Wednesday, March 9, 2016
Are high-deductible health plans working?
May I whine for a few sentences please? My staff and I have a high-deductible medical insurance plan. As the costs of coverage increased each year, we had to find a product that we could afford for our small private practice. As any small business owner knows, margins are tight, revenue is declining, and expenses inexorably rise. And physicians, unlike other retailers, cannot raise our fees. Would you want to invest in a company with this business model? If so, then contact me directly.
High-deductibles health plans are painful for consumers. The first several thousand dollars are borne by the individual. While we have a Health Savings Account (HSA), which confers a tax advantage, it is still painful to fork over wads of one's wages to cover medical expenses. Isn't that what medical insurance is supposed to do?
Would we expect fire insurance to cover only part of our house if it burned down?
But, I recognize that high-deductible health plans are an effective means to combat over-diagnosis and over-treatment, 2 of the deepest systemic failings in the medical profession. Indeed, highlighting these 2 practices has been a leitmotif of this blog. I have repeated in multiple posts my belief that patients need to have skin in the game if cost-effective medicine is to be achieved.
Just this past week I have seen how this works.
A close acquaintance has been suffering from arm pain and consulted an orthopedist. A steroid injection was administered and the situation fortunately improved. The individual contacted the physician's office for additional advice and an MRI of the arm was advised. The patient replied that she would research area radiology facilities for pricing as this service would be out-of-pocket as she had a high deductible plan. Later, on reflection, the individual decided to hold off on the MRI, particularly as she was improving.
There's a lot we can learn in this vignette.
• It's easy for physicians to order tests that cost them nothing.
• It's easy for patients to accept tests that cost them nothing.
I'm sure that if my acquaintance had full coverage with no deductible, that she would have dutifully accepted the advice for an MRI. Why not? The doctor wants the test and it's free. However, if this patient has to shell out a thousand bucks to view the internal workings of an ailing arm that's making progress, there may be some push back. My personal belief is that this MRI was not only expensive, but was not medically necessary, a terrible combination that is responsible for so much rot in our health care system.
Of course, I realize the dangers of high-deductible plans. Indeed, many previously uninsured folks who have been “rescued” by Obamacare are now facing this predicament. Many of them forfeit medical care that they and their families need because they can't afford it. For so many families, a $5,000 deductible is like not having medical insurance at all. This has to be fixed, and it won't be easy.
Let me share an arcane law of economics. It's easier to spend someone else's money. Consider this example. When you are in a fancy restaurant, and someone else is paying, do you order differently?
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.