Medical community weighs in on health care reform proposals

A tear slides out of Donna Epperly's eye as she sits in an exam room at Belle Terrace Health and Wellness Center and remembers the death of her son, Joey, last September. She also remembers the care she got then from clinic physician Angela Overstreet-Wright, and not just for her high blood pressure.

"I had a hard time dealing with that (death)," said Ms. Epperly, 57. "But she helped me through it."

Ms. Epperly is among the more than 45 million people in the U.S. without health insurance. It isn't offered through her job as a private baby sitter, and she cannot afford to purchase an individual policy on her own.

After years of debate and false starts, there is serious talk in Washington about providing coverage for the uninsured and reforming problems that cause the U.S. to spend far more on health care than any other industrialized country, but with sometimes inadequate results.

What that reform will look like depends on your perspective.

For Ms. Epperly, being able to go to the Belle Terrace clinic, which receives funding as a federally qualified health center, is a blessing. She pays a $25 co-pay per visit, which she likes.

"I pay here, but it's not like I would pay a private doctor," she said. "With no insurance, I would pay a lot."

She looked into buying health insurance a few times, but it was too high. She knows she isn't alone.

"There's so many people who need help with insurance," she said, and she is more concerned about children going without.

"Someone like me, I'm older," Ms. Epperly said. "But I see on TV so many children who can't get help, can't get care, because they don't have insurance."

If the government is going to spend more money, clinics such as Belle Terrace make sense to her.

"Putting money into clinics like this, that's a good thing," she said. "These clinics like this are great."

When she first started coming to the clinic, "my blood pressure was really bad," Ms. Epperly said. "But today it was great. It was right on it."

More than that, Dr. Overstreet-Wright takes the time to talk to her, she said.

"It makes you feel better when you've got a doctor who will sit and talk to you and listen to you," Ms. Epperly said.

For Melinda Rider, the CEO of the Neighborhood Improvement Project, which runs the Belle Terrace clinics, that is the concept of a "medical home" where the patient can be followed and the care managed. For her, reform is about good outcomes. Her clinics have to be able to show that to one of the federal agencies that funds it, the Health Resources and Services Administration.

"We have to demonstrate that our patients get better," Ms. Rider said. That might not be a bad idea for everyone, she said. Under Medicare, that is called "pay for performance," tying reimbursement to quality outcomes.

"All payers are starting to look at that more and more," Ms. Rider said.

It ensures the patient actually gets better and that care can make a difference.

"They're going to have a better life," she said. "They're going to live longer, they're going to feel better, take care of their families and go to work."

It would also be cheaper to keep those diseases in check.

"We spend an awful lot of money on health care but very little of it on preventive care," Ms. Rider said. "Most of our resources are devoted to high-end sick care."

Three chronic diseases that seem to be causing the most damage -- obesity, hypertension and diabetes -- could also show the greatest benefit from regular care.

"I think the emphasis on primary health care is really important, and the emphasis on prevention," she said. "We have an epidemic of hypertension and diabetes that show no signs of slowing down. If we don't deal with those upstream problems, the downstream is always going to be swamped."

But putting more emphasis on prevention means having the providers do it.

"We can't push everybody into primary health care if there is no facility there to do it," Ms. Rider said.

That cooperation is a key point to Dr. Terrence Cook, an Augusta allergist who is chairman of the Project Access Committee of the Richmond County Medical Society, which coordinates voluntary physician services for the uninsured.

Project Access does pretty well in getting uninsured people into primary care offices, and patients benefit from prescription assistance programs from the manufacturers, Dr. Cook said.

Where the system runs into trouble is when a patient needs more specialized care, especially complex surgeries, that would cost a lot of money to provide. In that instance, having access to some kind of insurance would help those patients, Dr. Cook said.

"If they had a basic plan that would cover certain serious illnesses and surgical conditions, that could be very helpful," he said.

But he's also worried about the "public option," a government-created insurance plan President Obama wants to see in the mix of plans offered to the uninsured through a centralized insurance exchange as a way of putting pressure on private insurers to keep rates down and provide better coverage.

If the public plan operates like Medicare, which demands the lowest rates a provider offers, it could affect what private insurers decide to do, Dr. Cook said. And that could affect those who already have insurance.

"Whatever the plan is, and depending upon how punitive the plan is, regular health insurance tends to line up and say, 'Me too. I want the same deal,' " Dr Cook said. "If it's not going to pay for this and it's not going to pay for that, well, they'll get on the bandwagon pretty soon and copy that. Whatever those restrictions are, pretty soon it will creep into the private-sector insurance."

He wonders what good those plans would do for the patients.

"It's not a great help to you if they're not going to pay for things you need," Dr. Cook said.

If the plans are that bad, physicians won't take them, which defeats the purpose, he said.

"If it's not a plan that the majority of practicing physicians will accept, then you've not solved the problem," he said.

A lack of providers is also a concern about health reform shared by Don Snell, the CEO of MCG Health Inc., which runs Medical College of Georgia Hospital. That concern came after a briefing some Georgia hospitals received earlier this year from the Massachusetts Hospital Association.

Massachusetts moved toward universal health care coverage by requiring adults to have some form of health insurance, with some subsidies, and requiring employers of 11 or more to provide coverage or pay a tax to opt out. Individuals could access plans through the state Health Insurance Connector. The Obama administration is pushing a similar model for the nation.

All has not gone smoothly in Massachusetts.

"The enrollment was much greater than they had anticipated," Mr. Snell said. "The program is larger than anybody had anticipated. That has caused them now to go back and say, 'Wow, how do we pay for the size of this thing and the scope?' "

That was echoed in recent weeks when a component of one of the Senate health care bills was priced by the Congressional Budget Office at about $1 trillion over 10 years. Mr. Obama insisted Wednesday that those figures are off and that the reform can be funded through redirecting subsidies already in the system and eliminating some charitable deductions for those making $250,000 or more.

Even if there is insurance, it doesn't ensure access, Mr. Snell said.

"What's being talked about is universal access in terms of insurance. But that doesn't ensure that there will be a provider network," he said. "Massachusetts is having trouble treating these patients because while they now have insurance or some sort of a financial vehicle, the rates are such where a lot of providers are not signing up for it."

Mr. Obama acknowledged this problem Wednesday. A similar problem happened with Georgia Medicaid managed care, with little more than "safety net" providers signing up for it, Mr. Snell said.

"And to this day there's not much more than the safety net providers," he said. "And that's one of the lessons I think that needs to be learned and incorporated."

Though there is talk of making significant changes, hospitals have seen this before and all that ends up getting reworked is how they are paid, Mr. Snell said.

"I think the hospital industry's fear is that maybe that's all that emerges," he said.

Paul Fischer, who helped found the Center for Primary Care clinics that now dot the Augusta area, is not optimistic either. Dr. Fischer, who is also a member of the Institute of Medicine, points out that the U.S. spends much more than other nations, including Germany and Japan, but still doesn't cover about 20 percent of the people.

"It's not that we're not spending enough money; we're spending enough money," he said. "We're just not getting enough value for the money that we spend."

He points to three main areas for reform: eliminating incentives for unnecessary care, reforming the way insurance companies operate and reforming malpractice laws, which he says account for about 20 percent of health care spending when defensive medicine is included.

"I think all Americans would agree they don't think they are getting their money's worth if they're spending 20 cents on the health care dollar to be able to sue their doctor," Dr. Fischer said.

The payment incentives encourage unnecessary and unneeded care, he said.

"There are things being done in health care that are being driven by profits and not medical need," Dr. Fischer said. "And the other part of that is that as a society we are producing way too many specialists and too few primary care physicians."

Primary care physicians tend to lower costs and specialists increase them, he said, but all of the incentives in the system steer medical students toward the specialties.

"If Washington ends up with legislation that does nothing for that difference, then they'll just make the problem worse," Dr. Fischer said.

Evidence that many areas won't be addressed can already be seen in the number of organizations that have joined hands with the White House, he said.

"To be quite honest with you, I don't expect health care reform this go-around," he said." If you look at what's happening now, everybody is cutting a deal with the White House. They're getting their little piece secured."

Pharmacist Stewart Flanagin , the owner of Hill Drug Co., had a similar view of the pharmaceutical companies lining up with Mr. Obama last week. The companies announced they will provide $80 billion more to cover 50 percent of the cost of brand-name drugs for Medicare Part D patients when they run into a coverage gap. Mr. Obama touted that money as a move toward a potential funding source for health care reform. Mr. Flanagin isn't so sure.

He and other retail pharmacies have been suing the drug companies for nearly two decades to stop their practice of giving discounts to mail-order pharmacies that they won't offer to retail. Yet more prescriptions are filled by retail pharmacists than by mail, Mr. Flanagin said.

"People buying drugs at retail are paying the highest price anyway because they're not getting the discounts that they're giving mail-order and everything else," he said. "There's just inequity across the board."

Fairness is what reform would mean to him.

"We're trying to make it a level playing field at the retail level vs. all of the other levels because that's the only way we can compete," Mr. Flanagin said. "If they would sell the drugs to everybody at the same price, there wouldn't be an issue, but they're not."

The uninsured are paying the highest prices of all, he said. He would like to see a situation where a customer gets the same price for a drug, regardless of where they pick it up.

Reach Tom Corwin at (706) 823-3213 or tom.corwin@augustachronicle.com.

Q&A

Q: How big a part of the economy is health care?

A: About one-sixth of the economy -- more than any other industry.

Spending on health care totals about $2.5 trillion, 17.5 percent of our gross domestic product -- a measure of the value of all goods and services produced in the U.S. That's up from 13.8 percent in 2000 and 5.2 percent in 1960, when health spending totaled just $27.5 billion -- barely 1 percent of today's level, according to the Kaiser Family Foundation, a nonpartisan health policy group.

Q: Why does President Obama say the health care system must be fixed first to repair the economy? Is it true?

A: It's absolutely correct, for a host of reasons, experts say.

"Health care is the economy," and fixing it would free money for other priorities, such as education and industrial innovation, said Meredith Rosenthal, a Harvard University professor of health economics and policy.

The health care system is dysfunctional and full of waste -- as much as 30 percent of all spending, she said. Unlike most other markets, consumers rarely know which doctors, drugs or treatments are best for them, don't price shop and, if they're insured, don't know the full cost of care. That all can lead to unnecessary spending.

Kaiser's president, Drew Altman, said health care costs have become pocketbook issues for businesses and both insured and uninsured Americans. Kaiser's polls on what consumers worry about find the cost of health care and insurance are equal with job security, gas prices and being able to pay the mortgage.

"People make the link, not just the president," he said. They're most concerned with how reform will affect them personally, he said.

Q: How do health care costs drag on the economy?

A: Growth in overall health care costs, including spending on the huge Medicare and Medicaid programs, is out of control, said Robert Laszewski, the president of consultants Health Policy and Strategy Associates. That limits how much money the government and businesses have to invest in solving the energy problem, developing products that can be sold to other countries, creating technology that can bring medical breakthroughs, building infrastructure and more.

Q: How do rising health costs affect workers and businesses?

A: Insurance premiums have skyrocketed, making it ever-tougher for workers and employers to afford them. From 1999 through 2008, annual premiums jumped 119 percent, according to Kaiser data. The average family premium paid by workers rose from $1,543 to $3,354 a year, and employer payments per worker jumped from $4,247 to $9,325.

During that span, worker earnings rose only 34 percent and overall inflation was just 29 percent. So worker income has barely kept pace with inflation, more of the paycheck is going to health costs, and there's less left over for things such as vacations, dining out, home improvements or a new car -- especially for low-wage workers and retirees. That represents a huge drag on the economic growth, considering that consumer spending powers about 70 percent of the economy.

For employers, particularly small businesses, rising insurance premiums mean there's far less money for new equipment, better facilities, research or expansion. That means fewer jobs, smaller raises and higher health premiums for workers, further limiting consumer spending.

Q: What's the impact of 50 million Americans having no insurance?

A: Ira S. Loss, the senior health care analyst at Washington Analysis, puts it this way: "We're paying to take care of those people."

Hospitals, particularly in inner-city and rural areas, charge patients with insurance more to help make up for those who can't pay their bills. And we're all paying more in taxes to cover extra payments by federal and state governments to hospitals that have more uninsured patients.

Q: Isn't health care one of the few parts of the economy that's growing?

A: Yes. Employment in the huge health care sector has grown by about 427,000 jobs -- nearly 3 percent -- since the recession began in December 2007, and it totaled 15.5 million jobs in April, the latest month with U.S. Bureau of Labor Statistics figures were available.

Most of the increases came in ambulatory care services (up 254,400 jobs) and hospitals (up 148,400 jobs). That was partly offset by job declines at pharmaceutical companies, drug wholesalers and pharmacies.

However, only 42,900 jobs have been added since January. That's because the steady growth in jobs in ambulatory care, hospitals and, to a lesser extent, health insurers, has slowed dramatically over those months, with hospitals adding only 7,700 jobs and insurers just 1,000.

-- Associated Press

Health center seeks to reduce strain on ER

In an effort to keep patients who need primary care from using the more expensive emergency room, the Neighborhood Improvement Project is opening the Belle Terrace Downtown Health Center.

The clinic was made possible through a $134,000 grant from the Georgia Department of Community Health, one of three pilot projects being funded around the state, said Melinda Rider, the CEO of the Neighborhood Improvement Project. The clinic will be housed in Professional Office Building II, 818 St. Sebastian Way, next to University Hospital.

The clinic, which will be open from 9 a.m. to 10 p.m., will have a grand opening in a few weeks, Ms. Rider said. It should allow the group to double the 7,000 patient visits it is providing through its clinic in south Augusta, Belle Terrace Health and Wellness Center, she said.

More importantly, it will help patients get better care in a more appropriate setting, she said.

"It frees up resources," Ms. Rider said. "Emergency rooms ought to be taking care of emergencies, and this will free up those resources to do that. And we can take care of those non-emergencies at a much lower cost."

If it is a success, the clinic could provide an example for others to follow, she said.

"If we can make an impact on that, that will be a tremendous help, really nationwide," Ms. Rider said. "I think they are looking for models. If we can develop that model, that's a tremendous cost savings."

-- Tom Corwin, staff writer

Vital statistics

18% - Georgians not insured

92% - The increase in average family health care premiums for South Carolinians since 2000

Source: healthreform.gov