Is healthcare reform a win or a loss for Americans?

Although the media has been focused on repeating the same town hall meeting shouting matches, one should look carefully at other thoughtful pieces appearing in business magazines like Fortune and Money which claim to have the objective truth about healthcare reform.

Because they have it wrong as well.

Shawn Tulley, editor at large for Money, wrote "You'll lose 5 key freedoms under health care reform" specifically indicating that Americans will lose the ability to have high deductible insurance plans funded by health savings accounts (HSAs) as well as the ability to seek specialty care without first being evaluated by a primary care doctor.

My concern about HSAs is a philosophical one, but important. Do patients understand when they can safely skip and when they need to be seen by a doctor or get the preventive tests they need? Unlike auto insurance, having a dent in the car left unchecked is one thing, but what about one's body? Research shows those most likely enrolled in HSAs are doctors and accountants which makes complete sense. The former know when to seek care and when to safely skip. The latter understand the tax advantage of HSAs. Patients in high deductible insurance plans are generally less satisfied, would prefer to return to comprehensive health insurance if given the opportunity, and typically avoid getting necessary testing or treatment done due to cost.

I've heard the argument that consumer driven healthcare will make people better consumers. Please. We've tried this with retirement planning. Employers jettisoned their pension plans and moved workers to 401k plans where employees would have more responsibility and skin in the game to do the right thing and plan for retirement well.

Companies discovered that people don't do what is in their best interest. Many never enrolled. Others invested simply in cash unaware that they needed to make investment decisions. As a result, employers are requiring new employees to opt-out of the 401k program rather than opt-in and changing the default investment to a target date mutual fund. It isn't that people don't want to do the right thing. They do. But if they can't handle retirement planning, how well do you think they will do with healthcare planning?

Which leads to the next cherished freedom that supposedly will be given up. The freedom to choose your doctors. Certainly having a trusted primary care doctor who can help get you better and help you navigate the healthcare system is critically important much the same way a trusted financial adviser can help people avoid pitfalls and traps. Was it poorly done a decade ago? Yes. No one I know of goes to medical school to become a "gatekeeper". We all train to become doctors. Some of us become primary care doctors - family physicians, internists, pediatricians, obstetricians / gynecologists - while others become specialists.

Mr. Tulley makes the mistake that many patients do in believing that getting the best care means "freedom" to access all tests, hospitals, specialists, and imaging studies. Is that what people really want or do they simply want the right doctor, the right care at the right time?

The supposed freedoms given up would not as be terrible Mr. Tulley claims since they are responsible for allowing the US to have the worse healthcare outcomes of any industrialized country in the world, highest costs per capita, and shut out millions from accessing medical care by being uninsured.

It's this kind of misinformation that is troubling. The quiet thoughtful analysis which is dead wrong.

Executive Physicals - Not Worth Your Money

FORTUNE recently published an article about executive physicals. These are where companies have sent their top executives to get health screenings done by prestigious institutions like Mayo Clinic and Stanford. If you get a free "executive physical", then you should take it, but let's not fool ourselves, it isn't "the Best Checkup You'll Ever Get" (Fortune June 23,2008). While some tests are cool and interesting, i.e. pulmonary function tests and ankle-brachial index, they provide no additional value to patients who have no symptoms. The vast majority of tests offered are the standard of care. The challenge is as patients we need to demand them because they are routinely offered in this country only 55 percent of the time (including the ultrasound to scan for an abdominal aortic aneurysm for men over age 65 who have ever smoked).

For thousands less, you can get the same care, if you have time to research what to get and when to get it. Otherwise if we don't have the time or the expertise, we outsource whether hiring a financial advisor or having an executive physical.

McCain's Healthcare Plan is the Worst - Consumer Driven Healthcare Not the Answer

FORTUNE magazine published an opinion piece in their March 17, 2008, issue titled Why McCain has the best health-care plan. McCain like many of his fellow Republicans believes that giving individuals more responsibility is a way to solve the healthcare crisis.

Frankly, expecting Americans will use tax incentives to find their own healthcare insurance is laughable. Already when tasked to fund their own retirement, the vast majority don't want the responsibility, are inadequately prepared and planning to work longer. This is despite planning for their retirement is in their best interest. Who wants to be forced to work longer if they don't have to? Companies are discovering that although they relinquished their responsibility of helping their employees' retirement by eliminating the pension plans for the cheaper 401k plans, workers are not better off. Many workers even fail to enroll in the 401k plans and many that do are only invested in the money market option, which won't keep up with inflation. Now many employers are stepping in, requiring mandatory 401k enrollment (workers can opt out), and defaulting the funds into a mutual fund that has better returns.

Experts who believe that the consumer will make the right choices when given the important job of finding their own health insurance, funding it, and making best use of it obviously aren't aware of the consumer experience with retirement planning. An entire industry has developed to help people plan for retirement. Will the same occur in healthcare? Who will be the healthcare advisors? Doctors? Insurance agents? A new field of advisors?

If the public approaches the responsibility of healthcare insurance the same way it does with personal retirement planning, our country is in big trouble. Unfortunately unlike postponing retirement, a person can't predict or delay when he will get ill. Relying on the public to shop for healthcare will result in many more being uninsured, others not getting preventive care, and a workforce that will be increasingly unhealthy and unable to compete in a global market. As an insider I know what to do in this new world, but what about the rest of us? Specifically, what about you?

Can Wal-mart and Large Businesses Solve the Healthcare Crisis?

Are large corporations like Wal-mart the answer to solving America's healthcare crisis? Certainly it and other organizations like Federal Express did far better than the government by resuming operations within days compared to weeks after Hurricane Katrina. A recent piece titled Wal-Mart: The New Washington is thought provoking. Excerpts from the NY Times article.

• While Congress wrings its hands over higher health care costs, Wal-Mart vowed to save companies $100 million this year by processing their prescription drug claims. (It already sells generic versions of prescription drugs for just $4, well below the national average.)
• Wal-Mart, H. Lee Scott Jr., said in an address to employees two weeks ago, “We live in a time when people are losing confidence in the ability of government to solve problems.” But Wal-Mart, he said, “does not wait for someone else to solve problems.”
• “With their unique combination of scale and speed they are able to leave any government agency in the dust,” said Amory Lovins, chairman and chief scientist at the Rocky Mountain Institute, an energy research group.
• “Wal-Mart is trying to assume the responsibility that their size confers on them,” said Len Nichols, health economist at the New America Foundation, which supports universal health coverage. “It’s a challenge to the government to step up to the plate.”
• Take the case of electricity-sipping compact fluorescent light bulbs. Since Wal-Mart began heavily marketing them two years ago, it has sold 145 million bulbs, saving enough electricity, it says, to forestall the need for three coal-fired power plants in the United States.

Now Wal-mart hasn't been the perfect corporate citizen. In late 2005, the revelation of a memo reinforced the belief that it didn't care about its workers when it indicated slowing healthcare costs by discouraging unhealthy people from applying for work. Others have maintained with the low wages and skimpy employee benefits, that Wal-mart was simply using the state and federal Medicaid programs to pick up their employees healthcare costs.

Nevertheless, its recent behavior over the past few years (as well as the actions of other large corporations), seems to suggest that these companies are finding that being part of the solution whether healthcare or environmental concerns is not only socially responsible but also financially sound. An article in Fortune magazine titled Business is Back reviewed the rise of businesses and CEOs to step back into the public eye after being embarrassed by a variety of scandals (think Enron and MCI-Worldcom) and lack of public interest after 9/11.

In my opinion, any healthcare reform will require these large corporations, who purchase the vast majority of health insurance, not only to demand better care for their employees but also to teach the healthcare system on what can be done to improve the speed, reliability, and efficiency of a system too antiquated and failing on every conceivable measure with respect to quality, access and costs.

If our healthcare system can learn from large corporations and large corporations can continue to be mission driven and responsible corporate citizens, you will see a healthcare system far better than those of other countries as the final result will be a uniquely American solution.

Fortune - Andy Grove's Answer to Fixing the Healthcare Crisis

My letter to Fortune magazine responding to Andy Grove, the former CEO of Intel, and his thoughts on how to fix America's health care crisis.

Dear FORTUNE:

As a practicing family physician, I found that what Mr. Grove's and many health care reform proposals fail to address is the shrinking supply of primary care physicians. Annually fewer U.S. medical school graduates choose to practice either family or internal medicine, yet demand for these providers increases as Americans live longer with more complex and chronic medical conditions. Countries with a robust primary care workforce not only improve the overall health of the population but also do so at a much lower cost by coordinating care, minimizing duplication of services, and intervening to prevent illness. Without addressing this problem, the prognosis is clear and grim. More Americans will suffer from expensive medical complications that were unaddressed and avoidable. I am thankful that I have the knowledge and expertise on how to stay healthy. The question is will you?