Obamacare or Nobamacare, why this is just a symptom of what is wrong with healthcare in the USA
The election is over and a large portion of the population has either renewed or newly purchased a new health care plan from one of the exchanges beginning this month. The insurance companies are slowly removing themselves from the exchanges and talk of a public option of some sort to fill in the void by President Obama and candidate Clinton was read about in our newspapers.
According to what we read, health care costs overall had been kept in check over the past few years, while our medical premiums, deductibles, and co-payments had skyrocketed, often pricing us out of plans we thought were going to take care of us through the following year.
Because of the frontloading by Obamacare with private insurance carriers who are making more money than ever, we are paying more, hospitals are joining hospital systems to avoid tier 2 status that often has higher deductibles or copayments and doctors are selling their practices to hospitals so they can be “in the game”.
Non-hospital-based healthcare providers are being picked off by insurers since they cannot combine forces which are considered antitrust, while insurers themselves are shielded from this. Groups such as psychologists and chiropractors are two examples of groups often maligned by large insurance carriers, even though they are often on the front line of what patients want because these services are often dollar for a dollar more cost-effective. The net effect is fewer practitioners are willing to stay in those networks and be paid very little, while the insurer underprices their services, the patient pays the bulk of the cost and the insurer pays a mere pittance. The insurers are quietly eliminating plans with out of network coverage, as an enticement for doctors to join their networks.
During the primaries, Bernie Sanders brought the idea of Medicare for all, which offers the simplicity of one insurer, one set of rules, and a proven system that has low administrative costs and has served our aging population well. This is likely what a public option would have looked like. In general, you can ask anyone who is under Medicare and they are going to tell you they like it, and enjoy an interstate network of doctors and hospitals. You can also ask those who chose a Medicare advantage replacement plan and you will quickly find out that they were promised one thing, while they got another even though the plan offered some perks and they have a much smaller network.
When you compare this to our state to the state system, with different insurers with different rules, regulations, drug formularies, etc., and the fact that their plan populations are not nearly broad enough, often we find ourselves paying more, while the insurer uses 20 percent of the income from your premium to fund advertising, the ugly free T-shirt at the baseball game as well as the administration of claims, fraud prevention, etc.
The dirty secret is that for years, the insurance industry has reduced primary care, the first place many of us go to an underpaid 10 minute or less office visit. Ten minutes or less is way too little time to evaluate you or your problem. Today’s typical visit results in tests, referrals to high priced specialists, and a whirlwind of copays, deductibles, and medical services that cannot possibly replace a good thorough evaluation your doctor cannot afford to take the time to do. The other dirty secret is that many of the procedures are unnecessary, expensive, offer increased risk, and do not improve the quality of our lives.
While there is no shortage of doctors, there is a shortage of primary care because the specialists are often overcompensated, while the primary doctors are paid a mere $40 or less for a Medicaid visit, and need to have their patients come back for other services just to break even. The other side of the problem is that our gatekeepers know little about the musculoskeletal system, and rather than evaluating you properly, they defer to what they know; blood pressure, diseases, medications, medical tests which can often be eliminated if they knew how to do a basic evaluation of the musculoskeletal system. The piecemeal allopathic idea of symptoms, medications, and the disconnection of how the body works often results in a huge misunderstanding of why things go wrong in the body and what could be seen using a holistic approach to management, a concept alien to most healthcare providers. After thousands of dollars of tests, patients often find relief in holistic chiropractic or other complementary providers and often pay a large portion of the bill themselves after the expensive mainstream approaches fail to work. Does that sound like your insurance premium is being used appropriately? This is why we now have an opioid epidemic and why so many people are on so many medications, more than any other country on earth.
While this sounds like a rant, the truth is that nobody is asking healthcare providers to offer policy improvements for primary care. Who is primary care anyway and did the way insurers forced primary care to become the 10-minute provider lower or result in huge costs increases, while we place more people on more medications for the symptoms rather than understanding the problems we face as we age? Do we need to redefine primary care to be more inclusive for other specialties and pay them more? Is there a doctor shortage; not really. Is there a shortage of doctors who want to work for less under primary care; definitely. Does the model need to change; for sure?
For insurers, the more they charge under the Obamacare 10/20 rule, the more they make. They have figured out how to make more money by making the system cost more. This is why even self-insured companies who use major insurers as their networks are seeing their costs rise as well. More rules, more changes, less efficiency, and the more we pay and our costs get higher. Allowing insurers to cross state lines may affect premiums somewhat, but insurers still have a profit motive, and this approach will not reduce the administrative burden on your local doctor or the hospital systems. Currently, federal workers have a blue cross plan that does go across state lines and it is also a federally funded plan. Plans like this are self-insured and simply using Blue Cross and their fee schedules as their network, while they pay the bill themselves.
The hospitals are now large monopolies and are getting ready for the new big idea called Population Health, which is the big idea of keeping the population healthy and disease-free, working with populations rather than individual health issues to solve health problems. Along with ACO’s (Accountable Care Organizations) and the Medical Home concept, this is likely to change our focus on how we deal with large scale health problems in systems, but a corporatized big-money approach is likely to cost more and fail to help us when we have problems we suffer from as individuals, as is often the case. If you have back, neck, knee, or shoulder problems, a population health approach is not helping you and it is likely your doctor has learned to make your problem fit what they know, not what you are suffering from; a bad idea.
Years ago, auto manufacturers realized they need to talk to their workers, to get better assembly lines and more defect-free cars. The healthcare policy wonks apparently make policy without the input of doctors in the front lines. Ask most doctors about how they like writing a 3-page electronic note for a sore throat, and they will give you a mouthful. Are the notes for us, for the insurer, for Medicare or for a huge database of healthcare info that is transportable? The truth is that we have no central database, the notes are protecting the doctor from an insurance carrier audit or clawback of fees, while the note really should be about our record on that particular patient that can be compared to previous visits to improve the quality and continuity of care. The note can be also used to communicate your management of a case to someone else, or protect the doctor from a lawsuit. The note should be able to add information to a national database, something that was promised but never delivered upon years ago. Most doctors would like simpler electronic notes that have intuitive software, that allows them to care for a patient, leave the room and finish, instead of the current reality of the doctor going home and then logging on to finish their notes for a couple of hours and constantly having to check things off to meet the requirements of things such as meaningful use, that may not even apply to the patients visit that day. If primary care doctors had fewer regulations and would be paid fairly for their time, as they used to be 40 years ago, that alone, while deemphasizing the over specialization of healthcare will bring costs down and bring in more doctors to primary care.
As Bernie Sanders suggested, simplifying healthcare with a Medicare for all model would be a good way of reducing costs because the government has more negotiating clout than most other insurers do. The 2003 drug bill that gave Medicare recipients drug coverage under Medicare was a great idea except for the fact that there was no provision to negotiate drug prices, which has since then led to the much higher prices we now see today. This was of course due to the influence and money of the drug lobby. Drugs cost more in our country than elsewhere.
It’s not what you pay, but what you get for what you pay is the problem here. Hospital monopolies have way too many expensive moving parts, with high priced executives often making more than the doctors themselves. According to Kaiser, only 11 percent of the dollars in healthcare went to doctors a few years ago, while the rest went elsewhere. What would happen if we no longer needed 45% of those who are working in hospital systems were no longer needed and what would it do to the unemployment rate here? Would it put a dent in costs? How do other countries run their hospitals? If we had one insurer and a more efficient system, how much would healthcare cost then? Would single-payer help us simplify the system and reduce the number of people avoiding care with a lower yearly deductible; absolutely. Chronic health problems caused by waiting to explode the cost of care, something that continues to help insurers profit while justifying to us why your premium again went up.
As you can see, Obamacare is a complex symptom, and moving it or reforming it, while indemnifying insurers even if sold across state lines will not reduce the cost of care as long as they have the ability to future manipulate the healthcare market place with changes that cost us more. This is an experiment that has long since failed.
Some models that seem to be working are concierge models such as the ones in Florida with primary care. Basically, the patient pays their doctor for yearly access in exchange for an agreement to give them access and limit their patient population. Global fees to a primary would drastically change the model, improve access since this is where the money is and doctors will keep notes for their patients benefit, not the benefit of the insurer and not have to worry about audits and clawbacks unless they failed to fulfill their duties to patients. It would also eliminate most of the fraud witch hunts since we have eliminated their fee for service. Contrast this with the insurance companies HMO model paying a doctor $200 a year plus patient co-payments with a model that consisted of phone triage, each doctor taking on thousands of patients and trying to run a practice with a long waiting list and short doctor visits. That is the model that moved us to the 10-minute office visit except in those days, most doctors had paper notes which took less time to do.
Perhaps, President-Elect Trump would do well to ask doctors how they would like to practice and how he can help make their lives better. While not all doctors will be happy with changes in our system no matter what we do, a system that rewards great service, care, and results in Trump’s Obamacare or Nobamacare.