Comments on: A simple proposal

By: Adam Bosworth’s Proposal for Healthcare 2.0 « Simples Assim

Adam Bosworth’s Proposal for Healthcare 2.0 « Simples Assim — Sat, 28 Mar 2009 22:42:04 +0000

[...] a comment » Adam’s proposal could really work, even some numbers aren’t accurate. It recalls Nota Fiscal Paulista, a tax [...]

By: adambosworth

adambosworth — Thu, 12 Mar 2009 14:25:18 +0000

A couple of comments.
The typical primary care physician is getting only $100/patient today on average. This isn’t my proposal. This is current fact. This proposal actually doubles it for at risk patients. So no matter how low the proposal may seem to you, it is actually a 100% raise for the compensation for the at-risk patients (call them 1/4 – 1/3 of the panel).
Cost savings are only going to be realized when consumers are engaged in a dialog with their physicians and others and engaged in an ongoing manner. It is relatively incontrovertible that a huge amount of the expensive procedures and hospitalizations required by our system are directly due to avoidable diseases due to lifestyles which have changed greatly for the worse in the last 20 years. We have to try to address this because we have no choice. Waiting for the baby boomers to all get heart disease and diabetes Type II and strokes and trying to treat that will be worse.
Financial incentives do work and this is actually the lynch pin of my proposal.
It would be great if the employers will pay and they do indeed benefit, but you have to prime the pump and prove that this is changing lifestyles.

By: James R

James R — Fri, 06 Mar 2009 19:57:51 +0000

Some observations

1) $100 for care coordination. “A typical primary care physician who treats elderly Medicare patients must coordinate care with 229 other physicians working in 117 different practices, according to a study by researchers at the Center for Studying Health System Change (HSC), Memorial Sloan-Kettering Cancer Center (MSKCC) and the Dana-Farber Cancer Institute” in the February 17 Annals of Internal Medicine.http://www.rwjf.org/qualityequality/product.jsp?id=38949

2)Cost savings as a result of preventive care. NEJM Feb 14th 2008 “Sweeping statements about the cost-saving potential of prevention, however, are overreaching. Studies have concluded that preventing illness can in some cases save money but in other cases can add to health care costs.3 For example, screening costs will exceed the savings from avoided treatment in cases in which only a very small fraction of the population would have become ill in the absence of preventive measures.” Bascially people will live longer and cost more in the end. http://content.nejm.org/cgi/content/full/358/7/661

3) Compliance vs outcomes – Numerous employers have used financial incentives http://seattletimes.nwsource.com/html/health/2008798417_wellness01m.html to encourage healthy behavior and early statistics are encouraging, portraying a work force that has improved in 12 of 14 risk factors.

4) Other financial incentive models – Medical Home Model we are starting to see primary care docs opt out of the insurance system and change a monthly fee of $50 to 100 a month for primary care retainers, hour long visits, limited practice size (500) no admin staff and double their gross to over $400,000 a year. http://seattletimes.nwsource.com/html/pacificnw/2008628080_pacificprimary18.html

There is disconnect between who pays for care (consumers, employers government) and who benefits from the savings so do a join venture with insurance companies or self-insured employers if you have a viable business model. There should be more then enough resources without tapping the Government HIT funds for the private sector providers and consumers. Amazing to see private sector firms like yours Adam ponying up to the public trough so quickly? What happens in year 4 when the funds are gone? Leave that money for public health and critical access providers.

By: Scott Kozicki

Scott Kozicki — Thu, 05 Mar 2009 07:55:11 +0000

Even if it’s off by 100%, it doesn’t change the fact that what PCP’s get out of the pie is ineffective relative to the value that they *could* create. Incentives are very important. There’s enough data liquidity in the system to move it effectively between patient, PCP, specialists, hospitals, labs, etc. You don’t need an EMR/PHR to do this. It helps with scale, but 90% of MD’s use faxes still as their channel of choice. But what’s really important is the relationship between a good doctor and the patient.

The model that I’ve been evangelizing is driven by the employer, since that’s where the money starts in the US. They can decide how much they want to spend relative to the ROI on the beneficiary. If you’ve got 3+ risk factors that are leading to an imminent $50K event, then it might make sense to spend upwards of $30K to intervene. Obviously, most people aren’t going to be in that situation (hopefully) but evaluating what their real risks are, what the potential cost of doing nothing is, and then balancing how much value the MD, the member, and the employer want to get out of that – well, there’s the solution right there.

By: Ha Vo

Ha Vo — Thu, 05 Mar 2009 07:21:55 +0000

Hi, loved the way you broke it all down into numbers. I totally agree with the online approach and as IT service provider I know that such a system can be implemented for just millions. The approach should be divided into a central vision, standards, security, authentication … For governmental bodies to regulate. All central data and most crucial services should be offered through an SOA based portal. This should allow the private sector to create their own tools in different technologies, using the key webservices that are provided through the centrally managed Portal.

Anyways, loved your blog! Thnx. Feel free to check my ideas and numbers about Health 2.0.

By: adambosworth

adambosworth — Sat, 28 Feb 2009 18:34:20 +0000

Quick reply. It is a back of the envelope calculation I’ve tested with a bunch of people in the health care arena. I’m told that there are about 130,000 primary care physicians. i’m also told consistently that after the costs of malpractice insurance and insurance filing costs, the average primary care physician is grossing about $150,000 a year or less. So I multiplied 130,000 times $150,000 which yields $19.5 billion. It may be off, but hard to see how it can be off by a lot.

By: John Smith

John Smith — Sat, 28 Feb 2009 18:13:04 +0000

I would like to know where that $20 billion figure for primary care visits is coming from? According the the National Health Expenditure (http://www.cms.hhs.gov/NationalHealthExpendData/downloads/proj2008.pdf) physician and clinical services accounted for about $500 billion (page 4 of the document) of healthcare spending in 2008. I am sure a lot of that is lab tests and specialist visits, but how are you getting only $20 billion for primary care? I just want to understand where the numbers are coming from.

By: e-Patient Dave

e-Patient Dave — Sat, 28 Feb 2009 01:01:45 +0000

Terrific post and terrific thoughts, Adam. It was great to see you deliver the pitch at TEPR, and I’m glad the slides are online. I’d *love* to see a fully animated version of the slides; the way you showed the progression year by year was gripping, compelling, irresistible. (Can you tell I appreciate it when something is communicated effectively?)

I got a vision today that the way we’ve been pumping money into our current healthcare system is a lot like a cancer, which grows uncontrollably by diverting well-meaning biomechanisms to grow new “pipelines” (blood vessels) to draw more nutrients (cash, blood) to itself, having lost all connection with why the mechanism exists in the first place.

It’s dysfunction at a biological level.

And in an instant I saw that we’d benefit from a hefty dose of what works for a lot of cancers, too: antiangiogenesis. Your proposal would divert the funds away from the dysfunction to something that serves system health.