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July 5, 2019

So much is in disarray with healthcare in this country. Frustration from physicians, dentists, therapists and related technicians centers around the low and sometimes absent reimbursement for services that require great skill and knowledge. Patients complain about the high cost of medicines and the scanty amount of time the doctor spends with them. We talk about healthcare disparity.

Politicians and government administrators talk about how expensive healthcare hits their budget. As mental health issues continue to escalate, most private practicing psychiatrists do not take insurance because the low reimbursement rate for services would drive them out of business. An emergency room visit for a bad “cold” may cost taxpayers an excessive cost when that “cold” could have been managed outside the emergency room. All the above is true.

Meanwhile the entities that are smiling include the pharmaceutical and insurance companies. Not only do they bathe in financial luxury, but they make the rules of the business. Insurance company CEO’s often compete with each other regarding their ¼ to ½ billion dollar salaries. Yes it is expensive for pharmaceutical companies to get a drug approved for market, usually in the billion dollar range, but once approved, that investment usually turns a profit in the first year of sales. After that, the company goes through smooth sailing with astronomical profits for the remainder of the patent. That is enough incentive for these entities to invest in NOT making any change in the healthcare system. They are doing just fine.

We are now seeing the rise of urgent care centers; they realize this is big business and they want a piece of the pie. Being very convenient for patients, many are turning to urgent care for their primary provider. This hurts the doctor patient relationship since you are most likely not to see the same doctor upon return visits. Many doctor visits are managed by physician assistants or nurse practitioners. Though these specialties do a wonderful job with healthcare education and preventive care, logic tells us that their expertise in difficult diagnosis or managing complex chronic medical issues is second to physicians.

So, without completely socializing medicine, here is my solution:

  1. Increase the professions of nurse practitioners and physician manage non-complex or non-urgent issues. Let them set up their private offices and received $72.00 then that is decent reimbursement for the nurse practitioner and a relief for the insurance company. Multiply this kind of incident millions of times throughout this country and you can see how our healthcare cost would go down. That comes to 90% reimbursement to the nurse practitioner (which is great) and a great reduction in cost for the insurance company. Both parties win. With a 90% reimbursement rate, (and allowing for a ceiling) the nurse practitioner could make a very decent living. Maybe not as much as the physician but there would be an understanding that these are very separate entities.
  2. Salaries would expected to be different.
  3. Much of this is already happening BUT the difference is that the billing for services is at a rate the PHYSICIAN would bill thus increasing the cost of medical care in this country. For example; a patient is seen in the emergency room for a bad nose bleed and a nurse practitioner manages the problem without a physician input. The ER may bill the insurance company $1,200.00 for the service since it was done in the ER and receive $850.00 as payment in full. If the same patient saw a nurse practitioner in his or her own office and billed the insurance company for $80.00
  4. like some states allow to do the above. Let midwives manage non complicated pregnancies and deliveries; these cases may not need the input of the physician. They do an excellent job of monitoring and maternal support. Obstetricians now get a flat fee (approx. $800.00) for nine months of non-complicated pregnancy. That’s a lot of time and responsibility to just get paid that amount. It discourages many to no longer deliver babies and resort to just GYN care.
  5. Have them do the job of routine physicals healthcare assessments, and managing minor medical problems. They can be in urgent care facilities and ancillary areas of emergency rooms
  6. The role of the primary care physicians would be different. Their role would be to treat and manage chronic, complex or difficult problems only. They would not have the role of preventive medicine, managing long questionnaires, or administering vaccines. These roles would be the responsibility of the nurse practitioners or PA’s. Physicians, however, would receive a far greater reimbursement for their services since they would be considered as experts in their field and not a “healthcare provider.”

So, if the doctor treats and manages an asthma attack in their office, his or her reimbursement from the insurance company would be very different. For example, today the doctor may bill the insurance company $200.00 for a 40 minute visit and receive $95.00 for the asthma management. In a new system the expertise of the M.D. would command a billing of $350.00 and the reimbursement would be $315.00. That would be great for the doctor since they would not have to see as many patients to stay in business and they could afford to spend more time with the patient. This benefits the patient. The insurance company still benefits since much of their outgoing cost for minor and preventative services are at a lower cost.

This system implies that the average salary for a PA or nurse practitioner would be significantly lower than the physician.

  1. PAY THE PSYCHIATRISTS!!! Many don’t realize that many psychiatrists do not accept insurance
  2. and for good reason. Psychiatrist get reimbursed by the insurance company at a rate that is dependent on the diagnosis. It may take many hours of psychiatric evaluation before a diagnosis is reached but the doctor may get paid “peanuts” if the diagnosis is not at all complex. Pay the psychiatrist for their time not the diagnosis. Pay them well for their expertise and many years of training since they are the ones who may prevent your loved one from suicide.
  3. Since most commercial insurance reimbursement amounts are tied to Medicare rates, increase Medicare rates for physicians. This would encourage more M.D.s to accept Medicare and Medicaid but Medicare and Medicaid would not have to pay out as much if much of the preventive and primary care is relegated to P.A.’s and nurse practitioners. Medicaid forces its M.D.s to comply with a plethora of rules in the area of preventive care. If this responsibility was shifted to P.A.’s and nurse practitioners (who do a better job) this frees the physician to do what he or she is trained to do.
  4. Have federal government coop with pharmaceutical companies as an option. The biggest hurdle
  5. for these companies is the initial cost to invent and get certified by the F.D.A new drugs and devices. If the federal government agrees to supply half the cost for research and development and the company adheres to a ceiling on the price of the drug at market then both entities win. The drug company may save 5 hundred million on getting the drug to market and the government saves from having to pay out ridiculous prices the companies may charge.
  6. PAY THE HOSPITALS THEIR WORTH!! They are life-saving institutions and are worthy of their efforts. Yes, an ICU stay for 2 weeks presents with an astronomical bill and a premature neonate stay in the NICU for a month may cost over a million dollars. Place an 80% cap on what insurance companies would have to pay and have the balance paid by government. With savings elsewhere in the system, government supplement should not break the bank.

In general, USA medical care is good, but we all are paying too much for it because of its structure, not necessarily management. In general, most medical care cost are for minor or non-complicated problems. It is just that the volume of these problems is high. Many of these problems are managed by intensive facilities such as emergency rooms and urgent care. If our structure connected people with a team of health care providers that are non-physicians then many visits can be managed via telephone communication, education and reassurance.

Case in point: a 3-year old child develops a fever at 2:00 am.-parents panic and take the child to the emergency room at a cost of $1,200.00. That same child’s parents could call on a pediatric nurse and be given advice to lower the fever and reassure the parents that the child can be seen the next day in the doctor’s office. The cost for that route could be approximately $150.00.

Patients get the idea that any ailment necessitates a trip to urgent care without contacting their primary care provider first. This process has to be stopped. During the days of HMO (health maintenance organizations) patients HAD to contact their primary care providers before any other service could be authorized. That was a good idea to save cost and it should be reinstituted.

Finally, education of chronic medical conditions to the public would be best served by free seminars sponsored by insurance companies and not drug companies. Education lowers health care utilization and costs; this would benefit the insurance companies.

Michael D. Darden, M.D.

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