By Kevin O’Connor
Times Argus (Barre-Montpelier, Vt.), Jan. 23, 2011
RUTLAND — Middlebury’s Dr. Jack Mayer knows that most patients want health care reform to cut rising prices. But he, along with a growing group of Vermont medical providers, hopes to point a scalpel at piles of related paperwork.
Back in 1976 when Mayer opened his first pediatric office in the tiny northernmost town of Enosburg Falls, the Bronx native often bartered his services for eggs, firewood or knitted afghans.
In a larger community and practice 35 years later, Mayer now works with two fellow physicians, a nurse practitioner and two full-time billing clerks who process claims for more than 200 insurance plans.
“Every company has its own paperwork, payment schedules and policies about what it will cover,” says Mayer, who notes that such overhead eats upward of 30 percent of U.S. medical expenses. “The administrative costs of my practice are enormous and don’t go toward improving health or patient care.”
Mayer isn’t alone in his assessment. So many Vermont medical professionals have similar concerns, the Legislature — now contemplating several plans to change the state’s health care system — will hold a public hearing in Montpelier this week to receive their testimony.
“What I hear from all my colleagues is, ‘For every hour I put into clinical care, I put another into paperwork,’” says Dr. Deborah Richter, a Cambridge physician. “They can’t give the care that patients need because of these obstacles.”
Richter is president of the Vermont Health Care for All campaign, which for almost a decade has pushed for what a state consultant proposed last week: a single-payer system to provide medical coverage to all residents.
Richter wasn’t sure if her peers would respond when the Legislature — welcoming public comment through Feb. 3 — invited them to speak Thursday from noon to 2 p.m. at the Statehouse. So far 50 colleagues have confirmed they’ll be there.
“These are busy doctors,” she says, “but they’re willing to talk.”
Nothing but billing
Take Dr. Adam Sorscher, an 18-year primary care physician who juggles work at Central Vermont Medical Center in Berlin, Dartmouth-Hitchcock Medical Center in Lebanon, N.H., (the New Hampshire hospital is Vermont’s second-largest health care provider) and the Good Neighbor Health Clinic in White River Junction. He finds problems wherever he goes.
“I see people at the clinic who have neglected preventive care because of the high cost,” Sorscher says, “and then we have to provide therapies that are more expensive and wouldn’t have been necessary if the health care system was better organized.”
Or consider Dr. William Eichner, an eye specialist who opened his Middlebury practice in 1976 and has added branches in Rutland and Ticonderoga, N.Y. To do so, he has increased his staff to 20 — three of whom focus solely on financial paperwork.
“They don’t greet patients, they don’t handle charts,” the ophthalmologist says. “They do nothing but handle billing and insurance claims.”
That frustrates more and more doctors. Richter points to a 2006 survey she sent to Vermont’s 840 primary care physicians. Of the 300 who responded, four out of five agreed with such statements as “Unnecessary paperwork increasingly is taking away more of my time from my patients” and “I don’t find the intrusion from outside managers and companies helpful.”
Providers say the resulting costs are pricing out more and more patients.
“I feel ashamed we’re the last developed country in the world not to have universal health care,” Eichner says. “I feel a moral imperative that everyone has access and that it be affordable.”
‘Have to kowtow’
Burlington’s Dr. Peggy Carey recalls when, lacking health insurance in her 20s, she was diagnosed with diabetes. Inspired by a nutrition course she took to deal with her diagnosis, she went to medical school and now works as a family doctor in a group practice.
“I wanted to change the system,” says the former English teacher turned 19-year physician.
Carey belongs to the doctor-led Vermont for Single Payer campaign and Physicians for a National Health Program. But she fights her biggest battles inside her practice.
“The majority of the paperwork that comes to me is not in reference to patient care,” she says, “but to what insurance plans allow or don’t allow.”
The problem isn’t limited to physical health. Psychiatrist Dr. Alice Silverman moved to St. Johnsbury two decades ago because the state’s rural Northeast Kingdom lacked enough mental health workers. Today she’s president of the Vermont Psychiatric Association — yet remains one of her region’s few resources.
“I’ve had a waiting list for years,” she says, “and there’s no one else I can refer to.”
Even so, insurance hurdles keep more people out of Silverman’s office.
“I may have someone who’s suicidal, but insurers say they have to see a provider in network, even when there is no one in network,” she says. “In psychiatry, people feel embarrassed enough — to have to call and get approval is a real obstacle. I spend 30 percent of my time trying to get care authorized.”
Burlington’s Dr. Joe Lasek, another psychiatrist, can relate. He works at the Howard Center, a private, nonprofit human service agency that takes care of his billing paperwork. But he still must tackle other insurance issues.
“If I try to get diagnostic tests or follow-up treatment for my patients, insurance companies can say no,” he says. “I have sick and sometimes suicidal patients who aren’t getting care.”
Such problems are keeping other professionals out of the business. Lasek’s wife has a medical degree.
“One of the main reasons she’s not practicing is these hassles,” her husband says. “I have other friends who are pulling back their hours or retraining in another field.”
Berlin’s Dr. Stuart Williams says a growing number of his colleagues support change. The 30-year practitioner is on the board of the Vermont Academy of Family Physicians, which found that a majority of members surveyed favor a single-payer system.
“It seems that physicians have capitulated responsibility to insurers,” Williams says. “We’ve become second tier when we recommend a procedure to a patient and have to kowtow to prior approval and paperwork to put that care in place.”
Different answers
Doctors may agree on the problem, but they aren’t united on the solution. While the Vermont Psychiatric Association has endorsed a single-payer plan, Williams — a member of the council of the Vermont Medical Society — says other medical specialists haven’t voiced a formal position.
Single-payer supporters believe state involvement will eliminate private insurers’ profit motives for questioning care. But they know that skeptics fear government interference.
“People worry that outsiders would be making decisions,” Sorscher says, “but important decisions already are being made by corporate entities.”
Proponents also point to the federal Medicare health insurance program, which, even with its own funding problems, estimates its overhead to be about 3 percent — a tenth of that of private insurers.
“It works for everyone over 65,” Eichner says. “Why not make it universal?”
Back in Middl
ebury, Mayer says physicians of all political opinions may complain about paperwork, but ultimately they’re most concerned about patients.
“If we as a nation take as a basic premise that health care should be a universal right of all citizens, equally, like Medicare, we will figure out an equitable way to pay for that,” he says. “My decision-making is impacted when I have to think about a person’s personal economics and how much some treatment will cost them. It’s just not fair for those financial considerations to get between me and the care my pediatric patients deserve.”
By Russell Mokhiber
Single Payer Action, January 20, 2011
Harvard Professor William Hsiao is a single payer supporter.
Twenty years ago, he helped push through a single payer system for Taiwan.
And now, he wants to do something similar in Vermont.
Over the past couple of months, Hsiao has been working feverishly – with a team of 20 researchers – to finish a report to the Vermont legislature on how to best implement a single payer system for the state.
Yesterday, he delivered his 132-page report.
And at the beginning of his one hour presentation to the legislature in Montpelier, he made it clear that “what I’m going to present is not necessarily popular for everyone.”
“Recently I was talking to an insurance executive,” Hsiao said.
“And I asked him if he was in favor of spending $50 billion to manufacture a new shuttle to the moon.”
“And he says – yes, if you will go.”
That got a chuckle out of the gathered legislators.
But clearly, the insurance industry is not at all pleased with Hsiao.
They are watching events in Vermont carefully.
The newly elected Governor – Peter Shumlin – ran on a single payer platform.
Shumlin said that in his first conversation with Hsiao last year, Hsiao told him that he had “given up on America.”
“I told him we are Vermonters,” Shumlin said. “We think independently. We take care of each other, and we do things that others dare not do.”
The Vermont legislature tasked Hsiao with putting forth and analyzing three proposals.
A pure single payer government run system.
The current system with a public option.
And Hsiao’s preferred system – a single payer system run by an independent board.
While Hsiao is not explicit about this in his report, the bottom line is clear – under Hsiao’s single payer proposals, the private health insurers in Vermont would be out of the business of marketing and selling basic health insurance.
That’s why the insurance industry would prefer to see Hsiao headed to the moon than on the ground speaking before the Vermont state legislature.
“Our analysis of the three health insurance companies with significant operations in Vermont – Blue Cross Blue Shield of Vermont, MVP, and Cigna – was much more limited than our analysis of other groups, partly because much of Act 128 has fairly clear implications for those companies,” Hsiao writes in his report.
“It is reasonably safe to assume that health insurance companies would oppose any major health system reform that reduces their autonomy in financing and paying for health care, increases government’s role, and/or introduces new competitors to their market.”
“However, given Vermont’s history with reforms such as guaranteed-issue, community-rating, and the Blueprint program, it must be noted that the remaining health insurers in Vermont – especially those run as non-profits – are likely more accustomed and potentially more open than insurers elsewhere to working with state-led regulations. In addition, a continued market for supplementary insurance would generate ongoing opportunities for private insurance in the state.”
“It is possible that one or more companies may be interested in partnering with the state and substantially reforming their business model in order to continue to operate in Vermont.”
And in fact, Vermont’s largest insurer – Blue Cross Blue Shield – with 75 percent of the state’s health insurance business – signaled yesterday that it might be interested in taking Hsiao at his word.
“If there’s a single payer system, we’d like to be the single payer,” Leigh Tofferi, the Blue Cross-Blue Shield lobbyist in Vermont told vtdigger.org.
But Hsiao warned of another possible insurance industry reaction.
“Of course, the opposite is also possible – that an industry with deep pockets nationally will oppose reforms due to the threats they pose to the Vermont market and other markets that could follow Vermont’s lead,” Hsiao wrote.
There’s not a mention of the report in today’s big three newspapers – the New York Times, the Wall Street Journal or the Washington Post.
Early indications are that supporters of a pure government run single payer system are willing to accept Hsiao’s public/private compromise.
Physicians for a National Health Program’s (PNHP) Deb Richter told vtdigger.org that while a government administered system “makes the most sense in terms of good policy,” the system doesn’t have to be controlled by the government to be effective.
And PNHP’s Don McCanne said that “although advocates of the pure single payer model will find some problems with this report on a reform proposal for Vermont, there is very good news in this analysis. The report emphatically confirms the superiority of the single payer model in ensuring that everyone is included while containing health care costs.”
“One very serious deficiency is that they decided to leave in place Medicare and Medicaid, primarily because of existing barriers to move them into a single payer system,” McCanne wrote. “Thus their proposal is not a single payer system. Leaving these programs in place sacrifices some of the important single payer efficiencies.”
“Within the next couple of days, we’ll have a clearer concept of where the single payer community should be on this report. Tentatively, it seems that it deserves our support, but support that is qualified by strong advocacy to make it right by such measures as including comprehensive benefits, and rolling in and eliminating Medicare and Medicaid,” McCanne said.
Governor Shumlin’s office is reportedly drafting legislation that will be introduced soon.
Clearly, Shumlin hasn’t given up on America.
Or at least on Vermont.