This article first appeared in the St. Louis Beacon, Aug. 4, 2009 - Right now, health-care reform is right at the top of the national agenda. Local, state and national politicians are setting up camp around issues important to them. They hold press conferences and release numbers. Interest groups -- ranging from business to drug companies -- are lobbying Congress.
But what about the people who work in the trenches of health care? The emergency room doctor, the hospital administrator, the home health care nurse, the physical therapist, the family doctor, the specialist?
For each, a specific problem tops the list, and often, those problems intersect.
Efficiency, for example, was mentioned nearly to a person. Most medical professionals felt that time and money are wasted on duplicating tests. Effective communication between institutions and professions occurs rarely, and usually, it's the patients who suffer.
Some people we spoke with have ideas on what needs to be done. Others just know something needs to be done.
Perhaps the only thing that all can agree on? "I don't think it can continue like this," says Dr. Karen Webb, chief medical officer with Saint Louis University Hospital.
Dr. Jay Moore
POSITION: Family doctor, St. Charles Clinic Medical Group, Wentzville, Medical Director for Quality and Process Improvement, SSMPO
ISSUES: The uninsured and underinsured
In his Wentzville practice, Moore sees lots of uninsured and underinsured patients.
"The reason we see so many is that there aren't many doctors who take Medicaid, and so those of us who do are swamped," he says. "We have to turn patients away every day because I can't afford to see any more."
Also, it's hard to get specialized care for the uninsured and underinsured, he says, and "I wind up having to treat patients for things I've never really trained to treat."
Take a patient with seizures, for example. Special tests are needed,and then medications. If a person is uninsured or underinsured, he won't be able to get in to see a specialist. Moore then has to orderthe tests and monitor the patient and the response to the medication.
"I'm an internist, not a neurologist, and I'm not always comfortable doing this. But what choice is there? If I don't take care of the patient, they aren't going to get care at all. So, I explain to the patient that it's not my field, but I'm doing my best. The patient gets substandard care that is probably more expensive than it needs to be, because I can't get the patient in to see a specialist."
Another problem for people who don't have insurance or don't have enough insurance is not getting in to see doctors at all. Over time, a small problem builds into a big, sometimes chronic one.
And often, Moore says, people can't get treatment in the earliest stages, when their conditions are easiest and cheapest to treat, because of insurance. Those people eventually end up in theE.R., where legally they can't be turned away. There, they get lots of tests and are usually seen quickly. That, he says, ends up costing more money, and when those people can't pay their medical bills, the hospital's costs go up for everyone.
In 2007, the U.S. Census Bureau reported 45.7million people under 65 were uninsured. According to the Kaiser FamilyFoundation, 79 percent of those people are U.S. citizens.
Furthermore, KFF reports in a 2008 primer on theuninsured, "70 percent are from families with one or more full-timeworkers and 12 percent are from families with part-time workers;two-thirds are poor or near poor; young adults, ages 19 to 29, comprise a disproportionately large share of the uninsured, mostly because of their low incomes; and minorities are much more likely to be uninsured than whites."
Moore knows many people have opinions about subsidized medical care. But really, he says, we're already paying for it through the back door.
HOW HE'D FIX IT: The fundamental issue for Moore is rethinking what he really values. If you look at our economy as a whole, how much is appropriate to spend on health care? Should it be more than on defense? Entertainment?
In 2007, the country spent 16 percent of the GDP on health care, according to the Congressional Budget Office, and Moore thinks that's well worth it.
"You have to decide really what is good health care worth," he says. "Because taking good care of people is expensive. There's just no way around it."
While we already spend a great deal on health care, our outcomes don't match that of other Western countries. Why?
"It's because our system is so inefficient," he says. "The money is not used to actually take care of people."
So, to provide coverage for everyone, Moore thinks money can be redistributed from current inefficiencies. For instance, having to spend money on coders, or people who just manage all the mountains of paper work, raises prices for care. If there were a more efficient overall system, used by everyone in the medical field, that money could be saved and costs lowered, he says.
Also, electronic medical records offer some hope, he thinks. While the technology is in the beginning stages, Dr. Moore thinks there's a lot of room for improvement and innovation. If there's a universal system, then money is saved when tests aren't repeated.
WHAT DOES THE HOUSE BILL SAY? While Moore says he's no policy wonk, and it does seem like the plan changes from day to day, Moore has three other things he think must be included in any bill.
First, coverage has to be expanded to make insurance available for everyone. That will cut down on trips to the emergency department and costs will go down overall.
Second, it has to pay physicians well enough so they'll participate and accept the insurance.
"If it winds up like Medicaid, where the payments are so low that most doctors just don't take it, it won't be very useful."
And finally, it needs to cover the services that physicians recommend: ancillary things like occupational therapy that Moore says are often crucial to recovery but not covered by Medicaid.
Mike Gorman
POSITION: Physical therapist, owner, St. Louis Physical Therapy
ISSUES: Insurance
Gorman sees the insurance issue from both sides. As the owner of a business, he employs 12 people and provides insurance for them. And since that business is physical therapy, Gorman also gets paid by insurance companies for his services.
As a business owner, Gorman is troubled that his insurance rates have gone up 20 to 25 percent every year for the past few years. That means his employees' premiums go up, and they also end up paying more out of pocket. He knows that's true for his patients, too. And it's also true for the rest of the country.
From 1999 to 2008, the average employer contribution to health insurance premiums went up 119 percent, from $5,791 to $12,680, according to a 2008 report from the Kaiser Family Foundation and Health Research and Educational Trust. For employees,that number rose 117 percent.
But from the medical provider side, Gorman says, he's not seeing any of that extra insurance money in what they reimburse for.
"I don't mind anyone making money," he says."That's fine, but you have to think, without us doing the care, they wouldn't be able to make their money."
HOW WOULD HE FIX IT? Really, Gorman isn't sure how he'd fix insurance. It's kind of a mess, he says. But he does have three ideas.
First, he thinks there should be an annual cap on insurance premium increases, possibly no more than 10 percent. This could help more employers afford insurance, Gorman thinks, and lead to fewer uninsured.
Second, Gorman thinks health-care providers should be paid based on quality of care they provide, not quantity. He'dmeasure that quality through looking at both the training those people have and the outcomes they get.
And finally, he'd like insurance companies to give providers a reimbursement increase once every two years. "How else can health-care owners keep up with with their business costs?"
WHAT DOES THE HOUSE BILL SAY? Employers will continue providing health insurance or contribute funds for them. But there's also assistance for small employers, whose payroll isn't more than $250,000.They're exempt from required coverage, though they'd have to pay a penalty. There's also a tax credit proposed for small employers who want to provide insurance to their employees, according to the bill.
The plan also calls for a cap on annual out-of-pocket spending. Many Democrats believe that a public health-insurance option will make the insurance market more competitiveand therefore more affordable.
Dr. Will Chapman
POSITION: Professor of Surgery, Director, Division of General Surgery, Chief Abdominal Transplant Section, Washington University
ISSUES: Affordability, efficiency
"I certainly agree we've got some challenges that we need to improve upon with our health-care system," says Chapman. "One is the ever-expanding cost of health care."
Chapman's other issue, like many of those we spoke with, is efficiency, and it could in some ways help with his first issue.
"We can definitely gain efficiency, some efficiency, in the way health care is administered and the way our plans for care are carried out and the way our systems run."
There are often duplications, he says, in tests. That duplication happens because physicians often don't have access to records.
"So we end up repeating testing and that's costly."
HOW WOULD HE FIX IT? With affordability, Chapman thinks increased efficiency would go a long way. In addition, electronic medical records and an established system for testing could trim the fat.
"That should result in significant cost savings," he says. "This is not a minor problem, it's a major problem."
WHAT DOES THE HOUSE BILL SAY? Again, several points in the bill cover both affordability and efficiency, including a cap on annual out-of-pocket spending and increased competition through a public health-insurance option.
The plan also focuses on prevention and wellness, but savings might not come right away for many of Chapman's patients. For people with liver cancer, he says, it could take 15 to 20 years before an impact is apparent.
Dr. Karen Webb
POSITION: Chief Medical Officer, Saint Louis University Hospital
ISSUES: Access, efficiency
At SLU Hospital, like at many hospitals around the country, accessibility is a big problem.
"One of the ongoing challenges in health-care delivery isn't just access to care, but patients being able to access the right care at the right place," Webb says. "People come to us and use our emergency room for non-emergency conditions because they either lack a primary care/family physician, or they feel as though they can't wait to be seen because its after office hours or during a weekend. While urgent care centers have helped to alleviate some of that issue, they don't help solve the problem of continuum of care, or building a relationship between a physician and a patient, which has been known to improve patient quality over time."
Often, she says, people can't afford health care, and if they can afford it, they can't get it because of pre-existing conditions.
Suddenly, problems pile up.
"They don't have health-care coverage and they can't afford it," she says. "Then they can't get good preventive care or any care, and they get critically ill, and that's not very cost effective."
Her other issue is efficiency.
"It's pretty fragmented," Webb says of the health-care industry.
There are many, many parties involved, from hospitals to insurance agencies, drug makers, physicians, pharmacists, and all use different systems for pretty much all they do.
"It's just all over the place."
HOW SHE'D FIX THEM: There are positives and negatives to the ideas out there for offering access, Webb says.
"Our health care system isn't really a 'system' at all; it's made up of many fragmented parts, which is one of the problems. The role that Saint Louis University Hospital plays in the community is, as we say, 'critical' because we offer services and have capabilities that a community hospital wouldn't be able to, so our operational costs are higher than most other facilities."
For example, if someone went to SLU Hospital for an MRI, the machine used would be the newest, with the latest technology, since future doctors are learning in the process.
"Would a single-payer system take that into consideration when paying health-care providers? I'm not sure. The system is too complicated at this point to assume that one solution will work well for everyone."
She does have more ideas for efficiency, though.
The mandatory use of electronic medical records would help, she thinks. So would the adoption of evidence-based medicine, which the Centre for Evidence Based Medicine at the University of Oxford describes as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." Basically, it combines clinical knowledge with scientific evidence in determining treatment.
WHAT DOES THE HOUSE BILL SAY? Under discussion now is a public health-insurance option as well as a provision to require insurance companies to guarantee coverage regardless of age, gender or pre-existing conditions.
Other approaches that could affect accessibility are expanding Medicaid, improving Medicare and affordability credits. Those affordability credits are hard to define at this point, since details are sketchy, but essentially they'd benefit low-income people who are ineligible for Medicaid by making insurance premiums more affordable, according to the bill summary.
As for efficiency, the plan proposes several solutions, including "modernization and improvement of Medicare," and administrative simplification.
Webb thinks many of the options for expanding coverage are viable. And with efficiency, she says, quality and efficiency should be rewarded with incentives; and all the parties involved, from drug companies to hospitals to insurance agencies, should be at the table.
"They've all got to be part of the solution."
Dr. Brian Schurgin
POSITION: regional medical officer, Schumacher Group, practicing emergency medicine physician, SSM system
ISSUES: Emergency department overcrowding, nursing shortage
"The big issue for us in emergency medicine is hospital overcrowding or E.D. overcrowding," says Schurgin, who works in the emergency department.
Hospitals often function at 110 percent capacity, and several things happen because of that. The emergency department becomes a holding room when there's overcrowding, so people aren't able to get in right away and get the help they may need.
Often, the people coming in aren't truly in need of emergency medical care, but they have acute problems. If that person should be in intensive care unit but instead is the E.R, it's even more work for the already overworked doctors and nurses, says Schurgin.
Schurgin's second issue might have something to do with the first: Nursing shortages, specifically of registered nurses, is a national problem. According to a March 2009 report from Reuters, "116,000 registered nurse positions are unfilled at U.S. hospitals and nearly 100,000 jobs go vacant in nursing homes."
HOW WOULD HE FIX THEM? For a long time, the assumption has been that people filling up the E.D.s are the uninsured. They're not, Schurgin says.
It's usually the elderly, he says.
As baby boomers age, more and more are ending up in the hospital, Schurgin says. That takes up beds, and when beds are full, people sit in the E.D.
We need more resources, Schurgin thinks, including more hospital beds. He doesn't just advocate for adding more beds, though, but thinking critically about where they're added and using them efficiently.
Also, he thinks we need to look at other options when the aging population is sick. Can people get care at home? Should families have more of the burden of caring for the sick?
Also, if people get better preventive care, he says, they're usually healthier. Therefore, they stay out of the hospital.
With the nursing shortage, Schurgin wants to see more incentives to get people into the profession, from loan forgiveness to better promotion of the career. While nurses are critical for care and recovery, when there aren't enough of them, Schurgin says, the E.D. can be affected.
In a hospital he worked at in Chicago, Dr. Schurgin says there were 300 beds, but only 250 were used. That's because there weren't enough nurses and they had to shut a unit down.
WHAT DOES THE HOUSE BILL SAY? Several proposals could reduce E.D. overcrowding. The plan calls for the expansion of community health centers as well as money to strengthen local health programs.
The bill also calls for workforce investments, including "expansion of scholarships and loans for individuals in needed professions and shortage areas."
Mardi Manary
POSITION: Home health nurse, Lutheran Senior Services
ISSUES: Access, education and advocacy
Manary started her career in pediatrics and finds many of the same problems there as she does as a home health-care nurse.
Those issues -- advocacy, education and accessibility -- intertwine, and like many other issues, branch out further from there.
"For us, probably the biggest issue is the underutilization of home health care," Manary says.
According to a 2008 report from the National Association for Home Care and Hospice, 7.6 million Americans received home health care.
Home health care is essential to people, especially the elderly, Manary says, but often doctors and hospitals don't inform patients about their rights to home health care. It's covered by Medicare and Medicaid in most cases if recommended by a doctor, but often, patients aren't told that, she says.
Those patients are discharged from the hospital not fully understanding their medication and wound care and very quickly they end up right back in the E.R.
Ultimately, if they do end up with home health care, it can cost two to three times as much after all the hospital visits, and that costs taxpayers and the government more, too.
"In the long run, we all pay."
HOW WOULD SHE FIX THEM? Manary would like to see better discharge at the hospital, which she thinks should begin from the moment of admission, not the day of discharge.
Along with that, she'd like to see patients get better education on their rights for home health care and their options.
"All the agencies that work with seniors, especially Medicare, need to be on the forefront of education," she says.
Next, with advocacy, Manary believes someone at the hospital, nursing home or Medicare should help patients with their decision making, from simply narrowing down all the choices to helping them understand the fine print.
"Health care and rights need to be taught," she says. "People don't understand. We think of it as something someone does to us."
As a result, she believes that if seniors have better access to home health care, their care will cost less because of fewer trips to the E.R.
WHAT DOES THE HOUSE BILL SAY? Under the summary, a few of Manary's concerns are addressed.
Part IV, Prevention and Wellness, calls for, among other things, "Expansion of Community Health Centers; prohibition of cost-sharing for preventive services; creation of community-based programs to deliver prevention and wellness; and funds to strengthen state, local, tribal and territorial public health departments and programs."
Of the six bulleted sections for reform, "prevention and wellness" is the shortest.
The bill also calls for "administrative simplification," which proposes to simplify paperwork for patients, businesses and providers, and that gets at Manary's biggest concern with the reform.
"Everyone wants to reform it with more rules," she says. "What we really need is more leeway."
For instance, so many codes are associated with Medicare that Lutheran Senior Services has to hire a coder to make sure they're all correct so they can get paid.
Her patients are paying attention to talk of reform, too, and they're also concerned. "Most of our clients are afraid because every time something is reformed, their rights and their benefits are cut."