Part 2: Health Care Experiences

Part 1

Inside the System

With any job you gain a perspective that outsiders never gain. I have been "inside" the system both as a patient and as a doctor. My years inside the system have colored my views, so let me tell you about them.

Medicine: The View from the Sharp End of the Needle

All my life I'd been about the smallest kid in my class at school. For years my mother dragged me to a succession of doctors, and they had told her I was anemic. No treatment helped. In 1955 we lived in Washington, DC, and the doctors finally put me into Bethesda Naval Hospital for six weeks where I got to sample the full menu of medical procedures. After three surgeries and another six weeks of the hospital ,I was cured and have been fine since. My memories are not unpleasant, but do include a great deal of waiting in hallways on gurneys, X-rays, tubes in every orifice, too much familiarity with the sharp end of the needle, and a general atmosphere of "wait and if it's unpleasant, well, it'll soon be over."

That experience prevents me from ever seeing one of my patients as anything other than a suffering individual. I've been there. I know fear, hope, shaky trust and the anesthetic balm of time.

Medicine: The View from the Blunt End of the Needle

In medical school I got to move to the blunt end of the needle, but let me jump ahead to 1970, when I worked in the Emergency Department in Burien, Washington. I had just finished a two hour stint sewing up several inches of lacerations resulting from a face vs. windshield altercation. The clerk comes up to ask how much she should bill the insurance company for my work. As I was paid hourly, I said $100, thinking that should cover my pay and the hospital's overhead. "Oh no," she said. "The other doctors charge triple that."

Back then, the insurance companies were much more likely just to pay what they were billed. And yes, they were billed. If a patient ever had the temerity to ask what something cost, whichever health care worker was in earshot would rush over in embarrassment to say, "Oh, don't worry, the insurance will cover it." Better that than to tell them how inflated the charges were.

Insurance Games

Some years later I worked with a physician who told me tales of the 1940's. Medical insurance had just come in. (How it happened was that the federal government had frozen prices and wages during the Second World War. Smart employers discovered it was easier to attract scarce skilled labor by offering health insurance as a benefit, something the government didn't pay attention to.)

This older doc actually chuckled as he told me how he would clip the newborn's frenulum so he could charge the insurance company $5 for doing it. (The frenulum is the little fold of tissue below the front of your tongue. He merely cut it with sterile scissors, which I suppose made no difference to the baby, except for the pain involved.) He chuckled again "I just wrote ‘tongue-tied' on the insurance claim form, and they paid it."

Recently another doc of that vintage told of his practice in rural North Carolina. He would remove a woman's appendix, presumably for cause. He would send a bill to her insurance company and a bill to her husband's. If both paid, he would send the duplicate payment on to the family, sort of a business-building gesture, I suppose. He said it was a common practice.

Doctors aren't the only ones who know how to play. Decades ago patients would ask why I didn't think up some reason to hospitalize them, so they could get a free physical, as their other physicians did. People still tell me that they have not been honest on their insurance application. (And I tell them I am not going to be dishonest with the insurance company.) One man I know had a bad knee and a new girlfriend. She still had her ex-husband's insurance card, so her new boyfriend went in for knee surgery under the ex-husband's name and insurance. People come in complaining of a spouse's symptoms in hopes of a prescription helpful for the uninsured spouse. You name it, people will do it. They figure the insurance company has a lot of money. (Gee, WHY does it cost so much?)

How Employers Got Hold of your Health Insurance

Just to finish with how health insurance reached its present state, the IRS did finally notice that workers were getting untaxed wages in the form of health insurance.

"It took some time before the IRS realized what was going on. When it did, it issued regulations requiring employers to include the value of medical care as part of reported employees' wages. By this time, workers had become accustomed to the tax exemption of that particular fringe benefit and made a big fuss. Congress caved and ruled that medical care provided by employers should be tax-exempt."¹

Back to my own experience. I have high expectations of myself, and early on in my career knew that I just did not measure up to what a Marcus Welby or a Dr Kildare could do. So I did not feel comfortable charging what the insurance companies would pay. Yes, I know this sounds un-American....

Fattening up the Medical Fee

By the way, how did insurance companies decide what to pay? The story I heard goes like this. When they started writing health insurance, they had no fee schedule. They sent agents out to doctor's offices and asked what they charged for a physical, for gall bladder surgery, and so forth. Back in the main office, they looked at all these numbers and they varied all over the map. Say the fees for an appendectomy started at $50 and went up to $400, but 90 percent of the time, docs charged $200 or less. What they did was set what they would pay at $200. Pay 90 percent of the bills in full, and let the high rollers fend for themselves.

What happened next was that the docs got hold of those insurance company "allowed amounts." Suddenly every insurance-covered appendectomy cost $200. Still, the insurance companies could easily cover their losses with premium increases in the booming post-war economy and everyone was happy.

When I came along, only a fool would concern himself with cost. Real men ordered every imaginable X-ray and lab test. This was the medical culture. I would ask specialists why my patient needed this or that test before the specialist even examined them, and they were either incredulous or excessively patient as they explained the situation to me. And often they would concede that "well, now, I guess we could get along without that."

My father, by the way, is Dutch. The Dutch are not known for throwing money around.

So, enter the idealistic young penny-pinching doctor on to the stage. He doesn't change what the insurance companies will bear. He charges what he thinks is fair. Comes 1982, and Medicare is feeling pinched, and freezes physician's payments. Who feels the squeeze first? As physician expenses rise, as they have done every year, our idealistic young doctor with no fat in his fee schedule, that's who. He has to choose between dropping the most money-losing part of his practice in order to remain in business and raise his family or looking for another job.

Medicaid Games

His first move is to stop seeing Medicaid patients. Treating Medicaid patients was the most money-losing part of a doctor's practice, and it still is. Washington Basic Health was, and probably still is, similar, so let me tell you a bit about that. Our elected officials get up and announce to Basic Health subscribers "We're giving you health care. Just go to your doctor and get it. You can even get chiropractic treatment or massage if your doctor prescribes it." Hey, swell, what a deal!

Then they tell the doctor. "We're going to pay you for each of these patients whether they are sick or not, so you'll get $15 per month for each Basic Health patient, and if you have a few hundred, that's a pretty piece of change and they can't all get sick at the same time, right?" Well, funnily enough, people started paying their Basic Health premiums about the time they felt sick, so yes, the doctor often found that person in his office before the first check for $15 even arrived. (Many people express amazement to me that the health insurance company requires them to wait three months to obtain treatment for a knee that was bothering them when they bought the policy. Think about it. No one can survive long by contracting to pay all expenses for someone else's misfortune IF the contract is written after the loss has occurred. Do you expect to go buy insurance for your flooded basement after the pipe has broken?)

The next development was that the State of Washington pointed out the fine print in the physician's contract. If the doc sent the patient on to a massage therapist, that $60 came from the doctor's $15 monthly payment. The decision not to refer patients for massage was a no-brainer, but the headache was still there. "Gee, doc, my back hurts and I called my congressman and she said that my Basic Health covers massage if you'll just sign a form."

Those are just not fun conversations. You try explaining to someone who has been told that they have a right to health care that you have to put some limits on it. Maybe the British are stoic about it, but many people here are not.

So, anyway, Medicaid patients were similarly frustrated and frustrating. While many were conscientious and did everything they could to get well, others had trouble just showing up for the appointment. You'd listen to the patient, examine them, rack your brain and come up with a treatment plan. Then, either Medicaid couldn't pay for its part of the plan or the patient couldn't pay or didn't have the personal characteristics that would allow them to do it.

For a while there, by the way, docs didn't worry too much about low payment rates from Medicaid. We were paid really well by Medicare until 1982, and even after that by private insurers.

Insurance Companies and Small Claims

The low payment rates were not the worst part, however. The worst part for me was the restriction on my medical practice. I really like to think about and practice medicine. Every single one of my medical school classmates went, not just into specialty practice, but into a sub-specialty. One is at the NIH, others are in health care administration, another designs pacemakers. I had the same fascination with detail and some semblance of their intellectual rigor, but I became a general practitioner. So, Jane Patient comes to see me with migraine headache. I know from the research and my experience that magnesium injections are very likely to greatly improve her headaches. It is not common practice, so I have to call her insurance company to get it covered. Someone on the phone with a three ring binder and no knowledge of migraine tells me that magnesium treatment isn't "reasonable and necessary."

Or, her husband Joe comes in with a cough. Many docs, back then, would prescribe an antibiotic. I'd take the extra time and give Joe the information he needed so he could understand why that wasn't a good idea. No X-ray, no expensive antibiotic, just a bill from us, twice the usual amount for "bronchitis." We would complete forms, write letters, but still not be paid.

If I may put in a word for the insurance companies here, I think they have a tough job. People can run up unexpectedly high medical bills, and medical providers include their fair share of the larcenous among them. Then, when they are covering family practice services, many of the claims are for $50, $80, $150. They cannot afford to hire MDs to look at all these claims. They set general guidelines and try to weed out the unreasonable bills -- say, the little girl who has had a circumcision. Or, they have some doc who finds that every child has a tongue-tie and they want to eliminate him from their panel of doctors, only to find that after all those un-needed surgeries, the guy has not just a nice new Mercedes but a very angry and talented lawyer.

Anyway, to deal with the multitude of small claims, they draw up huge databases of the treatment for every particular diagnosis. Comes now the guy who thinks that intravenous magnesium is the way to go, and the insurance company is not about to go to the medical library and check it out. It's a $45 treatment. Only a tiny fraction of their docs are sending in claims for it. The only businesslike thing to do is say "no."

For these reasons, over the years we gradually stopped participating in Medicaid, Medicare, and all HMO's. We'll complete forms that people with private insurance use to bill the company themselves, and we do work with state Labor and Industries, but that's as far as we go..

Patients with Choices

As a physician, I can tell you that once you get out of the insurance game, you run into a different kind of animal, the patient with a choice. That, my friends, focuses your attention wonderfully. A medical office burns money like a train burns coal. We have to ask our patients for a great deal of money to nourish my obsession with knowing all I can know and doing the best we can every time. When I am in the room with the patient, I know they are going to leave our office and ask themselves "Did they give me my money's worth." That means I listen carefully to understand

• Why they came
• Why they came today
• What question concerns them most?

It also means that I must absolutely, every visit,

• Get their permission to spend their time and money on any particular issue
• Tell them what to expect during and after the visit
• Help them obtain the most value possible from their visit to our office
• Communicate clearly how I see the issues
• Communicate why I believe a certain treatment will be helpful
• Discover what treatments will and will not be possible for them

I am not saying that physicians who take insurance do not do these things, although many, if they do, are not convincing their patients that they are. I know because those patients are coming to us. But anyone whose paycheck is coming from someone far away does not have that constant awareness that he must produce value this moment or his business will suffer.

A private physician is in business. There is an inherent honesty to any truly competitive business. That is, money doesn't come in unless you perform well compared to others who perform a similar service. The customers, our patients, have a choice and they vote with their dollars.

Despite our exit from the ranks of insurance-participating physicians, I don't blame insurance companies alone for high health-care costs. There are many factors that drive costs up.

Hands are Paid Better than Heads

One is that in all medical systems, private or government-funded, payment rates for procedures, such as surgery, are high compared to payment rates for what we call "cognitive services." That is, if I remove a prostate gland, I will receive much more money per unit of training and time for that service than if I work with a patient to determine if the surgery should be performed at all. Accordingly, 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 to it. Most of the time we are able to help patients find less expensive, more effective, and safer methods of dealing with their health problems, simply by taking the time to understand their situation well and considering all the options available to them. While they may spend more in office fees while we accomplish this, in the long run they usually save money in drug bills and other costs.

Conflicts of Interest

Second, while the practice of medicine is popularly thought of as a science, it is not. Medical practice is a service. A physicist doesn't' worry about the feelings of the atoms he is smashing. A doctor, on the other hand, must always be aware that the patient may not be served by thousands of dollars of tests to discover all there is to know about some particular symptom. If the doctor can get that symptom to go safely away at less cost to the patient, that's what we are here for.

One patient told me that he appreciated my advice to exercise more and cut back on fats. He understood that he might live longer if he followed it, but he suspected that his life might just seem longer. Another patient is ready and willing to make profound changes for those extra years. There is such variability in biologic systems, and such greater variability in the psyche of individual humans, that we have a far "fuzzier" understanding of human medical arts than we do of, say, chemistry.

And yet we justifiably feel the need of some guidelines and commonly-agreed-upon knowledge and standards of practice. Unfortunately, our sources are not perfect. We look to the Advisory Committee on Immunization Practices of the Centers for Disease Control for recommendations about immunizations, yet many members of that committee have ties to the vaccine manufacturers.² We look to the National Cholesterol Education Program for guidelines on prevention of heart disease, but most of the panel members have a financial interest in the companies that make the drugs that lower cholesterol.³ We look to the medical centers for practice guidelines, but the medical centers are greatly dependent upon pharmaceutical grants as well.⁴

All the current cry for "standardized" care would be fine if people were all the same. We aren't. I will always want, for myself, a physician who understands me as an person, and treats me as one, with all my idiosyncrasies and individual concerns.

Competition Improves Medical Care

Patients come to us with migraine headaches, high blood pressure, high cholesterol, and many other problems. Because we are independent of the insurance companies, because we can set our rates a little higher and afford to educate ourselves instead of partaking of the offerings sponsored by the pharmaceutical companies, we are able to give our patients the best of traditional medicine, or proven non-pharmaceutical remedies. We are able to practice medicine as it should be practiced, free of commercial bias. We can deal with patients as individuals, and we can do better than any computer or technician with a flow chart.

Given a free medical marketplace, we can compete. We can offer better service.

You've Got to Watch the Doctor

Put every doctor on salary or make every medical decision a matter of Medicare protocol, and you will get a different medicine. Medical administrators cannot just pay every doctor for every service billed, because some doctors will cheat. Medicare has over 125,000 pages of rules, over ten times as many as the Internal Revenue Service. Medicare's rules attempt to ensure proper care to patients while discouraging waste, by describing proper treatment in every possible circumstance. This, of course, is impossible. To simplify matters, the rules encourage a standard style of medicine. Those who write the rules pay no attention to many nutritional, botanical, or non-traditional remedies. The only innovative methods that they approve of come from the medical centers. Often these measures have a corporate sponsor.

I think that we humans are capable of more – of better medical education, of better communication with patients, of improving our society so that all can participate, and not just by getting an insurance card and going to some clinic. We are capable of changing our medical system so that patients and providers understand where the power lies… with the patient.

Health Care Consumers do have Power

The great illusion is that the doctors have all the power, and that the patient has none. Go to work in a public clinic sometime, as I have, and you'll discover that even there, the patients hold many important cards. They don't like your prescription? They're not going to take it. They are ill because of substance abuse and you think you can help? Think again.

Even at the other end of the scale, patients have more power than they realize. Tell your doctor that you really, really want an antibiotic for that viral sore throat and see how many turn you down. Tell her that you are really, really worried about that sore ankle, and most will do whatever they can to get that ankle X-rayed regardless of insurance company guidelines. They do not want to lose you as a patient.

How about LASIK? Here's a procedure that debuted at thousands of dollars per eye. Because there are many doctors that perform the procedure, and insurance companies frequently do not cover it, the price has come down considerably.

Interested in plastic surgery? Writes a surgeon from UCLA in the journalPlastic and Reconstructive Surgery, "Plastic surgeons that buck the trend toward discount cosmetic surgery must take concrete and potentially costly steps to implement a plausible strategy for distinguishing their practices within the crowded cosmetic surgery market."⁵

The US is alone among the nations of the world in the ease which it allows people to make a claim against their physician for malpractice. While trial lawyers make the claim that this adds little to the national health bill, any honest physician will tell you that it does.

I'll use the PSA (prostate specific antigen) test as an example. Of a thousand men who have this test to screen for prostate cancer, these will be the results.

• 900 men will have normal results on the test.

• 100 men will have abnormal results. These men will have an ultrasound test, and possibly a biopsy. The biopsy is done by placing a needle in the prostate to look for cancer.

• 70 of the 100 men with a high PSA will have no prostate cancer.

• 30 of the 100 men with a high PSA will have prostate cancer.

• Assuming the 30 men with cancer are treated with radiation and surgery, about 9 would become impotent due to the treatment. Another 2 would leak urine.

The 70 men who have a positive PSA test but no prostate cancer are said to be false positive on this test. Because of the large numbers of false positives on the PSA test, most authorities do not recommend routine screening using this test. In fact, we still don't know whether, even if the test were accurate, early treatment of prostate cancer prolongs men's lives.

These are the facts a Dr Merenstein explained to a patient on July 19, 1999. The patient decided against the test and several years later developed an aggressive prostate cancer. He took the doctor to court and won a million dollar judgment.⁶

In many countries, people do not even consider that one might take a doctor to court and accuse him of malpractice. Their legal system makes no provision for it.

There are many problems with our current malpractice system and it needs major reform. HOWEVER, one result is to place more power in the patient's hands. When the World Health Organization surveyed nations' health systems, "the U.S. was first among the 191 member countries in the category of responsiveness, the extent to which caregivers are responsive to client/patient expectations with regard to non-health areas such as being treated with dignity and respect, etc."⁷

This excellence in responsiveness may be because we have the money to spend, or because of that lawyer in the background, but in any event this demonstrates the power that lies with the patient.

Healthcare is not a commodity

A critical reason that national health insurance is a bad idea is that healthcare is not a commodity like eggs or flour.

A commodity is easily bought at a set price and given to someone. Medical care depends more upon the nature of the relationship between the doctor and patient, and upon the capacity of each. You cannot just "deliver" health care.

Compare these examples:

1. A prison. The doctor knows from experience that the prisoner/patient may be lying about pain, for example, in order to obtain narcotic pain relievers. Or the patient may be telling the truth. In the same vein, if the doctor is treating an abscess, the doctor may need to see the patient everyday in order to make it turn out satisfactorily.

2. A working and self-reliant family the doctor has known for decades. The doctor knows that the family can be relied upon to do their part, and to monitor the care of an abscess. They may require just two or three visits for treatment.

3. A young mother with minor skin blemishes. The careful physician will ask about her marital relationship, as her concern with her appearance may be due to marital stress. This will take much more time than just treating her skin, time happily paid for by the patient who knows that the doctor is on the right track, time not happily paid for by a third-party payer.

4. A patient with drug abuse. Employers fund many programs for treatment of drug abuse. So do the states. When employers pay, cure rates are high, because the employer usually tells the worker, "We need you sober. If you can manage that, forever, you can keep your job." The state says, "Go through treatment and we'll waive your penalty for drunk driving." People in such programs are much less likely to become sober for a significant length of time. Same program, different results.

5. A patient with back pain. If the patient is self-employed, I usually expect that this person will do their exercises and get well fairly quickly. If the patient hurt their back at work, I have seen the problem go on for years. In every country, researchers note that people injured on the job heal more slowly than those have nothing to lose by recovering.⁸

Spectrum of decision-making

The nature of the doctor-patient relationship falls on a spectrum. On the one end is the person who is unable to make any decision due to severe trauma. The health-care team makes all the initial decisions

At the other end of the spectrum is the person who is suffering from lifestyle dysfunction, such as drug abuse or spousal abuse. Here the health-care team can offer help, but success or failure depends upon the character of the patient.

If you believe the reports of Theodore Dalrymple, a psychiatrist who works with the poor in Great Britain, the social "safety-net" there impairs, rather than supports, the ability of such individuals to regain control of their lives. (See his Life at the Bottom: The Worldview That Makes The Underclass. He argues that the Welfare State adds to social alienation, endorses a sense of victim-hood, and fails to really ameliorate the unhappiness of the underclass.)

My view is that across the entire spectrum of medical intervention, medicine needs to better communicate to patients our understanding of what ails them. I find that the patient's response to, "Gee, you do have a problem. What do you see that you can do about it?" is often either to tell me what the solution is, or to ask what their options are. I tell the patient that I will answer every question with complete candor, and do whatever I can to help, but make it clear that their decisions and their actions are a major determinate of their success or failure.

Even with severe trauma, each individual's personal character contributes to the quality of their recovery.

Let us empower ourselves

The AMA and many large corporations now support national health insurance. It would relieve corporations of their burden of health insurance for workers and retirees. It would put trillions of dollars of spending into government hands, a bonanza for lobbyists, legislators, medical associations, and corporate interests. A hundred years ago physicians, like any other group, had to compete. This will be the final step in "welfare for doctors." National health insurance would not empower patients.

Alexander Solzhenitsyn discusses this inThe Cancer Ward.

"But is [the fact that it is free] such a great achievement? What do you mean by 'free'? The doctors don't work without pay. It's just that the patient doesn't pay them; they're paid out of the public budget. The public budget comes from those same patients. Treatment isn't free, it's just depersonalized. If the cost of it were left with the patient, he'd turn the ten rubles over and over in his hands. But when he really needed help, he'd come to the doctor five times over."

Endnotes

1 "How to Cure Health Care" By Milton Friedman. http://www.hooverdigest.org/013/friedman.html

2 http://en.wikipedia.org/wiki/Advisory_Committee_on_Immunization_Practices#Conflict_of_interest_waivers

3 http://www.webmd.com/content/article/90/100818.htm

4 When last I visited my alma mater, Duke Medical School, I attended a lecture at the Searle Library, built with a grant from… guess who?

5 Discount cosmetic surgery: industry trends and strategies for success. Plastic and Reconstructive Surgery 2002 Aug;110(2):614-9. "Discount cosmetic surgery is a topic of interest to plastic surgeons. To understand this trend and its effects on plastic surgeons, it is necessary to review the economics of cosmetic surgery, plastic surgery's practice environment, and the broader business principles of service industries. Recent work looked at the economics of the plastic surgery market. This analysis demonstrated that increased local density of plastic surgeons was associated with lower adjusted fees for cosmetic procedures. A survey of plastic surgeons about their practice environment revealed that 93 percent categorized the majority of their patients as very or moderately price-sensitive. Fully 98 percent described their business climate as very or moderately competitive and most plastic surgeons thought they lost a sizable number of cosmetic patients within the last year for reasons of price. A standard industry analysis, when applied to cosmetic surgery, reveals the following: an increased number of surgeons leads to lower fees (reducing their bargaining power as suppliers), patients are price-sensitive (increasing their bargaining power as buyers), and there are few barriers to entry among providers (allowing potential new entrants into the market). Such a situation is conducive to discounting taking hold-and even becoming the industry norm.In this environment, business strategy dictates there are three protocols for success: discounting, differentiation, and focus. Discounting joins the trend toward cutting fees. Success comes from increasing volume and efficiency and thus preserving profits. Differentiation creates an industry-wide perception of uniqueness; this requires broadly positioning plastic surgeons as holders of a distinct brand identity separate from other "cosmetic surgeons." The final strategy is to focus on a particular buyer group to develop a market niche, such as establishing a "Park Avenue" practice catering to patients who demand a prestigious surgeon, although this is likely a small segment of the overall patient population. Plastic surgeons that buck the trend toward discount cosmetic surgery must take concrete and potentially costly steps to implement a plausible strategy for distinguishing their practices within the crowded cosmetic surgery market."

6 http://depts.washington.edu/gim/calendar/hmcjc_abstracts/JCJul04Article1.pdf

7 The US Health Care System: Best In The World, Or Just The Most Expensive? The University of Maine, 2001.http://dll.umaine.edu/ble/U.S. HCweb.pdf This article goes on to say "However, this figure almost certainly covers over the existence of extreme disparities in responsiveness among different populations. In particular, it is obvious that the millions of people with either no insurance or else very limited access to health care via Medicaid, etc., have far greater problems finding responsive caregivers than those with an adequate degree of private health insurance coverage." This is true for some people, but give us a Canadian system and all would be consigned to a system ranking seventh.

8 " Work-related injuries are invariably related to protracted disability; however, confusion abounds concerning the genesis of this phenomenon. The present study examined the linkage between psychological disturbance and protracted disability in patients with work-related and non work-related injuries. A comparison was made between 1373 patients injured at work and 417 patients injured away from work on the variables of psychological disturbance and disability time. High but comparable levels of psychological disturbance were identified for both groups. People injured on the job were disabled longer, independent of psychological status." Leavitt F. The role of psychological disturbance in extending disability time among compensable back injured industrial workers. Journal of Psychosomatic Research 1990;34(4):447-53. Department of Psychology and Social Sciences, Rush Medical College, Chicago, IL 60612.