Health Care Reform - The View From the Inside Looking Out
As I write this column, a vigorous debate is occurring in Washington and all around the country regarding American Health Care. In this morning’s (June 13, 2009) Post and Courier, there is an Op-Ed piece by Berkowitz and Knapp that concludes: “All Americans and businesses deserve an affordable health-care system that controls costs, requires all to share the costs fairly, is accessible and delivers high-quality health care.” It is hard to argue with this sentence, but what does it really mean?
This column is focused on healthy aging. This writer and most who read it have the information and advice (perhaps worth what is paid for it) to enjoy a long, healthy life. Many of the people who read this column have access and insurance that is covered by Medicare, a federal program that has been in place since 1965. Although few ever describe it as such, Medicare is a welfare program for the elderly and certainly is what some disdainfully call “socialized medicine,” meaning that the government designed it, it applies to all citizens who are eligible, and the government pays for almost all of the benefits that recipients receive.)
Americans Deserve an Affordable Health-Care System that Controls Cost
This phrase is used often. The Declaration of Independence states: "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their creator with certain [sic] unalienable rights, that among these are life, liberty, and the pursuit of happiness." So, does everyone “deserve an affordable health-care system?” As a physician, I can only dream that all Americans are insured and have access to affordable health care.
For starters, it is helpful to explore our health system. Well, it is charitable to say that we have “a system.” What we actually have is a patchwork quilt of doctors and hospitals that try to deliver affordable health care within established constraints. The constraints are a terribly fractioned insurance industry — part federal, part state, part private and significantly uninsured. Although almost all physicians try to do what is best for their patients, doctors are enticed with powerful incentives to use expensive technologies and medicines — most of which are excellent but not always needed. Patients often demand these approaches after seeing advertisements that suggest they are just what the doctor should order! Only in few instances are medical records linked so that doctors and hospitals can care for patients of other providers in a comprehensive manner with all required information.
The current system often does not permit patients to be covered for pre-existing conditions by commercial insurance or for certain therapies or interventions that are clearly indicated. Who is practicing medicine: the insurance industry or your physician? And, why does the commercial insurance industry spend most of their time denying submitted bills and making the reimbursement process a nightmare? Contrast that to the relatively simple federal and state insurance that reduces the number of “middle men” who actually contribute nothing to health care except added expense and delay. Although physicians and hospitals correctly state that getting paid by the federal government and state is at lower rates than the costs, at least payment comes for medical services provided by the physician of choice.
Tort reform within the past decade has helped physicians practice medicine with less fear than before in this state. Although reform has improved the situation for physicians, physicians still have a responsibility to provide quality care. When mistakes are made by providers, rational awards should be given.
What is affordable health care? This part of the discussion is tricky. For health care to be affordable like other nations, several things must happen. First and foremost, health care must be rationed, resulting in long waits for routine care because so many people would have access with only a limited number of doctors, hospitals and clinics. Triage must occur, which would likely provide first for the sickest patients. Also, there aren’t enough primary care providers to screen all the people who would present for affordable care; it would take years to train enough physicians for this type of system.
If affordable is a code word for less reimbursement for hospitals, doctors, and the health care industry, then the incentives for training more providers to care for the influx of new patients would be removed. Universal access to affordable care would result in plenty of patients but fewer facilities and doctors.
Today’s medical students graduate with total educational debt of approximately $175,000. Without adequate reimbursement, they would be in debt for years, unless this hypothetical affordable health care system would also provide free education to people training to be doctors. Likewise, powerful economic incentives that have led to the development of new, expensive technology and new life-saving drugs would also be wiped away.
Requires all to share the costs fairly, while delivering high-quality health care
I am fond of saying that “fairness” is often like beauty being discovered through the “eye of the beholder.” What does it mean to share all costs fairly? Should people with greater wealth pay more than those with less? Should individuals and businesses be charged a flat tax? Should people who are relatively healthy not pay as much as people who are sick? These questions are difficult to answer.
Finally what is high quality care? A prominent physician friend of mine at Duke would regularly remind me that we are all going to die regardless of what is done or not done for us. We now spend most of our resources in the last three months of life on high quality health care. Should this phenomenon be labeled as misappropriated use of “high quality” resources? Most physicians and hospitals want to give high quality health care for the benefit of their patients. In addition, many providers have followed a recent trend toward evidence based medicine, which means that health care should be provided on a basis of what is proven through scientific studies to benefit patients. If evidence based medicine is synonymous with high-quality care, we may have already achieved it — despite the 100 percent death rate.
America has a complex, variable form of health care. Although it is adequate in many ways, it can be and should be improved. The purpose of this column is to point out just a few of the changes to our health care system as changes are considered. Without change, we cannot improve. We should all embrace change, but we should remain cautious about what we ask for since we may get it.
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