Stanley Feld M.D.,FACP,MACE

Part 2

Yesterday I presented my opinion on the May 14 New York Times article on “Retail Medical Clinics”. Today I am going I will refer you to links from the American Academy of Family Practice to see their response to this developing epidemic. I believe the AAFP approach is a good one. They have chosen to define the criteria for an effective well physician supervised clinic.  The subtext to me is they are also preparing their membership to respond and neutralize these clinics.

I have run some financial numbers on the potential cash flow of the clinics.  I will be very hard for them to be profitable unless they see large volumes of patients with few employees. This could effect patient through put, and generate long waits or rapid visit times. Rapid visit times can lead to decrease quality.

Again, these clinics do not answer the real problems facing the healthcare system. They are access to care to the uninsured, affordable and cost efficient delivery of care, and increasing the quality of care for persons with chronic disease.

If we were to solve the above mentioned problems we would be decreasing the complication rates for persons with chronic disease. This decrease in complication rates would decrease the cost of delivering care in the healthcare system by at least 50%.

Remember at the outset of this blog, I stated that no one asked physicians what the problems were. If they did they did not pay attention to the physician. Hopefully we can get the consumer to pay attention to the physician.      

Today’s solutions are tomorrow’s problems

Stanley Feld M.D.,FACP,MACE

Occasionally a media article will precipitate at response from me in this blog because I feel it is urgent to respond.

A New York Times May 14, 2006 front page story covered the development of free standing clinics in Wal-Mart, Target, CVS pharmacies. Several entrepreneurs including Steve Case former CEO of AOL and Rick Scott former CEO of the former Columbia Hospital System have gone into the business of “DOC in the Boxes” except without the use of DOCs (physicians). The plan seems to be to use Healthcare Providers. Physicians, in my opinion, should not be categorized as health care providers. They are Medical Care Providers. This is an important distinction in my mind and will carry over into my discussion for the Repair of the Healthcare System. All other Healthcare Providers should be called Physician extenders.

David Scull for The New York Times

“The MinuteClinic in a CVS store in Bethesda, Md., offers its customers a
number of vaccines.

Despite their diverse backgrounds, those executives and others share a
concept of “consumer-directed health care” a marketing and political
term that usually means higher out-of-pocket medical costs as a
Mass-market opportunity.”

In response to an email about this article I replied;
“the creations of free standing “DOC in the Boxes” is one of the complicated mistakes that business people make to distort the healthcare systems even further. Both Steve Case and Rick Scott are very smart guys, when it comes to picking the cherries off the trees, and making some money. I am sure they will make some money at this. They will also bale out just before it crashes.

I think Wal-Mart and CVS are indeed putting their reputation and good will on the line and are going to get a nose bleed.
These are again today’s solution to yesterday’s problems which in turn will case tomorrow’s problems.

Our health is our most valuable asset. I think it would be worthwhile if entrepreneurs used their intelligence to figure out how to fix the system and not break it even further. Medicine should not be viewed by the entrepreneur as a “money making space”. It should be approached from the view point of setting up systems to preserve our most valuable asset our health.”

An effective healthcare system should have three qualities. Those qualities are access to effective care, affordable care, and high quality care.

These clinics answer none of these qualities. When and if the clinics get busy, the wait time will be the same as emergency rooms and “Pediatric clinics”. The access to care problem will not be solved. Are these clinics going to be open 24 hours a day? I would doubt it. These clinics also do not solve the problem the 45 million uninsured who can not obtain affordable insurance coverage for significant illness.

The price structure for acute minor illness seems to be the same as the price structure negotiated and contracted by the insurance industry for physician and emergency room visits regardless of the retail fee charged by the physician and emergency room. These clinics do not solve the problem that 80% of the healthcare dollar is spent treating the complications’ of chronic disease. The key to Repairing the Healthcare System is decreasing the complication rate of chronic disease.

Non physician directed care for acute illness does not address the issue of high quality care at all. I assume if a patient was really very sick that patient would be sent to an emergency room from the clinic.

To me these clinics address a very minor part of the healthcare problem. This is not what “Consumer Driven Healthcare” is about. It is true these clinics give that patient a choice. Is it a wise option?

Clearly, the developers of these clinics are trying to pick the low hanging fruit and make some money. However, I believe the will find that these clinic do not satisfy the patients, nor the healthcare community’s needs, nor their economic goals. It could in fact intensify turf wars and be harmful to the large retail stores mission to provide good quality merchandise at an affordable price.

Today’s problems were yesterday’s solutions 1940-1980

Stanley Feld M.D.,MACE

Part 2
As the population grew older demand for health insurance for people over 65 years old increased. In the mid 1960’s the government through Medicare provided health insurance for people over 65 years old. Prior the Medicare, many physicians and hospitals as well provided medical care free to people over 65 years old who could not afford care. The income lost from non paying patients was made up by those who had insurance or those who could afford to pay.

Suddenly, with the advent of Medicare there was more money in the system. All the stakeholders were generating more revenue. Cost of insurance to business was not increasing at first. Hospitals were very effective in generating revenue. Hospitals expanded to generate more capacity and revenue. All patient evaluation was done in the hospital. One could not get paid by the insurance industry if you worked the patient up outside the hospital. There was no payment for outpatient evaluation or outpatient surgery. Insurance companies were happy for two reasons. First: Insurance costs were not rising. Second: the insurance industry became the administrator of the Medicare insurance plan resulting in increased revenue and higher net profits. Physicians were happy because they were collecting fees for service that were not paid previously.

Aside from the increase in money in the system, restricting payment for outpatient evaluation and procedures was the first big politically motivated economic mistake. The minor facilitating stakeholders, the hospitals, and the insurance industry were beginning to take advantage of the two principal stakeholders (intellectual property of physicians and the economic rights of the patient). The incentives of the physicians, hospitals and insurance industry began to become misaligned because of greed. Physicians started to mistrust hospitals, and hospital administrators. The hospital administrators’ eye was on the bottom line. The physicians were on efficient economical patient care. Hospital costs and physician fees increased. The insurance industry was happy. They not only sold policies to the business, they also administered Medicare money. Once again the more money in the system, the more money they made.

Next how this misalignment accelerated!

Preamble

Repairing the healthcare system.

This blog is about Stanley Feld M.D.,FACP,MACE’s  studied view for repairing the health care system

There is been much written daily about the defects in the health care system. All stakeholders have blamed for the severe distortion in today’s healthcare system.

Unfortunately few have asked practicing physicians what they think the problem is. Neither has anyone asked the practicing physician what an acceptable solution is.

Persons not affected by the distortions in the health care system pay little attention to the broken system. Fortunately 80% of the population is not sick and are not in need of an effective and functional system. People not immediately affected by any system do not pay attention the defects in systems. The healthcare system is vital to every citizen both in the short term or long term.

Our broken health care system can not be ignored any longer. Our personal health and the health of our citizens is the most precious asset we have as individuals, and vital to the country’s success and well being in the future.

In my view, we are going through a process similar to the slow boiling a frog. We are noticing the rise in temperature little by little, but are too lethargic to take action and jump out of the pot. The effort is much too difficult.

However, we must take action now!!  Soon, we will all be cooked.

What is the solution ?

In a consumer driven economic environment for most goods and services, the only way to get us out of this hot pot is for the consumer understand the structural defects in the broken healthcare system and then act. Someone must outline an effective and easy plan of action that involves all the stakeholders and aligns the incentives of all the stakeholders.

In reality, all of the stakeholders are to blame for the distortions in the system. They need to be answerable to the consumer. The consumer (patients) can exert power only after understanding the structural defects in the system.

The goal of this blog is to explain reasons for the defects, as well as the potential solutions. The solutions I will propose, in my view, will make ultimately fix the system.

Presently most of the stakeholders’ incentives are misaligned. The proposed solutions are aimed at aligning all the stakeholders’ incentives. All previous solutions have served to misalign incentives even further, in my view, resulting in our present dysfunctional system. The previous adjustments have resulted in a system that is much too expensive, has much too much waste, is inefficient, and almost unworkable. The result is that all of the stakeholders are very stressed and unhappy.

Over the next weeks or months, I will outline the problems and the solutions.