Wednesday, July 22, 2009

Health Care Reform

Democratic President Barack Obama is working with Democratic Speaker Nancy Polosi in the House and Democratic Majority Leader Harry Reid in the Senate to pass comprehensive health care reform in America. I just happen to be a newly licenced and practicing physician in Georgia and South Carolina and I have a few opinions on this issue.

First off, I don't think the federal government has any business handing out social services. Charity care is best and most efficiently provided on the local level. When things are done locally, both the giver and the receiver benefit. However, when the fed gets involved, charity care becomes an entitlement and givers and receiver quickly begin to resent each other. Already, one in four of the patients I see will not pay me for my services. I like to get paid, don't get me wrong, but I don't think the federal government should be handling this and they don't need to handle it.

Nevertheless, much water has passed under the bridge since LBJs "Great Society" was passed into law. As a country it seems we have gone against the founding fathers who specifically commented that they hoped this nation would avoided the pitfalls of socialist Europe. However, if we have decided as a nation that we are going to provide entitlement programs, then I think there are better ways to go about it than others.

I am pro-life. That means I do not support abortion except in extreme circumstances. I do not support active euthanasia, but I also think we should be wise as medical practitioners and educate the public as informed consumers so that we do not end up prolonging life unnaturally and preventing natural death. Doctors take an oath to do no harm, and sometimes that means not putting in the pacemaker or doing the surgery or getting the CAT scan.

But because I am pro-life, I want everyone in this country to have access to medical care. I have been a student and one of the uninsured. I have had experience of having medical problems without insurance. Fortunately, I was able to find a kind and charitable physician who was able to help me through the situation without charging. I ended up not being billed at all. Many are not so fortunate and end up in serious debt.

While the health care reform bill has not been finalized, it seems that Democratic leaders are leaning towards a government run insurance program which will compete against private insurance. In the past government provided insurance in the form of Medicare for the retired and elderly. Private insurance didn't care about this because they were uninteresting in covering these people anyways. Private insurance companies prefer to cover healthy working adults. And what ends up happening is that when these healthy working adults acquire a serious illness that prevents them from working or eventually retire, then they drop or get dropped by their private insurance company, and get picked up by Medicare which ends up covering the costs for cancer treatment, cardiovascular disease, nursing home care, and end-of-life treatment.

Even if people have money, it is easy to tax shelter assets, property, and savings away and let Medicare handle the big expenses. And that's what happens more often than not. It would be interesting to see how much money is paid to private health insurance companies vs. how much these companies end up paying out. I wouldn't be surprised if federal and state governments were shown to be paying the majority of health care costs. In my ED, I believe about 50% are medicare, 25% are self-pay, and 25% are private insurance. However, medicare patients tend to be older and more sick, so the 50% actually turns out to be a larger percentage in terms of billing.

The problem with the federal government expanding medicare is that private insurance will have a difficult time competing. Also, the more control the federal government has over payment, the more likely they will be to regulate best practices and determine what I can and cannot do for my patients. Medicare already determines payment. Each procedure and diagnosis is given a code and medicare has set pay schedules which determines how much they will pay.

Medicine is currently under a fee-for-service program, but medicare reimbursement is so pore for doctors yet lucrative for hospitals, Surgeons don't like doing procedures at hospitals any more. That is why surgeons have moved in increasing numbers into practicing at private surgery centers. A group of surgeons will invest in the surgery center and then collect the lucrative facility fee from medicare in addition to the procedure fee itself. Consequently, the same-day-surgery department at my hospital goes virtually unused. These fee tables that medicare has set up have influenced and determine what other private insurance companies will pay as well. A good analogy is that medicare has become the Walmart of medicine. They can pretty much set the price for any medical procedure or service and doctors are forced to accept it. But not just that, medicare has a set reimbursement. Simply put, for every dollar a doctor bills, medicare will only pay 55-80% of the bill, whereas medicaid only pays 25-50% of the bill.

I mean, whats with that. When I pay my taxes, I can't just make a decree that I will only reimburse the federal government 75% of the income tax I owe. How are they doing that to me? This reimbursement percentage which gets smaller and smaller each year is worse than me going into Walmart and offering to pay $750 for a $1000 plasma TV, it's like me going into Walmart with a gun and telling them they are going to take my $750 and I am going to take the TV.

Also, as part of this bill, it seems the fee-for-service model may get changed a bit. Currently, there is a set fee schedule for procedures. If a patient gets admitted for pneumonia and ends up having a complication and staying in the hospital, some think the federal government and insurance companies shouldn't have to pay for the complication. Therefore, there are some out there who are advocating what they call a "quality-based" system where if someone gets admitted for pneumonia, the government will pay for 2 days and if anything else happens requiring the patient to stay longer, the doctors and the hospitals won't be reimbursed.

The president of the American College of Cardiologists was on CNN yesterday advocating for a "quality-based" system. Cardiologists are a procedure-based specialty now-a-days. They hardly admit patients to the hospital anymore and are happy to just spend their time in the cath lab and doing nuclear stress tests in their office. So, a quality-based system will not likely affect them unless the government refuses to pay for the cardiology consult for post-op Afib. I think improving quality is a good thing, but I don't think this kind of pressure from the federal government is the right way to do things.

During Speaker of the House Nancy Polosi's press conference yesterday, she dug up a handful of people to share their medical insurance horror stories. And then she had a couple of people from the state of Massachusetts talk positively about health care reform in their state. Under Gov. Mitt Romney, the state of Massachusetts required that everyone in the state sign up for private health insurance. For those who could not afford it, the state government offered to help private citizens pay their the premiums for a private plan. While not absolutely perfect, several people at the press conference commented that they were glad that they had insurance even if it was a high deductible plan and that they were able to go to the doctor and get the treatment they needed.

The misleading thing about Speaker Pelosi's press conference is that the Massachusetts plan is not the Obama health care plan. In Massachusetts, the state is not competing against private insurance companies. Instead, the state is helping citizens afford their own private plans. The key factor here is that each citizen is still contributing something to their own health care. In our jargon, this is called having "skin in the game." But the benefit of having citizens contribute as they are able is that when the federal government covers 100%, people tend to over utilize the services. And this is exactly what is happening with medicaid, medicare, and self-pay/no-pay citizens. Many of them don't pay at all and use the ED as their personal health clinic for any cough, itch or rash. Of course, the enablers that ED doctors are, most EDs have a Fast Track or Express Care to deal with these overultilizers. But with an ever increasing population becoming dependent on the federal government, over utilization will become more of a problem, and that means increased waiting times and rationing of care and services as a result.

So, what should we do. I am not going to complain without offering a solution. I like the Massachusetts plan. Ideally, I wish the government would end medicare all together and states would assist their citizens in the purchase of private insurance. What state and federal governments can do is require that every citizen carry personal health insurance, and regulate the insurance industry so that they cannot refuse to cover people with pre-existing conditions and prevent insurance companies from dropping patients after they have developed a condition. They could also require that there be no cap in coverage, and they can determine what minimum services an individual government-subsidized insurance plan should cover. People should be required to contribute to their own health care. Having "skin in the game" will help prevent over utilization but because everyone is covered people will likely seek and receive more preventative care and thus require less emergency care.