Blog # 64
With the recent Supreme Court decision to uphold the “Obama care” Affordable Care Act, we can expect some significant reforms in our health insurance system. This act will increase access for those who are uninsured, protect those who are insured from cancelling benefits if they become seriously ill, allow for children to stay on their parent’s plan until age 26, and allow coverage for pre-existing conditions. The law will also require insurance plans to cover out-of-pocket costs for many preventive care services that screen for problems at their earliest stages, such as colonoscopies and mammograms.
Even in light of these positive changes, the American health insurance situation is clearly problematic, fraught with deeply entrenched and highly complicated issues for which there are no simple solutions. Even with Obama’s reforms, the current situation is neither healthy nor sustainable. As a physician who “works in the trenches” and confronts many of these issues on a daily basis, I have a few ideas about improving health insurance. I certainly don’t have all the answers, but I know some givens and some of what must change in order for our system to remain viable.
As a general model, I use the “body as automobile” metaphor, extending this to the realm of health insurance. The premise is simple—we need to maintain our automobiles to keep them healthy and running. We fuel them properly, do routine preventative maintenance, drive them in the manner they were designed to be driven, keep them clean and treat them with respect. We purchase automobile insurance in the event that we are involved in an accident that causes costly damage to our vehicle. It is our choice whether we purchase a very basic insurance plan or a more complicated and fancier plan that offers more frills.
The following are some of my thoughts about necessary reforms to the system:
- Establishing universal health insurance with a single-payer that has streamlined administration is an absolute necessity. This would serve to eliminate the ridiculous amount of red tape and bureaucratic waste in the current system. The profit-based private insurance companies squander billions of dollars via inflated administrative costs, shareholder profits and the disgraceful eight-figure salaries of the CEOs. Our taxes should provide all citizens of the USA with a basic policy to insure against a serious medical illness. More extensive and sophisticated coverage should be available at a premium, similar to automobile insurance where deductibles and “bells and whistles” are variable.
- The employer-based underwriting of medical insurance has to be terminated. Why should one’s employer have the financial responsibility and burden for this? This was an absurd and misdirected idea from the get go. The concept that the employer provides health insurance is as ludicrous as the idea that the employer should provide automobile insurance. It puts the USA at a competitive disadvantage, hinders employment, and thus puts a drag on the economy.
- Just as automobile insurance does not pay for routine car maintenance, I do not believe that health insurance should pay for routine preventative maintenance—the purpose of this health insurance should be to protect us in the event we need surgery, develop a chronic disease, have a catastrophic medical occurrence, etc. All of us need to have some “skin” in the game and expect that we will need to have some financial responsibilities for our medical care. We willingly pay it for our automobiles, why not for ourselves?
- Dental care (and other ancillary health care) should be included under the domain of medical insurance—it is ridiculous that specific areas of our bodies are treated differently in terms of insurance.
- The third party system engenders the concept of “other people’s money” paying for our expenses, which must change to a system of crystal-clear transparency and the thought process that it is “our money.” Patients, physicians and the payer all need to be in-the-know about the precise fees and charges for all medical expenses, and once this transparency exists it will help set up the necessary markets to allow for competition and for inflated medical charges to equilibrate. This transparency needs to apply broadly to doctors’ offices, clinics, labs, imaging centers, ambulatory surgery centers, hospitals, etc. Transparency will engender market competition, which will keep prices down.
I recently had some x-rays of my hand; I was in sticker shock when I saw the bill that was in excess of $1000 for this series of films that took the technician 5 minutes and the radiologist a minute or so to read and dictate a report. My insurance company paid the bill, so although I was initially incensed at what I thought was an excessive charge, I was happy that it was covered by my insurance and soon didn’t give it another thought.
- Meaningful tort reform needs to be established so doctors do not feel obligated to order medical tests on a “defensive” basis. Many of the lab, imaging and other diagnostic tests we order are not medically necessary, but are done on a “covering-our-ass-in-this-litigious society-basis.” After having spent time in court being grilled on the witness stand by a vicious plaintiff’s attorney with the following question: “Doctor, is it not your obligation to rule out the most serious possible cause of the patient’s presenting symptoms?”, I changed my entire philosophy of medical practice to be an extremely defensive physician. Thus, a gamut of tests that are largely done to keep me and other doctors out of the courthouse.
- Patients must take responsibility in shaping their own health destiny in terms of living a healthy lifestyle to avoid preventable chronic diseases that occur on the basis of tobacco, unhealthy eating, obesity and sedentary living. An appropriate system needs to be established to “reward” non-smokers who maintain a healthy weight and exercise regularly and to “penalize” those who drive up the cost of the program by volitionally pursuing unhealthy lifestyle choices. Much like speeding tickets or other infractions that jeopardize our safety and incur points that can result in a more costly automobile insurance policy, our health insurance policies have to incorporate risk into their premiums. Once again, we need to have some skin in the game.
- Patients need to understand that expensive diagnostic tests that are generally low-yield should not be ordered on whim for any mild symptom that presents itself. I have countless patients who literally demand cat scans for frequently inconsequential reasons, yet I rarely try to argue against pursuing tests from the patient/consumer who is absolutely determined to have a test done.
- Many physicians pursue diagnostic tests for a variety of reasons including: ready availability; habit; dogma; derivation of potentially helpful clinical information; reassurance; medical-legal documentation; and revenue to help offset the expensive cost of maintaining a medical practice. Before any medical test is performed, there needs to be a discussion between the patient and physician regarding whether the test is absolutely necessary and if there are less costly alternatives. Many tests are expensive, the additional information they provide does not make them cost-effective, and treatment could be rendered as effectively without the diagnostic information provided.
- The payment system for physicians needs to be modified, precisely how I am not sure. As in most things in life, there is a Bell curve among physician competence. Most are good, but there are some outliers who are exceptional and some outliers who are less than proficient. For example, Dr. NOT-so-competent operates on patient X and because of ineptitude needs to repeat the operation two additional times before the situation is corrected. Dr. Competent does the surgery once and achieves effective results. The inequity of the system is that Dr. NOT-so-competent garners three surgical fees from the insurance system and Dr. Competent just one, while the patient of Dr. NOT-so-competent had to endure unnecessary procedures. Something is just not right with this scenario! A fair and equitable physician compensation system needs to be established in which lack of competence and unwarranted volumes of diagnostic testing are not rewarded.
- An integrated electronic medical records system needs to be established. What we have now is disintegrated and spotty, in its most rudimentary phases of development and not ready for Prime Time. We need a system such that any medical doctor in the USA can access the records of any patient, and one that is integrated across hospitals, private practices, clinics, laboratories and imaging centers. I’m not sure why information technology has been so late to come to medical practice in America, but it is an unfortunate situation that needs to be rectified. Some brilliant software engineers from, let’s say, Apple need to come to the rescue with an intuitive, simple, universal and integrated system.
- The cost of devices and pharmaceuticals in the USA is out-of-sight as compared to many other industrial nations, significantly jacking up the cost of medical care. The establishment of some form of international co-op such that economic market forces could be brought to the world of pharmaceuticals and devices is in order. If an identical product is available in Canada or Europe at much less expense than in the USA, we need to broaden and open the market to allow these to compete with the devices and drugs available domestically to bring their prices down.
- Hospital expenses need to be kept in check. Transparency is truly lacking in this domain. If you were to examine your hospital bill carefully you would likely be bewildered trying to understand it and flummoxed when you realized what the charges are. There are many ways to cut the expenses of hospitals and I would start with reducing the billions of dollars that go to advertising and marketing and eliminating seven-figure executive compensation packages.
In summary, at the same time that many of us are true believers in capitalism and the free market, our sense of humanity, compassion and community should drive the necessity for universal health insurance to provide health care for those less fortunate than ourselves. In addition to insuring all Americans, we need a system that provides high-quality medical care that will not impoverish the nation. We certainly do not want a health care system that runs like the Department of Motor Vehicles. We must continue to provide incentives so that the health care field attracts bright and talented individuals and so that research and development by the medical, pharmaceutical and device industries continues to promote innovation.
A nationalized, single-payer, bureaucracy-streamlined, taxpayer-financed, medical insurance system is imperative. Patients must expect to have some financial responsibility as well as personal responsibility in terms of maintaining a healthy lifestyle—skin in the game—or else they will need to have increased financial liability for burdening the system. The employer-based system has to be terminated and the private health payers need to be melded into the nationalized system. The economics underpinning the new system must be highly transparent and competitive markets need to be established to keep costs down. Tort reform will mitigate the practice of defensive medicine. An integrated, universal electronic medical records system needs to be established. The current system of physician reimbursement must be revamped. The expenses for devices and pharmaceuticals need to be brought down by opening competitive markets. The end results of such reformation should be broad access to care for all U.S. citizens and significant cost savings. Without some or all of this, the system is destined to crumble.
Andrew Siegel, M.D.
Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food
Available on Amazon Kindle