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altEPM: We understand that you oppose the current health reform bill in the Senate. What do you see as its major problems?

Sen. Tom Coburn: This bill will ultimately divide the loyalty of the physician, not to be a 100% advocate for the patient, but to be sure and cover their backsides, so they don’t get in trouble with the government. The cost comparative effectiveness panel? You’re going to have to do things the way they think you need to do it. This [bill] guts the art of medicine.  For 80% of the people that will be just fine. But we will have changed our focus to the cost of medicine from the health of the patient. What’s the other bad thing about the bill? It’s going to raise everybody’s taxes. It’s going to raise everybody’s costs and it’s going to raise everybody’s insurance premiums.

EPM: Assuming that we need to control cost, what’s wrong with how this bill goes about accomplishing this task?

Coburn: The assumption [in Congress] is that we need to spend more money to control costs.  That’s ridiculous!  One in three dollars that we spend in health care today doesn’t do anything to help people get well or prevent people from getting sick.

I have a friend who now practices medicine. He’s an internist and a great doctor. A year ago he quit taking Medicare and Medicaid. All he does is cash business. He let four people go in his office. He only has one employee now. Those four people weren’t doing anything to help people get well. They were doing the business of medicine rather than the health care of medicine. Truly, 50 to 60 percent of the overhead of every health care organization is spent complying with the rules and filling out the paperwork. [My friend] now sees fewer patients, says he’s practicing the best medicine he’s practiced in his life, and he makes the same amount of money. His prices are very reasonable. And if someone doesn’t have money, he’ll still take care of them.
 
EPM: The supporters of this bill claim that it will increase the number of family practitioners in this country.  You are a family practitioner.  Do you agree?

Coburn: No. It will not increase the number of family practitioners.  This bill does nothing to pay family practitioners more, it only helps them pay off their loans. One in fifty doctors who graduated from medical school last year went into primary care. Just one in fifty. So how do you incentivize people to go into primary care? You pay them more! What [the government] is going to do is provide all of these subsidies for loans, but [medical students] won’t go. They’re going to realize that they can spend one more year in residency and earn twice or three times the earnings over the long haul.

EPM: What do you think will happen if this bill passes?

Coburn: Forty-five to fifty year old doctors are not going to play this game.  If they have a way to retire, they are going to do it.

EPM: Will we have more specialists or fewer?
   
Coburn: Medicare has created an absolute shortage of cardiovascular surgeons. They pay about $1,200 for a heart bypass now. These guys have 8 years of post-medical school training. They have 12 years of training in medicine before they ever get a start earning a penny. And now what used to be a $3000 procedure is now a $1500 procedure. The program at the University of Oklahoma shut down for cardiovascular surgeons because they couldn’t get anyone to go into it.
   
EPM: Senator Reid claims that this bill will cover everyone, cut the deficit and save lives.  What do you say?

Coburn: If you use real accounting, this is a $2.5 trillion bill that will run massive deficits. Here’s why. Number one, Congress will never cut Medicare. That’s $500 billion more. Number two, the doc fix. The doc fix will get fixed, but they’ll never cut spending somewhere else to pay for it. That’s another $274 billion. Then we’re going to increase those eligible for Medicaid. And we don’t have the money to pay for it. And then finally, everything you buy in health care now is going to get a new tax on it. Your drugs are going to get a new tax, your insurance is going to get a new tax, your medical devices are going to get a new tax. And then finally, since they charge you only $750 to not have health insurance, what do you think healthy people 40 and under are going to do? They’re going to take the $7000 or $8000 that they were contributing to their employer and they’re going to keep it, pay the $750, put $4000 away every year and if I get sick, then go buy the insurance. What’s that going to do to the insurance industry? The healthy people are not going to be in the pool. So the pool is going to be smaller and the pool is going to be made of sicker, older people. So everybody’s premium is going to rise. So not only are we going to have massive deficits from it, but the price that everybody pays is going to go up. Plus, we’re going to tax small businesses, we’re going to tax individuals, we’re going to raise the Medicare tax and then take the money from Medicare – which has a 75-year unfunded liability of $39 trillion – and create another government program.   

EPM: Can you explain your numbers?

Coburn: Over the next ten years, 55 million more Americans are going to go into Medicare. The baby boomers. My generation. We’ve been paying in, but the amount of money to pay for our health care is in deficit by $39 trillion over the next 75 years. In other words, that’s what we’ve promised but don’t have in the bank. And that’s the differential after the taxes are collected. So if you’re going to raise the Medicare tax, it ought to go to fund that differential rather than create another government program.
The government controls 61% of health care now, if you add up Tri-Care, VA, Indian Health Care, federal employees, etc… Tell me one of those that is efficient, working on budget and delivering the care that we want them to have. None of them. And we’re going to put the rest of the care in the government’s hands?

If you were to go back and look, when did health care inflation start at 2.5 times what the regular CPI was? When they instituted Medicare. Why? Because we have this disconnect between the purchase of health care and payment.

EPM: So how do you bring cost under control?
 
Coburn: First of all you incentivize tort reform throughout the country. You’d save $100 billion on health care tomorrow. The numbers on malpractice suits are that 80% that get filed get dropped because they’re just attempts at extortion. Of the 20% that either get handled or go to court, only net 3% end up being found in favor of the plaintiff. And the ones who win, who have legitimate injury, only get 40% of the money. And it takes forever for them to get compensated. So one of the ways to [reform] would be loser pays. Go to English law. You would save $100 billion the first year you had that in effect.
 
EPM: Would that really change the way we practice?
 
Coburn: It would over time. It would take 10 or 15 years for the changes to happen on the physician side. We’ve developed this habit [of defensive medicine] because of being sued inappropriately.

EPM: What other ways can we lower health care costs?

Coburn: Create real competition and transparency in the insurance industry. And you can only do that by allowing people to buy what they want. So if I want to buy a $25,000 deductible policy and I can find someone in this country to sell it to me, I can buy it. I can’t do that now. I live in Oklahoma. The highest deductible policy you can buy is $7500. Also, allow associational group health plans. Let small businesses come together and pool their resources and contract out on a broader base of indemnification. Small businesses have no buying power, so you allow them to combine. Finally, allow the markets to function. The problem with all of these bills in Washington is that they’re government centered, not patient centered.

EPM: You don’t seem very optimistic about your colleagues in the Senate.

Coburn: What ails Congress today, in my view, is people who are making decisions at this level who have never done anything except politics.  They are wonderful people, they care about the country, but they are clueless when it comes to common sense.
I don’t think anyone with less than 20 or 25 years of experience in life should be in politics; someone who has been around the block and knows how to prioritize things. The problem with Washington is that they don’t want to prioritize anything. They just want to keep charging it to our kids.
 

Comments   

# MD--Emergency medicineMichael Preston 2010-01-06 19:46
The tort reform argument is right on. We have got to take the fear out of practicing medicine. As a country we HAVE to address our poorly functioning health care system. Politicians are in this for the politics--votes . We have to reward primary care and let primary be the real gate keepers and reward them for doing it.
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# DITTOGene Mayeaux 2010-01-06 21:14
This is the most sensible group of statements made by any senator/represe ntative on the topic. Term limits would cure what ails Congress and provide every American with a true solution to our everyday problems.
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# md mmmwilliam b lauth 2010-01-07 03:41
like it. not everything but hits some major points. it is so large and complicated. it is a cultural problem that needs fixing and so enormous a problem that putting more money up is not the answer. i would agree that tort reform coupled with a one administrative payor (private or governmental)is a mandatory start but never possible in our democratic union. a two tier system is inevitable (those who can afford more with private funds and those who cannot). I also think the private practioner will be a thing of the past before too long and most patients will become recepients of huge outpatient unscheduled care centers which feed the specialists and the hospitals. when you think about most primary care today not much is really done in the office. I may be wrong but I think ED visits nationwide have now outnumbered visits to private internists. I think national insurance will drive more patients to EDs and less to PCPs. The best deal in medicine in in an ED.
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# Dr. TTyrone 2010-01-07 19:14
Senator Coburn's perspective is so rational and well thought out - yet why is irrationality and foolishness being foisted on the American people?
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# Senator's typical Republican responsesMatt Perl, M.D. 2010-01-08 00:00
I suggest that any physician who's interested in the current health care reform proposals read the NewYorker article by fellow physician "Testing, Testing The health-care bill has no master plan for curbing costs. Is that a bad thing?" by Atul Gawande

As to the Senator's comments:

1-The "art of medicine" has already been gutted by the insurance providers requirement for "pre-authorizat ion." Throw in limitations in prescribing based on drug tiers, and this isn't anything we already face. And raising taxes? Typical fear-mongering.
Answer 2-He's correct that "one in three dollars" doesn't do anything to help people. That's because typical insurance industry overhead is 20% or more. And about his friend ... sounds like the present system has driven him away from patient care.
Answer 3-He doesn't really know this; he's just guessing. And at least this may help.
Answer 4-Pure supposition; no basis whatsoever.
Answer 5-We seem to have plenty of CV surgeons in San Diego. Studies have proven that more specialists mean more procedures, not better healthcare.
Answer 6-What he proposes is exactly what's wrong with the current system. Healthy younger people choose not to have insurance, unless it comes "free" with their jobs. We need a larger pool to subsidize the sick and elderly. And I have yet to see a patient who, when told they'll have to pay the $2500 for their MRI because they don't have insurance, have been saving their dollars for that event.
Answer 8-. The Republicans controlled both Houses of Congresses in the first part of the last decade. I don't recall any real effort for tort reform then. I believe tort reform is great. Let's do it. But don't confuse that effort with reform of the insurance industry, which is what we're trying to accomplish now. I suspect that when it truly comes to tort reform, we see the typical hemming and hawing from both sides, with little real reform.

His other claims: $25,000 deductible-what a laugh. Nobody's going to pay that much money out of their own pocket when they end up hospitalized for an appendectomy, a motor vehicle accident, or a stroke. He calls for allowing small businesses to pool costs; this was a tenet of one of the original bills that was forced out by the Republicans caucus.

And his last allegation of "experience" being a requirement for rational prioritizing in politics. I think the last eight years of Republican control have proven that they have just as much ability to push debt to our future generations as anybody (they just run up the debt via the military-indust rial complex.
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# m.d.james henderson 2010-01-13 21:52
senaator coburn has not been practicing for some years, and his outlook is dated. He is also limited to a knee-jerk reaction by his severe right=wing extremism. Before this bill was passed, people, including this writer, were frequently denied coverage at any price
for pre-existing conditions, no matter what deductible they were willing to accept. And is a $25,000 deductible a real option for people who make $30,000-$40,000 yearly? senator coburn inherited wealth , and is unrealistic about what average people can afford. i also wonder what steps he took to control management fees in emergency medicine where it is standard for management to take 70% of physician reimbursement. Has he ever proposed any legislation to address the problems he mentions? if not, why not? sincerely, ed md.
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# Medico-Legal DiseasecareG. Schroeder MD 2010-01-15 20:50
My article in the OP-ED section of Dr Tom COBURN's hometown Newspaper on my concept of American 'Medico-Legal Diseasecare' support this distinguished Senator's outstanding and brilliant comments as an ethical citizen legislator
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# The Lawyer and Lobbyist plaguesbnative 2010-01-18 18:00
There's not an industry unaffected by the over-arching fear of lawsuits. I'm not a physician but I work in industry just as terrorized by lawyers. My husband is physician and he says physicians should organize like other groups do--i.e. against lawyers and lobbyists who are influence/extor t legislation that affects the practice of medicine. Healthcare reform without tort reform? Snort snort snort... Thank you Dr. Coburn for continuing to speak out.
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