Changing the Healthcare Paradigm: A Physician And Patient Centered Approach

I have been reading various articles and listening to pundits for months talk about healthcare reform. They have discussed ad nauseam everything from complete government takeover with single payer on one hand to free markets on the other.

Next week, we will be witness to the President’s healthcare forum. This is what we know so far:

• Tort reform is pretty much off the table.

The trial lawyers lobby has seen to that.

• There seems to be no political will to apply anti-trust regulations

This will continue to benefit the health insurance industry since they will be able to continue to run fiefdoms in various markets guaranteeing their market share and profits.

• The public option is really NOT an option.

If it does get implemented it will be a glorified version of Medicare Advantage where the program is administered by the insurance companies. A particularly sweet win-win situation for them since it means we will have to pay them whether we want private insurance or not.

• More taxes

We will be paying money into a governmental black hole for the next 4 years in the hopes that we will get inexpensive, comprehensive health coverage in the end. I have just two words about that – Medicare and Social Security (enough said).

• If you don’t like your insurance too bad

People who don’t like their private insurance plan will not be able to access the exchange system.

We are at a crossroads.

As a practicing physician, I am really concerned about the state of our healthcare system if the Congressional reform bill gets passed. Even if it is an amalgam of both the House and Senate bill, there are so many negatives that the basic tenets that are good, like coverage for pre-existing conditions and not being dropped from an insurance plan, will not make any significant difference in our healthcare overall.

Some have said that the reform effort is a stepping stone to a single payer system and I agree that is possible. What physician would want to enter a system where their freedom to practice medicine is controlled by government task forces, and where the final medical decision is made by a government administrator who will be all about cost savings, and NOT what is best for the individual patient?

The healthcare system in Massachusetts is a look into the future. They have a high number of medical residents that leave the state when they graduate, practicing physicians are also leaving, because of the physician shortage people have to wait to be seen by a doctor, and healthcare costs have gone up significantly since they instituted universal coverage. The physicians who do remain in practice MUST accept all health insurance since getting and renewing their license is contingent upon them doing so. I believe that a government law mandating that all physicians must take health insurance in order to obtain and maintain their license to practice medicine would be the only way to capture enough physicians to help implement this system.

I have a problem with this as someone who was trained that medicine is an art as well as a science. I also have a problem as a professional with being told 1) who I can see; 2) what tools I can use to diagnose; 3) what therapeutic treatment options I can use, and 4) how much my time and expertise are worth. Wouldn’t anyone?

It’s time to change the paradigm. In my opinion neither the government nor the health insurance industry is the answer to the problems of healthcare costs. They are actually part of the problem. The government’s intrusion into healthcare via Medicare has set the reimbursements without regard to real world costs. Because they are so low and continue to get lower, it leads to cost shifting from those who cannot pay to those who can. This is compounded by the for profit private insurance industry that has injected a new layer of costs that are designed to make sure that they get paid no matter what. They have devised ever more novel ways to increase revenue by 1) increasing the premiums to patients; 2) increasing patient out of pocket expenses via deductibles and co-insurance; 3) decreasing reimbursement rates to physicians; and 4) adding other methods to reduce payments like multiple procedure discounts(e.g., if a procedure has two sides you get paid 50% or less for the second side), and global surgical days (i.e., a physician will see a patient postoperatively for up to 90 days with no charge and may not charge for supplies ,or anything related to the surgery).

Enough, we are on a path that is unsustainable. Yes, cost is one aspect, but so is the medical workforce. The system will NOT run without enough qualified doctors, nurses and other health professionals.

These are some of the things I would do:

1. Get rid of insurance companies anti-trust exemption to promote real competition

2. Tort reform that includes a mandatory payment of legal fees for the losing litigant.

This could even the playing field for lawyers who take cases based oncontingency and decrease the number of frivolous law suits which estimates place as high as 40%.

3. Change the way health insurance companies pay benefits.

Since health insurance is unlike any other type of insurance, mandate that a percentage of the yearly premium be used to provide patient care after this amount is met; the patient pays the percentage as set forth by the insurance company. For example, if a yearly premium is 23,000 then 30% needs to be available to be used for whatever medical treatment or therapy the patient needs (as determined by the patient NOT the insurance company). After the $6900 is met then the patient is responsible for the 30%-40% or whatever is mandated by the insurance company.

• This would encourage the patient to seek medical care before a medical condition became more advanced. It would also encourage patients to shop for the most cost effective treatment. In short, market forces would be engaged in a positive way without limiting patient access.
• The patient would also be encouraged to purchase insurance because they would be getting real value. As it stands now, if a patient never sees a physician they merely pay money to the insurance company without any hope of getting it back. In addition, the increased deductibles and co-insurance have increased the out of pocket expenses and that has also limited patient access.
• Institute a rollover of the unused portion allowed for medical expenses. This would also benefit the patient because if they didn’t use it, the additional money would potentially add value to the insurance plan. It would encourage people to maintain coverage no matter their age or underlying health.

4. Encourage incentives for adopting a healthy lifestyle

In the form of premium reductions or possible tax credits

5. Allow patient to write off their medical expenses

from the first dollar instead of almost 7,000.

6. Allow physicians to write off bad debt

They would be encouraged to see more indigent people for free, and would also not need to go after and potentially ruin the credit of those patients who owe money. Currently, if a patient or insurance company does not pay, the physician is forced to write it off.

These are just some examples that I believe would put the power of individual health choices back where it belongs with the patient and the physician. People have good sense, and if given more control of their own healthcare costs along with clearly presented options that include cost transparency (from both health care providers and hospitals who will have to compete for a savvy patient consumer), they will choose what is best for them. When the inflated costs injected by the government and the insurance industry are stripped out, it would lead to a more affordable medical system that will work well for the foreseeable future.