Ricky's Riffs:

Random thoughts on Travel, Education, Health, and the World in General

New Models for Health and Healing

We are currently in a full-blown health care crisis. The Affordable Care Act (ACA, or Obamacare) roll-out was a disaster. People in some states are still struggling to register through exchange websites to buy insurance. Others resist being forced to get insurance at all (the young and healthy), while some have learned that, despite President Obama’s promise that they could keep their old insurance plans, they could not. For many, the new policies are shockingly expensive.

On the provider side, things are even worse. Allowable benefits have been reduced, and reimbursements slashed by 60% or more in 2013 alone. Facing these cuts, providers are being forced to leave insurance networks, provide reduced quality care, or just get out of practice altogether. Meanwhile, patient premiums are rising.

To be fair, there are some wonderful principles embedded in Obamacare. These will soon become a part of our national health care culture and include the following: (1) every person will have access to health insurance; (2) if one is unable to afford that insurance, our society (i.e., the federal government with our tax dollars) will provide assistance; (3) no one will be denied insurance because they have a pre-existing condition; (4) there will be a maximum out of pocket expenditure for the insured. These new principles help minimize the chance that a person will lose their life savings because of health care.

There is, however, a fatal flaw at the heart of the ACA. The legislation turns all of the responsibility for administering this radical new program over to the insurance companies. These are the very entities that (in concert with the pharmaceutical and medical device companies, surgeons and large hospitals) helped create this disaster in the first place. They failed to control costs, yet managed to increase profits; they undermined public health by downgrading protections.

Yet this industry is now rewarded with a huge transfer of public (taxpayer) funds into its coffers.

This is a classic example of a paradigm breakdown in preparation for a paradigm shift. People with vested economic interests in a system (the insurance industry) that failed to serve the needs of the public will now attempt to patch that system together, creating new versions of the “same old, same old.”

Because the insurance industry has been so deeply comingled with our views on health care, we assume this is part of the natural order. As a culture, we resist change. But why? Why should we reward these companies with the status of “middlemen” and allow them to skim dollars off of every transaction? No—the solution is disengagement. We need to minimize the insurance industry’s grip on health care.

When things fall apart, the radical becomes common sense

New ways of delivering health care will be driven by two forces: business leaders who have been paying rising premiums, and health care providers who are being forced, by shrinking revenues, to practice bad medicine.

Let’s look at a real-life example.

There are two types of health insurance most industries need to carry: general health and workers compensation.

The general health benefit covers doctor visits, hospital stays, medications, and other services related to personal health. These policies usually have deductibles and/or co-pays. They are our HMO’s and PPO’s. Through these plans we manage chronic diseases like diabetes and hypertension, as well as health emergencies that require immediate attention–such as broken bones or heart attacks.

Workers compensation, on the other hand, covers injuries received on the job: a back injury caused by heavy lifting, a chemical exposure, or a burn. There is 100% coverage for such work-related injuries. The insurance companies, however, control the type and level of care through a cumbersome and stringent review process.

Steadily increasing workers compensation premiums have been eroding company profits. In some industries, like construction and heavy manufacturing, premiums can be as high as $30 for every $100 of payroll. These costs are threatening high-risk industries with closure, potentially eliminating thousands of skilled and unskilled jobs.

But these costs are understandable. Once a worker is injured and a claim has been filed, expenses pile up quickly. They might include medical treatment, imaging (X-rays and MRI’s), disability payments, or attorney fees.

The solution seems clear. Workers need to side step the system. Not by giving up their right to treatment–a strong workers comp system must be maintained to cover those injuries that are not preventable–but by providing preventative care so that they avoid the injuries that drove them into the system to begin with.

For example, one of the primary causes of disability is low back pain. Imagine that a worker who is experiencing low back pain is able to get treatment for non-disabling pain before he or she is forced to file a workers comp claim and go out on disability. Imagine that person could go from the factory floor to an onsite clinic–at their work place–and be evaluated and treated by a chiropractor with an expertise in back health. Part of the treatment would be to teach at-risk workers the best stretches and exercises to prevent further damage and help strengthen their bodies. In addition, they would be instructed in proper ergonomic behavior at their workstations. Finally, imagine that the chiropractor could refer that hurting worker to a massage therapist, also on site, to loosen the muscles and provide a sense of well-being–then complement those therapies with yoga, meditation, or a boot camp program also offered on site.

What is happening here? The worker is having his or her pain acknowledged and addressed. Support is offered, and not just in word.

Much (but certainly not all) back pain will resolve over time, whether treated or not. But appropriate care will facilitate healing and improve results. When offering the services described above, workers will be far less likely to enter the workers comp system–thus less likely to incur the medical, legal and disability costs that are driving some high risk industries into the ground.

Now imagine that another worker can go to that same onsite clinic and see a medical doctor, a nurse practitioner, or a naturopath. This provider can evaluate the worker for systemic problems, and screen for the risk of heart disease and diabetes. After the medical professional does their evaluation, they can refer the worker to appropriate exercise or weight loss classes or even to a psychologist to help deal with emotional issues that may contribute to their problems. It is now well established that anger, depression, anxiety, and substance abuse will increase the risk of work injuries and disability.

How and why this works

The central feature of this plan is its focus on wellness and prevention. Once a worker has slipped into the workers comp system or the hospital/medical complex, treatment becomes much more labor intensive and costly. Treatment becomes reactive rather than pro-active.

In our current fee-for-service, or “sick care” system, reactive medicine is financially rewarded. The more treatment rendered after an illness or injury, the greater the reimbursement to doctors and hospitals.

And there is little profit in disease prevention for the pharmaceutical companies. Creating a society of people who are dependent on daily medication(s)–for the rest of their lives—is big business. When this is coupled with doctors’ fears of litigation, we end up with a health care system plagued by overtreatment.

In the onsite clinic I described above, providers are paid a set fee for a day of work. Their mandate is to keep workers healthy, not just to treat them when they are sick or injured. Mechanisms will still be in place for workers legitimately injured on the job, or suffering from the effects of chronic disease. But reducing the number diverted into the “reactive care” system will dramatically reduce costs to both workers and employers.

Positive effects will go beyond the purely economic. Benefits will be realized in the form of improved employer-employee relationships, less time lost getting to off site medical appointments, fewer disability claims, and greater incentives to attract high quality workers.

Doing the math

As with all paradigm shifts, change will come from the edges of power–in this case, from employers and workers who want to take control of their health care expenditures and providers who practice with a focus on prevention, rather than “sick care.” Real change will not come from the centers of power: the insurance industry or the medical/hospital complex.

Google has a full integrative clinic on its campus. Apple has opened a health center with medical doctors, chiropractors, acupuncturists, physical and massage therapists, and exercise physiologists. These companies get it. But they also have billions of dollars in reserve to fund these innovative programs

Is it possible to bring this concept into the factories and corporate offices of smaller companies? Yes—though Chief Financial Officers may resist adding a third health care cost to general insurance and workers compensation. But rather than see this as an additional expense, the onsite program must be viewed in light of how it reduces the costs of the other two programs: how much is saved with each worker kept on the job, and off disability.

The average cost of each workers comp claim is known to each industry, so a CFO can easily calculate the potential savings here. This also holds true (although it’s a slightly more complex calculation) on the health benefits side.

For example, a company of 1000 employees in a high-risk industry such as steel manufacturing reports six workers compensation claims per month, at a cost of $30,000 per claim to the company (medical plus ancillary costs including medical, disability, legal, etc.) If the model described above can reduce the claims by half, a $90,000 savings is realized. Even if that company is paying $30,000 per month for an onsite clinic, they have still reduced their monthly costs by $60,000. Savings will be realized on the general health benefits side as well, due to decreased sick days, injuries, and doctor appointments.

A new way

There are now companies springing up to implement these programs. I work with one—Mevident—as the Director of Onsite Services. We have a network of over 200 wellness providers and a technology platform that enables appointment scheduling, worker-provider communication, vertical quality control, and data collection. We have established protocols for wellness providers that describe scope of practice and provide guidelines that clarify when workers should be shifted into the workers comp or general health systems. We can customize our services depending on individual company needs.

We will undoubtedly be seeing other variations on this theme to satisfy this need.
The insurance/pharmaceutical/hospital/medical complex has controlled our health and health care system for decades. It has profited from our sickness. The sicker we have been, the more money it has made.

It is time to focus on prevention. And this is one way to do it. These on-site clinics will support workers, boost business profits, and contribute to a new era in American health care that is truly focused on wellness and health.

Dr. Ricky Fishman has been a San Francisco based chiropractor since 1986. In addition to the treatment of back pain and other musculoskeletal injuries, he works as a consultant in the field of health and wellness with companies dedicated to re-visioning health care for the 21st century. He is currently the Director of Onsite Services for Mevident. www.mevident.com

Copyright 2014 Ricky Fishman

8 thoughts on “New Models for Health and Healing

  1. Great concept but the evil forces of corporate greed will fight hard against it ignoring the economic reality of savings. We need a grass roots plan to inspire the people to make this a reality since certain industries like insurance, pharmaceutical, to name a few will resist and their lobbying efforts in Washington will outspend consumers and workers. Let’s do it!

    1. Ricky Fishman says:

      Thanks for the comment Steve. I agree the challenge is great given the powerful forces aligned against real change. I sometimes fantasize about forming a “providers union” to really challenge these forces. It seems oftentimes that there is a classic “divide and conquer” strategy taken by the insurance industry–squeezing all the providers so that they end up battling with one another over the remaining crumbs. If all the providers just said “no” and withdrew from all the networks and patients found that there were no providers to choose from, then the companies would have to re-consider their exploitive practices. We will see what lies down the road.

  2. Andrew Keehn says:

    Great insight in your piece. Again the insurance companies continue to exploit the American people and reap huge profits at the publics expense. Obama has negotiated a bad deal for the U .S. Public. He has given a guaranteed long term increase in their customer base and allowed them to NOT live up to their promise of lowering there rates to consumers. To the contrary they are raising rates to consumers and decreasing reimbursement to health care practitioners, profiting at both ends. We are now trying to follow the European model of socialized medicine with out socializing medical education, which is free in Europe. How can young drs. afford lower reimbursement with such high debt load from Med school? How can costs ever go down if we keep on handling health care in a reactive way vs. a preventative one?

    1. Ricky Fishman says:

      Andy–I so agree with your point about the imbalance between the cost of medical education and then the difficulty of trying to manage a health care practice (business). The average chiropractic school debt now is $150,000 for a full education. For medical school it is even more. Most people going into health care do it for the love of it. They want to help; to be healers. I believe that those people would still go into practice even if they did not become wealthy by doing so. But the disparity you describe makes this more and more difficult. Until these sorts of issues are addressed, the quality of care will continue to decline.

  3. David Fore says:

    Ricky’s concise assessment of the structure, promise, and perils of Obamacare are well-taken.

    Not mentioned, but implied in this post, are the countless ways that the healthcare ‘system’ resists any kind of change that doesn’t add to profits…

    The result is clear: you are hosed if you want to innovate beyond cynical ‘patient-centered’ programs that are just marketing campaigns in disguise or well-meaning but often useless rear-guard maneuvers to improve care within the incumbent system.

    That’s why I especially like when entrepreneurs come up with alternative healthcare systems that are coherent, compassionate, competent *and* go to the bottom line of the businesses paying for healthcare.

    Mevident isn’t going to replace our healthcare system–that’s not the point–but it is apparently providing valuable services to individuals, communities, and companies at lower cost. Even as it inspires others, perhaps to design similarly clever strategies that can help us rise above what’s ailing us.

    1. Ricky Fishman says:

      David, thanks for your comment. To me it feels like there is a “last gasp” for the insurance companies. Although they are incredibly powerful and clearly had a guiding hand in the writing and now implementation of Obamacare, I believe they are really incapable of seeing positive, “healthy” solutions to the serious problems at hand. The positive note here is that in this chaotic space lies opportunity to come up with creative innovative solutions rooted in improved patient care and sound business practices.

  4. You are identifying a huge problem, a debacle of a situation, and one that I am extremely passionate about as well, seeing a gaping hole and proposing changes and solutions to fill it, which I both resonate with and appreciate your efforts, bringing it up for discussion.

    So for me, it’s just the beginning, whetting my appetite to hear and discuss more from you. I want you to continue developing those systems of delivery of health care for workers comp, comprehensive health plan alternatives that deliver quality care cost effectively and expediently, other products or applications. I want to see more ideas, more proposals, so I could believe change is possible. You can be a light at the end of a seemingly endless tunnel. As long as there is a glimmer, I’ll keep going. The more clear and implementable your alternatives are, the more I’m going to want to actively participate in the change.

    1. Ricky Fishman says:

      Thanks for the comment Daniel. I have been thinking about and working on this problem for some time now and am grateful that I have found a team in Mevident that supports the implementation of these new ideas. We will definitely be moving forward in 2014 and I will keep you apprised of our progress.

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