My First Wonky Post

Most people who read this blog know I'm a ridiculous policy wonk, all the more so when it comes to health care. Well, I'm going to make my first pharma-healthcare post, so feel free to skip if you are already glazing over. That being said, as the Economist put it (to paraphrase): 'what the 20th C was to physics (you know, the discovery of the atom, nuclear bomb, space etc.), the 21st C will be to biology'. (with the central premise that DNA really means very little, compared to RNA).

Sack-up, it's coming. The next generation will get 'risk reports' evaluating their lifetime potential of developing every major cancer and chronic disease known to mankind, and then will quantify each diet or lifestyle change that can quantitatively reduce your individual risk to develop any specific disease. Personalized medicine is here; Selzentry (Pfizer's new HIV drug, maraviroc, which my infectious-disease-specialist friend CS thinks is unimpressive) requires a genetic test to determine the eligibility of the specific mutation of your virus for the therapy. All right, technically that's not that personalized...but targeted.

Anyway, what got me started is this post here at a random blog. The CMPI (Center for Medicine in the Public Interest, great blog here at DrugWonks; not to be confused with those morons at Nader's Public Citizen, who have proclaimed doom on innumerable drugs which have subsequently proven their worth), originally sent me there through their blog.

In general, the blog summarizes a typical situation for americans dealing with their insurance companies. These are companies steeped in processes and bureaucracies, each instituted originally to pry 1% off a specific subgroup of customers, or limit costs from rare procedures, or limit customer interaction with out-of-network providers. In the end, they are comedically inefficient. See this article that originally started the blog I cited:

Imagine American healthcare spending as a dollar bill divided into 100 pennies. How many pennies do you think represent spending on prescription drugs? Sixty? Eighty? Wrong. The answer is 10.5. The other 89.5 represent everything else—from doctor visits and hospitalization to administrative charges and insurance.

WAYYYYY toooo much money is being spent in ALL healthcare systems (not just the US) on useless administrative fees. The NewsOverCoffee blog from Pennsylvania (cited above) notes a personal experience:

Most recently for service in May I got a bill in August for close to $7000.

1. I called the doctors billing and was told it was rejected by my insurance.
2. I called my insurance, Capitol Blue Cross, and was told they had no record. The doctor, whom we've had and been receiving treatment from for nine years, was in Philadelphia, though, and must first be submitted to Independence Blue Cross who forwards to Capitol Blue Cross. The woman at Capital took my information and said she'd call me back.
3. Insurance investigates by calling Highmark Insurance.
   
4. She called me back and said that Highmark and Independence joined and Highmark handles professionals. She called them and they told her that the doctor's office was waiting for me to provide information to them.
5. I called the doctors' billing and explained what I was told.
6. Doctors' billing called Highmark and was told it was rejected for more information by Highmark, who then never asked anyone for more information.
7. The doctors office then called me and said they would walk Highmark through the code, happens all the time.

Previously we had a payment that went a year without being paid and on the very first phone call I had explained to Capitol what the problem was, but the customer service rep wouldn't believe me. A year later and several levels up we got it resolved and the problem was what I'd indicated in the beginning and the bill was paid in full.

This is intolerable. I would highlight the part played by administration costs in this article here (may have to register), from a doctor on the Medscape called "Breaking Even on 4 Visits a Day."

Essentially, this doctor came up with a novel practice concept, which I think perfectly illustrates how far away current systems (be they single-payer or fully private) have gone from providing true healthcare:

Seven years ago, I began exploring ways I could practice medicine without the hassles and pressures of managed care. I also wanted to find a way to reduce fees significantly for uninsured and underinsured patients.Here's how it works:

• We charge our patients a flat rate for office visits. Currently, the fee is $45.
• We do not file insurance; our patients pay at the time of their visit.
• We do not sign contracts with insurance companies.

I call this the "Access Healthcare" model, after my practice's name. The model is based on the idea that by significantly reducing overhead and improving collections to nearly 100 percent, you can charge much lower fees, improve access for patients who might not otherwise be able to afford care, avoid excessive patient volume and still have a profitable practice. We've been practicing this way for more than five
years, and we are thriving.

Great plan. Seems like the plan any family doc would want. The article's well worth a read, but a few things jumped out at me, that I'd like to highlight along with the theme of this post:

Our overhead has been consistent at 25 percent of total revenue. That compares favorably to the typical practice's overhead of 40 percent to 60 percent of total revenue.

WHAT? AT TYPICAL PRACTICE'S OVERHEAD IS 40% to 60%!!! With all due respect to the incredibly smart doctors who own and work in these practices......WTF!!! Are you kidding me? This is why healthcare costs are so high! OVERHEAD! man.

Our charges average $82 per patient visit. This includes the $45 office visit fee and an average lab and supply charge of $37. We require our patients to pay their full balance at the time of service. As a result, our collection rate stands at better than 99.5 percent, and we have shed many of the costs associated with trying to collect unpaid balances.

Another telling statement. How many healthcare costs are associated with the convoluted multi-party nature of the payment system? Check this out:

With one staff person and two providers, our ratio of 0.5 staff per provider is considerably lower than the national average of 3.9 staff members per FTE provider

Oh man...I'm beginning to think that not only should economics be taught in high school, but maybe in med school too. This is utterly preposterous and untenable. I cannot fathom an economic rationale for four staff per provider. Check out what this guy has done though, in leveraging his cash-up-front advantage:

Lab companies are willing to negotiate lower lab rates with me because their payment from us is guaranteed, and they realize savings from not billing patients or insurance companies. Discounts may be as much as 50 percent to 90 percent off list price, meaning that a prostate-specific antigen (PSA) test has cost me as little as $4. Other tests have cost even less. Most patients pay an average of $25 for lab tests that would have cost more than $100 if the lab company billed the patient or the insurance company directly.

Even taking his conservative number, he's saying that local labs will CUT HIM, A STOREFRONT 1-MAN PRACTICE, A 50% DEAL on tests because he does not present the administrative challenges of insurance companies. OMG. OMG.