US Healthcare Still Seeks the Right Balance of Private/Public Funding

The Organization for Economic Cooperation and Development tracks the total healthcare expenditure of the developed economies and compares these data indexed by per capita with the percentage of gross domestic product.  In 2012, the United States spent 17.7% of its almost 17 trillion dollar economy on healthcare.  Rounding out the top 20 largest budgets, the remaining nations spent 8.9-11.6% of GDP on medical care.  Do Americans live 33-50% longer and better to validate this increased cost?  Now is when the ideologues, pundits, lobbyists, politicians and professional advocates wage war.  There may be naysayers citing selected issues and numbers, but I challenge that we get better outcomes when you consider the summation of longevity, infant mortality, and number of disabled due to mental or physical frailty and death rates from cardiovascular events, cancer, trauma, substance abuse, liver and pulmonary diseases.  What we do have that is different from the rest of the world is healthcare virtually on demand despite the introduction of the various managed care plans.  Americans want access to their doctors; plans gain market share by competing on that basis.

The financial sustainability of our delivery system is in doubt, with or without Obamacare, which deals more with health insurance than with medical practice.  The baby boomers are here and the national demographics point to increased need for medical resources.  Doing business the same way is not an option.  Unfortunately, the discussion has been polarized on the national level to the let the free marker forces solve the problem versus the healthcare is a right and single-party payer for all sides that lob criticisms at each other across the financially struggling and physical ailing masses.  Making sense of what is true, who has credibility, and what should be done is daunting; particularly as a national initiative.  Many states have instituted reform, but extrapolation of their proposals to the entire country seems politically impossible and of uncertain efficacy.

But the Federal Government is the elephant in the room and is not going away. Between Medicare, Medicaid, the Veterans Administration, and Social Security Disability the Feds foot half of the health care tab.  Even the most strident free marketers can not set the clock back to the pre-entitlement era.  Economics has never been a precise science in less arcane areas than healthcare.  Let me suggest several unique aspects of medical practice in the US that suggest traditional economic principles and healthcare finances are an oxymoron.

The current market is “socialized medicine” to some.  Not only does the Federal Government directly fund 50% of healthcare, but the other half is indirectly subsidized by the Treasury as the cost of employee-provided coverage is tax deductible to employers. And the workplace is where the majority of non-directly funded Americans get their insurance.  The concept of providing patients more economically driven latitude in choosing their medical needs breaks down when the market is really determined between healthcare providers (the payees) and the insurance companies and governments (the payers).  Patients complain about copays, caps, and networks but that amount is trivial compared to their ignorance over the cost/pricing structure of the vast majority of their care.

Along the same line, there is a concomitant asymmetry of knowledge between providers and insurers of specific costs to determine rational pricing at the microeconomic level.  In a hospital or clinic, how do you allocate the indirect costs of depreciation, salaries, utilities, administration, parking, maintenance etc to the operating room, wards, cafeteria or pharmacy?  Given all the support services that are required to run the medical intensive-care units, how do you calculate a daily rate?  How much do you charge for IV fluids in a particular site when a myriad of disposables used throughout a healthcare network are bought by negotiation with a single provider, who may also may have packaged non-disposable hospital equipment in the negotiation?

Similarly, how do you deal with the moral paradox of physician service charges?  Nonspecialists will not be empathetic, but many specialties get paid for doing procedures.  Some of the hardest decisions I made as a cardiac surgeon were not to operate despite intense pressure by family and referring cardiologists that there was no medical alternative or the patient would die.  My rebuttal that I need not be the proximate cause of a fated event often was interpreted as lack of caring, although I viewed it as not wishing to inflict unnecessary pain and suffering.  This was never the best remunerative option.  And finally, in many settings doctors provide care where they should not have a conflict of interest in carrying out that care.  Emergency rooms, intensive care units, and radiology suits are often staffed by physicians under contract to hospitals who, because of potential individual liability, practice defensive medicine and order additional tests and imaging that are justified more by self-protective instinct than the financial benefit of the hospital or insurance provider.

There is no perfect answer to the best mix of public/private contribution to funding healthcare, nor the surrogate issue of market forces vs government largess in solving the evolving economic turmoil.  However, to my mind, a purely market fore based approach to our financial healthcare woes is not compatible with a commitment to providing a basic tranche of health care is a right for all citizens.  As Joseph Shrumpeter, the academic champion of capitalism’s benefits to society, once said “capitalism without failure is like religion without sin”.  The debris of creative destruction on outmoded technologies can be rectified, but the harms of inappropriate and insufficient medical care are not rectifiable.

By Norman Silverman, MD, with Ryan McKennon, DO and Ren Carlton

What Kind of Business Should You Start? – How Mark Zuckerberg Pivoted From Rating Hotness to FacebookFind Angel Funding & Venture Capital for Business Startups, Entrepreneurs, & First Time Founders – Episode 1

When it comes to brainstorming startup ideas, new entrepreneurs and even seasoned ones scratch their heads in confusion. Living in the information age, you can scan the current market and see countless new business ideas. With so many options out there, how do you know which one is right for you?

Why Would a Doctor Abandon a Steady Paycheck to Become an Entrepreneur?

As physicians, we are expected to be compliant with rules, restrictions, and regulations. We are expected to be risk averse. We are expected to be “providers,” but not necessarily innovators or leaders. As the healthcare system becomes increasingly consolidated into large overcrowded clinics, we are required to perform to the standards set by bureaucrats and clinic managers. These rules are often at odds with the best interests of patients and with our sanity.

The Alienation Of America’s Best Doctors

The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage.

Better to Live and Die in the U.S.A.

The United States healthcare system is often berated for how it treats patients near the end of life. They are purportedly attached to tubes and machines and subjected to unnecessary invasive procedures that cause inordinate pain with no potential benefit, there is underutilization of more compassionate hospice services. This “travesty” is expensive, as the care of dying seniors consumes over 25% of Medicare expenditures. We hear this story so often; it is almost taken as gospel-- but is it actually true? Is it more expensive and invasive to die in America than in other developed countries?

Gun Ownership and Doctors?

According to the Pew Research Center, there are approximately 32,000 gun-related deaths annually in the United States; 19,000 are suicide, 11,000 are homicide, and the rest are accidents, police shootings or of unknown causation. Moreover, there are more than 78,000 nonfatal gun wounds each year. Given the disproportionate number of victims that are less than 40 years of age, the morbidity and mortality of gun violence is significant. Physicians are involved with many types of public health issues, but few are as controversial or divisive as gun safety. Is it really an issue that falls within the medical domain?

O Tempora, O Mores: Affordable Care Act - Big Dream or Big Let Down?

I confess I was a strong proponent of the Affordable Care Act. My reasoning was subtler than the hallowed pantheons of its staunch supporters and the apocalyptic predictions of its detractors. Forty years after graduating medical school I concluded, after many stutter steps, the American healthcare delivery system was economically unsustainable and the citizenry was neither living longer, nor better, despite medical expenditures that dwarf any other developed nation. My career also allowed me to personally interact with cardiac surgeons from all continents and see that their clinical results and research efforts were laudatory by any standards.

High Depression Rates in Resident Physicians — Fact or Fiction?

The December 8, 2015 issue of JAMA had a startling key clinical point; the prevalence of depression or depressive symptoms among resident physicians in training was 28.8%. The data was generated by meta-analysis of 31 cross-sectional and 23 longitudinal studies published in peer-reviewed journals involving 17,560 trainees. Two-thirds of the trainees were in North America, but the others were from Asia, Europe, South America, and one from Africa. Sensitivity-analysis confirmed that no individual study affected overall prevalence by more than 1% and that the incidence of depression was not influenced by study design, continent of origin, surgical vs nonsurgical program nor level of residency year.

Can a Robot Outperform Your Surgeon?

In the current competitive environment, healthcare providers often attempt to separate themselves from their competition by marketing themselves as using the newest technologies for their procedures. This is an age defined by finding the next best thing and the American public responds to this strategy. My personal experience has been in cardiac surgery, but the principles are equally applicable to other specialties, particularly tertiary referral practices.

Hospital Administration Attempts to Cut Costs and Increase Quality at Expense of Physicians

A nonprofit hospital care system in Oregon with 450 beds has been in an acrimonious negotiation with its staff hospitalists for the past 2 years. The mounting economic pressures on this small, community oriented institution have had the expected consequences of hiring new administrators to implement the latest trends to rein in the budget and effect efficiencies of healthcare delivery-- as if that has been so successful in the rest of the country. The battle has really centered over the physicians losing control of their work time allocation, individual decision-making for diagnostic and treatment plans, as well as bristling at bonuses based on the administration’s definition of quality.

Michigan Physicians Society Supports Inner-City Education

Yesterday afternoon I had the privilege of helping to honor the graduating class of 2016 at Experiencia Preparatory Academy. They have 3 graduates this year that have overcome a special set of challenges, including moving from Mexico to the United States and having English as a second language.

Affordable Care Act: Affordable for whom?

Entering its third annual open enrollment period, Obamacare is the subject of cacophonous political acrimony, again, championed by its supporters and vilified by its opponents. Each side presents its own “metrics” of success or failure

Big Pharma Using Mail-Order Pharmacies to Maintain High Prices

The United States has the dubious honor of paying the highest prescription drug costs in the world. Many healthcare economists attribute this to relatively lax cost regulation compared to other wealthy countries; however, a decade of insurers paying only for generic drugs when available and limiting drug choice in specific formularies has had little modulating effect.

Mental Health Spending: A Story of Failed Supply and Demand

Several weeks ago I was in Palo Alto, California walking along Camino Real abutting the Stanford University campus. I noticed a newly-constructed high-link fence isolating the commuter train tracks from the pedestrian walkways. Another “shovel-ready” infrastructure project to nurture the economy?

Photos - MPS Auto Show Event - Lingenfelter Collection!

Our auto show event at the Lingenfelter Collection was a huge success! Approximately 100 attendees enjoyed an evening of learning, networking, and fun at the Lingenfelter Collection, one of the most notable car collections in the world! A special thanks to M1 Concourse and the Lingenfelter Collection for sponsoring this event.

Michigan Physicians Society Auto Show Event - Lingenfelter Collection!

We are excited to announce our next MPS event! MPS members will enjoy an exciting evening of learning, networking, and fun at the Lingenfelter Collection, one of the most notable car collections in the world! Learn about car collecting as an alternative investment strategy while enjoying a private tour of the Lingenfelter Collection.

Physicians Role in Drug Pricing

Two new drugs, Repatha and Praluent, were approved by the Food and Drug Administration several months ago amid much ballyhoo. Both are antibodies that specifically target PCSK9, a protein which reduces the number of receptors on the liver that remove LDL cholesterol from the blood. By blocking PCSK9’s ability to work, more receptors are available to clear LDL. This novel mechanism was proven safe and effective in clinical trials, lowering LDL cholesterol levels by 40% or more in patients already taking statin drugs. However, powerful treatment comes with a powerful cost-- over $14,000 per year for each patient.

Physician or Salesperson? - The Ethics Behind Patient Donors

Maybe it’s because we have entered the silly season with a full cast of presidential aspirants, but I have recently mulling over the perception of behavioral impropriety. To translate from spin doctor to medical doctor, I mean professional behavior that may not be overtly unethical, but exudes self-interest over patient well-being. In the academic world, full disclosure includes financial interest with potential conflict, disclaimer of previous publications, responsibility for informed consent and approval by the appropriate research committee. In our practices, particularly in the clinic or hospital setting, much focus is on constructing a firewall between the pharmaceutical and the medical-device sales force and medical providers.

Cutting Healthcare Spending - Big Data, Hospital Costs, and Outcomes

According to the federal Agency for Healthcare Research and Quality (AHRQ), inpatient hospital costs account for nearly 30% of healthcare spending in the United States and are increasing by about 2% per year over inflation. This cost issue is a focus of the Affordable Care Act, which is accelerating the move away from fee-for-service to a single, diagnosis-related comprehensive payment, similar to Medicare reimbursement. Such payment systems punish unnecessary testing, prolonged hospitalization, and readmissions.

Is Medical Science Dead? - Art, Science, and Quackery

On April 8, 1966, Time Magazine caused a national commotion when the issue’s cover was emblazoned with the question, “Is God Dead?” The Time article was a measured consideration of how society was adapting to the diminishing role of religion in an age of stunning scientific advances. The writer posited that people would no longer believe things out of received doctrine, but faith would steadily succumb to the scientific method as mankind unraveled the truths of the physical world at the expense of the myths of the metaphysical.

IMPACT OF ICD-10 - Increases Billing Accuracy, Headache for MDs and Patients

I strongly suggest that a pledge to read a synopsis of the philosophy of the 13th century Franciscan William of Ockham on a weekly basis be inserted in the oath of office taken by every government employee. Clearly highlighted should be his nominalist doctrine, Ockham’s razor, which avows that the best solution to a problem is usually the simplest. Pare to a minimum the number of confounding variables.

How do we treat pain? - Unrealistic Goals Leading to Opioid Addiction

In the weekend review from ACEP, two articles caught my attention. The first one was on new guidelines from the American Society of Addictive Medicine on the use of prescription medication to treat opioid addiction. These guidelines were created soon after the Centers for Disease Control and Prevention (CDCP) declared opioid use and resultant death as an epidemic. The second article refers to a study showing that pain is underdiagnosed and undertreated in the ED. This is the challenging dichotomy we live and work in.

Drowning in the Fountain of Youth - Genetic Predisposition

Recently I read in a New York Times magazine article that the 130th richest man in the United States wants to match his age with his Forbes magazine wealth ranking. His riches have not bought him a unique, scientifically-formulated elixir for immortality; nor is he a wacky proponent of perpetual hyperbaric oxygen chambers or cryogenics.

Yelp May Not Help

Concomitant with the metamorphosis of the practice of medicine into the business of healthcare delivery, patients have been transformed into customers. Healthcare providers compete not only on the basis of outcomes, best practices, centers of excellence, advanced technology and cost, but also on customer service

Find and Replace: Genetic Engineering in Science and Medicine

Shakespeare’s Hamlet proclaimed, “What a piece of work is a man,” but now, almost half a millennium later, this could be amended to what a set of sequences is man. The nobility, reason, infinite faculty and admirable form can be attributed to the 20,000 or so genes that contain the chemical code for specific protein formation

HIPAA Protects Millions with Unintended Consequences

The Health Insurance Portability and Accountability Act (HIPAA) was endorsed by Congress in 1996 and was the last significant legislative legacy of Senator Ted Kennedy. It is enforced by the Office for Civil Rights and mandates nationally recognized regulations for use and/or disclosure of an individual's health information by a “covered entity”. Such an entity is a health plan, healthcare clearinghouse or healthcare provider.

Studies Prove Communication and Teambuilding Training a MUST for Surgical And Hospital Staff

Although individual judgment and technical dexterity are obviously important, best surgical outcomes, particularly for complex procedures, reflect the performance of many medical providers before, during and after an operation. Professionalism and a competitive business environment both stimulate medical centers to continuously focus on quality assurance programs, and to improve patient safety.

Death Rates Plunge Due to Following Protocols, Not New Technology

We are regaled in the lay press about new medical breakthroughs a novel cholesterol-lowering drug mimics the effects of a genetic mutation and improves lipid profiles when conventional treatment is ineffective; new cancer therapies are tailored medications designed to specifically attack tumor cells without the nonspecific toxicity of conventional chemotherapy; hepatitis C can be cured by short-term oral agents, not prolonged courses of parenteral infusions; mitral valves can be repaired percutaneously without the potential risks of extracorporeal circulation.

How to Grow Your Medical Practice Online

Here at Michigan Physicians Society, we’re dedicated to the financial betterment of physicians by providing continuing education and technology, along with an extensive network of other like-minded professionals in our space....

Wealthy Physician Fallacy: What's the Value of Your Physician in 2015?

Wealthy Physician Fallacy - No matter the recent trend, cutbacks in payments for provider services is a relentless and persistent tool universally acclaimed as cornerstone to healthcare cost containment. Concurrent with the bludgeoning of physician income is the populist conviction that this is morally justified to combat physician greed and unwarranted overcompensation.