Health Reform and Primum non Nocere

Following the admonition to “First do no harm,” I will refrain from sharing a post I wrote before the Presidential Election that would not promote a productive conversation regarding the future of health reform.  Instead, I will share some immediate thoughts regarding the future President Donald Trump.

Twenty-one years ago tonight, I was installed as the President of the Iowa Academy of Family Physicians. In my President’s Address, I said that having grown up in Denison, in rural Iowa and similarly, begun my practice as a family physician in Titonka and Algona, both in rural Iowa, I was going to “dedicate my actions this year to promoting rural family physicians. Furthermore, by protecting rural medicine, I think in part, we  help to protect that which is rural in Iowa and in America, a goal worthy in and of itself.”

Donald Trump won because rural America wanted to send a message to Washington,     D. C. The flyover country–the land between the two coasts, or the “deplorables” as Secretary Clinton so crudely mocked–extracted its revenge. My efforts for health reform have always been geared to the underlying goal of protecting rural America and rural Americans who I view as “the salt of the earth.”  If Donald Trump is listening to rural America, if he cares about rural America, and if he wants to protect rural America, he needs to acknowledge the rural Americans who have obtained health care coverage through Medicaid, the Exchange, or as a child under the age of 26 through the Accountable Care Act and find an alternative way to protect their health care coverage.

If Donald Trump takes us back to a world of pre-existing conditions and significantly higher rates of uninsured people, then the massive red color that illustrated his electoral success across the national map, as well as nearly every state’s rural counties on election night will symbolize the bleeding and suffering of rural Americans’ unmet health needs.

I hope and pray that he achieves the same success in the world of public policy that he has achieved in the world of politics. I plan to offer my advice and as appropriate, my criticism in this process. My final thought for Donald Trump is “First do no harm.”




Health Reform and Uber and Food Trucks

Recent economic trends nationally and in Iowa include the proliferation of Uber contract driver taxi services and owner-operated food trucks. Both of these services rely on individuals starting a small private business in the competitive world of commerce.

My brother, my father, and my grandfather have all been owners of their own small businesses. The gumption and personal sacrifices needed to take on all the requirements necessary to run a successful small business have always humbled me. From advertising and marketing to hiring and personnel management, to municipal, state and federal regulations to eventual retirement, a small business person needs to consider every aspect of their business. Despite this, many individuals crave the freedom and independence that running their own business or being an independent contractor allows. Given the other options of being someone else’s employee in a large business or a government worker, I sympathize with and support individuals who are willing to risk their time, resources, and self in these challenging endeavors.

Unless a small business owner or freelancer is independently wealthy, one of the primary barriers for these new entrepreneurs is health insurance, which for many of these individuals makes the health insurance exchanges critically important. The current status of health insurance, with significant premium increases, higher deductibles and copays, and fewer plan options from which to choose because of insurers leaving the health exchanges, make these people’s situation more tenuous.

The difference in what these small businesses and independent contractors have to do to navigate the health care insurance system is daunting, especially when I consider my patients who work for Iowa State University. The difference reminds me of one of my favorite patients, who at the age of 65, retired as a janitorial worker at Iowa State. She retired with good retirement benefits and was happy and content. Since her retirement, I have seen her and enjoyed hearing her positive experiences with retirement. In this world of outsourcing and fewer benefits for individuals working at jobs such as janitors, I am sure many janitors in the United States would not be able to retire at 65 as my patient did. It is this contrast between the benefits—be it retirement benefits, on-site child care, or health insurance—that government and major corporations can offer their employees compared with small business persons or independent contractors that I continually rail against.

In the few years since the enactment of the Accountable Care Act (ACA), I sense two economic orbs rapidly moving away from each other. On one hand, with independent professionals such as Uber drivers, food truck operators, and microbrewers, we see more and more people choosing a small business or independent contractor approach. Yet, the individual health insurance orb seems to be moving headlong toward higher premiums, and higher deductibles and copays with fewer and fewer  choices in the marketplace.

The Presidential and Congressional elections will decide the course of the nation for the next four years for many essential elements of American life including health care coverage. Either tweaking the existing ACA or totally replacing it will be a necessary task for the next Congress and President. Many years ago, our country  wisely created Social Security and Medicare. Both are celebrated examples of economic protection for our citizens. The ACA was created as another mechanism for economic and health protection for Americans. It has dramatically helped millions of American but I firmly believe it must, just as Social Security and Medicare were, be adapted over time. For individuals driving Uber taxis and operating food trucks, if we do not change the course of the ACA, they will not have health care coverage in the future. This blog is dedicated to preventing that future.

I look forward to working to create a different and better future after the November elections. Who you vote for is a personal choice but your vote will have a profound impact on the future health care of many, many Americans.

Health Reform and a $10,000 Neighborly Visit

A friend of mine, a family physician, told me about a visit he had with his 93-year-old neighbor recently. This neighbor had known my friend for more than 20 years and was my friend’s patient.  His neighbor is a wonderful man and a big basketball fan. He grew up on a farm in northeast Iowa and remembers when his farm received electricity in the 1930s. He was the electric power supervisor for the district that included downtown Chicago in the 1960s and remembers the riots following the  1968 Democratic Convention there.

The neighbor had a heart valve procedure earlier this year and because of complications, had an evaluation with his cardiologist the day before my friend’s visit. At the cardiologist’s evaluation, the neighbor’s cardiac drug regime was significantly changed. My friend was called by the neighbor’s wife and asked to come over to her home when her husband, the neighbor, was having chest pressure and nausea. The wife had called First Nurse, a 24-hour nurse hotline, and was told to call for an ambulance. My friend, knowing the patient’s previous work up and having been told of the change in the cardiac meds, evaluated the neighbor. Based on the evaluation, my friend had the neighbor lowered his cardiac meds and by the next day, the neighbor was back to the baseline of his cardiac status.

I guarantee you that if the neighbor had been taken to the Emergency Room by ambulance, he would have been admitted to the hospital.  From my experience, I believe a ninety-three-year-old patient with a history of heart valve surgery who was experiencing chest pressure and nausea would always be admitted to the hospital by the emergency department physician.

The rule of thumb is that a physician clinic appointment costs $100; an Emergency Department visit costs $1,000, and a hospitalization costs $10,000. My friend, in evaluating his neighbor, saved Medicare $10,000.

As I said in a previous blog entry, my clinic is in a Medicare Accountable Care Organization (ACO), as well as a Blue Cross Blue Shield ACO. One of the key aspects regarding ACOs is the prevention of unnecessary Emergency Department visits and hospitalizations. In that blog entry, I promoted how the relationship between the family physician and patient would be invaluable in this ACO effort.

In my family medicine practice, I try my best to see my patients on the same day if they call in with an acute illness, which is what we call open access scheduling.  Recently, a patient called in with significant back pain and asked to be seen. I told my nurse to get her into the clinic that day. My nurse told a temporary receptionist who, unfortunately, did not know my policy and scheduled the patient for the next day. Sure enough, the patient went to the Emergency Room that night.

In the world of ACOs, my friend’s intervention was successful; my intervention failed.

At a meeting of different Medicare ACO representatives from across the state of Iowa, I heard that one Medicare ACO was considering using a company that creates a mobile physician service that allows for an enhanced home visit to sick elderly patients on weekends, thus a house call just like Marcus Welby MD, a popular television family physician in the 1960s and 70s.

In the world of higher and higher health care costs leading to higher health insurance premiums and the eventual inability of some individuals to afford health care coverage, I return to my roots believing that good primary care relationships and services are key to helping correct these problems.



Health Reform and “Yuge”

Former Vermont Governor Howard Dean speaking this week at the 2016 Democratic National Convention quoted Donald Trump. According to Governor Dean, Donald Trump said that he’s going to replace the Affordable Care Act (ACA) with ‘something so much better’— something ‘Yuge,’ no doubt.”

In researching this “something so much better,” I could find only a mismatched set of random ideas such as buying health insurance across state lines, establishing Medicaid block grants for each state to administer, allowing Americans to import medications, eliminating the individual mandate but still preventing insurance companies from excluding patients based on pre-existing conditions, and expanding tax exemptions for corporate health insurance to individuals.

Contrast this hodgepodge of convoluted, disconnected ideas from an individual who apparently was caught off guard when asked during this year’s primary campaign about health care to the years of experience Secretary Clinton has in promoting and planning successful health reform. She did it in Arkansas when former President Bill Clinton was governor; she did it when she passed the Children’s Health Insurance Program in 1994, and she did it when she was a senator from New York. She watched as the Affordable Care Act was passed when she was a member of President Obama’s Cabinet. Her health care reform efforts, past and present, certify her convictions.

Yes, the ACA definitely needs to be tweaked. Medicare needed to be tweaked.  Medicaid needed to be tweaked. Both Medicare and Medicaid resulted from a bill President Lyndon Johnson signed into law in 1968.  Medicare and Medicaid have been tweaked and will continue to be tweaked and evolve in the coming years. I fully believe that if anyone can successfully tweak the ACA, I trust Secretary Clinton to do it. I trust Secretary Clinton to tweak and refine the ACA in the years to come. I simply would not trust Donald Trump to eliminate the ACA and create a new, replacement health care system that would continue the coverage of the more than 20 million Americans who have enrolled since October 1, 2013, when the first open enrollment began for the ACA, commonly referred to as Obamacare.

Under a President Hillary Clinton administration, I think we can discuss solid ideas such as the expansion of Medicare to individuals older than 55, the importation of prescription medications, allowing Medicare to negotiate medication prices with pharmaceutical companies, and immigration reform which would allow health care coverage for  undocumented workers.

Let’s await the election results in November and see which way health reform goes. Whatever the outcome,  it will make a “Yuge” difference for many of us.



Health Reform and ACO incentives-Getting it Right

We need to get this right. As I have said last month, I continue to be dismayed by the evidence that health care costs are not being controlled. For example, in Minnesota, one of nation’s top health care managed states, Blue Cross/Blue Shield announced that it would not sell individual insurance policies next year due to concerns over cost. Skyrocketing health care costs will affect the affordability of private insurance and the existence of public healthcare programs such as Medicare, Medicaid, and subsidized insurance sold under the Exchanges.

Accountable Care Organizations (ACOs) are made up of health care providers organized to establish contracts with insurance companies or public payers. If at the end of the year, health care costs for a given population are less than anticipated, the shared savings are distributed in part to those ACO providers. The questions for ACOs are two-fold: one, can shared savings be realized, and two, will those shared savings negatively affect patient care as was reflected with Health Maintenance Organizations (HMOs) rationing of health care in the 1990s? One added development is that many ACO contracts include downside risk. That means if the ACOs health care costs for a given population exceeds the cost estimate, the ACO will pay a portion of that excess cost.  This is highly problematic because physicians did not go to medical school in order to gamble with downside risk.

My clinic, McFarland Clinic of Ames, Iowa, is involved in two ACOs, a private insurance ACO with Blue Cross/Blue Shield of Iowa and a Medicare ACO associated with the University of Iowa. The numbers: we have about 24,000 patients in our private ACO and about 17,000 patients out of 75,000 total patients that are in the University of Iowa Medicare ACO. This year Medicare expects to spend about $8,500 (this cost does not include certain high-cost patients or the cost of medications for the entire population) per patient per year on this population for a total of cost of $637,500,00. An average trip to the Emergency Room (ER) for a Medicare patient of McFarland Clinic costs $912 and a hospital admission costs $11,567. Roughly 30 percent of Medicare ER visits were deemed for non-essential emergency room purposes when evaluated by a respected formula. Many chronically ill elderly patients have multiple health issues and are deemed so medically complex that a trip to the ER automatically results in a hospital admission. Finally, during a one week study at the Ames emergency department, 70 percent of Medicare patients seen in the ER had contacted their primary care physician’s office in the previous 24 hours. I am on committees for both ACOs.

The goal of this blog post and for my two ACOs is to determine how we lower needless ER visits and hospital admissions. My answer is that we provide incentives to primary care physicians both during office hours and outside of office hours in ways to care for Medicare patients that avoid them going to the ER, which often results in a hospital admission.

What actions performed by primary care physicians (usually family physicians and internists) would accomplish this goal? Some tested actions include open access scheduling (sick patients are seen the same day), a 24 hour nurse hotline with backup availability to talk to a physician before recommending an ER visit,  after hour clinics during the evening, on weekends, and holidays, an urgent care option with access to x-ray, lab, IV hydration, and sometimes CT scans. The goals would also include seeing all patients once a year and include a risk-stratifying process, seeing high-risk patients more often, and finally, good cross coverage of patients so when the primary care physician is away, the patient will be seen in a clinic with adequate records easily accessible.

Given the data available from Medicare, we can give accurate rates of ER visits, hospital admissions, and hospital re-admissions per thousand for individual clinics and down to the provider level. The proposal that McFarland Clinic is considering would provide incentives to primary care physicians by tying some of the shared savings distribution to the rates of these costly activities. Primary care physicians who were successful in lowering these rates would be  rewarded at a higher level when shared savings are distributed. Another incentive idea is tied to the submission of diagnoses to Blue Cross/Blue Shield and Medicare. Diagnostic codes help create the actuarial cost estimate for any given patient’s health care in a particular year. My brother-in-law is an actuary for Mutual of Omaha. I have always said that I did not learn to be an actuary in medical school but in a bizarre way, my accurate diagnoses submitted to payers does add to the actuary’s estimate in a way only I can affect. Once again, we can generate data regarding diagnosis codes used or dropped (used last year but not this year) at the provider level. This data also could be used to encourage primary care physicians to accurately code. Accurate codes often correctly raise the estimated level by which shared savings is calculated. A higher cost expectation then makes shared savings more possible. As with lower ER rates, primary care physicians could be rewarded if they more appropriately code their patients’ visits.

Another incentive idea is tied to the submission of diagnoses to Blue Cross/Blue Shield and Medicare. Diagnostic codes help create the actuarial cost estimate for any given patient’s health care in a particular year. My brother-in-law is an actuary for Mutual of Omaha. I have always said that I did not learn to be an actuary in medical school but in a bizarre way, my accurate diagnoses submitted to payers does add to the actuary’s estimate in a way only I can affect. Once again, we can generate data regarding diagnosis codes used or dropped (used last year but not this year) at the provider level. This data also could be used to encourage primary care physicians to accurately code. Accurate codes often correctly raise the estimated level by which shared savings is calculated. A higher cost expectation then makes shared savings more possible. As with lower ER rates, primary care physicians could be rewarded if they more appropriately code their patients’ visits.

I am sorry for this slow, boring slog through the interworking of ACOs but I firmly believe that it is this tedious dissecting of these processes which will present incentive opportunities which will make ACO’s work.

The next step for McFarland Clinic is a work group of primary care physicians to devise a transparent, somewhat simple, understandable formula by which to distribute shared savings to primary care physicians. The goal would be to create a formula which would drive certain actions which would increase the size of the shared savings pie. This would be a win-win-win situation; health care costs would diminish; primary care physicians would be rewarded for their efforts and finally, hopefully, health insurance premiums and public payer costs would be more reasonable. This is what we have to get right.

I will keep you inform of the workgroup’s conclusions and ultimate results of our two ACOs.

In a later blog, I will discuss the question of quality care versus rationing of care as found in an ACO.

As an aside, with this post we move into our fourth year with this blog. I am pleased that our readership spans the US and 33 foreign countries.



Health Reform and Medicare for All…Seniors

One of my favorite movies is “White Christmas,” which starred Bing Crosby and Rose Mary Clooney. In one scene, Rose Mary Clooney’s character sings a song in a nightclub about her unhappiness with Bing Crosby’s character. She sings, “Love you didn’t do right by me. . . you planned romance that just hadn’t a chance and I am through.”

In a fashion similar to that Irving Berlin song, after years of touting private health insurance by helping to create the Healthy and Well Kids in Iowa (HAWK-I)—Iowa’s CHIP program, and working with Co-Opportunity Health—Iowa’s health care CO-OP that went bankrupt, I have come to the conclusion that the private health insurance market under the Accountable Care Act (known as the ACA or Obamacare) has not done “right by me.” More importantly, it has not “done right”  the citizens of the country. For reasons that I will clarify later, I now support expanding Medicare to individuals 55 years of age in a graduated, voluntary enrollment process.

First, we must examine the current insurance market. It is drowning under 20 to 40 percent annual premium increases; outrageous and morally reprehensible drug prices; poor insurance enrollment; deductibles ranging from $6,000 to $10,000 and sometimes more, that make having insurance still mean not having access to affordable health care; a significant number of private insurers leaving the exchanges, and more than 20 states that have not accepted Medicaid expansion even though it would not cost state governments. Overall, millions of Americans endure not having health care access because they have no insurance, no Medicaid, or are underinsured, which is the equivalent of having no health insurance.

I fully acknowledge the more than 20 million Americans who have health care access under the ACA and I am thankful for that. I also believe under different circumstances, Congress would have made technical changes which would have improved the ACA in meaningful ways. One of the most significant changes to the ACA made by Congress was withholding money destined to help sustain health care CO-OP’s like Co-Opportunity Health. The non-CO-OP private insurers instigated that theft.That was another “did me wrong” moment.

My proposal is that Medicare allows individuals from 60 to 65 years of age to buy into the Medicare system with premiums determined by income based on a sliding scale and no premiums for Medicaid income level individuals. Additionally, every year the age limit of 60 goes down one year until age 50 with the idea that if monitoring enrollment indicates a need to suspend further age decreases below 55 years of age so that 55 becomes the floor. Also, Medicare for its entire population will begin to negotiate prices with pharmaceutical companies for their medications and those deductibles greater than $2,000 per year be banned for health insurance policies sold to individuals with incomes less than 250     percent of the Federal Poverty Limit (FPL). These parameters would be up for some thoughtful and reasonable negotiation.

Why expand Medicare as a buy-in option? Several reasons: first and foremost, the most vulnerable group in this pre-Medicare population has diabetes and hypertension. They smoke, use illegal drugs and/or excessive alcohol. They also have significant mental health issues. Under this proposal, these individuals would have actual, legitimate access to good medical care now and as they age into the current Medicare program for individuals 65 years and older. They know that they need health care. That is why they represent the largest group of insurance buyers on the exchange. The second reason is that Medicare expansion for this high-risk and high-cost age group might make private insurance more affordable for the rest of the population with the elimination of this age group in the insurance risk pool. Finally, because Medicare is a federal program, it would allow states that have not expanded Medicaid to have their 55 to 65-year old low-income patients have full access to health care. A side benefit would be that Medicare expansion would allow more individuals to retire earlier because their health insurance is covered, opening up jobs in the economy. Current figures are not available on the number of Americans age 55 to 65 who continue to work past retirement age simply to maintain their health care coverage.

Two side notes: One, I am impressed that Medicare is taking action through Accountable Care Organizations (ACOs) to lower the cost of health care. My Medicare ACO with the University of Iowa Alliance which follows 75,000 Medicare-covered-people is making great strides in improving quality and lowering cost. I am chair of its Clinical Operations Committee. Two, Iowa Governor Branstad signed the Medicaid Oversight legislation which will improve the oversight of Medicaid by for-profit Managed Care Organizations (MCOs).I have hopes of reasonable oversight because this legislation will have to assure the care of all Medicaid patients in Iowa.

Finally, at church Sunday morning, I noticed a significant number of small children present with their parents and grandparents, which coincides with a birthday party yesterday for my 2-year-old granddaughter.Her birth was noted on this blog at the time.

This post offers a mechanism that provides adequate health care access for the grandparents and non-grandparents of this country who are age 50 to 65 while at the same time, stabilizing health care insurance for these children and their parents.

You should note that I continue to give private health insurance companies a “piece of the action” to insure individuals in businesses and individuals younger than 50. I hope that I will not soon be replaying that old, forlorn love song once sung in a movie set nightclub by Rose Mary Clooney.