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“It is the duty of the next Congress to reform America’s health care system. In 2009, Congress must take up and act on meaningful health reform legislation that achieves coverage for every American while also addressing the underlying problems in our health system. The urgency of this task has become undeniable.” These are the opening words of Senator Max Baucus (D-Mont) the Senate Finance Committee Chairman in his Call to Action, Health Reform 2009, a white paper that has been described as the blue print for the health reform legislation that will be introduced by him and Senator Ted Kennedy. Every emergency physician owes it to himself to become familiar with the proposed plans and the assumptions those plans are based upon. Only then can we engage in meaningful debate and become actively involved in shaping the future of our specialty specifically, and health care generally.

Before we get down to the facts, I must warn you of the emotion that will drive this debate. Listen to Senator Baucus’s opening to the Executive Summary. “The link between health care costs and the economy is undeniable. Reforming the health care system is essential to restoring America’s overall economy and the financial security of our working families.” Everyone agrees that the burden of health insurance contributes to the disadvantage that American industry experiences in global competition. But linking words like “restoring the economy” and “financial security” to health reform suggest that legislators will attempt to drive health reform with the insecurity of the current economic crisis. The worst possible scenario would be for Americans to look for scapegoats to blame for the economy and end up with health reform that makes the economic situation worse.

Let’s look at the first assumption of every health reformer: poor quality of health care. Without citation, Senator Baucus states that “Studies show, for example, that adults receive recommended care for many illnesses only 55 percent of the time. Children fare even worse.” Do such statements reflect the truth, a distortion, or a gross misunderstanding of the facts?  Just as importantly, will reform change this? Reformers claiming that the US has poor quality health care often cite the World Health Organization studies that show that we rank lower in life expectancy and infant mortality as compared to other industrialized nations. But the truth is that these studies show a tightly packed group where ranking has little significance. Moreover, such rankings fail to consider that life expectancy and infant mortality may have much more to do with heterogeneous populations with different genetics and lifestyle than the skill of the health care system. Unless the government is given the ability to mandate control over such things as unhealthy food, obesity, smoking, and early pregnancy, it is unlikely that any health reform will impact this standing.

Everyone supports universal access to care. Senator Baucus has proposed a Health Insurance Exchange, a national marketplace where people can bargain collectively for insurance. Portable, personal insurance that is not tied to a specific employer makes sense and will likely result in lower insurance premiums for everyone. It’s interesting to note, however, that it was government regulation that prevented such an open market in the past. Legislation that allowed companies to write off insurance costs while preventing individuals and small businesses from doing the same created this problem. But it is good that they now see that it must be changed.

The problem of underinsurance will remain, however, unless costs are brought under control. The white paper cites a shocking story of a woman who was diagnosed with leukemia. She had insurance, but her annual payout was capped at $37,000 per year. So M. D. Anderson Cancer Institute demanded an up front payment of $105,000 before beginning chemo therapy. High costs equates to diminished access. Fix one problem and you will fix both. If we only mandate insurance or provide government subsidized insurance, thereby solving the issue of access, and don’t lower the overall cost of care the whole project is doomed to failure from the start.  

The Baucus plan calls for an interim expansion of Medicare, Medicaid, and SCHIP until such time that individuals can obtain private insurance through the Exchange. However, Massachusetts discovered one practical problem to this approach when they attempted a similar statewide plan. After mandating insurance and providing a government back stop for private insurance, Massachusetts experienced a massive shift from private to public funded insurance. Why? One can only assume that individuals and businesses saw that their share would be less through tax increases than through funding private insurance. It is simply cost shifting of another kind. Whether intentional or not, it is a way of backing into a totally subsidized and controlled government health system that is funded by a small percent of wealthy taxpayers and corporations. It will only work until the wealthy flee and the corporations take their increased tax burden out of their employees. Moreover, this approach never addresses the underlying cause of the problem, cost. The white paper adheres to the conventional wisdom that costs can be controlled by a refocus on prevention and wellness, rather than illness and treatment. In other words, cheaper primary care rather than expensive specialty care. Senator Baucus proposes a “Right Choices” card that will “guarantee access to recommended preventative care, including services like health risk assessment, physical exams, immunizations, and age and gender-appropriate cancer screenings.” Prevention is good, but good health care doesn’t prevent death, it only delays it. Finding that someone is sick sooner will not lessen the overall cost of health care. In fact, it might even increase it. One oft-quoted study found that the average individual will spend over 60% of his or her entire life’s expenditure on health care during the last years of his or her life. Treating problems sooner, thus living longer, will not change this equation.

The only way an emphasis on primary care can effectively reduce costs is for family physicians to become gatekeepers, preventing access to more expensive subspecialty care. In some cases patients don’t need subspecialty care. But who should decide that? No offense to my FP colleagues, but I don’t want someone making more for doing less. Most countries with socialized systems will boast of the ease and low cost of getting primary care. But the down side is long waiting times to receive subspecialty care, if it is available at all.

The Baucus plan has some good suggestions that we can all agree on, however. First, there are savings to be had from an easily accessible, unified health record. Knowing every test, every diagnosis, and every treatment that a patient has received would reduce unnecessary testing and treatment. This is a must.

Reducing fraud and abuse is a goal of the Baucus plan that we can all support. And all will agree that incentives, such as those provided to drug companies and medical equipment manufacturers, should play no part in utilization. However, experience tells us that the public sector is not immune to manipulation by well-heeled lobbyists with a lot of cash to spread around. It just goes into political coffers instead of physicians’ wallets. My suspicion is that the public sector experiences more problems with fraud and abuse than the private sector. Enlarging the public sector of health care will only worsen this problem.

The Baucus plan rightly calls for reform of long term care services. Again, it is government regulation that has made it difficult for families to care for their aged loved ones in private, less costly settings. Properly crafted legislation will be welcome, though not likely to have a huge impact on the total cost of care. Only rationing end of life care will do that.

Tragically, health reform supported by the incoming democratic congress and president make only a passing nod to liability reform. Pointing to states that have enacted malpractice caps, legislators claim that tort reform will have little substantive impact on the total cost of care. But this fails to recognize the impact that the fear of litigation has on the practice of medicine. Overtesting and overtreating are direct results of this fear. If physicians were given safe harbor from suits by practicing within published standards of care–set by a panel of experts utilizing the latest evidence based clinical decision rules–the cost of care could drop dramatically. Moreover, if malpractice awards were paid out at regionally set rates, by health courts or commissions, rather than by uneducated juries, claims and suits would come under control without injuring plaintiffs.

The Baucus white paper warns that “In the short term, health care reform would cost taxpayers more than the government can achieve in savings from all reforms and financing changes.” He is right. A plan such as is proposed will cost more. Medicare and Medicaid costs have continued to rise since their inception and both are likely to go into bankruptcy in the foreseeable future. But he warns that “If we fail to act, however, we will double our current national expenditure on health care from $2 trillion to $4 trillion, continue to witness the plight of tens of millions of our citizens with health insurance cost shifting to those who do, continue to tolerate poor quality that leads to nearly 100,000 deaths a year, and watch our businesses become less competitive and our nation go father into debt.” I believe that his warning is an attempt to scare us into following him off a cliff.

Mark Plaster, MD, JD, is the founder and executive editor of Emergency Physicians Monthly

Click here to read part I of this series by Paul Hochfeld, MD
 
 
7 Ways to Lower Health Costs

1- Publish ‘suit-proof’ standards of care for the management of specific problems

2- Mandatory comprehensive accessible electronic medical
record

3- Drastic limits on product liability for drugs tied to eased FDA rules speeding drugs to market

4- Greater freedom to use appropriate levels of providers (i.e. PAs, NPs, nurse techs, paramedics in hospitals)

5- Insurance coverage for preventive care and chronic care, but not routine primary care

6- Large scale health cooperatives (patient owned vs investor owned)

7- Eased restrictions on coverage for elder care settings

-Mark Plaster, MD

Comments   

# MDJ.P. Gregoire, MD 2009-01-05 23:32
Admirable. I especially like # 1 above.
I disagree with # 5. Good routine care is a key and access to preventative medicine. With universal coverage and access to health care, outcomes would be much improved.
In addition we need to ensure universal coverage with individual responsibility as a key component. Many aspects of the medical savings account encourage discretion in utilizing health care resources.
Moving from entitlement to ownership will go a long way in self rationing of medical care.
Reply
# Julia Cameron 2009-01-08 21:11
I would agree with Dr Gregoire above, additonally I have always felt that some type of personal resposibility should go along with any form of insurance, esp public. If I am going to pay for your medical care, I have the right to expect you to use that money wisely.
Reply
# universal carejohn dente 2009-01-16 17:16
With the bailout of Wall Street, and an automotive industry that cannot produce a vehicle that anyone wants to buy, there are those who now want to add to the burden of the long suffering taxpayer the burden of providing universal healthcare.Abse nt from all these fantasies is the extent of the care provided and the responsibility of the receipient of the government largesse.

So we'll assume that health care is a right, even though the moral and plilosophical arguments for this right are debatable. But, will the taxpayer have any rights? Will the taxpayer be able to refuse to pay for treating diseases that arise from the patients overindulgence in tobacco, alcohol, illicit drugs, food, or promiscuous sexual behavior? How many heart valves does the intravenous drug users get? And if the recipient of the care is abusing his body how will anyone know? Should patients be monitored for such behavior? Why not? Proceeding from who will get care we must ask when and where the care will be provided. If a patient walks into the emergency room with the sniffles will he be immediately sent to the family practioner or clinic assigned to him by the system? And if he needs emergency care will he only be permitted to use a certain emergency room designated by the providers? At least this will stop the not uncommon behavior of serial emergency room visits. And when the families who always want everything done ,as long as it is not they who are paying for it, are told that less aggressive measures are all that can logically be offered will they accept this?

And returning to the issue of the moral right to medical care why is it that some small business owners are being taxed without mercy to pay for other people's care while they cannot afford to insure their family ? I doubt unmiversal health care will make this situation more equitable. Yes, everyone has rights; it's just that some people have more rights than others.


John Dente M.D., FACEP
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