Double Trouble: The Problem
For dozen of years, politicians, business people and consumer advocates have tried to separately attack two of the major problems of America’s healthcare delivery system. At one pole was Medicaid’s often-crushingly high cost to the states. On the opposite side was the uninsured. The increasing interrelationship of these problems was realized but barely discussed; now it is. Offering at least a small measure of hope that this new perspective just might lead to the solutions that have proved so elusive.
Known fact: low-income jobs too-rarely offer healthcare coverage. Major results: today there are more than 50 million Americans covered by Medicaid in some way. This has led an increasing number of states to say to these employers, “We cannot afford to bear the burden that should be yours”. At least ten states are currently trying to shift more of that cost and obligation to the employers, attempting to literally force them to provide healthcare insurance to at least a good number of their employees.
There is a proposal in the New Jersey legislature which would require companies bidding for state contracts to prove they supply healthcare insurance to their employees. Maryland recently passed a bill that requires the state’s largest employers to spend at least 8% of their payrolls on health benefits for employees.
Connecticut is reportedly considering legislation that would compel companies with more than 5,000 employees to provide healthcare coverage…through either participation in a company plan or through payment into a state fund.
Georgia and Vermont have shown much interest but little legislative action so far; however, statehouse leaders say this is a definite agenda item. Several years ago, Oregon proposed a law that would require all employers to contribute to a healthcare fund; the bill did not pass and since then the state has tightened restrictions on eligibility for state aid. Last year, California voters just barely defeated a bill designed to force large employers to supply some form of health insurance for their workers.
In every case, adherents that failed so far promise to bring up similar bills in the near future. There is little doubt that at least some will eventually pass.
Meanwhile, there is also a move afoot in various states to publish listings of companies that do not offer healthcare coverage for their employees…apparently hoping to win over some through sheer embarrassment. Massachusetts has already published several big names -- including WalMart, Dunkin’ Donuts and half a dozen other of the state’s major employers. All of whom quickly replied “Why me?”, calling this a national not a state problem. In the case of Dunkin’ Donuts Corporate, they said it simply isn’t their problem and blame it all on the franchisees.
The National Academy of Sciences estimates that over 18,000 adults die each year because they cannot get proper medical aid. But across the country the Medicaid figure averages out to 16% of a state’s yearly budget. In the face of this, Tennessee is threatening to drop 300,000 from its Medicaid rolls and Missouri is set to drop 90,000…each saying there simply are not funds available to do what they know should be done.
The nay-sayers who claim all this legislation can lead to additional disaster now point to giant General Motors, whose bonds recently were reduced to “junk” rating by Standard and Poors. Their most-recent annual report lists employees’ healthcare costs (including retirees) at over $5 billion is 2004…which adds more than $1,500 to the cost of every new GM car.
In the face of all this, there is a bill before Congress that would cut projected Medicaid spending by $10 billion over a five year period. How can you ever solve a problem big as this?
Read on......
Double Trouble: Urgently Seeking Solutions
Healthcare think tanks have been talking among themselves and publishing reports for years; but with too-few consensus results because the agendas of these groups is apparently too disparate. Now there seems to be a new urgency, a new realization that the system is getting close to a breaking point; that Congress is never going to take on the job of fixing it...and somebody has to instead show them how to at least start to do it.
For close to a year, high-level representatives of two dozen groups and industries have carried on a number of low-profile and rarely publicized meetings in an effort to face the clearly-related Medicaid and uninsured-employee problems head-on and find a common ground that can be taken to the feds for some form of approval. The groups literally cover the spectrum; from the U. S. Chamber of Commerce and the Heritage Foundation to Families USA…from the AARP to the AFL-CIO…from the American Hospital Association to the American Medical Association…from major companies to major health insurance plans…from giant pharmaceutical companies to the National Governors Association.
The stated goal of all these meetings and analysis is to work with the clock ticking and to therefore present by the end of this year a series of common sense proposals that will offer some form of coverage to a large number of the uninsured in the shortest possible time. To do it high-profile enough to force the parties to pay attention and take some action.
Apparent agreement by all sides is that there is no single solution. That forcing small companies to assume the additional burden of healthcare coverage for low-income workers often tends to price the company out of competitive local markets. At the same time, mandating the addition of major healthcare coverage across the board for large companies can price their products out of world markets. And that merely ignoring the problem also makes people needlessly suffer and die.
Point is that these recommendations will carry a preamble that the time for talk is long past and something has to be done. And that the recommendations being made are well-thought out, specific and doable with some pain that will have to be shared all around. (For another system in pain, see the final item on page 4.)
Will they march on Washington? No one is talking about that but there is a feeling among this group that it is absolutely imperative we finally face up to the problem that has been ignored and/or papered over for so long.
Re-engineering Healthcare Delivery
Rebuild an 85-year old hospital literally in the shadow of Microsoft and it seems logical that the doctors and administrators would borrow mightily from the thinking of their innovative near-neighbor. Instead Virginia Mason Medical Center used the systems-driven thinking of Toyota Motors as their guidepost to increasing the quality of care, reducing the sometimes intermin-able waits-for-service and the often lack of coordination between departments that many accept as part of the system. According to hospital spokespeople, it has resulted in better service to their patients and a more-pleasant work environment for just about every member of their staff.
Over fifty years ago, Toyota developed a system that really streamlined what the American auto companies thought was a streamlined system. Result was faster delivery, less waste, maximum end-to-end efficiency at every level, more-satisfied workers and customers. Today Toyota is at the top of the market and mighty GM and Ford are going through high-profile struggles.
Convinced that this system-thinking would work in hospitals and other facilities as well as in auto assembly lines, the CEO of Virginia Mason traveled to Japan for “training”, returned several times and adapted the Toyota innovative ideas to the needs of his 350-bed hospital’s rebuilding. Using assembly-line thinking to solve the highly personal problems of compassionate and efficient care, it almost-immediately resulted in a redesign of plans that eliminated a costly 13,000 feet of space that just wasn’t needed. This in turn eliminated an estimated 34 miles of excess and unnecessary staff walking time a day.
Following systems-delivery plans…in less than seven months the hospital reduced the previous prep time for chemo from three hours to one hour; eliminating patients’ cranky and often-fearful wait time and allowing staff members to do more of what they do best. From the accountants’ point of view, the money saved enabled the hospital to treat fifty more patients a week.
Adhering to a dual strict mindset of 1) refusing to merely accept existing approaches and 2) championing those willing to “open minds”, administrators claim to have sharply reduced inventory costs, shorted bill-collection time, reduced infection rates and, most importantly, greatly improved both patient and staff stress while increasing satisfaction all around.
"Parallel Trading" Expands
Americans aren’t the only ones trying to save some money on their prescription purchase by buying from abroad. Parallel trading -- effectively an “underground” system that diverts specific drugs from one country where the price is low to a neighbor where the prices are higher -- has quickly grown into a major business that accounts for more than $6 billion a year for Europe’s pharmaceutical wholesalers.
The government of each European country negotiates the price of a particular drug; this price is partially built on ability-to-pay. Result is the prices are relatively high in most of Western Europe and from 35% to 70% less in Eastern Europe. So Eastern European pharmaceutical wholesalers regularly divert some of the drugs they buy to the wealthier countries; repackaging them, inserting new instructions in the language of the new recipient, but never opening the original container.
The pharmaceutical companies estimate that this “illegal system” costs them billions of dollars needed for research. But the western governments that buy these trans-shipped products in bulk are happy to save the money. For example, it is estimated that 15% of all pharmaceuticals in Great Britain currently are the result of parallel trading.
The problem recently made it to the European County of Justice, which refused to rule on a case that pitted GlaxoSmithKline against a Greek government commission. The court claimed lack of jurisdiction; this was considered a major setback to the drug companies bent on stopping the cross-shipping.
They Did it!
A less-than-100-bed, few-months-old hospital in Jacksonville Florida proudly points to the fact that it is one of the first to the future. Baptist Medical Center South claims it is paperless…and the staff and doctors’ everyday caring for patients seems to say they indeed have bridged the gap. Best of all, it also seems to be working well for both patients and the staff.
Doctors make the rounds with small wireless devices in hand…which means most-recent test results are literally at their fingertips at all times. Medicine that is administered at bedside is immediately entered and monitored on compatible wireless devices and immediately electronically matched to a patient’s own bar code. So, in effect, computers oversee patients’ records and billing, day-by-day, procedure by procedure. Insuring both a high level of care while accurately controlling more-mundane but most-necessary medical inventories.
The staff points-with-pride to what they have accomplished and to the giant medical centers that have tried and ended up with failed first attempts. Apparently the staff was in on every bit of every planning stage from the beginning, eliminating the often-seen problem of “paperless” hospitals designed by engineers and computer specialists rather than doctors and nurses and hands-on administrators. BMCS claims the various staff teams spent months analyzing every aspect of necessary physician analysis and patient care…and that satisfying these needs was the primary target of system development.
Programmers didn’t lead the way…medical staff did. Seems simple but is apparently most-innovative and a system that could act as a guide for some of the giant hospitals dreaming-of or struggling-to change over to “paperless”.
"Concierge Medicine" Struggling
It was highly-touted as one possible answer for doctors tired of being tied down by managed care. Individual patients or families pay a rather-healthy fixed fee per year for as-much-time-as-needed same-day appointments and round-the-clock telephone access. Family practitioners and internists are free of the ten-minute patient consult; plus both the smothering paperwork and restrictive fees fostered by insurance companies.
The return of patient-financed personal-care medicine. Though Entrepreneur Magazine has listed it as one of thirteen “Hot Business of 2005”, it seems to be growing slower than hoped for, this according to its spokesperson group, the Society for Innovative Medical Practice Design, which reports that its membership list is still just under 200 groups.
Problem is obvious; it’s all about those fees that average $2,500 for an individual and $4,500 for a family. There are just so many affluent locations in the United States that can support such practices and, even in these locations, the physicians have to invest a lot of capital during the time it takes to build up to the minimum 400 or so patient contracts per doctor seemingly needed to support such a practice.
Route taken by a few groups though is to concentrate on building a “business”, discovering that the medical practice aspects will then follow naturally. Which has sometimes meant looking for venture capital to support the doctors until their patient base reaches comfortable levels. CooperativeMed in south Florida did just that in 2002 and is now in the process of seeking other doctors in other locations willing to “changeover”. They have opened a second office in northern Florida and have set a goal of 40 practices around the country.
MDVIP, also of Florida, has 73 doctors in fourteen states signed onto cooperative contracts. The company offers start-up advice, basic financial training in learning how to adapt to a professional life free of the restraints and of the financial support of managed care.
More Mini-Medical Plans Offered
Exxon-Mobil...Home Depot...IBM... Intel...Sears...Denny’s. These major companies and perhaps a score more have offered -- or are planning to offer in the near future -- limited coverage plans to usually-new employees who are willing to take some chances in order to save some money on their portion of the company’s healthcare coverage. Such as controlling the number of doctor plan-covered visits a year, sharply restricting the number of full-coverage hospital days, placing plan-cost ceilings on the most-sophisticated (and expensive) medical tests.
These “Mini-Medical Plans” aren’t new but they are now getting more popular as both employees and employers struggle with rising healthcare costs. Employers say this is a “window” that enables them to better control steeply-rising healthcare costs, offer a degree of coverage to all and still remain competitive. New hires say it simply opens the full-time job market while giving them some level of coverage.
Most of these plans are designed so that almost anyone can qualify, even if a family member has a semi-serious existing condition. The employee’s age is rarely a deterrent. And if the individual’s costs go over coverage, providers almost-always bill them at lower group rates.
QIOs Help MDs Become IT- Friendly
CMS has begun funding a major three-year effort to help physicians -- mainly in smaller primary care practices, where the help is most-needed -- switch over to electronic health information technology. Many of these practices apparently have the basic system either installed or available to them, but simply don’t have it working at maximum efficiency.
So frustration often leads to many of these falling back to greater use of paper.
Their service is advisory, not technical. Plan is that they will act as the “middleman” to enable the practice and the IT vendor to better understand the needs and restrictions of the other. Once this is accomplished, the QIO moves on, though still on-call as needed.
Eventually the plan is for QIOs to also help prepare hospitals for the installation and greater use of a higher level of information technology… including computerized physician order entry and various bar coding methods.
A Bit More About Us
“On the Record” is a monthly joint effort of NJPR staffers and a medically-knowledgeable editor. Every article is researched and written just for this newsletter.
Our original purpose, over sixteen years ago, was to inform, enlighten and occasionally entertain readers, which hopefully we will continue to do.
But we all now exist in an era dominated by rapidly-advancing IT and EMR. We have tried to keep abreast of it and will increasingly try to make you aware of what is either new or over-the-horizon. In an effort, quite, honestly, to reinforce the image of professionalism, quality and dependability that has been NJPR’s hallmark for over thirty years.
Transcription Tips
HYPHENS: Use a hyphen to join a noun and a participle to form a compound modifier whether it comes before or after a noun: bone-biting forceps; he was panic-stricken; mucus-coated tongue; callus-forming lesion. Use a hyphen between a number and a word forming a compound modifier preceding a noun: 3-week history; 5 x 3 x 2-cm mass; 2-year 5-month-old child; 8-pound 5-ounce baby. Single space after a suspensive hyphen (one used to connect a series of compound modifiers with the same base term): We used 3- and 4- inch bandages. It is recommended to spell out words used as modifiers: the intrahepatic and extrahepatic ducts, NOT intra- and extrahepatic ducts.
If possible, do NOT end or start a line with a hyphen, try to “attach” the associated word or phrase.
Medical Minutia
Christopher Columbus, who first landed in the new World at age 41 and in apparently excellent physical shape, returned to Queen Isabella suffering from a mysterious illness. Best current guess is it was a severe form of arthritis that was most likely caused by a bacteria which is also responsible for food poisoning. He may also have been afflicted with one of several possible related diseases.
Columbus made three other trips to the New World, but returned a bit more crippled each time as the disease continued to progress, causing fevers, bleeding and attacks of what was then diagnosed as a form of gout. He died – literally a broken man -- at the age of 54, two years after returning from his last voyage.
Spam-Fighter Fights HIV
In one of the rarest of possible crossover solutions, Microsoft engineers have discovered -- apparently almost by accident -- a similarity between the workings of computer anti-spam tools and the pathways HIV cells use to mutate in the human body. The project is two years old and has just moved into mainstream basic medical research. Microsoft began this project partnering with the University of Washington and Australia’s Royal Perth Hospital. Now Mass General and the University of Toronto have joined in the development project.
Anti-spam software, of course, searches for word patterns and common phrases as a method of protecting our normal e-mail from being overwhelmed by a crush of unwanted solicitations. Microsoft’s “data-mining” technology is said to be able to search through millions of HIV strains and identify potentially-dangerous genetic patterns and mutations ten times faster than any prior research technique.
Hope is that, using this technique, Microsoft and its medical partners will find the HIV virus faster and either slow it down or kill it quicker…saving millions of lives sometime in the future. Best guess, though, is that it will take between five and ten years to even begin human testing of such a vaccine, which just could also become a major cancer-fighter!
Auditing the News
America’s mental health apparently leaves a lot to be desired, based on the results of a $20 million project that included in-depth interviews of 9,282 households selected at random in 34 states. Conclusion was that 25% of Americans meet the basic criteria for having mental illness within the past year and that, in turn, 25% of this group could be classified as having a “serious disorder” which regularly effects their ability to function fully. Those suffering from the most-serious mental illness -- such as institutionalized schizophrenia -- were not included in the totals.
A total of 27 similar studies are still in process in countries around the world; the United States was the first to report.
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The American Jobs Creation Act opened a recently-expired year-long incentive period that permitted companies to return “sheltered funds” from overseas at a temporary but very-generous tax rate...5.25% rather than the standard 35% rate.
The pharmaceutical giants, who consistently told the IRS that their major profits come from international sales -- which most Americans found hard to believe – may have been truthful after all. Best estimate is that as a group, they benefited the most from this “window” and returned $75 billion to the U. S. at this extremely-low tax rate.
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If you are going to follow that promise-of-better-health apple-a-day philosophy, make it a Red Delicious; this according to a Canadian government report published in the Journal of Agriculture and Food Chemistry.
Red Delicious has more than six times the health-enhancing antioxidants as the lowly Empire variety. Following the “Red” was Cortlandt, Ida Red, Golden Delicious and Macintosh. And always be sure to eat the skin which, in every case, has many more times the antioxidants of the apple’s flesh.
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Computer-literate patients like to have access to their electronic medical records and welcome the opportunity to communicate with their doctors via e-mail to fill basic requests such as prescription renewals. This from an online survey of 4,282 members of a large health system which was underwritten by the Agency for Healthcare Research and Quality. Each patient was a registered user of MyChart, which facilitates such actions.
The doctors, though, said they still preferred to have patients call the office with such requests.
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The consumer group Families USA recently analyzed healthcare cost estimates from a number of government agencies and sees an unending upward spiral. They report that this year the average premium cost of families covered through their employer will average close to $11,000, with over $900 of that amount targeted to caring for the uninsured. By 2010 cost of family premiums will be over $17,000 with somewhere over $1,500 targeted to covering the uninsured. Families USA says there are now 48 million Amer- icans without health insurance and that, on average, uninsured patients pay about a third of their cost of care. Some of the rest is covered by the government; most of the rest -- well over $40 billion in 2005 -- is considered uncompensated care and ends up absorbed by hospitals and in additional healthcare plan premiums.
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Once again, NJHIMA’s Annual Meeting at Caesar’s Atlantic City on June 23 and 24, 2005 was voted a huge success by those lucky to attend. As usual...lots of fun and learning, excellent speakers and exhibits.
On a personal note, our congratulations to Anna Sawczak, RHIT of Robert Wood Johnson University Hospital was the winner of the NJPR $100 drawing.
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According to an article in Stroke, a small sample of patients who, four years after a devastating event, still had trouble understanding and speaking, were given intensive therapy which directly resulted in marked improvement. Each received 30 hours of speech training over a ten day period. Some improvement was immediate in almost every patient and this improvement was maintained after six months.
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Canada’s universal health system was dealt a potentially body blow recently when the country’s Supreme Court threw out Quebec’s ban on private insurance plans that would permit patients to more-quickly get much-needed operations or other specialty medical services. This new freedom to choose only applies to Quebec, but it is anticipated that the other nine provinces will be similarly affected in cases sure to be quickly filed.
The once-proud system -- called “Medicare” and in operation since 1984 -- is currently suffering from a lack of sufficient funds. Which has resulted in extremely long waits for necessary service, a shortage of available doctors and a widespread need for additional state-of-the-art diagnostic equipment.
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