Reforming Healthcare for Whom?

By Lawrence A. Nord, M.D
          I will never forget the look of pain on the young man's face. As a physician, I had seen it a thousand times before. One never really gets used to suffering even after 30 years of practice. It was all that my patient could do to fight back the agony that was welling up inside in his tortured back.
          My office assistant told me that he didn't have health insurance. Was I surprised? As a 26-year old carpenter with a wife and two children he was what demographers call "the working poor." His employer could not afford to buy him health insurance and he could not afford to purchase it, on his own, with an annual income of $34,000. Could I safely treat this patient without any expensive tests such as an MRI scan? I didn't want him to incur a debt of $1,500 for an MRI, but I also didn't want to be sued for not ordering such a diagnostic test.
          Agonizing decisions had to be made. I didn't need to remind myself that I am a physician who cares, not a bureaucrat who plays with numbers, real or imagined. Why can't the most prosperous country in the world provide this patient affordable healthcare?
          My frustration grows as I watch the healthcare debate in Washington. Every polemic that spews forth from the Political Left or Right stifles the constructive discussion we should have. Is that a surprise? There are six lobbyists for every member of the House and Senate working on health care! They are so busy spinning the issue they all must be dizzy.
          We must address the unsustainable growth in the cost of healthcare before we submerge budgets of the family of the carpenter to the federal budget that already is drowning in red ink. All patients in the U.S., regardless of insurance status, have access to healthcare, be it through a physician's office or through a hospital emergency room. The idea that reform is about getting people health care is more of a myth than reality.
          For many patients, our health care system is too expensive. Accessible-affordable health care must provide a health system where all patients are covered by some form of coverage. Out of pocket medical expense must be limited to no more than 10% of annual income. It is imperative to getting costs under control that all people have insurance. While this may seem contradictory, it isn't. Under the status quo, those who pay subsidize those who don't or can't pay.
          My father was a physician here in Central Illinois before me and my three brothers took up the cause. When Dad first practiced, patients would pay or maybe even barter farm products to reimburse him. He only needed a small office staff because he was not burdened by complex insurance forms and fighting for his patients so insurance companies would pay their claims.
          What was once a doctor-patient matter is now the focus of a feeding frenzy. The backdrop here is that there are too many hands in the till. We have too many outside sources siphoning the life out of this system. This has to be curtailed. Health costs can be brought under control by restoring a closer relationship between the patient and his/her physician.
          Whatever happens, taxes cannot be raised. An increase in funds would prove to be a perverse disincentive against reform. Here some steps that we should take:
          Pharmaceutical Costs: Encourage physicians to prescribe generic or generic equivalent drugs unless ineffective or contraindicated. We could achieve a 75% cost reduction in drug costs.
          Hospital Expenses: We must stop shifting injured and ill Medicaid (43 million) and Uninsured (46 million) patients to emergency rooms. Paying physicians at the Medicare reimbursement level for this group of patients would encourage physicians to see them in an office setting, offsetting emergency room costs by 50%.
          Litigation Reform: Pay full economic losses to a patient but curtail non-economic (pain and suffering) damage caps to $250,000 plus looser pay legal costs. Texas and other states have already taken a step in this direction. This reform will reduce defensive medical practices by 30%.
          Insurance Costs: By allowing patients to purchase health insurance across state borders, competition would reduce costs. Regulate insurance companies administrative expenses and profits to 10-15%. These steps should reduce premium costs by 10%.
          Privately insured patients: We can encourage the growth of Healthcare Savings Accounts much like IRAs. This would push more patients toward healthier lifestyles as they push to maintain their funds in their HSAs. This would encourage patients to make behavioral changes for a healthier lifestyle. Non-used funds in their HSAs would rollover year to year. Converting from a low deductible to a high deductible (HSA) policy would result in a 30-40% health care premium savings.
          Living will: End of life health care expense can be reduced by 15% by respecting quality of life rather than quantity of life issues. The last 6 months of a patient's life consume 50% of lifetime medical costs.
          Catastrophic insurance: People should have this type of insurance for the same reason that drivers want (and are often required to have) comprehensive insurance coverage.
          Electronic Medical Record (EMR): The Veterans Administration (VA) has an EMR program in place. The government wants to pay each physician's office $44,000, paid over 5 years, to install an EMR. Why doesn't the government develop a uniform-national EMR that can be used by all participants (hospital systems and physician offices)? The government should update and maintain the system. Cost savings would be in the billions.
          The 46 million Uninsured Patients can be divided into three groups based on income. The upper 1/3 make more than $50,000. They can afford, but elect not to purchase coverage. They should be required to purchase catastrophic insurance. The lower 1/3 are poverty level patients whose annual income is less than $14,500 for an individual or $26,000 for a family. They should receive Medicaid coverage. The middle 1/3 are the working poor, such as this young man with back pain as noted above. They should receive partial Medicaid coverage along with tax deductions; so no more than 10% of their income is used for medical care.
          By implementing these various cost reduction recommendations we can substantially improve and truly have accessible-affordable health care with out raising taxes.
          My mind wonders to what attracted my father, my brothers and me into this profession. In no doubt we were drawn to the challenge of helping people find the path to good health. It is my hope that we will see real leadership rise to the occasion in shaping that policy, in order to preserve the best healthcare system in the world, but to make it more accessible-affordable for all its citizens. I want that young man with the painful back to find the road to health and to be able to do so in a way that we all can have pride in.