Vail Valley Voices: Doctor says this is no way to reform health care
Vail, CO, Colorado
As a physician, when it comes to health-care reform, I vacillate between disbelief and despondence.
I am not against reform. In fact, I believe it is long overdue. However, simply bringing 50 million more people into a broken system is a fundamentally flawed plan.
Real reform is much more than rearranging the health insurance industry. Real reform needs to address eight key areas:
1. Duplication of services. In medicine, the drive to be the best means you can’t be left behind. So if a hospital down the street purchases the latest MRI scanner, your hospital had better do the same (and, if possible, leap frog over to an even better model).
So why not have hospitals and clinics and doctors all work together and purchase one piece of equipment between them and use it really efficiently? Because, under the current rules, cooperation is illegal! So instead, individual physician groups and hospitals are forced to duplicate services to remain competitive, which perversely can drive costs up.
2. Lack of price transparency. What physicians and hospitals charge has no relationship to what they collect. And formulas for how physicians are paid vary from contract to contract and from insurance company to insurance company. Some insurers pay secretly-agreed-to amounts for specific services regardless of what the provider charges.
Providers can’t selectively charge different prices to different entities (including their family members) without jeopardizing contractual reimbursement agreements. And they can’t discuss what they are actually reimbursed without running afoul of their contracts. So uninsured patients are particularly vulnerable in this situation. They face staggering bills not because the cost of the care was so high, but because they have been ensnared in a secretive billing system that has no connection to reality.
3. Bureaucracy of care. The amount of documentation, form processing, service coding and data entry required in the background of a patient-physician interaction is vast, complex and overly burdensome. Every insurance carrier demands its own forms, has its own processes, and its own rules, requiring multiple individuals to be employed to handle this bureaucratic nightmare.
Just like medical records would benefit from the standardization afforded by electronic health records, service documentation and billing should be uniform across insurers and providers.
4. Constant shadow of malpractice. The threat of malpractice is an ever-present looming shadow in every patient interaction, coloring physician behavior in very subtle but real ways. Perhaps the conclusion on the X-ray report is not as definitive as it could be. Perhaps just one extra lab test is ordered just in case, or an additional specialist opinion is obtained. Multiply this across billions of yearly patient interactions within our health care system, and you’re talking real money.
Medicine is fundamentally an imperfect science. For patients, there are no financial disincentives to pursuing legal action and for casting as wide a net as possible. For physicians, the incentives for avoiding malpractice are vast. Until this imbalance is addressed, unnecessary costs will continue to creep into the health care system one patient interaction at a time.
5. Personal responsibility vacuum. The vast majority of diseases are in part (if not in whole) related to our lifestyle choices. Certain behaviors simply need to be singled out as contributing to health-care costs and taxed appropriately — either by increased insurance premiums or direct taxes on the products themselves (such as a heavy levy on tobacco products). And if hospitals are not to be paid for medical errors (which I agree with completely), why should insurance companies cover head injury care for a motorcycle rider who refuses to wear a helmet?
6. Lack of a unique universal patient identifier. Before the Health Insurance Portability and Accountability Act (HIPAA) came along, patient records could be married across systems using an individual’s Social Security number. As privacy advocates insisted that tying the Social Security number to health information opened significant privacy holes, patients began to refuse to provide this number during health-care encounters, eliminating the one link that could have kept their data together. Without one number that is uniquely tied to one individual regardless of their location, health status, or insurance carrier, the EHR will be nothing more than a fancy (and expensive) way to handle paperwork.
7. Irresponsible government subsidies. The U.S. government has helped create an incredibly perverse food system where it often costs less money to purchase fast food than to purchase fresh produce. So long as our diets are nutritionally vapid, the chance that we will become a healthier nation (regardless of how much money is spent on medicines and procedures) is remote. Ultimately, health-care costs can only be impacted if our lifestyles change. Our government subsidizes a lifestyle based on sitting and driving, all while eating a corn-based diet loaded with chemicals.
This goes far beyond “prevention” in the traditional sense. It’s not about detecting disease early. It’s about creating an environment where overall disease incidence is reduced.
8. Rationing of care. Unlimited access to all care for everyone is simply not financially feasible. Although it may be logical to stop offering kidney dialysis to patients over age 85, the perspective changes when the patient is your mother who has lived well on dialysis for the past five years. Offering an experimental tissue transplant that has a 5 percent chance of success seems insane, until your child’s life is on the line.
Ultimately health care is an intensely personal experience, and emotion wins over logic every time. Not openly acknowledging that no plan can offer everything to everyone without regard to resource availability or costs is disingenuous.
What the Congress seems to want to pass is the “idea” of coverage without dealing with the personal implications. The public deserves to know what they will be paying for and what services they will be entitled to.
So what should Congress and the administration do to truly reform health care and reduce health care costs?
1. Allow cooperative business models between care providers.
2. Decriminalize open discussions of charges and reimbursements.
3. Standardize documentation and billing processes.
4. Pass meaningful tort reform.
5. Subsidize optimal nutrition, not food lobbies.
6. Tax behaviors and products that contribute to disease.
7. Implement a unique patient identifier system.
8. Clearly define the boundaries of services and insurance coverage.
So instead of trying to pass something — anything — before the end of the year and take credit for “reform,” Congress and the president should first address the true issues contributing to health-care costs and pursue the tough work needed to make real changes that won’t ultimately break the bank. And honestly and comprehensively educate the public about each proposed change and the entire impact it will have.
Force-fitting 50 million people into a broken mess is absolutely not the best first step. Our current system broke slowly over decades. “Fixing” it in a matter of weeks is unrealistic and doomed to failure.
Dr. Elizabeth Klodas is a practicing cardiologist in Minneapolis and a part-time Eagle County resident. She is the editor-in-chief of the American College of Cardiology’s cardiosmart.org web site and on the advisory team of Vita Prospera based in Edwards.