Medical Gumbo

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DECEMBER 9, 2009 12:28AM

Health Care Reform -- A Doctor's Tirade

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For some time, I have wanted to vent my opinion about health care reform. However, at this time, we don't know what health care reform will look like, or even if there is going to be a public option, so all I can do is offer a few general arguments in favor. (Note to Congress: it would be quite useful if you could tell me precisely what I am supposed to be for.)

1. I am sick of taking care of uninsured patients. Not because I don’t get paid when I see them, but because taking care of uninsured patients is one of the most frustrating things I do. Uninsured patients can’t afford blood work. They can’t afford X-rays, biopsies, ultrasound studies. In the hospital, when I get an uninsured admit, I order every test I can think of, knowing that as soon as the patient is discharged he won’t be able to afford to get any outpatient studies. I painstakingly adjust medications for a hospitalized patients, knowing well that I am wasting my time — the patient is likely to stop talking the meds within a few weeks or months because he can’t afford outpatient doctor visits to get refills.

I don’t understand why many of my colleagues think it is perfectly all right to treat only those who can afford care. Medicine is about helping people, and the people who need the most help aren’t always the ones who have the ability to pay. I don’t like working in a system that excludes people from care so arbitrarily. That may suit some people’s sense of social justice, but it doesn’t suit mine.

2. Our national survival depends on reform. How do you think the American experiment is going to end? By losing a war? Civil conflict? Succession of several states? Corruption? I think the greatest threat to our survival is that we will spend ourselves into a hollow shell, then involute. Health care is the single greatest national expense. It currently eats 17% of our GDP, and is projected to reach 25% in less than a decade. We can’t afford that.

The health reform bill is the first comprehensive step the government has ever taken to rein in costs.

Every time the issue of health reform comes up, someone brings up “rationing.” There is only one way to avoid rationing, and that is to create an infinite supply of money. Other than that, somebody has to be denied something he or she wants. Denying care to the poor is the dumbest and least moral way to control costs. Severity of illness does not correlate with income, so providing care only to those who can afford it fails to match level of care with need. Perhaps this is okay if we are talking about iPods or trips to Jamaica, but if we are talking about human lives, it is unacceptable. We have to ration, if by rationing we mean committing the most resources to the people who can use it the most.

3. Reform won’t cost us more money or add to the debt. I’m not a Polyanna liberal who thinks reform will cost zero dollars and zero cents. It will cost —  probably a lot. But it will cost much less than than doing nothing, and that should be our primary concern.

Does fixing a roof cost money? Yes. But it is cheaper than allowing the roof to continue to leak.

The problem with the current health care system is that, as a privately owned, largely unregulated entity, it is run by the same Wall Street people who took $800 billion in taxpayer money, sat on it to pad their balance sheets, then paid themselves record bonuses. Such people are only interested in balance sheets, stock value, and profit margin.

Medicine has never been strictly a profit-driven enterprise. It is a field of science, and a human effort to reduce the sum total of human suffering. It is not always possible to profit from delivering comfort to the suffering. Until we accept that, our health system will always be dysfunctional. Once we do, we can more efficiently care for people. That will save money -- but the money it saves must be re-invested to relieve more suffering, not paid out to executives.

4. None of the Republican counter-offers will help. Republicans favor tort reform, interstate insurance, tax breaks, reimportation of drugs, and “competition” to improve health care. Let’s look at each in turn.

First, tort reform. As a doctor I’d love to see my legal liability decreased. But tort costs, including malpractice insurance, only make up about 2% or less of health costs, and tort costs have not been increasing. That means that tort reform would be a one time savings, but wouldn’t affect cost growth, which is more important. Nor is there any meaningful correlation between tort restrictions and low cost care. Louisiana, for example, has very strong tort restrictions. And in 2004, it ranked 34th among the states and the District of Columbia in per capita Medicare expenses. California, which also has strong tort controls, ranked 51st. (Data from the Kaiser Family Foundation.)

Allowing insurance companies to sell policies across state borders won’t help either. Has lifting similar restrictions in banking helped the financial system? No, what it did was spark a rapid consolidation of banks that has led to the too-big-to-fail monstrosities Bank of America and Citibank, both of whose insolvencies continue to hobble our economy. It is very likely that interstate "competition" among insurance companies will only lead to stronger companies buying out weaker ones, and to a rapid consolidation much like the experience we have had with banks. Leveraged buyouts are not going to lower health insurance costs.

Tax breaks are subterfuge for doing nothing. We have been cutting taxes since 1980 in this country, and health costs have spiraled upwards. Insurance companies have every conceivable tax advantage. Employers can offer insurance to employees, and both employee and employer get a tax benefit. Uninsured individuals can write off health expenses. Health Savings Accounts (HSAs) have been available since 2003 as a tax-free way to save for insurance costs. All that, and premiums rise every year. Tax cuts have been tried, and tried, and tried — and found wanting.

Some argue for importation of drugs from foreign countries, particularly Canada and Mexico, to save costs. This is the dumbest idea out there, bar none. The message it sends is that in America we aren’t capable of standing up to pharmaceutical companies, so we will allow other countries to negotiate prices for us. Mexico and Canada should not be setting drug prices for U.S. citizens, or crafting our health policy, but that is exactly what this proposal would do. Mexico's equivalent of the FDA would decide what drugs Americans would be able to get. And I can easily imagine Mexico and Canada levying an export tax on all drugs bought by non-citizens. Then we would be paying for their health care system. This is called serious policy?

Finally, we keep hearing about “competition” and about how the free market will “innovate” to solve heath care problems. Never mind that so far the free market’s response to the health care crisis has been to raise prices to force high risk patients into the ranks of the uninsured, while increasing competition for healthier, wealthier populations.

A lot of people think capitalism is the American way. But capitalism is an economic system, not an ethical one. Just because capitalism often generates solutions that are best for the American people doesn’t mean it always will. I believe in the free market solution when it is the best solution. The free market may produce innovative products like the PC, but it has a horrible record with clean air, conservation, public safety, and a mixed record in human rights. And competition often generates redundant services. Every hospital has to  have its own MRI, PET scanner, heart center, transplant team, or cancer center, regardless of whether the community really needs all these shining pavilions, or can afford the billions they cost.

If you want to see free market redundancy in your own home, go look at your drawer full of cell phone chargers. Each one is different and compatible with one phone only. I have owned three different Verizon phones, each of which used a charger that was unique to that model. This is an example of the failure of the free market to create a universal standard. Everyone who competes ends up re-inventing the wheel. This same one-phone/one-charger approach cripples the health care industry, with computer systems that can’t talk to one another, insurance companies that vary widely in what they will pay for, and drugs and medical devices that cost a different amount depending on what plan you are on. Cell phone companies redesign their chargers because it benefits them, not you. The same goes for companies in the health care industry.

The free market is an idea, not a religion. Somebody’s got the two mixed up, and that somebody should not be making public policy.

5. For America, the public option is probably the best solution. Private carriers still cover 65% of Americans, and it would foolish to do away with that infrastructure. Better for the government to insure more Americans while incurring the least social upheaval. Doing that would mean picking up the uninsured and leaving the insured system intact.

Detractors argue that the public option will eventually swallow the private industry. I see no reason why that has to happen. Public universities have done nothing to affect the prospects of private universities, even though public schools cost much less. My local Barnes and Noble seems unperturbed by the public library a mile away. Fed Ex and the USPS live together. So do public and private airports, taxi cabs and subway systems, police and private security firms. Private carriers can adjust to the new system, and find a profitable way to co-exist with the public option.

Conservatives are certain the free market can innovate, and the government can’t. So why can’t the private insurance industry come up with a line of products that complements the public option? Last summer I vacationed at a private resort that bordered the Smoky Mountains National Park. Everyone seemed happy with the arrangement.

On the other hand, on the left there are a number of people who argue that we should do away with insurance altogether, and adapt a Canadian-style single-payer system. Medicare for all, they proclaim. While this approach has interested me at times, I don’t think proponents understand what they are asking for. Medicare covers about 15% of Americans. To enlarge it to cover everyone, it would have to grow to more than six times its current size, a staggering increase that would, in the best of circumstances, take years to achieve. That would leave us to deal with private insurers for years to come. Better to accept their existence, at least for now, and move on.

6. Universal health insurance should mean the rebirth of primary care. Primary care medicine is dying. Family doctors are among the lowest paid and most overworked physicians. In the U.S., less than half of all doctors are in primary care, and very few young doctors are entering the profession.

I am not certain that the current health reform will solve our shortage of family physicians in this country, but provisions in most of the bills being considered, emphasize on patient outcomes rather than complexity of care. Since family doctors specialize in low tech and preventative care, this change in approach should give them a boost.

Why not, as some propose, do away with the family doctor, and go with nurse practitioners and other trained professionals? Because no one else does it that way. In virtually all the foreign countries that the World Health Organization ranks ahead of the U.S. in quality of health care delivery, the primary care doctor predominates. In Canada about 70% of doctors are family docs. Studies done in the U.S. have shown that as the number of primary care doctors that practice in a given region increases, health care expenditures fall and patient outcomes remain the same or even improve. We can’t control health costs without an army of primary care physicians.

This is a time of hope for both doctors and patients. Change will be painful, as it always is, but leaving things the same will only give us more of what we are getting — higher and higher costs, and poorer medical care.

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As you suggest, competition in health care actually drives up costs, especially, as you note, when it results in unnecessary programs such as multiple heart transplant programs in the same area and redundant expensive high-tech equipment.

Another issue that needs to be addressed is physician ownership of lab, imaging, and other diagnostic services. There is a real conflict of interest when the physician refers a patient to a facility in which the physician has a financial interest.

We desperately need to find a way to separate health insurance from employment. When you lose your job you are thrown into a situation in which your insurance either ends, or you have to pay an expensive premium for COBRA insurance. For many people, the insurance itself is so expensive that they can't afford to use it.

We seem to be in the process of turning ourselves into a third-world country, with people walking around with easily-treatable conditions and bad teeth because they can't afford to get them fixed.
I agree with you. There is something called the Stark law which is supposed to prevent physician ownership of labs and similar facilities. Big groups seem to be able to circumvent this problem. I once interviewed with a group in Baton Rouge who had their own MRI, CT scanner, and laboratory. They milked Medicare for everything they were worth, in my opinion.