Faber Healthcare Solutions

With the costs of health care on the rise, and the number of uninsured Americans larger than ever, both major presidential candidates have plans in place to reform the system. Unfortunately, both their plans are seriously flawed, and, as I have said before, until we as a society are willing to reconsider what our expectations are from a comprehensive health coverage plan, we will never be happy.

The candidates’ plans are presented in no particular order. Full disclosure: I am registered as non-partisan, belonging to no political party.

Senator Obama’s plan, in his own words, “begins by covering every American.” However, despite this assertion, details listed further down his web page, make it clear that he is offering availability to everyone, but not necessarily coverage.

In addition, Mr. Obama writes that everyone will have access to the same plan as federal employees and that they would have “affordable premiums.” One has to wonder who can afford such premiums. Reviewing the 2008 premiums for these plans, which vary by state and within states, the plans are hardly cheap. Lower cost individual plan premiums run $3,939/year, and family plans are $9,060/year. More expensive plans run $6,522/year for premiums, and families pay $15,081/year. Hard to call that affordable.

Of course, we forget that when employers pay for plans, that money is really coming out of the employee’s pocket, because it is the total compensation package that the employer pays for, and truth be told, if health coverage were not offered, that additional money would be available in the form of salary. But most people don’t think that way.

Senator McCain, on the other hand, clearly offers a plan with universal access, not universal coverage, saying “access to health care for every American.” His program relies on private enterprise to provide coverage to all Americans instead of implementing a government controlled plan. This, however, is simply not realistic. Health plans, despite what they want the world to think, are in the business of making money, and have no interest in covering the sickest (read: most expensive) patients. The Senator writes about his GAP program – Guaranteed Access Plans – but details are conspicuously absent.

To make matters worse, Senator McCain’s program offers tax rebates to employees who opt out of employer-offered health plans, with the intention that those people would use the rebate money to purchase their own health plan. Alas, he appear to have ignored the rule of unintended consequences: as young, healthy people, who can purchase cheap health coverage, opt out of employer-offered plans, and the sicker people remain with the ‘more affordable’ plan, the employer plans will become more expensive with each iteration as the plans find their members costing more each year, and ultimately the gap between those who do and do not need comprehensive care will grow wider yet. (The irony of gap v. GAP is not missed.)

Lastly, it is worth bearing in mind that foreign governmental plans that provide comprehensive coverage for all citizens (i) have special, usually high, taxes that pay for those plans, and (ii) have many coverage limitations that would shock most Americans. It is hard to imagine a universally accepted national health program in this land of opportunity that would have coverage limitations such as no dialysis over the age of 65, or no pacemakers over the age of 70. On the other hand, if such limitations, which are not unheard of overseas, would be absent in a national American program, the costs of our national health care would certainly exceed today’s 16% of GDP by a large margin, and that money would have to come from somewhere.

Health costs rose around 10% in the past year for smaller businesses, and coupled with increasing costs for transportation, energy and supplies, they have been cutting back on health coverage for employees.

A survey conducted by the NJ Business & Industry Association found:

- While 4 years ago 92% of the smallest companies provided coverage, today only 77% do.

- 76% of the companies who dropped health coverage said that they did so because of costs.

- 52% of the companies who do provide coverage require employees to pay part of the premiums.

Premiums are expected to rise about 10% this year again. If it were because health costs went up, and health plans made only a modest profit, this would be a difficult but understandable reality. But as the AMA reports, the health plans are making a big buck at our expense (and force physicians to spend money fighting claims unnecessarily), and would rather lose members than lose profits.

What will next year hold?

An online PHR is nothing more complicated than a web-based repository for a patient’s own medical history, including allergies, hospitalizations, vaccinations, surgeries, medications, tests, and family medical history. This is exactly the kind of record that every person should have, as it is invaluable during examinations and emergencies. However, having that information online is concerning.

• - Access to the data, and the integrity of the data itself, can be compromised by server failures.
• - The data itself may be vulnerable to hackers or other unauthorized access.
• - The server, and the company that owns it, may be offshore, and not subject to US law.
• - Even if the server is in downtown Dallas, the data on it is not subject to HIPAA’s privacy regulations, which protect a patient’s personal health information at a doctor’s office or hospital.
• - The data could be subject to subpoena, by courts and insurance companies.

There are a couple of industry titans developing online PHRs. Microsoft has HealthVault, and Google has developed Google Health. Both packages are currently in beta release.

There are alternatives to online PHRs without sacrificing the technological benefits of computerization. There are PC-based systems, which help patients organize their information, enabling them to print it out, put it on a disc, or email it to their provider. Similar software is available embedded on portable flash memory drives, some with data encryption.

Both these systems have risks, such as loss of data, potential privacy concerns, and physical loss of the drive or disc. However, the data under greater control of the owner that web-based systems, cannot be subpoenaed, and do not merely rely on the person’s memory at a fixed point in time.

One of the gaping holes in American residency training is the utter lack of business training. Today’s physicians graduate from medical school having learned the cutting edge of medical care. Of late, residency programs have learned the value of patient relations, and have successfully integrated humanism courses into the educational framework of residency. Unfortunately, many new physicians are launched into the workplace ill-prepared for the business of healthcare.

Graduating residents have told me that they have great anxiety over their graduation, not because their medical safety net will be removed, but because they feel unprepared for their upcoming roles as business owners and bosses. Recent graduates have told me that they felt their residency programs let them down by not providing proper education about the business of healthcare. Established physicians have told me that it took them many years to learn, through trial and error, how to run their businesses. They also admitted that there were many more errors than they would have hoped, and that they remain unsure if their acquired knowledge is even correct.

It is heartening, however, that today residency programs are aware of this shortcoming, and are taking strides to remedy it. In fact, I have been invited to speak to medical residents at a number of major NYC academic medical centers in the coming weeks to supplement the young business awareness programs these schools have begun to implement.

The previous generation of physicians had a rude awakening, following the Reagan years, of the realities of medicine as a business. All signs indicate that the next generation of physicians will be better prepared, and I sincerely hope that is the case.

There has been a recent explosion of walk-in health centers, such as Minute Clinics (recently bought by CVS). These centers charge a flat fee, usually $45-$65, for an appointment-free quick sick check, what Wal-Mart, in its centers, calls a “get well” visit. Such centers are utilized not only by sick adults, but also by parents for sick child visits, even though the centers are almost never staffed by physicians, only nurses and nurse practitioners.

There has been much debate as to the propriety of these centers. Advocates say that it allows patients to obtain quick, high-quality care, and allows them to get back to other important activities in their lives. Detractors voice concerns that these quick visits to non-physicians risk missing more serious conditions.

Additionally, and perhaps amazingly, in a recent survey by MSNBC, 35% of patients who utilize these centers are insured, and came to walk-in health centers instead of their own doctor, even though the centers do not accept their health insurance plan. Surely the wait time, plus the rising amount of copays, have swayed them.

Walk-in centers certainly pose a challenge to the conventional medical practice, particularly in pediatrics. Pediatricians must begin to offer similar services, including quick appointments with little waiting time, at a competitive price. The price is certainly a sticking point: fee-for-service practices cannot subsist on $60 sick visits, certainly not when that price includes a rapid strep test, and providers who participate with managed care have no control over the patient’s copay amount, which may likely approach $40 or $45.

To remain competitive with these services, physicians will have to foster quality relationships with their patients, a relationship that patients not only appreciate but also rely upon, one that patients value over the cost savings of a walk-in health center, as well as provide timely appointments … or their patients will start to walk, and follow their wallets.