Physicians Are Talking About: What to Do to Reform
Healthcare
Nancy R. Terry
http://www.medscape.com/viewarticle/706774
As the healthcare debate heats up, the only point on which all parties agree is
that the present healthcare system does not work.
An estimated 50 million Americans are uninsured, and the number continues to
rise as more people lose both their jobs and their health insurance. Americans
spend more than $2 trillion a year on healthcare, which is, by some estimates,
40% more per person than the next most costly country. President Barack Obama
and Congress are mobilizing to reform healthcare. Yet, change alone does not
guarantee improvement.
In a flurry of postings on Medscape's Physician Connect (MPC), a physician-only
discussion board, doctors debate what reform measures would salvage US
healthcare. Many physicians are as wary of increased government intervention as
they are frustrated by the bureaucratic, profit-driven excesses of private
insurance companies.
"As someone who has lived with illness (a congenital immune deficiency) for
longer than I have been a doctor, I know first hand how broken our system is,"
says a dermatologist. "I live in fear of losing my health insurance since I know
I am uninsurable through any private program. A public option is the only way to
go."
"What would a greatly expanded role for the federal government mean for
healthcare in this country?" asks an anesthesiologist. "Rationing for patients,
with fewer treatment options and increased difficulty visiting a physician." An
infectious disease physician agrees, "Obama's thrust to mandate a
Medicare-for-all, single-payer [program] will ultimately lead to healthcare
rationing of services -- not for the young and healthy but rather for the
elderly, who are the sickest and most vulnerable among us."
The rationing of medical services is frequently cited by a number of physicians
as an alarming but predictable component of a national healthcare plan. Yet,
other physicians contend that rationing of services already exists. "The
private, for-profit insurance carriers have contributed to the healthcare crisis
by cherry picking the insureds," says an orthopedic surgeon. "To have a
different premium price for those with preexisting illness denies insurance to
those who need it most," adds an emergency medicine physician. Another MPC
contributor comments, "Instead of making people wait, we just deny elective
procedures altogether to people who don't have insurance. That's American
rationing."
Advocates of free enterprise favor maintaining a system of multiple insurance
providers because, they argue, free enterprise ensures maximum efficiency. In
contrast, other physicians claim the exorbitant cost of healthcare can be
largely attributed to profit-maximizing insurance companies. "Insurance
companies are responsible for the high cost of healthcare," says an MPC
contributor. "THEY set the premiums, and the reimbursement and the schemes that
are squeezing everyone. All in the interest of profit -- not healthcare."
A national healthcare plan, according to other physicians, would afford no
greater efficiency than the current system. "Already doctors aren't accepting
Medicaid because of dwindling payments, hassling paper work, confounding delays,
long waits, impersonal attention -- medicine DMV [department of motor vehicles]
style," quips a pediatrician. "So, everyone will have insurance. Just not that
many will have doctors."
Still others see little difference between the options of private and public
insurance plans. "The schism between private health insurers and government is a
ruse," says a general surgeon. "Medicare is already outsourced to private health
insurers. Medicare-for-all will be a big boon for health insurers. Their volume
will go up as will their profit margins as government-sponsored
cost-effectiveness research demonstrates how much of the expensive medical
treatments are "ineffective." Another win-win for government and health
insurers. It's all a numbers game -- shift to preventative healthcare and the
healthy are happy and the sick are shoved under the carpet."
Obviously, there is no easy solution. The best option, according to some MPC
physicians, is to keep open as many options as possible. "Most of the primary
care societies and academies favor a one-payer system," comments an MPC
contributor. "If we are to give at least basic healthcare benefits to our
citizens, we need it [a public plan]. It is not the perfect system, but at
present it is the best option available. If a person wants concierge care, he
should buy it."
"Will someone please explain what is wrong with a 2-tiered system?" asks an MPC
contributor. "A basic plan with some basic coverage for those who cannot
contribute and the premier plan for those who do contribute. The water
analogy...everyone can drink tap water, but if you want bottled water, you gotta
pay."
"Sounds OK to me," responds another contributor. "Coverage for treatments for
which there is good efficacy data (not just statistical significance but
clinical significance) and everything else, well, if you want it, feel free to
buy it."
Few physicians are comfortable with a proposal favored by Congress that
participation in a public plan be mandatory for all physicians who accept
Medicare patients, although a nephrologist is "okay with mandatory participation
for 1 to 2 years to support the government effort, but the mandatory
participation should expire automatically afterwards."
Healthcare reform, however, is not simply a question of the number of insurance
plans available. Recognizing that any insurance option must coexist with a
reform agenda, physicians offer a range of proposals how a more equitable,
efficient healthcare system might be achieved.
Hold the insurance companies accountable to insure patients who have a
preexisting illness.
Set one premium level for all insurance participants, with varying deductible
and copayment amounts.
Establish a fund, patterned after Alaska's Permanent Fund, to cover the cost of
insurance for those who cannot afford it. The fund could be built up by taxing
commodities and activities that increase the risk for illness, such as tobacco
and alcohol use.
Incentivize preventive medicine, especially in the management of lifestyle
diseases, such as diabetes and hypertension.
Reduce redundant and defensive testing.
Reform the tort system and eliminate malpractice insurance.
Initiate a national campaign to promote fitness programs, improved nutrition,
self-care programs, and disease prevention.
Establish national licensure for nurses and doctors to decrease the costs of
multistate practice.
Eliminate state-by-state variations in insurance laws to unify the method of
determining eligibility for healthcare insurance.
Eliminate the fee-for-service model, and put doctors on salary.
Physicians, according to an MPC contributor, are in the best position to offer
practical, constructive solutions for healthcare reform. "We need to stop coming
to the table primarily motivated by protecting our incomes," said an emergency
medicine physician. "Instead we should come to the table as citizens who have
insight into why our healthcare system is so sick."
Physician discussion about health care reform can be found at:
http://boards.medscape.com/forums/.29f41650.