Many Americans assume that once they finally become eligible for Medicare, their worries about skyrocketing health care bills will be over. Unfortunately, that just isn’t the case.
According to Fidelity Investments a 65-year-old couple retiring this year should assume they will need approximately $240,000 to cover medical expenses in retirement— even though they have Medicare insurance coverage. This represents a 6.7 percent jump over Fidelity’s 2008 estimate of $225,000.
Just as in every other sector of our health care system, Medicare has been hit hard by the soaring cost of care. As a result, Medicare beneficiaries are paying more and more out of pocket. Some health care reformers suggest that because Medicare’s administrative costs are very low, the program is inexpensive. That just isn’t true—administrative costs represent a relatively small portion of total health care spending. As I have explained in earlier posts, overuse of advanced medical technologies bears primary responsibility for pushing medical bills heavenward.
This helps explain why, in just the past seven years, the amount a retired couple can expect to lay out in the form of co-pays, deductibles, out-of-pocket costs for prescription drugs, as well has certain services not covered by Medicare has jumped 50 percent, from $160,000 to $240,000.
Even if you’re not approaching retirement, it is worth understanding how much Medicare costs beneficiaries because the program is so often held up as a model for universal health insurance. It is important to recognize that Medicare is not free—far from it. And universal health insurance won’t be free either, even if a public-sector plan is available.
There will be subsidies for low-income families, but households earning over $70,000 or $80,000 will no doubt be expected to pay most, if not all, of their own premiums, co-pays and deductibles. Just how much they will have to shell out depends on how successful we are in eliminating unnecessary, ineffective and exorbitantly expensive tests, drugs and treatments from the system. We know that indiscriminate use of new tests, drugs and treatments on patients who don’t benefit is driving health care inflation.
But the truth is that many Americans are accustomed to being over-medicated, irradiated, sliced wide open and then sewn back up. Moreover, one man’s over-treatment is another man’s income stream. It won’t be easy to pass legislation that reins in spending, but the alternative is to create a national insurance program that will take an enormous bite out of the typical upper-middle-class family’s budget.
Medicare serves as a warning. It is fast becoming unaffordable for many seniors. Keep in mind that nearly half of all people on Medicare (48%) are making do on incomes below 200% of poverty ($20,800 for a single person and $28,000 for a couple in 2008.) Income includes Social Security as well as dividends, capital gains, salaries from part-time work—in short, every penny that comes into the house. For many, Medicare has become an enormous burden. We need to squeeze the waste out of Medicare, and use that more efficient, more effective program as the pattern for national health insurance.
Medicare, Medigap and Medicare Advantage
Medigap insurance fills some of the holes in Medicare insurance, and helps many seniors, but it, too, can be pricey. Seniors can choose from up to 12 different Medigap policies; the benefits are standardized but premiums and deductibles vary widely. Moreover, Medigap isn’t a very good value, as Marilyn Moon, a former trustee of the Medicare system tells the Columbia Journallism Review’s Trudy Lieberman in an interview that the Review published last week: “When people buy ‘Medigap’ insurance, on average they may be getting back only seventy-five cents worth of health care for every dollar they spend.
Administrative costs are also high,” warned Moon, who is now vice president of the American Institutes for Research, “But going without such coverage is risky since the basic Medicare package has no catastrophic protection for those with very high expenses. “ (Hat tip to Lieberman for a very informative interview on a subject that often is ignored. )
Many Americans are shocked to discover that if they are enrolled in traditional Medicare, there is no annual cap on how much they may have to spend out of pocket. The more services the beneficiary uses, the higher his expenses in the form of co-payments for outpatient care (usually 20 percent of the cost) and inpatient care. A $1,068 deductible covers your first 60 days in the hospital, but if you stay longer, you will be charged $267 a day from day 61 to day 90, and $534 per day from day 90 to 150–plus all costs after 150 days. Then seniors have to face the spiraling cost of prescription drugs. Even if you have Medicare Part D, the new program which provides coverage for medications, you can spend as much as $4,350 before the second half of Part D kicks in and covers 95 percent of any further drug bills.
Some retirees receive Medicare through a private insurer. But even these “Medicare Advantage” plans may or may not cap out-of pocket spending at $3,000 to $5,000 a year—and usually only certain services count toward the limit.
Bringing Down the Price of Medicare
In her interview with the Columbia Journalism Review, Moon offers some suggestions for making Medicare more affordable. First, “if Medicare is an insurance plan, then it must cap the amount that people spend on their own, just as there is a limit on out-of-pocket spending offered by most good commercial insurance policies,” Moon observes.
Secondly “Deductibles should be combined. People pay a separate deductible for physician and outpatient care and a very high deductible for hospital services, now over $1,000 a year. Coinsurance amounts are confusing and vary by type of service. Until you simplify the basic structure so that people don’t feel it’s necessary to buy supplemental coverage . . .If people know that they have one deductible, say $350, and modest coinsurance up to a limit of perhaps $4000 they would pay out of pocket, then they can decide whether they want supplemental [Medigap] coverage,” Moon explains. “That would help them decide how much added protection they need, and at what cost.”
Moon acknowledges that, today, “almost no one” is talking about these reforms. “But when health reform discussions begin about what a basic benefit package would look like for younger families, it will become obvious that Medicare is lagging behind, and politicians will take notice.”
At that point, Medicare will probably put a lid out-of-pocket spending. But how will the program pay for the change? Medicare is running out of money: “The program actuaries projected that the hospital trust fund, which pays for hospital benefits, will be out of money by 2019. With the downturn in the economy,” Moon notes, “that date is likely to move up by several years when new projections are issued this spring. Payroll taxes, which now fund those benefits, will be too low to pay for all the care people will need, causing a shortfall. To keep hospital benefits people have now, the trust fund needs new revenue.”
President Obama has proposed cutting payments to Medicare Advantage insurers and reducing reimbursements to hospitals, based on outcomes. But that won’t save enough to make Medicare sustainable, says Moon. “The system will still need new money. Over the long run, you need to change the way health care is delivered, and it will be quite a while before spending slows, even if some of the ‘fixes’ people discuss are successful. Until we . . . find a way to dramatically slow the growth of spending, this problem will not go away. We just delay fixing it.
Solutions involve making hard choices. Moon is blunt: “Either taxpayers or beneficiaries pay more, or providers of care get paid less or do less. Most groups hate at least one of the options, so there’s really no consensus.”
“Rising costs are not a Medicare problem but a health system problem,” she adds. “We have not been willing to make sure we are getting value for the dollars we spend. We have not been spending money wisely. Until everyone—providers, patients, and others who have a stake in manufacturing drugs, devices, new treatments—becomes realistic in what the system will bear, we are not going to see any reduction in the growth of health care spending.”
When Lieberman asks whether “paying providers based on the quality of care they deliver is
likely to solve the financial distress?” Moon replies: “That can only work in a large institution like a hospital, and even there it will take time” As I have argued in the past on Health Beat, “It’s difficult to do at the physician level. We don’t have good measures of good quality of physician visits . . .”
By contrast, steering patients away from their local hospital and toward “Centers of Excellence” that tend to do a very high volume of a particular procedure could reap significant savings. “If they are very good at a particular surgery, for example, they may create fewer complications that ultimately raise costs,” Moon explains. Though she admits, the idea of having to travel away to a Center of Excellence has “not always been a big hit with patients.” Patients need to learn more about the rate of errors and infections in the average hospital; this might make them more willing to leave home.
Finally, some have suggested that Medicare should raise funds making wealthier beneficiaries pay more for Part D, the Medicare drug benefit. But Moon disagrees: “This is another step that unnecessarily complicates the program, and making wealthier beneficiaries pay more will not raise that much money. This is similar to the provision that requires individuals with incomes over $80,000 (families over $160,000) to pay more for Part B benefits—those that cover doctor services. If there’s a similar income cut-off, it will not affect that many people, since there are just not a large number of high-income seniors.”
At the same time, it could weaken Medicare. “If we make the premiums high enough,” Moon points out, “some wealthy beneficiaries will opt out of Medicare, and go elsewhere for insurance.” This would undermine national support for Medicare—ultimately, it would be likely to become a poor program for the poor and the middle-class—much like Medicaid.
If people age fifty-five to sixty-four were allowed to buy into Medicare, that could raise some money. But there is a real danger that most 50-somethings would stick with the private insurance they have now—and only turn to Medicare when they became very sick. If that happened, the cost to Medicare could sky-rocket. “That could mean higher payroll taxes, which many people believe are unnecessary,” Moon observes.
Finally, there is the question of removing fraud and waste from the Medicare program. “We know that there is fraud on the part of doctors and hospitals that game the system, ” Moon acknowledges “and that should be aggressively handled. The issues of waste and abuse are more subtle. Was a particular treatment or test necessary, or was it wasted money? Sometimes we can judge that only after the fact. One person’s waste is another’s valued benefit. We need to know much more about what works and what doesn’t. “
As I’ve discussed on Health Beat in the past, while we have some good comparative research, it will require what Moon calls “an investment in research and communication,” to change the system. “It will take time,” she says. Patients need to be educated. American hate to be told “No.” But “the public needs to realize that refusing to insure certain tests and treatments that do not work is a good approach, not a bad one.”
In the end, Moon stresses the connection between Medicare and national health insurance. Journalists interested in health reform should take a hard “look at the lessons of Medicare—both the good and the bad,” says Moon. “Health reformers can learn from Medicare as they craft a health reform proposal.”
My guess is that serious Medicare reform will begin this year: everyone should pay attention because it will provide important clues as to where national heath insurance is headed.
The problem I think we have here, both with respect to Medicare and the broader healthcare system is a culture of entitlement and selfishness. Patients and their families think they should get any intervention that might possibly do some good whether it’s a prescription, an imaging test, a surgical procedure or heroic end of life care. If more money is needed to support the system, we just need to tax a small population of high income and wealthy people more. Doctors want to please patients and avoid lawsuits. So, they tend to overtreat because they suffer no adverse financial consequences for doing so and perceive risks (from lawsuits) if they don’t. Often they benefit financially as well. Many hospitals treat patients more intensively than they need to and, more often than not, get paid more for doing so. Drug and device manufacturers want to sell product and make profits. They don’t want comparative effectiveness research to get in the way of that. Insurers want to avoid covering sick people and trial lawyers cling to the capricious jury system for settling medical disputes. There is plenty of fraud in the durable medical equipment and home health segments, along with unnecessary treatments in nursing homes that are intended to drive revenue, even when it’s clear that the patient won’t benefit.
At the same time, all of these stakeholder groups will meet in Washington and agree that we need to reform the system and vow to work together on a bipartisan basis to do so. In the next breath, they say, in effect, whatever you do, DON’T CUT ME. Everyone wants to solve the problem at someone else’s expense. It won’t work.
By contrast, the UK has a different culture. They long ago reached a societal consensus to spend a smaller percentage of GDP on healthcare than even most of their European counterparts, let alone the U.S. As I understand it, the system is, in effect, one giant HMO. It’s virtually impossible to see a specialist without going through a GP (PCP here) first. You probably won’t get the referral unless the GP is absolutely convinced that you need one. His bias is toward saving money and not aggressive treatment. The country has an organization called NICE that uses QALY metrics to make coverage decisions and help determine how much to pay for new drugs and devices if they are covered at all. Other care, like dialysis, is rationed by age. While none of this would be acceptable in the U.S. (yet), it illustrates some of the tough choices that need to be made if the society is serious about controlling healthcare costs.
Barry,
Very well said.
It is the idea that we can afford “excellent” care for all (advocated by some in this forum) that stands in the way of a good system.
We should have comparative effectiveness research and give it some teeth – no reimbursements for ineffective treatments or treatments with too little
“bang for the buck”.
We need some kind of malpractice reform so that physicians that practice cost effective medicine aren’t sued.
We need to confront the amount of care that we provide in the last 6 months of life – much of which only prolongs life minimally but does little to improve comfort.
I am pessimistic that we as a nation are willing and able to confront these issues head on. Much of the curent debate on health care reform (including on this forum) seems to be premised on the idea that “if we do this right, everyone will come out ahead”. It ain’t so.
And if the government persists on its course of cutting Medicare physician reimbursements (partly by not increasing them to cover inflation) you will see more and more physicians not taking Medicare. Watch what happens to out of pocket expenses and copays then.
Barry & Legacy Flyer–
Thanks for your commetns.
Barry–You write: “At the same time, all of these stakeholder groups will meet in Washington and agree that we need to reform the system and vow to work together on a bipartisan basis to do so. In the next breath, they say, in effect, whatever you do, DON’T CUT ME. Everyone wants to solve the problem at someone else’s expense. It won’t work.
“By contrast, the UK has a different culture . . ”
I totally agree.
Barry, often, when I respond to you, I say “But . . ” Here there is no “But.”
I cannot argue with your assessment.. Everone in the system–including patients–is reponsible for the problems, and everyone is going to have to give something up. (Patients just have to give up their attachment to overtreatment that exposes them to more risks than benefits.)
This doesn’t mean that patients have to give up effective care, but they are going to have to begin to understand that much of the care, tests, treatments they receive today are not effective.
Lebacy Flyer –
I don’t think Barry is saying we can’t afford “excellent” care for all–if we define excelent care as truly effective care.
But I’ll leave it to Barry to respond to you on his own,
For my part, I can only say that we have more than
two decades of health care resarch prooving that 1/3 of our healthcare dollars are wasted on superfluous, ineffective treatments. (see http://www.dartmouthatlas.org
You seem to agree that much money is wasted on ineffective treatments.
Follow thorugh on that ligc, read teh Dartmouth reserach, and it bcomes apparent that we can afford to evoer everyone if we cut back on over-treament.
This will take time– a long time to make the cultural shfit.
But it will happen–in part because we, as a nation, we are no longer rich enough to squander billions by overypaing for health care, and paying for ineffective, unproven care.
Maggie,
I think we are actually very close in what we believe should happen, but we are separated in how it should be described.
“I don’t think Barry is saying we can’t afford “excellent” care for all — if we define excellent care as truly effective care.”
I am sure that George Orwell (author of “Politics and the English Language”) would have a field day with your statement that we can have “excellent” care for all if we only re-define what excellent means.
But if we use the conventional meaning of excellent, we cannot afford “excellent” healthcare for everyone anymore than we can afford excellent education, housing, transportation, for everyone. I do think we can afford good health care for everyone and that should be our goal. And in my opinion, the search for excellent healthcare for everyone (which is unobtainable) detracts from our ability to provide good healthcare for everyone.
Let me tell you how the rubber actually meets the road – at least in my specialty. I work in diagnostic imaging and like many other people believe that it is overused. But there is no bright and shining line that separates an “indicated” or “cost effective” test from one which is not. Put another way, if we can detect 90% of a condition for $100, 95% for $500, 98% for $5,000 and 99% for $20,000 – where is the cutoff ? (this is a realistic calculation and I can give you many examples of this scenario)
In this setting, the search for “excellence” would dictate that we spare no effort to detect a treatable condition. (And if human life is priceless, then there is no test that is not indicated if it has ANY chance of detecting a treatable condition.) But how does it play out in court if a doctor chooses not to order a particular study and the patient ends up having the condition? – those that benefited from the physicians action in not ordering the test (insurance policy holders, taxpayers, etc.) are not represented, but those that are hurt are. Physicians soon learn that using discretion and trying to avoid “unindicated” tests while risking a lawsuit is a fool’s errand.
What needs to happen is that we need to explicity state that what we can provide has limits – we CANNOT provide excellent care for everyone, but we can provide GOOD care for everyone. (Alternatively, we can play games by re-defining the word excellent) We need to get good data to determine what the effective tests and treatments are and furthermore where the appropriate cutoff is. And then we need to SUPPORT our physicians on the front lines if they follow the guidelines.
I agree with you: “This will take time — a long time to make the cultural shift.”
I wish I was as optimistic as you about the eventual result: “But it will happen–in part because we, as a nation, we are no longer rich enough to squander billions by overpaying for health care, and paying for ineffective, unproven care.” I have been watching this a long time and things are getting worse with respect to “unindicated” tests and treatments, not better. I think a more likely response is across the board cuts that does not distinguish the wheat from the chaff – this appears to have been the governments primary approach up until now.
As both a term and a target, I prefer “good” or “good enough” care to “excellent.” I think for too many people, “excellent” means whatever I want when I want it with little or no out-of-pocket cost.
In my perfect world, the healthcare system would work something like this:
1. To the extent that we can identify specific tests, procedures, treatments, drugs and devices that are not cost-effective based on a reasonable QALY metric or some other appropriate criteria, we won’t pay for or cover them with insurance, either public or private. Patients who want those can self-pay if they can afford to.
2. End of life care will be governed by common sense and by what other developed countries define as good, sound medical practice. This means that everyone gets pain treated as aggressively as they like but we won’t perform surgical interventions or treat late stage cancer or provide kidney dialysis to elderly patients with advanced Alzheimer’s or dementia. People should be encouraged to execute living wills or advance directives to state what they want and don’t want even though it won’t and can’t cover every possible circumstance.
3. For all other care, I want my doctor to treat me with the following mentality: I want you to use your accumulated expertise and experience to deal with my medical issue(s) as well as you can. Compassion and courtesy are very desirable traits as is respect for my time (waiting to be seen). I don’t want you to practice defensive medicine. Pretend I am a member of your own family and you are paying the entire bill out of your own pocket. The probability that I will sue you for failure to diagnose a disease or condition because you practiced evidence based cost-effective care is ZERO. If the test will provide no or minimal value, don’t order it.
4. The medical tort system will be changed to fully protect doctors from inappropriate lawsuits if they practice cost-effective, evidence based medicine.
5. It would also be helpful if the medical profession did a better job of weeding out the very small number of doctors who account for a disproportionate share of malpractice.
6. Widespread adoption of electronic medical records will provide critical infrastructure to help us to better understand what works and what doesn’t as well as reduce duplicate testing and adverse drug interactions, especially in hospitals. It will be supplemented by ongoing comparative effectiveness research.
The financing of health insurance is a whole separate issue. The key issues, in my opinion, are (1) should there be a public insurance option and, if so, how would it be structured and (2) how far up the income distribution should we subsidize the purchase of insurance and how generous should the subsidies be. The importance of the need to bend the medical cost growth curve down toward what the society can afford and sustain suggests that our primary focus should be there.
Barry wrote:
“I want you to use your accumulated expertise and experience to deal with my medical issue(s) as well as you can.”
————–
IMO, you are not defining good care up front for all to see, and are thus opening the over treatment arena encouraged by fee for service medicine!
Can this alone overcome the conscious and subconscious incentives of a fee for service payment system?? I think not, so you must add another layer of incentives to overcome the subjective over treatment incentives. Now if you do define good care upfront no matter how providers are paid, then you statement above becomes unnecessary!
Barry,
Your ideas are already the way they practice medicine in MN and WI, which is why it is comparable to the rest of the world.
The idea that there is a small number of bad doctors that account for a large proportion of malpractice is Trial Lawyer myth. A very small number of specialties OB, ER, Neurosurgy, Radiology provide the vast majority of the advanced care we think of as modern medicine. They are also involved in all of its attendant disasters. The reason that “a small number of…” is because the awards in our jackpot system can be gigantic in a few cases which then dominate the total payout for that year. You might as well say that the largest awards are typically a large fraction of the total. Example: a recent CP case won, and that is the right word, $80 M from a jury. That is a big fraction of the total MA awards for the year. And this for a genetic disease! Evidence based is just to lower doctor pay, not to provide protection in court.
once again the analytic community (y’all) is swimming upstream against voter preferences. there was a medicare catastrophic law that protected against the devasting expenses you speak of here. it was repealed. medicare was subsequently expanded to include a drug benefit (which was also in the short-lived catastrophic bill) that provides first dollar coverage, a violation of the most basic insurance principle. so we have a program that pays modest prescription costs but cuts people with catastrophic illnesses loose. one could construe that as the machinations of an evil system that wanted to avoid such big payouts, but the sad reality is that is reflects public priorities.
The premiums for Medicare are too high?
What are you talking about?
They are a bargain!
Part A costs beneficiaries nothing, while Parts B and D cost only 25% of the actual premium.
What do you want, a 90% discount?
Don Levit
Jim wrote:
“once again the analytic community (y’all) is swimming upstream against voter preferences.”
———
Yup! In that vein of thought, I believe we need to decide if healthcare is a public good or an individual good only subject to caveat emptor rules and to what you can afford. If the latter, then you only get what you can contract/afford to buy. If the former, then the analytical types among us must be given some heed!
Legacy Flyer, Barry, NG, Christopher, Jim
Thanks for your comments.
Legacy Flyer–
I agree that we need cut-offs. But rather than defining cut-offs in terms of cost, I would define cut-offs in terms of risks.
Evey test carries some risks (usually risk of a false positive and unnecessary anxiety, but sometimes unncessary treatment in the form of a biopsy, or even a unncessary lumpectomy if the test discovers
very small breast lesion that would have disappeared if not detected.)
I would look at “number needed to test” to save one person’s life and the number of people likely to wind up with unncessary treatment because a test was finding “pseudo disease” (that would never develop or would disappear.)
On that basis, I would say that “average risk” women don’t need MRI breast scans. The risk that the test will find tiny lesions that lead to unnecessary treatment is too high.
On the other hand, I would fund MRI breast scans for women at high risk (mother died of breast cancer, etc.) whatever their income level.
That would seem to me to be providing “excellent” care for both the average-risk and the high-risk women.
Cost of most tests should not be an issue at this point because there is so much low-hanging waste in our system in the form of treatment where minimal or possible (but unproven) benefits don’t outweigh the risks.
I’m more optimistic than you becaue this is the first time in a long, long time that we have had intelligent people in the White House who have a good shot at support from Congress (particularly after the 2010 election when REpublians will be running in states that Obama won.)
Clinton lost Congress, and the last truly intelligent president before Clinton was Jimmy Carter–who also didn’t have Congress behind him.
This takes us back to Nixon–intelligent in his own way, but warped by paranoia, which takes us back to LBJ– very good on domestic issues.
That was a long, long time ago. Many people have forgotten what good government looks like.
I see a real opportunity here. We have a strong, shrewd and thoughtful president and a Recession/Depression which is just beginninig–and which will lead Congress to do things legislators never thought they would do –in terms of standing up to lobbyists profiteering on health care and hiking taxes.
In the hard times ahead, I’m hoping that the American people will understand that virtually everyone has to give up something. Certainly Obama will appeal to our better selves.
Barry–
I agree that how many people will need subsidies is a major question.
If we continue spending as we are now spending,
I think all housholds earning up to $80,000 will need some subidy.
That’s well more than 50% of the population– probably it’s around 65%??
(That’s a stab in the dark)
In any case, we are talking about millions of people.
Moreover, if we are spending at the current rate, a household earning $90,000 will probably face an annual health care bill (including premiums, deductibles, co-pays and things not covered) of around $9,000 to $12,000 that they will have to pay out of pocket, with no subsidy, unless an employer is helping with their insurance.
I expect that more and more employers are going to back out of health benefits, especially if universal coverage is avaiable
If your employer drops your health benefits he may give you a pay raise to compensate–but in this recession, I wouldn’t count on it.
Bottom line, a great many statisically upper-middle class families are going to find themselves paying substantially more than they do now (assuming that most now have employer-based insurance.)
This is going to be a shock, but it may make people more interested in containing costs . .
And finally, as you know, I’m not willing to live in a society where poor children get care that is “good enough” while you or I (and our children) get excellent care.
See my response to Legacy Flyer– I define excellent care as all care that is effective (more than just “marginally effective”) where the likely benefit outweighs the risks.
NG- I agree–we have to move away from the perverse incentives of fee-for-service.
Christopher– I’m going to write about malpractice soon. Found some very good new sources.
I’m afraid that nuch of what you say is malpractice myth.
Jim–
That Medicare law was not repealed because of “voter preferences”
It was repealed because of politics.
Someone wrote a very, very good book focusing on that law and its repeal(I’m sorry I can’t remember the name.) It was not one of the Beltway’s finest moments.
As for the notion that the Medical Modernizatoin Act(which brought us part D
partial prescription coverage) reflects “voter priorities” — please
read my posts about how that law was passed.
It barely squeaked by, under cover of night, with at least one legislator bribed.
This is not an expression of the will of the people.
People are not happy with part D, not just because of the donut hole, but because drugs are over-priced. Insurers don’t really try to negotiate steep discounts (the way the governments of other countries do) they just pass the high costs on in the form of high deductibles for cancer drugs, etc.)
Meanwhile, the drugmakers spend more on advertising than they do on reserach.
Medicare itself should be providing part D–it has the clout to negotiate for steep discounts (and no one to pass exorbitant costs on to if it doesn’t).
Administrative costs also would be lower.
I will wait to hear what you have to say. It will likely be malpractice myth myth, though. The trial bar has expanded liability and made it very procedurally difficult for doctors to defend themselves. No other country does it this way.
Don–
I’m wondering if you read the entire post.
First: there is the fact that “nearly half of all people on Medicare (48%) are making do on incomes below 200% of poverty ($20,800 for a single person and $28,000 for a couple in 2008.) Income includes Social Security as well as dividends, capital gains, salaries from part-time work—in short, every penny that comes into the house.”
Secondly, I’m not focusing on the premiums, I’m talking about the co-pays (20 percent for outpatient care) deductible for hospital care and very high cost for lengthy hopsital stays. (Which, in some cases, are entirely necessary–for example, burn victims with severe burns)
A great many seniors will have outpatient surgery (catarc operation, for exmple, roughly $7,000)–and have to pay 20%.
Plus a thousand or two a year for presciprtion drugs not covered.
etc. etc.
The average amount that the typical Medicare patient pays out of pocket, annually, is $3,000.
$3,000 a year may not seem excessive–but FULLY HALF of these people are scraping by on less than $28,000 a year for a couple.
That means a great many couples are living on $16,000 or $18,000 a year.
If you were in that income brakcet and had to pay $3,000 a year (or $6,000 a year for two of you) in out of pocket expenses, how would you afford it?
Probably you wouldn’t take some of the medications you need; you would put off the cataract operation . . if your knees hurt so badly that you had trouble walking, you wouldn’t even consider a knee operation (outpatient surgery, you would be paying 20 percent . .)
Some would argue: “These seniors should have saved more”
But median income, adjusted for inflation, has been flat for a couple of decades.
Today, median household income is about $55,000.
That means half of all Americans earn less than this. Imagine raising a family on joint income of, say, $45,000–before taxes. Let’s say you hoped to send a child to college. Just how much would you be able to save for retirement?
Maggie:
I am with you.
I was being sarcastic in my assessment.
Even with such discounts in the premiums, the plans are simply not affordable for the vast majority of seniors.
I don’t know how the health care system has survived so long in its present form.
Those of us who participate in this very intersting forum have our souls at risk.
How can we know what we know, and not fight to make positive changes?
Don Levit
Don–
I’m so glad that you were being sarcastic. I wondered what you were thinking . ..and assumed you just skimmed the post.
And yes, we do have to fight for positive change
We are arguing about the definition of excellence in health care again.
Some definitions of excellence are illogical, and resemble the old joke – “the operation was a success but the patient died.“
In my mind and in most people’s minds, excellence in medical care is synonymous with effectiveness in medical care.
Unfortunately, some people in medical care, especially administrators, salespeople, and some researchers, tend to define excellence in terms of how much high tech care is offered to patients.
The issue of kidney dialysis and kidney disease in the US and Britain, mentioned already in this thread, is a good example.
Kidney dialysis is not available to everyone in Britain, with the usefulness of dialysis in extending quality of life considered as a factor in choosing who receives dialysis. Some US commentators can wax apoplectic about that. In the US, thanks to Hubert Humphrey getting patients with kidney failure included in Medicare, dialysis is available to everyone.
That should mean that people with kidney failure do better in the US than in Britain, right?
Wrong.
The death rate from kidney failure in Britain is considerably lower than in the US.
But that is population data. There may be other explanations besides excellence of care – for example perhaps people in the US have a greater tendency to get kidney failure than in Britain because of health habits.
However, the death rate for people who have been admitted to health care systems with kidney failure – people being managed for kidney failure – is higher in the US as well.
You not only have a lower chance of dying of kidney failure in Britain, but if you go to the doctor or hospital with kidney failure you have a lower chance of dying in Britain.
That is the essence of the definition of excellence in health care in a nutshell. What counts is not that you had the chance to use a high tech treatment or test or procedure. What counts is what happened to you as a result of your care.
By that measure, Britain has a higher level of excellence in care of kidney failure patients than America, despite not paying for dialysis for a small number of patients.
This article on Medicare is very informative. Thank you. I have forwarded it to my associates. But, as Marilyn Moon pointed out, Medicare can be easily fixed. She makes several good suggestions. The money is already here–much of it our own tax dollars churning through our current hybrid system. A government-run program is malleable–whereas private plans are not. There will be political pushback from the usual suspects, but making the case for care and compassion with regard to our seniors should not be difficult. Oops, I forgot–Billy Tauzin appealed to our love for our mothers when stiffing us with Plan D.
Ms. Moon remarks that “almost no one” is talking about the needed Medicare reforms. She does think, however, that “when health reform discussions begin about what a basic benefit package would look like for younger families, it will become obvious that Medicare is lagging behind, and politicians will take notice.”
That brings me to my latest area of concern. Just what does a “basic” plan or package look like? What would be a basic plan for a diabetic, or someone with cancer?
Other free market democracies seem able to deal with these issues–even though the level of expectation and the cost of high tech treatment is rising everywhere.
Diabetics in France or Canada are not skimping on their meds and forgoing doctor visits as is the case in the US (AP, April 13).
Just this week, a letter to our local paper spoke of a neighbor collecting cans to pay for essential treatment.
Sometimes I wonder what kind of country we’ve become.
I’m going to go look at Fidelity. For some reason I thought the amount for a retiree was $400K.
Maybe retirement isn’t out of reach after all!
“However, the death rate for people who have been admitted to health care systems with kidney failure – people being managed for kidney failure – is higher in the US as well.”
Pat,
I wonder how many people with kidney failure also have additional co-morbidities like heart disease and diabetes. What if the patient dies from pneumonia? Is there any consistency among OECD countries in how they determine the cause of death under these circumstances? Is there even a standard definition of kidney failure? As I’ve learned more about the healthcare system over the past several years, I’ve come to view international outcome statistics with increasing distrust and not just when they make the U.S. system look bad. On the other hand, regional outcome comparisons within the U.S. are presumably at least using the same definitions so I’m more inclined to trust and believe, say, the Dartmouth data.
The studies I have seen look at the diagnosis of kidney failure, then keep track of the survival. Co-morbidity obviously exists, but to suggest that we have more is questionable. Health care data is, if anything, more accurate in Britain since almost everyone is in the NHS, whereas US data is always bothered by people lost to follow-up, although data of this type is pretty good.
This is also not unique to Britain. One study looked at the US, Britain, Canada, Australia, and New Zealand. US did the worst in kidney failure management. A second study looked at US, Britain, France, Germany, and Canada. Again US finished last.
These same sort of results occur with trauma care, coronary artery disease, congestive failure, chronic lung disease, intestinal disorders, and diabetes. We beat Germany by a very small margin in coronary artery disease management, and beat everyone in cancer management (although as Maggie has discussed in other threads, there are arguments to suggest that lead time bias messes up our cancer results, especially in prostate and a couple of other cancers.)
No! No!! No!!!
The only way universal healthcare can work, is by doing away with the cumbersome, expensive private insurance companies altogether!
Who needs them? They’;ve been responsible for driving up costs, by paying exorbitant fees charged by hospitals, doctors, pharmaceutical companies, DME companies, and all the perks physicians require for their loyalty to a particular hospital or drugs. That’s been pitiful!
Doctors have been persuaded that they must have expensive malpractise
insurance to keep up their current lifestyle. Well, guess who makes much more than $249,000/year? Any less than the prospect of making less than $500,000, creates a cacaphony of wailing from that elite group, many of whom admit patients to hospitals unnecessarily, in an ill advised attempt to cover themselves, on the off chance that the patients’ conditions might deteriorate over night. That’s why Home Health Agencies exist, to manage cases out of hospital (much
less expensive, with fewer nosocomial infections). The “superbugs” have given us a reason to keep people out of those “houses of pestilence” (as they were called at the turn of the 20th century). Our motto should be “home is best”, as patients often become more ill after their admission than before it, even with the new expensive technologies and treatments.
With “safer” surgery due to the overuse of antibiotics, we have more “bionic” parts in any one person than was imaginable, when more conservative treatment should have been done, prior to yanking out whatever hurt, to put in the newest and, thank goodness, gender appropriate parts. I would have a knee replacement if a clever physical therapist hadn’t suggested that I try a knee “band”, 5 years ago. I don’t play tennis or golf, and wouldn’t have if I’d had that new part.
IV antibiotics and blood transfusions can and should be infused at home, with greater use of designated units of blood.
The practise doctors now have, when their payment is less than acceptable, such as Medicare, is to see patients twice each time they present with a need for a test of any kind. Once, to draw blood in their office (and charge mightily for that), and again a few days later for what’s termed by some patients as the “okey-dokey” office visit, to find out that the results of their tests are normal, or they need to take more Vitamin D, iron,or follow a lower carb diet. That used to be accomplished by a telephone call.
Going to a specialist for situations that aren’t the purvue of family practitioners can be decided quite adequately by Nurse Practitioners. I’ve known doctors who say they “don’t believe in NPs”, as if their role is some new religion. Usually that means the doctor was found to have made a mistake by one of those well educated providers, and it still rankles.
Oh yes, change is coming big time, and it will involve less,to no use of
“high horses”, and no insurance types making medical decisions.
Pat,
I think the unfavorable U.S. performance in managing the diseases that you cited can be caused by several factors, some of which have different policy implications. Four important factors that come to mind are (1) lack of access or inability to afford appropriate care, (2) failure of physicians to provide appropriate care be it prescription drugs, blood tests, stress tests, or coaching, (3) infections acquired in hospitals because of process failures, and (4) patient non-compliance.
Factor #1 can be due to either the inability to afford health insurance and/or co-pays or an inadequate supply of medical resources, especially in rural and low income metropolitan areas. Factors 2 and 3 could be addressed by better information ranging from electronic records for doctors and hospitals to better information for patients about the quality of providers. Factor #4 is probably related to the higher percentage of low income people in the U.S. vs. elsewhere.
I think we need to put our emphasis on restructuring payment incentives in order to provide more of the right care, less wasteful and cost-ineffective care and to reduce regional practice pattern variations. If we do that, it will, over time, free up resources to address the insurance affordability issue. Patient non-compliance is likely to remain more intractable.
The data cites information about patients who are in the health care system, not who are excluded, so access is a minimal issue. Physician failure to order drugs, tests, treatments is also not a factor — we do a lot more of that than the British. Complications of more aggessive treatments, including hospitalization, is a factor, but not the decisive one. Patient non-compliance comes closer, but isn’t it exactly.
I think the critical fact is that in the other countries the system is based on the relationship between the primary care provider and the patient. People have a PCP — the discussion of bounced patients indicated that a lot of the failure patients have no PCP and don’t see a doctor. They see the PCP often — doctor visits are more frequent in European system. When they see their PCP, they are allowed to spend more time. Also, the PCP’s feel that the responsibility for the patient is predominantly theirs, not specialists’.
I am guessing in the absence of data, but my guess is that the reason that kidney failure patients who have entered the system do better is that the PCP is keeping careful track of them. They are watching the results of therapy in terms of labs and well being, they are inquiring as to what the patient is doing and making additional suggestions. They are scheduling patients who are not doing as well for repeated visits. They are doing that because the system encourages it, and, as we have seen in Britain, sometimes pays doctors incentives to make sure they do it.
Check out this article:
http://www.innovations.ahrq.gov/content.aspx?id=275
It shows how a low tech approach using a higher level of intensity of patient contact had spectacular result in a setting where traditional US hospitalization and ICU care had failed.
I wonder if the 240k number — for what you need in retirement for health care — was produced by a company that sells investing services?
Pat,
If a good ongoing relationship with a PCP and the opportunity for frequent doctor-patient interaction to the extent necessary is as important to improving healthcare system quality as you say, it’s going to take a long time to fix the system given the current shortage of primary care doctors. Even if we raise their compensation by 15%-20% or implement a UK style P4P approach, which would require electronic records for data gathering, where will the supply come from as demands on and for PCP’s will only increase as we bring the currently uninsured and underinsured into the system? Perhaps we could use NP’s and PA’s much for fully than we do now, though that would probably run into opposition from the AMA. The shortage of nursing school faculty is also a significant constraint on increasing the supply of NP’s. We probably need to increase compensation there as well. It’s going to take quite some time to fix the PCP and NP supply problem, but the sooner we get started the better. On the positive side for PCP’s, with women accounting for a much higher percentage of medical students these days, large group practices should be able to offer both a salary and (more or less) regular hours which make for a more family friendly lifestyle than practicing solo or in a small group.
The article I noted shows a large regional health care system being able to create a program based on high intensity PCP coverage right now. Granted, they use NP’s and PA’s for most of the contact, and the PCP’s time is not paid for directly by third party payers. However, they do note that the system did recover the costs because of lab, exercise lab, and other ancillary charges generating enough income to pay the NP and PA staff, as well as savings from avoiding undercompensated long term stays in hospital by very sick people. Each NP or PA covered a caseload of 250 patients with congestive failure.
We will need to add staff to accomplish this sort of thing on a wide basis. However, given the collapse of employment right now, opening programs to turn former financial sector workers, retail workers, and auto workers into health care workers seems like an obvious move. Using stimulus funds to pay people to teach in these fields seems obvious as well.
AMA and most specialty organizations officially support NP’s and PA’s. Some individual doctors not so much, but many do. One interesting thing in the SMDC program is that the NP’s and PA’s were part of the cardiology department, and the cardiologists were very happy to give them the time consuming low-compensation patients in order to devote their own time to things they liked doing better and that paid more.
One thing — the fact that this program was run through a large health care system supports Maggie’s idea that large systems are the hope for the future in their ability to make and support decisions that improve care. Kaiser CEO George Halvorson is a major supporter of these types of plans, as are many other large systems. In the absence of more rational reimbursement patterns, the large systems have the ability to take advantage of the kinds of financial benefits that SMDC used to rationalize this program to make the programs overall financial winners for the systems. Private doctors in solo and small practices can’t do that, and will need to wait for changes in compensation patterns to make these things work. That is one reason why I think that incentive programs from third party payers, including Medicare, will be important to make these important changes work, either by encouraging affiliation with larger systems or offering direct compensation for these type of services, usually uncompensated or poorly compansated now.
Pat S, Harriette, Barry,Ginger, Pat S. Camerican, Barry,
Pat S., Tim, Pat S.
Thanks for your comments.
Pat S.–
On excellence in care–
the dialysis example is a good one. And I agree that “excellence” is defined by results– though I would add, results, and efficiency.
In other words, we’re looking for value– results over dollars spent. Luckily better care is also usually more efficient care– better outocmes, and lower costs usually go hand in hand.
Hariette–
Thanks– I also thought it was a great interview.
What would a basic comprehensive plan look like? I think Zeke Emanuel
defined it pretty well in his book when he called for a plan that would be more comprehensive than “80% of the employer-based plans available today.”
In other words, we’re talking about the plans the top 20% of Americans workers have now. I have had plans like these–and they are very good.
Typically, there is no annual cap on how much the insurer will pay, and no life-time cap. So if you develop cancer, you won’t go bankrupt.
At the same time, such plans typically won’t pay for “unproven” or “experimental” treatments.
If you want an experimental treatment, you have to sign up for a clinical trial–taking the chance that you’ll get the
placebo rather than the new treatment. (Since most
treatments that make it to Phase II trials utlimately fail, chances are you’ll be luckier if you get the placebo.)
Typically, you’ll find your co-pay and deducitibles are pretty low as long as you stick with specialists in the plan’s network. (The insurer has negotiated lower feees with these specialists in return for guaranteeing them plenty of business.) If you have a good plan (as I do now)
these specialists are generally very good.
A good plan also will cover physical therapy– maybe 40 sessions a year–and it may well cover acupuncture.
Very likely, a public-sector insurance option will steer you toward hospitals that are “centers of excellence” for various procedures by cutting your deductible and co-pays if you go to these hospitals.
And co-pays will be significaintly higher for a brand-name drug if a generic is available.
I don’t think we can expect national health reform to give us unlimited choices, or every treatment under the sun that someone is trying to sell. But I think we have to understand that insofar as national health insurance is steering us toward more effective care–and away from unproven care, or wasteful care (in the inefficient hopsital close to home) it is actually looking out for our health.
Barry–
I have looked at the OECD data–and I should point out American reserachers often are collecting the data.
I’ve also spoken to European doctors who are appalled by how medicine is practiced here–giving children with an earache antibiotics, for instance, when what they need are painkillers. Still doing PSA tests . . Fee-for-service medicine distorting what we do . ..
Outcomes are better in Europe for several reasons:
a) The overall populatoin is healthier because Euorepans won’t tolerate allowing so many of their citizens to be so very poor. As I’ve discussed, poverty is the leading cause of premature death from treatable diseases and the percent of the populatino that is poor is much, much higher in the U.S.
I’ve run a chart in the past showing a direct correlation between how much a country spends on social goods (through higher taxes) and the percentage of poor children. The U.S. is an outlier in both cases–we spend much less on social goods and have a much higher percentage of children living in poverty.
b) often in Europe there are no co-pays for preventive care. So there is no reason to skip the doctor’s appt.
c) drugs are significantly less expensive because Eureopean governments do not believe that drug-makers need to make double-digit profits (As they have for much of the past 25 years), pay their executives $20 million, or take doctors to resorts while making huge donatoins to politicians campaigns. (There political campaigns are not nearly as long and not nearly as expensive.)
So people are more likely to be able to afford to take their meds.
Ginger– $240,000 is just for healthcare. A retiree also needs housing, food, clothing, etc– and often Social Security does not cover all of that.
Pat S–
I agree about our performance when compared to other countires– except on cancer.
There really is No evidence that we do better in treating cancer.
We simply test many more people more often for cancer– breast cancer, prostate cancer, etc. etc.
As a result, we catch the cancer earlier.
Thus our “five-year-survivial rates” are higher. I I live in the U.S. and my twin sister lives in France, I may be having annual mammograms, and dicover that I have breast cancer at age 40.
She discovers she has breast cancer at age 43.
We both die of breast cancer at age 46.
But the U.S. adds me to the number of people who survived for moer than 5 yeas after the cancer was detected. The fact is the U.. wa sno more successful in treating my cancer; I simply endured the anxiety of walking around knowing hta tI had cancer for an extra 4 years.
In adition, often we diagnose a breast cancer that never would have spread–and might have disappeard. Still, the woman has a lumpectomy or mastectomy. This doesn’t happen nearly as often in other counries.
We diagnose much more prostate cancer, but this doesn’t mean we “save” the patient. We have no clear evidence that any of our treatmetns for prostate cancer extend life.
And we are far more likely to torment a patient with an incurable cancer–like liver cancer. A close friend in Italy died of liver cancer a few years ago. When it was diagnosed, the doctor told him the truth: nothing can be done. Rather than trying to string hiim along for a few extra months, he sent him home (to his very comfortable home) with very strong-painkillers, showed his wife how to administer them giving him more or less as needed, and the doctor made home visits.
This was compassionate care.
Unless a palliative care specialist takes over your case, you would be hard-pressed to get such compassionate care here.
camerican–
There are a number of non-profit private sector insurers that do a better job of avoiding over-treatment than Medicare does.
I’m thinking of Puget Sound, Geisinger, Kaiser in Norther California.
And they do a good job of providing preventive care. Kasier in California is the one healthcare system in the u.S. that has managed to demote heart disease–it is no longer the no. 1 killer among Kaiser’s patients.
Private insurers like Puget Sound make very good use of nurse-practioners.
Much of what you say about overtreatment is correct, but somebody needs to be making decisions about which treatments work, and which don’t. That can be a non-profit insurer’s phsyicians–or a panel of physicians and medical experts working for the government.
It’s the profit motive that drives overtreatment.
Barry–
You’re right higher rates of non-compliant patients in the U.S. is tied to the fact that we have more people living in poverty.
But this problem is not intractable (as other developed countries as shown)– if are willing to pay the taxes to support education and social safety nets needed to lift people out of poverty.
Pat S.– I agree that the emphasis on primary care– and having someone actually oversee most of your care–makes a difference in Europe.
But poverty remains, by far, the biggest factor driving premature death in the U.S. Acess to health care (or lack of access0 accoutns for only 10% of these deaths.
If we wanted a healthier population, a true war on poverty would do us more good than all of the health reform in the world. Maybe, once we’ve achieved universal access to care, we’ll figure that out. ..
Tim–
You write: “I wonder if the 240k number — for what you need in retirement for health care — was produced by a company that sells investing services?”
An EXCELLENT Point. I almost said something about this in the post, but hated to muddy the waters.
First, companies in the financial servcies industry often try to scare us that we won’t have enough money for retirement because they want us to put more money into thier mutual funds.
Also, as another reader pointed out $240,000 is an aggreagate number. Many people who wind up in nursing homes for years spend far more than that; many people who are quite healthy until they are 70 and then suddenly suffer a fatal stroke spend far less than that.
On average, Fidelity acknowleges, most retirees spend $3,000 a year out of pocket. But that’s still a huge amount if you’re part of the 50% with income below $20,000 a year. IF your income is $15,000, $3,000 take a big bite out of it.
Pat S
The program that you describe sounds like a very good one–and a potential model.
But note that it is located in Minnesota and Wisconsin. Minnesota is the one state in the nation that does not have a shortage of primary care physiciains, and Wisconsin also is known for enlightened low-tech efficient care.
I am afraid Barry is right: the shortage of PCPs and nureses makes a large roll-out of a plan like this impossible at this time.
I’m also not enthusiastic about the idea of , “opening programs to turn former financial sector workers, retail workers, and auto workers into health care workers”
My long experience with people in the financial sector tells me that very few possess the emphathy needed to be a good nurse practioner or physician’s assistant. And many simply aren’t intelligent enough to comprehend he complexity of dealing with patients suffering from four chronic diseases.
Selling your company’s stock funds and bond funds to unsuspecting clients is about as easy as selling anything else. Often brokers don’t really understand the products they are sellin–certainly not the risks.
As for retail workers and auto workers–I cannot imagine that many possess the dedication, fortitude, intelligence and imaginatoin to become good nurses.
It seems to be that nursing, like medicine, is a calling– either you really want to do it, or you don’t. The person who just sold me Knee-high’s at Macy’s probably doesn’t. She found bending down to look for knee-highs I wanted irritatingly hard work.
I can, however, imagine that some of the very bright young people graduating from college this year and next might take a close look at nursing and other jobs in the health care sector– as an alternative to banking, real estate or insurance.
If they are bright, young, idealistic and willing to work very hard, they could become excellent NPs and PAs.
That’s the one good thing about the economy’s collapse–so many bright young people who would have gone into investment banking will now have to find something else to do.
Over the years, as I saw all of those baby bankers coming to Wall Street, all I could think was “a mind is terrible thing to waste.”
If we pay older nurses more to teach, we could recruit the teachers needed. Still, the whole process will take four or five years, just to get people in the pipeline.
Maggie —
I already agreed with you about the lead time issue and its potential impact on cancer results in the US vs elsewhere. It is particularly obvously a factor in prostate disease, and may be an issue in other cancers.
Also agree that poverty and its effects are a major problem in the US, although poverty itself is not that different in Britain and, to some extent in some other European countries. The difference is the safety net — unemployment, medical care, housing,etc.
As far as whether people from finance and other fields, I agree on my post about the values issue. My main point is that there a lot of people out there looking for work, and training them to be NP’s and PA’s would be a useful thing for everyone.
BTW — we are short of PCP’s in Minnesota too, maybe not as short.
Pat —
The person in charge of healthcare reform in Minnesota (sorry I can’t remember his name) told me
Minnesota has enough PCPs.
(Of course people can disagree on what is “enough”)
Maggie,
You just went on a diatribe about how half of all doctors graduate in the bottom half of their class, dont follow guidelines appropriately, and in general are doing only a mediocre job of delivering healthcare.
And your solution to this is to put out more PAs and NPs, with 1/3 the training of MDs, to serve as “primary care practitioners?”
This doesnt jive. Either doctors are poorly trained and arent doing a good job of delivering evidence based medicine, or they are overtrained, and their jobs could be replaced by PAs and NPs.
Which is it?
Joe Blow–
A great many nurses can do the job that doctors in the middle of the curve do.
In other words, nurses in the middle of their Bell Curve are often as good (and often better) than doctors in the middle fo their Bell Curve) when it comes to primary care.
How can the nurses be better?
They are not as arrogant–much quicker to look things up, consult with others.
The extra years of training don’t, by and large, make physicians better at primary care, preventive care or managing chronic diseases (the areas where we knwo we fall short.)
That’s not what medical schools for dccotrs emphsize.
Primary care and chronic disease managment depend on cognitive skills–being able to listen to and talk to a patient. This, unfortunately, is not what sub-specialists are trained to do in medical school
A good portion of primary care encounters can be satisfactorily handled by following well established rules or guidelines. Advances in computer technology allow us to incorporate those rules and guidelines into computerized decision support tools. NP’s are willing to follow rules and guidelines because they were trained to do so. Doctors are more likely to want to use their judgment. My insurer offers a nurse hotline which I’ve used twice in the last year or so including once while on vacation 2,000 miles away. I was well satisfied with the guidance I received and it saved a trip to the ER both times.
A panel discussion I attended at the University of Pennsylvania a couple of years ago sponsored by its School of Nursing included a presentation by an expert who grew up in Denmark. She claimed that a U.S. NP can competently handle up to 85% of all primary care encounters. She further stated that a U.S. trained NP has as much training as a PCP trained in Denmark. If this is the case, we should focus on increasing the supply of NP’s as fast as we can to help relieve the shortage of PCP’s and, once we’ve trained them, we should make sure they are permitted to practice to their full potential.