What my doctor thinks of Obamacare?

(The Week, August 29, 2012)

Lawmakers in D.C. may truly be committed to improving America’s health-care system. But according to actual physicians, our leaders are going about it all wrong

Want real health reform that is in the interest of you and your family? Don’t make the same mistake that Washington did. In formulating ObamaCare, the politicians listened to lobbyists, policy wonks, academics, health theorists, regulators, and occasionally to each other. But they failed to listen to the people who actually care for patients: Doctors. Granted, the lobbyists for physician groups were at the table, but not the doctor him or herself. Ironic, isn’t it? Especially when it’s the doctor who has the daily responsibility of directly caring for the patient.

Go ahead, ask your physician at your next visit what she or he thinks of current Washington-directed reform and its impact on the doctor-patient relationship. What you hear will likely surprise you, because it will likely be markedly different from what you hear from Washington. The policy theorists are simply too far removed from the reality of front-line patient care. Health reform, whether via the implementation of ObamaCare or the GOP’s “repeal and replace” plan, should no longer ignore the input and counsel of experienced, front-line, practicing doctors.

Here is a sampling of what my own internist, who has taken care of thousands of patients over the past 20 years, shared with me:

Frist: We hear the electronic health record (EHR) will solve much of what ails our health sector.

Doctor:

The EHR is not the savior of the medical system. In fact, it is effectively destroying the relational aspect of the art of medicine. Instead of talking with a patient and hearing her “story,” we are being relegated to looking at a computer screen and pointing/clicking during the visit. I know there are long-term benefits to an EHR, but most internists who value the art of medicine will tell you it is killing the “story.” And it is expensive. Physicians with EHRs see 15 to 30 percent fewer patients (and work later into the night). And yet with ObamaCare, we will be asked to take care of an additional 30 million patients.

We are told that increased government regulation and monitoring will reduce waste.

Unnecessary regulations and increased paperwork are drowning us and reducing quality of care. We have allowed just “one more thing” to be added over and over again. The camel’s back is now breaking. I have never seen physicians as depressed and stressed in my 20 years of practice. At each visit, I am required to tell the government whether the patient I am seeing had a flu shot last winter! Please help me understand how that improves care. I know the many quality metrics (i.e.: check this box) mean well, but they are having the opposite effect. They are diminishing quality because they (the boxes) become the focus of each visit, rather than the human interaction.

But increased documentation in charts and billing surely improves value to the patient?

Hardly. We are now working with 17,000 diagnosis/billing codes — absolutely ridiculous. There are nine codes for abdominal pain (right upper, left upper, right lower, left lower — you get the idea). And the government has recently increased the number of codes from 17,000 to 155,000. The bottom line — 300 codes would probably cover everything. It could be printed in a four-page leaflet, not three large volumes. It is unnecessarily complicated and it does absolutely nothing to improve patient care.

Doesn’t more careful documentation with the required codes help eliminate fraud?

That’s ridiculous. It is just the opposite. The actual diagnosis/billing codes have nothing to do with fraud. The EHR creates the appearance of a perfectly prepared note. In truth, it simply makes it easier to copy and paste from note to note. The note is filled with unnecessary information, making the truly pertinent information hard to find (and therefore negatively impacts patient care). The nice-looking, “electronic documentation” in the EHR opens the door for the unethical doctor to game the system and get away with it. It just makes it easier for them to upcode and not get caught. Fraud is skyrocketing while the EHR provides the cover.

But Washington tells us that “evidenced-based medicine” is the surest way to better outcomes.

Quality care comes from a careful, professional analysis of a clinical situation that leads to a correct diagnosis and treatment for the particular patient at hand. Quality care will never be found by mindlessly marking boxes or following algorithms that are at the heart of what is being called “quality measures and evidence-based medicine.”

What stands between you and caring for the patient?

The paperwork is overwhelming — nursing home admission forms, medical device forms, diabetic supply forms, home health forms, insurance records requests for “additional information.” Everyone has their form that must be completed. All forms roll downhill and the internist is the final resting place. Regulations requiring more needless paperwork mean less time for patients.

The law in Washington is that your reimbursement is to be cut every year. But you seem to be working harder than ever.

Reimbursement for our services continues to decline, because overhead costs rise. I am very blessed. I am paid well. But I have not seen a raise in 13 years. While CEOs, managers, administrators, benefit managers, and insurance executives see regular raises and bonuses. Physicians in our clinic feel fortunate that our pay has not declined. Yet our workload is so much heavier than it once was. Not because of patient volume, but because of the higher expectations of patients, the higher complexity of medical care, and the excess “stuff” that we are being required to do.

I’m told the primary care shortage of 40,000 doctors over the next 10 years can be met by non-physicians.

The suggestion that non-physician practitioners can fill the primary care needs of the American people is simply false. Their training, knowledge base, and ability to form a complete differential diagnosis is limited. The press often proclaims that nurse practitioners can replace doctors. There is a role for the NP and we need to support that role. But to suggest that someone with two years of training can provide equivalent care to that of a physician who, after college, has spent four years in medical school, three to four years in residency (working days and nights), and who, each day, makes hundreds of decisions for which he or she is ultimately responsible is not only wrong, it disrespects the training and ability of the physician. Remember, quality care is not measured by patient satisfaction surveys, but instead, by the ability to properly diagnose and treat a patient.

So… we’re not moving in the right direction with health reform?

At the age of 49, I feel that the practice of the art of medicine is becoming impossible, even for those of us who live for the chance to care for others. Our goal should never be to cure disease. Instead, our goal should be to heal people. The direction of our present system is negatively impacting the ability of good doctors to try and heal people. We must remove the growing distractions and be allowed to spend time with each unique patient and their “story.” We need to ask of each regulation or mandate that “seems” to sound so good: How will it impact the doctor-patient relationship? It is now, and will always, be within this relationship that healing occurs and true quality care is found.

Those are the words of one, but they are the sentiment of many. Ask and see.

And what is interesting is that this sort of conversation from the front-line would never make it all the way up to my office when I was majority leader of the U.S. Senate. The existing, overly restrictive filters of Washington lobbyists and bureaucracy simply don’t allow such real-life information to flow all the way up to the legislator.

So for the next round of reform, let’s make sure we don’t ignore the insights of real-life doctors. Let’s make sure this time around they are at the table.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

This article was originally featured in The Week http://theweek.com/article/index/232510/what-my-doctor-thinks-of-obamacare

Need for Affordable Care Cuts Across Party Lines

(The Hill, August 1, 2012)

Need for affordable care cuts across party lines
By Tom Daschle and Bill Frist

On June 28, 2012, the Supreme Court issued a decision that affects the health and well-being of every American, as well as the fiscal future of our nation. By affirming the constitutionality of the Patient Protection and Affordable Care Act (PPACA), the private and public sectors can now turn to implementation, along with natural and needed shaping and modification of the underlying policy along the way.

The court’s decision can and should be a turning point for our national discussion and action on healthcare. Though the upcoming elections might amplify our differences in the short term, it is in the long-term interest of every American to begin now to work together and forge consensus-based solutions for our nation’s most critical healthcare challenges.

The United States currently has an expensive, uncoordinated and inefficient healthcare system. By 2020, healthcare spending will make up one-fifth of our national economy. Excessive and wasteful healthcare spending fuels our nation’s exploding federal debt and imposes unsustainable burdens on our federal and state governments, employers, individuals and their families. This is a grave threat to our nation’s future health, economic viability and ability to compete in an increasingly competitive global marketplace.
As the co-leaders of the Bipartisan Policy Center Health Project, our mission is to bring together federal, state, business and workforce leaders to develop health system solutions that address ongoing budgetary and healthcare reform challenges. We are embarking on a new initiative to confront and curb the country’s out-of-control healthcare cost growth: Our goal is to promote a rational, competitive, accessible and affordable healthcare system. We will be collaborating on this initiative with Alice Rivlin and former Sen. Pete Domenici (R-N.M.), the distinguished co-chairs of the Bipartisan Policy Center Debt Reduction Task Force. The task force is dedicated to reducing the federal deficit and helping America achieve a sustainable fiscal path, which simply cannot be accomplished without significant healthcare reform.

Healthcare cost containment is a profoundly complex and divisive issue, but we are steadfast in our belief that this issue can be addressed in a meaningful way. We as a nation cannot wait any longer. Our broken healthcare system can be fixed; there are solutions to each of the challenges. But we will never devise and apply them until we commit to do so together, reaching across the political aisle to work with one another.

All Americans generally agree on the end goals for health reform — appropriate and effective patient care, lower costs and easier access for all. We might not agree on the individual mandate, but we do agree on the power of embracing personal responsibility for our health and health decisions. We do not always agree on the most effective way to execute state insurance exchanges, but we can agree that these exchanges provide opportunities for states to use the power of market competition to control costs and engage their constituents on the individual level.

We all know that greater transparency in pricing and outcomes will help eliminate duplication, waste and inefficiency. We want to see our system provide frictionless and coordinated care that brings satisfaction to caregivers and peace of mind to patients. We want our health records and data systems to be brought into the 21st century through health information technology, providing vital health information when and where it is needed instantly and securely. The only question is how we get there.

Healthcare is in a period of explosive growth and transformation. Every day, the sector performs technological miracles, creates jobs and saves lives. We must harness this power, but at the same time, strive to do more. The American healthcare system has the power to be more efficient and more accurate, without sacrificing our nation’s capacity for private-sector innovation, productive public-private collaboration and incredible technological advancement.

Allowing healthcare costs to soar at unsustainable levels and allowing America to fall behind on key indicators of care quality and access is not a political victory for either side of the aisle. Assigning blame along partisan lines gets us nowhere.

A healthy population, a happy and productive workforce, and affordable healthcare are vital to the future of our nation. Unless we are willing to work together to transform our healthcare system for the better, these essential goals will remain out of our reach.

Former Senate Majority Leaders Daschle (D-S.D.), now a senior policy adviser at DLA Piper, and Frist (R-Tenn.) lead the Bipartisan Policy Center’s Health Project.

This article was originally featured in The Hill http://thehill.com/blogs/congress-blog/healthcare/241701-need-for-affordable-care-cuts-across-party-lines

Why both parties should embrace ObamaCare’s state exchanges

(The Week, July 18, 2012)

By Bill Frist, M.D.

Largely lost in the fight over ObamaCare is a worthy provision that lets states develop insurance systems that are right for them — but they must act soon.

When the new health care reform law was being debated in 2009 and 2010, everyone talked about “death panels.” When challenged in court, everyone debated the individual mandate. After last month’s Supreme Court decision, the conversation has now switched to Medicaid. During all of this, however, we have largely ignored what is perhaps the most innovative, market-driven, and ultimately constructive part of the law: State exchanges.

Originally a Republican idea, the state insurance exchanges mandated under the Affordable Care Act (ACA) will offer a menu of private insurance plans to pick and choose from, all with a required set of minimum benefits, to those without employer-sponsored health insurance. These exchanges are expected to bring health insurance to an additional 16 million Americans. Unlike the Medicaid expansion, these Americans will gain private insurance, and can choose the plan that’s right for them.

The exchanges should facilitate competition among private insurers as they design new benefit packages and cut prices to stay ahead of the game. While I’m slow to favor a mandate, these exchanges will offer those who can benefit from insurance a broad array of tailored options and varying prices that should help them find it. Helping more Americans find and compare the private insurance they need and can afford should be an easy principle both political parties agree on.

As a doctor, I strongly believe that people without health insurance die sooner. Sure, they can eventually go to an emergency room. But it is often too late. They wait longer to get a breast lump checked out. They wait until their nagging cough turns into a fulminant pneumonia. They skip preventive care and then show up to the ER with severe, costly, late-stage symptoms that are harder and more expensive to treat.

State exchanges are the solution. They represent the federalist ideal of states as “laboratories for democracy.” We are seeing 50 states each designing a model that is right for them, empowered to take into account their individual cultures, politics, economies, and demographics. While much planning has yet to be done, we are already seeing a huge range in state models. I love the diversity and the innovation.

Helping more Americans find and compare the private insurance they need and can afford should be an easy principle both political parties agree on.

Want a more conservative, small-business focused exchange that bans abortion coverage in all its plans? Try Utah and its state exchange, originally founded under Gov. Jon Huntsman. Think that President Obama missed a huge opportunity to steer the nation towards a single payer system? Try Vermont, which plans to ultimately transform its state exchange into a single payer system, Green Mountain Care, that will offer coverage to all state residents. With soaring health care costs one of, if not the most, dangerous threats to America’s greatness, a new round of national health care experimentation is exactly what we need.

But the clock is ticking. While the exchanges must be fully operational by January 1, 2014, they are also required to submit a blueprint for approval by mid-November of this year, which will indicate if they plan to run their own exchange or will participate in a federal-state partnership. While almost all of the states have at least planned for an exchange, roughly half took a wait-and-see approach as they awaited the Supreme Court ruling. This means that in the coming weeks we will see a frenzy of state activity and legislation as governors rush to meet this deadline. Enacting some sort of exchange establishment legislation is expected to be crucial to receiving federal approval for a state-run exchange. And though some GOP governors refuse to set up an exchange of their own, I see little advantage for states to default to the federally designed, one-size-fits-all exchange when they can design and run their own.

The silver lining is that with much planning left to do, there is still time to get involved and design the exchange in your state. I urge everyone — citizens, small businesses, health industry stakeholders, churches, large employers — to actively participate in shaping your exchange so that it reflects your state’s values, economy, and common sense. Then, starting in 2014, we can see a variety of big ideas and small tweaks all working together to show our nation what works and what doesn’t.

Simply put, state exchanges represent a distinctly American opportunity to improve our local communities and at the same time help our nation avert a major crisis. Let’s take the plunge.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

This article was originally featured in The Hill http://theweek.com/article/index/230655/why-both-parties-should-embrace-obamacares-state-exchanges

How the Supreme Court’s ‘ObamaCare’ ruling will affect you

(The Week, March 13, 2012)

By Bill Frist, M.D.

The nation’s highest court is about to judge the president’s signature legislative achievement — and it’s not just politicians who are invested in the outcome.

Is the new health care law constitutional? You might think it doesn’t matter — or at least, that it doesn’t matter to you. But the fact is, the Supreme Court’s decision on President Obama’s Affordable Care Act (ACA) will almost certainly affect you directly.

How, exactly? For one thing, the court’s decision could play a key role in determining our next president and possibly your next congressman. If you are poor, the ruling may decide whether or not you have coverage. If you are not poor, it will impact how much you pay for health care. If you own a small business, it might determine if you must purchase health insurance for your employees. And if you work for a large business, it may determine whether you still receive your insurance from your employer. If you’re a doctor, it will likely affect your reimbursement. If you’re a patient, it will determine your benefits.

On March 26, 27, and 28, the Supreme Court will hear extensive oral arguments on the constitutionality of the ACA. This is the culmination of 26 states filing suits in federal district courts and opinions from seven federal appellate courts. A final written opinion likely will be delivered in June, 18 months before the individual mandate kicks in and just five months before the presidential election.

If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

The ACA is a highly charged law that, according to the latestRealClearPoliticsaverage, is viewed unfavorably by half of Americans. The law essentially does two massive, controversial things: (1) Mandates that individuals purchase health insurance coverage, and (2) expands Medicaid by 16 million enrollees. This expansion means almost one in four Americans will be on Medicaid, the government program originally intended for our poorest citizens. If you don’t purchase insurance, you will pay a fine of $695 per adult and $347 per child.

Together, these provisions will reduce the uninsured by 32 million, but will still leave an estimated 23 million individuals uninsured in 2020.

The focus of the Supreme Court opinion will be on the constitutionality of these two issues, though two additional items will also be considered. One is whether the entire law falls if a part of it, such as the mandate, is ruled unconstitutional, and the other is whether the court has jurisdiction to rule at all now, since the law has yet to go fully into effect.

There is already plenty of discussion on the legal merits of the case, particularly as it regards the taxing power and the Commerce Clause. But what are the very real implications of the upcoming ruling? Here is what to look for:

1. If the court upholds the individual mandate, it will take effect 18 months later — unless Congress acts to repeal or postpone it (which won’t happen as long as Obama is in the White House). If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

2. If the individual mandate is ruled unconstitutional, the court will then decide whether to let the rest of the law stand, including the expansion of Medicaid and the largely popular individual insurance reforms. If the rest is left intact, the Congressional Budget Office projects that 16 million of the 32 million Americans expected to gain insurance under the law would be ineligible for the new coverage and that non-group, individual premiums might increase 15 to 20 percent. It would then be up to each state to decide whether or not to adopt the individual mandate.

3. If the court decides that the Medicaid expansion is constitutional, it will take effect in 2014 — unless Congress acts to postpone, repeal, or not fund it. But if the expansion is left intact, with almost a quarter of all Americans covered by Medicaid, the program would grow to include a portion of the middle class.

4. If Medicaid expansion is overruled, coverage will remain at current, varying state levels, and an estimated 16 million low-income individuals will not be able to take advantage of the new Medicaid coverage that would have begun in 2014.

5. Politically, if the new law is judged constitutional, Democrats will celebrate the judicial affirmation of the spirit and substance of the historic reform, illustrating President Obama’s leadership. Republicans would fan the existing flames of unpopularity among the majority of Americans, citing federal government overreach, rallying around an election call for repeal as they did in 2010. If any part is unconstitutional, the bases of both parties will be emboldened to make health reform the defining issue, after the economy, in the elections in November.

This one is worth following. It will be a game-changer. And not just for the politicians and pundits in Washington. It’s a game-changer for you, too.


 

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

 

This article was originally featured in The Week http://theweek.com/article/index/225477/how-the-supreme-courts-obamacare-ruling-will-affect-you