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The SCOTUS healthcare watch will end this week. Some of the Supreme Court members have committments to teach classes in Europe by the first week of July. We will know the fate of ACA on Thursday.

There is no sense in predicting the fate of ACA. I'm more interested in getting people the appropriate amount of health care.

I've always advocated health care over health insurance. Oh, sure, I hear the argument that if you can't pay for the health care, no one will be able to access health care other than those who can afford it. That's a good argument. If you have no insurance, you will most certainly die an early death. I do want the ACA to be upheld, but I refuse to make myself sick waiting for the ruling. So, say we wave our magic wands and everyone has health insurance. Now what?

The real work on health reform will begin? Well, one can hope....

Today, I can't write a short diary. It's too complex. I write from the heart on healthcare, but the complexity of health care administration gets in the way of the emotional, anecdotes of every day people losing their livelihood and lives due to our awful healthcare system.

Health Care vs. Health Insurance

It turns out that having health insurance is not an indicator of people actually receiving health care for their ailments. Health insurance by itself is not an indicator of quality (pdf) health care. Health insurance maybe the key that opens the door, but health insurance is only one barrier to health care. The rest of the equation deals with other access issues. Are there enough doctors, nurses, offices and hospital beds. Do the available hospitals offer enough cardiac, diabetes or asthmatic care? Will enough doctors, dentists and hospitals participate in the patient's health insurance plan? Does the insured have enough money for copays or coinsurance necessary to be able to use the insurance? Will access to care make any difference in managing chronic health conditions like asthma, diabetes or heart disease? Which insurance plans improve cancer care and which ones skimp on cancer care?

The reality is that many people simply think they are insured up until they get sick and find out their insurance is a junk policy that doesn't pay for vital care they need to live.

The Maze of Insurance

You've heard doctors and patients decry the "paperwork". It's mostly electronic today. We should decry 837's, 835's, 271's....and more. Healthcare workers have a love/hate relationship with the people who understand the paperwork. These somewhat resented workers know what to submit, when. They know what insurance or fund will pay for treatments under what circumstances. They find and work with government block grants and charities for the uninsured. It's befuddling. It's aggravating. There are over 3,500 insurance plans operating in the United States. Although every plan will drop within a broad framework of indemnity, HMO, PPO, Medicare or whatever, each plan has it's own set of phone numbers, web site, quirks and personality.

Our insurance determines our care. The lacy mesh of private insurance is bad enough, but it loses cohesion when the patient is injured in a car crash or on the job. Those claims go through different networks (plural). They could go to court adding yet another layer of personnel and paperwork. These claims often use a different set of doctors. They often disregard the patient's history. The separate worker's compensation and auto crash personal injury from regular health insurance adds to the mess. We need to address this issue as well. People in car crashes and job related claims have uneven results. We need to find a way to incorporate personal injury and on the job injuries into the main stream reimbursement system, which will call a brouhaha over liability and lets just say it would be a "cluster of love" trying to sort that out. This along with malpractice makes single payer somewhat attractive. What we have now creates an environment that foments duplicated services and prevents coordination of care.

The reality for people injured in car crashes and on the job is that they have to work with doctors who are often more interested in maintaining a good relationship with the Worker's Comp or Auto insurer than them.

Value Driven Health Care

Buried deep in the ACA timeline is the poorly understood provision calling for insurance reimbursements to be based upon quality measures. It is supposed to take effect January 2015. This provision is the basis for many health care doctors, nurses and hospital administrators ambivalence toward ACA. It's a game changer. Make no mistake - the health care business is a game to most who work within it. "What's the new rule? Ok, here's how we're going to play it." This "game" shapes the health care our patients receive, but it's not a "game". It's real life. The patients are largely unaware of how they are manipulated into thinking a course of treatment is necessary or unnecessary according to their insurance situation.

There is little agreement on what "quality" means. The patient simply wants to feel better. CMS and State medical boards wants to see fewer readmissions within 30 days, no "never events", no errors. Doctors and hospitals want to see generous patient contact requirements (i.e. a diabetic patient must be seen 6 times per year - great for the doctor tough on the patient with a job and family). The hospital wants more generous reimbursements. Everyone wants less paperwork. The patient's main problem with hospitals? The surveys say! They want good information about what's going on with their situation and (I kid you not) better food.

The value driven initiative is thorny and we still haven't found the yard stick we plan to use. Patients want relief from their ailments without filing for bankruptcy. Ethics people haven't weighed in yet. Private insurers don't care, they just raise their premiums to pay whatever. Their solution is to offer junkier and junkier plans for those who no longer can afford the "gold-plated" plans to give the appearance of insuring everyone. Public insurance cares! Those are our tax dollars! Medicare, Medicaid, SCHIP and Tricare cares, but there is the partisan divide. The GOP touts "personal responsibility" and "death happens" which favors people who have wealth and personal connections vs. the Dems (IMO) more practical view that everyone is going to need healthcare at some point and we all need to face this together, share and share alike.

We are in denial if we believe that doctors and hospitals prescribe care regardless of a patient's insurance situation, EMTALA be damned.

The Backbone Issue

We need to face some inconvenient truths about the U.S. health care system. The bothersome facts are:
1. We spent about $2.6 trillion on healthcare in 2010 (Keiser estimates it to be 17.6% of our GDP in 2009). That was about $7,600 per capita in 2009 and it's estimated to be about $8,402 in 2010.
2. About $800 billion is estimated to be spent annually on wasteful, fruadulent or abusive medical expenditures.
3. About 5% of the population utilizes about 50% of all medical resources annually.
4. Medicare has done a better job of controling costs and has better patient satisfaction than private insurance.

We need to tell doctors and hospitals to stop driving up futile utilization by specifying what practices are wasteful. We must denounce the malpractice meme. (States that passed tort reform aren't saving any money.) Doctors and hospitals need to tell patients when the tests, drugs or treatments they are demanding aren't going to help them. We need to suggest, and create incentives that promote viable public health measures like dietary, physical fitness guidelines or ideal rest times between work sessions. We need to not only suggest guidelines but give people the resources to eat right and exercise. Employers need incentives to give their workers the time and resources to live healthier lives.

We will not throw grandma from the train. That's wrong, but essentially that's what would happen with the GOP health plan if grandma runs out of money. It is just as wrong to fight to the end with every resource that makes the patient unbelievably uncomfortable - no matter what - simply because their insurance will pay for it. What we need is a more ethical way to allow people to die on their own terms instead of exploiting their health insurance or letting them die simply because they don't have health insurance.

Did you know that in some hospitals, patient's advance directives are routinely ignored? We cannot allow a family member to rescind them after the patient becomes incapable of participating in their care, because they disagree with the Do Not Resuscitate Advance Directive. We cannot allow nurses or doctors to ignore them because they disagree with the DNR Advance Directive. It's about the patient, not the family or nurse or doctor.

As to "personal responsibility", the time where we had a stay at home mom who made sure we ate our greens, got bed on time and exercised are gone. Our high stress, frenzied schedules and sleep deprivation foment unhealthy habits. We have to help our patients find ways to live healthier, so they feel better and need less health care resources. The conservative argument to this approach is to call us socialists, but what they offer is too little rest, less money, less time, more pressure, more stress and all that negativity will only lead to more sickness, suffering and early death. This impass has to end, because the status quo is breaking us.

We are in denial if we think our current health care system can continue as is.

Costs and Affordibility

The main complaint about ACA is that it didn't do anything to control health care costs. As if those trying to pass the bill didn't attempt to deal with costs. Those provisions were either thrown out or watered down to try to get non-existent bipartisan support. We don't have anymore political backbone today than we had 2-3 years ago to take on the healthcare cost issues. One thing for certain, the GOP solution of "Let them Die!" is totally unacceptable to most of us. The posted GOP plan to replace ACA is anemic. Low on substance and big on hyped memes. I hate to link to it, but if you must, you can go here to read the memes on malpractice reform, being able to buy insurance across state lines, increase HSA's, prohibit abortion coverage, but keep the prohibition on pre-existing conditions. Somehow these "specifics" will reduce the $2.6 trillion we spend on health care to be somewhat manageable? Bullshit.

The anti-health care reform crowd peddles "death panels" and "cuts to Medicare". They make shit up. All hoopla, no substance. The right blithely ignores the real death panels run by our private insurance corporate empire. They fail to acknowledge the price gouging done by the pharmaceutical corporate empire. They fail to see how the generousness of one insurance plan encourages over utilization while Medicaid patients get under utilization. They clamor for choice and ignore the fact that our system gives people few choices. Private insurance gives their enrollees a take it or buy it on your own approach. Again, a policy that favors private insurance company's with a fiduciary duty to increase profits to make life and death decisions for us.

We are in denial if we believe private, for-profit corporations are better suited to determine our life or death care.

So, What's a country to do....

We find our backbone.


We find our resolve to cure our ailing health care system. It will need to include a combination of insurance, hospital, physician reimbursement reforms. The value reimbursement and efficacy studies must be done. Wasteful practices need to be identified and unfunded. We must find a way to standardize the insurance plans. We must find a way to bring in car crash and worker's compensation and coordinate it with the patient's private insurance situation.

The uninsured will seek care if they can afford to do so. That means we need to put in a pricing system the uninsured can afford. That will make up for some of the revenue losses of cutting wasteful ordering. We expand the RAC auditing to private insurers and go after abusive and fraudulent private insurance claims as aggressively as we go after government insurance claims.

Can we cut $800 billion from the pie? Maybe. Cutting waste, fraud and abuse while adding new patients are mutually exclusive actions. It will be a bumpy road while shifting the dollars around.

Corporations and People

Employers will need to make some changes and so should the general populace. We need to take a brutal self inventory of the unhealthy American Lifestyle. We live unbalanced lives. Schools need to reintroduce recess and more physical fitness. We need to come down hard on employers who routinely use salary, non-exempt employee status to demand routine 11-14 hour work days. We need to change up our culture that brought us 2 hour commutes, urban food deserts, fast food with little or no exercise. It's making us sick.  

Going for Broke

We're kidding ourselves if we think a single-payer system will cure all that ails the U.S. healthcare system. It could certainly help, but there is more than single-payer out there. Countries like Japan, Germany and the Netherlands don't have single-payer, but have systems that cover everyone. Maryland uses an "all payer" system that has effectively kept hospitalization costs under better control than the rest of the country. The uninsured in Maryland have less fear of hospitals than other parts of the country. We do need to acknowledge some validity in the GOP stand on "personal responsibility". The GOP needs to be less brutal in their approach to health care. No doubt tying cost sharing to obtaining health care services leads to less health care purchasing, but at the cost of killing people. Killing people is not what health care is all about.

Can we do it?

Can we reform health care so we cover everyone and reduce spending?

Will we face reality?

If we all share the sacrifice...

Yes, we can.

Will we do it?


Denial is a powerful defense mechanism.

We'll see.

Originally posted to JDWolverton on Tue Jun 26, 2012 at 08:52 AM PDT.

Also republished by Community Spotlight.

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Comment Preferences

  •  Tips for Health Care Reality (24+ / 0-)

    I'm still a proponent for care over insurance every day of the week...and a sensible funding system to go with it.

    If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

    by JDWolverton on Tue Jun 26, 2012 at 08:52:29 AM PDT

  •  Litigation and waste (7+ / 0-)

    Wow!  Very impressive article on health policy.

    I would like to chime in on health costs.  You cite that the US spends $2.6 trillion on health care, and call this an inconvenient truth.  Is that amount too mucb or too little?  By itself the number 2.6 trillion is meaningless.  

    Typically we give this number meaning by comparing our spending with health costs in other countires, and in most analyses, the US spends more per capita than other countries with poorer outcomes to show for it.

    As a doctor, I was taught that if I wanted to know the patient's blood sugar, I should order a blood sugar test along with sodium, chloride, potassium, sodium bicard and perhaps some kidney function tests as well.  Even if I had no need for this other information.  I was taught to do this because if there was some problem with the patient, I would be held liable by my failure to to look at these other blood chemistries.  Faced with the possibility of a lawsuit, we order the additional tests.  

    The additional tests add to the cost of the care, and only serve the purpose of of protecting the doctor and hospital against a possible future suit.  AND if one of those unwanted tests came back abnormal, then MORE tests are needed to track down the abnormal result, adding yet more to the costs of care (because of course you could easily be sued for failing to follow up an abnormal result).  False positive rates for such testing is around 1-2%, so if you order 100 such tests in the course of the week, you can expect 1-2 of them will come back abnormal, even if all your patients are perfectly healthy.  

    Only rarely did I ever order a sodium level because I had reason to be concerned about the patient's blood or kidney function.  I'm sure 90+% of the time I ordered a sodium level, it was done as a hedge against a lawsuit.

    I relate this to show how lawsuits and litigation work to drive up health costs.

    OTOH, I have seen my share of doctors acting irresponsibly with their patients.  But I have never seen one of those doctors sued for their irresponsible behavior.  Go figure.

    "The fool doth think he is wise: the wise man knows himself to be a fool" - W. Shakespeare

    by Hugh Jim Bissell on Tue Jun 26, 2012 at 02:11:14 PM PDT

    •  Thanks for your thoughts. (1+ / 0-)
      Recommended by:

      I added the per capita stuff. I have to go teach right now. I'll check back at break.

      If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

      by JDWolverton on Tue Jun 26, 2012 at 03:16:56 PM PDT

      [ Parent ]

  •  Access to care (1+ / 0-)
    Recommended by:

    Should also include making sure people can get to doctors and specialists. I have medicaid, yet I had to put off a doctor's appointment last month because I didn't have the cab fair to get there, and the bus doesn't run anywhere near it. My other half is supposed to go see a Neuro, but it's a five to six hour bus ride each way, and the bus here (to our area)runs from 6am to 7:30pm there's no way to get him there and back. This is the only Neuro in the area that takes his medicaid HMO.

    It should also mean people getting therapies that they need to improve function. This includes PT, OT, Pulmonary Therapy, speech therapy, etc. My doctor has been trying for years to get me into Pulmonary therapy, medicaid won't cover it. I have very limited functional breathing stamina. I literally have to sit in the kitchen before I get what I came for for a few minutes and sit again before trying to get back to my room. I can't walk to the end of the driveway, and what used to be a five minute walk to the mailbox by the office takes 45 minutes, and sometimes sends me to the hospital. I know I'll never get back to where I was, but I should be able to do more than I'm doing. Pulmonary therapy could help that. I don't feel safe exercising at home because it's way too easy for me to over do it and my lungs to go into crisis. So I don't risk it, because my kids need me home, not spending weeks in the hospital.

    "Madness! Total and complete madness! This never would've happened if the humans hadn't started fighting one another!" Londo Mollari

    by FloridaSNMOM on Tue Jun 26, 2012 at 05:33:42 PM PDT

  •  Insurance (1+ / 0-)
    Recommended by:

    As long as private for-profit insurance companies have such an outsized role in ACA, I question how much costs can be reduced and care expanded.

    If everyone had access to a single payor system, I think health professionals would move into underserved areas.  

    Don't look back, something may be gaining on you. - L. "Satchel" Paige

    by arlene on Wed Jun 27, 2012 at 06:41:14 AM PDT

  •  Bravo! Well done! (1+ / 0-)
    Recommended by:

    You've summed it up very smartly.

  •  Can't say that I agree with you about how (1+ / 0-)
    Recommended by:

    advanced directives should be followed or not. As an ICU nurse, I am all too familiar with families who appear stoic in the face of their loved one's impending death and yet they cannot bring themselves to "follow through".

    For many families, "pulling the plug" on mom or dad (let alone a child) is akin to giving up.  So, by rescinding the directive, this allows them to hold on to any hope that there is a remote possibility their loved one will pull through one more time. Hope is a very powerful motivator.

    •  Advance Directives aren't signed by the family (0+ / 0-)

      They are the patient's wishes as to how they want their medical treatment to proceed. They are signed by the patient. The are the patient's decision as to how they want to be treated. The family's signature is no where on the document.

      It's a legal designation. How Advance Directives are to be followed up is a JCAHO accreditation issue and a compliance issue. I'm a little surprised as an ICU nurse, that you don't know this. Violating an Advance Directive is a reportable risk managment violation. Ignoring an Advance Directive is a violation of the Patient's Civil Rights and is investigated by the OCR.

      I totally understand they are difficult to comply with. Saying good bye to people who loved you and nutured you is heart breaking. The point is that it is the patient's wishes that should prevail, not their family, not you as a nurse and not the patient's doctor.

      If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

      by JDWolverton on Wed Jun 27, 2012 at 04:55:00 PM PDT

      [ Parent ]

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