The Problem With Healthcare Bundling
I have written here often on the various reasons healthcare in the U.S. costs more than it does in any other developed country in the world:
· Legislators Need to Prevent Denial of Access to Healthcare,
· Government Belligerence Isn't the Answer to Fixing Healthcare,
You might think I had about run the gamut of ways the U.S. healthcare wastes money and denies care, but there's one topic I haven't covered yet: healthcare bundling of costs into single payments for doctors. In my case, the bundling of the costs of prenatal, delivery, and postpartum care into one extremely low Medicaid payment.
As I've written before, most of what goes into a good office visit with a physician can’t be measured and therefore is totally missing from any heatlhcare payment to physicians:
To my way of thinking, most of what was the best of prenatal care, delivery, and postpartum care has disappeared and sadly without even anyone to mourn its passing. So, what did we have that worked so well and was so important to the best long-term results?
Let’s start with postpartum care. As a group of doctors, including the American College of Obstetricians and Gynecologists (ACOG), we have always failed our patients in postpartum care, and we have failed in postpartum care for a long time. When I was in medical school, we were taught that postpartum care ended at the six weeks postpartum visit to check that the uterus had returned to its normal size.
To make matters more complicated, it is now my understanding that ACOG recommends transition to some other primary care provider for the rest of a woman’s healthcare issues . This manufactured and unnecessary gap in postpartum healthcare adds one more nail in the coffin of continuous care, which is supposedly our official goal.
In this way, general practitioners or family practitioners would be ideal except that ACOG has had a war against primary care doctors delivering babies for as long as I can remember, which is about 50 years.
Today, postpartum depression, suicide, homicide, drug overdose, myocarditis, pulmonary emboli, preeclampsia, eclampsia, hypertension, stokes, as well as bleeding and infection, can cause postpartum deaths. These conditions are real and they exist in real time and in real life, not just on an electronic medical record (EMR) checklist. Having experienced no maternal mortalities in my approximately 6000 deliveries, I can tell you that most of these postpartum problems are either avoidable or easily treatable in their early stages. And many of the problems are not the purview of the primary care physician who does not regularly handle pregnancies. It makes far more sense for women to continue to go to their obstetrician for women's healthcare issues. Suggesting that women switch their healthcare to a primary care physician after their six-week visit to their obstetrician makes no sense. It also assumes women have access to primary care physicians, a medical specialty that our current healthcare system is destroying by rescinding their hospital privileges and replacing them with hospitalists.
What will pop up on the EMR form is whether we have filled out the relatively useless Edinburgh postpartum depression inventory and, of course, if the physician has indicated the need to send the patient to a psychologist or a psychiatrist for the treatment of depression. That also preserves and defends the relatively territorial aspect of medical practice.
So, the intangibles which cannot be measured are the ones that provide the best care, the best satisfaction, and the best outcomes. I have always encouraged the entire family to come for prenatal visits. This way I got to know the family and they got to know me and they all got to know the new life in the mom’s uterus before birth. This is the opportunity to do real, meaningful prevention of postpartum depression.
As I have indicated above, I think that obstetric care is disintegrating, and I don’t think its passing will be mourned by anyone, because mourning requires the recognition of loss and you can’t lose something you didn’t know was present.
In order to make life more pleasant for the obstetricians today it is fairly customary to have many different providers during the prenatal course and for mom to not know the delivering doctor or to even have met the delivering doctor. There is enormous value in one provider getting to know the family during the prenatal course, and to provide the continuity of care through delivery and postpartum not only for the first year, but for decades. My patients had no need to find a primary care provider to take over their care of women's health issues after their 6-week checkup of their uterus. I could provide the postpartum follow up as well as any other provider and I did for years.
Bundled care is the term given to one payment for all services rendered. So, what that means for obstetric care is that every single visit, including the delivery with one or two postpartum visits is included in one price. The $1400 payment I received for taking care of a Medicaid patient for 10 months in no way reimbursed me for the care my patients received.
For over a decade, I had my own practice with 26 employees including three doctors, one of whom was the first perinatologist in the state of North Dakota. I also had in my office the first neonatologist in the state of North Dakota.
Certainly, there were upsides to having my own practice. For example, I could see patients as often as they needed to be seen without arguing with the CEO, but there were downsides. As a physician in independent practice, I did not have a large enough patient base to go after providing care for groups like the nurses in the hospital or the teachers at school who generally have very good insurance. These healthy, low risk groups would be "bought" by the Preferred Provider Organizations (PPOs). The PPOs wanted to take in the people with the most money and the least need for healthcare. PPOs were not interested in people with little money, those often excluded from a PPO group. No matter what these groups call themselves or how they justify themselves, their main goal is to make as much money as possible for the least expense. Because my private practice was relatively small, I lacked the clout to negotiate with the big companies for inclusion in their programs. As a result, I was left caring for the excluded group who had the greatest need and the least ability to pay.
We have heard a lot about Medicaid recently, including Medicaid fraud, abuse, and waste. The point of bundling care is to limit care, exclude healthcare service, and save money by depriving consumers of healthcare access. In the United States, approximately 40 percent of births are financed by Medicaid, the single greatest payer for maternity care. Nearly 2 out of every 3 adult women are enrolled in Medicaid during their reproductive years, ages 19 through 44. Medicaid's bundled fee for my total obstetric care was $1400.
As I’ve said before, the best care is the cheapest care. What that means is that a term delivery producing a healthy mother and a healthy baby is the absolutely cheapest way to deliver obstetric care. Denying care simply puts off taking care of early healthcare problems which can be addressed easily and putting off treatment until the medical problem requires thousands of dollars to resolve. Medicaid refuses to pay reasonably for a good delivery but will pay more for a delivery which goes south, more often than not, for lack of good care.
Medicaid is a very good deal for states and the federal government, at least as far as normal obstetric care goes. For physicians, Medicaid reimbursement of a $1400 bundled payment for providing 10 months of care is reprehensible. In the U.S., between the years of 2014 and 2017, it should be noted that 95 percent of physicians said they accepted new patients with private insurance but only 74 percent of physicians accepted new patients with Medicaid coverage.
This gap is much larger in some states than in others. Medicaid offers no appreciation for the good value physicians supply for keeping patients healthy. Furthermore, Medicaid claims departments are extremely difficult to deal with. One time in my private practice my staff had to submit a claim 11 times to get paid—a claim for about $50.
Years ago, an IUD would cost about $800 cash for my clinic, and the reimbursement from Medicaid was $200. What did work though was if the patient bought the IUD at the pharmacy and brought it with them to the clinic for insertion. Then we could at least break even on the visit. Medicaid is unanimously disliked by providers and patients alike largely because of hostile claims processing. I have had claims denied because they were submitted on the wrong size paper. Trying to get paid by Medicaid can be a challenge. And even if you are paid, you can find the payment disappear from your clinic checking account two years later with no explanation.
Today we have healthcare disintegrating in front of our eyes. Much is because of the Centers for Medicare and Medicaid Services (CMS) and legislative health policies. Now I'm not accusing CMS and legislators of getting up every morning and planning to wreck medical care, but they are not getting up every morning planning to sustain and repair our healthcare system. The Department of Justice is finally looking at the mess caused by the pork in the Medicare Advantage program, but there are no plans to repair the program. As I've written before, the Medicare Advantage program is robbing huge sums from the Medicare program to no advantage to patients. Medicare Advantage plans should be abolished.
There are also no attempts to reign in the private equity problems caused by Humana, CVS, and UnitedHealth. Large private equity organizations come in and buy ten hospitals, plunder the organizations for a few years, siphon off billions of dollars from the hospitals, and then close the hospitals, creating healthcare deserts and leaving communities in shambles.
Statista has many charts about the cost of healthcare in many countries. You can register for a free individual account to access many of their graphs. Their assessment of the problems with healthcare in the U.S. state the issues remarkably clearly (click see more on link):
It [the U.S.] is also the only high-income developed nation without universal health coverage allowing some 7.6 percent of the U.S. population to be uninsured….The miserable performance of the United States compared to other high-income countries has shown that the health system, as it is, is not working. When global comparisons are made, the United States alone accounted for 42 percent of total spending on health globally, which was higher than the combined spending on health by middle-income countries and low-income countries.
Our legislators need to wake up and care about the healthcare of their constituents. If other developed countries offer universal healthcare with much better results, it’s time to stop calling universal healthcare socialistic and start looking at how other developed countries provide healthcare to their residents for much less money and gets much better results.