Disclosure: I work in a small family run, nationally respected, innovative, trail blazing, conservative, effective, essential, medical/dental, chronic pain practice, with one doctor/dentist. We serve our entire state and plus parts of our surrounding states. We are the only game in town and this is not by choice. Our doctor will be the president of a national academy concerned with TMD. Primarily we treat TMD (TMJ) and secondarily Sleep Apnea. We are innovators in quality of care, conservative treatment, treatment coverage, patient advocacy, narcotics prescribing, dealing with narcotics abuse and TMJ care under a medical model. We have many patients with private insurance, such as, BCBS, MVP, Cigna, UHC. We have many patients with government run programs, such as, Medicaid, Medicare, V-Hap and Tricare. We have been closely involved in the development of policy that has opened up coverage opportunities for patients and improved the lives of thousands. We are unique in our experience, perspective and success, mostly because of the reality that only one other state has the TMJ law we have.
I am a patient. I am the son-in-law of the doctor. My wife and I are the clinic directors: we are involved in running the clinic, the business, solving technical issues, training staff and we see patients. I have virtually no medical training or perspective out side the context of this office. I did grow up in a household that provided a perspective on Mental Health Care, which I do value, as much as chronic pain care. I know something about both of these areas, do to my father and my father-in-law. I grew up with great healthcare coverage because my father worked for Kaiser and I did not want for anything medical. This lead me to be stereotypically concerned with healthcare in America and for myself…I did not see it as a huge issue until I worked for my father-in-law and I did not take care of myself to any great degree until more recently. I am relatively healthy luckily. I have a masters in fine art and am a licensed art teacher. I am part of a trailblazing generation of cartoonist with an education in cartooning. I am one of a handful of cartoonist with a BFA and MFA in our field. There for I am expert on the unique role comics in American culture and in its role in the essential value of art education (there is a need for more public and governmental support in these areas). But I am not an expert in Health Care. If you want to actually call on someone for advice I would recommend my father-in-law, Dr. Jeffrey Crandall. Who is a Republican. I am a Democrat; emotionally libertarian, intellectually socialist. This brings me to my perspective, which surprises even me.
Partisanship:
This is a Bipartisan issue that does not need Bipartisan support. It is too important to be bogged down in politics. The regrettable manipulation of this issue by Washington insiders has lead to a furry that on some levels speaks to real concerns, but truly has distracted from effective communication.
Co-Ops
On the surface this seems like a great idea, as long as it is divided into small manageable numbers of participants. In other words a national Co-op would be to bureaucratic and take to much away from advocacy. But to small of a Co-Op will be insufficient in negotiating appropriate rates with hospitals. There would have to be mandatory requirements to provide availability to all who want to participate regardless of income level, a member run board with truly transparent process for claims and clear requirements for coverage that approach true concerns of efficiency and effectiveness of treatment that is not discriminatory to body parts or preexisting conditions. If done intelligently I would prefer this option to any public plan.
Public Option
If I did not work in the medical field, I would blindly be in support of this option. However, I must underscore that the three public plans we currently accept in our office are truly not what I consider an acceptable model. They are not good programs. They are broken programs. Tricare is the worsted of the three, in the fact that they treat our veterans and military to a bureaucracy that fails to support their care and hinders our ability to care for patients. I can’t tell you how many staff meetings we have had where we have discussed the option of dropping Tricare and we know the essential need and duty we have to serve our military. At times, Tricare makes it impossible and our patients just woefully agree and accept their fate. Medicaid pays, sometimes late, but at a rate that relies heavily on our charity, which we have in abundance. Medicare is not as bad, but their reimbursement rate governs our rates and we are not seeing the rises in revenue reported in other areas of Medicine. We just raised our rates for the first time in over a decade and it was by less then 10%. I am worried that another public option will be another broken program, made more expensive and inefficient by bureaucracy. By the way, the low payouts are passed onto other patient’s insurance premiums and out of pocket expenses.
Universal Health Care
A single payer system does work for many countries, much more efficiently then ours. And the longevity of life is greater, in part do to this. But the care for chronic illness is poor in these systems, complex issues are miss handled and miss treated. There are benefits in our chaotic, but independent system that meets needs for some patients more effectively then these other systems, unfortunately the numbers of patients that are benefiting in our country is shrinking.
Private Insurance
Don’t by their hype. While some do have well intentioned professionals in their midst. The vast majority of these companies in our experience pay 20% less then they should to doctors. They are just as bureaucratically inept as government programs. They stand in the way of efficient care for patients despite logic. They are just as big a part of government games as any other. They are the corrupt corporation conspiracy they are accused of being. Only government reform can keep them in line, and yet they are in the room making the reform.
Diagnosis v. Procedure v. Results
Our Doctor out of necessity takes more time to collect data and patient information then any other Doctor I am aware off. This results in the correct diagnosis, in what is a very complex issue. If all my doctors did this I would never get in, but on the other hand in our office we are efficient and we are providing a quality of care that is appreciated and has helped reduce redundant expense and avoided misdiagnosis. It is not unusual because of the nature of the complexity of TMD that we are the 7th Doctor in 20 years that has tried to help a particular patient. Yet there are doctors we know of who use this method of note taking to abuse their patients, because of a lack of research and understanding and the nature of victimization in our patient pool. That being said all you have to do is turn on Discovery Health to realize that there is little incentive for Dr. to take the time to discover what the problem is, before treatment. My wife went through this type of experience and we hear it in our practice every day. Dr. need to be reimbursed primarily for their Diagnosis and the validation of this diagnosis. Results are a great incentive, as long as they are not applied in a black and white manner that discriminates against chronic pain and terminal disease. Procedures should be the least important measure of expense. The system as it stands promotes redundancy and unnecessary procedures and has lead to the over payment of surgeons and dentist and the underpayment of PCP’s and TMJ “specialists.” As it stands if you want to make money, become a plumber.
Chronic Pain
While there is plenty of discussion about dealing with life threatening issues and preventative medicine there is virtually no mention of managing chronic pain. This is shocking because of the level of cost it ways on the system and how it affects our economic productivity, let alone our pursuit of life liberty and happiness. Many of the solutions to other problems efficiency effectively lead to discrimination and the care for chronic pain patients. These are problems that deserve efficient and accurate diagnosis, but leave a reality of long-term care that does not always result in fixing the problem, simply managing it and reducing progression of the problem.
TMD (TMJ Dysfunction)
It is time that patients with TMD are no longer discriminated against. The TMJ has always been cared for by dentists, but finally two states require medical insurance coverage for a problem that involves bone, nerves, muscles, tendons, joints, soft tissues, the mind, posture, breathing and yes teeth. I have heard that 25% of our population experiences some sort of jaw pain in their lifetime. We know from anecdotal and empirical evidence that TMD is a complex condition subject to miss diagnosis and requires sometimes coordination between Dentists, ENTs, Neurologists, Physical Therapists, Psychologists, Pharmacists, Orthodontists, Oral Surgeons, PCPs, Sleep Specialists and TMJ specialists (technically there is no such specialty, which is why we are not likely at any table in the room helping form the government healthcare proposal). And yet, only 16 states cover surgery and only 2 cover conservative treatment. Which in our office means that 95% of TMD patients are either paying out of pocket or not getting treated at all. There is a huge correlation between, domestic abuse, poverty, chronic head ache pain, TMD, drug abuse and borderline personality disorder. Yet, there is little communications between practitioners who deal with these issues that affect our communities nation wide. In Vermont, once we started offering effective care and there was insurance coverage we became a practice that helped solve virtually all the problems the health care bill is concerned with. We have a waiting list of 250 people all the time. We have serviced 1% of our states population to date. That is one Doctor for the entire state.
Dental Care
Should be covered under Medical. It is time the Dental Community start being respectably included in the care for the human body and at the same time not be able to get away with price gouging and elitism.
Malpractice
This is such a small issue. Important, but small in the context of inefficiency.
Narcotic Prescriptions
Our practice is particularly skilled and experienced at appropriate effect prescribing of narcotics for chronic pain. When other means are insufficient, it is appropriate to prescribe opioids, if they are effective in reducing (not necessarily elimination) pain. But you must have what we have in place a well written Opioid Contract, an effective Prescription Monitoring System, clear communication between law enforcement, Doctors, pharmacists, substance abuse programs and patients. With out this we have over prescribing, under prescribing, fear and abuse.
Staffing Shortage and Training
We know there is a staffing shortage first hand. Our state has been trying to recruit PCP’s, Dentists, Nurses and PA’s for a long time. Our office has searched far and wide to find a competent dentist to join us, and we had one of the worlds best ready to, but he decided to stay closer to home and stay at the Military hospital in Bethesda. We need another TMJ “specialist.” But we have exhausted most hope. It could be very likely that my father-in-law will be forced to retire or die before we find a replacement. Where will our state be then? We need more trained professionals. The problem being that the best Dr. are working with patients, not students. There are not enough schools and not enough teachers. There needs to be an effort to fix this issues. Canada is having the same issue, so it does not matter if it is universal or not, if you don’t have the doc you don’t have a shot.
Staffing
I am reasonably compensated for my work. When and if I am lucky enough to get a teaching positions (another subject) I will get a pay cut. We need hardworking, empathic, professional, intelligent staff…there’s your job growth…oh wait you can’t hire teachers of my caliber, because of the ones that are already there so there for our educational system cannot produce the type of staff we need to run the system.
Research
The elephant in the room ir research. I cost us a lot, but brings us untold benefit. It should the included in the cost and the costs should be shared in a system that is efficient.
Pharmaceutical Companies
The amount they pay on research is substantial and relates directly to the amount American’s pay for prescriptions. But it is marketing that is the most expensive part of their operation. Marketing prescriptions is ethically immoral and should be stopped. Then prices should be lowered. But there should be some effort on our part to support increasing prices over seas for our pharmaceutical products sold to those nations that can afford it, why should we have to pay. At the same time we need to increase the availability of cheep prescriptions for nations that cannot afford it, particularly African nations.
Electronic Medical Records
There should be a universal system, that is made affordable for both hospitals and small individual practices like our. We would benefit greatly from Electronic Medical Records that could be manipulated easily to serve our clinical, scheduling and insurance needs. It would increase efficiency and quality of care greatly. We have tried to convert our self, but the expense and effort is to costly on our own.
Administrative Cost
I have heard that administrative cost accounts for 30% of health Care costs. This speaks to the problem with both government run and privately run insurance.
Supplies
Supply cost are just as bad as Rx. I can get the same quality tool from a jewelry catalogue as from a dental supply catalogue for 20% of the price.
Conclusion:
I am sure I am forgetting points I would like to make, but this is certainly enough to chew on. Some of this is already being considered and some may be new to you, but old in the on going discussions of healthcare. This is a major issue, above the importance of Art education and education in general, and certainly a developed respect for comics as America’s visual/literary cultural art form. But all of this is interconnected. And in my mind honestly is secondary to the more prudent necessities regarding the intertwined issues of global warming, energy independence, our security and our economy…oh wait there we have it healthcare and education again. All I know is if we can solve global warming we can save more lives and more money then we would solving healthcare. But I have little faith in either, because as Fereed Zacaria recently pointed out if it isn’t a Crisis, America can’t fix it. Still I show up every day and try to solve issues on my end, it would be nice to have better help. More TMJ docs, better insurance coverage, electronic medical records, better training and communication, a full time Art Ed job for me, more funds to reduce my carbon foot print, a health insurance plan with no deductible (I didn’t even get into that, but I do have personal story there too), and some pay for all my cartooning work. But I know you are facing impossible odds and constant bickering. Makes you whish our for fathers dreams of a Republic had come to fruition sometimes. That’s coming from someone who wants government to leave me alone and stop embarrassing me, but paradoxily provide all the help I need to pursue my potential, life, liberty, happiness and a future for my daughter and her kids.
I am a patient. I am the son-in-law of the doctor. My wife and I are the clinic directors: we are involved in running the clinic, the business, solving technical issues, training staff and we see patients. I have virtually no medical training or perspective out side the context of this office. I did grow up in a household that provided a perspective on Mental Health Care, which I do value, as much as chronic pain care. I know something about both of these areas, do to my father and my father-in-law. I grew up with great healthcare coverage because my father worked for Kaiser and I did not want for anything medical. This lead me to be stereotypically concerned with healthcare in America and for myself…I did not see it as a huge issue until I worked for my father-in-law and I did not take care of myself to any great degree until more recently. I am relatively healthy luckily. I have a masters in fine art and am a licensed art teacher. I am part of a trailblazing generation of cartoonist with an education in cartooning. I am one of a handful of cartoonist with a BFA and MFA in our field. There for I am expert on the unique role comics in American culture and in its role in the essential value of art education (there is a need for more public and governmental support in these areas). But I am not an expert in Health Care. If you want to actually call on someone for advice I would recommend my father-in-law, Dr. Jeffrey Crandall. Who is a Republican. I am a Democrat; emotionally libertarian, intellectually socialist. This brings me to my perspective, which surprises even me.
Partisanship:
This is a Bipartisan issue that does not need Bipartisan support. It is too important to be bogged down in politics. The regrettable manipulation of this issue by Washington insiders has lead to a furry that on some levels speaks to real concerns, but truly has distracted from effective communication.
Co-Ops
On the surface this seems like a great idea, as long as it is divided into small manageable numbers of participants. In other words a national Co-op would be to bureaucratic and take to much away from advocacy. But to small of a Co-Op will be insufficient in negotiating appropriate rates with hospitals. There would have to be mandatory requirements to provide availability to all who want to participate regardless of income level, a member run board with truly transparent process for claims and clear requirements for coverage that approach true concerns of efficiency and effectiveness of treatment that is not discriminatory to body parts or preexisting conditions. If done intelligently I would prefer this option to any public plan.
Public Option
If I did not work in the medical field, I would blindly be in support of this option. However, I must underscore that the three public plans we currently accept in our office are truly not what I consider an acceptable model. They are not good programs. They are broken programs. Tricare is the worsted of the three, in the fact that they treat our veterans and military to a bureaucracy that fails to support their care and hinders our ability to care for patients. I can’t tell you how many staff meetings we have had where we have discussed the option of dropping Tricare and we know the essential need and duty we have to serve our military. At times, Tricare makes it impossible and our patients just woefully agree and accept their fate. Medicaid pays, sometimes late, but at a rate that relies heavily on our charity, which we have in abundance. Medicare is not as bad, but their reimbursement rate governs our rates and we are not seeing the rises in revenue reported in other areas of Medicine. We just raised our rates for the first time in over a decade and it was by less then 10%. I am worried that another public option will be another broken program, made more expensive and inefficient by bureaucracy. By the way, the low payouts are passed onto other patient’s insurance premiums and out of pocket expenses.
Universal Health Care
A single payer system does work for many countries, much more efficiently then ours. And the longevity of life is greater, in part do to this. But the care for chronic illness is poor in these systems, complex issues are miss handled and miss treated. There are benefits in our chaotic, but independent system that meets needs for some patients more effectively then these other systems, unfortunately the numbers of patients that are benefiting in our country is shrinking.
Private Insurance
Don’t by their hype. While some do have well intentioned professionals in their midst. The vast majority of these companies in our experience pay 20% less then they should to doctors. They are just as bureaucratically inept as government programs. They stand in the way of efficient care for patients despite logic. They are just as big a part of government games as any other. They are the corrupt corporation conspiracy they are accused of being. Only government reform can keep them in line, and yet they are in the room making the reform.
Diagnosis v. Procedure v. Results
Our Doctor out of necessity takes more time to collect data and patient information then any other Doctor I am aware off. This results in the correct diagnosis, in what is a very complex issue. If all my doctors did this I would never get in, but on the other hand in our office we are efficient and we are providing a quality of care that is appreciated and has helped reduce redundant expense and avoided misdiagnosis. It is not unusual because of the nature of the complexity of TMD that we are the 7th Doctor in 20 years that has tried to help a particular patient. Yet there are doctors we know of who use this method of note taking to abuse their patients, because of a lack of research and understanding and the nature of victimization in our patient pool. That being said all you have to do is turn on Discovery Health to realize that there is little incentive for Dr. to take the time to discover what the problem is, before treatment. My wife went through this type of experience and we hear it in our practice every day. Dr. need to be reimbursed primarily for their Diagnosis and the validation of this diagnosis. Results are a great incentive, as long as they are not applied in a black and white manner that discriminates against chronic pain and terminal disease. Procedures should be the least important measure of expense. The system as it stands promotes redundancy and unnecessary procedures and has lead to the over payment of surgeons and dentist and the underpayment of PCP’s and TMJ “specialists.” As it stands if you want to make money, become a plumber.
Chronic Pain
While there is plenty of discussion about dealing with life threatening issues and preventative medicine there is virtually no mention of managing chronic pain. This is shocking because of the level of cost it ways on the system and how it affects our economic productivity, let alone our pursuit of life liberty and happiness. Many of the solutions to other problems efficiency effectively lead to discrimination and the care for chronic pain patients. These are problems that deserve efficient and accurate diagnosis, but leave a reality of long-term care that does not always result in fixing the problem, simply managing it and reducing progression of the problem.
TMD (TMJ Dysfunction)
It is time that patients with TMD are no longer discriminated against. The TMJ has always been cared for by dentists, but finally two states require medical insurance coverage for a problem that involves bone, nerves, muscles, tendons, joints, soft tissues, the mind, posture, breathing and yes teeth. I have heard that 25% of our population experiences some sort of jaw pain in their lifetime. We know from anecdotal and empirical evidence that TMD is a complex condition subject to miss diagnosis and requires sometimes coordination between Dentists, ENTs, Neurologists, Physical Therapists, Psychologists, Pharmacists, Orthodontists, Oral Surgeons, PCPs, Sleep Specialists and TMJ specialists (technically there is no such specialty, which is why we are not likely at any table in the room helping form the government healthcare proposal). And yet, only 16 states cover surgery and only 2 cover conservative treatment. Which in our office means that 95% of TMD patients are either paying out of pocket or not getting treated at all. There is a huge correlation between, domestic abuse, poverty, chronic head ache pain, TMD, drug abuse and borderline personality disorder. Yet, there is little communications between practitioners who deal with these issues that affect our communities nation wide. In Vermont, once we started offering effective care and there was insurance coverage we became a practice that helped solve virtually all the problems the health care bill is concerned with. We have a waiting list of 250 people all the time. We have serviced 1% of our states population to date. That is one Doctor for the entire state.
Dental Care
Should be covered under Medical. It is time the Dental Community start being respectably included in the care for the human body and at the same time not be able to get away with price gouging and elitism.
Malpractice
This is such a small issue. Important, but small in the context of inefficiency.
Narcotic Prescriptions
Our practice is particularly skilled and experienced at appropriate effect prescribing of narcotics for chronic pain. When other means are insufficient, it is appropriate to prescribe opioids, if they are effective in reducing (not necessarily elimination) pain. But you must have what we have in place a well written Opioid Contract, an effective Prescription Monitoring System, clear communication between law enforcement, Doctors, pharmacists, substance abuse programs and patients. With out this we have over prescribing, under prescribing, fear and abuse.
Staffing Shortage and Training
We know there is a staffing shortage first hand. Our state has been trying to recruit PCP’s, Dentists, Nurses and PA’s for a long time. Our office has searched far and wide to find a competent dentist to join us, and we had one of the worlds best ready to, but he decided to stay closer to home and stay at the Military hospital in Bethesda. We need another TMJ “specialist.” But we have exhausted most hope. It could be very likely that my father-in-law will be forced to retire or die before we find a replacement. Where will our state be then? We need more trained professionals. The problem being that the best Dr. are working with patients, not students. There are not enough schools and not enough teachers. There needs to be an effort to fix this issues. Canada is having the same issue, so it does not matter if it is universal or not, if you don’t have the doc you don’t have a shot.
Staffing
I am reasonably compensated for my work. When and if I am lucky enough to get a teaching positions (another subject) I will get a pay cut. We need hardworking, empathic, professional, intelligent staff…there’s your job growth…oh wait you can’t hire teachers of my caliber, because of the ones that are already there so there for our educational system cannot produce the type of staff we need to run the system.
Research
The elephant in the room ir research. I cost us a lot, but brings us untold benefit. It should the included in the cost and the costs should be shared in a system that is efficient.
Pharmaceutical Companies
The amount they pay on research is substantial and relates directly to the amount American’s pay for prescriptions. But it is marketing that is the most expensive part of their operation. Marketing prescriptions is ethically immoral and should be stopped. Then prices should be lowered. But there should be some effort on our part to support increasing prices over seas for our pharmaceutical products sold to those nations that can afford it, why should we have to pay. At the same time we need to increase the availability of cheep prescriptions for nations that cannot afford it, particularly African nations.
Electronic Medical Records
There should be a universal system, that is made affordable for both hospitals and small individual practices like our. We would benefit greatly from Electronic Medical Records that could be manipulated easily to serve our clinical, scheduling and insurance needs. It would increase efficiency and quality of care greatly. We have tried to convert our self, but the expense and effort is to costly on our own.
Administrative Cost
I have heard that administrative cost accounts for 30% of health Care costs. This speaks to the problem with both government run and privately run insurance.
Supplies
Supply cost are just as bad as Rx. I can get the same quality tool from a jewelry catalogue as from a dental supply catalogue for 20% of the price.
Conclusion:
I am sure I am forgetting points I would like to make, but this is certainly enough to chew on. Some of this is already being considered and some may be new to you, but old in the on going discussions of healthcare. This is a major issue, above the importance of Art education and education in general, and certainly a developed respect for comics as America’s visual/literary cultural art form. But all of this is interconnected. And in my mind honestly is secondary to the more prudent necessities regarding the intertwined issues of global warming, energy independence, our security and our economy…oh wait there we have it healthcare and education again. All I know is if we can solve global warming we can save more lives and more money then we would solving healthcare. But I have little faith in either, because as Fereed Zacaria recently pointed out if it isn’t a Crisis, America can’t fix it. Still I show up every day and try to solve issues on my end, it would be nice to have better help. More TMJ docs, better insurance coverage, electronic medical records, better training and communication, a full time Art Ed job for me, more funds to reduce my carbon foot print, a health insurance plan with no deductible (I didn’t even get into that, but I do have personal story there too), and some pay for all my cartooning work. But I know you are facing impossible odds and constant bickering. Makes you whish our for fathers dreams of a Republic had come to fruition sometimes. That’s coming from someone who wants government to leave me alone and stop embarrassing me, but paradoxily provide all the help I need to pursue my potential, life, liberty, happiness and a future for my daughter and her kids.
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