A modest proposal for health care reform – Rant

EDITOR’S NOTE: The November issue of 225 carried a guest column on page 105 titled “Reinventing health care,” by Baton Rouge pediatrician Chris Funes. His column is a summary of the following collection of position papers he wrote last summer.

Health care in the United States, as it is currently structured, is unsustainable. Physicians are compensated based on utilization of resources, with more (and more expensive) care rewarding physicians the most compensation. Recent graduates, after years of exhausting, expensive, and often degrading training, are released into the workforce with almost none of the idealism that pulled them to the profession originally; that idealism replaced with a mercenary business attitude of ‘eat what you kill.’ Terrible medical catastrophes paralyze entire families with debt, and loved-ones who need extraordinary care that the families are unable to afford. Only the ‘lucky,’ who have an often well-intentioned doctor or hospital to blame for the injury, get help; usually after years of litigation and after a large part of the money they need is claimed by attorney fees. Lastly, and most importantly, patients lack access to care that could improve the quality and quantity of their lives, decrease suffering, and allow them to be productive citizens – care that is available, but is as close as the moon as far as these patients are concerned.

To fix the problem by mandating that everyone have health insurance is as silly as to try to stop car thefts by providing all potential thieves with cars of their own. The problem isn’t that people are not insured, it is that health care is too expensive for most people to afford proper insurance. As more people fall under government-sponsored programs (which have tremendous negotiating power with providers), those with commercial insurance are forced to pay more than their share (in premiums and in taxes,) until they are forced to join the government lot. This leaves an ever-shrinking pool of ‘privately insured’ to shoulder the burden, which again, is unsustainable.

Instead of thinking within the ‘boxes’ into which the problem has been carved, every aspect of heath care has to be subject to fresh thinking. This proposal relies upon the following precepts, which will be discussed more fully in the position papers below:

• Medical education should be provided free, in exchange for compulsory service in a National Health Services Corps upon completion of medical residency.

• (Almost) all patients should have to provide at least some minimal contribution to their own care – care that costs nothing is considered ‘worth-less’ by the patient.

• Bad care is more expensive by a wide margin; when evidence is found that a better way exists to provide care, doctors should be expected to provide that care, explain why they feel they shouldn’t, or not be paid.

• New treatments that provide incremental improvements in outcome for extraordinary increases in cost, should not be paid for by insurers or government payers, without evidence of clear benefit.

• We cannot continue to pay a huge portion of our health care dollars for care in the last few days of life (out of guilt, or inability to deal with the normal process of dying.) When families insist on care that is futile, they should have to pay for that care themselves.

• Penalizing incompetent physicians needs to be separated from compensating patients with medical catastrophes. No one should have to be at ‘fault’ for someone with a tragic medical outcome to get financial assistance for their care – and this process needs to be taken out of the normal insurance model. A workers’ compensation-type model would allow everyone with horrible injuries due to medical care to more quickly receive help, and save money by decreasing litigation, and decreasing unnecessary medical care by physicians trying to protect against such litigation. A new process-improvement based approach could weed out the sources of injury; and when bad, truly negligent, or irresponsible physicians are at fault, could help them find a new line of work.

A Proposal for a National Health Services Corps

Most physicians choose medicine as a career for several reasons. Medicine is a respected career that earns practitioners the admiration of the general public. The monetary rewards are tangible, and allow a lifestyle of comfort, and the ability to provide for a family. The work is often stimulating, and intellectually (and often physically) challenging. At the outset, most aspiring physicians are, above all, drawn to the profession by idealism – the ability to help, serve, relieve suffering, cure illness, and participate in the betterment of the lives of their fellow human beings.

However, after years of sleepless nights, exhausting and often degrading experiences, and living in near poverty, medical graduates emerge into the real world facing hundreds of thousands of dollars in debt. Idealism is dead, or at best, forgotten. Realism sets in, and choices are made. Residencies are selected by the ability to reverse fortunes. Careers are selected with lifestyle and monetary reward foremost in mind. Even worse, deserving would-be physicians from less affluent backgrounds, those most likely to return to their communities to serve those most in need, don’t even consider medical school because the cost is prohibitive.

I propose an alternative. Medical education that is free, available to the most deserving as a true meritocracy, in exchange for 2 to 4 years of compulsory service in a National Health Services Corps. New graduates would emerge free of debt, able to choose residencies based on their own preferences and calling. Upon completion of residency, these highly trained and motivated physicians would serve in areas of need, providing care for those most in need. They would be compensated fairly, but being debt free, would be able to live comfortably, if not lavishly. There would be a constant new stream of workers (perhaps in the allied health and nursing careers as well,) many of whom might choose to stay in the ‘Corps’ beyond their obligation. Upon completion of their service, they would be free to continue their careers where and how they chose. Without burdensome debt, and with their idealism still intact, these physicians would form the backbone of our health care system as the compassionate and beneficent caregivers our system direly needs.

The length of service would depend on the cost of tuition borne by the government. Someone who desired training at a more prestigious institution, with higher costs, would owe more service. Someone who had debt from college could elect to defer payment until released from their service, or serve more time to emerge debt free. There would be no option for repayment of tuition after the fact, in exchange for release from service, as this would be very similar to the system that now exists. A provision could be considered, however, for someone who was willing and able, to pay full tuition prior to matriculation, in exchange for avoiding compulsory service. (The hope would be that for all but the most affluent, beginning a career debt free would offset the temptation to avoid service.)

This National Health Services Corps would ensure that evidence based care would be provided for our most needy citizens, at sustainable costs, by highly trained physicians with their dignity and idealism intact.

A Proposal for Common Sense ‘End of Life’ Care

It is estimated that 10 – 12% of heath care expenditures occur at the ‘end of life.’ Also, approximately 40% of the Medicare budget is spent on care in the last 30 days of life. Even subtracting care given to patients who are seriously injured, and require lifesaving care, and patients in the prime of life who are undergoing expensive care but still succumb to disease or injury; we spend a huge portion of our health care resources providing futile care at the end of life. Often this care is given to patients, who if they were able, would decline that care in favor of death with dignity.

Most of us, given the information and opportunity, would decline the same care that we impose on those we love. Whether out of guilt, or ignorance of their wishes, we extend the lives of family members or loved ones beyond their natural courses, using artificial means.

I propose an alternative. As a prerequisite for obtaining or renewing health insurance premiums, patients should be required to list their wishes as to end of life care. They should be given realistic and clear information as to the probability of success, as well as long term quality of life, of life extending therapies (such as CPR, mechanical ventilation, etc.) adjusted for their age and current health. Hospice and other alternatives should be presented in the same manner.

For those who still choose futile or non-recommended end of life care for their loved ones (who are unable to make choices for themselves,) the family should be required to pay for that care.

Likewise, organ donation should be an ‘opt out’ rather than an ‘opt in’ process. In places where organ donation is assumed to be the default, rather than the exception, organs are much more readily available, and patients are transplanted sooner, while their general health is still relatively good.

A Proposal for Malpractice Reform (and Care of those with Catastrophic Medical Injuries)

Currently in medicine, the system that exists to deal with catastrophic medical injuries is borne of the confluence of several bad hypotheses. First, if a patient is injured during the provision of medical care, someone has erred, and is at fault. Second, that person or entity should be punished for the ‘error.’ Third, that punishment will prevent future ‘errors.’ Fourth, if the punishment is financial, it will compensate the injured patient for their injuries; or if the injury resulted in death, will compensate the family for their loss. Lastly, at the end of the day; with a traumatized provider, an injured patient (and/or a devastated family), and multiple well-compensated attorneys; the process can be considered a success.

The system is a farce. Any patient who truly suffers great injury during the provision of medical care will tell you that the financial compensation did not make them whole. Likewise, a family who loses a member, or has to care for one terribly injured, will tell you that their loss is not abated by the financial compensation. So what went right? Has a bad physician learned their lesson, never to ‘err’ again? Studies show that bad physicians continue to practice bad medicine, while good physicians who caused unintentional harm as the ‘sharp end of the (health care) knife’ often feel scarred, guilty, and embarrassed by a process that reduces them to non-person status. Many quit medicine altogether.

So who wins? The attorneys?

I propose an alternative. First, as described eruditely in the book, Internal Bleeding, most medical ‘errors’ are not truly errors at all. Medicine is a human enterprise, and as such, is not perfect. Doctors make ‘slips,’ unintentional deviances from the best course, because to do so is human. Someone who gets off at the same exit for work every day, may accidently get off the same exit when headed to church on Sunday. The way to fix slips is process improvement. Eliminate the human element whenever possible, with automation, simplification, and fail-safes. Anesthesia as a medical discipline, has achieved unprecedented safety by doing this very thing.

Second, uncouple compensation for medical injuries from the process of finding what went wrong. Families and patients should not be left destitute just because no one could be found to blame for their injury. Rather than pay outrageous medical malpractice premiums, doctors and hospitals, (and insurers ?), could pay into a workers’ compensation type plan that would defray medical costs and provide income support for injured patients – regardless of fault being determined. The costs of such a program would easily be covered by savings from unnecessary litigation expenses, while making sure that more money goes to the injured party, instead of attorney fees.

Third, a new system would be needed to look at all injuries, as well as near misses (much like the non-punitive system the FAA uses to increase airline safety,) to determine when education, counseling, punishment, or career change are needed on the part of the physician. This body could also use the data to push performance improvement initiatives, with financial incentives (and disincentives) for organizations or physicians who did not comply.

The tort system has been an abject failure at improving care, compensating the injured, and preventing future injuries. It needs to be removed from the arena of health care, in favor of a system of continuous process improvement. Catastrophic medical injuries should not mean financial ruin for an already devastated patient and family. Good physicians should not practice fearfully with the sense of a guillotine hanging overhead awaiting their every human slip. Bad physicians should be removed from clinical patient care.

A Proposal for Cost Sharing for Medicaid-funded Physician and ER Visits

Proposal: To create a pilot program to promote judicious use of Medicaid resources through the utilization of small co-pays for medical visits, and to evaluate for effects on outcomes.

The need: Louisiana, as is the case with most states, is in a crisis situation. Utilization of Medicaid resources continues to increase, while funding of programs continues to decline. More children than ever depend on Medicaid to provide medical care, but access to pediatricians continues to decline. Excessive use of emergency rooms, urgent care centers, and doctor’s offices for unnecessary visits strains already limited resources, and decreases access by forcing doctors to limit Medicaid enrollment in their practices.

The plan: Impose a small co-pay to apply to doctor’s office visits, with slightly higher co-pays for after hours and emergency room visits, with certain restrictions

• Would not apply to ‘well child’ care

• Would not apply to infants under 12 months of age

• Would not apply to doctor initiated visits, such as follow-ups, or interval visits for chronic health problems (to avoid discouraging such visits.)

• Would not apply to children with chronic health problems such as cerebral palsy, or problems related to prematurity

• Would be scaled, with patients less than 50% of poverty paying only $3, 50-100% of poverty paying $4, and patients >100% of poverty paying $5. ($10 for ER visits?)

• Could utilize Medicaid card as a debit card “filled” with value equal to a number of co-pays, to encourage plan participants to be judicious stewards of Medicaid resources. (After card value is depleted, members would be responsible for co-pays for that year.)

Benefits: This plan has the potential to offer benefits to the patients, the physicians, and to the state (as the insurer of patients on Medicaid.) For patients, fewer frivolous visits, and a payment methodology that more resembles private insurance, may mean that more doctors accept Medicaid patients. Also, doctors who currently accept Medicaid but limit enrollment numbers may be able to serve more patients. Contributing even this small amount to their own health care coverage may give patients a greater sense of pride, and a desire for a more active role in their health care decisions.

For physicians; having a small co-pay, (even if only for some visits) in addition to the usual Medicaid fee schedule; has benefits. First, there would be a modest increase in physician reimbursement for an office visit. Second, patients would be incentivized by the higher co-pay for ER and after-hours clinic visits, to seek care first at their physician’s office, reinforcing the physician’s role as a medical home. Last, Medicaid would function similarly to other insurance plans, adding a degree of legitimacy.

For the state, the financial savings could be significant. Fewer unnecessary visits equal immediate savings, with indirect savings on administration and management of accounts later. Barring co-pays for well checks insures that EPSDT provisions are still met, and that preventive visits are encouraged. ER visits would be discouraged in favor of office visits with the primary physician. Also, improved reimbursement coupled with decreased physician frustration could result in more providers accepting more Medicaid patients.

The site: I would suggest that Baton Rouge is the ideal community in which to pilot such a program. The community is fairly large, but has only one true hospital ward for children, allowing for easy outcome measurements. Physician participation could be measured over time, and satisfaction surveys conducted before, during and after. Emergency room and after hours clinic visits could be tracked and measured.

The opposing viewpoint: Those who are opposed to co-pays for those on Medicaid say that they would be a barrier to care. First, we are quickly approaching unsustainability, and something has to be done. Second, the ‘exceptions’ listed above account for many of the legitimate concerns that might result in children not receiving care they need. Third, we cannot legislate good parenting – if a parent will not take a child who is seriously ill to the doctor because of a small co-pay, that parent probably is already making bad choices for that child, and a different form of assistance is necessary. However, it is unfair to assume that parents of limited means would not do what is necessary to see that their child got the care she needed. In my experience, parents are parents, and usually do whatever they think is best for the child, ahead of their own needs.

Summary: The prohibition of co-pays for children receiving Medicaid is an anachronism that is no longer viable in today’s medical economic environment. Utilization patterns have changed, and what was true when Title 19 legislation was first introduced, is no longer true today. Experience in private insurance models have shown that co-pays are a legitimate and effective tool for encouraging appropriate use of medical resources, without resulting in worse medical outcomes. It seems inherently unfair that a patient in Louisiana at 151% of poverty will likely spend 25% of their income for medical care or insurance, yet a patient at 149% of poverty is expected to contribute nothing. For the average patient who will have only a handful of illnesses requiring medical attention, the total cost will be negligible. To the state, the savings could be significant.