What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.

What I Would Like to See in Healthcare Reform (Part 1)

I often tell people that if all I had to do was take care of patients, life would be grand. It is the countless hours of dealing with the administrative aspects of healthcare that have practically ruined the practice of medicine for many physicians. You should care; it takes away from our time with you.

TheHill.com, noted that physicians and their staff spent over 15 hours per week complying with quality reporting requirements and that for every hour a physician spends with patients, an additional two hours are consumed completing administrative tasks related to the visit. This meaningless (to physicians, anyway) work has costs in both time and money, leads to burnout, and is increasingly mentioned as the reason for early retirement. I, for one, found myself daydreaming in a committee meeting the other day and I calculated that it was 3361 days until my 65th birthday. That's 9 years, 2 months, and 15 days. No, am not planning to retire early, but sometimes I sure wish I could. Healthcare needs reform.

The average person thought Obamacare WAS healthcare reform. In reality, Obamacare did nothing to actually improve the healthcare system; it simply added more people to the rolls. Don't get me wrong. Having more people insured is not a bad thing. But we need more than just additional enrollees in a broken system.

After Trump was elected, there was an initial, overly optimistic assumption that Obamacare was on its last leg. Recent infighting among policy makers suggests Obamacare may be more like the proverbial cat with nine lives. I only hope true reform is part of whatever "replacement" or "repair" Congress and the President come up with.

In particular, let's hope some of that reform will significantly scale back a bloated, paranoid bureaucracy that sucks hundreds of billions of dollars out of healthcare that could go to those who actually care for patients. And, perhaps, some could go back into the taxpayers' pockets.

Back in 2012, Berkshire Hathaway CEO Warren Buffett called healthcare "the tapeworm of the American economy". To be more accurate, the federal government is healthcare's tapeworm. In an online article in Medical Economics last year, Ryan Gamlin, who studies what drives inefficiency, waste, and harm in U.S. healthcare, found that "as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare." That is a nice way of saying there's a ton of money wasted going to paper pushers.

Helen Adamopoulos, writing in Becker's Hospital Review in 2014, noted that US hospital administrative costs account for more than 25% of hospital spending, more than double that of Canada, for example, where hospitals receive global, lump-sum budgets. In contrast, US hospitals must bill per patient or DRG (diagnosis-related group), requiring additional clerical and management workers and specialized IT systems. They also have to negotiate payment rates with multiple payers with differing billing procedures and documentation requirements, driving up administrative spending. Not to mention all the personnel, time, and IT required to satisfy CMS’s (the Centers for Medicare & Medicaid Services) monstrous appetite for "quality" and "safety" data, with the ever-present threat of fraud and abuse hanging over every unintentional misstep.

What should be a simple process of billing for services provided is a minefield. And anyone who has ever tried to understand a hospital bill knows it is an impossible task. Aliya Jiwani, writing in BMC Health Services Research, notes that billing and insurance-related (BIR) administrative costs in 2012 were estimated to be $471 billion and that fully 80% of this spending, which provides little to no added value to the healthcare system, could be saved with a simplified financing system. Jiwani predicted that greater use of deductibles under Obamacare will likely further increase administrative costs, stating, "Empirical evidence from similar reform in Massachusetts is not encouraging: exchanges added 4% to health plan costs, and the reform sharply increased administrative staffing compared with other states."

A CNBC report of a Health Affairs study tagged the extra administrative costs of Obamacare at more than a quarter of a trillion dollars, an average of $1,375 per newly insured person, per year, from 2012 through 2022. The Health Affairs blog authors reported, " The overhead cost equals a whopping 22.5 percent of the total estimated $2.76 trillion in all federal government spending for the Affordable Care Act programs during that time."

What do I wish we could be different in our healthcare system? In March, I will discuss some specific changes that would reduce the administrative burden on healthcare providers and, in many ways, return us to a simpler, more direct, and frankly better transaction of healthcare.

Resolve to Improve the Health of our Region

January is a time of resolution, and often our New Year resolutions focus on diet and exercise. My friends, we need a city, county, and region resolution to lose weight!

In July, 2016, Sabrina Perry wrote an article for HealthGrove.com – a health data analysis and visualization site – titled, The County with the Highest Obesity Rate in Every State. She repeated the American Medical Association’s contention that obesity is a disease and noted that the World Health Organization considers obesity a global epidemic. I perused the article with interest, looking for the county in Texas that got the dubious honor of being the fattest. Unfortunately, it was our very own Angelina County.

Look around and it is evident. Angelina County has the highest obesity rate in Texas, coming in at 37.5%. That means nearly 4 out of 10 of us aren’t just overweight; we are downright fat. To achieve the dubious distinction of being fat, you have to get to a body mass index (BMI) of over 30. To give you an idea what it takes to qualify as obese, consider a 5’11” male such as myself. My appropriate weight is less than 180 pounds (and probably more like 160 pounds). Any more than that and I am considered overweight. But to be considered obese – which is what 37.5% of Angelina County residents are – I would need to weigh 215 pounds or more. For me, that would be at least 35 pounds overweight, if not more. I routinely see patients with a BMI of 40 or more, which is considered extreme (or morbid) obesity. That would be a whopping 100 pounds overweight for me.

What can we do?

Dan Buettner, author and founder of bluezones.com, has been writing for years about particular geographic pockets around the world where people live longer. According to the website, “Residents of the Blue Zones live in very different parts of the world. Yet they have nine commonalities that lead to longer, healthier, happier lives.” So much of this is what has been preached to us for decades: don’t smoke, eat your vegetables and legumes, exercise, don’t overeat, and drink wine in moderation. On top of this are stress-related factors, having strong family and friend relationships, and spirituality.

It’s not just that we are obese. Our overall health is terrible. The Robert Wood Johnson Foundation ranks population health by county. In Texas, many of the lowest ranked counties are in deep East Texas. Wouldn’t it be great if Lufkin could be known not just for pump jacks and forests, but also for the health of our citizens? This can only work for communities if each of us individually works at it. We have family, friends, and lots of churches. Strengthen those relationships. And, let’s stop smoking, exercise, and eat right!

I recently participated in a set of strategic planning sessions hosted by the Texas Forest Country Partnership called Stronger Economies Together, or SET. The purpose was to set goals for growth across a broad spectrum of our regional economy, from forestry and tourism to manufacturing and healthcare. Our SET healthcare workgroup noted that we have significant work to do if we are going to impact the poor healthcare factors and outcomes the Robert Wood Johnson Foundation identified in the deep East Texas region. We set an ambitious goal simply to raise our overall health ranking from the lowest 20% to the next lowest; in other words, from poor to still below average. But we have to start somewhere.

This will require a multi-year effort working with all aspects of the healthcare and social service community to start to move the dial toward a healthier region. We can do it, but we all need to make – and keep – that that resolution for better health!

Add HPV Vaccination to Your Kids' Christmas List

The Centers for Disease Control and Prevention (CDC) refers to itself as the nation's health protection agency. Among other things, they monitor infectious disease outbreaks (such as Zika, influenza or AIDS), and they issue recommendations for vaccines and immunizations.
There is a quiet epidemic in our country, and it is oral/throat cancer related to human papillomavirus (HPV) infection. We've known about HPV causing almost all cervical cancer for a long time, but the number of oropharyngeal cancers related to HPV infection has risen dramatically in recent years. Ever since actor Michael Douglas announced in 2013 that he suffered from HPV-related throat cancer, people realized HPV poses a threat not only to women, but to men as well.

HPV infection is very common. According to the CDC, 80 million people - about one in four - are currently infected in the United States. There are more than 150 related HPV viruses, but only a handful are responsible for causing most HPV-related cancers.

 HPV is so common that nearly all sexually active men and women get it at some point in their lives. Most of the time, people get HPV from having vaginal and/or anal sex. Men and women can also get HPV from having oral sex or other sex play. Sometimes no symptoms develop, and 9 out of 10 infections go away on their own within a year or two. However, the more serious HPV types can cause the infected person to develop cancer.

The CDC states that HPV infections can cause cancers of the cervix, vagina, and vulva in women; cancers of the penis in men; and cancers of the anus and back of the throat, including the base of the tongue and tonsils (oropharynx), in both women and men. This year in the United States, HPV will have caused more than 30,000 cancers.

The good news is that there are vaccines against the most significant cancer-causing types of HPV. But for vaccination to be as effective as possible, it needs to be given at age 11-12, before teenagers become sexually active. This isn't about whether or not our kids have sex; it is about lifelong risks of routine sexual activity.

Rather than get hung up on (or deny) how HPV infection happens - and the unpleasant types of cancer it can cause - we should put into practice what the CDC recommends and the American Cancer Society endorses: vaccination of our boys and girls.

As noted above, routine HPV vaccination of all children should be initiated at age 11 or 12. The vaccination series can be started beginning as early as age 9 and up to age 26, though late vaccination is not as effective.

There are several available vaccines, but Gardasil 9 (the newest version) protects against 9 types of HPV that are responsible for about 90% of cancers related to HPV and is now the sole HPV vaccine available through government programs. Even if someone has already had sex, they should still get HPV vaccine. (Even though a person’s first HPV infection usually happens during one of the first few sexual experiences, a person might not be exposed to all of the HPV types that are covered by HPV vaccines.)

According to Debbie Saslow, PhD, Director of Cancer Control Intervention for HPV Vaccination and Women’s Cancers for the American Cancer Society, “HPV vaccination has the potential to prevent tens of thousands of cancers and hundreds of thousands of pre-cancers each year." 

If you could prevent your child from getting cervical, vaginal, vulvar, anal, penile, and oropharyngeal cancer, why wouldn't you? HPV vaccination may be the best, long-term gift you can provide for your kids.

History and Medicine in Angelina County

I recently came into possession of Angelina County Medical Society meeting minutes dating back 80 years, from 1936 to 1954. These archives were kept by Dr. W. D. Thames. A walk down medical memory lane with these records is remarkable. Some facts are simply mundane. For example, dues in 1936 were $10.50 per member - $488 in today’s dollar. That makes our current County Medical Society dues of $100 seem like a bargain.

More fascinating to me is that even though the practice of medicine has changed profoundly over the last 80 years, little of the economics and politics of being a physician has changed. For example, charity care issues were documented back in 1937. We struggle with that today. The physician-patient relationship – what today would be assessed by patient satisfaction scores – was the topic of lectures in 1938.

The broad legislative issues on the table today are hardly different than those in 1938 when a Legislative Committee was appointed. Scope of practice issues with optometrists and chiropractors were discussed way back in 1941. In 1953, Dr. Arnett “encouraged members of our society to join the American Association of Physicians and surgeons, which is a political organization of doctors. Its purpose is to stop socialized medicine.” (What would they say now?)

Some issues from the past seem frankly quaint today. In 1952, Dr. Arnett was to appoint a committee to investigate a physician who took out an ad in the Lufkin Daily News, apparently quite the no-no at the time. The next month’s minutes document how that physician “apologized and said it wouldn’t happen again”. The Society even had a secret ballot to vote whether he was guilty or not guilty of advertising. He was acquitted on a 9 to 2 vote.

Admirably, the Angelina County Medical Society minutes also contain notable evidence of community involvement and civic leadership. In January, 1940, the Society was holding joint meetings with city and county officials and the Chamber of Commerce directors to discuss a federal aid program for the building of a county hospital. It was these very discussions that spurred local industry leaders to join together to build a new hospital. The legend we pass down is that in 1941, Arthur Temple, Sr., President of Southern Pine Lumber Company, W.C. Trout, President of Lufkin Foundry & Machine Company, E.L. Kurth, President of Southland Paper Mills, and Col. Cal C. Chambers, President of Texas Foundries, along with ten other businesses and industries, joined resources, refused federal funds, and raised one million dollars to build the non-profit Memorial Hospital (now CHI St. Luke’s Health Memorial). But we have forgotten the groundwork was laid the previous year by the healthcare community, the city and county leaders, and the Chamber of Commerce, all working together. Such cooperation and leadership can still take place today.

Another more poignant event occurred in February, 1954. Then President Dr. Gail Medford “read a letter from the Negro Chamber of Commerce wanting help from the Angelina County Medical Society in their plan to improve sanitary conditions in the colored community. Drs. Taylor and Spivey, City and County health officers, were appointed to work with the colored organization.” We cringe now, thinking about Jim Crow segregation and disparities in neighborhood services and conditions. But do we recognize similar disparities in healthcare today? Are we addressing the needs of the indigent, uninsured and underserved populations among us? Is the medical community as approachable today as it apparently was in the segregated 1950s?

Technology has revolutionized healthcare over the last eighty years. But technology cannot replace the heart. Let us not forget our calling, our oath, and our love for the patient. The practice of medicine should never be just a job. It is a profession.

I invite everyone to the Salute to Healthcare banquet on Thursday, November 10, 2016. Help us recognize and honor those in our community who set the standard in healthcare and who are true to the calling – the profession – of medicine. Call the Chamber at 634-6644 for ticket information.

Empowered – and Inundated – by Pink

There is a minor malady that comes around every season. It is characterized by a drop in energy, glazed eyes, and a strong desire just to sit and do nothing. This condition usually strikes around mid-October and peaks about the end of the month. Luckily, it doesn’t long. After a week or two of wearing dark clothes and drinking Standpipe coffee, it resolves completely with no lasting effects. I call it pink fatigue.

October has barely begun and I have already been interviewed both for the City Hall Update about the upcoming Power of Pink! celebrations in Lufkin and Livingston and by KICKS 105 about breast cancer for their website. I have an on-air interview with Danny Merrell this morning. October 18th is the 5^th annual Power of Pink! event in Livingston, and October 20th is 24^th annual Power of Pink! in Lufkin. Nearly 500 women are expected in Livingston, and an incredible 800 women in Lufkin. And even though it is not a breast cancer-specific event, the American Cancer Society’s amazing Cattle Baron’s Gala is October 15th. October is a busy – and very pink – month!

I jest about getting pink fatigue, but I hope it never, ever happens. We cannot tire of fighting this disease. Breast cancer is the most common cancer in women (246,660 new cases in the US anticipated this year) and the second most common cause of cancer death in women (40, 450 deaths predicted in 2016). Only lung cancer kills more women. The good news is that the cure rate for breast cancer that is caught early is really quite high. Today, most cases (61%) are diagnosed at a localized stage (no spread to lymph nodes, nearby structures, or other locations outside the breast), for which the 5-year survival is a stunning 99%.

The American Cancer Society reports that from 2003 to 2012, breast cancer death rates decreased by 1.9% per year in white women and by 1.4% per year in black women. Overall, breast cancer death rates declined by 36% from 1989 to 2012 due to improvements in early detection and treatment, translating to the avoidance of approximately 249,000 breast cancer deaths. That is truly remarkable!

But we must not succumb to pink fatigue until ALL women who need mammograms are getting them. Our minority communities, for example, still fall behind when it comes to getting mammograms and other screening tests.

The American Cancer Society recommends that women at average risk of developing breast cancer should have the choice to start annual breast cancer screening with mammograms beginning age 40 to 44. Women age 45 to 54 should get mammograms every year. Women age 55 and older should switch to mammograms every 2 years, or have the choice to continue yearly screening. Always, the risks of screening as well as the potential benefits should be considered.

These guidelines are for women at average risk for breast cancer. Women with a personal history of breast cancer, a family history of breast cancer, a genetic mutation known to increase risk of breast cancer (such as BRCA), and women who had radiation therapy to the chest before the age of 30 are at higher risk for breast cancer, not average-risk, and should talk to their doctor about appropriate screening. If in doubt, or you just can’t remember, get a mammogram every year. It is just easier that way.

Please don’t get pink fatigue! Support cancer research for prevention, early detection, and curative treatment for all by participating in something pink this month. Contact Lindsey Mott at 639-7613 for tickets to Power of Pink! Contact the American Cancer Society at 634-2940 for tickets to Cattle Baron’s Gala! Or go online to www.CHIStLukesHealthMemorial.org and click the link to purchase a pink flamingo for $15. Put it in your yard or at your office to show support for breast cancer awareness. All flamingo proceeds go to support patients in need right here at the Temple Cancer Center. Go pink! #BC4TheBirds