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Connecticut's Medical Community Examines Multiple Challenges In Health Care Reform

ARIELLE LEVIN BECKER

September 08, 2009

Ask Dr. William Handelman what's wrong with the health care system and three of his patients come to mind.

One was covered by the state's HUSKY insurance program for poor children and their families, but the family lost their coverage when their son graduated from high school. The patient stopped taking his blood pressure medication without telling his doctor, had a brain hemorrhage and, after being airlifted to a hospital, died.

Another lost his health insurance after switching careers and went a year without taking his medication, aggravating an underlying kidney disease. At 27, the patient is probably facing dialysis within five years, Handelman said.

A third patient, who has insurance, ran out of money for the co-payments on the medications he needs after a kidney transplant. Hartford Hospital, where the transplant was done, arranged for him to get the medications, but the patient didn't have the money for gas to get there. So Handelman, a Torrington nephrologist and president of the Connecticut State Medical Society, took care of the gas money.

And those were just in the past month.

"I don't know of any doctors who think the current system is fine and dandy," Handelman said.

But there's far less agreement among doctors and hospital officials on how to fix it. Their positions vary widely, from advocating a single-payer model — a system in which health insurance is handled by a single agency, a concept that has gotten virtually no attention from lawmakers — to advocating changes with little role for government and many positions in between.

Their wish lists vary, too: Limit malpractice awards. Change the way care is rewarded so that doctors are paid more for spending time with patients instead of just performing procedures. Leave care decisions to the patient and the doctor. Allow medical professionals to determine standards that government programs use to hold providers accountable.

Cover Everyone, But How?

There are some areas on which many doctors and hospital officials generally agree. Many providers, for example, think it's important for more people to be covered.

"The more people who are insured, the better off it is for everyone, and the better off it is for providers," Hartford Hospital Vice President Kevin Kinsella said.

But some say the nature of the coverage can be as important as who gets covered.

That's because the rates of payment that hospitals and doctors receive for patient care vary widely depending on who is paying. Medicare and Medicaid pay below the cost of treating a patient, so care for patients on those programs is a money-loser for providers. Doctors and hospitals can make up that money on the fees they charge private insurance companies.

According to the Connecticut Hospital Association, state hospitals lost more money treating people on Medicaid than they did treating those without insurance in 2007, the last year for which data are available.

Part of the hospitals' Medicaid and Medicare losses come from the administrative costs of complying with government rules. By contrast, some uninsured patients are able to pay their bills and some of the money they can't pay is covered by a state fund for uncompensated care.

Stephen A. Frayne, the hospital association's senior vice president, said the problems that hospitals already have with government health programs underscore a concern about how health coverage is expanded.

"From our perspective, expanding coverage is great, and looking for ways to reduce the cost is terrific, but you have to make sure that when you expand this coverage you're going to make it possible for those you're depending upon to provide the care to actually stay in business," Frayne said.

Paying For What You Get

If you're one of the 20 to 25 patients Dr. Ayaz Madraswalla sees a day, he might counsel you for 20 minutes on eating a proper diet or talk to you about quitting smoking.

"I make 20 bucks for that," the Mansfield family doctor said. A specialist performing a procedure on the patient would earn far more.

Money isn't the reason Madraswalla chose to become a primary care doctor. But he and other physicians say they are frustrated with the way the health care system seems to undervalue prevention, paying more for a surgeon to treat a problem than for a doctor to help a patient avoid the problem in the first place. It's one reason experts cite for a shortage of primary care physicians, something that could become more problematic if 40 million to 50 million more people get health insurance and need doctors to see them.

Lawmakers are looking at several changes to the way doctors and hospitals are paid.

"There has to be some recognition within the payment system that there is value to people who don't necessarily perform procedures, but who perform the thinking functions that are necessary for a physician," Handelman said.

Some doctors have reservations about how health reform will change that. Dr. Laureen Rubino, chief of surgery at Eastern Connecticut Health Network and president of the Hartford County Medical Association, supports making preventive care a higher priority. However, she said she worries that health reform might make it more difficult for patients to see specialists and lead to lower reimbursement rates that could make it more difficult for physicians to maintain practices.

Lawmakers have also discussed tying doctor or hospital pay to patient outcomes and specific standards. A House proposal, for example, calls for reducing payments to hospitals if Medicare patients are readmitted for potentially preventable reasons, a move intended to prevent hospitals from discharging patients too soon.

Hospital officials say it is important to make sure the standards do not penalize hospitals or doctors for things that are not their fault — if, for example, a patient is readmitted after failing to take the prescribed medication at home.

Similarly, some doctors say the move toward evidence-based standards is a good one but caution that doctors shouldn't be held financially accountable for things their patients control. Madraswalla, for example, could counsel a patient to quit smoking, but should he be paid less if the patient fails to quit?

Malpractice

Many doctors say health reform must target another culprit — the malpractice system and the "defensive medicine" they say it promotes.

It goes like this: Doctors worry about the consequences of missing a condition in a patient. So they order more tests than necessary to be extra sure of their diagnosis, driving up health care costs.

Rubino said she believes that tort reform would stop the growth of medical costs and should be a key piece of health care reform.

"If we don't get tort reform in there, we will continue to protect ourselves by ordering [tests], and the costs will continue to go up," she said.

Kurt Barwis, the president and CEO of Bristol Hospital, said doctors should be afforded "safe harbor"-type protections that people in other industries receive if they follow the proper procedures but still have a bad outcome. Barwis said that people who are harmed should not lose their right to be compensated, but that shielding physicians who take appropriate steps from liability would help eliminate unnecessary tests and costs.

"When people do things wrong, I'm not saying that people shouldn't recover and be compensated for their pain and suffering," he said. "But I am saying a step in the right direction to create an environment where people don't feel like they have to do double or triple the things to protect themselves, I think is a critical element to how we can succeed."

Changes to the malpractice system have not drawn the attention from lawmakers that doctors might like. And some analysts are skeptical that it is a large driver of medical costs. The nonpartisan Congressional Budget Office concluded in a 2004 report that "savings from reducing defensive medicine would be very small."

States with limits on malpractice had no statistically significant difference in per-person health costs from states without limits, the CBO analysis said. The report noted that "some so-called defensive medicine may be motivated less by liability concerns than by the income it generates for physicians or by the positive (albeit small) benefits to patients."

Flood Of Paper

The malpractice system frustrates many doctors. So does paperwork.

"It's become much more difficult to practice medicine the way I thought that we should be practicing medicine," Madraswalla said. "If you see the amount of paperwork that comes across my desk every day, to me it's staggering."

Much of that comes from trying to coordinate permission for tests, procedures or medications for patients with many different insurance plans. His office, Mansfield Family Practice, includes five doctors, a nurse and two physician assistants, and 16 full-time positions to handle the support work, including four to handle referrals and make sure that patients have the proper authorization to get the care their doctors suggest.

Madraswalla supports a single-payer system. He believes that medicine is not compatible with a for-profit business model and he sees a trade-off with government payers. Medicare, he said, "beats physicians up" because it pays so much less than they charge. "But from a patient standpoint, if you have Medicare, you can basically get what you need."

Handelman thinks medicine will change significantly under any system overhaul. The majority of state doctors currently work in practices with just a few physicians — a system he likens to "mom and pop" practices.

That stands in contrast to the well-integrated systems like the Mayo Clinic or the Cleveland Clinic that President Barack Obama and other reform advocates have pushed as models, where primary care is linked with specialists by far more than referrals.

Many of the savings that advocates of health care reform talk about come from such efficiencies. In Connecticut, at least, Handelman cautioned that it will not come quickly.

"That can't possibly happen overnight," Handelman said. "It would take at least a generation to transform medicine to where we're all practicing in Mayo Clinics and Cleveland Clinics."