Monday, March 24, 2008

Health Care

The following is something that I wrote about in a letter to officials almost 2 1/2 years ago. However, it is from an editorial that I wrote almost a decade ago. Health care is the principal driver in our budget every year, and it is a huge cost for just about everyone in society today. Here is part of that letter:

"I have lobbied in the past to create administrative centers to handle the costs associated with paperwork and the labyrinth of health care plans and insurers. I have used examples where one person may utilize ten or more different venues of health care. Instead of being one person, he/she is treated like ten people with paperwork recreated again and again. If we had administrative centers that treated that person as one individual, we could substantially reduce administrative costs per patient. Not only would this be less costly, but we would reduce patient error and get better, more complete information on each patient. While I don’t envision said centers as gatekeepers, they would be able to more efficiently schedule both time and facilities. This would give us an opportunity to stop the proliferation of medical equipment such as MRI machines. Fewer machines could be utilized more efficiently with better centralized scheduling. This would cut down substantially on costs. The centers could be used to bulk purchase pharmaceuticals, reducing costs. Finally, freed from paperwork, health care officials could do more of what they do best, heal the sick.

Centers would also help to reduce medical errors by giving everyone involved the same information in a timely manner. If we were to combine this with the Computer Physician Order Entry (CPOE) system proposed by a consortium of health care groups through the Massachusetts Technology Collaborative (MTC), the results would be astounding. Not only would this save a tremendous amount of money for our health care facilities, but it would save lives.

Over the last few years, we have invested a lot of state resources into keeping people out of nursing homes and in their own apartments. We should continue this effort by factoring a few elderly units into every state assisted housing project. By building electronic arrays into these units, one nurse or personal care attendant can watch whether people are ok in their own homes. We should utilize technologies in-group homes such as cameras, telephony assessments, and computers to provide assistance to those in little need in order to avoid future larger costs. They can tell if people are taking medications. Again, this is a common sense approach that is part of an overall plan focused on people living healthier less expansively.

Plans to control costs don’t have to be as sweeping as this, but should be combined into a broad initiative. The issue of reuse of pharmaceuticals at Nursing homes is a good example of a small common sense cost savings.

Data Collection is another area where we can do better. For example, there are data collection tools for both Medicaid and Medicare. We use MMQ and the feds use MDS (through CMS) systems. Essentially we collect the same data to ensure against fraud. Each facility uses 1-1 1/2 registered nurses to enter data. This is 50,000-75,000 per facility, and we have 400-500 skilled nursing facilities in Massachusetts. If we eliminate the state duplication and piggy back off of the feds, we save $20-30 million that we are paying for. Plus, we could eliminate most of department staff that looks at the data and does field inspection. That would save us money as well. One of the reasons for not changing in the past has been that the feds do mostly auditing with auto accounting data software, while we do more field inspections, but the feds are starting to do more field inspections. Additionally, Nursing Homes need JCAHO certification to get paid by feds. We have DPH do the same thing. This is done less with hospitals than with nursing homes, but same issue. We need to stop the certification duplication.

Health systems that use community pharmacies waste money. The average supply dispensed of an average drug is a twenty-day supply. The average Medicare patient spends $25 per day on drugs. Waste is estimated at fifty per cent. Why? Two things. First, patient gets sick and is off meds. Second, patient has to change dosage. Systems are now being put in place in some hospitals to give dosage as needed on a day-to-day basis to stop waste. It is estimated in one community facility in my district that they would save $400,000- 600,000 in that one facility if they went to day-to-day dosage. Plus, hospitals pay less for drugs than do pharmacies. It is relatively easy to save where a hospital owns a nursing home. Should we do a pilot program?

Look at payment plans in Massachusetts. Institute of Medicine has estimated that we could save $265 billion nationally by changing our billing structure. Need to conduct a pilot program “to identify, pilot test, and evaluate various options for better aligning payment methods with quality improvement goals. Examples of possible means of achieving this end include blended methods of payment designed to counter the disadvantages of one payment method with the advantages of another, multiyear contracts, payment modifications to encourage use of electronic interaction among clinicians and between clinicians and patients, and bundled payments for priority conditions.” We should explore federal funding to conduct pilot programs. Again, this is a function that could easily be accomplished by setting up regional administrative centers

We should look at the creation of regional health and human service organizations. Many of our agencies handle parts of a problem or duplicate a type of service offered by another agency. Better coordination of efforts would lead to a reduction of costs through duplication and would lead to better services through a more holistic approach to a person’s problems. Just as we know that an individual with a chronic illness has multiple illnesses in most cases, an individual with a substance abuse or domestic violence problem may also need educational, job training, or housing assistance. By providing comprehensive services to combat multiple symptoms, we are able to avoid recidivism of individual in use of social services.

As we listened to businesses on our listening tour, we promised business that we would not merely pass an economic development bill, but would partner with businesses in order to maintain a better economy for the Commonwealth. We need to do the same with health care. Now that we have passed this unprecedented health care bill, you have given."

Health Care is an incredibly complex issue that people try to break down into a seemingly simple issue of single payer. No one state can do this alone. For example, single payer advocates don't take into account multi-state companies or tourists that would have their own health plans. That means we can't eliminate handling all the other health plans in our health facilities. But we can have a single biller plan. It gets us to the same place. Additionally, we can better use technology in a state where we have some of the most technologically advanced companies in the US. Regardless of how we do this, we have to get better at controlling costs and we need the federal government to step up on this.

14 comments:

Mark Belanger said...

That's a whole mess of good ideas.

What stopping us from doing some or all of these things?

BTW - when I say "us" I mean "you" :)

Good piece on NECN the other night.

Southview said...

Dan.....Pie in the sky proposals and long winded speeches are not going to solve any of our States medical problems. Nor is the present forced to buy insurance scam. What the people need and want is an efficiently run "UNIVERSAL HEALTH CARE SYSTEM"
Bowing down to the interest of the Insurance Companies is not what THE PEOPLE want! Medicine by Insurance is not a good way to go, no matter what the Insurance Industry tells you. That is a politically expedient way of doing nothing while trying to look like you are doing something. You get what you pay for and that is just how the system works. Only those that can afford a high priced policy (Blue Shield Blue Cross Gold All Inclusive) can expect unfettered treatment, and who can afford that, State Workers can, right DAN!
If you and the State Legislature were trying to get the same policy that you enjoy at the same price you pay would be a good start for the citizenry. Then we could graduate to a one payer system.
DAN just a note of how the Insurance Scam works...My wife worked for the State and paid $35 dollars a week for her insurance. I on the other hand, having the very same policy with the very same company, was paying $4 dollars per hour from my union wages. Do the math...And the kicker was we could use only either hers or mine, not both....hmmmmm, we paid for it why couldn't we use it? To my mind that is insurance fraud! Where were you then?
All the people want is to not have their medical issues at the mercy of the Insurance Industry and the ability to feel reassured that the doctor treating them isn't more concerned with what is or isn't allowed by your insurance Policy!
A sliding scale Medical Tax would be appropriate to help pay for it with a bidding process by the Insurers. I know this is probably way beyond the ability of you politicians to deal with but it would be a start. Why don't you just send out a questionnaire and ask the people what they want and include a section for ideas?
Universal Health Care will come so why not be on the leading edge insted of the cows tail?

Greg said...

Dan, I agree that "single biller" is a great step. However "single payer" is still an even better one.

Your letter seems eager to wring out duplication of effort and inefficiencies on the provider end of things, yet it leaves in place the multiple insurers and their redundant processes, which only drives up costs. When a private insurer even comes close to Medicare's single digit overhead, then I might change my mind, but not until.

As you probably know from my writings, I've had many recent difficulties with BCBS. I remain convinced that as long as insurers are the gatekeepers to proper medical care, rather than doctors, we are simply spitting into the wind.

Yes, the issue is complex, but many, many others have solved it. Last time I checked, most of Europe, even with high tourism rates, does a fine job in providing great timely care. (And they find a way to handle the tourists as well) There are many different approaches being used across the Atlantic (multi tiered, public-private combos, etc...) and most of them are far superior to anything our current insurer-driven model provides in both cost and outcome.

Williams does a fascinating Winter Study course on this subject. I can hook you up with the guy who moderates the course. (a former Pfizer research doc) I'm sure that he's love to look at the political angle of this as well as the medical/insurer.

Anonymous said...

Kolchak- the Health Care Stalker

Ross said...

Just can't stay away, eh, Clark?

Anonymous said...

And anonymous at that!

Anonymous said...

well Ross suggested on his blog that maybe Bozman could coax me out of retirement---so anonymous is
OK----eh Da Snoop--who has outed himself-----chbpod

dan bosley said...

Greg,
I agree that single payer is preferred, but I would prefer this on a national basis. We get so hung up in interstate commerce clause rulings and health care shift to surrounding states, and a bureaucracy to sort it all out, that it is very difficult to accomplish in one state. Given the inability to get something done on single payer, we need to move ahead on some front. The single biller gets us a lot of efficiencies.
The infrastructure that we have in health care acts as a drag on any reform efforts. Hopefully, as Jack has stated, as more and more middle class families can't afford health care, Congress will decide to act.
BTW Jack, I pay a lot for my health care and have some very big co-pays on several drugs. It does impact me and I don't know how some families afford their prescriptions.
Clark, good to see you on site.....or at least read you on site. I have to be accurate or people scorch you with email.

Anonymous said...

Thanks Bozman- I have added this blog to my favorites list and will be checking daily---I have been thinking for the past hour or two--(a long time for me) and you are undoubtedly my favorite history major grad----you go guy-----and say Hi- to Robert Moses--- chbpod

Greg said...

Dad - It's agreed that a national plan is much preferable. I should have made that clear in my comment.

I doubt that a state by state solution of any sorts is going to work. Hence my criticism of the current program.

Raymond Tolosko said...

Speaking as a primary care provider (nurse practitioner), the mound of paperwork to insurance companies is overwhelming...couple that with only fifteen minutes per patient and one has an EXTREMELY long work day (not to mention return phone calls to patients at the end of the day).
My job is to see the "not so complex patient", however in reality...I'm seeing as complex as the doctor I work for.
One very important point is the Mass Health coverage. There are so many patients on Mass Health driving up in their 2008 pick-up trucks or SUV's and getting free health care, while working under the table.
Our Mass Health program is REALLY BAD. There needs to be a plan in place to get someone off Mass Health the day they get on it.
Disability is another big problem, there are patients that are abusing the system so badly and ruin it for those who really need it.

Greg said...

Dan - did I just call you dad? Yikes. Freud would have a field day.

dan bosley said...

Greg, and on Sunday!! Yes my son.

I try to answer most of my own email (except for the dozens of form email that comes in on a regular basis). If someone has enough initiative to email, they should get an answer. But there are times when I am overwhelmed with all sorts of things going on and run through these as fast as I can.
On one occasion a few months ago, my office received a phone call from someone in the district who called to say if I was going to have staff answering emails for me, they should at least get my name right. I had misspelled my own name! I ended up calling the person to tell her that I had indeed screwed up. It happens.
Dad

dan bosley said...

Jacquie, I agree with your assessment. We need to get people off of the system, or at least using the system in a more productive manner. That is why I proposed my single biller system. I think it will be more efficient until the feds finally come to grips with this. We need to do a better job at management for those who truly need the system and screen for those who are abusing or aren't eligible. By the way, the Governor has started a commission on the underground economy. I had cosponsored a version of this filed on behalf of the AFL-CIO earlier in the session. The commission hopes to root out corruption in the system on things like this.