Health Care Reform Letter to the President
(part 2)
NOTE: The first part of Dr. Beamer’s ‘Letter to President Obama’, dated June 19, 2009, was published in the December 2009 edition of San Antonio Medicine magazine. An explanation of the problems seen with our current health care system, along with possible solutions, are detailed below.
Explanations of the Problems
1. Empowerment:
Our current delivery system has made emotional infants of patients and parents. Patients/parents need to learn about how they can care for themselves and their children. Empowering and educating patients/parents will be the most effective dollar usage. There is an attitude of “Take care of me. I can’t take care of myself.” Although this may be true in some instances, most patients can positively impact their own health. Education needs to be a required part of receiving medical benefits. Many of the patients and families I see do not feel empowered enough as parents to care for the most basic problems at home. Consequently, they misuse and over-use the ER – at a great expense to the taxpayers. Education is needed.
2. Nurse educators/Case managers:
Any patient with a chronic disease or who has had more than one trip to an ER in a month should be assigned to a case manager. Sheer volume probably precludes home visits ( although this might be useful for “frequent flyer” patients); but the case manager can find out if it is an education problem or an “entitlement” problem and direct the patients to appropriate classes or link them to an appropriate clinic or facility where they can seek care. There is a tremendous nursing shortage right now and active recruiting is critical. (See Medical Health Corp Plan under providers.)
3. Social service:
Health Care Plans do not work in a vacuum. You cannot treat patients without understanding the home environment to which they return: An asthmatic child who lives in a home of smokers; a single mother with 5 children who cares for her elderly/disabled mother; a diabetic who has no transportation or takes 2 buses to get to the clinic; working parents who cannot take another day off from work(or risk being fired) to have their child seen by a physician; a drug addicted man/woman who is “self medicating” their depression; or, an individual with an IQ of 80 ( low normal) who has a complex health issue that requires multiple meds and visits. This screening needs to be done at a central site with drug counselors, mental health counselors, transportation specialists and individuals who can help people fill out the required forms.
No health care plan is complete unless it addresses home environment and how it affects a patient’s health. Each recipient of “universal health care” should be screened for environmental risks and limitations to good health.
Look at some relevant underlying social issues: We who have cars, nice homes, friends and education often lose sight of the horrific home environments of the patients we serve. It becomes easy to judge others when we possess many genetic and social gifts. “They need to pull themselves up by the boot-straps,” makes no sense for those who have no boots. I routinely see young women who have been sexually abused by relatives since they were very young. They grew up in a home where education was not valued. No one read to them or encouraged them. They lack self-esteem, education and hope. We cannot take away the emotional scars from their youth, nor fix all of their problems; but we need to recognize the real need in our society for counseling and mental health care. When it comes to distribution of dollars, we should focus on improving the environment and the opportunities afforded children in order to break the cycle and raise a generation of emotionally stable, productive citizens.
4. Psychiatric Care:
This is a much-needed area, but it also lends itself to use of medications rather than insight therapy or counseling. My experience is with the pediatric community and I am seeing an alarming number of psychotropic drugs being prescribed at high doses for children. This is both expensive and potentially dangerous; and, therefore, deserves greater oversight.
ADHD is a major problem:
ADHD is being diagnosed by teachers rather than qualified clinicians, and I believe that much of what is diagnosed as ADHD is either bright children who are bored in class (active minds wander when the pace is slow because we can “leave no child behind”), low IQ (you can’t stay on task when you don’t understand what everyone is talking about), learning disabilities or chaotic home environment with poor boundaries. Ritalin, Concerta and all similar drugs are being passed out like candy, and there is a lot of pressure on primary care providers to write prescriptions because the schools insist on one before the child will be allowed back into the classroom. Often these kids develop problems sleeping (they are on amphetamine!), so another pill, Seroquel is given to help with their sleep. Or maybe they become moody because they are sleep-deprived; or they enter puberty, and are given the label Bi-polar and started on Lithium. Parents receive SSI benefits for their “affected child” and there is an incentive to continue, rather than reduce, medications. Physicians are able to bill higher for caring for a patient on multiple medications. Side effects from one medication lead to initiation of another...
We desperately need good mental health care because many of these children have severe emotional problems. But their treatment is likely not found in a pill. I propose that in-home assessments should be done on any child receiving psychiatric medications. If indicated, parents are referred for parenting classes, which must be completed or actively entered into before any medication is prescribed. Before a child is diagnosed with ADHD, formal criteria must be met with a survey completed by teacher, parent and a trained professional. Behavior modification techniques must be implemented as a first line of reconciliation, and parents must show a log of “star charts” etc., before medication is initiated. Pills are not a substitute for parenting.
5. Pharm-D:
This is an individual who evaluates medications and drug interactions. Pharmacies must have a central point of shared information. A Pharm-D should routinely be reviewing medications for any individual who is on more than 2 chronic medications. As a hospital administrator, I saw a lot of iatrogenic illness created because of drug interactions. In an ideal world, the patient’s doctor is the one monitoring medications; but the reality is that patient’s use the ER to fill their prescriptions. They don’t know the names of their medications when new ones are prescribed. If they are seeing several sub-specialists, new medications are started and doctors outside of that field may be unaware of drug interactions. Also, with the use of generics, patients may be taking furosemide and lasix or Albuterol and Ventolin, thinking they are two different medications.
6. Medical “Home”:
This will provide less expensive, safer and more efficient care. Patients will be assigned a specific doctor, hospital, lab center and outpatient radiology center. If a patient goes to a facility outside of his/her network, there is a significant co-pay (co-pay will be waived/returned if the problem is deemed a true medical emergency; i.e., level ½). With our current system, patients “doctor- and or hospital-shop”. There is redundancy of testing and no one has the complete picture of the patient’s problem. Additionally, patients with complex problems arrive at a facility that is unfamiliar with their problem and the wheel is either re-invented or decisions are made in a void.
I have experienced each of the following on a reoccurring basis: A transplant patient shows up with fever, but does not know his/her medication. A cardiac patient is having problems breathing, but the mother does not know what kind of heart problem they have or what their normal saturations are (I want to give oxygen; but if it is a Cyanotic heart condition, I will make the child worse by giving oxygen). A V/P Shunt patient who had surgery (for some tumor that mom can’t remember) and all of their other films and operative reports are at another institution (no comparison films). It is often difficult to get information from outlying labs/clinics, imaging centers or hospitals in a different network; and, it is impossible to do so after hours or on weekends.
By appointing a “medical home,” data can be centralized and accessible for each patient. This is an essential component to preventing over-utilization or poor decision-making.
7. Web-based Medical Chart:
Data is wonderful, if you have it in a timely and easily-accessible form. Your best IT specialist needs to be working on a web- based system that directly interfaces with Medicaid /Medicare providers. I have worked at too many facilities that have antiquated technology and non-interfacing programs. Physicians and health care providers do not have the luxury of spending hours sifting through medical records, labs and radiology from multiple sources, which arrive at staggered intervals. Ideally, when a recipient of government-assisted medical care has a lab drawn, or a radiographic study done – at any facility – their “number” is recognized by the system and the information is placed on a web- based chart. (HIPPA issues can be addressed, but assigning a number other than their social security number should help protect identity). That chart can then be accessed at any facility. This would prevent redundancy of labs and give physicians immediate access to results. Pharmacies, too, need to be linked to this data so that all medications can be entered. It is unlikely that time-efficiency will be a part of obtaining clinic/hospital notes from a web-based chart; but medications, radiographic studies and labs are essential knowledge for any physician caring for that patient. Those items can become large ticket items. It probably would be possible to get “site visit/chief complaint” and discharge summaries into the chart, though.
8. Providers:
We need a pool of well-trained providers who use evidence-based medicine to provide the best care at the lowest cost. We do not need providers who rely on Medicaid/Medicare patients as their base income because they cannot build a practice with insured patients. We do not need providers who are so overworked with the volume of patients that they have no time for continuing education. We need providers who are not trying to abuse the system by ordering unnecessary tests or monitoring multiple psychiatric medicines to pad their own accounts. Doctors need to be paid fair value for their work, in a timely fashion; and, they also need to be current on the management of disease. Asthma and hypertension management, as an example, has changed a lot in the last decade.
Some Ideas and Solutions for the Problems
A. Medical Health Corp: Today’s graduating medical students average greater than $200,000 in debt. This deters many from going into primary care or seeking work with a large Medicaid/ Medicare population. Although there are scholarships or supplemental grants for individuals who provide health care in underserved areas, the programs are very limited. The MHC would pay for medical school and provide a salary through residency, much like a military scholarship. These medical Captains would then serve in the Corps for 5 years after completing their specialty of choice. At the end of their government commitment, they could elect to remain in the corps and advance through the ranks or they could move into private practice. Their pay would be based on a base salary plus productivity. One of the problems with flat salary for physicians is that it reduces the incentive for hard work. Why see 50 patients a day when you can see 20 and get paid the same?. Conversely, if a doctor says he/she is seeing a hundred patients a day, they are not providing good care. There needs to be a few “defaults” set into the system so that people who are seeing a lot of patients also have their charts reviewed to ensure that they are providing appropriate care and not just setting up a revolving door or a Rx clinic. The Medical Health Corp would be a way of building the nursing work force as well.
B. Continuing Education:
Any physician who provides care for Medicaid/Medicare must attend a yearly or bi-yearly, 2-day refresher course. They will be reimbursed for their time and they will get a folder with pathways and medication usage for the most common CPT codes in their specialty. In the ER, I see a wide variety of health management by physicians in the community, some excellent and some poor. Standardizing the management, based on evidence-based medicine, will lead to better patient care.
C. Pay for Time:
Procedures are reimbursed, but time and clinical acumen are not valued. Any physician who works with the Medicaid/Medicare population recognizes that they are paid for procedures, not to talk to their patients. Sometimes taking time with a patient prevents unnecessary procedures or medications. It is probably more cost-effective in the long run to pay physicians for their time. By taking extra time with a patient, a physician can explain why they are not going to prescribe antibiotics for a viral infection; or the patient with headache, chest pain or abdominal pain is stressed because of the death of a parent, layoff, or divorce; medications or invasive studies, then would not be needed. A listening ear is curative or at least uncovers the need for additional counseling and appropriate referral. If doctors feel forced to see high volume Medicaid/ Medicare patients in order to meet their overhead, because reimbursement is so low, then Medicaid/Medicare will likely pay more down the road for prescriptions and diagnostic studies.
D. Minimize liability:
We need to greatly reduce the role of lawyers’ influence in health care. Any practicing physician will tell you that the threat of malpractice leads them to order extra tests. Too many small towns are left without OB-GYN and family practice coverage for deliveries because malpractice costs are prohibitive; you cannot deliver enough babies to pay for the insurance. Everyone with abdominal pain gets a CT, and the list goes on and on. Gross negligence – wrong leg removed, impaired physician – deserves legal action. But unless the government is willing to pay malpractice insurance for all providers, the risk of lawsuit must be removed. Even the best doctors make mistakes. We must allow for human error. Even if a suit is dropped, it is costly both financially and emotionally.
These are just a few of the ideas I have with regard to implementing a cost-effective, yet substantial health care plan for many. I welcome the opportunity to meet with you and share more of my ideas as you move forward in developing a health care policy.
Respectfully,
Cynthia L. Beamer, MD
All expressions of opinions and statements of supposed fact are published on the authority of the writer, and cannot be regarded as expressing the views of Bexar County Medical Society (BCMS). It is not the intention of BCMS to endorse any opinion/view published in San Antonio Medicine magazine, but rather to provide potential publication of member physicians’ opinions/views as editorial space allows.
