Medicare for All, or "Eat well, take your medications, and good luck!"

I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:

Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 

And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can notdo a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!

On interdisciplinary patient care and the corporate takeover of health care

The following is a gues post by Seiji Yamada, MD, MPH

In July 2015, on the 50th anniversary of the founding of the University of Hawaiʻi John A. Burns School of Medicine, the school invited its alumni for a Saturday morning symposium on "Transformative Medical Education in Hawai`i."  The last panel of the morning, on the future of medical education in Hawaiʻi, featured the deans of medicine, nursing, social work, and the associate director of public health.

Dr. Peter Donnelly - Kanaka Maoli family physician, practicing on the Neighbor Islands, my mentor in Hawaiian Pidgin and how to be local (I fail abjectly on both counts) - asked what the panelists think of nurse practitioners telling him that they can do anything he can do, at less cost.  One panelist suggested, "If you can't beat them, join them," so you might as well go get your MBA.

The claim that a non-physician provider can do the work of a physician at less cost ignores (perhaps willingly) the distinction between earning less and costing less.  Certainly non-physician providers earn less than physicians.  Dr. Stephen Kemble - psychiatrist and a stalwart for single-payer, who had been decrying the business takeover of health care from the audience all morning - noted that with regards to the provision of mental health, the evidence shows that non-physician therapists can actually cost the mental health system more than psychiatrists.  (He was citing an unpublished study performed by a Hawaiʻi health insurance outfit.)

Of note, a study in the September 2015 issue of Medical Care found that diabetic patients cared for by nurse practitioners had comparable rates of  preventable admissions as primary care physicians. The provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care. The medical profession as a whole must shoulder part of the blame for the present situation.  Specialty control over the reimbursement system results, naturally, in disproportionately higher reimbursement for procedures and disproportionately lower reimbursement for primary care. See Outing the RUC: Medicare reimbursement and Primary Care. [1] This ensures that most medical students will choose specialty training so that there are not enough primary care physicians to care for all of us.  To the extent that physicians obtain MBAs and figure out how to game the extant reimbursement system [e.g. hire an N.P. to consult on patients so the gastroenterologist can perform colonoscopies in the surgicenter (anus to anus time of under 10 minutes) all day] - the proceduralist specialties are complicit.  Indeed, there is no reason why the gastroenterologist should explain the risks, benefits, and the bowel prep for screening colonoscopies.

We family physicians learn during residency that the practice of primary care is, in many ways more complex than specialty practice. [2] A well-trained, experienced provider of any discipline can deal with many complex patient problems for which a less intensively-trained, less experienced provider may order unnecessary tests or referrals.  Thus, while a primary care physician may earn more than a non-physician provider, the cost to the health care system may be less.

In addition, the provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care.  These days, you can be largely assured that if you presents to the ED with a headache, you’re going to get a CT scan of your head.  If you present with abdominal pain, you’re going to get a CT of your abdomen.  Many patients with symptoms clearly suggested of reflux are kept in the hospital for observation to “rule out myocardial infarction.”  So, conversely, while a primary care physician may earn less than an emergency physician, the cost to the health care system may also be less.

While part of the problem may be that the nursing profession is eager to escape the yoke long placed upon it by the medical profession - perhaps the larger problem is what Dr. Kemble identified as the incursion of the business model into health care.

The business model is predicated on delivering a standardized product with quality controls on what can be measured at prices that the market will bear.  Thus at any fast food franchise, one can reasonably expect a hamburger without too much E. coli in it, at the price listed behind the counter.  The MBAs who run our health care systems have no concept of the importance of, for example, a longitudinal patient-doctor relationship to health outcomes.  If they can replace an experienced primary care physician with a lower-paid "provider," it's better for the bottom line. 

We in family medicine should not be picking a fight with the nursing profession.  (For the sake of patient outcomes, I am happy to help nurse practitioners improve their practice, and I am happy to learn from them what they do best.)  I think that the main problem is the marketplace model of health care.  Capitalism has always depended on maintaining a certain percentage of unemployment in order to keep workers a little afraid of losing their jobs and therefore toeing the line.  The corporate takeover of health care means pitting the lowest rung of the physician class, the primary care physicians, against a growing workforce of providers with different qualifications eager to take their jobs.  From where I stand, I think that all health workers need to unite against that.

[1] Freeman J. Outing the RUC: Medicare reimbursement and Primary Care. http://medicinesocialjustice.blogspot.com/2011/02/outing-ruc-medicare-reimbursement-and.html

[2] Freeman J, Petterson S, Bazemore A. Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties. Am Fam Physician. 2014 Dec 1;90(11):790. http://www.aafp.org/afp/2014/1201/p790.html