Will Increased Transparency Fix the U.S. Healthcare System?

us healthcare

by Linda M. Girgis, M.D., Family Practitioner

Several recent articles called for increased transparency in doctors’ earnings and in their conflict of interests. Those calling for this transparency think this revelation will suddenly drive the free market and make patients informed consumers.

Many believe physicians and medical groups will lower healthcare costs in an attempt to win patients under a more transparent system. Here’s why their arguments are flawed.

When Medicare published the earnings of doctors earlier this year, few people got a true picture of what these numbers mean. The numbers did not reflect any overhead expenses. Much of the public falsely believed this represented pure profits for physicians. However, this was gross earnings not not net profit. Overhead expenses easily reach 50% or more in many practices. This newly released transparency was more misleading more than helpful.

The notion that we should compete for business by cost altering is also a false assumption. I do not get to set the amount that I get paid. I get paid only what the insurance company says that I am allowed to get paid. I can change my fees all I want, up or down, but I will be earning the same regardless. [This needs clarity, doctors do not set prices, but insurance companies do, asking physicians to adjust their fees is pointless because we only get paid what the insurance companies are willing to pay]

Creating a “rate sheet” of services based on competitive pricing at the doctor’s office will only affect self-pay patients. With the passage of the ACA (Obamacare), this truly represents only a tiny fraction of all patients.

Transparency in earnings will not drive any change in the healthcare system because it’s out of physicians’ hands. Perhaps a more revealing transparency would be the earnings of executives at healthcare insurance companies. Their incomes, after all, are directly proportional to the amount of money the insurance companies profit and the costs of services they keep contained.

Transparency in how services are covered and denied would drive a true improvement in healthcare but perhaps at a loss of income for some executives.

Revealing Conflicts of Interest

While transparent billing is an issue, physicians are also facing a call for transparency with conflict of interest issues. Many of these are talking specifically about relationships with pharmaceutical companies. The vast majority of physicians have no relationship whatsoever.

Many doctors, myself included, no longer even talk to pharmaceutical representatives in our offices. There are some who say something as small as the gift of a pen is enough to influence us and our prescription pads. The introduction of the Sunshine Act greatly curtailed pharma activities in this regard.

But even drug prescriptions frequently are dictated by insurance companies more than physicians. More often than not, we are prescribing medications for a patient based on their insurance formularies. A prior authorization can no more influence my prescribing habits than a pen with a medication logo on it. It comes down to cost savings for the insurance plans and, since most patients can’t afford the exorbitant costs of so many medications, the choice of medications is left in the hands of the insurance companies pharmaceutical committees.

Physicians are frequently up against a bureaucratic wall as we seek the best medication for our patients only to be turned down by an uncaring person sitting at a phone bank miles away from us.

It’s flat out ridiculous to think even the nicest pen in the world can over-ride the realities of insurance or our calling to help improve the lives of our patients.

Are They Keynote Speakers or Shills for Pharma?

Doctors who give lectures often are paid by pharmaceutical companies. There is no other profession where the experts are expected to be keynote speakers for free. Many of the abuses that did occur over the years have been remedied by the Sunshine Act, if doctors don’t fill these roles, who will give these valuable teaching lectures? Nurses, medical students, others?

Surely educational lectures should be given by the experts who best understand the issues. Only when other professions offer up their experts for free should physicians be expected to do the same. There is no shame to be compensated for time and expertise. Sure, a speaker should disclose if they are working for any companies. But, that should not pre-judge their content as biased. We are physicians afterall, we know how to listen for information that can best help our patients.

Pharma and Research

Critics also challenge transparency of Pharma funded research. Again, if they don’t support development and clinical trials, who will? There is a real need for proper oversight by agencies such as the Food & Drug Administration, but pharma is uniquely posititioned to support research. They are the ones developing new and novel medications. They also have the scientists on hand who can vet the safety of new medications. The last thing a pharmaceutical company wants is a drug recall. No one wants to see Phen-Fen again! Pharma is highly incented by market forces to keep drugs safe and effective.

Transparency has a place in the healthcare industry but it needs to focus across the breadth of medicine, not just on physicians. Any patient who reads their EOBs (Explanation of Benefits) knows that physicians have been transparent for decades on their fees. We have never attempted to hide any of this. Even if we wanted to, it has been decided for others to put it out there on our behalf. Those of us practicing on the front lines lost that war long ago.

Let’s Look at the Big Picture

If you want a free market and true competition, reform all the third parties who are profiting from medicine. And let medical decisions return to the ones in the exam rooms treating the patients.

Do we want the most cost effective healthcare system driven by big corporations that profit by denying care? Or do we want healthcare workers who are free to provide the best medical care to all patients?

 

credit:  Linda Girgis, MD

credit: Linda Girgis, MD

Bio:  Dr. Linda Girgis MD, FAAFP is a family physician that treats patients in South River, New Jersey and its surrounding communities. She holds board certification from the American Board of Family Medicine and is affiliated with both St. Peter’s University Hospital and Raritan Bay Hospital. Dr. Girgis also collaborates closely with Rutgers University, University of Medicine and Dentistry of New Jersey (UMDNJ), and other universities and medical schools where she teaches medical students and residents.  She recently completed a medical mission in Egypt.

Doctors Reject Ron Klain as Ebola Czar

Ron Klain poll, doctors and Ebola Czar

click to enlarge, credit: Whitehouse.gov

Ron Klain, the newly appointed Ebola Czar, has come under harsh criticism from physicians for having no prior healthcare experience. Klain, formerly was Chief of Staff to Joe Biden and Al Gore and is known as a Washington insider. He is a lawyer with no formal medical training.

We asked our doctors, “Do you approve of the newly appointed Ebola Czar, Ron Klain?” The response was overwhelming:

  • 79 % No
  • 21% Yes

What Doctors Think of the Ebola Czar

A few physicians were willing to take a wait and see approach. One Physiatrist wrote, “There are few physicians qualified or competent to run a major government task force. He is running an organization, not making medical decisions. The team will likely contain qualified scientists and physicians as well as on-the-ground experienced people. I would reserve judgment until we see the team assembled, and the responses developed and implemented. Right now, it’s all just knee jerk reactions.”

For more about Ebola protocols, click here.

One ophthalmologist reflected the majority opinion. He wrote, “Something is terribly wrong when the Czar is obviously chosen on the basis of who is most likely to contain the political fallout, rather than who has the most expertise in containment of bio-hazard. The Czar should specialize in bio-terrorism and bio-warfare. This should be obvious to anyone who understands the medical, environmental, and healthcare systems hazards.”

Do We Need an Ebola Czar

Many physicians questioned why we needed another administrative position to execute on Ebola matters. One Family Practitioner asked about Nicole Lurie, MD, MPH, who is the Assistant Secretary for Preparedness and Response (ASPR) for the Department of Health and Human Services.

From the HHS website, “The ASPR serves as the Secretary’s principal advisor on matters related to bioterrorism and other public health emergencies. The ASPR also coordinates interagency activities between HHS, other Federal departments, agencies, and offices, and State and local officials responsible for emergency preparedness and the protection of the civilian population from acts of bioterrorism and other public health emergencies. The mission of the office is to lead the nation in preventing, responding to and recovering from the adverse health effects of public health emergencies and disasters.”

As a physician, what do you think about the new Ebola Czar? What attributes should a candidate have? We discuss Ebola thoroughly on our new Infectious Disease Hub, if you’re an M.D. or D.O., please join us.

Why Ebola Preparedness Is So Haphazard

Ebola preparedness

Click to enlarge

Ebola news scrolls by on our screens fast and furious.  A suspect case here, a hospital failing there, airborne rumors, social chatter with scary and conflicting information.  There seems to be precious little information coming out of official government channels.

Twenty-six Ebola outbreaks have occurred since 1976.  Researchers and medical teams documenting information about containment, contact lists, and patient care.  This outbreak, the first to touch an urban area, has screamed out of control debilitating nations as the death count relentlessly mounts.    The World Health Organization predicts up to 10,000 cases a week and in a best case scenario two months before the virus is back under control.

Extensive information about containment exists.  Ebola protocols have been around for decades and have improved as we learn from each outbreak.  Why then are so many mistakes happening now that Ebola has reached the United States?

Ebola Mistakes

Many within the community spoke about the Keystone Cops calamity that seems to be out there.  A list of mishaps include:

  • Releasing the first patient for two days into the community before transporting him by ambulance for hospitalization.
  • Hospital staff wearing light protection in the early days of Duncan’s treatment; now two nurses have contracted Ebola, and the contact list reaches 76 people.
  • A nurse with a fever and Ebola patient contact calls the CDC about her low-grade fever and is cleared to fly; now 132 passengers and airline staff are on another watch list.
  • Dr. Nancy Snyderman, after being potentially exposed to Ebola when her cameraman contracted the disease, “elopes” on voluntary quarantine for Chinese food.  Her “sorry, not sorry” response was she was asymptomatic and therefore not a threat.

Our most recent Ebola posts here.

We are also hearing from the physicians on the front-lines that they have received little, if any training.

One ER physician wrote, “As an ED physician, I have received no Ebola preparedness training. Neither has any other ED doctor or any of our ED nursing staff. We have NO IDEA if we have any personal protective gear or any protocol in place. But I did read in our local paper that our hospital is telling the media we are prepared for Ebola. In fact, they are holding a press conference today to explain it to the public! What a farce.”

A second physician wrote, “As an ED physician at a county hospital, I have still had ZERO training from my hospital on how to screen or isolate a potential Ebola patient. We have had no drills. No meetings. We have no isolation protocols, no plan. We are not prepared. No one believes it will come here, or infect enough people to be a real threat to the U.S. The CDC has told them not to worry and that it is hard to get sick from Ebola. So they don’t worry.”

Medical Personnel Search Online for Answers

Our infographic looks at the disconnect between medical teams and the flow of information.  Physicians, are searching for best practices and are often turning to online sources.  As of today, approximately 60 percent of all conversations in the Sermo community are focused on Ebola.  Physicians are sharing stories about preparedness, patient treatment options, the possible Ebola vaccine and travel bans.

Doctors look to multiple channels for Ebola information.  Fifty-four percent of doctors say they are checking with the CDC regularly, and 52 percent they are getting clinical information from their peers in Sermo.  If you’re an M.D. or D.O. you can join the community to learn more about Ebola.

What do you think about Ebola preparedness in the United States?  Do you support strict measures such as a travel ban from hot zones?  Where do you get clinical information about Ebola?

Doctors Support Travel Ban from West Africa

click to enlarge

click to enlarge

In recent polling, a full 75 percent of physicians favor a travel ban from West Africa until the Ebola outbreak is better controlled.

The Sermo Physician Poll asked, “Do you believe all travel from West Africa should be halted to the US?”

  • 75% Yes
  • 25% No

With a total of 1,312 votes taken from October 3rd through October 10th, 2014.

Stopping Travel from West Africa

While 75 percent of physicians supported the ban, many wanted an exception for humanitarian aid. James Wilson, MD, Vice President of Ascel Bio and an infectious disease forecaster said, “We still need to get supplies, medical aid, and health care workers into the hot zones to help prevent the spread of the disease. We need to treat the people who need it most to prevent the virus from going global.”

Wilson also noted travelers from West Africa are actively traveling to South America, and trying to enter the U.S. from the South. “Ascel Bio has received several reports of West Africans arriving in South America.  There is now a suspect case of Ebola in Brazil.  The Department of Homeland Security’s Customs and Border Patrol have claimed they intercept illegal immigrants from West Africa, who attempt to enter the United States via the southern states.  The prospect of a surprise translocation of Ebola becomes far more complicated when examining these data points.”

One vascular surgeon who supports a travel ban wrote, “What we know for sure is the current screening methods used before leaving West Africa (questionnaires and temperature checks) don’t work all the time. That’s been proven in Dallas. Here’s an instance where preventative measures can make a huge difference in limiting the spread of this virus.”

A physiatrist expressed a common concern about travel and the movement of people who feel threatened if a ban comes to fruition. He wrote:

“The problem with banning travel from a specific location is it creates fear and desperation in the people from that area, causing them to find alternate ways to get wherever they wanted to go. But now they have to hide where they came from, making epidemiological efforts difficult or impossible if they do get sick. It’s not very hard to find an alternate travel route, and the more circuitous the route, the more potential exposures along the way. We just need to take this opportunity to learn to deal with this type of problem. More examples are inevitable as global travel is only going to increase.”

Ebola Preparedness In the US

The same poll asked physicians about preparedness in the US after the Dallas patient. The question asked:

Do you believe the experience of Dallas will significantly alter our medical preparedness writ large in America?

  • 56% Yes
  • 44% No

Physicians discuss preparedness training in detail on the Sermo Infectious Disease Hub. Our doctors share information from their local officials and also discuss best practices on site among dozens of infectious disease experts. There are many things to consider including contacts in the community, proper isolation of suspected Ebola patients and even the handling of testing equipment.

Wilson wrote about the testing equipment in Dallas, “There was a comment in the reporting on the recently deceased Ebola patient that on his first visit his blood was drawn, and routine labs were performed.  Implying, samples were sent back for routine processing in the main laboratory for CBC and chemistries.

Beyond the obvious concern of unnecessary exposure of the phlebotomist and laboratory staff, along with infection control considerations during sample prep, the key question was how the automated machines handled the specimen… with a specific eye towards inadvertent aerosolization of the specimen.”

As a physician, have you had Ebola preparedness training? Are there other infectious diseases that you are worried about such as EV-D68? If you’d like to discuss this more you can join the Sermo community, and join the conversation.

Ebola Infects Health Care Worker, Now 2nd US Victim

header

A nurse at Texas Health Presbyterian in Dallas, TX who cared for Thomas Eric Duncan has contracted Ebola according to local health officials.

The unidentified nurse had an “inadvertent breakdown of protocol.”  While the press isn’t giving details on the new patient, members within the Sermo community are saying it was a female nurse, and the infection occurred on his second visit when he entered his final hospitalization.

James Wilson, MD Vice President of Ascel Bio and an infectious disease forecaster wrote, “Finally, at Day 17, we have a 2nd case of Ebola in Dallas.  The individual was a healthcare worker who was reportedly wearing “full” PPE but not identified as “high risk” on CDC’s contact list.  Now we have reports (as expected) that the individual may have breached protocol.”

A surgeon within Sermo wrote, “I can easily imagine how someone could breach the CDC protocol.  They don’t shed the protective gear by themselves, so it well could have been a colleague that caused the breach.”

An internist, referring to preparedness training said, “technique, technique, technique!  Practice, practice, practice and use the Buddy System.”

You can read more about Ebola preparedness training on one of our earlier posts.

Wilson goes on to make a few points about the new patient.

  • Out of all the cases on the contact list, note it was someone who dealt with the original case while he was maximally infectious and expelling infectious fluids.
  • You can wear all the PPE protection in the world and still contract an infection if you fail to observe proper protocol for removal of your gear.
  • We should have seen far more cases if this heavily mutated Zaire strain was in fact, as some have claimed, a highly efficiently transmitted (read:  airborne) agent.  But we have not.  It is impressive that none of the family members have exhibited symptoms yet.  Again, the majority of cases incubate within the 7 – 10 day window of exposure.

The Ebola outbreak is being discussed thoroughly on our Infectious Disease Hub.  If you’re an M.D. or D.O. please join us as we discuss preparedness training and tracking contact lists.