Cavalcade of Risk #141: Backyard edition

Fresh off hosting Grand Rounds, Louise Norris bravely tackles this week's Cavalcade of Risk (and, apparently, the backyard). As usual, she cleans up, raking in some terrific posts and mowing down strawmen.

Kudos, Louise!

Some Thoughts on Government Healthcare

As the "life and health guy in a P&C shop," I get to hear some interesting anecdotes about home and auto clients, and a recent adventure is quite illuminating:

Our client was cited for speeding in her '98 Mercedes. Oh well, these things happen. The state, however, was unsatisfied with her "proof of insurance;" they said they needed such proof for her '99 Jaguar.

One little problem: she's never owned a Jaguar, '99 or otherwise. We faxed up the proof of insurance for the Merc, along with a note explaining that this was her one and only vehicle. Apparently, this didn't satisfy the Columbus solons, who promptly ordered her vehicle confiscated and impounded [SEE UPDATE FOR CLARIFICATION].

My colleague spent most of yesterday on the phone with the local constabulary and the DMV, trying to get the matter resolved. Finally, he was able to obtain a hard copy of the actual ticket, which clearly showed the Mercedes as the offending vehicle. That should have been that, but the folks in Columbus said they needed direct confirmation from the locals, who in turn claim that they had already provided the necessary information.

He said, she said.

Meantime, the client is without transportation while the State continues to claim, in the face of contrary factual evidence, that they are right and she is wrong.

Now what, you may ask, has that story to do with health care?

Very simple: these are the folks who will be deciding what care you will receive, or even if you are to receive any care at all. It is not unreasonable to imagine the following conversation, come 2015:

Surgeon: Well, Mrs Smith, we're ready for your kidney surgery.

Mrs Smith: Kidney surgery?! But doc, I'm here for a fractured ankle.

Surgeon: No, Mrs Smith, the folks at HHS say it's your kidney, and they're the ones in charge.

Mrs Smith: But I have my family doc's note right here!

Surgeon: That's of no interest to me, HHS says your kidney goes, and so it shall.

Ah, brave new world!

UPDATE: Several people have asked the rather obvious (except, apparently, to me) question: so if they're looking for a Jag, why'd they take the Merc?

I completely missed that.

Here's the answer: she was driving the Merc, but her license was suspended. Since she had already sent in proof of insurance on the Merc, she assumed everything was copacetic. Unfortunately, it was not, and she was pulled over for driving with a suspended license and the car was then confiscated.

But her kidneys are fine

Doctor Nurse Redux

Way back in 2008 we riddled "When is a Doctor not a Doctor?". The answer: when they are a nurse.

It seems the more things change the more they stay the same.

Now the N. Y. Time is asking "When does a nurse want to be called Doctor?"

When Sue Cassidy went to a clinic because of pain in her ear, a woman with a white coat and stethoscope entered the exam room and said "I am Dr. Patti McCarver and I am your nurse."

Dr. McCarver calls herself a doctor because she returned to school to earn a doctorate last year, one of thousands of nurses doing the same recently. Doctorates are popping up all over the health professions, and the result is a quiet battle over not only the title “doctor,” but also the money, power and prestige that often comes with it.

Let's face it. Calling someone Doctor has much more prestige than calling someone nurse, therapist, or even attorney. There is a certain "cachet" about the title . . . Doctor.

Unless of course the title is preceded by the word witch.

It seems that doctors, the REAL doctors, are taking exception to the use of the word doctor by anyone that isn't a REAL doctor.

This battle is not new.

Medical doctors have often sought to differentiate themselves from osteopathic doctors and chiropractic doctors and fought to exclude these medical practitioners from their inner circle. In some states only a medical doctor has authority to write a pharmaceutical prescription but those lines have blurred in recent years.

The deeper battle is over who gets to treat patients first. Pharmacists, physical therapists and nurses largely play secondary roles to physicians, since patients tend to go to them only after a prescription, a referral or instructions from a physician. By requiring doctorates of new entrants, leaders of the pharmacy and physical therapy professions hope their members will be able to treat patients directly and thereby get a larger share of money spent on patient care.

As demand for health care services has grown, physicians have stopped serving as the sole gatekeepers for their patients’ entry into the system. So physicians must increasingly share their patients — not only with one another but also with other professions. Teamwork is the new mantra of medicine, and nurse practitioners and physician assistants (sometimes known as midlevels or physician extenders) have become increasingly important care providers, particularly in rural areas.

But while all physician organizations support the idea of teamwork, not all physicians are willing to surrender the traditional understanding that they should be the ones to lead the team. Their training is so extensive, physicians argue, that they alone should diagnose illnesses. Nurses respond that they are perfectly capable of recognizing a vast majority of patient problems, and they have the studies to prove it. The battle over the title “doctor” is in many ways a proxy for this larger struggle.

As the demand for primary care increases the medical community responds by finding ways of accommodating the demand by creating a new level of primary care provider.

Meanwhile those entering medical school that are looking at four years of intense training followed by an additional three to five years of residency and internship before they can fly solo are abdicating the role of primary care in favor of a specialty. They are asking themselves why they should spend 7 - 10 years in school plus accumulating a ton of debt only to earn a little more than a school teacher when they are finally ready to fly solo.

A primary care nurse practitioner or physician's assistant can perform many of the same duties of a primary care doctor. The minimum training for a nurse is two years. According to the Bureau of Labor Statistics nurses earn an average of $65,000.

A nurse practitioner usually has 2 years of additional training beyond a nursing degree and earns an average of $85,000 per year.

Roughly the same amount of time is required to become a physicians assistant and a similar pay scale applies.

Nurse practitioners and physicians assistants earn about half of what a primary care physician earns, but this goes beyond earning power.

There is a real need for primary care providers and that need will only increase over the next few years. This is especially true in light of our aging population and the advancing wave of baby boomers.

If medical students opt for specialty practice over primary care the doctor shortage will only get worse.

Twenty-three states allow nurses to practice without a physician’s supervision or collaboration, and most are in the mountain West and northern New England, areas that have trouble attracting enough physicians.

It is time to rethink our view of primary care. More education does not equate to better care.

Grand Rounds: Autumn Hues edition

Louise Norris presents a colorful, thoughtfully laid out collection of the best of the past week's posts from around the medblogosphere.

I was particularly impressed with how obvious it was that Louise had read each entry, even with a short deadline, and the fact that she and Jay are also hosting this week's Cavalcade of Risk.

Kudos, Louise!

Anthem out of the Wood(s)

Normally, we wouldn't bother posting about something that, after all, affects so few people, but I think there are some interesting lessons here.

Via email from Anthem:

"Wood Anesthesia and Pain Management, LLC, in Wood County, Ohio, has chosen to terminate its provider contract with Anthem effective 10/25/11 ... Consequently, Anthem members may be billed by Wood Anesthesia and Pain Management for any balance not covered by Anthem. However, since our members do not have a choice of anesthesiologists for surgeries performed at Wood County Hospital, Anthem will apply the equivalent of any member liability amounts" [emphasis added]

Anthem goes on to say that, although they'd really like to have hammered out an agreement that would keep the gas-passers in-network, the carrier has an obligation to its members (and, of course, its shareholders) to "negotiate a contract that will keep their health care costs as affordable as possible."

Remember: health care costs drive health insurance costs.

As we've previously discussed, "hidden providers" like anesthesiologists (and radiologists, etc) often have no incentive to belong to any network, and this case graphically illustrates why: "members do not have a choice of anesthesiologists for surgeries performed at Wood County Hospital." This is often (generally?) the case at most hospitals, and is one reason that folks are surprised (and not in a good way) when they are balance-billed for services rendered where no negotiations are possible.

It's fashionable to bash the carriers for heavy-handedness (and, frankly, they often deserve it), but here we have a very public airing of the specific problem.

I also got a bit of a smirk from this:

"[P]ayment for services will be issued to the member, who will then be responsible for making payment to Wood Anesthesia and Pain Management."

Nice.

This serves two purposes: first, the provider is going to have to go after the patient directly in order to be paid. One wonders how well that will work out. Second, and not-unrelated, is the fact that these patients will now see first-hand how much this part of their medical procedure really cost. One of the biggest problems with our current system (and, of course, the gummint-run ones, as well) is that the patient is insulated from the true cost of care. We know how much that oil change costs, because we foot that bill. And we know how much those peas cost, because we bought the can ourselves. But when health insurance (or the government) becomes an intermediary, the price is obscured and distorted.

What a great teaching moment.

Cheesy insurance?

Just noodlin' here:

Important Medicaid Case in Supreme Court

Just a quick heads-up on a case the Supreme Court has already accepted for review this term - it's known as Douglas v. Independent Living Center.

The issue in simplest terms, is whether Medicaid recipients and providers can sue a state for failing to pay the rates required by the Medicaid Act. Well, that seems straightforward enough . . . before, that is, one takes into account the actual law and the courts' reading of the law.

The linked article reveals some of the complications - for example, that the Ninth Circuit previously ruled the State of California "failed to produce evidence that it complied with requirements that do not appear in the [federal] statute." Huh?

With all the attention given this term to the probable hearing of the Obamacare appeal, other important insurance-related issues such as Douglas v. Independent Living Center aren't getting any air time. This case is worth following because of its potential to increase the cost of Medicaid--even before the increase in Medicaid cost that will result from Obamacare.