Sunday, October 4, 2009

The Health Care Debate Part 2

The Healthcare Debate
The View from the Trenches, part 2

The last article I posted cast light upon the virtues of a single payer system for the delivery of health care to the people of our country. In the time since I wrote that article I’ve had the opportunity to discuss the matter further with many of my colleagues. Responses ranged from enthusiastic agreement to belligerent argument, with several variations in between.

The most commonly voiced objection to a single payer system is that “the government can’t manage anything.” I think there is evidence to the contrary, but the objection raises a very valid point. Reports out of Washington are daily reminders of the incredibly dysfunctional apparatus that is our federal government. An article written by a medical doctor who has been serving in our nation’s capital for the past year casts a bright light on this fact. Our representatives are bogged down in a quagmire of lobbyists, special interests, bloated staffs and insulation from their true employers, namely us.

Politics and perception overshadow careful analysis, scientific study and simple truth. It seems that few congressmen have the time or desire to study this issue from a truly objective vantage point. They glean their information from a bevy of special interests bent on preserving their own slice of the $2.4 trillion healthcare pie and ignore most of the facts that would allow a truly educated decision. In my last article many of these facts were presented.

But, assume for the moment that it is true that the government is not capable of properly administering a Medicare for all system. What is the answer? It seems to me that policy could start at the federal level and then be administered by private insurers. Certain minimum requirements would be mandated, including what and what is not covered, establish appropriate reimbursement for providers and set insurance premiums at a reasonable level. That sounds like a step towards rationing you might say; correctly. But it is no different than what occurs now everyday.

For example, a teenage boy comes to see me with a condition called gynecomastia. This means enlarged breasts in a male. The abnormality may be minor, barely noticeable or it may be a gross abnormality. Either way the unfortunate boy suffers terrible ridicule from his peers. The condition is easily remedied by a surgical procedure, subcutaneous mastectomy. Despite the potential psychological damage the boy may have to endure if the condition remains uncorrected, this procedure is almost never approved by insurance companies; they consider it cosmetic. The patient, his parents and I are left with a dilemma, how do we provide appropriate treatment for this teenager? If the family has resources they can pay out of pocket, probably $4-5000 for the outpatient surgery. I could lie to the insurance company and give them a diagnosis that they will cover, but I really don’t want to commit fraud. What I almost always do is take photos and send them to the insurance company, argue with the medical director at the insurance company, have the parents call the insurance company and after all this, once in a while, the surgery will be approved. In many instances I can find a way to take care of this patient, but sometimes the patient remains untreated.

Denials by health insurers are a daily occurrence and are the current form of rationing health care. It seems to me that any health care reform will have to draw the line somewhere. There certainly is no argument from anyone that a facelift or breast implants (except for reconstruction after cancer surgery) are cosmetic and should not be covered by insurance, just as no one would argue that removal of a cancerous portion of colon should not be covered. There are, however, numerous conditions like the one cited above that are in a gray zone. How they will be dealt with is one of the central issues to any reform proposal.

Having raised these points, what, then, is the answer? The answer lies in spending the healthcare dollar on healthcare. The previous article cited the very high administrative costs for private insurance under the current system. These costs would need to be eliminated and the savings redirected to actually providing care. A government sponsored health plan, one that people could purchase at true cost, should be developed. Health savings accounts coupled with high deductible insurance should be offered. These entities put the power of choice directly in the hands of the consumer and direct the healthcare dollar to patient care, not to administration. A plan such as this is what I have for myself and my family. I have a deductible of $5200, a heath savings account which can be accessed for smaller or uncovered incidents, but catastrophic insurance that pays 100% of costs after the deductible. This allows me to save money each year, but protects me at the same time.
A few other points need to be made. I see the health insurance industry licking their collective chops at the prospect of health care reform as it is currently being proposed. A mandate that 50 million individuals who currently do not have health insurance all of a sudden be covered presents an unexpected bonanza to all the Aetnas and United Healthcares out there in insurance land. Many of the uninsured are that way by choice, foregoing health insurance and playing Russian roulette with their health; many are healthy and rarely use the health care system. Adding these people to the rolls of the insured will put a large amount of money into the insurer’s pockets. I think policy should be that this money be used for health care and not for insurer’s profit. In particular, this windfall should be earmarked to help defray the costs of providing health care to the indigent and those for whom requiring health care coverage would be a great burden.

Health care reform should include relief for providers from frivolous malpractice claims. I am lucky to live in Texas where recently passed reforms have made our state one of the more attractive places to practice medicine. The reforms do not prevent meritorious suits from being filed, but have drastically reduced frivolous claims.

Finally, any reform should be a change in health insurance, not health care. Doctors, nurses, therapists and technicians all receive very thorough training and the overwhelming majority wants only the opportunity to take proper care of our patients and to return them to good health. We all work together towards this goal. Those doctors whose only motivation is earning money soon find themselves in trouble and out of work. There is talk of legislating “clinical, best practice guidelines” with the suggestion that providers that do not adhere to such guidelines face some penalties. However, good medical care cannot be legislated. It is taught in our medical and nursing schools, during internships and residencies and through years of hard work and experience. Every patient is a unique individual and most do not fit into the classic illustrations presented in our textbooks. Despite what one may read, doctors and all allied health professional do a pretty good job of policing themselves and this should be allowed to continue.

In conclusion, I think that any reform of health care insurance should allow the providers to continue to provide high quality care. Money earmarked for healthcare should be spent on the delivery of such care, not on administrative costs or profits. A properly and efficiently administered single payer plan is the most cost effective and efficient system, but any private company that can provide health care coverage within legislated guidelines should be allowed.

Let’s hope that our representatives in Congress can suddenly find the wisdom and fortitude to give us such a system.