In this study, Dr. Ashraf A. Hilmy, with a surgeon's objective, no-nonsense precision and an unabashed lack of political correctness, dissects the current state of health-care delivery in America. In practice since 1979, he is board certified in surgery, anesthesiology, critical-care medicine, and health-care administration. He received an MBA from the University of Texas, Pan Am with an emphasis on health-care administration. He has served as both chief of surgery and staff at several institutions and has practiced in every scale of facility-solo, partnership, and group practice. Dr. Hilmy is uniquely qualified to render an informed opinion about health care in the United States. In his professional judgment, there is no question that the current system is faltering and in need of radical reform. No other country in the world spends so much on health care and has so little to show for it. Written with the layperson in mind, Health-Care Reform offers insightful, well-researched, supported arguments. Though it does not set out to offend anyone, people will be offended-as a portion of the drivers of escalating health-care costs are laid squarely on their shoulders. Health-Care Reform addresses how health care is delivered in America. By comparing our delivery system to those used around the world, Dr. Hilmy breaks down different cost drivers with anonymous case examples, and finally, offers suggestions for realistic reform.

Health-Care Reform

A Surgeon's PerspectiveBy Ashraf A. Hilmy

iUniverse, Inc.

Copyright © 2012 Ashraf A Hilmy, Hilmy, MD, MBA, FACS, FACHE
All right reserved.
ISBN: 978-1-4759-5230-8

Contents

Introduction...................................................................viiChapter 1: Health-Care Delivery in the United States...........................1Chapter 2: Comparative Health-Care Delivery Model Analysis.....................11Chapter 3: Drivers of Health-Care Costs........................................19Chapter 4: Specific Examples of Anonymous Cases................................39Chapter 5: Meaningful Reform...................................................57Chapter 6: Postscript/Obamacare................................................95Conclusion.....................................................................99Bibliography...................................................................101

Chapter One

Health-Care Delivery in the United States

About half of the health care delivered in the United States is done by private, physician-owned practices, down from 70 percent in 2002 to 50 percent in 2008. This statistic does not differentiate between independent hospitals hiring physicians and integrated healthcare systems hiring physicians. It also does not differentiate between physicians employed by the government (Veterans Administration, National Health Service) and large, integrated health-care systems. Indeed, the overall number of employed physicians is increasing and is projected to grow by 24 percent between 2010 and 2020, according to the Bureau of Labor Statistics.

But that does not mean that they are being employed by large, integrated multispecialty group practice organizations such as the Mayo Clinic. These statistics pool all employed physicians into one big pot. There is a big difference between being employed by a standalone hospital as a hospitalist (a primary care physician who practices at the hospital without an outpatient practice) and being employed by a large, integrated, multispecialty health-care system. Though the physician is employed, and thus will be a statistical number adding to the pool of employed physicians, that employment model does not offer the advantages of a comprehensive health-care system, as will be illustrated.

With the exception of a few large multispecialty group practices—Mayo Clinic, Scott and White, Kaiser Permanente, and Marshfield Clinic, to name a few—the majority of health care is delivered through small, mom-and-pop or cottage industry practices on a fee-for-service basis. The introduction of the group practice model occurred around the turn of the twentieth century. It was pioneered by the Mayo brothers in Minnesota and by Garfield and Kaiser around the Great Depression at a time when that concept was unheard of.

Under the current model, payment flows from the payer source—private insurance, Medicaid, Medicare, and private pay—separately to providers, which include hospitals, medical practices, and ancillary providers (labs, outside radiology centers, etc.). There is no integration of services or resources between these providers. It's a free-for-all model with everyone billing separately for their services (fee-for-service).

The cottage industry model consists of multiple independent practices—family practice, internal medicine, surgeon, cardiologist, gastroenterologist, etc.—that are all geographically and otherwise independent of each other. Each practice has its own record keeping. Some have paper charts and others electronic medical records of varying types that do not communicate with each other or with hospital medical records. Without the pooling of resources, the cost of advanced information technology that would allow for all physicians to have access to a common electronic medical record is out of reach. Consequently, each practitioner does not have immediate access to information contained in other medical records. Each practice has its own billing and administrative staff, all of which could be pooled together to serve a larger group practice for a fraction of the cost.

There isn't an overseeing body that could implement best-practice guidelines and insist on evidence-based medicine as the gold standard to be emulated. Each practitioner is independent and answers to no one. There is no accountability because there isn't a physician employer. There is no group organizational culture. There is also no economic credentialing. For example, when comparing the cost of health-care delivery among different physicians for similar outcomes, if it costs the system twice as much for me to remove an appendix than it does my colleague and the outcomes are similar, then I'm costing the system too much money compared to my colleague, and I should be counseled accordingly.

At the end of the day, the cottage-industry physician answers to no one. He is not held accountable for the cost of care that is being delivered or for the best practice guidelines that are to be emulated. His compensation is dependent upon how many procedures he does. His financial rapport with his colleagues depends upon referring patients to them for further testing, and the "scratch my back, I'll scratch yours" principle takes hold. Also consider this in light of the "cover my ass" medicine that is practiced in fear of medico-legal retribution. Everyone is scared of being sued, so many times multiple experts are called in to manage cases. There is an old saying in medicine: "It is easier for six people to carry the coffin."

In cottage-industry medicine, physicians have no allegiance to any particular hospital, laboratory, or imaging center, so patients are sent to various facilities for fragmented portions of their care depending on the preference of the treating physician. There is no pooling of resources, so each medical encounter is a new one for the patient. There is no common medical record, so needless documents are generated and regenerated. Diagnostic tests are repeated over and over at the discretion of the treating physician. There is no medical home for the patient.

Frank, a sixty-seven-year-old man with a history of diabetes, high blood pressure, and heart failure, presents to the emergency department of hospital X at 10:00 p.m. with complaints of abdominal pain, nausea, and vomiting. The emergency medicine doctor on duty evaluates the patient. A decision is made that the patient needs to be admitted to the hospital for further evaluation and treatment of his abdominal pain, which is believed due to acute cholecystitis—an inflammation of the gall bladder—and for management of his diabetes and heart failure, both of which are out of control.

Frank's primary medical provider does not practice at hospital X and so does not come to take care of Frank's medical needs. The emergency department does not have access to Frank's medical records from his primary provider. There is no way to know what has been done for Frank's diabetes and heart failure, like what medicines he has been given, what tests have been done, and what treatment strategies have been implemented. Similarly, the treating physician does not have access to the evaluation that was done for Frank at another hospital, hospital Y, a couple of days earlier for the same complaints.

Another barrage of tests is ordered—blood work, an echocardiogram, a CAT scan of the abdomen, and an abdominal ultrasound, all of which have been done at another facility just days before. The same conclusion is reached: Frank has a bad...