Top Doctors 2009: Defining Health Care

This year, Denver's best physicians help you wade through what has become the issue du jour: health-care reform. PLUS: Our annual, must-have list of 283 docs in 83 categories.

October 2009

Doctor Q&A

Denver's Top Docs talk health-care reform.
Dr. Mark A. Earnest
Internal Medicine (University)

What are the fundamental differences between universal coverage and universal health care?

The phrase "universal coverage" would simply mean that everyone has some form of health insurance, whether they get it through work, individually, or through a government-sponsored program. Of course, health insurance doesn't always mean access to health care: Individuals may have Medicare, Medicaid, or even some private plans and still be unable to find a doctor because there are none in the community who are taking patients with that particular form of insurance.

"Universal health care" means different things to different people, and that creates much of the political tension that arises around the use of the term. For some, the phrase means that everyone would have the same form of health care; everyone would have equal access to care on equal terms. To some this is appealing. To others it means a loss of choice and the ability to "buy up"—that is, those who can afford more expensive, and sometimes more effective, treatments can do so. A less expansive meaning of "universal health care" is simply that everyone has access to basic health care—however "basic" is defined.

Dr. John Ogle
Pediatric Infectious Disease (Denver Health, Children's)

What is the State Children's Health Insurance Program (SCHIP), how does it work, and how is it impacting Colorado's kids?

Like Medicaid, SCHIP (called the Child Health Plan Plus, or CHP+, in Colorado) is a partnership between federal and state governments that provides funds to states for health insurance for families with children. The program was designed to cover uninsured children in families with incomes that are moderately low but too high to qualify for Medicaid. In February 2009, President Obama signed legislation expanding the program to an additional four million children and pregnant women, including for the first time legal immigrants without a waiting period.

In Colorado, we have about 97,000 children that are eligible for CHP+. But there are two issues surrounding SCHIP that often come up in conversation. One is that many of the families that could qualify for SCHIP aren't aware that it exists or don't have the skills (language, education, or otherwise) to fill out the necessary paperwork. At Denver Health, we have staff that can assist families who need a little extra help with that process. The second issue is the same one that surrounds much of the health-care debate today, which is whether or not health care is a right or a privilege. Many people who think health care is a right support SCHIP. Those who think paying for health care is an individual responsibility most likely won't support this program.

Dr. Kelly L. Moore
Obstetrics and Gynecology (Rose)

President Obama spoke to the American Medical Association in June about medical malpractice lawsuits—why do so many doctors believe these suits should be capped?

Most physicians believe that you can't have a serious discussion about reforming health care without discussing reform of the legal processes that govern medical malpractice. Physicians make mistakes, and most recognize that patients should be fairly compensated when preventable errors occur. The challenge comes in deciding what is "fair compensation." Currently each state's laws differ, which results in wide variability in the amount of financial award two different people with the same injury will receive. Even within a state, awards for the same injury can differ greatly depending on the juries. On top of that, because the nature of our legal system can result in lengthy and costly court cases, insurance companies have learned that it's often faster and less expensive to settle the cases rather than fight them to their just end, even when no physician error has occurred. Unfortunately, this results in an increased number of frivolous lawsuits filed with the hopes that physicians and insurance companies will settle out of court. In the end, this causes spiraling costs for medical malpractice insurance, which can be more than $100,000 per year in certain states and have caused many competent doctors to close their doors for good.

Capitation and tort reform (the laws that govern how lawsuits are handled) have been established in some states to help control frivolous suits by setting limits on the amount of financial award people receive in lawsuits. In the past there have been lawsuits in which there was no physician error, but instead unfortunate outcomes that resulted in million-dollar awards. Having lawsuits spin out of control without any regulation has driven up health-care costs across the country. So far in Colorado, we've been lucky because we have fairly reasonable laws that regulate medical lawsuits—but every year malpractice attorneys try to get these laws changed to enable them to increase their financial rewards.

Dr. Philip S. Mehler
Internal Medicine (Chief Medical Officer, Denver Health)

American health care is the most expensive in the world, yet it doesn't necessarily have better outcomes than less expensive systems elsewhere. Why?

Yes, health care in the United States is too costly. Currently, 16 percent of the U.S. gross domestic product is devoted to health care; at the current pace of growth, it could reach a staggering 25 percent by the year 2025. As a country we spend $21 trillion for health care—almost $650 billion more annually than other industrialized countries—yet U.S. health-care outcomes are worse than in many other developed countries.

There are a number of reasons. First, 16 percent of the U.S. population—almost 47 million Americans—lacks health insurance, while many more millions of Americans experience gaps in their health-care coverage. Lack of insurance coverage is associated with higher health-care costs, increased emergency room use, and worse patient outcomes. Second, we have much higher administrative costs—insurance companies are making billions on administration fees. Third, we frequently use expensive, high-tech treatments, which, at times, can lead to unnecessary care. Lastly, our payment system is misaligned. Insurance companies and government programs should be paying for good outcomes: If I achieve good blood pressure in a group of patients, the insurance company should pay me. Right now, we're getting paid for doing more tests, rather than doing better medicine. Until we change the incentives, we're in trouble. In addition, much of U.S. health-care delivery is fragmented. If you're sick—say, there's something wrong with your lungs—you go to your primary-care provider, and he orders an X-ray. It comes back, and he sends you to a pulmonary specialist, who orders another X-ray. There is inadequate communication between the doctors. America needs a vertically integrated health-care system, where all patients have a medical home.

Dr. Karen Kelly
Internal Medicine (Lutheran, St. Anthony Central; New West Physicians)

It's a phrase we're hearing every day— so what exactly is a "medical home?" In very simple terms, the medical home describes the basic mission of primary-care medicine: to form a long-term partnership with patients in caring not only for their acute illnesses but also to promote a healthy lifestyle. The term is gaining recognition these days because it can also mean that the primary-care doctor—or any doctor that knows you inside and out—you're seeing is serving as the big-picture person for all of your medical care. She manages your care using a broad view—she can refer you to a specialist, she can connect you with a physical therapist, she can recommend a fitness center, but she also keeps tabs on what happens at the specialist's office or at the therapist's clinic so she can provide effective, coordinated care. Essentially, the medical home approach streamlines health care, making it more convenient and less costly by ensuring that tests and procedures are not duplicated.

The idea of the medical home isn't necessarily new, but it's making headlines recently because some experts see it as a way to cut soaring costs and improve quality of care. Doctors' offices in Colorado can become official "medical homes" by applying for accreditation through the Department of Health Care Policy and Financing (the home of the state's Medicaid office). To offer an officially recognized medical home approach, these offices must meet certain standards like 24-hour access and same-day appointments, and they need to collect patient health data. And, docs offering a medical home approach can benefit from it: In Colorado, the state Medicaid program began offering additional money in July to pediatric offices that are medical homes. Some private insurance companies are offering similar incentives for family practices.

Dr. Christopher Lang
Cardiovascular disease (St. Joseph, Good Samaritan; Kaiser Permanente)

What is health information technology (HIT)?

Health information technology is exactly what it sounds like: software and computing technology that organizes and stores health-care information. That information includes all the medical information in a paper medical record, including medical diagnoses, medications, allergies, test results, insurance information, and more. But HIT isn't just electronic medical records—the software also includes tools that help doctors avoid dangerous medication interactions and reminders that necessary tests are overdue.

HIT has the potential to transform medical care by improving the quality, safety, and cost of care. HIT can organize key medical information and make it available at all times to all medical providers. The same technology can empower patients to become more involved in their care by allowing them to review care plans, medication lists, and lab results; it also can allow them to communicate by e-mail with their physicians.

But there are obstacles to HIT's success: These software systems are complex tools that require training and time to master, and the start-up costs are substantial. The electronic medical data must be secured against unauthorized access and data loss. Doctors often find new technology disruptive because it changes their workflow and has the potential to compete with the patient for the doc's attention in the exam room. And, finally, not every physician believes that directly answering patient e-mails would improve care.

Dr. John M. Williams
Allergy & Immunology (St. Joseph, Good Samaritan, Children's; Kaiser Permanente)

What does preventive medicine involve, and why are health-care experts interested in upping this type of care?

Preventive care should be akin to putting up signs warning drivers about a sharp turn ahead instead of just building another expensive trauma center at the end of the turn to treat the crash-related injuries.

But for preventive medicine to work—meaning that we stop disease before it starts—we need more participation and coordination between patients, physicians, and health-care systems. Patients need to work to lower their own risks for disease. Doctors and health-care systems need to be available and accessible to provide patients with information and advice in an affordable, efficient fashion. Sharing valuable medical information within our health-care systems and with our patients is another key to prevention and control of disease. That is, "integrated care systems"—ones in which doctors talk to each other, patients take responsibility for their own health, and electronic records are used—are better at preventing disease than our current disintegrated systems.

Our current national health-care debate revolves around the high costs of reactive treatment. Once we invest in primary care and the electronic medical record infrastructure, we will have better preventive care, and, as a result, we'll have healthier people while decreasing the need for expensive procedures and treatment. This would be a major shift in the culture of health care in our country, but it is a great opportunity to improve our health and health-care systems.

Dr. Elizabeth Baker
Family Medicine (Littleton, Parker, Sky Ridge; New West Physicians)

Boutique and micropractices are becoming more and more popular. How do they work, and why are they attractive to both patients and doctors?

Though these phrases sound similar, they represent two very different practice types. Both, however, are a response to the increasing pressures that most doctors face—too many patients, not enough time, and way too much paperwork.

A micropractice is a practice that revolves around the doctor-patient relationship, with few ancillary staff members—no receptionist, no nurses, no billing department. Using health information technology, it's possible for the doctor to schedule and greet patients, spend extra time with them, answer after-hours phone calls, and take care of the business side of the practice, too. In my mind, it's a little like an old country doc, only with computerized medical and billing systems and a cell phone. The advantages for patients are twofold: The doctor can often spend more time in direct contact with the patient, and the doctor can often schedule same-day appointments. This is an advantage for doctors too; the biggest complaint that most of us have is not having enough time to spend with patients. The disadvantage to patients is that these practices are small, which means it can often be difficult to find a micropractice that's accepting new patients.

A boutique practice is one in which patients buy a "membership." In exchange for an annual fee—usually thousands of dollars—the patient is guaranteed unfettered access to his or her physician. The doctor limits the number of patients in the practice to ensure same-day and extended appointment times, after-hours availability, and quick phone and e-mail responses. While the benefit to patients is obvious, these practices have been ethically controversial because they're not available to lower-income patients, even if they have insurance. Doctors enjoy increased income, decreased overall number of patient visits, and more time spent with patients in these kinds of practices.

Dr. David Kaplan
Adolescent Medicine (Children's)

Why aren't our medical records already electronic, and why is it so important for us to switch now?

Everybody underestimates how complicated it is to migrate health-care information to the electronic world. After all, if a mistake is made or the system goes down, it can cause serious harm. Plus, there's a massive amount of medical information—too much at this point—for the current care systems and providers to digest and use to deliver care in a safe, efficient manner. It's a major transition to move this huge amount of information into electronic form, but it's going to have a profound impact on the way we provide health care if we can get it done.

At this point there are really just a handful of hospitals that are fully electronic. The Children's Hospital is one of them—we're probably in the top one percent nationally in terms of developing complete electronic records. Others in Colorado are at various stages of development. The switch is, as you might imagine, very expensive. Children's has spent about $40 million to complete its electronic medical records. There's also a workflow transition. You have to put computer workstations in exam rooms and all the wards, which means nearly 5,000 workstations in Children's alone.