Every day I practice medicine I get a new story.
Today I attended a "pod group" meeting over lunch. Billed as meetings of primary care providers hosted by our local medical group to allow us to get together and share items of importance to our practice, the meetings instead have degenerated into coaching sessions about how to "code" patient encounters in order to maximize income, for the medical group and, secondarily, for us.
The care provided by family practitioners, pediatricians, and general internists--primary care providers-- is known to be the most cost effective in medicine. We know our patients. We understand where they are coming from. We can use this knowledge to tell, often, when a belly ache is a sign of serious disease, when a serious investigation is needed, or when reassurance and a little "tincture of time" is all that is needed.
You might think that the knowledge of the cost effectiveness of primary care would lead to comfortable salaries rewarding us for the money we save the health care system as a whole. But it just isn't so. Primary care providers are the lowest paid of all physicians.
So, on a Tuesday afternoon, for an hour at lunch we sat and listened to the medical director of our group explain that we could earn another $500 apiece next year if we made sure that our asthmatic patients all (actually the cutoff for the bonus is somewhere over 95%) received preventive medication in addition to any medication needed for treatment of asthma exacerbations.
Supporting proper use of medical knowledge in this way is a new thing in medicine. It is called "pay for performance" and among those who apply business models to medical practice it is thought to provide incentive to get doctors to do the right thing. A long digression could review the scientific literature which has sought to test this assumption (summary: the evidence of benefit is dubious), but I am really just introducing the concept to lead to the ironic tale of the day....
After I'd had enough of this meeting I returned to my office and was entertained by the first message of the afternoon. The mother of a 20 year old patient of mine, a young man with mild but persistent asthma, called. For many years his problem had been well controlled with only a single oral preventive medication taken once daily. Without it he had need for periodic "rescue" medication. With a recent insurance change (from Health Net to Anthem) his medication was no longer covered. Despite my "prior authorization" request, the insurance company had denied him the medication which had kept him stable for years.
Instead, their rules required that he first try and fail any of a number of alternatives, including "a long-acting beta agonist". The irony of these rules lies in the fact that the use of a long-acting beta agonist would be in direct conflict with the message of our noontime meeting, a clearly inadequate and counterproductive alternative.
But I caved in. I wasn't prepared to fight another windmill today. I wrote a prescription for an alternative (not the long-acting beta agonist, but an inhaled preventive drug), discussed the change with my patient's mother, and let her know that I'd go to bat for the previous prescription that we knew worked if this alternative didn't.
I don't object to doctors getting a kick now and then to prescribe cost-effectively and to practice state of the art evidence-based medicine. I pride myself in trying to do just that. (Thus a five-minute addition to one visit today to explain to an eighty-eight year old obese woman with controlled cholesterol that she didn't need a blood test every three months!) But that a change in insurance resulted in:
-- a patient's losing access to a medication that works,
-- the need to complete the paperwork for an ultimately rejected prior authorization request,
-- the need to explain all this to his mother,
-- a patient having to try a new medication which may not work as well as the one he'd used in the past
just doesn't seem right.
What we need in this country is a simple single health plan
for all. Let's take the new President at
his word and let him know what we think.
Here's his suggestion line: http://change.gov/page/s/healthcare. And here's where you can get more information
about the change we need: http://pnhp.org/
.
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Cross posted at dagblog.com, where I have proclaimed the end of an era, and no one is named Saxby .
]]>Comments are off until the data mining is over. Then we'll share.
(Come back if you want to get scared.)
]]>Dissociated Press
December 2, 2008
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"We've taken stock in
A menu of items to be served at the spare, but attractive, Art Deco style building showed bargains were available, including the "Ayn Rand Grand? Ragout" for a nickel per serving. According to the menu, this offering is made with a "fresh water broth into which is introduced just a hint of beef and vegetables, all seasoned with care to enhance its substance. This recipe is so popular that diners not only stand in line to order a bowlful of this light offering, but find themselves soon wanting to come back for more!"
Continuing the Art Deco theme, Krewl Grewl has commissioned a new line of glassware to be used in the restaurant. These items were on display, and were not only joyously colored but were in fact crafted to a mirror finish sufficient to offer diners a reflection of themselves as they sit before these Depression Glass style plates and bowls.
"We're excited about this opportunity to participate in this economy and to create jobs and investments in our communities," Greenspan remarked. He then suggested that the
"We expect to be as omnipresent in our communities from coast to coast as Starbucks once was, only with more 'staying power' in the market. I have faith that my partners in this enterprise will bring their talents to bear to assure such success for the future of Krewl Grewl, destined to become the venue of choice for American's looking to satisfy their appetite."
Coming up: "Soup's On!: Greenspan Cooks Up a Rich Stew"
Learn how the former Fed Chief's experience in the free market helped Krewl Grewl leverage "17 dollars, small change, and some pocket lint" to gain nearly $25 billion in government assistance to grow this exciting franchise.
ALSO: Newswoman Andrea Mitchell of NBC researches conflict-of-interest concerns raised over government funds being awarded to the same people in charge of disbursement. "We're not conflicted at all about receiving these funds," declares Treasury Secretary Paulson in assurances made at Congressional oversight hearings.
While the financial crisis has affected almost all countries, lines can now be drawn between those who have cash and reserves, and those that don't. The ones that do - China, Russia, Brazil, Saudi Arabia, Japan, Norway - are in the catbird's seat. Those that don't - ranging from tiny Iceland to the United States - are facing the constraints of being debtor nations.
But while the structural reality of the world has changed dramatically, the cognitive reality hadn't - until now.
If you had followed the coverage of the summit of the world's leading economies (the so-called "G20″) held in Washington on November 15, you could be excused for thinking that the meeting was a flop. Other than vague promises on the part of the collected leaders to do something about the world financial system, there was no bold plan announced, no specific solutions to the world's problems. The coverage in the United States treated the summit as a non-event that amounted to a photo-op for world leaders and a lame-duck American president.
In fact, however, the G20 summit revealed a developing world brimming with confidence about its ability to solve current problems and a developed world lost in the mist. That was reinforced at the meeting of Asian-Pacific nations last week in Peru, which led to the declaration: "We are convinced that we can overcome this crisis in a period of 18 months," the leaders said in the statement. "We have taken urgent and extraordinary steps to stabilize our financial sectors and strengthen economic growth." Sometimes rhetoric matters, and the fact that most affirmative statement of confidence in the ability to solve the current credit crisis came not from New York, Washington, or London speaks volumes to the world as it now is.
Today, the rest of the world is forging new links with one another in recognition of the fact that they will have a central role in shaping the future. That is why outside of the United States, images of President Hu of China speaking candidly with President Lula of Brazil, or both huddling in serious discussion with Singh of India and Medvedev of Russia matter. For years, these countries looked to the United States as either an adversary or a bulwark, and assumed that in the end, action by the United States would determine outcomes for better or worse. No longer. The contrast between the Washington summit, where the U.S. leader was mute and ineffectual, and the summit a week later in Peru where the tenor was "yes we can!" rather than "how can we?" was stark.
For sure, banks in many parts of the developing world have taken hits, as they were exposed to the same toxic assets that have brought the credit system to its knees. Yet banks in many of the emerging countries are not as vital to the system, especially in places like China or parts of the Persian Gulf, where government spending and state-capitalism are the major source of economic activity. 50% of China economic activity is spending by the state.
The developing world is now helping bail out the financial system of the developed world, with cash injection (Abu Dhabi into Barclays; Prince Alwaleed of Saudi Arabia in Citigroup, and soon perhaps China into AIG) and developed world governments are abandoning the model of bank-led capitalism and taking a much larger role in the economy. "Their" model of strong state intervention in the economy is now the one becoming universal, not "ours."
The crisis has radically shifted the way that the emerging world views its role. To borrow from psychology, the implosion of the western financial system has created that cognitive break, and rather than finding themselves brought low, emerging nations have been able to weather the storms. They have faced no strong outcry domestically and if anything have gained in stature by swift and strong action to address root causes and fix what's broken. China's vast $600 billion dollar stimulus package is one example; Abu Dhabi guaranteeing the debts of Dubai is another; and President Lula of Brazil declaring an end to the developing world's dependency on finance from the developed world yet another.
Having been forced to abandon the psychological dependency on the United States, they are taking responsibility for shaping the world around them. In the past week, there have been major meetings between Russia and Brazil, between China and Brazil, between China and multiple countries. Many say that the lesson is no longer to treat the United States as wiser and stronger economically, and not to look to Washington for lasting solutions. The crisis is their wake-up call about their own importance, and they are seizing the moment.
Given the despair and confusion in the developed world, this is a good thing. The global system is too big for any one country to sustain it, and while it'ss a painful time, it might just lead to greater balance and stability going forward. The new leaders recognize that no one of them can create that world alone. With the new Obama administration in Washington, and Hillary Clinton at the State Department, they might find a partner who understands that as well.
For a look at additional blogs and other writings of mine, feel free to visit River Twice Research.
Amongst all the mortgage mess/credit crunch/bank bailout/global recession palaver the condition of the distressed homeowner continues to get short shrift.
This is perhaps because to pay too close attention to this problem is to be reminded of how we got ourselves into this mess. Not just that the meltdown in home values precipitated the current crises, but that the artificially prolonged housing bubble was a main structural prop in our economic house of cards.
We took a real truism - that property values in the
To accomplish this feat our financial wizards invented complex new financial instruments better suited to creating the illusion of wealth than actually creating it. "Masters of the universe", preying upon the almost primal yearning for one's own home, cynically exploited those desires in order to keep the charade going for yet one more round.
And we all joined in.
My main purpose here is to point out that the stretching of a
basic truth beyond recognition does not alter that basic truth; in this
instance, that home values in
The Fed would create a program wherein every resident homeowner who owes more on their home than it is presently worth is given the option to refinance their mortgage at the home's present value, and at a 30 year fixed rate. In return--with an eye toward that eventual price rebound--the homeowner will sacrifice some equity opportunity for a fixed period of time.
The Federal program would require participating banks, mortgage companies, investment banks or packaged securities holders (the bank) to offer the restructure deal to all eligible homeowners who opt to participate. No cherry picking.
The average value of a home in the
The Fed provides banks 2/3 of the difference between the original mortgage and present value; in our example: $66,000. This punishes banks ($34,000 or about 6.5% of their original investment) in a modest but meaningful manner for their irresponsible lending, but enables them to replace a toxic asset with a relatively strong one, as well as providing a jolt of desperately needed liquidity, which when multiplied by most of their eligible mortgages, would significantly add to the banks' health.
The homeowner is relieved of $100,000 in debt, and has the remaining $400,000 put on significantly more affordable terms. In exchange the homeowner signs a 7 year (could be 5 or 10?) "equity note" where he gives up any equity accrued (above $466,000) during that period.
To recoup its money, the Fed packages the notes, and issues
7 year bonds (or some other instrument?) backed by the notes. Investors
worldwide who have confidence that the
The homeowner would not be required to actually refinance the home at the end of the 7 years. The Fed gets repaid when the homeowner eventually sells the home, or when she refinances at some point to free up equity accrued above the amount at the end of the 7 years. Her mortgage remains based on the $400,000 principle until that time. What the Fed will likely do to pay the bonds is just issue some simple interest debt backed by the liens on the participating homes, then pay off that debt as it is paid when the homes sell or refinance.
The 7 year term is a best guess. It is based on the average
My thinking is that there would be a self-fulfilling aspect to this plan; the massive injection of liquidity would spur more housing purchasing, which would in turn raise home values. I would hope that this effect would go a long way toward assuaging the frustrations of those homeowners who do not directly benefit from the plan.
This proposal is meant as a starting place in an attempt to
help out distressed homeowners, put a floor under the housing market, and infuse
a huge amount of liquidity into the credit markets without that infusion coming in the form of more national debt.
I've obviously left out tons of detail, but the general idea is all here. If there
are fundamental flaws in the idea, or any
ideas for improvement, please let me know.
When Paulson and his colleagues talk about issuing mortgage loan guarantees, they aren't talking about anything calculated to prevent homeowners from losing their homes. They are talking about ways for mortgage companies and investors to get paid even if (or more precisely, when) homeowners default on their loans and are foreclosed upon.
This is one reason banks aren't making significant loan modifications for homeowners, and why the much-touted "Hope for Homeowners" plan has only 42 applications to date. If you were a bank, would you make significant loan modifications for homeowners when you can foreclose on them and then get the entire amount of their loan plus interest from the government?
Unless we come up with a useful plan for keeping people in their houses, nearly every loan undertaken from 1998 forward will soon be underwater because of the huge amount of unsellable real estate on the market. (Since the number of people who now qualify for a mortgage is less than the number of people who qualified in previous years, those foreclosed-on houses aren't going to fill back up anytime soon.)
If you think this is crazy, please call your elected representatives and demand a plan that will keep people in their homes and neighborhoods.
]]>The employer is self-insured--that is, the company maintains its own fund for payment of medical expenses for all employees, and pays a major insurance group to administer it. How blessedly simple! The employer saves money by hiring a manager instead of paying premiums to an insurance company that must pay for management and also provide a profit to its shareholders. For a $15 co-pay, I can go to whatever doctor I choose, undergo whatever procedure I choose, and if the procedure is not covered and/or I go to a doctor who has not agreed to the fee structure set by the insurance company it will still be available but will simply cost me more. I contribute to the monthly premium and have a $250 annual deductible for optional procedures--all quite manageable for the average working person.