Employer Mandates: No Good Choices

Yesterday I mentioned a new CMS report noting that the current health care reform proposals that have passed the House of Representatives would improve coverage, but increase costs. While that undoubtedly was the big news of the day, there was another finding that I thought was of interest:

"While some employers will offer insurance for the first time, because of new access to insurance plans, other small employers will drop coverage because paying a penalty to the government will be less expensive than actually offering coverage to their employees..."

Patricia Murphy, The Capitolist, November 16, 2009

For purposes of reference, the current employer mandate features in the House bill are that employers must provide insurance or pay a penalty of up to 8% of their total payroll. Companies with total payrolls under $500,000 are exempt, and the penalty to phased in for businesses with payrolls up to $750,000. Businesses with ten or fewer employees get tax credits to help provide coverage. (Erica Werner and Ricardo Alonso-Zaldivar, Associated Press, Novemebr 7, 2009)

I’m not a small business, but I hope I might be excused for trying, on occasion, to think like one. And if I’m a small business, my decision to offering a health care package probably depends on the type of employees I’m trying to hire and keep. If I need highly educated or technically skilled workers, employees who command higher levels of salary, I’m probably going to provide the benefit. I’ll do so simply because this is the best way to recruit the highly select staff that I need, in order to stay competitive and continue to profit, and I’ll probably continue to do so regardless of the presence or absence of any kind of government mandate.

But I would argue that it’s not these highly sought-after employees that are the focus of health care reform. The currently uninsured employees we’re really worried about are, by and large, those who are essentially unskilled or hourly workers employed by either a small business or a large corporate retailer. These are people who are relatively easy to hire and easy to replace, and there seems to be a ready supply of them. The market impetus to provide insurance for them simply does not exist. This seems especially true in the midst of a recession.

So here’s my decision point as a business owner. Let’s pretend I’ve got twenty employees and a payroll of a million dollars. The government is going to require me to either provide insurance to my employees or pay a fine. It’s uncertain if I will be required to provide a full benefit to the employee or if the employee will cost-share, if I will be required to provide single person or family coverage, or the limits of coverage included within the benefits package. So for purposes of my calculation, I’ve taken the annual cost of my own individual “real-life” family policy ($16,230, of which the employer pays roughly $9,890) as a baseline. (Granted, it’s a pretty good policy, but certainly not the equivalent of the “high-value” polices subject to taxation in the current Senate version of the health care bill.)

Let’s say my company has ten employees. For my workers, the total cost of coverage will be $98,900. This compares with a penalty of 8% of payroll, or $80,000. The disparity between the fine and the premiums get larger as the number of employees rises. For example, if I have fifteen employees my cost is 148,350, and the differential is $68,350; if I have twenty employees, the numbers are $197,800 and $117,800, respectively.

So if the two obvious choices are to pay a penalty to the government or provide health insurance to my employees, I might certainly choose the less costly option. I might be even more prone to do so if I know that there are expansions of Medicaid or other subsidies to help my lower-paid employees buy insurance on their own. But there’s a third choice as well. I could decide that health insurance is an important benefit, and make up the difference between the premiums and penalties by either tightening my worker’s wages and taking the difference out of their salaries, or by letting a few go so the remainder can have their benefit. Neither of these are good choices.

Given this analysis, why would any business actually want to provide health insurance for their employees? Some large corporations such as Wal-Mart have come out in favor of employer mandates as a way to level the playing field and eliminate the competitive advantage held by companies that do not offer insurance. One might be forgivien for wondering if this support is real or simply a response to the knowledge that the train is roaring down the tracks and it's best to be on board, but the support is there nonethless. Advocates can also point to the State of Massachusetts, where employer mandates within their 2006 overhaul of health care did extract compliance from the vast majority of affected employers. (To be fair, the employer requirements were less stringent than as proposed in the current House bill, but so too were the proposed fines.) It remains to be seen if the public spirit shown by employers in the Bay State is shared throughout the country. One hopes for the best, but has unfortunately come to expect the worst.

So what’s the solution? The goal should be for businesses to opt to provide health insurance, not be forced to do so. But if employer mandates are the way to go, it would make sense to raise the penalty to an amount equivalent to that of the health insurance itself in order to eliminate non-compliance as a cost-saving choice. But much better, I think, to either rely fully on an individual mandate with generous subsidies to truly make insurance affordable (I remain desperately troubled by the idea that a family, even with a subsidy, should be required to buy insurance instead of using the funds on other needs), or to accept that the best and most cost-efficient way to solve the problem is simply to establish a baseline level of benefit for all Americans.

(Author's Note: When I originally put this note down on paper, I was using an Associated Press article as a reference. This morning, I was flipping through the news and found another AP article by David Lieb about small businesses dropping health care coverage. This article said:

"Both the House and Senate versions would offer temporary tax credits to offset a portion of the health insurance costs for businesses with fewer than 25 employees and average wages of less than $40,000...

Legislation passed by the House would impose a tax penalty on businesses with payrolls of more than $500,000 that don't offer health insurance or fail to pay at least 72.5 percent of the premium costs for a health plan with federally mandated benefits."

Granted, the differences in the provisions may seem minor, but they are differences nonetheless. So is it any wonder that nobody really understands what's going on?)

Health Care Costs Money: Who Knew?

Noted online yesterday morning:

A report by the Centers for Medicare and Medicaid Services sent Democratic staffers scrambling over the weekend after the 31-page study revealed potentially damaging findings about the cost and coverage of the health care bill passed by the House of Representatives Saturday night. The report said, among other things, that rather than cutting costs, the bill would increase them by $289 billion over 10 years…

…the analysis from CMS's chief actuary, Richard Foster, found that the House bill will achieve its primary goal of significantly helping uninsured Americans by providing new access to affordable health insurance. However, Foster also warns that the expansion will come at a cost to the federal deficit, which will likely increase, and to seniors, who could lose access to some of their own doctors under the plan as cuts to Medicare force some providers out of the market.

Patricia Murphy, The Capitolist, November 16, 2009

I’ve always thought that out of every relationship, good or bad, you find something of value. Originally this thought came to me over an eel roll, when I recognized that were it not for being totally tossed over by a certain dark-haired girl, I’d still not know the joys of sushi, nor have anything but a passing acquaintance with female cosmetic paraphernalia such as the eyelash curler. (Such knowledge has served me well in understanding of the makeup toolkit of my bride.) And so I must thank the worst boss I ever had for at least introducing me to the following equation, one which effectively summarizes the entire problem of any health care system.

Access x Quality = Cost

(Access is the number of people who have entry into the health care system, while quality represents the number of services provided. Cost is, well, cost.)

Given that this equation is true…and while I could go into excruciatingly painful details as to why, just for the moment accept that it is…is the recent report by the Center for Medicaid Services really a surprise? You increase health care access to an unrestricted level of services, and costs go up. You could have seen this coming a mile away.

It seems to me that the fact that this report is somehow startling or controversial is simply because nobody wants to make any hard choices. Hard choices require hard thought, which is anathema to our increasingly polarized, sound-bite democracy. (One wonders if Henry Clay would have succeeded in holding the Union together given the current media frenzy.) The hard choice here is to figure out what we really want. We can’t have increased access to care, increased services provided, and cost containment. You can have increased access or quality of care, but only at increased cost. You can lower costs, but only at the expense of denying people access to the system or by restricting benefits.

My suggestion: Policymakers should listen en masse to the fifth cut on Meat Loaf’s legendary Bat Out of Hell.

Don’t be sad…in health care reform, two out of three ain’t bad.

Inner Rumblings

I have come to the conclusion that America is the most bowel-focused nation in the world. Scholars of health beliefs, those who put together models for the purpose of enlightening the masses and acquiring tenure…I think I got that backwards…may be able to prove that this is not true. Perhaps they have done surveys of non-Western cultures, cultures in which bowels are simply part of Tao, that they ebb and flow as a river. Perhaps they are considered a sign of karma, a symbol of regeneration as everything that goes in comes back out once again. Perhaps they are mere entrails, things to be tolerated as part of this worldly purgatory we know as earth. Perhaps I hold this mistaken belief because, by accident of fate, Northeast Florida and East Central Kansas are uniquely bowel-conscious, and that these regions are joined in some mystical fashion by the good offices of St. Bonaventura (the patron saint of intestinal disorders). Perhaps there’s grant funding out there for me to find out.

I have come to this conclusion because I have recently fallen victim to the same obsession. This is a direct result of the ED “swing shift.” One of these shifts goes from 5 PM to 1 AM. While that’s no problem for night owls like me (everyone who knows me understands that I’m essentially non-functional before the day hits double digits), it does mean that by the time you get home, eat, wind down, and try to go to bed it’s often pushing three o’clock. It doesn’t help that I do everything the sleep hygiene articles say not to do, including using the bedroom as a platform for television viewing. It’s in the effort to lull myself to sleep that I’ve discovered the late-night world of the colonic infomercial.

The best of the bunch, and the one that really captured my attention, featured a “scientist” being interviewed by “serious, skeptical journalists” before a “live studio audience” drawn to the show by their “interest in health” to hear “what doctors don’t want you to know.” (In fairness, the audience did appear to be alive, as evidenced by the applause they dispensed at regular intervals when the camera cut away to them after a particularly profound pontification.) The highlight of the show was where he showed a picture of what was claimed to have emerged from his colon after use of his cleansing elixir. It was a mass shaped in roughly a semicircle, a dark black serpentine creation that appeared frightened to see the light of day. And that night, and for nights thereafter, I mused upon this picture. I was fascinated by the question of how he got it to come out in one piece like that, and I was absorbed in wondering how and why he would chose to fish it out of its watery grave. (There actually is a third question involved…if it did not come out in one piece, how did it get its shape…but we’re really not going there at all).

(Interestingly, my late-night viewing habits have also resulted in a fixation with the work of Edward R. Murrow after happily watching “Good Night and Good Luck” on the movie channel for what has to be the fourteenth time. I wonder how he would have covered the issue of colonic hygiene on the renowned “See It Now”:

“We don’t eat fiber, our fruit intake is low, and our sense of fullness is exceeded only by our sense of seeming self-satisfaction. How that can happen in a land where nutrition is plenty, ripe for the taking? Murrow and Friendly can see no answer but in our own internal Harvest of Shame. And as we consider our nation’s colonic health, we find it true that, as Cassius said, “The fault, dear Brutus, is not in the stars, but in ourselves.”)

I try very hard not to hold myself on a higher plane than my patients. (Well, okay, sometimes I do, especially when the ED patient‘s chief complaint is “Been sick, honey, been sick since the Korean War.” First patient I ever saw in my residency. True story.) But for me, bowel movements are simply one of the less tasteful functions of life, and to consider them an object of inspection and contemplation is just another sign that somebody needs to get a life. As one of my nursing colleagues put it, “Bowel movements are a necessary evil, not an object of fascination.”

I can still vividly recall the dialogue with one the first patients I saw with a bowel complaint while working at the University Of Florida:

Q: “Any problems with your bowels?”

A: “Doctor, I had a BM this morning. It was loose, not like my usual ones that are big. There were just some little pieces that looked like a rabbit. It was floating, so I poked it with a stick and it came back up. I called the ambulance. Does that mean anything? I knew you’d want to see it, so I brought it in with me. It’s in the baggie in my purse. Do you want to see it? ”

In the interest of science, there is an answer to the question (two answers, actually). The first is that stools float when there is a lot of undigested fat in them. The second is that I have no desire to touch, let alone look in your purse, and that I will trust your description of the malodorous event without feeling any need whatsoever to conduct any further investigation.

So what happens when the person with irregularity (polite term) comes into the ED? Most of the time we take an x-ray to demonstrate that there is in fact stool in the colon, and that there are no signs of bowel obstruction. (Every scenario has an ED nightmare we try to avoid, and writing off an obstruction as constipation is the risk element here.) Back when x-rays were printed out on acetate films, you could hand-carry the snapshot up to the patient, hold the film up the light, and show them the pebbly cylinders that go up, around, and down in a reasonable imitation of a tuba. Now that everything is digital and the films can’t be lifted from the computer screen, patients just have to trust you when you tell them that they’re really full of…it. (Which reminds me of several jokes that I can’t tell you.)

Then there’s therapy. The United States is an action-oriented society, and when we want our bowels to move we want them to move yesterday. Traditional stool softeners, such as fiber, fruits, and increasing physical activity, do not fit our lifestyle. So we want powerful agents, and lots of them; agents that let us know they’re working not just through the production of the desired product, but through the suffering that lets us know we’re cleansing both the bowel and the soul.

So my prescription for those who want action, and lots of it, is a preparation called Go-Lytely. It comes in a gallon jug, which more than satisfies the American desire to supersize everything in sight. (Including the output.) This solution acts by drawing more fluid into the bowels through the process of osmosis. As fluid enters the colon it not only helps to soften the stools, but the resulting distension of the bowel lumen stimulates peristalsis to help expel the intestinal contents. (Got that? There's going to be a quiz.)

Personally, I think the brand name Go-Lytely represents one of the most creative marketing ploys ever unveiled on the face of this earth. Go-Lytely does no such thing. The person who takes it goes heavily, goes forcefully, and goes quickly in an eruptive fashion reminiscent of Mt. St. Helens (or, if you prefer a classical analogy, like Vesuvius). From what I’m told, it’s a miserable few hours. On the other hand, after the potion has done it’s duty, I understand there’s a sense of completion, a lightness of being, and state of happy exhaustion like that which overtakes one who’s done a good day’s work.

I may need to try this someday, especially as I push closer to fifty and the inevitable colonoscopy begins to rear (no pun intended) it’s head. But I’m honestly still working up to it, partially because I dislike pain, partially because I’m not sure I’ve got enough reading material to peruse while the vile agent does it’s work, and partially because I fear I’ll end up like the last excreting Kansan who made national news (“Kansas Police: Woman Pried From Boyfriend's Toilet After Sitting on It for 2 Years,” Associated Press, March 12, 2008.)

You know, I think I’ll keep a stick handy as well.

Villian Comparison: The Child Speaks!

VILLIAN COMPARISON

I am The Child, as commonly referred to on my dad`s blog. I am now twelve, and have gained permission to write on my dad`s blog. I promise that this blog will keep you entertained through the times. This column shall contain such myriad subjects as Candy, Neopets, puppies, yo-yo tricks, and…..

Um, this guy.-------

To start with, villain comparisons. This will list my favorite bad guys of all time, and their rating from 1 to 10.

Sepulchere: Found in the game DragonFable, this bad boy carries a doom blade and has a penchant for destruction. He also tries to rule the earth, but it doesn`t seem to work out, now does it?

Evil Rating: 9 out of ten. Who can resist a DOOM-blade wielding doom knight?

Drakkath: Sepulchere`s evil minion in DragonFable, and his slayer in Adventure Quest Worlds, this chaos lord-in-training never knew he was going to be his master`s killer!

Evil rating (normal): 4 out of ten. Just a worthless pile of scraps, really.
Evil rating (chaos): 10 out of ten. The chaos powers he suddenly gets are AWESOME. I mean, he beat the lord of evil himself.

Gravelyn: The daughter of Sepulchere, and also his best kept secret, Gravelyn is only a girl, but she vows to finish what her father started after Chaos Drakkath is gone!

Evil rating: 7 out of ten. Just a girl, but not a bad evil ruler.

Gnats: Blasted things! Can`t they just bug someone else for once?

Evil rating: 8 out of ten. I HATE GNATS!

Zorbak: The all-mighty Moglin wizard himself, creator of the dreaded Undead Kitten! Brothers with the dreaded Kabroz, who just hate each other. Oh, the irony.

Evil rating: 6 out of ten. He`s so narcissistic. Only cares about his little blue self. Sheesh.

Xan: An insane pyromancer, wanting to torch stuff for no apparent reason. And what`s with the flaming skull? That`s overkill. But he DOES have cool fire powers.

Evil rating: 8 out of ten. He`s powerful, and pretty cool too.

Sir Malifact: A cursed knight, he fell under a dark spell. In return for great power, he became a doom knight bent on destruction! Very powerful and dangerous.

Evil rating: 7 out of ten. He used to be a good guy, you know.

Twig: The EVIL moglin who loves fish and ice cream. Has a dreaded ice cream blast, and can summon whales. Very stupid, but dangerous. Keep your distance.

Evil rating: 10 out of ten. He`s awesome. Need I say more?

Deady: The most powerful evil ever, he comes from the planet Necros, which he blew up. Very, well, deadly. Anger courses through his stuffed body.

Evil rating: 17 out of ten. The awesomest thing since Adventure Quest Worlds!

Perspective

Mr. Baskin came in yesterday with a mass in his neck. He’s 42 years old, smokes a pack of cigarettes each day, and drinks a beer three to four times a week. It’s getting harder for him to swallow. He works hard for a living as a laborer and tends bar part-time to make ends meet. He has no insurance and has yet to see a doctor for this. He’s not eating and has lost twenty pounds over the last year. He’s got a large, rock-hard growth under the skin on the left side of his neck. It’s lumpy, irregular, and fixed to the underlying tissue. Looking into his mouth you see that something under the skin is trying to push his left tonsil out of place. Everything screams bad. I walk out of the room and look at the nurse, who has seen the same things. “He’s going to die, isn’t he?” she asks as a statement of fact. And because his exam is what it is, and because one of the prime rules of emergency medicine is “Nice people get bad disease; dirtballs live forever,” I simply look back at her and nod.

If you have insurance, what I do is arrange an outpatient CT-guided needle biopsy of your neck mass by radiology, and set you up to follow-up a few days after the procedure with an ENT for the results. If you’re uninsured, I tell you that at our hospital we care for anyone regardless of money, and admit you to have the procedure done so you don’t fall through the cracks of the system. And either way I have to tell you, a person who I’ve just met and who doesn’t have any reason to know or trust me, about the thing on your neck. I tell you I can’t be sure exactly what it is. It might be some infection or some glands might be inflamed, or it might be a growth of some kind like a tumor. I explain to you that the best way to find out is to have someone take a piece out of it and look at it under the microscope. You don’t understand, but then you do. Your eyes get wide, and when I ask if you have any questions you shake your head for no reason other than something to do.

I have no idea how health care reform would affect him. I have no idea if his employer would carry insurance or opt to pay a fine. I have no idea if he would opt to take the subsidy to buy insurance or choose to pay a fine. I have no idea if he even works for a salary or works for cash. I have no idea if he could have a doctor to see him weeks or months ago no matter what kind of coverage he has. And in the end, it really doesn’t matter. First he’s going to undergo an operation, to be followed by radiation therapy which will dry out his mouth and cause painful ulcerations. Later, when the cancer comes back as they always do, he’ll have a laryngectomy and use an artificial voice box. Over time he’ll be unable to swallow and need a tube in his stomach for food and water, and the only thing he'll be able to put in his mouth are soft plastic swabs saturated with lemon-flavored glycerin solution and an occasional ice chip. And despite all this, the best care anyone has to offer, he’s still going to die.

Health care has very little to do with policy and politics and insurance plans.

Health care is a 42 year old man who’s going to suffer and die and you can’t do a damn thing about it.

The Nose Knows

I’ve had people ask me from time to time what doctors actually talk about in the ED. I think the assumption is that, just like on television, we spend most of our time either talking about difficult cases, weighing critical medical decisions, or discussing relationships. The truth is much, much stranger than you ever thought.

Here’s what passes for intellectual conversation one day last week. One of my colleagues was trying to dictate the medical record of a patient with a nosebleed. Just for the record, nosebleeds (“epistaxis,” from the Greek meaning “really disgusting”) are one of the least favorite things to care for in the ED. I don’t know anyone who thinks it’s an interesting clinical challenge, and I think it’s because nosebleed’s don’t just bleed. They bleed in a particularly unpleasant fashion. Blood by itself is really pretty innocuous...a little thicker than water, it has a little sheen to look at it and slickness to the touch, but you get it on your gloves and you move on. (If fact, in some cases of vaginal bleeding you’ll intentionally break up a blood clot with your fingers to look for fetal tissues suggesting a miscarriage.) With a nosebleed, however, you get blood mixed with snot (“mucus,” from the Latin “also disgusting”) which results in a product of varying shades, the consistency of snail traces, and a tendency to stick to everything worse than internists on old people (there’s a reason that specialists in general internal medicine are known as “fleas”). Add to it that when this stuff comes out of the nose, it either flows down the back of the throat and results in gagging and occasional retching of the nasal blood and mucous plus stomach contents, or (if you’re in just the right place) it comes out the front, punctuated with sneezes seemingly designed to cause maximum damage to the physician, who is inevitably standing in front of the patient trying to see where the bleeding’s coming from at that exact moment.

Treatment just adds to the fun. Fortunately, the bleeding often stops on it’s own. Rarely you’ll be able to see the bleeding spot along the nasal septum and cauterize it with silver nitrate. More severe bleeding comes from the back of the nasal cavity, and can’t be seen by the physician without the special tools and toys of the ENT specialist. So to get the bleeding to stop, the ED doc goes on a fishing expedition which essentially consists of jamming things…pieces of foam, plastic balloons…of increasing discomfort into the nose until the bleeding stops. And you’re doing this in the face of continued hemomucoid (“blood and pus” from the Arabic, “that’s bound to ruin your shirt”) expulsions directly towards the operator, who has to lean into the line of fire to see what he or she is doing.

At this point, the patient will be in pain (it hurts to have stuff jammed into your nose), and will feel short of breath because they can now use only one nasal passage instead of the requisite two. They don’t like you very much for what you did, and you’re not too enamored of them for making you do it. Hopefully, though, the bleeding will stop. If it does, you call the ENT and arrange follow-up for the next day, because if someone’s going to pull that stuff out of the nose and make it bleed again it sure isn’t gonna be you. If it doesn’t, you drag the ENT out of bed. (To be fair, I will say that ENT physicians so rarely have to come to the ED that when they do, they actually have a pretty good attitude about it. The chance for them to do something acute makes them feel like they’re a golden retriever and you’ve just thrown them a new red rubber ball.)

So anyway, the other doctor is trying to dictate this chart and is trying to figure out the right adjectives to describe the nosebleed. This got us started on all the different adjectives that can be used to describe bodily fluids and the ways they emerge from the body. This became a large-scale discussion involving the entire health care team in a management-friendly collaborative process. The only rule was that it had to be an adjective that you might actually hear used, not something like “paralleling the national debt” to describe a volume of fluid. (Please note that we’re talking adjectives here. The fluids themselves are nouns. You can combine two nouns to make it an adjective…for example, a mixture of mucus and pus can be described as mucopustular… but we thought that was cheating.)

At the end of the day, we decided that there were really four categories we could use to describe bodily fluids:

Amount: Scant, rare, mild, moderate, large, copious, voluminous, massive, elephantine. (Nobody really uses elephantine. I just wanted to see if you were paying attention.)

Rate: Oozing, dripping, steady, profuse, gushing.

Quality: Clear, discolored, purulent, creamy, thick, viscous, foamy, frothy, foul-smelling, feculent, phlegmatic, gooey. (I would personally never use the latter term, because it would permanently ruin Starburst and Japanese Rice Candies and Jujyfruits for me for life. But I actually know a physician who uses that term…copiously.)

Method: Pulsatile, spurting, projective, explosive.

Taking these general categories, one can mix and match to describe the clinical fluid of their choice. (I actually started to write some examples here, but as I did I began to lose my appetite. I’ll let you string together some examples of your own and you’ll get the general idea. “Feculent,” “copious,” and “explosive” is particularly queasy combination.)

In my continuing quest for medical immortality, I would like this system to be known as the “Rodenberg-Other People Adjectival Classification of Bodily Fluids (ROPA-CBF).” I look forward to it’s immediate inclusion in curricula everywhere. And thank you for your support.

The Clown Car and Health Care Reform

The recent passage of the House of Representatives version of health care reform has got me thinking about the clown cars at the circus. (And no, the joke is not what you’re thinking. That one is waaaay too easy, and I like to feel like I’ve worked for my laughs. Besides, that’s not really a joke, but merely a statement of fact, just like I’ve heard it said that the mother-in-law joke is not really a joke, but a very serious question.) Thoughts of health care reform brought me to the circus because I always wondered who was driving the car. With so many clowns packed into such a small space, there seemed to be no way that a single clown had enough space to work all the controls. And while it seems to be obvious who’s driving health care reform, and who’s trying to stand in its way, it seems much less plain who actually drives the health care system.

(I think the other, subconscious influence on me might have been that I always seem to have a Schoolhouse Rock song percolating about in my head, and lately its’ been “Three Ring Government.” Schoolhouse Rock is why I also know that interjections show EXCITEMENT or EMOTION and are usually set apart from a sentence by an exclamation point, or by a comma when the feeling’s not as strong. It’s also why I know that legislative bills often wander around the Halls of Congress on their little legs in a state of semi-permanent depression.)

(Incidentally, in the course of writing this blog I also did some research into the history of the Clown Car. It turns out that the gag was first performed at the Cole Brother’s Circus in the 1950’s. Opinions vary on how it’s done. Most references say that the car parks over a trapdoor in the floor of the ring that’s covered with hay or straw, and that the wild actions of the disgorged clowns distract the audience from looking down. Others describe a hollow shell with ledges and grab-ons that allow the clowns to hold on and fit themselves in the car. But what I found more interesting was that the term “clown car” is now used to refer to a particularly fertile woman, such as the “Octo-Mom.” No comment needed, I think.)

Under most circumstances, the question of who’s in charge is actually a pretty easy one. It just depends on who you ask and who’s the villain de jour. The folks driving the car can be the evil insurance companies who charge high premiums for great profit and little return. It might be the government who provides too many benefits, too few benefits, or not enough for me and too many for you. It might be lawyers that force doctors to raise costs and shy away from complicated patients by practicing defensive medicine. (I’m still trying to figure out exactly how terms like 4-3, Zone, and Cover 2 apply to clinical practice.) It might be doctors who shun the care the uninsured to line their own pockets. It might be the administrators whose very existence depends on the proliferation of paperwork that takes time and resources away from medical care. It might be the bean counters for whom patients and medical staff are nothing more than cost centers, and who worship at the Altar of Profit, or at Least Solvency, to the idol of the Third-Party Payer. It might be drug companies and makers of medical devices, who coax doctors to prescribe expensive medications and cajole consumers with slick television ads. It might be unscrupulous health care providers and agents fraudulently milking the system. It might be societal expectations themselves that place an emphasis on the use of technology rather than thought and reason, assumptions that demand immediate satisfaction and flawless performance in an inherently inexact art. (I actually have no problem buying into the latter rationale. At a very basic level, I believe that our attitudes towards health are driven not by a particular individual or institution, but reflect, for better or worse, what we expect of society as a whole.)

But figuring out who’s in charge of the health care system is more than an exercise in blame. Thinking hard about the issue rather than relying on the blame game is key to determining where the most effective interventions within the system might be.

A number of years ago I did some part-time work for hospitals as a physician documentation consultant. In essence, my job was to remind doctors to actually write down on the chart the things they were thinking. Physicians work with a lot of commonly understood but unstated assumptions about patient care. For example, if we say that a patient has come to the ED complaining of pressure-like chest pain and shortness of breath on exertion, virtually every ED doc will have the same three or four things on his mental short list of likely causes. But because these thoughts are a given in daily use, we tend not to write things down so there’s no track record of the thought process nor of the work that goes into the cognitive part of care. Entering these thoughts within the medical record provides a much clearer picture of care for utilization review, quality improvement, physician profiling, and risk management activities.

While I’d like to think these are good and valued goals in their own right, the reason I got paid for doing this is because hospital reimbursement Medicare Part A is based on something called a Diagnosis Related Group (DRG). A DRG is a group of diagnosis within the same organ system that share a similar intensity in the use of hospital resources, and therefore are reimbursed at the same level regardless of actual cost to the hospital. The hospital that provides care at less cost than the DRG will reimburse makes money; the facility whose costs exceed the DRG payment suffers a loss.

DRG assignment is based on review of the medical record for the physician’s documentation of the principal diagnosis (the main reason the patient was admitted) and notation of any accompanying complex medical conditions (comorbidities) or complications of care which can drive up the intensity of the provided hospital services. Successfully maximizing reimbursement requires the physician, and no one else, to fully and completely document the clinical status of the patient in the medical record. For example, clinicians are well aware that pneumonia in nursing home patients (especially those with swallowing difficulties after a stroke or who feeding tubes in place) is often due to aspiration of stomach contents into the lungs. Patients with these kinds of pneumonias often stay in the hospital longer, and have more complex medical issues, than other patients with pneumonia from a different cause. But if all you write down in the medical record is a diagnosis of “pneumonia,” the hospital is reimbursed a set amount regardless of the cause. Of you take a further step and document that the patient has “aspiration pneumonia,” payment increases. And if you also note in the record that the patient has concomitant chronic renal failure or uncontrolled diabetes, reimbursement rises again. The key is that the physician has to write down what’s going on. (Those of you “in the know” will recognize that this is a slightly dated and very simplistic explanation of the system, but please bear with me for the sake of argument.)

But what came to me as I was doing this work is that despite the many outside interlopers nibbling at their heels, it seemed like from a day-to-day, operational view, physicians still actually ran the health care system. In the very narrow sense of the work I did, physician documentation drove reimbursement. But what drove the costs was the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And I think this concept of the doctor in charge plays out in a larger sense as well. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, paperwork is not completed, without the doctor starting the chain of events.

(I should note that I believe this not because I happen to have an MD after my name, but because it makes intuitive sense. Nothing gets done in health care without a physician either ordering a test or treatment or passively consenting to the demands of others. And as far as the MD goes, I’m of the belief that outside of the hospital, the abbreviation rarely needs to be unveiled. The only indication I have of my degree in the house…my diplomas are somewhere in the garage, because the Residential Cat isn’t easily impressed and The Child considers my educational achievements as minimal compensation for the fact that I have not memorized the plot of every episode of “Chowder” ever aired…is a framed poem called “My Daddy, MD” whose first verse reads, “Whenever Daddy signs his name he always signs MD; so everyone will know, that he belongs to me.” Okay, it’s syrupy, but I like it. Yet I thought it was well over the top…or under the ground...when I was visiting a cemetery once to find that a head stone was engraved with “Richard Barber, MD.” I would think at that point, it probably doesn’t matter. Does heaven really have special, close-in parking lots for doctors?)

So if physicians are driving the clown car, are they necessarily the cause of this mess we call health care in America? I really don’t think so. Driving the clown car over the trap door is probably the most crucial part of pulling off the gag, and the driver has to be able to do his job to the best of his ability despite all the hangers-on who want in on the show. And while the doctor may drive the car, the car itself is provided by the circus, and once the door is open the success of the act depends on the mercy of the rest of the clowns.

So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. Here’s an example. I recently read a study that said that only 20% of physicians in the US will accept Medicaid patient into their practice by choice. Another 20% refuse to do so. The remaining 60% see Medicaid patients not by choice, but when they have to, such as when being on call at a hospital. We already know that it’s difficult for Medicaid patients to get into physician’s offices. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician? Or that physicians will flock to see patients on “public option” programs with undefined reimbursement rates, especially when whatever revenue the physician makes from these is offset by higher taxes and by cuts in Medicare rates?

I recognize that this runs very close to the border of saying that doctors are nothing but mercenaries. But if any of us running a small business had widgets to sell, and one group of customers were willing to pay a higher price for the widgets, wouldn’t you preferentially sell to the higher-paying group? Of course you would, and you’d be entirely within your rights to do so. And until we abandon any vestige of the status quo, put all physicians on salary, and have a single payer system, that is the way it will continue to be. (That being said, I think most physicians recognize that part of their charge is to help those in need. I even once heard a cardiologist I personally dislike as a human being…and referring to him as "human" is pushing it…take another doctor to task for refusing an uninsured consult in the hospital. “Ten percent of everything we do ought to be for free," he said. "It’s not like you don’t have food or your kid’s not going to college.” However, there is a world of difference between giving away 10% of your work…your “societal tithe,” as it were…and greater amounts. There are some studies that show ED physicians often give away over half the care they provide. I’d be quite happy to have that time, and money, back.)

So it seems to me that if we really want to achieve health care reform within the current context…and that includes not only expanding insurance coverage, but also getting patients the care they need…we should focus less on the payment plans and more on the physician. We need to find ways to get patients into the physician offices, and to make sure they get the care they need. Unfortunately the simple solutions are not very helpful. For example, I’ve heard people say that physicians should be required to accept Medicaid or unfunded patients into their practice as a requirement of licensure. But how exactly does that work? The burden will clearly fall more on primary care physicians than specialists, which is inherently unequal. And if we already have an epidemic of medical school graduates opting out of primary care to go into high-technology, high-revenue, stable lifestyle specialties, how will this practice impact care in the long run? And enforcement seems to be a problem as well. Will there be “financial police” to audit doctor’s office and decide if they’ve seen enough Medicaid patients or not? And while we might be able to entice physicians by raising reimbursement rates for patients on public assistance, what does that do to the goal of controling costs?

Crafting real solutions based on the key role of the physician requires more than a knee-jerk reaction. It needs to include a realistic assessment of why, despite the strong tradition of service to all, physicians choose to restrict their practices to certain patient groups. (There is more…a lot more…in play than just money.) It needs to include an evaluation of if there are, in fact, enough physicians in the right places and the right specialties to achieve the overall health care goals for the nation. And it needs to identify a set of operational, clinical, and financial incentives designed to entice physicians into providing care for patients who will now be covered by new expansions of Medicaid and “public option” programs, as well as to provide care to that percentage of the population who will remain uninsured.

Send in the clowns.