Healthcare-Reform - 1 views
started by Frederick Smith on 10 Jan 10
started by Frederick Smith on 10 Jan 10
started by Frederick Smith on 10 Jan 10
started by Frederick Smith on 10 Jan 10
To the Editor: Re: "Health Care Talks Show Sharp Democratic Divide" (news article, Dec. 15): In an August 2009 Washington Post column, Clinton advisor Paul Begala lamented the absolutist position on health insurance reform he encouraged the Democratic President to take in 1994.
Now advocating incremental reform, Begala noted that the 1935 Social Security Act excluded surviving spouses, agricultural and domestic workers, and employees of government, railroads and non-profit organizations - all later piecemeal additions, like disability benefits and inflation-adjusted cost-of-living increases legislated in 1956 and 1974.
As a physician who prefers single-payer insurance and would settle for a "public option," I am willing to stomach even this imperfect bill. Democrats are unlikely to have the 60-vote majority needed to pass any comparable health reform after the 2010 elections.
It would be tragic to forgo extending access to life-saving medical care to tens of millions, while prohibiting insurers' abusive coverage exclusions, limiting their non-medical administrative costs (including profits), and providing mechanisms to constrain Medicare costs. Frederick A. Smith, 12/16/09
The doctor-patient relationship: There is a lot of talk about government's role in health care interfering with "the doctor-patient relationship," and - among some - an assumption that doctors oppose health care reform. Actually, the majority of physicians back the Senate bill. American Medical Association delegates recently voted to support the Senate bill (against determined opposition within the ranks).
Doctors want change, in part, because of painful experiences with private insurers - like the great frustration I felt a number of years ago when I evaluated a 22-year-old woman who had just been employed by a small non-profit. After I diagnosed systemic lupus, the insurer refused to pay for treatment because she had had "swollen, painful joints" before she was insured. My written protests did no good. I have often wondered what happened to that young lady, whose only hope to pay for treatment was to get a job with government or a large corporation whose insurance plan did not exclude pre-existing conditions.
The decline of primary care: Among physicians, primary care doctors tend to like the parts of the bill that increase Medicare reimbursement and loan-forgiveness for doctors who choose to go into primary care (internal medicine, pediatrics or family practice), as well as help with obtaining (now prohibitively expensive) electronic medical records and incentives to manage a "medical home" that includes more ancillary staff as "physician extenders."
Without such Federally imposed changes, the practice of office primary care will likely continue dying a slow death as a specialty choice. The following all play a role:
* Primary care doctors have a particularly large paperwork burdens imposed both by commercial insurers and by public and private regulators. Beyond writing or dictating detailed notes about office visits and telephone communication with patients, they do a lot of duplicate writing in their manually updated charts, as they maintain separate lists of medical diagnoses, medications, preventive interventions and lab results - all of which an electronic medical record (EMR) could update automatically.
* Primary care docs do not earn enough to hire the extra ancillary staff who might help keep up with the huge "retail" burden of phone calls and duplicate writing in charts. I burned out, in my 25th year of medical practice, from 12- to 14-hour days making phone calls & updating charts until 9 or 10 at night.
* Doctors (especially in primary care) have mostly been unable to afford the huge up-front expense of EMR. Fortunately the current Federal stimulus plan includes money to help doctors acquire EMR.
* On average, current medical students will graduate with $150,000 in debt. There's no way to readily repay that as a primary care doc. So their increasing tendency is to go into higher-paying subspecialties (cardiology, etc.), especially those with the highest pay and the easiest hours (taking the "ROAD" to radiology, ophthalmology, anesthesia, dermatology, or going into orthopedics or ear-nose-throat).
Health care priorities: Health care is so important to our well-being as a society that I believe the entire society (through our elected representatives) does have to help decide about our healthcare priorities. Such decisions include:
* What kinds of health care we place priority on: For instance, do we agree that all children and adults (regardless of ability to pay) should be able to receive proven preventive vaccines before we think about replacing the aortic valve in a frail 94-year-old? (One NY-metro insurer does not cover adult flu and Pneumococcal vaccines; yet very expensive and high-risk operations on the frail elderly often raise no questions about payment.)
* How doctors are reimbursed: The entire society may have to agree on a decrease in the reimbursement for doctors whose high pay is inversely related to ease of lifestyle (and only tenuously related to length and intensity of training or malpractice insurance). In my view, this pay has been hiked too high over the years via a "usual, customary & reasonable" insurance philosophy that has kept primary care underpaid (despite the more cognitively- and labor-intense nature of primary care practice ).
Health care rationing: Another objection to broader governmental/societal involvement in how the health care system is managed is that healthcare will, for the first time, be "rationed." The truth is that OUR CURRENT SYSTEM DOES RATION HEALTH CARE, BUT WITH THE WRONG CRITERIA: Did you have swollen wrists before you got insured and the doctor diagnosed your lupus? Are you employed (recession or not)? And, if employed, do you have the right job, or are you of an age, which automatically confers good health insurance? The wrong answer means "Use the ER, try to pay the bills afterward, and go bankrupt if you can't." Is this a legitimate way to "keep our costs down," with health care distributed primarily to the lucky, those working for large corporations, those aged 65 or above, the very wealthy or the extremely poor (Medicaid)?
We are the only highly developed country in the world with such an irrational system. Even countries like Switzerland that rely entirely on private health insurers have strict rules that prevent the abuses & gaps - and the unconscionable profits for insurers' CEOs and shareholders - that exist in our country.
No society can allow unlimited use of/payment for medical resources (like repeated, duplicative CTs and MRIs and other imaging tests) for inappropriate reasons and at inappropriate intervals. (Primary care docs are those most disciplined about appropriate testing; many studies have demonstrated that they produce "better outcomes at lower costs.") U.S. health care consumes so much of GDP (we are approaching 20% - almost twice that of other developed countries, which all have better health outcomes) - that our best businesses are having increasing difficulty competing in the world economy.
It's time for a substantial change in how we organize health care in the U.S. (I haven't even talked about the morally unjustifiable position of having 40,000,000+ uninsured, with 45,000 deaths/year attributed to lack of insurance and early access to medical care) in a wealthy country, when other developed countries have shown how universal insurance and access can be obtained at a lower cost.)