first submission to Daschle


Community Healthcare Discussion Group

The focus of this letter is to make practical suggestions for the new administration to consider to address some of the issues in the health care system. A general overview of issues we thought were the most important include the following; lack of standardization, lack of regulation, lack of system-level design, gross inefficiencies, corporate greed, obfuscation of information necessary to make informed decisions regarding health care, lack of education about lifestyle choices necessary to ensure better health, lack of openness to alternative therapies, overuse of biologically active chemicals in our food supply chain coupled with their attendant (poorly understood) health effects.
These problems are systemic problems. The concept of healthcare as a business rather than as a basic human right or public service for the greater good is at the root of many of these problems. Powerful lobbying groups in Washington (big pharma, insurers) are making tremendous profits by influencing the legislature to pass bills which benefit their sponsors at the expense of the American people. This has been going on for a long time. We only have time and space here to address the issues that are most important to us, and that we know the most about.
 
1.)    The central healthcare issue of our time is access to affordable, high-quality primary care.  As many have observed, there are too many specialists, too few Board-certified Family Medicine practitioners, and too many uninsured (45.7 million Americans, in one recent tabulation).  This problem is most acute in low-income urban and rural areas.
2.)    Health care costs are excessive, and are consuming an unsustainable proportion of GDP (16%).  On a per-capita basis, health care expenditures in the U.S. are twice those of Western European industrial democracies and Canada.
3.)    Statistical measures of health outcomes in the U.S. (morbidity and mortality) do not even approximate those of countries which spend much less of their GDP on health care.   For example, many sources currently rank the United States 28th in the world in infant mortality, far behind nations such as Sweden, France, Japan and Germany.
4.)    Medical errors (of omission and commission) documented by the Academy of Medicine, many of which are medication-related, may cause nearly 100,000 deaths annually.
5.)    Health care records and clinical documentation is fragmentary, episodic, and frequently not accessible electronically, except within proprietary/bureaucratic “silos”. This indicates a lack of standards and protocols, and the lack of regulation enforcing compliance to these directives.
6.)    Mass media advertising by pharmaceutical companies distorts the health care economy from a rational, “needs” basis to an artificially-induced “demand” basis.  Hospitals and providers, too, are “penalized” by the demand economy if they fail to advertise.  This diverts scarce resources from necessary investments in staff, training and technology.
7.)    In the wake of declining federal support for funding of basic biomedical research, funding by pharmaceutical companies impose artificially short time-to-market constraints, discourages original thinking and in the long-run, stifles innovation.
8.)    In certain areas, the private health care insurance market is highly concentrated, allowing anti-competitive (even criminal) behavior by carriers and those in league with them.  See, for example, Rhode Island.
9.)    Because of complex, overlapping public/private health care insurance, providers must spend an inordinate amount of time and resources “registering” patients at each encounter, verifying their eligibility for medically necessary procedures, and ensuring they are reimbursed on a timely basis.   Even when these data are stored electronically, they must be re-certified at every episode of care, and even solicited and recorded twice for the same encounter:  once for the hospital, and again for large physician group practices.  This is burdensome and inefficient, for patients and providers alike.
  10.)    The current macro-economic crisis offers the United States an historic opportunity to address structural inequities in our health care insurance system, which have contributed to the decline of American manufacturing and other basic industries.  At the same time, we need to invest in high-technology American jobs that will help make our health care delivery system more efficient.  A large-scale strategic investment in health care information technology, coupled with rationalization of our dysfunctional health care insurance sector, would allow the United States to accomplish both of these objectives.

To a large degree, many of the problems facing the healthcare system are problems of information sharing, which can be solved by the implementation of an intelligently designed systemic approach to securely storing and sharing patient data with various healthcare providers – it is equally important that these records are accessible by the patients themselves. It is the job of government to mandate compliance with these standards.
The legislative measures that have been passed are often extremely detrimental to the efficient delivery of healthcare to the patient – some examples follow.
 
1.  There is no national standard for an individual's insurance ID card.  Insurance identification cards often are packed with a confusing jumble of policy numbers, group numbers, Third Party Administrator (TPA) numbers, etc.  Even with substantial investment in insurance eligibility software and clearinghouse membership, our organization struggles with capturing accurate and up-to-date insurance information at the point of service.  This results in denial of payment, rejection of claims and back-end overhead as patient accounts staff chase the patients and the insurance companies for accurate information and billing protocols.  Some of these claims eventually get paid; others do not.  Those that do get paid do so at a very high administrative cost.  A national standard for the format and content of insurance identification cards would be a simple step to eliminate much of this waste and inefficiency.
 
2. The health insurance industry has a practice of negotiating policies that include (increasingly steep) copays and then holding providers responsible for collecting them which puts debilitating financial strain on providers.  The copayment is at a provision of the insurer's contract with the insured.  Yet, it is the burden of the healthcare provider to collect this money.  This adds tremendous cost to the delivery of healthcare. Hospitals must employ cashiers, clerks, financial counselors or advocates. In effect, we are administering the insurance company's policies for them.  In emergency departments, we are not legally allowed to withhold services due to a patient's lack of ability to pay.  Often as not, they don't pay.  This leads to yet another avalanche of added costs the providers must take on in order to try to collect this money via dunning statements, collection personnel, outsourced collection agencies, and, eventually, the millions of dollars expensed to the bottom lines of institutions as bad debt.
 

3.  The Federal Deficit Reduction Act included a provision whereby subsidies provided to drug distributors for the dispensing of their products to Medicaid patients must be tracked more closely.  The final rule that evenually was imposed requires that hospitals report NDC codes with drug charges reported on Medicaid insurance claims.  This is a revolutionary practice in institutional healthcare billing, and it places tremendous cost upon the provider.  Previously, Medicaid bills reported codes that simply indicate what drug, type of administration and dosage was administered to a patient.  The new requirement forces billing departments to keep track of the most intimate details of pharmacy inventory, as the NDC number for a drug is specific to the manufacturer, distributor and package size.  Hospital pharmacies purchase the same drugs from many distributors, acquiring variously packaged versions from various manufacturers based on any number of factors.  Now, there must be staff in the pharmacy monitoring the turnover of inventory and updating billing databases each time the stock turns over. This requires that hospitals administer and mediate a sweetheart deal struck by drug distributors with the federal government.  

  Public policy should promote healthier lifestyles, particularly in regards to diet and exercise.
Chronic disease places an enormous strain on the health care system. Although early detection of cancers, heart disease and diabetes are valuable, education should focus more on actual prevention. Early stages of imbalance can often be corrected and prevented from developing into chronic disease by the use of diet, exercise, herbs, alternative therapies and stress reduction. We would benefit from supporting research into and education on this type of prevention.
The government should fund educational initiatives in nutrition, cooking, gardening, how to shop for and prepare healthy meals. End the mass subsidization of the petrochemically based agribusiness in the US, promoting smaller, environmentally sustainable farming practices.  Encourage physical activity of all citizens regardless of age to promote better health. Promote civic taking of responsibility for our own health as patriotic. Provide initiatives for people to produce as much of their own food locally and organically as possible. And most importantly, provide strong leadership from Washington.
The current model of healthcare reimbursement is disease-based rather than wellness based.  Illness is more profitable to many sectors of the industry that wellness.  Reimbursement for inpatient services usually increases with the severity of diagnoses, and for outpatient services it increases with the complexity of services: in either case, the utilization of more resources is what's necessary to maintain the bottom line.  Wellness-based programs (diabetes education, nutrition counseling, cardiac maintenance, etc.) are woefully underpaid and often not paid for at all by private and government payers.  Therefore, they are small and command little attention in the institutional setting.  They are relegated to the "community service" sector of institutional operations--a euphemism for "service we have to offer but don't want to put anything into because it's a financial loser."  If we could devise a reimbursement model that emphasizes wellness-based programs , everyone would benefit.  Patients would see the results in their health as these programs proliferated and expanded; providers would reap the benefits of offering  and expanding these programs if they were made profitable; insurers would save billions in payments for the treatment of serious chronic disease that could be prevented if patients participated in these programs.
Our group was diverse in its perceptions of healthcare, and all opinions were valid. We expect that our group will get larger and even more diverse. The problems are well known, the solutions will require a great deal of effort, leadership and money. Our intent is to try to articulate particulars that will lead to solutions. We do not think that filling out the questionnaire provided on the change.gov website would lead to this end. Hopefully, we will provide one or more position papers that will be detailed enough to cause some action to be taken.