Recently, the Democratic leadership in both Houses of Congress published "An American Solution, Quality Affordable Healthcare" aimed at “informing” and persuading the American Public to accept their ideas of how and why healthcare needed to be changed in the U.S. These “12 Points” outlined and rebutted below state a utopian outlook, without a realistic achievement, thus should be labeled as an Op-Ed, or Talking Points, not as an edict.
The creation of a healthcare system as described within the Democratic Op-Ed creates an unrealistic world touted by politicians. As a practicing Physician, I am a small business owner, have increasing costs of business with decreasing profit margins.
I possess first-hand knowledge of nationalized healthcare’s failures when simple procedures are not performed in timely fashion, and those patients then travel to the U.S. spending thousands of dollars in both travel and time to receive the care that Canada, Great Britain, or the EU failed to provide.
The Democratic “solution” fails to describe the details of the proposed plan, the reality of our current “national system” (aka Medicare/Medicaid), the resulting consequences to our families’ health, and the true costs of both running a medical practice, and receiving medical care.
An American Physician’s Perspective
Low Cost
Basic economic principles dictate that supply and demand are the two main components of pricing goods and services. A greater supply of a good/service with less demand of that good/service drives prices lower, while the inverse is also true.
Within those simplistic parameters comes a differentiation of QUALITY of the good/service. Therein lies the biggest impact of pricing similar goods/services. Offering a cheap supply for a highly skilled demand is not an economic model we want to experiment with when it comes to our health.
Currently, in both Great Britain, and Canada, U.S. insurance companies are consulting with those governments to aid in the privatization model currently used in the U.S. because their systems are ineffective, and ultimately cost the taxpayers much more than any private system currently in place in the U.S.
Higher quality care comes with a higher price tag for yet another reason: Debt
An American-trained physician, or one trained in a country and through a program where reciprocity exists with American standards and institutions such as Great Britain or Canada, incurs large amounts of debt. Medical school, resident training and any other sub-specialty training/education places the newly trained general practicing physician (family practitioner, pediatrician) well into a six-figure debt prior to opening their own practice.
Leasing office space, hiring nurses and office staff, purchasing medical equipment, computers, etc., puts many general practitioners at the several hundred thousand dollar debt- mark prior to their first day of business! Sub-specialists, like me, incur even larger amounts of debt with the additional years of training (more lost income), exams, licensing, specialized equipment and other resources necessary to practice cardiovascular surgical care in hopes for a greater return financially as well as professionally for this sacrifice. What many do not realize is that it takes a minimum of fifteen years, with an average being about twenty (20), to take someone from high school and train them as a cardiac surgeon. Some specialties take even longer!
The subject of lowering healthcare costs cannot be adequately debated, until the much maligned topic of Tort Reform is addressed. Malpractice insurance continues to rise nationally as we are forced to practice Defensive Medicine on our patients. The continual fear of malpractice suits, forces the ordering of additional tests, sometimes seemingly frivolous ones, to curb the constant threat of a malpractice suit. Many times these tests are demanded by the patient with a veiled threat to sue! What would otherwise be a diagnosis of a sinus or migraine headache is escalated by a bevy of unnecessary MRIs and CAT scans to ensure the absence of a life-threatening condition such as a cancerous tumor because that is what the patient is most concerned, not because clinically it is a sinus headache.
Another example is the pregnant woman presenting to the ER demanding an ultrasound under the auspices of fetal demise (the baby quit moving) so she can see what the baby looks like! Threats are implied or explicit, and we as physicians find our hands tied behind our backs. We are forced to order non-essential tests at the insistence of our patients due to a threat of malpractice litigation.
As physicians, there is nothing we can do except to order the tests, risk not getting paid for them by the patient’s insurer because they are non-essential, and still face the threat of a malpractice lawsuit if we actively pursue payment from the patient! We learn to “write off” these losses as a cost of doing business. The non-payment by insurance carriers, coupled with the patient’s refusal to pay for those non-essential services/tests creates a cycle of practicing defensive medicine.
In order to provide true healthcare reform, the issue of Tort Reform has to be addressed. As practicing physicians in the U.S., we are not protected from frivolous lawsuits. In our profession, physicians are sued for antibiotics not working, an arm not healing properly after a break, an athlete’s subpar speed after an injury, etc. In all of these cases, mistakes were not made by the physician, but are direct results of patient adherence to instruction and how the body heals and is biologically and physiologically comprised, completely removed from a physician’s care!
In Texas, 2003 marked the passage of Proposition 12 which limits the amounts of non-economic damages plaintiffs could receive in malpractice judgments. If an otherwise healthy patient has a negative outcome resulting from gross-negligence (e.g. wrong knee replaced, an opposite kidney removed, instruments left inside the body) that person may sue for real economic and punitive damages not related to the cap on “pain and suffering”.
The cap is on non-economic damages and is not related to that of potential income earnings. Contrary to what most believe, there is no absolute cap on economic damages. A physician or other healthcare providing entity may be found responsible for more financial damages in many circumstances. Again, this is not what the opponents of basic Tort Reform will tell you.
For example, an instrument is left in a 50 year-old father of three who makes $90,000 a year, has a second surgery to remove the instrument and dies from complications related to these events. He leaves behind a widow and their children in the prime of his life. The $250,000 cap on noneconomic damages is basically for “pain and suffering” with the family recovering much more based on the loss of earnings potential and number of dependents.
As a result of Proposition 12, the amount of malpractice cases filed and judgments awarded in the State of Texas has dropped significantly. Colleagues of mine have seen their malpractice insurance rates drop from an annual rate of over six-figures to less than $25,000 annually. That allows us to reduce the amount of unnecessary tests, visits, medications, and other expenditures that are passed on to the patients, reducing the overall cost of healthcare in Texas for both patient and physician. Meanwhile, patients still have superb legal recourse to collect rightful losses outside the realm of casual frivolity.
An unanticipated result of Prop 12 has been the large amounts of physicians relocating to Texas applying for licenses to practice medicine. The average number of physicians relocating to TX since 2003 has been 3600 per year!
No more co‐pays or deductibles for preventative care
Loss of deductibles or co-pays for preventative care, does not mean, that patients will no longer pay deductibles/co-pays for medical care, only preventative care. Yearly check-ups, vaccinations, etc. are preventative care, whereas Emergency Room visits, sick care, broken bones, and surgeries are considered acute care.
Visiting your doctor for an acute illness under the proposed plan will still require co-pay or deductible, so in essence, nothing will have changed, except for government interference, and the Fed’s knowledge of all healthcare related issues for each of us.
An annual cap on your out‐of‐pocket expenses—no longer driving Americans to financial ruin
Financial ruin due to health care expenses is very rare. The majority of insurance policies offer an annual cap on the amount of out-of-pocket expenses an individual/ family incurs. A patient pays a certain percentage of healthcare expenses, until they reach a maximum out-of-pocket expenditure. Once that is reached, then the insurance provider pays for any additional healthcare services.
Those with no insurance, who or are otherwise unable to pay, are guaranteed healthcare regardless of their ability to pay at any Emergency Room in the U.S. All hospitals in the U.S. are required by law to perform life-saving surgery (if provided), treat injury and illness, and perform labor/delivery services to every single person who enters their facilities regardless of their ability to pay.
Another very important, yet overlooked, and regarded as insignificant aspect of current healthcare in the United States is the amount of services rendered on a pro bono basis. I personally donate approximately 17-18% of my practice to pro bono care. This care is delivered to the individual patient and also delivered by charities and other community organizations. I do not personally know of any physician colleague who denies treatment of such a patient. Some take on larger burdens than others, but our oath to care for the infirmed holds us to an altruistic standard. This standard is one, in which I dare say no one in a bureaucracy feels compelled to truly believe, except when it comes to keeping their own job in place.
Medicare and Medicaid provide insurance to the elderly, and the indigent American respectively. These two populations of Americans are the most susceptible to lack of healthcare. Most Senior’s are no longer employed due to retirement, or their inability to work, thus are on a fixed income/Social Security benefit which limits their cash-flow. Medicare guarantees healthcare and prescription coverage to all Americans who enroll upon reaching the age of 65, regardless of income.
Again, there is no difference in the proposed nationalized healthcare and what we already have, except for the government’s intervention, knowledge and rationing of care. Why don’t we start with fixing Medicare and Medicaid first instead of enlarging a defunct system that everyone agrees needs to be over-hauled in the first place?
An end to rate increases based on pre‐existing conditions, gender, or occupation
Stating that insurance rates will not increase due to a person’s current overall health or their occupation is not based on good economics or fairness.
Individuals employed in high-risk occupations, such as construction workers, chemical plant/refinery employees, welders, entertainers/performers, and even athletes, all incur real risk of injury each and every day they work. Writers, accountants, teachers, and engineers do not amass the same amounts of risk as those in the abovementioned occupations.
High-risk lifestyles such as tobacco use, alcohol consumption, poor nutritional choices, and lack of exercise, all determine a person’s overall health. It is common knowledge that certain lifestyle choices directly affect a person’s health and risk of illness. The single biggest decision a person makes which would negatively impact my business as a cardiovascular surgeon would be if no one decided to smoke!
Patients, whether it is from pre-existing conditions, occupations, or other risk factors, should pay more for their use of healthcare if able, based on their higher risk of healthcare use excluding basic preventative measures. Americans, as a people have the highest rate of heart disease and diabetes than any other developed country in the world. Americans’ lifestyle choices and incessant need for immediate gratification directly impacts the inherent age-related and societal risk of heart disease, cancer, diabetes, hypertension, and a myriad of other diseases that have exploded in prevalence over the past twenty-five (25) years.
The government will have no other choice than to “assess” a person’s healthcare risk, and give him/her a rating according to their overall health upon acceptance into the “plan”. The American taxpayer should not pay the same amount for a heart healthy 35 year old teacher, with a healthy weight, zero tobacco use, and no cancer history, as a 35 year old welder who chain smokes, has a BMI over 35 (very obese) and currently has high cholesterol and pre-diabetes. Neither of these two individuals will have the exact same amount of healthcare needs, but our taxpayer dollars, according to the proposed plan will pay the same amount for both, and the welder’s cost of care will be the exact same as the teacher’s. This is not fair, not practical, and not possible over the long-term.
Group purchasing power of a national pool if you have to buy your own plan
These options already exist. Large group plans outside of employer-sponsored plans are offered via professional associations (AICPA, PRSA, etc.) unions, service clubs (Lions Club, Rotary Club, Knights of Columbus), buyer clubs (Sam’s Club, BJs, Costco), alumni groups, etc.
A national pool of all “uninsured Americans” is not realistic if for no other reason than that each state has different laws and regulations in place for insurance carriers. Blue Cross Blue Shield, for example, has a completely different charter and company for the State of TX, Blue Cross Blue Shield of TX. It is not just one unified plan or carrier. To uniformly grant a “national pool” option when the laws in Colorado are different than Alabama creates a much-larger debate of States Rights vs. Federally Mandated/Imposed laws. This is not a debate that our current Administration or Congress is prepared nor desires to engage.
Guaranteed, affordable oral health and vision care for kids
Oral health and vision care in children are issues which currently have many remedies outside the realm of government mandates. Many vision care providers exist offering free eye exams and steeply discounted eyeglasses. Costco, Sam’s Club and Wal-Mart all offer vision care at their stores to name a few examples. Most communities also have resources that provide the same.
Dental health is rarely a life-threatening issue. In reality, dental insurance covers very little even under the best situation with your care relying heavily on ones pocketbook. Public service programs, school-sponsored events, and health fairs all contribute to the common knowledge of the merits of brushing teeth and flossing
If these options are not viable and a family qualifies, states may provide discounted plans or free plans for children through CHIP/Medicaid.
Keep your doctor and your plan if you like them
The reality, again steeped in solid economics, is that the decision-makers in business will not offer private insurance at a cost to their bottom-line if nationalized healthcare is offered. The creation of nationalized healthcare will create a system of elitism never seen before in the U.S. in terms of who gets access to physicians, hospitals, and procedures. Those who can afford to pay cash will receive access to the best care offered. The rest of us will be forced to succumb to the nationalized plan, as a result of a sound financial decision made by employers.
The physicians with the best reputations and statistics in their respective fields may be inaccessible to a great majority of the public. This is already true and commonplace in the primary care arena. How many Americans over the age of 65 have tried to find an established general practitioner or internist who takes new Medicare patients? Every day, my mostly Medicare patients, tell me that the doctor I recommended to them for assuming their primary care, no longer accepts new Medicare patients.
More plan choices, including a high‐quality public health insurance option that would compete with private companies
In the private sector, if two insurance giants such as Aetna and Blue Cross Blue Shield wanted to merge, the government would call thousands of hours of testimony, mountains of paperwork, and months of deliberation before allowing a so-called “big player” like that to exist, due to the fear of monopolizing the market. The purpose of anti-monopoly laws is to keep our economy thriving based on its need for competition and eliminating anyone from becoming a sole-provider of goods and services.
If passed, the Federal Government instantaneously becomes the largest Insurance Company in our nation and will usurp the power from each and every one of us that wants to choose our healthcare plans. By creating a Federal Insurance Agency, smaller/independent companies close, the healthy competition that should occur between insurance providers no longer is possible, and thousands of Americans are instantaneously unemployed when their firms close.
True competition cannot exist with a government subsidized health insurer.
Possibly the greater question that should be asked is one related to the enormous profits collected by private insurers. Most if not all private insurance companies follow the Medicare fee schedules on reimbursing doctors for their services. While most patients rate their private insurers as good to excellent, finding the root cause of such a disparity among the soaring premiums, high co-pays and deductibles, and the astronomical profits of insurance companies, leads one to believe that the patients are being sold a bill of goods based on the fear that unless you have private insurance you will receive inferior service.
An end to coverage denials for pre‐existing conditions such as heart disease, diabetes, or cancer
The illusion of endless care regardless of current condition, state of health, age, or lifestyle is just that - an illusion. Under a single payer government system, sacrifices have to be made. At what age do you treat kidney failure patients with life-saving dialysis to keep their blood clean? All ages? Less than 90? Less than 80? What about the Federal Insurance Agency attempting to eliminate genetic conditions through mandatory pre-conception genetic testing, or forcing pregnant women to undergo prenatal testing for the purpose of “eliminating” risk by determining an embryo’s viability? These are all questions regarding rationing care. In order to “save money”, the Federal Government will preserve resources for younger and healthier patients.
In addition, pharmaceutical research and development and disease research will be significantly slowed, if not halted. If Americans are not enjoying longevity, the need for further research funding for diseases such as cancer, Alzheimer’s, or heart disease will be virtually eliminated.
Get the care you need with an end to lifetime limits
Baby Boomers are quickly approaching 60, and with it, a very large segment of the American population approaches the age when the accrual of health debt skyrockets. Knee replacements, pacemakers, cancer surgeries, are all real and viable treatments for an aging population looking forward to a long, well-deserved retirement. As this population ages, the frequency of doctor and hospital visits, coupled with costly lifesaving and quality of life preserving procedures, make this a debt of mammoth proportions.
The majority of our healthcare dollars are spent within the last six months of life. Limits will have to be placed and tough decisions made under the proposed system.
Each individual is allotted a certain amount of money for healthcare over the cost of their lifetime. Patients on Medicare or private insurance are both given a financial limit of care. Once that amount is met, regardless of the circumstances (e.g. age, disability, recovery outlook) the patient/family acquires all financial accountability for any additional healthcare costs once that monetary limit is reached. The proposed idea of unlimited lifetime benefits is not feasible; otherwise it would be currently utilized in both private insurance and Medicare models. Financial healthcare limits will have to be decreased not eliminated, if for no other reason than the surging number of aging Baby Boomers with longer than expected life spans.
The concept of a patient’s lifetime monetary limit of healthcare access, is strictly based on economics and relies on the basic assumption that despite an average “health debt accumulation” (e.g. lifestyle choices, genetics, illnesses) throughout one’s life, catastrophes may occur which are generally provided for by both private insurers and Medicare.
Once these limits are met, especially in the instance where quality of life is in question, an assumption is made that further expensive care provides little or no benefit to the patient. A terminal or irrecoverable condition to the patient has occurred and further expenditure of healthcare dollars puts undue stress on the families and more importantly the patient through a prolongation of a dismal condition. Nationalized healthcare in any form does not and will not provide for the terminal or irrecoverable condition. The Government will have full control of patient’s care for terminal cancer, Alzheimer’s, AIDS, etc., taking the decision-making away from the patient/family and leaving them at the mercy of a bureaucrat.
Currently, in the UK for example, if a person over the age of seventy-five (75) falls and breaks a hip, it is considered a life-ending injury, and the patient will not be treated, regardless of their current quality of life.
An unlimited lifetime benefit is not sustainable financially. Period.
Job and life choices will no longer be based on health care coverage
The impacts of risky or dangerous social habits that detrimentally affect ones physical and mental health are a real and constant drain on the American health-care system. Americans are addicted to immediate and instant gratification. We want what we want, when we want it, and exactly how we want it. We smoke cigars, and cigarettes, consume large quantities of alcohol, eat the unhealthiest of food without restraint, and for most of us, think little about the implications on our health.
As a heart surgeon, I know for a fact my practice would be negatively impacted if my patients had never smoked. These are Americans that had they never made the choice to light/inhale a cigarette, may have never seen a scalpel, Emergency Room, or even a surgeon like me.
Make no mistake, unhealthy lifestyle choices are the single largest and most preventable cause of disease in this country. Eliminate our negative social habits and you will greatly decrease the amount of money spent on healthcare in this country.
Opponents argue that as a developed country with traditionally the best healthcare in the world, the United States falls well short on outcomes as they relate to similar nations with a dominant form of nationalized healthcare. I will argue that these nations have a greater hold as a society on choosing healthier lifestyles and they ration care based on “necessity” (i.e. younger, healthier patients receiving more care). The prime example of this is obesity. It is no secret that our population continues to get larger and with it the increased use of healthcare monies on this population. This mindset of health irresponsibility must be changed.
Doctors—not insurance companies—in charge of health care decisions
By creating a nationalized healthcare system, the federal government instantaneously becomes the insurance company, the gateway of access, and provider of medicine.
Regardless of what the private insurers say, they continually interfere in the patient-physician relationship in many ways, the most common being denial of services the physician deems necessary. Why would our government think any differently?
A set treatment plan for one person is not a treatment plan for all, and a nationalized, government-run system will ultimately determine who gets what treatment/procedure, not the physician. Anytime a third- or fourth-party is included in the intimate relationship between patient and physician, decisions are made via committee, instead of according to necessity and personal preference.
As a physician who trained in a Veteran's Administration hospital, this government-model currently exists, and the rationing of health-care based on a budget is real.
I ask you to remember the last time you stood in line at the County Clerk’s office to pay your car’s registration, or phoned a government toll-free number. How many different lines did you have to stand in? What was the wait? Did you get close to the front, only to have the counter attendant “close for lunch”? How many attempts did it take to get a live person to answer your call? How many different departments and people did you speak to before getting your question answered? Imagine the implications of a pregnant woman in distress during delivery, or an 85 year-old patient with chest pain and a possible heart attack arriving at the ER, and having to wait until someone “authorized” a procedure!
These scenarios will exist. The bureaucracy in Washington will be held blameless and we, the physicians will be the left to make the morally right decision of treating a patient regardless of the cost, or whether we are compensated. The government policymakers are counting on this scenario as a way to cut costs for their nationalized plan. Furthermore, since there will be no other options available to the American public other than the government-sponsored plan, we will all suffer. The patient will receive sub-par care and the blame game will start and end with the physician, and the U.S. Government will enjoy no culpability.
More family doctors and nurses entering the workforce, at better payment rates, helping guarantee your access to quality care
What is their plan here? This is the second biggest hurdle to overcome when discussing true Healthcare Reform, right after the one of Tort Reform. True job satisfaction cannot be bought or gained merely by short-term financial incentives.
Adding a Government Oversight component to the health care system only adds more paperwork to an already grueling schedule. General Practitioners spend on average 60-90 minutes on Medicare, Medicaid, and insurance paperwork, per 15 minute appointment. If that physician sees twenty-four (24) patients per day, or three (3) patients per hour for an eight (8) hour day, that’s a full twenty-four (24) hours of paperwork to complete for each day a physician sees patients. Much of the money made from seeing these patients is already spent on people hired to complete the paperwork!
In reality these physicians will be forced to see fewer patients, increasing wait times to see a physician, and eventually compromising the quality of care for patients.
Of course, better payment rates will attract more doctors and nurses to the field of family medicine, but exactly how does that fit into the government's idea of reimbursement? It's no secret that historically we as physicians have continued to see significant declines in our collections despite increasing our volume of patients, and working longer hours. The best and most efficient health-care providers should take the greatest amounts home to their families. A government-run, single insurer system makes this model null and void.
A family practitioner making $150,000 annually will not be able to pay off his medical school debt, business loans, or purchase additional equipment unless his family adversely suffers financially. The cost-of-living in Texas versus Seattle or New York City is extreme in its differences. That family practitioner’s salary of $150,000 in areas like NYC where an average 3 BR house can cost close to $1M coupled with the constant threat of malpractice lawsuits does not create an enticing environment for new doctors. How does that physician survive financially?
Based on most currently proposed incentive models which reward good, cost-efficient doctors, the difference between the designation of an "excellent” and an "average" doctor may only be 2% financially. That is the equivalent of a $3000 bonus for the above referenced Family Practitioner.
This is considered a bonus for someone who is providing exceptional medical care?! What is the incentive to spend hours away from our own families? Why should we work longer hours or on weekends? After-hours calls will be eliminated, or otherwise cost the patient for that call.
As a cardiovascular surgeon, I will no longer penalize my family for my long hours away from them. I will no longer be able to spend the night at my patients’ bedside. I will no longer be available for after-hours care/calls, and I refuse to spend any more hours preparing the mounds of paperwork for the distinction of the Federal Government deeming me “excellent”.
A 2% bonus is not the reason I went to medical school. A 2% bonus is not the reason I spend unimaginable amounts of time away from my wife and kids, and a 2% bonus, unfortunately is not enough for me, or many of us who got in this wonderful field of medicine, to stay.
If Washington is truly interested in discussing Healthcare Reform, then a discussion to enlist Tort Reform into any proposed plan is necessary. If our Congress and current Administration are serious about how our families are cared for medically, then protecting those of us who provide that care, many times at a cost to our own families, must be approved via legislation. Stopping the frivolous lawsuits, putting a cap on non-economic damages, while at the same time allowing for gross-negligence to be punished on a case-by-case basis in our courts must be passed.
In order for healthcare reform, TRUE reform to occur, the physicians must have a unified voice, and that will only transpire when Tort Reform is included into any discussion of cost-savings and healthcare. Washington must address the reason behind the rise in health-related costs, and it’s the practice of defensive medicine by physicians. These “Solutions”, as outlined by the Democratic Leadership fail to address Tort Reform, while noticeably lacking the necessary details as to how/what the as-yet proposed reform will occur.
As a physician, I never thought our elected officials, those for whom I have supported and voted, those same Americans who claim they were also called to serve, would turn their backs on the medical profession’s sacrifice at the expense of America’s health. ___________________________________________________
In reference to...
"An American Solution, Quality Affordable Healthcare"
PREPARED BY OFFICES OF DEMOCRATIC LEADERSHIP AND HOUSE COMMITTEES ON WAYS AND MEANS, ENERGY AND COMMERCE, AND EDUCATION AND LABOR
JUNE 19, 2009
http://edlabor.house.gov/documents/111/pdf/publications/DraftHealthCareReform-12ReformHelpFamilies.pdf
