Empty Promises
Suppose that Congress did something really silly. Say it passed a law requiring all health plans to pay for an hour of free conversation every year between patients and doctors, to discuss whatever is on the patient’s mind — sports, politics, the weather, or even health care. Surely even the densest reporter would have the presence of mind to ask, “Where are the doctors going to find all the additional hours to provide this service?”
Yet Congress did something almost that silly last spring. It promised almost everyone in the country access to a whole slew of preventive services with no copay or deductible. (See Timothy Jost’s summary here.) Yet I cannot recall a single reporter asking how all these extra services are going to be provided.
An even more important question is: How will the attempt by millions of American to obtain more preventive care services than can possibly be provided affect the triple problems of cost, quality and access to care. As I explained at Kaiser Health News the other day, it will probably make all three problems worse than any are today.
I don’t know about your experiences, but the last time I was at a primary care facility, I didn’t see a lot of idle resources. That is, I didn’t see a lot of doctors and nurses standing around with nothing to do. My observation is consistent with national statistics. One out of every five Americans is currently in an underdoctored area. And all the predictions have the doctor shortage growing worse and worse through time. To meet the increased demand for preventive care, the need for more doctors will be even greater.
Let’s start with Health and Human Services Secretary Kathleen Sebelius’ announcement that beginning September 23, 2010 all new health plans will have to cover without any copay or deductible the services recommended by the U.S. Preventive Care Task Force.
To this lengthy array, the Secretary added, no doubt for political reasons, regular mammograms for women in their 40s. And political pressures are unlikely to abate. Women’s groups, for example, are clamoring for free contraceptives. Then Congress, again for obvious political reasons, added additional services for Medicare enrollees — including a free yearly checkup and prostate cancer (PSA) tests for men.
So what would it take to provide these services, if all the beneficiaries opted to take full advantage of them? In a 2003 study researchers at Duke University Medical Center estimated that it would require 1,773 hours a year of the average doctor’s time — or 7.4 hours every working day — for the average doctor to counsel and facilitate patients for every procedure recommended by the Task Force. And remember, every so often a screening test turns up something that requires more testing and more doctor time.
Overall, it’s probably fair to say that if everyone took full advantage of all of the services the Task Force recommends, we would need every family doctor in America working full-time on the task — leaving no time left over for any other medical services!
Not only can the current supply of medical personnel not come anywhere close to providing what has been promised, there will be collateral damage when patients try to get these services. For one thing, health care costs will rise. Numerous studies have shown that screening tests and similar services add to health care costs, rather than reduce them. For the individual whose cancer is caught in its early stages, say, treatment costs are lowered because of early detection. But this savings is more than offset by the cost of screening thousands of healthy people who do not have cancer.
Another consequence: As millions of healthy people try to get free preventive services they will crowd out care for sick patients whose need for care is greater. This will especially be true if patients are in insurance pools that pay doctors different rates. Patients in higher-paying plans seeking preventive services will tend to displace the more urgent needs of patients in lower-paying plans.
For its part, the Obama administration is caught on the horns of a dilemma. On the one hand, it wants to be seen as the champion of preventive care — because these are the only tangible services that touch the lives of the 80 percent of the population that is basically healthy. On the other hand, a vast increase in insurance coverage for such services will only serve to increase health care costs and in the process crowd out access to care for those who have more serious medical needs.
There is a robust literature that finds many preventive screenings do little to prolong life; cost more than they save; even cause harm health by turning up false positives.
I also imagine it will be difficult and time-consuming for doctor to assess which screening tests their patients qualify for — because the recommendations vary by sex and age. This suggests many people will ask for screenings for which they do not qualify. They will become agitated when asked to pay for them. Doctors will have to write-off many charges after the insurance company (rightly) refused to pay for screenings that were not warranted or covered. Mandated preventive screenings have the potential of turning into a bureaucratic mess.
As the demand for preventive services increases, the supply of preventive services should naturally increase, yes? Except that Obamacare calls for a 21% payment cut to the supply (doctors’ reimbursements for preventive services).
Devon,
On the government health care website there is a list of the preventative screenings that are permissible by age and sex so it should be fairly easy for doctors to know what would be a covered service or not. It can be easily printed out.
Brian,
You are correct in stating that if the demand increases (screenings) supply (doctors) should increase also. That to me is more doctors or nurse physicians being trained or imported (H1B Visas) to fill those positions, not more money going to doctors. That is a supply side argument with no relationship to demand. It is also why costs are skyrocketing.
I agree totally. what we have is one big con job.
Question: Will people realize the promises are empty before the election?????
We are not going to get 100% compliance with screenings by eliminating co-pays. We did not have that level of compliance when I was in the military and everything was free. What this does lead to is the idea of value based insurance. Eliminating co-pays on cost effective screenings, or ones with a favorable effect on QALY should incent people to use them more. 100%? Nope. COnversely, we should also consider increasing co-pays on procedures/tests with questionable benefit.
Steve
Great post. Why should insurance have to pay for all of my preventative work? My car insurance does not pay for oil changes. What if everyone suddenly went to get their “free” oil change? We’d be overwhelmed.
Good post. If for no other reason, it demonstrates the hypocrisy in the Obama Administration.
I wonder how many patients with serious illnesses will face delayed or no appointments at all because of the preventive care mandates? The additional physicians’ time will have to come from somewhere but no one seems able to say how that will be done.
Virginia,
Auto insurance is for liability (something you causes) whereas health insurance is to indemnify (to protect you from). That is why auto insurance does not pay for an oil change but health insurance will pay for preventative measures.
You can get indemnity insurance on your car with a pre-paid service contract which will pay for your oil change.
This is symptomatic of the entire health care bill. Absolutely no thought has been given to how the government will deliver on all the promises it has made.
Some perspective for those of you that aren’t primary care physicians….
To provide a complete preventive physical for all patients in our practice (all of you should have one):
3,000 patient lives… 8.2 history and physicals/day 365 days/year…no days off
Many cover much more….(I have a friend who covers 9,000 lives… 24.6/day)
Concierge….500 patients…1.4/day
If regular hours (M-F) and a 1 month vacation:
3,000 lives….12.5/day
9,000 lives….37.5/day
500 lives……2.1 lives/day
And no half days for golf….
We can only work so hard and do a good job…
Erik,
At present:
It’s not truly “health insurance”; it’s accident or sickness insurance.
Physicians do preventive screening in their sleep..If a Doc needs a print out, he shouldn’t be practicing.
John: Regardless of grandfathering all plans renewing after 9/23/10 do require up to age 26 deps, unlimited LT max, no pre ex for under age 19, and no maximums on essential health benefits. Grandfathered plans (those that don’t change cost shares by more than 15%+ a medical cpi calculation) do not need to add no cost share preventive. There are greater details and exceptions, but that is the main idea. So yes many of the “benefits” are going into place, especially 1/1/2011 when many plans renew.
More perspective:
The change in this generation…
More females are going into family practice. Weekly work hours are the driving force behind this. FP’s previously worked 70-80 hour weeks. The current average ranges from 40-60 hours.
John
You just got a major shout out from Mark Levin on his Talk Show. If your ears aren’t burning, they should be. He thought your analysis is brilliant.
Art
Dr Chris,
As I said it is indemnity insurance. Preventative care is the basic physical/medical history every doctor I have ever been to will complete annually as part of a routine doctor visit.
The argument now is how much preventative care should a doctor give for X number of dollars and where are those dollars going to come from.
Doctors feel the patient should be responsible in a Direct Pay arrangement while PPACA thinks doctors should be willing to perform these minor routines at their contracted rate with no pass-through to the consumer. The PPACA method saves money for the consumer which will and should encourage early detection and intervention which saves even more money in the long run but costs doctors in reduced TPA payments. I always thought prevention, early detection and intervention were the cornerstones of good medicine.
The question is how many ways can a doctor bifurcate an office visit to maximize their profit?