Sunday, September 13, 2009

The View from the Trenches
David Gelber MD

So much of the news these days centers around the great health care debate. The sorry fact of about forty five million uninsured Americans coupled with millions more that are under insured has kicked off this great discussion; something that is long overdue. It is unacceptable that citizens of the supposedly greatest nation on this planet have to worry about the consequences of an unexpected illness. Although there are frequent comments about access to care and quality of care, the truth is that any debate on health care insurance and spending comes down to one thing: money. How much is spent and who gets to profit from the health care dollar is the real center of the debate.

I am a very busy general surgeon practicing in a seven surgeon single specialty group. From my perspective I have had to look at health insurance as a provider and consumer. It is a daily occurrence to find myself caring for a patient without resources. Those that have insurance always require assistance negotiating the maze of regulations, restrictions, copays, exclusions and everything else that encumbers most private insurance. And, yearly my partners and I sit down and review the options available for health insurance for our thirty employees, ourselves and our families.

I have watched politicians offer their comments and opinions with regard to the solution to this crisis and have occasionally laughed out loud at either the ignorance or the duplicity that they present to the public. The great scare phrases: socialized medicine, government controlled medicine and other similar buzzwords ignore the simple truth that we already have a health care system that is essentially run by the government. Not one policy maker in government acknowledges this reality, a reality that my colleagues and I live with every day. They talk about solutions such as computerized medical records and expanded preventive care. I agree that both are important and should be a part of any health care package. It is ingenuous, however, to tout either of these as the only solution to the crisis that exists.
Preventive medicine is already being practiced on a wide scale. It is true that some alteration in destructive behaviors is possible if an individual is given proper incentive. But, unfortunately, our patients are still human beings; humans who will still eat the wrong food, forget to wear their seatbelt, smoke a cigarette or have an extra drink. And, even if all the unhealthy behavior can be modified, people will still get sick. They may be a little older or it may be a different disease, but they will still catch a cold, fall and break a hip, or step on nail and develop an infection. A fantasy world where everyone is perfectly healthy until they suddenly die at age one hundred twenty is many years away.
The computerization of the healthcare industry is something that is necessary, but will require some investment to achieve. One of the major frustrations we face in our office practice is obtaining old records on our patients. The simplest solution to this problem is a web-based or individual based system of medical data collection. Every test result, operative note, lab test, X-ray report and any other bit of medical information should go into a database for that individual and be made available to any entity that is properly authorized to access it. In addition, the individual could carry it with them on a card or something as simple as a USB flash drive. Such a database would be no different than the credit databases currently maintained by the major credit reporting bureaus.

Still, the big issue in the health care debate is money. What I get paid is, in fact, determined by the government, not only for Medicare, the national health plan for the elderly and disabled, but for every health plan, private or public. Every insurance company bases their payments on what Medicare allows. Most of them pay at Medicare rates or slightly above and this reimbursement has steadily fallen over the years. When I started in practice in the Houston, Texas area eighteen years ago, I was paid about $1600 to perform an open cholecystectomy, at that time the most common surgical procedure I performed. Laparoscopic surgery was in its infancy and payment for this new technique to remove a diseased gallbladder was about $2500. These were typical payments from private insurers. Medicare was somewhat less at that time. Today I can expect to receive about $700 for a laparoscopic cholecystectomy, be it a patient with Medicare or with private insurance. Open cholecystectomy actually pays a little bit more, which is appropriate as open surgery (that is a regular, larger incision) is usually a more difficult operation performed on a sicker patient. These dollar amounts are in real dollars and do not account for inflation. I recently read an article, written by a professor of healthcare economics, that talked about cost shifting that is done by physicians to compensate for the poor reimbursement from Medicare and Medicaid. This was the reality twenty years ago, but the days of such a practice have long passed. Oh, I can bill Aetna or United Healthcare $3000, $10,000 or $50,000 for a Laparoscopic Cholecystectomy; I will still get paid about $700. Truly, the days of private insurers making up for poor government reimbursement are long gone.
The burgeoning population of uninsured patients is creating a huge burden on the nation’s healthcare providers. In 1991, as a group, we did about eight per cent of our work on Medicaid and uninsured patients, mostly emergencies that came to us while on call for various emergency rooms. In 2009, our group as a whole now sees about 22% of our work being done on uninsured patients only, still mostly admitted through hospital emergency rooms. If Medicaid patients are included, the number goes up to about 27%. Medicaid is the government sponsored healthcare program for the indigent and reimburses at a rate that is below Medicare.
A simple truth that I rarely see mentioned is that almost every uninsured person in this country could receive adequate healthcare coverage without spending a single dollar more on healthcare than we presently spend. Administrative costs for privately insured healthcare in the United States are around thirty one per cent, based on a study published in the New England Journal of Medicine in 2003. Every other developed nation has administrative costs around seventeen per cent. The other fact that is rarely cited is that overhead costs for Medicare run about three percent. The highest number cited for Medicare overhead cost is around nine per cent, still far below costs for private insurers..

Medicare pays our practice reliably within two weeks of submission of a claim. The money is directly deposited into our group’s bank account. Scheduling surgery on a patient with Medicare does not require a person in my office to call someone at the Medicare office to get approval. Years ago we did have to deal with the Texas Medical Foundation (TMF), which was the agency Medicare required us to contact for precertification of certain procedures, but it was found that this was not cost effective. It was determined that nearly one hundred per cent of the proposed surgeries had the proper indications and the TMF was a colossal waste of the taxpayer’s money. A patient with Medicare also has the luxury of choosing almost any facility or provider, something that is not true of most of the private insurers, these being an amalgam of PPO’s, HMO’s etc.
Nine out of ten physicians that I speak with about this issue agree that Medicare or a Medicare-like system for everyone would be the best solution to the health care crisis. Such a system need not be completely administered by the government, but any private insurer should be required to offer equivalent benefits, reimbursement and comply completely with all Medicare guidelines.
Why do our political leaders ignore these facts? There is no question that the health insurance industry is directly responsible. The huge dollars involved create a strong incentive for the insurance industry to maintain the status quo. If one examines the numbers closely it is plainly seen that there is enough money in the system to more than adequately care for everyone in the US. In 2007 total healthcare spending was $2.4 trillion. This amounts to about $8000 per person, more than enough to provide adequate coverage for everyone.
Of this $2.4 trillion spent on healthcare about 60% comes from private insurers while the other 40% is from government programs, Medicare and Medicaid. Studies suggest that administrative costs for these private insurers are around 31% or $446 billion. If these administrative costs were reduced to 10%, then the savings would be more than adequate to cover all the uninsured in the nation.

There is one other point I think needs to be made. The media frequently cites a statistic that goes something like this: A vast sum of money is spent caring for patients in the last six months or year of their life. I would love to have the luxury of knowing ahead of time which octogenarian that presents to the emergency room at 2:00 a.m. with a perforated colon is going to die shortly after surgery, which one is going to develop multi organ failure, but linger for two months and then die, which one will be ill for two months and then recover and which one will sail through surgery and leave the hospital within seven days. Unfortunately, only the powers above are privy to such information. Until physicians develop such clairvoyance we are limited to using our skill and judgment to treat each patient as an individual, on a case by case basis.

Years ago, when I first started in private practice I made several predictions. The first was that within ten years we (physicians), would all be working for Medicare rates. This has essentially come true. The second was that eventually a single payer system would replace the current hodgepodge of insurers we have now. At the time most of my colleagues were aghast and strongly against such a system. In fact, several of our local physicians left Canada to avoid such a system and it is true that the Canadian system is plagued by long waiting times for necessary care. However, the US has a vast medical infrastructure in place and proper and fair implementation of a Medicare for all system seems to be the simplest, least expensive and fairest solution to our health care crisis.

As part of my research for this article I made an informal poll of my brothers as to the type of health insurance they provide their employees. Of note is that I have eight brothers, two of whom are also physicians and the rest are owners of businesses with from three to two hundred employees. Only one of my brothers did not provide health insurance to his employees. He said he recently had to drop it, because it was too expensive. He added that for his own family he had “a crummy HMO with the closest in network hospital forty miles away.” He then added that his health care plan for his family was “don’t get sick.” Unfortunately, such a plan is the norm for far too many families these days.