Basic Healthcare Reform and Bill of Rights, Part 1

The Twinkie Plan

I love these images:

I got these images from http://www.calorieking.com/. It wasn't particularly hard. I just typed in www.calorieking.com, put in Twinkies as a search term and there is was -- ALL the information I needed to make a meaningful choice concerning the biggest decision I had to make in 2006 -- should I buy a package of Twinkies?

Of course, an alternate would have been to go to the snacks section of my local grocer and pick up a box of Twinkies and I could have seen the information there as well. Imagine that there were two easy-to-reach public sources to make such a key decision.

Eating a Twinkie must be the most important decision I have to make this year, because I believe that if things are extremely important then the information must be readily available. If things are unimportant then the information is buried in a sea of bureaucratic Texas horse manure.

Sort of like the decision in choosing health plans. Can't be important. Must not be important. You ask why?

Because no one on the freaking planet has any meaningful information to share about what exactly is in my, or any other, health plan.

If your health plan was a food it would be yanked off the shelves faster than a fly on a horse's behind by the USDA or other such agency for failure to properly label and inform the public about its contents.

I looked at the entire booklet that my own health plan sent me. This is what I learned -- bubkis. (For those outside of my own family not fluent in New York Lower Eastside terms, the definition of bubkis is "nothing.") Actually, it is kind of worse than "nothing." It sort of means lacking in any meaningful substance and lower than the lowest form on earth.

Ergo -- Health Insurance Plans in America.

Let's compare the two:

On the Twinkies label I learned the calories, fat, protein, carbohydrates, fiber, and, of course, the all-important ingredient - alcohol. While dismayed that my Twinkies contained no alcohol, I see that all the other major food groups were represented.

What did I learn from my health plan information? I have a 30-dollar deductible for some things, but not others, and frequently on alternate Tuesdays (except during the Winter Solstice). I learned that some tests may require precertification.

Let me give you the 411 on this tidbit -- if your health plan tells you some tests require precertification it really means that any test that is ordered on YOU will need precertification. I think that the only test not requiring precertification is for Ebola virus titers if you are an original descendant of a single tribe of pigmies in the South Congo. You don't know which test and whom to call.

If you get sick, you don't know which operation is covered and when. You don't know which drugs are on the plans approved list until you need that drug. There is NO published information concerning the day-to-day needs of your health plan.

Next: Mr. Martin's Dilemma

Related Topics: 10 Ways to Make Your Health Benefits Work for You, Medicare Rx Benefits

Technorati Tags: healthcareplans, patientbillofrights, healhcarereform

Expectations vs. Entitlement, Part II

Let's apply the expectation/entitlement principles to a few of the issues of the day.

Are all Americans entitled to access to the finest healthcare? I would say that in a modern affluent society, we should have the expectation that as a national community we should all contribute to assure this but alas...it is not an entitlement.

Consider this:

"As we look at Avastin and Herceptin pricing, right now the health economics hold up, and therefore I don't see any reason to be touching them," said William M. Burns, the chief executive of Roche's pharmaceutical division and a member of Genentech's board. "The pressure on society to use strong and good products is there."

Burns, in cold blood, stated this economic fact which effectively assures a death sentence to many he does not know.

I am not entitled to that drug for free or even at a reasonable cost. I can expect it- but is only my expectation. We are not entitled to have reasonably priced medications. No matter how greedy the pharmaceuticals appear to be we still are not entitled to determine their price.

How would you feel if you were one of the participants in the clinical trials for these treatments? Knowing what you know today, were they entitled to your participation? Should you expect their motives to be as pure as yours when you chose to participate?

What is Roche entitled to? They can expect whatever reaction the medical community doles out at them for this brazen behavior and disdain for that failure to view themselves as a partner in the public trust of medicine. They should not be surprised if doctors around the country stopped using all Roche products across the board.

They are not entitled to get my business. In fact, if Congress enacted severe price controls on the pharmaceutical industry it would not be fair or unfair - it would just be the expected response to irresponsible corporate behavior. One thing I know for sure- Congress in entitled to make any law they want. I don't expect this would happen. I am at least entitled to expect it to happen - A guy can dream, can't he?

The major difference between expectations and true entitlement in medicine has to do with the consequences of actions - where they originate and to whom they are targeted.

Your recourse stems from you. Your behavior dictates the punishment. If you are entitled to, for example, full thought and consideration of your medical problems in your best interest, your recourse is not only from your behavior but you have real recourse in the governing and licensing bodies that helped create that entitlement in society.

If you truly did not get what you were entitled to by law, you may have recourse in the court system. You may have the ability to report a healthcare facility or physician to the Office of Professional Conduct. You may even report the party who did not afford you a real entitlement, like safe transfer from an emergency facility to a treating hospital (a legal entitlement under a statute called the EMTALA Act) to authorities for civil and possibly criminal penalties. True entitlements come with substantive rights to allow you to try to regain these entitlements.

Unfortunately, most things in healthcare that people think they are entitled to are really their own expectations- some reasonable and proper, others selfish and self-serving. The more we increase the public discussion of these expectations and entitlements the more we will begin to flush out true core values in healthcare.

Next installment: The best stories of the most entitled patients, doctors, and corporations I have seen...
Dr. K.

Related Topics: Medicare Benefits, Clinical Trials

Technorati Tags: avastin, herceptin, roche, cancertreatments, entitlement, expectation

Responses to Comments, Part II

As per "the almighty dollar" comment: Your anger is directed to the wrong party. It is not the doctor who is consumed with the dollar but the greedy insurance companies. As a point, in my office, the 5 major insurance companies that I accept owe me hundreds of thousands of dollars for services rendered. I saw the patient. The patient was treated with compassion and expertise.

Shouldn't your insurance company pay the bill? They often do not and have many tricks to delay payments.

Doctor's offices have bills to pay and malpractice etc. Aren't doctors entitled to get paid by the insurance company on a timely basis especially since you as the patient paid a lot money to THEM for an insurance plan that the doctor is a part of?

As far as the Waiting no More than 30 Minutes in an office comment attached to the "doctors schedule 15 minutes apart to make money comment":

I do not know why you made up 30 minutes, why not 15, why not 45. The reality is that dependent upon the day I can schedule an office day with all intentions of being on time and the first patient comes to me with cancer in the pelvis and I have to discuss complete removal of half of the pelvis. This is not a 15 minute visit and can even be a 1 hour discussion.

The patient traveled 3 hours to see me. Do I tell them to come back? No. Do I discuss them and give them full attention. Yes.

If I scheduled only 2 patients an hour, after this first patient, I am already 30 minutes behind. Following that a child comes in with a fracture that takes an hour to reduce. Now I am starting 1 hour behind. This is not an excuse but reality. You can see how this can happen.

It does bring up the point- are you entitled to be seen in a reasonable amount of time or is it an expectation?

In my practice I NEVER leave a room until ALL questions are answered. In the last year we did a study of my patient hours. The average wait time was longer than your 30 minutes. In all the patient visits, 12 patients left due to the time.

Once they are in the room they get 100% from me for as long as they need. I always apologize to a patient for being late and often tell them exactly why- for example the pelvis tumor. Patients who arrive to the office are told the current wait time and are offered to reschedule if that is too much.

When I get in the room I give them my heart and my soul. That is what they are ENTITLED to in my practice. It has been also what they have learned to EXPECT. Complete attention to their problem. Do I please all the patients? No way.

On the money issue- Neurosurgery doctors pay over $130,000 in malpractice, over $100,000 in rent/supplies, over $250,000 in personnel to support the practice and $50,000 in associated expenses.

United Health Care pays about $80.00 for a visit. Assuming you saw the 10 patients a day that you want them to see that would be $800.00 a day. They do office hours 4 days a week and operate 1. That is $3200.00 a week in office hour billing. In 50 weeks a year that is $160,000 a year. If they do 3 laminectomies (spine operations) a week (which is all they would get at 8 patients a day) all in Medicare and Managed Care they were reimbursement is $2500.00 per operation. This would be at 50 weeks a year $375,000 a year. Added up- gross revenue is $535,000. Expenses are $530,000. This leaves $5,0000 a year as take home salary.

This is based on your assumption that:

1. Doctors should see one patient an hour
2. Doctors should accept the payment of all healthcare or managed care

The numbers don't add up. Your energy should be at TORT REFORM and INSURANCE REFORM.

Try this idea:

1. The government should pay all malpractice insurance premiums if the doctor accepts insurance plans
2. The insurance companies charge less money each year for premiums if they make whopping profits the year before.

This piggybacks on to looselink's interesting comment:

"I recently met a doctor who told me she was a concierge doctor. She said she got really tired of the 15 minute in and out office visit. she limits her practice to 300 patients per year; all of whom pay her $1200 up front in order to get instant appointments, phone calls returned and even house visits if necessary. I'm not sure how I feel about that! It is a rather elitist concept, but she claims that she is able to provide much better medical care for fewer patients this way."

Is this what people want? Some do. Some do not. Replacing your roof costs $15,000 to $30,000. How much should replacing a hip cost? You tell me.

In answer to meloh's following comment:

"You see, sir, I have been waiting by my loved one's bedside for 10 hours today, hoping you would drop by for a hospital visit which will take you maybe 5 minutes and for which you will be paid $300."

You may have been waiting 10 hours by your family member's bedside. Most probably your doctor has a schedule of when to see the patient. You should find out that schedule. As for the 5 minutes - that is a ridiculous generalization. I have spent between 5 minutes (on a very non-complicated case) to 30 minutes depending on what the patient needs.

As far as the $300.00 for the hospital visit - there is the problem. People like you think that the average doctor is making millions in the practice. Untrue. Average pediatricians make about $120,000 a year. Surprised? Also, for the record, a hospital office visit from Medicare pays approximately $32.00. You should get your facts rights before you make such generalizations.

As per the most disgusted poster, so self-named as "disgusted101":

"It would also be nice to hear a physician be HONEST from time to time when they SIMPLY HAVE NO IDEA, then say I HAVE NO IDEA and send us to someone who may be more qualified, HOWEVER doing this shows they arent all they would like us to believe they are.

GET OFF THE HIGH HORSE AND BRING BACK THE COMPASSION THAT YOU ARE BEING PAID FOR is exactly what I would like to tell most physicians."

Most physicians I know will often tell a patient when appropriate that they SIMPLY HAVE NO IDEA and send out to another physician. I do that whenever it is needed- often 2-3 times a week.

I will refer to a rheumatologist, neurologist, and often another Orthopaedic Surgeon as I tell the patient, another perspective may help here. If your doctors are not doing that, change doctors. Additionally you seem to think that doctors get paid for compassion. That is not true. They get paid to render a service to help you with your disease.

A good doctor adds to that service compassion and care. That is what separates that doctor as an exceptional one. When I show compassion to my patients it is not because I am getting paid for compassion it is because that is how I practice. There are non-compassionate doctors who have remarkable surgical skill. They too have a role in medicine.

If there is a Neurosurgeon who if the world's best at saving a patient's life who has a bleeding blood vessel in the brain but is not compassionate, this is a valuable person in society. Just as not all teachers have the same total qualities as others and not all in the clergy have the same as their colleagues there will be a wide range of qualities in medicine as well. To expect ALL physicians to be exactly the same is unreasonable.

In conclusion I would like to thank "anonymous":

Though perhaps a little rough around the edges, the doctor's answer strikes me as basically correct. The covenant relationship between doctor and patient entitles the patient to the best care within the doctor's capability and to conscientious and respectful treatment and service. In actual practice, the latter entails that I am I entitled to your conscientious effort to see me on time and to give me your full attention when you do. But it would be madness to insist that my rights are somehow being violated if the reason I am being kept waiting is your conscientious treatment of another patient.

Keep the discussion coming!

Dr. K.

Related Topics: Does Pain Keep You Up? Test Your Sleep IQ, The Emotional and Economic Costs of Pain

Technorati Tags: healthcare, medicalpractice, entitlement, expectation

Comments on Expectation vs. Entitlement: Part I

Thank You:

I want to thank ALL the commenters on this issue. Obviously a nerve has been hit. Excellent!

A couple of important points:

I bring up the issue of expectation and entitlement not as a personal issue but because it obviously is one that occurs daily in medicine.

The analogy to the restaurant, of course, was just a metaphor. The serious differences are obvious.

Starting off with jesusfreaki1965:

"It isn't us versus them, it's us and them working together for health care solutions. There needs to be a change in attitude on BOTH sides."

VERY WISE POINT! It should be Doctors and Patients against insurance companies and corrupt politicians who pander to these special interests.

As far as the personal slurs from vc5937- no problem I can take it. You don't know me and I don't know you.

For the record, my patients in my practice are guaranteed to see me the same day if they insist. All my patients receive my personal cell phone and I am available 24/7 for them through this cell phone. They also get my e-mail. We end hours when the last patient who wants to be seen is seen. If a patient can't get to the office after surgery for staple removal I drive over and do a house call.

I am insurance-blind in my treatment of patients. Patients who can't pay are treated with the respect of all patients and we simply discuss with them what they can pay. If a $6,000.00 operation is too expensive I have, in the past done such surgery for as little as $500.00 on a one year monthly budget. If you are interested in my specific practice you can go to http://www.walkandmove.com.

There is a trade-off though. So you do not have to wait 3 weeks to see me, you may have to wait longer in the office. I don't expect a medal for this. I am not entitled to any awards. It is just the way I CHOOSE to practice.

An important point: Doctors ARE NOT employees of patients. Payment is for services rendered - the doctor-patient relationship is not an employee relationship. You cannot FIRE your doctor...you can simply choose to no longer use his or her services. That is not firing. If you go to Wal-Mart (another metaphor) and do not like the service you no longer patronize that store. You do not fire Wal-Mart.

As per the Patient Bill of Rights: The specific things in that Bill of Rights are excellent. In fact I agree that those specific things that are in that Bill of Rights do represent an entitlement. There are thousands of other things that are not covered in that Bill of Rights that are actually expectations.


To be continued...

Related Topics: Does Pain Keep You Up? Test Your Sleep IQ, The Emotional and Economic Costs of Pain

Technorati Tags: healthcare, medicalpractice, entitlement, expectation