Dear Reader
This month we are taking a break from our series on brain aging. The Olympic Mountains call, but I hope to carve out some time to return to that subject next month.
In my practice of general medicine, I am always confronting problems and looking for solutions. With this habit of thinking, I've spent a good deal of time pondering a solution to our ailing health care system and have posted
on our website. My editor, Carolyn Latteier, has waded through all this to provide you with the brief summary that follows.
Introduction
Section titled “Introduction”Many people are amazed that I do not support single-payer medicine. They point out that we spend a higher fraction of our income on health care than any other nation yet have a lower lifespan and higher infant mortality than countries with universal health care. They think that routing all payments through the federal government would provide more care at less cost. After some forty years of the study and practice of medicine, I have very different ideas about what it would take to provide better health and healthcare in this country. In this article, I'll cover what is wrong with our current system, why single-payer insurance would not help, and, finally, what I see as building blocks for a better system.
The US Health Care System – Cookie Cutter Medicine
Section titled “The US Health Care System – Cookie Cutter Medicine”Here's what I experience as a physician. Jane Patient comes to see me with a migraine headache. I know that magnesium injections are likely to greatly improve her headaches, but this treatment is not a common practice so I have to call her insurance company to get it covered. Someone on the phone who knows a lot less about migraine than I do tells me that that treatment isn't "reasonable and necessary."
Why does this happen? To put the best light on it, insurance companies have a tough job. They cannot afford to hire MDs to look at all their claims, so they set general guidelines and standard fees. This standardization contains certain biases. For example, payment rates for procedures such as surgery are high compared to payment rates for what we call "cognitive services." If I remove a prostate gland, I will receive much more money per unit of training and time than if I work with a patient to determine if the surgery should be performed at all. I am going to have better luck sending my kids to college when I just schedule the surgery compared to spending poorly-compensated time looking for an alternative. Any insurance plan, government or private, encourages a standard style of medicine. As well, those who write the rules pay no attention to many nutritional, botanical, or non-traditional remedies.
Instead, money flows for over-sold screening tests, over-sold medical treatments, or high profile, hi-tech "breakthroughs." For example we as a nation spent about $3 billion on bone marrow transplants for breast cancer patients.1 The medical world, patients and doctors, was agog at the gee-whiz technology. Studies eventually showed the transplants to be no more effective than more established treatments.
Good medical care cannot fit into the standardized strictures of insurance companies. Medical care depends more upon the nature of the relationship between the doctor and patient and upon the capacity of each.
Single-Payer Systems – Are They Any Better?
Section titled “Single-Payer Systems – Are They Any Better?”A national health care system with universal coverage – sounds pretty good, doesn't it? But what is the reality of single-payer systems?
Long wait times are standard. Under national health insurance systems, waiting times for cancer treatment are legendary. The median wait for prostate surgery in Great Britain is about eight months;2 for cataract surgery, seven months.3 One in every 60 Britons is currently on a waiting list to enter the hospital for an "acute" problem. In Canada, people with heart disease wait many months for surgery. In 1994, researchers determined that pre-surgical delays increased the likelihood of disability. Over a one year period in Ontario, for example, 71 patients died while waiting for CABG [coronary artery bypass grafting], 121 were removed from the list permanently because they had become medically unfit for surgery… and 44 left the province and underwent CABG elsewhere."4
Those 44 fleeing heart patients point to another flaw in single-payer systems. Despite the long waits and rationing of universal health care, the rich can still buy better care. In all countries, even Canada, those with more money obtain more medical care. The Prime Minister of Canada, for example, obtains his health care at a "private, corporate healthcare clinic."5 Eighty-four percent of Canadian politicians and physicians interviewed said they sometimes jump the queue in the government healthcare system.6 In Great Britain, the NHS earns millions of dollars per year taking care of those who can pay privately. Hospitals cater to these paying patients, to the point of advertising that they offer television with Arabic language subtitles.7
By contrast, the U.S. system, even with all its faults, is the only one that provides emergency care to all people at every hospital without exception. We also have myriad ad hoc programs to provide care to those cannot pay for it. I do not argue that we cannot and should not improve our system, but I do believe that the best solution will arise from an unemotional consideration of all the facts.
When I consider the prospect of national health insurance in the US, I look at the Medicare and Medicaid systems already in place. There is a myth that Medicare's overhead is only 3 percent. This figure is taken from a Medicare announcement, and quoted by promoters of a Canadian-style program. However, the Canadians report a 13 percent administrative overhead.8 The 3 percent figure claimed by US Medicare is a bureaucratic whopper.9
Further, all who deal with the US Medicare system are aware that hospital and physician costs of dealing with this program far exceed that of any private insurance. You may submit a claim for payment to a private insurer, and someone there will process the claim with some degree of efficacy. Medicare requires that the provider put the claim into electronic form and send it directly to Medicare computers. As often as not, the Medicare computers will spit out the claim. Then the provider must telephone Medicare, which involves spending a significant portion of a human lifetime on hold.
In addition, hospitals shift Medicare costs to other patients. In Washington State actuaries analyzed hospital financial data and showed that Medicare payments to hospitals were about 80 percent of the actual wholesale cost of providing the service. Similar shortfalls in the Medicaid program resulted in a cost shift of $738 million from these government programs to private insurance. This shift added about 5 percent to the cost of private commercial health insurance, as hospitals raised costs to these insurers to cover their losses under Medicare and Medicaid.. This hidden tax added about $900 to the cost of a typical family health insurance contract.10
Do we want our health care to go the way of public education, Social Security, and national defense? Public education is widely regarded as dysfunctional; Social Security faces bankruptcy; and national defense is hardly a model of responsible political stewardship.
If Not National Healthcare – What is the Solution?
Section titled “If Not National Healthcare – What is the Solution?”I think that we humans are capable of better medical education, of better communication with patients, of improving our society so that all can participate, and of changing our medical system so that patients and providers understand where the power ought to lie – with the patient.
I believe true healthcare reform lies in a combination of industry reforms and physician/ patient responsibility. I'm talking about a system where doctors can treat patients unconstrained by insurance cookie-cutter systems and patients have control of their own care. To achieve such a state will take many reforms. Here are some I propose:
Insurance Reform
Section titled “Insurance Reform”First, we need to separate health insurance from employment. Give individuals the same rights a corporation has to purchase health insurance with pre-tax dollars. Then, allow insurance companies to offer "no-frills" insurance. Most states require coverage for things like hairpieces in Minnesota and alternative care in Washington State. Personally, I'd prefer the choice of insuring only for standard medical care. Finally, to save you money, allow insurance companies to choose which doctors they wish to deal with. Some doctors are very good at milking the system. Others are expert at giving you value for money. The insurance companies don't wish to needlessly get between you and your doctor, but they should have the ability to help you obtain medical care at the most reasonable cost.
Power to the Patients
Section titled “Power to the Patients”At the same time, increase the availability of Health Savings Accounts, which are the best way for us to have maximum control over our health care choices at minimum expense. To increase patient control, require all doctors and hospitals to publish the price of all medical services and allow patient ratings of doctors via the internet, for all to see. Prohibit the lawsuits which have hampered such efforts in the past.
Change Medical Training
Section titled “Change Medical Training”Allow people to enter the health care field with some initial training, then study to improve their skills and responsibilities while performing appropriate health care tasks under supervision. The military "corpsman" program should be thus emulated, with scholarships to academic medical training for those advancing in skill and wishing to work in underserved areas. In addition, create a range of new medical training levels and specialties. For example, a fully qualified gastroenterologist with a certain amount of experience should be allowed to train and supervise nurse practitioners or physician assistants to perform colonoscopy or endoscopy.
Free our educational systems from pharmaceutical companies. This expensive subsidy convinced an entire generations of physicians that all illness is best approached through a pharmaceutical means.
End restriction of the number of doctors trained. Did you know that when the number practicing seems too high, the training programs will restrict their supply of orthopedic surgeons?11 We are paying a price for allowing certain medical specialty boards to restrict competition. If we end that, we will see the same kind of competition we see for dental service.
Don't Pay For Marginal Benefits
Section titled “Don't Pay For Marginal Benefits”If you break your arm, that $200 X-ray provides a great benefit, as does the $300 emergency evaluation to rule out damage to nerves or blood vessels and to determine the best treatment. The initial cast or splint is valuable. After that, each dollar spent on orthopedic or other care brings less value. The second or third X-ray helps that orthopedic surgeon avoid a lawsuit, and physical therapy beyond a few visits helps you get back to full performance sooner, but again with less value per dollar spent. Some economists estimate that about the first 70 cents of each health care dollar bring some value, and the last 30 cents are entirely wasted.12
Social Solutions
Section titled “Social Solutions”Infant mortality is greatest among the underclass. Single-payer medicine will not restore the family, reduce drug abuse, bring doctors into rural Alabama, or end wife-beating. Helping people of all talents enter the workforce should be our primary goal. We need to make our political and legal system work as well for the ordinary person as it does for the educated and the intelligent. Every aid organization in the world knows that the highest goal is to enable people to care for themselves, to "teach them to fish instead of giving them a fish." Study after study shows that when a person's job goes away, so does their health. We need to empower people and hold them responsible as well. Huge amounts of money are expended on people using methamphetamine and other "terminal" drugs. Even more money is spent caring for the children they beat up. We must stop returning these children to these families.
For a fuller version of these proposals,click here.
Conclusion
Section titled “Conclusion”Single-payer health care will simply trade one set of problems for another. Yes, we need to extend the best medical care to the largest number of people. But let's make changes wisely. Single-payer is not what its proponents make it out to be. If we really want to help suffering people in our society, the measures listed above are much more likely to achieve our goal.
Half-Priced Cardiac Monitoring Available
Section titled “Half-Priced Cardiac Monitoring Available”You may now obtain 24 or 48 hour cardiac rhythm monitoring at our office for less than half the current local price. This test requires a physician order. The test determines the cause of irregular heartbeat or palpitations. It is also used to monitor known cardiac arrhythmias. A 24 hour monitor costs $265.
Endnotes
Section titled “Endnotes”1http://www.discover.com/issues/aug-02/features/featbad/ Insurance companies were initially dubious and had to be sued to pay for the transplants.
2http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12893857&dopt=Abstract
3http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=12434504&query_hl=4&itool=pubmed_docsum
4 "Waiting lists for health care: a necessary evil?" Dr. Richard F. Davies, Rm. H147, University of Ottawa Heart Institute, 40 Ruskin St., Ottawa ON K1Y 4W7. Published in the Canadian Medical Association Journal 1999 May 18;160(10):1469-70. Online at http://www.pubmedcentral.gov/picrender.fcgi?artid=1232610&blobtype=pdf
5 Business Concerns about Canada's Healthcare
BDO Dunwoody/ Chamber Weekly CEO/Business Leader Poll
by COMPAS in the Financial Post
for Publication May 17, 2004 page 4
http://www.queensu.ca/cora/polls/2004/may17-private_healthcare.pdf
6 Business Concerns about Canada's Healthcare
BDO Dunwoody/ Chamber Weekly CEO/Business Leader Poll
by COMPAS in the Financial Post
for Publication May 17, 2004 page 3
http://www.queensu.ca/cora/polls/2004/may17-private_healthcare.pdf
7 Cash-strapped NHS hospitals chase private patient 'bonanza'
Anthony Browne, health editor
Sunday December 16, 2001 at http://society.guardian.co.uk/privatehealthcare/story/0,,620021,00.html
8 The United States Should Adopt National Health Insurance by David DeGrazia, at The Opposing Viewpoints Resource Center located thru PT Library ProQuest search service
9 http://www.aapsonline.org/brochures/myths.htm
10 https://www.premera.com/stellent/groups/public/documents/pdfs/dynwat%3B5604_31738992_1348.pdf
11 US Federal Trade Commission, at http://www.ftc.gov/be/workshops/healthcare/nicholsonslides.pdf
12 http://econlog.econlib.org/archives/2005/06/healthy_debate.html