Over the weekend, I read a piece by Brian Klepper on “What Worksite and Retail Clinics Mean for the Primary Care Crisis” over at Robert Laszewski’s excellent blog, Health Care Policy and Marketplace Review.
Klepper is a health care analyst based in Atlantic Beach, Florida who often writes for The Health Care Blog. I met him at a healthcare conference in Washington D.C. a few months ago and found his ideas very interesting—although we don’t agree on everything, as you will see.
Intrigued by Brian’s post, I decided to write a comment. Bob Laszewski then got in touch with me and suggested that he turn my comment into a full-fledged post, and asked Brian to reply.
Below, Brian’s original post, my reply and a link to his response.
What Walgreens Surely Sees
by Brian Klepper
Though it probably went mostly unnoticed in the cacophony of health care stories, last week’s news that Walgreens had bought the two largest and most well-established worksite clinic firms, iTrax and Whole Health Management, was a harbinger of very big changes in health care. Walgreens, the ubiquitous drugstore company that, with Wal-Mart and CVS, has already leveraged its pharmacy platform to establish a strong footprint in retail clinics, undoubtedly startled many health care observers with its announcement. After all, isn’t the company doctor a relic?
Actually, no. The worksite clinic – and by way of disclosure for the better part of the last year I have worked closely with a small, very innovative, Orlando-based startup worksite clinic firm, WeCare TLC – has been reinvented and refitted with 21st century tools, and offers the promise of nothing less than a paradigm shift toward dramatically better care at significantly lower cost. Understanding how these structures work and how they differ from both old-fashioned medical practices and retail clinics provides clues into what Walgreens likely sees and why that matters to American health care.
There are several parts to this puzzle, but one is the abject failure of America’s primary care community to establish a strong base of power by leveraging its ownership of the referral process. Last December I pointed out that primary care faces a labor shortage crisis because, for many years, the AMA has worked hand-in-glove with CMS to create financial rewards for specialists at the expense of primary care physicians (PCPs). This act of sabotage has been abetted by the health plans, who have blindly followed CMS’s lead on reimbursement, and who likely have their own reasons for disempowering primary care. As Benjamin Brewer MD argues compellingly in yesterday’s Wall Street Journal online edition, the resulting financial pressure on primary care physicians has made their practices increasingly untenable. Reform is a pipedream, he says, unless health care’s foundation, primary care, is re-established. The current issue of Medscape Family Medicine has a point-counterpoint discussion that chews on how practicing docs or policy-makers might respond to this problem. Robert Centor MD argues that physicians could develop smaller concierge practices, while Charles Vegas MD calls for a single payer system that would reimburse primary care physicians at levels that are more sustainable.
To me, though, these discussions miss the deeper and more practical point. Part of the reason that primary care is failing is that, as a discipline and like the rest of medicine, it has remained a cottage industry. Its practitioners lack unity and the strength that organized collaboration conveys, mostly working in little businesses that, on the whole, have not seen the need for or been able to afford investment in management tools and practices that have become available to them.
Even though many internists, family physicians and pediatricians view primary care in terms of its "comprehensiveness" and its "diagnostic and management puzzles," to use Dr. Centor’s terms, over time the downstream medical specialists and the health plans have defined primary care in terms of quick handling of the simple and routine. Embroiled in the day-to-day struggle to care for patients and keep their practices afloat, dependent on health plan reimbursements that have been tethered to a narrow definition of their roles, they have suffered from a failure to imagine what the broader needs of their patients and purchasers might involve, what opportunities might exist and what those opportunities might mean.
One unhealthy byproduct of these circumstances has been a disconnect between PCPs and the specialists they refer to. Patients and purchasers (i.e., the patient, the employer, or the government) have been the pawns of this lack of continuity. Encouraged by health plans alternately chanting the "choice" and "managed care" mantras, health care has become dominated by two models. In the gatekeeper model, the PCP makes the decision to provide care or to refer. In the independent patient model, the patient refers himself. (In Medicare-heavy markets, like Miami, specialists like cardiologists and endocrinologists have become primary care physicians to the elderly, poor management of resources but comfortable for patients and lucrative for the specialists, if expensive to the rest of us.) Once the patient leaves the primary care office, the PCP typically has little involvement in the services – appropriate or inappropriate – delivered by the specialist. Each physician’s office is its own silo and, even though we know that most wasted services and cost occur downstream of primary care, nearly all health care reimbursement discourages primary care physicians from participating as expert patient/purchaser advocates in the management of the full continuum of care. It’s a curiously corrosive policy that is re-enforced by the niceties of professional courtesy: "Don’t mess with the care I give to my patients."
There is dawning awareness that this is a core, resolvable problem in health care, though, and some change is afoot. The Patient-Centered Primary Care Collaborative, a coalition of large employers and professional groups, has been advocating for changes in reimbursement and the roles of primary care physicians. Longtime progressive health care heavyweights like IBM’s Paul Grundy MD, Bridges To Excellence’s Francois de Brantes and NCQA’s Peggy O’Kane are doing a great job articulating a new vision of primary care, but whether their campaigning can get traction with mainstream health plans and provision of care is another matter.
Markets, like nature, abhor vacuums. As Scott MacStravic noted a few days ago, over the years various efforts have taken stabs at what we now know as retail clinics. Catering to convenience, the uninsured, the underinsured, and those who aren’t interested in a regular primary care physician relationship, this is catch-as-catch-can medicine, mostly provided by nurse practitioners and physician assistants, under the notable sponsorship of Wal-Mart, Walgreens and CVS, which co-incidentally, stand to gain through cross-selling in their pharmacies and other departments as well.
Many physicians and their associations are apoplectic over the apparent success and staying power of the retail clinics, arguing that these operations may deliver sub-standard care and that they lack a real connection to the full continuum. I wonder whether all the fuss makes sense, and whether this is really a good expenditure of their energies. Retail clinics are corporations, after all, and unlike most physicians, who practice what they’ve managed to keep up with, these corporate clinicians access continuously updated information tools and practice based on evidence-based guidelines. No room in corporations for flying by the seat of your pants. And, in a sense, this is their strength. It seems very unlikely that organized medicine will win the battle against the retail clinics. They seem to be thriving.
Even so, there’s no question that retail clinics, for all their positive attributes, are NOT medical homes. At this point, anyway, their clinicians and patients probably don’t generally develop deep, trusting relationships, and the professional medical capabilities at play only go so far.
Let’s also not forget that the great majority of American’s still do get their coverage, however tattered and iffy, through their workplace. Which brings us back to a fascinating phenomenon: the re-emergence of worksite clinics.
Unlike retail clinics, worksite clinics ARE medical homes. Although most early worksite clinic ventures have focused on jumbo employers, properly configured they work even for small employers. (The group I’m working with has operated an onsite clinic for their 60 employees and their families for three years. It operates 5 hours a week, has created tremendous savings, and the employees are very happy with it.) The clinicians eat lunch every day with the employees, and develop a bond that matters when managing care.
These aren’t our parents’ doctors’ offices. Peggy O’Kane said it well. “It’s much more proactive than the old model of just thinking about you when you show up for an office visit. It’s creating an ongoing relationship with the patient.”
Because they’re built from scratch, these clinics can take advantage of incentives, IT, analytics and care management programs that in turn help the practice identify and manage health problems and costs. In the WeCare clinics, employees and their family members come to the clinic for free, without co-pays and without paying for drugs and labs. This approach brings in low income employees and their families who often don’t see doctors because they might have to pay something for the visit or for their prescriptions, and it dramatically reduces the costs of care that is needed when people avoid primary care.
All WeCare physicians use Electronic Medical Records (EMRs) that can receive or transmit patient information to other systems. Soon we should have embedded best practice guidelines that alert physicians to potential care gaps, and help them avoid exacerbated care and costs. All patients are encouraged to receive Health Risk Appraisals, and those evaluations are validated through claims analysis that help identify chronic patients and those who might, on the basis of historical information, potentially have an acute event in the near future. Identified patients are paired with clinicians for further evaluation and management, to try to impact or head off the problems.
When data on the network is available, the high performing specialists (in terms of quality and cost) within each specialty are identified and referrals are steered to them. And when the patient is referred, ideally the primary physician connects with the specialist, and urges that he/she be consulted prior to any significant care. In other words, the primary care physician becomes an expert guide and advocate as the patient navigates through the system, working on behalf of both the patient and the purchaser, and helping to hold the other players in the system accountable.
At this point, employers, more than health plans, see the sense in this model. While the health plan benefit structure can be tweaked to optimize use of the clinic, the clinic itself is distinct from and sits in front of the health plan. The employer invests up front in the clinic to generate immediate, substantial savings in the plan.
And those savings can be VERY substantial. In a report by the City of Port St. Lucie on the WeCare clinic’s performance during its first 6 months of operation, the clinic was found to produce a 3.1:1 hard return on investment, with dramatic savings in primary care visits, drugs, laboratory, sick hours and employee out-of-pocket savings. There were also soft savings that they know exist but that haven’t been quantified yet in HR testing (like drug screens and Department of Transportation testing), in the full range of lost productivity costs, and in workers’ compensation savings.
Nothing but inertia prevents conventional primary care practices from reconfiguring in this way, but it takes a concerted focus on managing population- and systems-level information as well as individual patients’ conditions. It’s an expansion of the traditional primary care physician’s role, and so far, there don’t seem to be a lot of PCP’s with the leadership and business focus to drive these models from the base of a conventional practice.
And that has created an opportunity for, first, the worksite clinic vendors, and second, behemoth corporations like Walgreens who see the potential to capture primary care, and with its control of referrals, the possibility of controlling all health care. Because worksite clinics are focused directly on employers, they work around the health plans, and so become a disruptive innovation that the health plans must learn to accommodate. By realigning the incentives, by using tools, data and programs to identify and manage risk at the level of primary care, and by enforcing downstream accountability from the primary care base, these models have the potential to reinvigorate primary care, and to drive tremendous new improvements in quality and efficiency, and to help re-establish health care stability and sustainability.
Over the long slog of the last several decades, the health care’s various sectors have become increasingly inward-focused, unaware that their roles are within a larger system, and insensitive to the larger well-being of both the patient and the purchaser. Primary care has been compromised. There is rampant excess in the specialties. Health plans have often abrogated cost and quality management in favor of simply bundling, financing and marketing health care services. And employers have become frustrated with unrelenting, rampant cost growth.
These dynamics have created an opportunity for vendors who can establish systems that identify and manage health/financial risk directly on behalf of employers and others who own that risk. Walgreen’s – and undoubtedly other big organizations will follow suit here – surely sees the vacuum and, through its purchases, has placed a bet squarely on the transformative power of worksite clinics. That step could be more meaningful than anything occurring in state and national health policy reform. If nothing else, if the physician community remains scattered and dis-united, it could spell the end of medicine as a cottage industry, and the next big phase of true corporate medicine in America.
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To Brian Klepper: On Corporate Medicine
by Maggie Mahar
Brian, I agree with 90 percent of what you say—particularly when you write so eloquently about what has happened to primary care. I believe that we need to make primary care far more attractive to doctors. One way to do it would be to forgive all med school loans for students who choose to go into primary care (or become family doctors, pediatricians or gerontologists), especially if they agree to work, for a few years, in areas where they are most needed.
But when you suggest that corporate medicine is the answer, I have to disagree. In the early 1980s, Paul Starr published his Pulitzer-prize-winning book The Social Transformation of American Medicine. At the end of that book, he predicted the “The Coming of the Corporation”:
“Those who talked about health care ‘planning’ in the 1970s now talk about health care ‘marketing’…" Starr wrote. “Everywhere, one sees the growth of a kind of marketing mentality in health care. And indeed, business school graduates are displacing graduates of public health schools, hospital administrators and even doctors at the top echelons of medical care organizations. The organizational culture of medicine used to be dominated by the ideals of professionalism and voluntarism, which softened the underlying acquisitive activity. The restraint exercised by those ideals now grows weaker. The ‘health center’ of one era is the ‘profit center’ of the next.”
Starr went on to explain that because the U.S. had failed at national health care reform, “The failure to rationalize medical services under public control meant that, sooner or later, they would be rationalized by private control. Instead of public regulation, there will be private regulation and instead of public planning, there will be corporate planning.”
The goal driving that planning, Starr suggested, would no longer be better health, but rather “the rate of return on investment.”
So when you tell us that: “Wecare clinic was found to produce a 3.1:1 hard return on investment,” I have a question. Where did that return go? Was it plowed back into our health care system, in order to provide access to high quality care for Americans who cannot afford care? Or did it go to shareholders?
I have no objection to investors making money. I, myself, am an investor. But there are some sectors of our society where I wouldn’t try to turn a profit. (I don’t invest in war, cigarettes, or the healthcare industry—in the latter case, because I know far too much about the industry.) Given the fact that our health care system is in shambles—and that we cannot afford to provide decent care for millions of Americans– I do not think that this is the time to try to figure out how make a profit on the sick and the dying. Any savings that can be achieved by providing more efficient, more effective care should go back into the system so that we can provide better care for more people.
Like many others, I believe this is the time to find a public solution to a public problem. We have had enough of private-sector health care planning, with drug-makers deciding what drugs should be developed—and how much we should know about them. We have had enough of for-profit insurers deciding who should be covered, and who should be left by the side of the road. We have had enough of unscrupulous surgeons taking kick-backs from device-makers who tell them which devices to implant in our bodies. Meanwhile, the same device-makers conceal information about defects in those devices, leading to many deaths. They are sued, but they view the cost of the lawsuit as simply “part of the cost of doing business.” The profits they have made on their over-priced products more than cover the expense.
Since the 1980s, we have experimented with “corporate medicine,” and discovered that Starr was right. The goal driving for-profit medicine is always “the rate of return on investment”—not better health. The history of our for-profit hospitals is a long, sordid tale of corporate crime. Time and again, the most successful investor-owned hospitals have bilked taxpayers, bribed doctors and gulled investors. In the most harrowing cases, one for-profit hospital resorted to performing hundreds of unnecessary heart operations while another kidnapped patients. (I devoted an entire chapter of Money-Driven Medicine to the history of for-profit hospitals)
This is why so many of us want to see evidence-based guidelines drawn up by panels of physicians and researchers who have absolutely no financial interest in the outcomes. Health care is a public good, and as such, should be delivered by non-profit organizations overseen by government organization that reviews quality and is accountable only to the public. (HealthBeat readers, please see my recent post on NICE as a model for a government agency insulated from both political and industry pressures.)
We have tried experimenting with for-profit medicine, for-profit public schools and for-profit prisons. In each case we have failed.
Why? Because when a for-profit corporation tries to deliver a public service, inevitably, there is a conflict of interest. By law, a corporation’s first obligation is to make a profit for its shareholders. Its customers come second. It is not supposed to lie to its customers—but caveat emptor (buyer beware) always applies.
As economist Rashie Fein once said, “We live in a society, not just in an economy”. Corporations, on the other hand, live only in the economy. And properly so: that is their mandate.
Sometimes corporations tells us that they want to play a role in shaping society. (So Enron built a football stadium, Philip Morris gave scholarships to Hispanic women; Pfizer would have us believe that it is a philanthropist) When they do that, it’s time to take a close look at the corporation. Chances are they are hiding something. (I spent nearly 20 years of my life covering Wall Street, mainly for Barron’s, and so I know, all too well, that you can never be too cynical about the motives of a publicly traded corporation.)
Now, of course, some will argue that private-sector corporations are always more efficient than non-profits or government. As you put it: “No flying by the seat of your pants if you’re a corporation.” And you go on to suggest that this is why we should believe that corporate medicine will always use the newest, best medical evidence available when establishing guidelines for care.
If corporations are that intelligent then how does one explain the entire U.S. auto industry? (Forget about the cost of health benefits. The industry seems incapable of designing a competitive car—incapable even of forecasting the oil crisis, and the need for smaller, more efficient cars.)
If corporations never “fly by the seat of their pants” how, then, does one explain an operation like Enron, which made up the rules for its business as it went along. Or WorldCom? Or Merrill Lynch? Think of the waste and fraud in corporate America that begins with obscene executive compensation and ends with insiders selling their shares just months before a stock tanks.
Then there is Walgreens. Its CEO earns $9.780,000– substantially more than most primary care doctors, though I would venture to suggest that his job is no more difficult than that of a busy family practitioner. Most of his compensation comes in the form of stock and stock options. So when a primary care operation produces a hefty return on investment in Walgreen’s clinics, the doctors who provide the care are helping to boost Rein’s salary. I would suggest that there are better ways to invest those savings in our health care system—perhaps by funding SCHIP so that all children in the U.S. have access to health care.
Further, Business Week reveals that Rein has a connection to 10 members of the Walgreens board. Long, hard experience has taught us that when the CEO of a company has close ties to board members that CEO (along with the board members) are likely to be over-compensated. The CEO’s power goes unchecked, and too often, absolute power corrupts.
Meanwhile, Walgreen’s stock is not doing well—down 20 percent for the year. No doubt management is concerned about this. I wonder how they will use their clinics in order to try to boost their share price?
Then, there are complaints from shareholders about how the company is being run. This from comments to the Wall Street Journal’s health blog: “At Walgreen’s pace of new store openings, it will blow away its goal of 7000 stores by 2010 (by about 400 stores)…I say GREAT, but at what cost for its investors and the company??? We just had a “heart attack” in the stock price.. EASE UP ON THE NEW STORE CONSTRUCTION… the marketplace can’t handle it yet. When a new store opens and it takes away form existing Walgreen’s stores, but does NOTHING for the district’s income, what does that tell you??? Hmm, maybe due diligence (read as: better market studies) should have been done BEFORE that money was spent. I figure it takes about $6million per new store opening, I wonder what would happen if you add a billion or two to the bottom line…”
The Wall Street Journal reports that as generics replace prescription drugs, Walgreens is having a hard time making money on generics– in large part because Wal-Mart keeps prices low. Is Walgreens a desperate company that has set out on an ill-fated building boom while simultaneously branching out into a business that it knows nothing about—primary care? I don’t know enough about the company or the stock to know. But it certainly seems a possibility. (Reins, btw, is a relatively new CEO; he came on board a year or two ago.)
Finally, Brian, I very much like the idea of work-site clinics. And I’m sure the clinics you are personally involved with are doing their best to deliver rational, evidence-based medicine.
But even so, to avoid conflict of interest these clinics must be not-for-profit. As a society, we can’t afford to try to make a profit on a health care system that is going broke.
But I would add that work-site clinics do little to address one of the biggest problems in our health care system—lack of access to care. Most of the people who are uninsured don’t work for corporations that are wealthy enough to set up a work-site clinic.
We need neighborhood clinics—in inner-city neighborhoods, and in desperately poor rural areas. There is, of course, no profit to be made on these clinics. And this is why we don’t have them.
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You can read Brian’s response to my reply here.
When there are market distortions one has to ask why. In this case there is a shortage of primary care physicians. Without going into any of the usual reasons, in a capitalist society there is only one answer – the “profit” isn’t high enough.
I’ve had several workmen come to my home over the past year. Most have a minimum charge that ranges from $85 to $100 just to show up. I’m not saying anything against plumbers or appliance repair men, but most make do with a high school education. They get to charge these rates because demand exceeds supply.
My dentist charged $115 for a cleaning last week. It was done by a technician. My doctor gets $35 for a visit.
The situation would resolve itself if the value of the service was properly accounted for and the market was allowed to regulate itself. Perhaps this could still be done in the existing framework where the government determines the worth of every medical procedure, but then what this means is that primary care is not being evaluated properly.
Given the way things work these days, I have to assume that means that this group doesn’t have a big enough lobbying effort.
I don’t have any ideas on how to fix this, but putting bandaids in the form of clinics is only postponing dealing with the problem.
I really want to comment on obstacles to reform. We held some focus groups in 2006 to learn what was important to the public and what would make the public move on reform and they said: “show us what it would look like.” We don’t do that in health care reform. We dive into details and lament what is wrong. What we need to do is start painting pictures of the possible. That’s what the Founding Fathers did with the Federalist Papers. About a third were about what was wrong and two thirds were about what it could be. It was not until the last five that they gave any detail at all about the Presidency, the House, the Senate, Supreme Court and taxes.
That’s where health care reform starts–in the details. We instantly bore or ignite the audience and then wonder why we have no traction.
I just returned from a luncheon honoring Don Hewitt, Creator of 60 minutes and Ex. Producer CBS News. He said the most important things a good journalist does is tell stories, write well and bring stories to life with words.
That’s what we need to do with health care reform–paint that picture.
Kathleen O’Connor, CodeBlueNow!
I am more inclined to agree with Brian. If work site clinics can offer a medical home, use electronic medical records, pay clinicians a competitive salary and benefit package, identify the most cost-effective hospitals and specialists and measure results, the work site clinic model has the potential to reduce healthcare costs for self-funded employers by keeping their employees and family members healthy and avoid unnecessary and wasteful treatments by less cost-effective hospitals and doctors. If the savings accrue to the employer who can then afford to pay higher wages thereby helping to mitigate the middle class squeeze, that would be a good thing. The key here is to use information technology and to get the incentives right. The biggest objection I can see to the clinics is from employees, especially those who may have significant medical issues, who do not want their employer to know too much about their health status because they fear it could adversely affect their promotion opportunities or worse.
Walgreens, worksite clinics, retail clinics, the future of primary care, and the place of for-profit firms in the health care delivery system
Bob Laszewski hosts a fascinating confab: a dialogue between Brian Klepper and Maggie Mahar — nominally about Walgreens and its recent acquisition of two workplace clinic companies, but taking a much broader look at primary care in the U.S., whether
I’m more on Maggie’s side than Brian’s.
I would not go so far as to say that for-profit companies should not operate in the health care space, but it is essential to be skeptical about motives and to structure the market carefully so that profit motive coincides with public health as much as possible. That is the key: allow firms to take profits, but only when they demonstrably add value as judged by independent metrics oriented towards public health and efficiency.
Barry, I don’t think you really addressed Maggie’s points. You present some good insights about Walgreens, but I don’t see how that impacts the concern that a public company by its nature is designed to put the return on shareholder investment as first priority, even if that doesn’t coincide with improving health or making healthcare affordable.
As an aside, Maggie, as you know “for-profit” does not equal “publicly-traded.” I think you are eliding the distinction a bit here, because private for-profits have a wider range of behaviors than public for-profits. It can be even more ruthless about profit than a public company, as in the case of huge private equity companies that buy up public companies in order to remove them from public scrutiny as they fire, restructure, load up the companies with debt, etc. On the other hand, a private company can be the extension of the personality and goals of the controlling interest or individual. The owner may not see maximization of profit as the goal, but may engage in explicit satisficing, or may see profit as a means to a social end. This is not a major point, but it bugs me when the two types of for-profits are treated as identical.
I should have read Brian’s response to Maggie’s response before commenting. It is no longer clear that I am closer to her view than his.
Brian’s point that even non-profits often lose track of the public interest is well taken. Regardless of whether we have for-profit organizations in health care, so long as we retain private organizations we will need to make far better efforts to align the incentives of these organizations with public health and efficiency objectives.
jd,
I think one of the key differences in viewpoint with respect to healthcare between Maggie and me is that she seems to think that profit or the pursuit of profit is a bad thing and I don’t.
If the drug industry is spending too much of its R&D money developing “me too” drugs that are no better than older and cheaper medicines and NIH thinks it could do a better job developing breakthrough therapies, why doesn’t it? All Congress has to do is allocate $10 or $20 billion to NIH and tell them to develop and commercialize great new drugs. I don’t think it would be that easy, but they are certainly welcome to try.
For device manufacturers who pay surgeons to use their devices exclusively, a little transparency would go a long way. Transparency also includes allowing hospitals to tell other hospitals what they pay for devices which they are not allowed to do under current confidentiality agreements.
While Maggie highlighted some of the past scandals involving for profit hospitals, the non-profit hospital sector is not pure either. Approximately 85% of hospital beds in the U.S. are controlled by non-profit institutions. I don’t think they have done a very good job of controlling costs, embracing price and quality transparency, developing episode or package pricing for expensive surgical procedures or doing much else to help doctors and patients easily determine which hospitals provide the most cost-effective, high quality care and which don’t.
Doctors, with the exception of those who work for a salary, all work in pursuit of profit. For those who own their own imaging and/or lab equipment, they have an incentive to run more tests than needed to maximize their income. Doctor owned ambulatory surgical centers (ASC’s) cherry pick the most profitable (well insured) and lowest risk patients leaving the higher risk, poorly insured and uninsured to get treatment in full service hospitals.
A Medicare for All approach is unlikely to work well, in part, because government cannot get the price of every service and procedure right. There are just too many of them. Everyone knows that Medicare overpays for some procedures and underpays for others (especially primary care). As for its lower administrative costs, no less an authority than Alain Enthoven has suggested that these can be attributed as much to under management (too much fraud and too little oversight) as to efficiency. Medicare probably pays its bills too quickly to allow for sufficient oversight, and I question how good its analytics are as compared to what the private insurers have.
As for private insurers, the individual health insurance market is dysfunctional. To stay competitive, they have to try to avoid covering the sickest people. They cannot be expected to offer policies on a guaranteed issue basis unless coverage is mandatory, and we cannot mandate coverage unless it is affordable which means a huge chunk of the population will need subsidies. Moreover, as I understand it, between 30%-40% of the private commercial health insurance market is controlled by non-profit insurers (mainly the Blues), but their premiums are no lower or only nominally lower than the for profit insurers. One possible interim step that could improve matters would be to apply the same rules as apply to long term care insurance. That is, once accepted for insurance, you cannot be canceled later if your health status deteriorates as long as you continue to pay the premium and the insurer cannot raise you premium unless it does so for the entire class – either people who bought a similar policy or bought it in the same year, etc. A more robust high risk insurance pool could also help people who are otherwise uninsurable to obtain coverage.
The work site clinics described by Brian have their incentives properly aligned, I think. The same is true for the drug retail sector, primarily because they actually make more money on generics than they do on branded drugs.
Primary care’s future
Brian Klepper and Maggie Mahar argue about retail and worksite clinics. Are we looking at models of the future?
As jd mentions, “private” for-profits do have a wider range of behaviors than “public” for-profits. A private equity group can be more ruthless about profit than a public company.
Habana Health Care Center and fourty-eight other nursing homes in Florida were purchased in 2002 by a group of large private investment firms. Within months, the number of clinical registered nurses was half and budgets for nursing supplies, resident activities and other services also fell. The new investors and operators were soon earning millions of dollars a year from their new homes.
Residents of those homes fared less well. Over a dozen died from what their families contend was negligent care in lawsuits filed in court. Regulators repeatedly visited, finding malfunctioning fire doors, unhygienic kitchens, in other words, they created a hellhole.
These fourty-nine homes were some of the thousands of nursing homes across the nation that large Wall Street investment companies have bought in recent years. It includes prominent private equity firm Carlyle Group – better known for buying companies like Dunkin’ Donuts – who bought Manor Care late last year.
These types of private for-profits have acquired nursing homes, cut expenses and staff, sometimes below minimum legal requirements, increased profits, and quickly resold facilities for “significant” gains. If the Carlyle Group deal with Manor Care is successful, they then could sell it to Dubai, which has more money than it knows how to deal with. But by regulatory benchmarks, residents at those nursing homes are worse off then they were under their previous public for-profit owners.
The Carlyle Group already plans to restructure its operations which will comprise about 300 corporate entities that could obscure ownership and make it more difficult to regulate care. It would split the company’s real estate holdings from the rest of the business so the properties could be used as collateral to raise funds in credit markets to expand the business.
Ownership structures with multiple stakeholders have been used by other private-equity firms to minimize liabilities and shield them from regulator inquiries like when cutting staff is made to improve profit margins. They use these kinds of structures to avoid taking responsibility when taking control of nursing homes. Private equity is buying up this industry and then hiding the assets, and when residents are dying from lack of proper care, there is little the courts or regulators can do.
The Private Equity Boom
http://www.washingtonpost.com/wp-dyn/content/article/2007/03/14/AR2007031402177.html
Barry–
I really don’t want people who own a stock (in this case, Walgreens) plugging it on this blog–even if they disclose.
Also, you ask: “If the drug industry is spending too much of its R&D money developing “me too” drugs that are no better than older and cheaper medicines and NIH thinks it could do a better job developing breakthrough therapies, why doesn’t it? All Congress has to do is allocate $10 or $20 billion to NIH and tell them to develop and commercialize great new drugs. ”
Why don’t they? I’m afraid everyone knows the answer.
Campagin contributions from drug makers.
Robert, Kathleen, j.d. Greg
Thanks for your comments.
Robert–
On why primary care docs aren’t as well paid: Their lobbyists aren’t as powerful as some surgeons’ groups because they are not as well paid and cannot make enormous campaign contributions.
But it’s also because of the way Medicare decides fee schedules. The people on the commitee who make the decisions are specialists, not family docs–and guess what . . .?
See this post on Who Decides How Much to Pay Specialists.” http://www.healthbeatblog.org/2008/01/who-decides-how.html
Kathleen–You’re absolutely right; reformers do get bogged down in the mind-boggling details.
Though when one tries to paint a picture of what health reform would mean–not everyone is happy with the picture.
If we’re going to make high quality healthcare available to everyone, we can’t afford to cover everything that everyone might think they want–even if there is no evidence that it works.
And some people won’t be happy about that.
The best way to paint pictures, I think, is to describe healthcare in countries where everyone has access and outcomes are generally better. . .
There were parts of Michael Moore’s movie, Sicko, that were inaccurate, but he did a very good job of portraying healthcare in Canada and in France.
jd–
Yes, I do recognize the distinction between private and publicly-traded for-profits–and of course, a private company’s pursuit of profits also creates a potential conflict of interest.
Greg’s information about nursing homes is extremely interesting and a story that I have been meaning to look into.
But by and large private non-profits don’t have a big stake in the health care industry, which is why I focused mainly on publicly traded companies in my post.
Also, publicly-traded companies are driven by Wall Street’s obsession with short-term (this quarter, next quarter) earnings.
It’s possible (though certainly not always the case) that private money will take a longer view, and therefore make better decisions that will, in fact, benefit the customer.
As for whether non-profits can also lose sight of their “mission”–absolutely.
Research shows that this is particularly likely to happen when non-profits find themselves competing, head-to-head with for-profits, and the non-profits start doing some of the things that their competitors do.
There is a lot of research on this subject, and despite Barry’s generalizations, the truth is that for-profit hospitals have a truly terrible history of cheating anyone and everyone. There is not a single large chain that has become the subject of an FBI raid.
This sort of thing rarely happens with non-profits–though it does happen.
Health Affairs has published comparisons showing the non-profits do much more in terms of service to their communities, on average they charge less, and have outcomes that are as good and very often better.
For-profit hospitals are outlawed in New York State–with good reason. They are more commonplace in the South, where politiciains were paid off to make them legal. (Some also saw for-profit hospitals as a way to keep healthcare segregated.)
When I was at Barron’s, back in the 1980s, I did an huge study of non-profit HMOs vs. for-profit HMOs–the differences were stark. For-profit HMOs rationed what they would and wouldn’t cover based on price; not-for-profit HMOs tried to “manage care” by figuring out what was and what wasn’t effective, the way the Mayo Clinic in Rochester, Minn does.
Ultmately the for-profit HMOS drove most of the non-profits out of business.
Greg– Thanks again for the information. I am going to follow up on this story . . .
Robert, Kathleen, j.d. Greg
Thanks for your comments.
Robert–
On why primary care docs aren’t as well paid: Their lobbyists aren’t as powerful as some surgeons’ groups because they are not as well paid and cannot make enormous campaign contributions.
But it’s also because of the way Medicare decides fee schedules. The people on the commitee who make the decisions are specialists, not family docs–and guess what . . .?
See this post on Who Decides How Much to Pay Specialists.” http://www.healthbeatblog.org/2008/01/who-decides-how.html
Kathleen–You’re absolutely right; reformers do get bogged down in the mind-boggling details.
Though when one tries to paint a picture of what health reform would mean–not everyone is happy with the picture.
If we’re going to make high quality healthcare available to everyone, we can’t afford to cover everything that everyone might think they want–even if there is no evidence that it works.
And some people won’t be happy about that.
The best way to paint pictures, I think, is to describe healthcare in countries where everyone has access and outcomes are generally better. . .
There were parts of Michael Moore’s movie, Sicko, that were inaccurate, but he did a very good job of portraying healthcare in Canada and in France.
jd–
Yes, I do recognize the distinction between private and publicly-traded for-profits–and of course, a private company’s pursuit of profits also creates a potential conflict of interest.
Greg’s information about nursing homes is extremely interesting and a story that I have been meaning to look into.
But by and large private non-profits don’t have a big stake in the health care industry, which is why I focused mainly on publicly traded companies in my post.
Also, publicly-traded companies are driven by Wall Street’s obsession with short-term (this quarter, next quarter) earnings.
It’s possible (though certainly not always the case) that private money will take a longer view, and therefore make better decisions that will, in fact, benefit the customer.
As for whether non-profits can also lose sight of their “mission”–absolutely.
Research shows that this is particularly likely to happen when non-profits find themselves competing, head-to-head with for-profits, and the non-profits start doing some of the things that their competitors do.
There is a lot of research on this subject, and despite Barry’s generalizations, the truth is that for-profit hospitals have a truly terrible history of cheating anyone and everyone. There is not a single large chain that has become the subject of an FBI raid.
This sort of thing rarely happens with non-profits–though it does happen.
Health Affairs has published comparisons showing the non-profits do much more in terms of service to their communities, on average they charge less, and have outcomes that are as good and very often better.
For-profit hospitals are outlawed in New York State–with good reason. They are more commonplace in the South, where politiciains were paid off to make them legal. (Some also saw for-profit hospitals as a way to keep healthcare segregated.)
When I was at Barron’s, back in the 1980s, I did an huge study of non-profit HMOs vs. for-profit HMOs–the differences were stark. For-profit HMOs rationed what they would and wouldn’t cover based on price; not-for-profit HMOs tried to “manage care” by figuring out what was and what wasn’t effective, the way the Mayo Clinic in Rochester, Minn does.
Ultmately the for-profit HMOS drove most of the non-profits out of business.
Greg– Thanks again for the information. I am going to follow up on this story . . .
In regards to pharmacueticals, please look at the bayer-dole act which allows newly discovered drugs, that were discovered through the NIH or money from the NIH to basically be handed off to for profit pharmaceutical companies for production, further development and profit. So, you paid for these meds development through taxes, you continue to pay for it with your medicare tax, and finally, you have to pay for it when you need it. I wish I could charge the general population three times for the same product!!!
Story on nursing home debacle appeared in ’07. Good job by NYT
http://www.nytimes.com/2007/09/23/business/23nursing.html?scp=2&sq=carlyle+nursing+homes&st=nyt
Paul Levy, CEO of BIDMC in Boston, summarizes an interesting presentation by Brent James on his blog today which can be found at: http://runningahospital.blogspot.com/. The two key points are: (1) the factors that affect life expectancy can be summarized as 40% behavioral (tobacco, alcohol, obesity, exercise, etc.), 30% genetics, 20% environmental and public health, and 10% healthcare, and (2) we need to reorganize medical practice along the following lines:
“We can begin to overcome these problems by practicing medicine with a “Shared Baseline” approach (a form of LEAN production) in which you measure, learn from, and (over time) eliminate variation arising from the professionals — while retaining the variation that arises from the patients. He terms this “mass customization.” This will assisted by full use of electronic medical record capability, and it will need to be done to make full use of EMRs. Finally, care needs to be organized around the team of care givers, and not the individual practitioners.”
It looks to me like the work site clinics Brian is describing embrace this approach. I think making better use of information technology and getting doctors out of their individual silos will offer more promise than arguing over whether healthcare organizations themselves should be for profit or not for profit. As an aside, for profit organizations, whether publicly or privately owned, cannot sustain themselves over the long term unless they please enough customers enough of the time. If they don’t, their stockholders will eventually wind up with nothing and deservedly so.
Lets simplify this discussion a bit.
The major stakeholders are all major corporations linked by organizations with lobbying power.
Physicians and their patients are hard working caregivers and carereceivers focused on those tasks.
Retail clinics, workplace clinics or whatever-clinics are modes of delivery.
EMR’s connected to other systems are simply documentation systems connected to information systems to increase efficiencies.
Neither are a solution to the present physician predicament.
There are only two ways for workers to unify in this country.
Unionize and Strike.
or
Form corporations.
The former is not practical, unethical and illegal.
That leaves one option.
Put another way, there is no other option.
Forming a replacement for what the AMA is supposed to be or should be is also not an answer. The AMA has failed because organization hold no sway in this society.
Only unions that strike and major corporations do.
Someone please disagree with me.
lgc
Lets simplify this discussion a bit.
The major stakeholders are all major corporations linked by organizations with lobbying power.
Physicians and their patients are hard working caregivers and carereceivers focused on those tasks.
Retail clinics, workplace clinics or whatever-clinics are modes of delivery.
EMR’s connected to other systems are simply documentation systems connected to information systems to increase efficiencies.
Neither are a solution to the present physician predicament.
There are only two ways for workers to unify in this country.
Unionize and Strike.
or
Form corporations.
The former is not practical, unethical and illegal.
That leaves one option.
Put another way, there is no other option.
Forming a replacement for what the AMA is supposed to be or should be is also not an answer. The AMA has failed because organization hold no sway in this society.
Only unions that strike and major corporations do.
Someone please disagree with me.
lgc
In response to the last comment, I would state that many doctors practices are incorporated as are non profit and for profit hosptitals, so the idea of forming corporations does not solve the problem. The issue is influence on decision makers and the degree of organiztion and the size of these other players on the medical landscape. The American Hospital Association exerts immense influence on the political process, yet it is a trade organization acting in the same manner as the AMA. Another example is the trial lawyers who have exerted great influence on medical liability reform through their trade association. The difference in each instance is that these organizations have a uniting goal for their members and generate enough expendable cash to effectively lobby congress. There ae no million dollar plus primary care physicians who can easily cough up sizable donations to the American College of Physicians to rally to their cause, but there are plenty of health care executives seemingly making 6 to 7 figure salaries who can do so. Same can be said for the several physician specialty societies that do an excellent job of lobbying and maintaining the current meidcare fee schedules despite what is becomng a crisis in the primary care fields. All can be traced back to the common denominator, which is those who have the bucks can fight more effectively to protect their interests in Washington while those that don’t lose. Has it ever been otherwise? Forming corporations is only saying what is needed is more effective organization and lobbying of decision makers, which is what large corporations do, but well funded organizations can be just as effective if they have a defined common goal.
Dr. Matt, Keith and Louis
Dr. Matt is right. In contrast to what Barry suggested, NIH does do some of the most important drug research But legislation passed by Congressmen on Big Pharma’s payroll gives that reserach to for-profit drug-makers, at no cost.
The taxpayer never sees a return on his investment. Instad, he pays top dollar for drugs created at NIH–so that the 10 percent of Americans who own 90 percent of the nation’s wealth can pocket double-digit returns.
Keith & Louis–
Louis, Keith is right corporations have Power because they have Money.
And internists don’t make enough money to form a super-wealthy corporation or lobby.
Though I do think that if
family docs, pediatricians, gerontologists etc. got together they could have more political power–particuarly if they talked to their patients about the need for health reform.
I’d love to see pamphlets in their waiting rooms, explaining what’s wrong with your health care system.
The problem is, family docs are too busy to have time to talk to patients about these issues. Still, pamphlets could let them tell patients where they stand. . .
I’d like to return to the main point of the post, which is that the profit motive needs to be abolished in health care.
Maggie, I’m aware of most of the history you describe in your earlier response to me, and I agree with your take on it. But I don’t think you’ve yet shown why incentives can’t be structured in such a way that the profit motive leads to greater efficiency and value creation in health care.
Yes, the for-profit HMOs forced many non-profit HMOs to behave more like for-profit companies which focused more on pricing and utilization management than on care management and prevention. But what if the market had been structured more like the Dutch market, in which there is guaranteed issue, risk adjustment, mandatory health coverage and other reforms? Do you think it still wouldn’t work here, though it does work in the Netherlands and Switzerland?
Or is your argument that, though this is possible, it’s too complicated or difficult to achieve, and so we should just abolish for-profit health care? That’s a hard case to make, because it isn’t just a matter of what we “should” do as a matter of abstract policy, but what we “can” do as a matter of political reality.
In the end, I don’t for a moment think that the nation would suffer if all healthcare went non-profit. Yet it is very unlikely to happen, and many of the same reforms that are needed to make a non-profit system work would also make a for-profit system work (or at least, work a lot better).
“In contrast to what Barry suggested, NIH does do some of the most important drug research But legislation passed by Congressmen on Big Pharma’s payroll gives that research to for-profit drug-makers, at no cost.”
And who decides which specific drug companies are to receive and benefit from this valuable technology? Can’t NIH personnel apply for and receive patents on new discoveries? When oil companies want to explore for oil and gas on federal land or off the continental shelf, they must bid for the right to explore. When cellular telephone technology was developed, licenses to provide service were auctioned. Even if the NIH is not (or does not want to be) in the business of taking new discoveries through clinical trials, it’s hard for me to understand how supposedly valuable technology can be simply given to a specific drug company when, presumably, numerous drug companies would be interested in acquiring it.
Barry and J.D. —
Thanks for your comments:
Barry, you write: ”
” it’s hard for me to understand how supposedly valuable technology can be simply given to a specific drug company when, presumably, numerous drug companies would be interested in acquiring it.”
You really just don’t get it. You seem to think that the relatinship between govt and enormously wealthy corporations is fair and honest.
Ezra Klein explains how the world works: , a vast amount of medical research actually takes place in the hated public sector. The federal government funds 36% of all U.S medical research. In fact, of the 21 most important drugs introduced between 1965 and 1992, 15 were developed using taxpayer research. A study done in 1990 looked at 32 drugs on the market and found that 60% wouldn’t have been created without federally funded research.
So what we’re seeing here are dual subsidies. When the NIH discovers a drug, as they did with the cancer drug Taxol, they license it to drug companies at an absurdly low cost. Bristol-Meyers Squibb is currently the proud owner of Taxol, they sell it for $20,000 when it only costs $1,000 to manufacture, and the NIH gets .5% of the royalties. So taxpayer research ends up enriching the drug companies . . . Brilliant.”
Yes, drug companies bid for the right to produce–but they bid at “absurdly low prices.”
Why does NIH give its research away at absurdly low prices? Because that is what the White House and the majority in Congress want it to do.
Why is that? Two words: campaign contributions.
BTW– people working at NIH don’t take out patents on their reserach because they understand that the research belongs to the taxpayers who funded it. It would be illegal for anyone at NIH to try to profit from it.
j.d.–
There is a lot of good writing on what should happen in the for-profit sphere and what should be controlled or regulated by the public sphere.
In general, if something is a “public good” and especially if it is a necessity–there has long been a consensus that it needs government regulation if not government control.
So, in the past utility companies that provide heat, light and water have been regulated. We don’t want them “profiteering” (.i.e making excessive profits) on the necessities of life.
As a result, utilities can’t raise rates without getting permission from the state, etc. Traditionally, investors could make money on utilities, but only relatively modest amounts. Utility companies paid good, steady dividends (maybe 5 % or so–depending on where interest rates were–and where inflation was-at any particular point in time.)
But you did not expect any big capital gains from utilities. This were good stocks for conservative investors who wanted to save long-term–not for speculators who hoped to strike it rich by trading stocks.
In more recent years, utilities have tried to become “growth stocks”–with some disastrous consequences. Think Enron.
Enron did not see itself as in any way involved in providing a public service. If you see the very good, very funny movie about Enron (“The Smartest Guys in the Room”) you’ll find that the people who worked there thought it would be hilarious if they blacked-out all of California.
What is upsetting is that most of what Enron did was perfectly legal. The deregulation which allowed Enron to flourish was pushed through during a conservative Republican administration and it has created many problems. (See books on Enron, particularly “The Smartest Guys in the Room)”.
Many people–including some Wall Street analysts–believe that if health care companies like drugmakers and insurers are for-profit, they should not be “growth stocks” that try to deliver double-digit earnings and capital gains.
See my book “Money-Driven Medicine” where I quote Wall Street analysts talking about this. They believe health care companies should be businesses that, like old-fashioned utilities, are regulated, are not allowed to “gouge” the public in their pricing, and deliver modest returns.
Some analysts warn that if drug-makers, insurers, for-profit hospitals continue to cheat and gouge, they will be taken over by teh govt–or that, at the very least, prices will be capped.
IF the private insurance industry was regulated in this way (wasn’t allowed to cherry-pick, wasn’t allowed to sell policies filled with holes) many insurers would probably simply go out of business. They wouldn’t find the business profitable enough to be really attractive.
(This is the way it was before Ronald Reagan changed the HMO law in about 1981. For profit insurers never used to be in the health insurance business. Reagan changed the law to make it much easier for them to compete with not-for-profit HMOs–and ultimately, drive many out of business while also greatly lowering the quality of health care. )
Drug companies also need to have their prices regulated –as they are in every other developed country in the world. Today, as you see in my comment to Barry above, the NIH is already doing much of the most valuable drug resesch. We don’t need to give it away to for-profit companies–and if we had serious campaign finance reform, we wouldn’t.
Education is another “public good” that seems to work best when it is not-for-profit. This is in part because, like health care, it is labor-intensive.
You don’t want schools or hospitals “down-sizing” to increase their profits. When you raise teacher-student ratios (or try to teach hundreds of kids on closed-circuit TV as some for-profit outfits have tried) kids don’t learn. When you raise nurse-patient ratios, patinets die.
The rules that work in for-profit businesses–being “lean and mean,” for instance– do not work well when you are trying to produce and deliver a public good.
Rather than the “profit-motive” you need what not-for-profits call a sense of “mission” driving decisions.
following this discussion peripherally.
Just read today’s (4/4/08) front page WSJ article on not-for-profit hospitals, I encourage all following here to check it out.
Maggie, wonder what you think about the article. My first impression, especially when looking at the flat screen TVs and the executive pay and the reinvesting bond revenue in tax free higher return securities, and the counting wages as “community benefit” and the small percentages of charity care and the suing patients and……….
wait, what’s the non-profit part about again?
Sounds like a lot of money being passed around on things other than patient care. Does calling it non-profit mean anything?
pcb–
The piece in the WSJ is very good– I was planning to quote it in Part II.
Clearly, there are not-for-profits and there are not-for-profits.
Some do provide a huge amount of service for the poor. Often these are academic medical centers located in inner cities which also provide a public service by training med students. (Training students costs more than they pay in tuition and labor, though the govt gives these hopsitals extra money to help cover the cost.)
But clearly some not-for-profits do not deserve the tax break. I wrote about this on http://www.thehealthcareblog.com before I started this blog. See
Increasingly, not-for-profit hospitals built in affluent suburban areas really are not earning the tax break. They have purposefully located in areas where there are very few poor people. And they don’t bus them in.
Moreover, in areas where real estate prices are very high, the fact they don’t pay property taxes is an enormous break that many don’t deserve.
We really need to audit not-for-profits to see how much community service they provide.
And while flat-screen TVs may be a relatively small cost, the TVs and all of the other amenities do add up.
It seems to me inappropriate for hospitals to spend money on what are clearly frills while there are so many poor people not receiving care, and so many not-for-profits struggling to stay open in very poor areas.
I think those wealthier hopsitals should probably have to pay a tax that would go into a fund to help hospitals in inner citites and in rural areas.
If they want flat-screen TVs in their rooms, fine. But they should charge their patients for them so that the flat-screen TVS pay for themselves.
And given the healthcare crisis in this country, there is something inappropriate about all of the marble, atriums, towers, mahogany, etc.
I’m sure people heal better if they have sunlight, and certainly they need very clean, pleasant surroundings and healthy, appetizing food.
But I don’t think that the expensive finishes, super-expensive art work, or furnishings helps anyone heal. It’s all for show–to boost the hospital’s prestige, and to make very wealthy patients feel that this is a hospital for “their kind of people.”
The money might much better be spent on health information technology & preventing infections.
I just got around to this post and comment threat. Too long to read from the monitor, so I’m printing it out to read later. (Maggie Mahar is costing me a fortune in paper and ink. This time it runs to twenty pages.)
Forgive me, but I have to tell this:
Guy called a plumber to do a small job. The plumber spent about forty-five minutes and handed him a bill for two hundred dollars.
“Holy cow!” the guy said. “I don’t make that kind of money and I’m a surgeon!”
The plumber said, “Well I didn’t make that much either when I was a surgeon.”
==========
I just got a recommendation at another comment thread to get Paul Starr’s book “The Social Transformation of American Medicine.” According to Wikipedia Star was a Clinton adviser with superior credentials. Just passing it along…
Hootsbuddy–
I’m smiling out loud– both teh paper and ink and your plumber.
Yes, Paul’s Starr’s book is fantastic. Won a publitizer in about 1982, and for good reason.
His book inspired me to write my book. I
basically pick up where he left off.
He writes a brilliant history of American medicine from the beginning to the early 1980s, with a focus on the
period fro the 1960s to the 1980s.
In the eary 1980s he could see that we were enteriing an era of “corpoate medicine”–i.e. for-profit medicine
that would be money-driven.
He hoped it wasn’t true, but of course it was.
My book focuses primarily on the period from 1980 through the early 21st century . . .
Do read Starr’s book; you’ll enjoy it.
The permalink to Klepper’s reply is
http://healthpolicyandmarket.blogspot.com/2009/03/will-cigna-remake-health-plan.html
The worksite clinic strikes me as a very promising idea. I’m sure that doctors face the same array workplace environments we all do. (I was in food service.) At one end is a grinding, stress-filled, pressure cooker that takes all your energy and at the other end a more peaceful place with a reasonable schedule and work load where you might also have a life. (Food service extremes run from institutional operations with adequate staff and normal schedules at one end to 24/7 fast food operations with high employee turnover and the boss spending half his life as a line employee.) Brian Klepper reports no problem finding and retaining staff and I can believe it.
I like the idea that these operations are positioned to challenge more powerful, embedded interests — hospitals, specialists, drug and appliance companies, Congressmen and their multi-layered incestuous symbiotic relationships you have described so well. I especially like that otherwise uninsured or underinsured family members may also benefit.
With a more generously staffed national network of public health departments doing the same thing for the unemployed, there might be enough worms in the apple to bring about some real systemic changes.
That 3.1:1 “hard” ROI he mentioned interests me. I know you don’t like it if it went to shareholders, but I’m wondering if that might be something other than actual funds. I’m thinking indirect savings in less lost worktime/overtime, workers comp charges, better attendance, reduced FMLA interruptions.
The more I read the better I like a 3-tier approach with a bare-bones Medicare-E at the bottom and two private insurance plans for those who need/want more.
Yes I remember when there are market distortions one has to ask why. In this case there is a shortage of primary care physicians. Without going into any of the usual reasons, in a capitalist society there is only one answer – the “profit” isn’t high enough.