brunt of health insurance price increases under Obamacare. Of those, 3% are paying for Obamacare health insurance and getting garbage in return for their money, while the remaining 2% are uninsured. This is the magnitude of the primary problem we are supposedly trying to solve. 
 
The 17% of Americans on Medicare are not upset at Obamacare. The approximately 23% of Americans on, or eligible to be on, Medicaid are not angry at Obamacare either (although the 1% eligible for the Medicaid expansion in states that chose not to expand it, might be angry with their Governors). Some of the 50% or so, who are getting health insurance through their employer, and used to get rather flimsy insurance in the past, may be somewhat disgruntled because the Obamacare imposition of “essential benefits” caused their share of premiums and deductibles to rise, and their ability to choose their doctors to plummet. This is the secondary problem we are supposedly trying to solve. 
 
The <a href="https://housegop.leadpages.co/healthcare/" target="_blank">American Health Care Act</a> (AHCA) addresses neither problem and exacerbates both. 
<h4>
Three Pronged Care</h4>
The proposed GOP solution is “<a href="https://www.whitehouse.gov/repeal-and-replace" target="_blank">three pronged</a>”. Prong One repeals Obamacare (whatever that means) and replaces it with more widespread, but less generous, subsidies for the individual market and reduces funding for Medicaid, while also reducing Obamacare taxes on corporations and wealthy individuals, including taxes slated to increase the longevity of the Medicare trust fund. Prong Two is a flurry of yet to be determined regulatory relief that the Secretary of Health and Human Services will be supposedly providing at his discretion. Prong Three consists of new legislation, which will require the support of at least some Democrats in the Senate, to relax both the definition of Obamacare “essential benefits” and the regulations on health insurance corporations, so cheaper insurance plans can proliferate across the land (as they did before Obamacare). 
 
The most important thing to understand about the Three Pronged Care proposal is that although the CBO can, <a href="https://www.cbo.gov/publication/52486" target="_blank">and did</a>, estimate the effects of the first Prong, nobody can estimate the cumulative results of all three Prongs, because nobody knows what the second Prong is and because it will take an act of God to make the third Prong materialize. Since we are talking about health care, think of this as some sort of orthopedic, cardiac or transplant surgery. First you cut the patient open, then you remove or adjust the offending parts, and then you put in something new and hopefully better. Coming in after a previous surgeon messed things up is obviously harder, but cutting the patient open and walking away until you figure out if you want to or are able to do more, is hardly a viable option for the patient, and will likely result in a huge malpractice suit (plus a copious prison sentence) for you. 
<h4>
What if Prong One is as good as it gets?</h4>
Unfortunately, this is precisely what Paul Ryan and his ragtag coalition are proposing to do with Prong One, whose sole effect will be to add insult to the Obamacare injury. Once we accept the premise that the Federal government has an obligation to help people get health care, the remaining disagreements are just haggling over price. And once we dismiss highfalutin principled rhetoric, the problem with Prong One is that for most people, in absence of Prongs Two and Three, this is just a stingier version of Obamacare. The GOP argument that two imaginary birds in the bush are better than a real bird in hand flies in the face of millennia of human wisdom. On top of that, there is absolutely nothing in Prong One that even begins to address the fundamental problem in our health care system, which is the unit price of health care services. Therefore, premiums and deductibles will likely continue to rise unabated. 
 
In all fairness though, there is a twisted argument to be made that if you cut subsidies and there is less money available, insurers will work hard to lower the price of their products to match what the “market” can bear. That may be true if the reduction in funds affected the entire market, instead of at most 10% (likely 5%) of it, and the least profitable 10% to boot. In “normal” markets, a non-participation rate of 10% percent is certainly sustainable and actually pretty good for the sellers. That said, smaller health insurance vendors currently specializing in Medicaid managed care could step into this niche and offer a commercial product through their existing underpaid networks. If you’re a physician, this prospect should set your hair on fire. 
<h4>
The Free Market Delusion</h4>
At some point we will need to collectively disabuse ourselves of the notion that a market in health care insurance could be created without abolishing the provision of health insurance benefits through employment. I know everybody is talking about Flo and the little lizard selling health insurance on TV as the ultimate solution to health care affordability, but that is nothing short of demagoguery. Note that practically all auto insurance is business to consumer (B2C), while health insurance is overwhelmingly business to business (B2B). I suggest you try buying a cow from a feedlot and see for yourself how much negotiating power your consumer status bestows on you in a B2B market. If you want to try a free market solution for health insurance, you would need to do more than just kick a few poor people off their subsidies. You would need to kick 150 million people off their employer health insurance plans. Good luck with that. 
 
I have to admit that there is something compelling about the conservative vision of a portable health insurance product that people buy and carry with them wherever they go. Obviously health insurance that is intended to serve people from cradle to grave cannot be a game of Russian roulette with covered benefits, or as Mr. Ryan refers to it, “patient-centered” insurance. Equally obvious is the fact that State and Federal governments will still have to honor their obligation to help those who can’t afford to purchase insurance for a predefined set of “essential benefits” on their own. Will such semi-free health insurance market deliver the health care affordability we seek? Not likely. The deceptively simple truth is that you cannot successfully tackle the pricing failure in the health insurance market without first taking an axe to our dysfunctional health care delivery system. 
<h4>
The Three Prong Shuffle</h4>
Obamacare not only failed to put a dent in health care delivery prices, but arguably made things worse by actively encouraging system consolidation. Under the best case scenario, a heavily modified GOP Prong One plan (e.g. higher tax credits, lower tax cuts for the rich, more money for Medicaid), will not change the Obamacare trajectory one bit and will not provide meaningful relief to people hurt by Obamacare. All this tinkering and re-tinkering with an insignificant portion of the health insurance market is like obsessively unclogging the kitchen sink on the Titanic. The sketchy descriptions of Prong Three, the free market prong, are just too ridiculous to consider at this point, but Prong Two, the regulatory prong, has great potential. After reading the <a href="https://rules.house.gov/sites/republicans.rules.house.gov/files/115/PDF/115-AHCA-SxS-MNGR-Policy.pdf" target="_blank">manager’s amendment</a> to the Ryan Make America Poor Again plan, I would like to offer my own citizen’s amendment. 
<ul>
<li>New Prong One: Swallow hard and let the AHCA die a merciful death. Extend some temporary relief to the 5% hurt by Obamacare. Give Secretary Price a chance to affect regulatory changes first. Medicare is the de-facto price setter for health care services. The Secretary can affect changes to Medicare fee schedules and payment models that will quickly ripple through the commercial sector. I would start with the <a href="https://www.ama-assn.org/about-us/ruc" target="_blank">RUC</a> and hike the relative value of comprehensive primary care. I would create a monthly CPT code that can accommodate subscription based primary care (not quite what the Direct Primary Care lobby wants, but darn close). And I would engage in a long string of multi-payer initiatives to accelerate dissemination of measures to control unit prices, while leaving behind the naïve and failed attempts to cut utilization.</li>
<li>New Prong Two: This is not a purely health care prong, but it is necessary because this is the only way to fix health care in America. Get those tax cuts done, renegotiate trade agreements, fix the education system, get infrastructure projects going, get manufacturing back, drain the swamp, and create lots of opportunities. Introduce specific pieces of legislation along the way to negotiate drug prices, break health system monopolies or at least encourage independent, small and more cost-effective practices to thrive. Keep up a brisk regulatory and deregulatory program to curtail the flow of billions of health care dollars to opportunistic corporations that do not provide care or any other benefits for patients. Think creatively about connecting health insurers’ participation in State/Federal programs to affordability in the individual market (at the very least make it count in Medicaid RFPs).</li>
<li>New Prong Three: If all goes well, we can finally do away with Obamacare, which should become automatically obsolete if Prongs One and Two are executed successfully (otherwise Obamacare will be the least of our problems). If the economy catches fire and more people have good paying jobs, and health care unit prices are at the very least contained, fewer people will need subsidies or Medicaid welfare. Make a note to schedule a symbolic full repeal and replace on January 21st 2021. I am certain it will pass with strong bi-partisan support. </li>
</ul>
Will Washington DC put the horses in front of the cart for a change? Not by choice. However, the good news is that all of a sudden Prong One seems to be on life-support in the House and dead on arrival in the Senate. The excellent news is that President Trump made another <a href="http://insider.foxnews.com/2017/03/15/president-donald-trump-tucker-carlson-tax-returns-obamacare-disaster-wiretap" target="_blank">promise</a>: "We will take care of our people or I’m not signing it" (it being Prong One, whatever it ends up being, if it ends up being). The disastrous news is that no self-respecting Democrat will engage in any effort to help the President help the American people. That would be too much to ask of our elected representatives. </div>

There are approximately 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare ...

How does your primary care doctor coordinate with your psychiatrist?

9:32 PM Meme Art Studio 0 Comment

By Pierre Gingerich-Boberg, Medical Student<o:p></o:p> Reviewed by Claudia Reardon, MD<o:p></o:p> I’m stuck in behaviors that are making me unhealthy.  My smoking makes my asthma worse, and I don’t want to end up with emphysema like my dad.  I smoke when I’m anxious, and my finances, my teenager, my boss, and my increasing weight all make me anxious.  Now to top it off, my chronic headaches are getting worse.  My problems are physical, but I know they’re also mental.  But the idea of seeing a psychiatrist makes me even more anxious!  What should I do?<o:p></o:p> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5ZWkNPuSeKsEwK3FmrvIY0Rfq95F7IacuJkVf2zV8fSp4t84kQoifBEe66Vc_Ivjbrd3DGyAkW43qig9LTOYb6-rk0QrySgfTHLfl_mG6EwfxTBkJJyK4ye0SGx_XB4OCDx-EWwkRxBwh/s1600/IC+graphic+part+1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="118" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5ZWkNPuSeKsEwK3FmrvIY0Rfq95F7IacuJkVf2zV8fSp4t84kQoifBEe66Vc_Ivjbrd3DGyAkW43qig9LTOYb6-rk0QrySgfTHLfl_mG6EwfxTBkJJyK4ye0SGx_XB4OCDx-EWwkRxBwh/s1600/IC+graphic+part+1.jpg" width="200" /></a>Patients need primary care doctors who can comprehensively address the varied aspects of their physical and mental health. Health systems are starting to recognize that multi-disciplinary teams (sometimes called patient-centered medical homes) can be an effective way to provide <a href="http://www.psychiatry.org/practice/professional-interests/integrated-care">integrated care. </a> How might this look for our example patient?<o:p></o:p> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> First, it’s worth noting that traditional <a href="http://integrationacademy.ahrq.gov/lexicon">primary care</a> doctors already spend a lot of effort helping patients with a wide spectrum of behavior issues.  We saw this for our example patient.  Her anxiety is an example of a classic mental health problem—others might be depression, panic attacks, and addictions. Primary care docs refer some of these patients to psychiatrists, but primary care docs are treating the majority directly.  Our patient’s headaches are likely a functional ailment. Like irritable bowel syndrome and general aches and pains, headaches are real problems that often defy simple solutions.  Standard treatments focus on limiting symptoms while helping patients cope with the stressors and psychological distress that often contribute.  Finally, our patient faces problems with health-related behaviors including tobacco use, diet, and stress management.  These and other common behaviors are hugely important for the development of chronic diseases.  <o:p></o:p></div> <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuXw0Z1_O4xNQqCWAK4j2aFkrXXoyr_8n8_2M51rwpH67urSpaVedtIwNDpGEVwJfgOENOTZnaf2-nXuGlieZslyPpS1NYU9tgxacue5a3HGrWhgPMjg3WwFIEgafQhz6IPDN8gt11EUrw/s1600/IC+graphic+part+5.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuXw0Z1_O4xNQqCWAK4j2aFkrXXoyr_8n8_2M51rwpH67urSpaVedtIwNDpGEVwJfgOENOTZnaf2-nXuGlieZslyPpS1NYU9tgxacue5a3HGrWhgPMjg3WwFIEgafQhz6IPDN8gt11EUrw/s1600/IC+graphic+part+5.jpg" width="320" /></a>Our patient’s picture might seem complex, but primary care doctors face such complexity (and more) every day! Frankly, patients often are dealing with too much for their doctors to address optimally in a 15-20 minute time slot. One approach is to triage—to ask what’s treatable and doable, and what can wait until the next appointment. The limited time available for counseling tends to push primary care doctors toward relying on treatment with psych meds. A second approach is to refer the patient to a psychiatrist.  But psychiatrists in many communities are spread too thin, so patients often wait weeks or months for an appointment. Then there’s stigma--our example patient’s anxiety around psychiatric care is actually pretty typical.  This helps push up no-show rates for first visits with a psychiatrist to 30 or 40%.  It’s no wonder that careful studies show that only a fraction of the mental health problems in our communities are ever diagnosed, and fewer still are adequately treated.<o:p></o:p> <div class="MsoNormal" style="margin: 0in 0in 0pt;"> A third option returns us to the <a href="http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Guide-to-Health-Homes-Design-and-Implementation.html">medical home</a> concept.  At the VA and increasingly in federally qualified health centers (FQHCs), mental health services are being brought into the primary care setting.  Here, <a href="http://www.hipxchange.org/Access">behavioral health consultants</a> (BHCs) share space with primary care doctors.  These are generally psychologists or social workers, that is, non-physicians. BHCs’ schedules are intentionally left mostly open, so that they’re available to see patients immediately after a non-threatening ‘warm handoff’ from the primary care doc.  The BHC can offer expert counseling for the patient, and advise the primary care provider on diagnosis and treatment.  BHCs arrange for a small subset of their patients to get a subsequent visit with a psychiatrist (a specialist physician), who is also in-house.   All the BHC patients get systematic evaluation and follow-up by phone or with visits to make sure their needs don’t fall through the cracks.<o:p></o:p></div> <iframe allowfullscreen="" frameborder="0" height="160" src="//www.youtube.com/embed/Z8Kx0GxSle0?list=PLf3_-c0tpWquEz-UdYwSWBTBIJwwKfARC" width="280"></iframe> When a behavioral health consultation system is in place, problems of waiting times, missed appointments, and incomplete records are eliminated for most behavioral health visits.  Primary care docs have more time to focus on medical issues, while getting the expert consultation they need to optimize behavioral health care for their patients. Finally, because most behavioral issues can be addressed efficiently by BHCs, specialty psychiatrists are not so swamped, and waiting times can be greatly shortened for the small group of patients needing psychiatric care beyond what can be managed in the primary care setting. <a class="twitter-share-button" data-count="horizontal" data-related="APAPsychiatric" data-via="APAHealthyMinds" href="http://twitter.com/share">Tweet</a><script src="http://platform.twitter.com/widgets.js" type="text/javascript"> </script>

How does your primary care doctor coordinate with your psychiatrist?

By Pierre Gingerich-Boberg, Medical Student Reviewed by Claudia Reardon, MD I’m stuck in behaviors that are making me unhealthy. My smokin...

The Arithmetic of Health Care

11:05 PM Meme Art Studio 0 Comment

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Adam Smith would disagree, Karl Marx would be appalled, and heck even Milton Friedman and Ayn Rand would be raising objections. But for some peculiar reason, there are enough contemporary lesser economic minds scattered throughout the entire philosophical spectrum, that are advocating for, and enabling the execution of, a government induced transition of our health care system to an oligopoly model of business. It all started with someone stating that our health care system is broken, and my guess is that a multitude of otherwise very intelligent people took that to mean literally broken into a multitude of useless shards of uneven size and quality. Hence the frantic attempts to glue the “fragmented” Humpty Dumpty system together again, and unlike the legendary efforts of all the King’s horses and all the King’s men, it seems that we are well on our way to putting together something that never was, and arguably never should be. 
 
Consolidation is the name of the game. Health systems are buying each other and are morphing into insurers. Private equity is buying whatever it can buy. Insurers are buying each other and are buying health systems and everybody is buying physician practices. In health care nowadays, either you are buying something, or you are selling yourself, and sometimes you do both. While these unholy matrimonies are executing, those who sell technology for health care are following a similar consolidation path, because small firms are rarely able to service large corporations adequately. The government who initiated, or wholeheartedly endorsed, all this fragmentation rhetoric, kicked off the consolidation bonanza by chartering Accountable Care Organizations (ACOs) and by imposing a slew of regulations favoring large health systems, not the least of which is the acquisition and prescribed use of very expensive and very complex health information technology. 
 
And the early, anecdotal, results are beginning to trickle in. Last week the <a href="http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?ref=business" target="_blank">New York Times</a> published an article about the consolidation battles of two saintly health systems in Idaho (St. Luke and St. Alphonsus), waging holy war on each other for the right to acquire more physician practices, and with them, more patients to refer to more services within the system. Area doctors seem distraught and the prices of medical services in the larger St. Luke system seem to have tripled following each acquisition. The hundreds of comments to the article include many more similar stories from all over the country. The NYT article is not the first one to highlight the inflationary effects of mending our broken health care system, and you can find plenty more anecdotal stories <a href="http://online.wsj.com/article/SB10000872396390443713704577601113671007448.html" target="_blank">here</a>, <a href="http://online.wsj.com/article/SB10000872396390444433504577649523985288422.html" target="_blank">here</a> and <a href="http://www.sfgate.com/default/article/Private-cardiologists-selling-to-hospitals-4063646.php" target="_blank">here</a>, and for those insisting on being surprised, there is always the early 2010 <a href="http://content.healthaffairs.org/content/29/4/699.full" target="_blank">Health Affairs</a> study of California-style defragmentation effects on the price of health care, and a grim warning regarding the implications to health care reform. 
 
The fascinating part of this process is that health information technology is being cited by all players as a major driver for consolidation itself and also for the subsequent increase in costs of services. Information technology, if you remember, was supposed to reduce costs for the health care industry just like it did for other industries. Instead, it seems that the complexity and unaffordability of technology is driving small providers to sell themselves to the highest bidder, and the ensuing oligopoly is then justifying its immediate price increases by the need to outfit its newly purchased assets with state of the art information technology.  It seems that the fancy brand-name buckets of glue used to put the health care Humpty together are way too expensive. The apologists for the consolidation trend observe that this is just an upfront investment and soon we will be reaping the benefits just like all those other industries. These editorial opinions ignore the fact that Walmart never increased its prices to account for the world’s most sophisticated supply-chain software system and neither did anybody else in those other industries. They also ignore the Kaiser experiment in our own backyard, where billions of dollars in technology, over many years, may have resulted in better quality (according to Kaiser), but had no beneficial effect on consumer premiums for Kaiser plans, which are keeping pace with all other less integrated and less technologically advanced entities. 
 
Many health care technologists are accusing doctors of misusing technology to emulate the inefficient paper chart process and hence are failing to realize the benefits of new technology. My guess is that we have a very similar problem with health care reformers, who are envisioning technology as the glue needed to create 19th  century business models for health care, because it worked so well for railroads, banks and car manufacturers. And to that end, the technology paradigm forced on health care is big, heavy, slow, expensive and in every way corporate and duly regulated by government. It feels like iron from an era that has ended about 10 years ago. The disgruntled physicians, who are complaining about health information technology not being like their iPhones or their Facebook, are instinctively recognizing that both the technology and the business models it enforces are dead. 
 
From a technology point of view, the information age is over. This is the collaboration age and information availability is assumed, just like electricity is assumed. When I can sit in my kitchen and casually chat with a colleague in Karachi, while we are both working on the same Google document and can see each other’s edits in real time, as if we were in the same room, huddled around the same table, and at zero cost to both of us, there is suddenly no ability to comprehend why having two (or seventeen) physicians coordinate patient care necessitates the formation of a new corporate structure supported by technology yet to be built and standards yet to be defined. We have the technology to support all the lofty goals of true health care reform, and the technology itself is dirt cheap, which makes economies of scale, once available from physically owning and controlling as many means of production as possible, insignificant in modern service industries. Those dwindling economies of scale are of course outweighed by the monopoly’s age old ability to set prices, which may be nice for the conglomerate, but not so nice for the rest of us. 
 
The assumption that a corporate office must control everything, including customers, through computerized means, in order to create efficiency and accountability is only true if that efficiency is to be reflected in the corporate bottom line, and said accountability is to corporate shareholders, or the corner office. The assumption that government must dictate and regulate every aspect of the business and its technology tools in order to protect consumers is only true if the business is a large monopolistic corporation. It doesn’t matter how greedy you think doctors are, a million doctors running hundreds of thousands of small businesses cannot do a fraction of the damage one monopoly can do with a proverbial stroke of a pen. Thousands of hospitals operating independently, largely as contractors for those independent doctors, can never muster the necessary clout to unilaterally raise prices or hoard information, and hundreds of insurers (or fund administrators) negotiating separately, can never drive hospitals, doctors or patients into bankruptcy. And government’s job is to ensure that everybody plays by a clear and simple set of rules. 
 
This is what we mean when we say that health care is local. This is what Adam Smith’s books were all about. And this is what we should be doing (with or without a single payer). Instead of erecting regulatory barriers to simple collaboration, we should be smashing any large pieces left over from times when Humpty Dumpty was ruling the walls on which it was sitting, because health care is not literally broken or fragmented. It is distributed.</div>