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Wait and See

This past weekend, I awoke to a dreary Saturday, Christmas Eve: rain falling, gray skies and no sunshine in sight. The weather has been oscillating between frigid cold and moderately warm. Christmas Day is within twenty-four hours of the writing of this blog. Over the past few weeks, our office has received a large number of Christmas Cards and generous gifts. These acts of kindness affirm the need for our staff and me to recognize how important it is to give to others. Over the years, I have established the tradition that all presents are to be opened on Christmas Day. So many of them were taken home and put under the fireplace hearth.  

One of the stark realities of life is that illness does not take a holiday. We had a busy week caring for the infirm. Moreover, those who had met their out-of-pocket for the year desperately wanted all possible testing related to their illnesses to be performed before the New Year, so that they might enjoy the benefit of their insurance company paying one hundred percent. Many of the out-of-pocket amounts were greater than $ 6500.00, so a sizable amount of money was spent for their illnesses or their family's illnesses throughout the year. It is expensive being ill or having a chronic active sickness. But does it have to be?

Last week, I had the privilege of attending a Trustee meeting of the Kroger's Employee's Health and Welfare, Plan and Trust. This is the ERISA health plan for the store workers in Kroger who are members of UFCW 1529. Their medical benefits are bargained for during Union and Management negotiations. The benefits change for year to year as each side of the table wishes to add or subtract reimbursable healthcare services from the current Plan document. I have never taken a role in the Kroger/Union bargaining process, but I am sure it is an intense activity. The Health Plan is totally self funded, which means Kroger and some of the employees put money into an account which is used exclusively for health care. There are a number of exclusions from coverage in an effort to make sure that physicians, clinics and hospitals do not get paid for treatments that are not medically necessary.

Those of you reading this blog may believe that all charges incurred by the order of a physician should be considered medically necessary, but in reality they are not. There are very few genetic tests that reveal any true helpful information that might influence anyone's care. The current wave of genetic tests span almost every specialty of medicine and these tests cost thousands of dollars. Many times the laboratories that perform these tests waive the fee to the patient if their testing is not covered under their insurance. Why? Because they sell their results to the pharmaceutical industry for research purposes. If they receive any money from an insurance company, they would be essentially double dipping. That is not illegal, but morally corrupt. The medical industry is filled with double dipping and the practice is hidden extremely well. Only the mongoose can smell the breath of the snake.

Although I cannot disclose the actual people and specific conversations I encountered in the Trustee meeting, I can disclose the general direction that healthcare and insurance companies are looking at to woo employers to buy more health related services with the idea that the employee will either choose a less expensive care path or the company buying the service will save money because an employee's health will be positively impacted, thereby avoiding costly illnesses.

One the sales pitches was for Kroger to spend a sizable amount of money to a company that has an "employee only" primary care clinic that would mostly be staffed by physicians. Each employee would enjoy twenty minutes of one on one time with a physician. The physician would allegedly care for the employee on all aspects of their care. If referral care is necessary, the physician or his/her designee would make the necessary referral and follow-up on it. The sales team related that if there was an acute event that required urgent attention, they would most likely refer the employee to The Little Clinics (TLC) in Kroger stores for evaluation and treatment. TLCs are staffed by Family Nurse Practitioners. The Employee only Clinic would also dispense generic drugs to the patients and of course, charge Kroger an extra fee for the dispensing of the medication. So far in the Memphis Area, they have two locations with limited hours of operation. Neither site has been open for longer than 12 months. The physicians who staff the clinics were picked from doctors ready to retire from their own private practices or hospitalists with spare time on their hands. Both are mere employees working for a salary and benefits. The physicians and nurse practitioners have no equity in the program what-so-ever. Essentially they have no skin in the game. I think that bodes poorly for the patient.

If you know me and you know how I react to sales representatives trying to sell me a pig in a poke, primary care repackaged and more expensive, you'll know I was not in favor of their proposal.

The second presenter to the Trustees was a pharmacist who firmly believes in biometric screening. She wanted the Kroger employed pharmacists to do onsite finger prick cholesterol and blood sugar testing at their stores and well as blood pressure monitoring. She also believed that the pharmacy could become more active in screening employees for flu using rapid tests and possibly following strict protocols by physicians, to dispense Tamiflu® if the tests were positive. She wants everyone to enjoy the benefits of immunizations and believes everyone should come to the pharmacy to let a pharmacist administer the inoculations. She strongly urged that people get the flu shot that has four strains of the flu virus in it instead of the currently used three strain version. By Tennessee State law, pharmacists are prohibited to make diagnosis and treat patients for disease. However, she stated that they can diagnose and treat if they have a physician who is overseeing their care and they adhere to strict medical protocols.

I pointed out that biometric screening, although well intentioned, does not prevent disease nor alter disease outcomes on a grand scale. This program really has nothing to offer, other than pharmacists wanting to crack the greater healthcare delivery door open to health practice activities. I think their (Clinical Pharmacists) ultimate goal is to get their licenses expanded similar to Family Nurse Practitioners. Every inch of freedom given to pharmacists to diagnose and treat disease is a step in the direction of affirming autonomous medical practice without going through a rigorous internship and residency of which medical physicians are mandated. Talk about putting the Rooster in the hen house.

The third group of presenters were a subdivision of Cigna. There were four account reps, two females and two males. Their greatest focus points were to perform biometric screening on all of the Kroger employees, steer Kroger employees away from using the emergency department as their episodic clinic of choice and steer laboratory testing on their employees to their preferred providers Quest and LabCorp. Those two laboratories gave Cigna the greatest discounts on laboratory services.

There was a tremendous amount of discussion about the projected savings, but no hard data to back up their claims. As I picked apart their proposals, I asked them if they ever asked the flagged employees who abuse the emergency services why they had that behavior. They said no. I asked them if they had ever considered asking their physicians who are on their PPO to help them solve this problem, they said no. Before I could get the next question out of my mouth, one of the female Trustees interrupted me, spoke and essentially told me to shut my yap. The Cigna reps were very uncomfortable having a physician in the room with them. Those four account reps did not like physicians. And I did not like them. They believed strongly in the stick method of redirecting patient care (steerage) verses the carrot. The stick method for all of you who do not know what that means is a method that penalizes the patient harshly for using a non-preferred provider or laboratory. But their proposed carrot was extremely limited and their thoughts about implementing a stick or two were extremely harsh.

I have no idea what the Board of Trustees decided the following day in regard to which programs, if any, to consider or reject. Everyone went out to dinner together that evening except me; I was invited but I went back to the office to pick up where I left off that afternoon.

As I reflected on the proposals, I was greatly saddened by the fact that physician input has long been left out of each of these proposals. My profession has eroded into nothing more than skilled labor pool in the healthcare workforce. I don't know if physicians have abandoned their administrative responsibilities to their patients or that the healthcare industry in general has pushed them to the curb. The first proposal, the one where physicians take a bit more time with each visit, is totally funded by Kroger and it is not related to an insurance program what-so-ever. It gets the middle man out altogether.

If I could do one thing that would change the direction of healthcare in this country, it would be to get all those middlemen out of the industry. I would gut the medical insurance industry and return those exorbitant premiums back to the patients so they could choose the best physicians for their care. I would change the healthcare delivery model so that monies would be directly deposited into healthcare providers' business accounts so that they would have the ability to see patients, order laboratory testing and imaging and encourage them to construct fees that benefit everyone, including the patient. All healthcare would be non-profit with an excess earnings yearly of less than 5% of their total gross income per year. Salary caps would be put in place so that large institutions like Baptist and Methodist could not pay their administration more than the salaries of those who work for other non-profits like the Red Cross or Salvation Army.

If anyone wishes to earn over one million dollars a year in healthcare or its related services, then they would have to find another occupation. Let them go into the entertainment or financial industries, there are plenty of opportunities for them millions of dollars if they were good enough. But if they don't have what it takes to be successful in a free market, they would be out. Now these high paid administrators cut the hospital personnel to the bone, hire less-than-qualified physicians (hospitalists) and physician extenders to staff their facilities and extort a captured population of sick patients for their own personal gain. Running a hospital is nothing more than a large iteration of operating a fast food restaurant, the biggest difference is that the fast food restaurant has better food.

No fast food restaurant can survive selling product to their customers that costs $0.57 per plate, but a hospital does. The last published salary I could find pertaining to the Baptist Memphis Hospital CEO was over 3.5 million dollars per year. Cigna CEO David M. Cordani made over 49 million dollars and Cigna-HealthSpring President Herbert A. Fritch made 50.5 million dollars last year. And you wonder why healthcare costs so much? Don't forget, there are employees beneath them that also made millions of dollars a year. It's the millionaire club.

Despite this dark, dreary Saturday, I believe all is not lost. The American populace will somehow rise up and fix these problems. When the collective have had enough of the high cost of mediocre care, they will revolt like they've done in the past. If all lives matter, then all healthcare matters. They American public deserves better in all ways.

Ho, Ho, Ho, I hope all of you had a Merry Christmas! Donald Trump is taking office in January to bring in the New Year. I wonder what reforms he has in mind for Healthcare. Will he drain the swamp of those healthcare administrators who believe they are worth more than those who actually deliver the care? Or will he ensure that hospitals and insurance companies can generate as much money as possible since they are free range businessmen who have a captured patient pool and they believe that the right to receive proper healthcare is just a marketing tool for an expensive and fruitless therapeutic luxury.  Seeking healthcare from a non-profit healthcare organization is not the same as going to a for-profit Titan football game. Most of us have no choice, we have to go to those physicians who are on our healthcare plan and we must be cared for in hospitals that are sanctioned by the same healthcare plan. Doesn't that just feel odd in some way?  

Will the new President Elect change the Healthcare in America? Rep. Tom Price (R-Ga.), the chairman of the House Budget Committee and an early Trump backer, was chosen to lead the Department of Health and Human Services. We'll just have to wait and experience it.

In the meanwhile, have a prosperous New Year!

Doc

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