Let’s look at the facts: 

• The bill was written by and for Big Pharma and the medical insurance industry. Senator Max Baucus a member of the congressional brain trust who brought us the healthcare reform bill admitted he never fully read it and has no idea what is even in it. Now he admits to having no clue what was in the bill he helped shove down our throats…. Unbelievable? Surprising? No just business as usual.
• Those on Medicare were told that they would see no change in their benefits and would be able to keep their physician. In fact, 11 million senior citizens will see premiums go up because of cost cutting including the removal of Medicare advantage. Furthermore, since there has been a decline in the number of physicians who currently are accepting new Medicare patients or who take Medicare at all, it is likely that seniors will not be able to keep their doctor and will pay more for less.   
• The nomination of Donald Berwick to head CMS means a philosophical shift of our healthcare system to the British model of medicine that puts a premium on cost and not the needs of the individual. An example of this is the decision by the FDA remove Avastin from the medication available to treat advanced cancer because it is deemed that the good of extension of life is outweighed by the cost of the medication. Medicare has already stopped covering the use for Avastin to treat ovarian cancer ovarian cancer in Colorado.

It is clear that the relentless drive to reform the health care system was a cynical political push for a win at all costs. We were told what we wanted to hear and there was no attention paid to the consequences. Every single card was played – from the class card to the race card. Doctors were demonized and getting us to fight among ourselves achieved the goal of distraction. Now that the smoke has cleared it is pretty obvious that in the name of expanding healthcare to approximately 30 million more people, we have sacrificed what is best about our healthcare system – individualized patient care, the doctor patient relationship, and the drive towards innovation. However, the costs have not changed.

Welcome to the world of one size fits all medicine where the patient will become a cost center and treatment will be geared towards cost containment while the potential for profits to be made on the backs of patients and doctors for the medical insurance industry, the hospitals and Big pharma are limitless.

The contents of the oils spill contain several components. Each has the potential to cause health risks to those who are exposed to them. These are some facts of some of the most toxic substances:

 1. Benzene 

Is a colorless liquid that has a somewhat sweet odor. It evaporates in air quickly and can dissolve into water. Therefore, it can be present in rain water carried distances and can have an effect on the ground a distance from the original source. Reports from the EPA have put the amount of Benzene measured near the Gulf of Mexico at 3,000-4,000 parts per billion (normal 0-4ppb). The EPA has set the minimum benzene exposure in drinking water at 5 ppb and the Occupational Safety and Health Administration (OSHA) has placed safe exposure of benzene at 1part per million parts of workplace air for 8 hour shifts in a 40 hour work week. The EPA considers it a carcinogen at 1,000 ppb. Exposure to benzene vapors can cause a myriad of symptoms from headaches, nausea, dizziness, and drowsiness to rashes, respiratory difficulty. It has also been linked  to leukemia and lymphoma. More Benzene Facts

 2.  Hydrogen Sulfide

This is a colorless flammable gas that is highly toxic that has a characteristic  “rotten egg” odor. It is 20% heavier than air, and therefore will accumulate on the ground and in confined spaces. At concentrations above 100 ppm the olfactory nerve (the nerve that controls the sense of smell) is affected and the person can no longer detect the foul smell. However, if the person has a prolonged exposure to a low concentration the ability to detect the smell will also be lost. Exposure to the gas at low concentrations (0-10 ppm) can cause eye, nose and throat irritation. At moderate concentrations (10-50 ppm) it can cause headache, dizziness, nausea and vomiting and cough. Respiratory difficulty; and at high concentrations (50-200 ppm) it can cause convulsions, coma and death. The EPA has measured the level of hydrogen sulfide gas in the gulf at 1000 ppm (the normal is 5-10 ppb).Most countries put a safe legal limit in the work environment of 10 ppm. In addition, protective equipment such as air respirators is mandated. More Safety Facts 

3.   Methylene Chloride

Is a colorless liquid with a slightly sweet aroma. When it enters the body it is broken down into carbon monoxide. It can cause liver damage, respiratory depression, confusion, and headache. In those with heart problems it can exacerbate angina causing worsening chest pain. With chronic exposure it can cause bronchitis, problems with vision and balance problems. With prolonged contact with the skin it can cause burns. Because of its toxicity, its exposure has been limited in the workplace by OSHA . When released into the air methylene chloride has a half life of 30 days and can be carried to the ground when it rains. Studies have shown that it causes tumor formation and has been shown to cause spontaneous abortions in humans.  When heated it forms hydrochloric acid, carbon dioxide, carbon monoxide and the highly toxic phosgene gas (which was used as a chemical weapon in WWII). 

4.   Corexit 

The chemical used to break up the oil is broken down into propylene glycol and sulfonic acid. In humans propylene glycol can cause eye and skin irritation (dermatitis), irritation of the respiratory tract and can exacerbate eczema. However, it has an even more toxic effect on marine life since it can kill the organisms that make oxygen thereby lowering the oxygen content in water . The nature of the sulfonic acid salt in the Corexit is unknown since the formula is proprietary. However, sulfonic acid can cause irritation of the mucous membranes (in the mouth) and skin irritation.  

It is clear that the oil spill in the gulf is a toxic mixture that has the potential to not only destroy the ecosystem of the gulf, but to harm the short and long term health of both the residents of the gulf and people living in neighboring states who can be adversely affected by toxins carried in the jet stream and rain carried from the gulf. It makes one wonder how long it will be before we see a rise in illnesses from not only the workers and volunteers who are cleaning up the spill without proper protective equipment such as respirators and protective clothing, but also those in neighboring states ….only time will tell.

I started my journey as an idealistic optimist who believed that my voice could be heard. That belief took me to Washington to meet with my Congressmen. It was a hard lesson to learn that the political status quo and the power of special interests were more important than doing what was best for patients. It has been equally frustrating to listen to pundits who know absolutely nothing about what it takes to keep a practice open and to provide excellent care to patients. It remains a mystery to me how the opinions of those who have no idea what its like to make payroll or pay for malpractice insurance while fighting increasingly more losing battles with insurance companies and the government for the chance to treat his or her patient as they were trained have been allowed to dictate the conversation about healthcare reform.

I have come full circle. I decided that I can either complain about the problem or do something to be part of the solution. This is something we each can decide to do. Instead of complaining about how we are losing jobs to other countries, why don’t we just pay a little more to buy from those who make things here in the USA?  Instead of complaining about illegal immigration, why don’t we make the choice to hire companies who can document that they follow the rule of law and hire documented workers? We get what we pay for. It is now time to make a choice.

My choice is to take back my power as a physician for myself and for my patients. In my opinion, it is the middle man that has led to the explosion in healthcare costs and has insinuated itself between me and my patient. I can no longer sit back and hope that the Government will help me (The passing of the healthcare reform bill made that plainly obvious that wasn’t going to happen). You only need to look to the fact that the stocks for the pharmaceutical industry and the medical insurance industry went up after the bill passed.

My solution is the creation of Best Price MD (www.bestpricemd.com). It is simply a consortium of healthcare providers – from physicians, specialists, surgeons, and dentists to integrative providers such as chiropractors and acupuncturists. All of our providers have one thing in common, that is their willingness to provide a discount on their services to those without insurance and those who do have insurance, but have high deductibles. The patients have pricing transparency with no hidden fees and the ability to compare and shop for the best price from the provider of their choice. Providers get to remove the bureaucracy and paperwork which provides a barrier that keeps costs high for the patient and operating costs high because of administrative costs such as billing and collection departments. It is simply old fashioned market driven interaction. The patient pays for what he or she wants or needs in consultation with the provider. No more paying outrageous premiums for the privilege of paying more when you actually need to access medical care. It provides patients the means to save their money and access truly affordable medical care when they need it. It is also a way to go back to initial purpose of medical insurance. i.e., the use of insurance for the treatment of catastrophic conditions.

Best Price MD provides the opportunity for the doctor and the patient to rebuild their relationship while removing cost and the treatment restrictions placed on them by both the insurance industry and the government. This is one solution that will allow medicine to become doctor and patient centered once again.

Since the passage of healthcare reform, there has not been a lot of talk about the role that hospitals will play. What no one talks about is the fact that there has been a quiet movement or shift of doctors from private practice to hospital employees. Many smaller community hospitals and doctor owned hospitals have gone out of business because they could not afford to keep their doors open. In addition, there has also been a quiet consolidation of hospitals. For example, in Atlanta, groups of specialists have become hospital employees.  With the movement of various specialists, hospitals have now become specialty centers for specific patient care.

It is not hard to visualize a future where there will only be a certain number of hospitals that are able to provide care for specialized diseases such as cardiac care, or orthopedic surgery.  If that happens, access will be restricted since patients will be limited as to where they will be able to go to receive their care.  If there was only one specialty heart center in the city and only a certain number of doctors on staff, by definition, there will be a limited number of patients that can be treated at any specific time. Unfortunately, these changes will likely lead to the de facto rationing of care.  In addition to the problem of access, costs will likely go up because of the lack of competition.

The demise of Lehman Brothers and the consolidation of other large financial companies have led to very few winners in the financial industry – the biggest of which is Goldman Sachs.  The banking industry has seen a few surviving large institutions such as Chase and Citibank. What the larger banks didn’t acquire in mergers, the FDIC removed by taking over and closing hundreds of smaller and community banks. Makes you wonder if the credit unions will be next on the list.

Like the banking industry and financial industry the biggest and most powerful entity will survive and competition will be crushed. In medicine it is the hospital. The hospitals wield a lot of power.  Recently, the Georgia Hospital Association tried to carve out an exemption for hospitals at the expense of physician owned ambulatory surgery centers (ASCs). There is a proposed 1.45% “bed” tax on medical services to create a Medicaid fund. The hospitals had language inserted into a bill (HB307) that would “protect hospitals from bills that are harmful to hospitals for three years” essentially giving hospitals the power to “veto” any language in a bill that they didn’t like. When you take in to account that: 1.) doctors were not at the negotiating table; 2) non-profit institutions get to draw from a fund to treat indigent patients while private physicians don’t; and 3) by law 2-4% of the patients treated in private physician owned surgery center must be indigent. i.e., they must treat them for free to keep their facility open (yet they must pay all of the taxes as a small business). Fortunately physicians were able to contact members of the Georgia legislature and stop the carve out. If the move had been successful, the hospitals would have been in a position to remove competition from the private ACSs which provide a less expensive alternative for patients. You see how uneven the playing field is.

Access to physicians, was one of the main promises of Obamacare.  If this trend persists, it looks like you might have to wait longer and travel farther to receive the care that you need.

There have been several iterations of the ICD. The most recent is ICD-10. Seven countries have adopted it to date. The first country to adopt it for clinical use was Australia in 1998 then Canada in 2000. The most recent country to adopt it was Thailand in 2007. The United States is scheduled to adopt it in 2013. Just in time for the major pieces for the healthcare reform pieces to take effect. The mad rush to pass healthcare reform makes a lot of sense when this time table is taken into consideration. It finally brings the US healthcare system into the global healthcare system overseen by the WHO.

How will our healthcare system change when 30 million new people will be covered and will need healthcare? The system in British Columbia, Canada provides an example of what we can expect. They have adopted a healthcare system that has clinical treatment guidelines set forth by a protocols advisory committee. Our healthcare reform system also sets up an advisory panel that will use evidence based medicine.

These advisory panels set up treatment flow sheets that will make it easy for healthcare providers such as physician assistants to provide care. Now I understand how Governor Rendell can make the statement that he did a couple of weeks ago that health care providers are “just as good as primary care physicians”. Although we have a shortage of physicians, the statement is clearly based in the premise that anyone can use algorithms to cookbook medical care. All you need to do is connect the dots. 

This is great until you apply it to the real world. Take for example the treatment of middle ear infections or sore throats. I have treated many children who finally get referred to an ENT after months of recurrent ear infections after they have speech delay and/or are not doing well in school because of hearing loss from the chronic infection. I have also treated adults with hearing loss that resulted from childhood ear infections that were never definitively treated as children with ventilation tubes. What is lost in these guidelines is the fact that in some patients surgical intervention is cheaper in the long run because it can solve the underlying problem instead of managing the symptom.

The one size fits all approach takes away the importance of individualized medical care. Although these guidelines are based on research they will inevitably lag behind research, and that will have a negative impact on patient care. For example, the Canadian Advisory Panel guideline for the treatment of sore throats is not true. “With the exception of rare infections by certain pharyngeal bacterial pathogens (e.g., Corynebacterium diphtheriae, Neisseria gonorrhoeae and Arcanobacterium haemolyticum), antimicrobial therapy is of no proven benefit in the treatment of acute pharyngitis due to bacteria other than group A streptococcus”.  I just drained an abscess on a patient who was not placed on antibiotics because the strep test was negative. He actually had a staphylococcal infection. This blanket application if applied to other diseases such as screening mammograms and other ailments can lead to people falling through clinical cracks and getting sicker requiring more expensive and invasive care.  The practice of good medicine will always be unpredictable and will require the ability to practice the art of medicine.

A preview of the future:

1. the payment set up with covered medical services in British Columbia
2. Physicians in the US are already being paid using this system of bundling charges.  The Canadian fee schedule is similar to rates paid by Medicaid. If healthcare reform leads to the implementation of the ICD-10 fee schedule with the adoption of these lower rates, it will likely lead physicians in private practice to drop out of the system in order to stay in business. Quite simply, adding this to the ever rising overhead and malpractice premiums will simply be overwhelming.  

Besides taxing us from everything from our unearned income, to payroll taxes to medical devices we can look forward to paying into a pot for the next four years. I only hope the money will be available for healthcare.  As it stands now, it will be used to set up yet another government bureaucracy run by various task forces and yet another Czar to oversee the entire mess. If we’re lucky they will actually use the money for the intended purpose, but I have visions of the social security lock box. It is hard to believe that this will end up any better than Medicare, The Post Office or Social Security – big, bloated and bankrupt.

The bill sets up committees to study ways to deliver care.  A committee to study what another committee is supposed to do? Sounds like bureaucracy at its finest. It is hard to believe that that money used to ‘study’ things will be used for patient care. By the time 2014 rolls around what money will be left to implement medical care?

The government sold healthcare reform with 5 basic talking points:

     1.  You won’t be able to be kicked off of your insurance when you really need it 

• Turns out that the insurance companies CAN kick you off if they pay a fine or if they deem that a person has committed fraud when they filled out their application. It is not hard to imagine that an insurance company will figure out pretty quickly that it would be cheaper to pay the fine than to pay for coverage of a long term chronic illness. 

      2.  You won’t be denied medical care for pre-existing conditions. 

• If the insurance company deems that you have lied on the application you will be denied coverage.
• Sick children are no longer considered to have pre-existing conditions, but what about women who are pregnant? 

      3.  You can keep the doctor you have if you are already covered. 

• With the cuts in Medicare reimbursements that have already happened (no more consultation fees) and the looming 21% cut at the end of October. Many more physicians than the current 30% are looking to opt out of Medicare.  When the commercial insurance reimbursement rates drop (as they invariably will since they pay at a percentage of Medicare) there will be more doctors looking to leave commercial insurance as well. 

      4.  Health care reform will lead to increased access 

• There is no way that there will be an increase in access when you take into account; 1) the physician shortage, 2) Those physicians who will leave medicine after the passage of this monstrosity (a recent poll of physicians states that 35% would leave the profession), and 3) those who will stop taking insurance all together because they are simply fed up. 
• Expanding Medicaid to those who are currently uninsured is not going to help since most doctors are not taking Medicaid now.  Currently access to specialists is pretty poor, it will decline further. 

       5.  Health care reform will cover 30 million more uninsured people 

• The bill will cover approximately 7 million more people over the next nine years and leave over 100 million people underinsured. 

       6.  The health care reform bill will decrease the deficit 

• The CBO numbers do not take into account the “doctor fix” and the government takeover of student loans was added to pad the numbers. 
• If you do real world accounting by adding in the “doctor fix” (over 230 billion dollars) you actually wipe out the cost savings and you increase the deficit (anywhere from 400-700 million dollars.) 
• It is likely that the estimated costs will likely be much higher. How can anyone really know what is going to happen in the next 10 years. To say that these numbers are optimistic is being kind. 
• The Health care reform bill has done absolutely NOTHING that would really lower the cost of health care. 

The pharmaceutical companies got three major cost raising concessions

          – the government cannot go out of the country to shop for cheaper drugs

- the patent for biologics was extended to 12 years from 7 thereby locking out cheaper generic drugs. (For example a patient can continue to pay over $1000 a month for a drug like Embrel instead of getting some relief.

- patients will not be able to buy cheaper over the counter medications with their health savings account only more expensive prescription medication. 

The health insurance companies may whine about their profit margin, but they get millions more people to add to their roles. Most of those people will only see a doctor 1-2 times a year for routine things, but will pay 14% higher premiums for the privilege. 

The hospitals which account for the biggest piece of the Healthcare pie got a pass. Surgeons have had to deal with bundling of charges for over a decade. What about applying that to hospitals? That would have certainly lowered the cost. Since bankruptcy caused by medical costs are largely due to the hospital charges.

- There has been no legislation to change their habit of itemized billing where they stand to make a profit on everything from the single pill of Tylenol to the box of Kleenex in your hospital room. 

I got a call from a fellow physician today who talked about picking up stakes and doing medical work overseas. I have a feeling I am going to get a lot more of those types of calls from fellow physicians in private practice. There are only so many physicians that the hospitals can employ and only so many more patients a physician can see. 

 It seems that the ultimate goal of this exercise is to eventually make all physicians government employees under a single payer system. As it stands the system created by health care reform is a give away to the pharmaceutical industry and the health insurance industry (you just need to look at the rise in their stocks today). It certainly can be seen as the first step on a slippery slope towards single payer. The powers that be are banking on physicians going along like lemmings, but  I have no doubt that if we don’t they will institute some sort of draconian policy to make us do it like they have in Massachusetts(medical licensure is tied to taking the state insurance plan). If that happens, good luck finding a physician who will want to deal with this. 

However, we as physicians are individuals. There approximately 890,000 doctors currently practicing in the US. Those of us who want the autonomy to practice medicine the way we were trained, those of us who run a private practice who are entrepreneurs at heart, those who are tired of being pitted against our patients and other physicians (the specialist vs. primary care physician meme), and those who are just sick and tired are NOT going to take this. Those of us who can will retire or leave medicine all together. Those within the system will simply opt out.

The President’s summit on Thursday amounts to nothing more than six hours of theater. Not one physician in Congress has been invited to attend. The physicians for single payer have also not been invited. It is his chance to hear from the people on the front line, and it is obvious this bill is NOT about the health of our people. It is about raising revenue, controlling the medical industrial complex completely. How else can you explain the proposal for the government to a) take over control of the cost of insurance premiums; b) limit provider medical decisions based on cost, and c) control what is medically covered for the patient. Under the proposed health care reformed, the government will control how much an insurance company can charge, decide what is covered medically, and sanction the provider for deviating from the norm.

 These are some of the proposal highlights that concerned me the most:

 Delay and Reform the High-Cost Plan Excise Tax. 

Part of the reason for high and rising insurance costs is that insurers have little incentive to lower their premiums.  The Senate bill includes a tax on high-cost health insurance plans.  CBO has estimated that this policy will reduce premiums as well as contribute to long-run deficit reduction. The President’s Proposal changes the effective date of the Senate policy from 2013 to 2018 to provide additional transition time for high-cost plans to become more efficient.  It also raises the amount of premiums that are exempt from the assessment from $8,500 for singles to $10,200 and from $23,000 for families to $27,500 and indexes these amounts for subsequent years at general inflation plus 1 percent.  To the degree that health costs rise unexpectedly quickly between now and 2018, the initial threshold would be adjusted upwards automatically. To ensure that the tax affects firms equitably, the President’s Proposal reforms it by including an adjustment for firms whose health costs are higher due to the age or gender of their workers, and by no longer counting dental and vision benefits as potentially taxable benefits.  The President’s Proposal maintains the Senate bill’s permanent adjustment in favor of high-risk occupations such as “first responders.”

• Unintended consequence, this can have an adverse affect on people with chronic illnesses who often have expensive policies because the insurance companies deem that they are very expensive to underwrite. It is adding insult to injury to have to pay 40% more for an insurance policy that is a lifeline. Those who can’t afford the premiums will be forced to choose lower cost premiums on policies with less the coverage and restricted services with resultant restriction of access to care.

 Comprehensive Sanctions Database

The President’s Proposal establishes a comprehensive Medicare and Medicaid sanctions database, overseen by the HHS Inspector General.  This database will provide a central storage location, allowing for law enforcement access to information related to past sanctions on health care providers, suppliers and related entities.   (Source: H.R. 3400, “Empowering Patients First Act” (Republican Study Committee bill))

• This has a chilling effect on doctors and other healthcare providers who run afoul of government. There is no mention of what steps exist for the appeals process before you are put on the hit list. Moreover, allowing ‘law enforcement to have access to information’ will have the intended effect of making providers obey the system without deviation because of the threat of criminal prosecution. .

 Modify Certain Medicare Medical Review Limitations

The Medicare Modernization Act of 2003 placed certain limitations on the type of review that could be conducted by Medicare Administrative Contractors prior to the payment of Medicare Part A and B claims.  The President’s Proposal modifies these statutory provisions that currently limit random medical review and place statutory limitations on the application of Medicare prepayment review. Modifying certain medical review limitations will give Medicare contractors better and more efficient access to medical records and claims, which helps to reduce waste, fraud and abuse.  (Source:  President’s FY 2011 Budget)

• Providers will be subject to more random reviews at the pleasure of the government. This has the potential to waste productivity and adds to the stress that providers already experience in dealing with Medicare. Providers are already subject to a 10,000 fine per occurrence for committing fraud (Fraud extends to overbilling AND under billing Medicare). Providers will be looking over their shoulder even more then they do now. With audits and criminal prosecution looming, it will only drive more providers out of Medicare further decreasing the Medicare patient’s access to care.

Broaden the Medicare Hospital Insurance (HI) Tax Base for High-Income Taxpayers

Under current law, people who earn a salary pay the Medicare HI tax on their earned income, but those who have substantial unearned income do not, raising issues of fairness.  The House bill includes a 5.4% surcharge on high-income households to improve the fairness of the tax system and to support health reform.  The Senate bill includes an increase in the HI tax for high-income households for similar reasons, an increase of 0.9% on earnings above a specific threshold for a total employee assessment of 2.35% on these amounts. The President’s Proposal adopts the Senate bill approach and adds a 2.9 percent assessment (equal to the combined employer and employee share of the existing HI tax) on income from interest, dividends, annuities, royalties and rents, other than such income which is derived in the ordinary course of a trade or business which is not a passive activity (e.g., income from active participation in S corporations) on taxpayers with respect to income above $200,000 for singles and $250,000 for married couples filing jointly.  The additional revenues from the tax on earned income would be credited to the HI trust fund and the revenues from the tax on unearned income would be credited to the Supplemental Medical Insurance (SMI) trust fund.

• Increases and extends taxes

 Medicaid for Working Families

Beginning in April of this year, States will be allowed to expand Medicaid eligibility to more individuals.  Starting on January 1, 2014, all low-income, non-elderly and non-disabled individuals will be eligible for Medicaid.  This includes unemployed adults and working families – all people with income below $29,000 for a family of four (133% of poverty).   

The Federal Government will support States by providing 100% of the cost of newly eligible people between 2014 and 2017, 95% of the costs between 2018 and 2019, and 90 percent matching for subsequent years.

All states will be treated equally and will not receive any special matching rates under this provision.

• Great, except it does not address the problem of access to physicians who take Medicaid.  The number of providers has been dropping every year and those that still take it are stretched beyond their capacity.

 Investing in Primary Care

The Act invests in grant programs that support the training of primary care providers, including family medicine, pediatrics, general internal medicine, and physician assistantship.  It also provides payment bonuses to primary care physicians.

• In fact there is a shortage of doctors  in general – both primary care and specialists. Good medical care dictates that a patient has access to both for comprehensive care. There are times that the primary care physician must refer a case to the specialist. If this system is implemented, it will be harder to find one who 1) will not have an available appointment for months, or 2) one who will be within the system. The reform effort has made specialists superfluous, and because of that a two level system will likely result. Those who have the means will leave the system to get specialty care, and/or individualized patient centered care (concierge, fee for service).

It is clear why there is an emphasis on training and expanding the workforce by adding additional, health care providers like the physician assistants and nurses. There will be an exodus of physicians from this system and they will have to have someone to replace them. 

Next week, we will be witness to the President’s healthcare forum. This is what we know so far:

• Tort reform is pretty much off the table.

The trial lawyers lobby has seen to that.

• There seems to be no political will to apply anti-trust regulations

This will continue to benefit the health insurance industry since they will be able to continue to run fiefdoms in various markets guaranteeing their market share and profits.

• The public option is really NOT an option.

If it does get implemented it will be a glorified version of Medicare Advantage where the program is administered by the insurance companies. A particularly sweet win-win situation for them since it means we will have to pay them whether we want private insurance or not.

•  More taxes

We will be paying money into a governmental black hole for the next 4 years in the hopes that we will get inexpensive, comprehensive health coverage in the end. I have just two words about that – Medicare and Social Security (enough said).

•  If you don’t like your insurance too bad

People who don’t like their private insurance plan will not be able to access the exchange system.

We are at a crossroads. As a practicing physician, I am really concerned about the state of our healthcare system if the Congressional reform bill gets passed. Even if it is an amalgam of both the House and Senate bill, there are so many negatives that the basic tenets that are good, like coverage for pre-existing conditions and not being dropped from an insurance plan, will not make any significant difference in our healthcare overall.

Some have said that the reform effort is a stepping stone to a single payer system and I agree that is possible. What physician would want to enter a system where their freedom to practice medicine is controlled by government task forces, and where the final medical decision is made by a government administrator who will be all about cost savings, and NOT what is best for the individual patient? 

The healthcare system in Massachusetts is a look into the future. They have a high number of medical residents that leave the state when they graduate, practicing physicians are also leaving, because of the physician shortage people have to wait to be seen by a doctor, and healthcare costs have gone up significantly since they instituted universal coverage. The physicians who do remain in practice MUST accept all health insurance since getting and renewing their license is contingent upon them doing so. I believe that a government law mandating that all physicians must take health insurance in order to obtain and maintain their license to practice medicine would be the only way to capture enough physicians to help implement this system.

I have a problem with this as someone who was trained that medicine is an art as well as a science. I also have a problem as a professional with being told 1) who I can see; 2) what tools I can use to diagnose; 3) what therapeutic treatment options I can use, and 4) how much my time and expertise are worth. Wouldn’t anyone?

It’s time to change the paradigm. In my opinion neither the government nor the health insurance industry is the answer to the problems of healthcare costs. They are actually part of the problem.  The government’s intrusion into healthcare via Medicare has set the reimbursements without regard to real world costs. Because they are so low and continue to get lower, it leads to cost shifting from those who cannot pay to those who can. This is compounded by the for profit private insurance industry that has injected a new layer of costs that are designed to make sure that they get paid no matter what. They have devised ever more novel ways to increase revenue by 1) increasing the premiums to patients; 2) increasing patient out of pocket expenses via deductibles and co-insurance; 3) decreasing  reimbursement rates to physicians; and 4) adding other methods to reduce payments like multiple procedure discounts(e.g., if a procedure has two sides you get paid 50% or less for the second side), and global surgical days (i.e., a physician will see a patient postoperatively for up to 90 days with no charge and may not charge for supplies ,or anything related to the surgery).

Enough, we are on a path that is unsustainable. Yes, cost is one aspect, but so is the medical workforce. The system will NOT run without enough qualified doctors, nurses and other health professionals. 

These are some of the things I would do:

1.  Get rid of insurance companies anti-trust exemption to promote real competition 

2. Tort reform that includes a mandatory payment of legal fees for the losing litigant.

This could even the playing field for lawyers who take cases based oncontingency and decrease the number of frivolous law suits which estimates place as high as 40%.

3. Change the way health insurance companies pay benefits.

Since health insurance is unlike any other type of insurance, mandate that a percentage of the yearly premium be used to provide patient care after this amount is met; the patient pays the percentage as set forth by the insurance company. For example, if a yearly premium is 23,000 then 30% needs to be available to be  used for whatever medical treatment or therapy the patient needs (as determined by the patient NOT the insurance company). After the $6900 is met then the patient is responsible for the 30%-40% or whatever is mandated by the insurance company.

• This would encourage the patient to seek medical care before a medical condition became more advanced. It would also encourage patients to shop for the most cost effective treatment. In short, market forces would be engaged in a positive way without limiting patient access.
• The patient would also be encouraged to purchase insurance because they would be getting real value. As it stands now, if a patient never sees a physician they merely pay money to the insurance company without any hope of getting it back. In addition, the increased deductibles and co-insurance have increased the out of pocket expenses and that has also limited patient access.
• Institute a rollover of the unused portion  allowed for medical expenses. This would also benefit the patient because if they didn’t use it, the additional money would potentially add value to the insurance plan. It would encourage people to maintain coverage no matter their age or underlying health.

 4.     Encourage incentives for adopting a healthy lifestyle

 In the form of premium reductions or possible tax credits

 5.     Allow patient to write off their medical expenses

 from the first dollar instead of almost 7,000.

 6.     Allow physicians to write off bad debt

They would be encouraged to see more indigent people for free, and would also not need to go after and potentially ruin the credit of those patients who owe  money. Currently, if a patient or insurance company does not pay, the physician is forced to write it off.

These are just some examples that I believe would put the power of individual health choices back where it belongs with the patient and the physician. People have good sense, and if given more control of their own healthcare costs along with clearly presented options that include cost transparency (from both health care providers and hospitals who will have to compete for a savvy patient consumer), they will choose what is best for them. When the inflated costs injected by the government and the insurance industry are stripped out, it would lead to a more affordable medical system that will work well for the foreseeable future.

Congressional health care reform relies heavily on both Evidence-based guidelines and evidence-based individual decision making to set the standards of care for medical treatment and outcomes. In fact, House bill 3962, in an effort to control costs, creates a new layer of government bureaucracy that inserts itself between the doctor and the patient. A national health commissioner and task forces will evaluate and decide everything from what medications a physician will be allowed to prescribe for a patient, to what surgery will be approved, to what outcomes will be expected for a particular medical condition. The ‘universal healthcare Czar’ along with the task forces will also decide whether or not hospitals will be reimbursed for care rendered based on predetermined outcomes. For example, if a patient is re-admitted within a prescribed number of days after discharge, the hospital will not be reimbursed for care given. It does not take into account factors such as how ill a patient may be. This new layer of government effectively removes the power of the individual physician and patient to decide what is the best course of treatment.

Why should you care? You should care because the application of evidence-based medicine can potentially limit health choices of both patients and physicians.  In the reformed healthcare system recommended by Congress, alternative treatments will be pressured to end, and physicians who practice alternative medicine in extreme cases will be criminalized. The money in the system will continue to flow to well funded studies underwritten by the pharmaceutical industry, and those companies without deep pockets will continue to be unable to afford the cost of  in depth studies to critically evaluate the efficacy of such treatments. Alternative treatments will fail to pass the standard of evidence-based medicine precisely because they lack the funds to enter the game, and thus the cycle will continue. In short, if alternative treatments are not evaluated by the guidelines of evidence based medicine, they will never be accepted as a valued treatment option.

It can also be argued that evidence-based medicine has exponentially increased the cost of health care. In theory, the essence of evidence-based medicine is science. However, in practice it has become more about money. The system has become one where the pharmaceutical industry has been given the edge. For example:

• Many of the prescription drug trials are not independent  

They are often funded by the very drug companies that stand to gain if their drug is found to be effective in trials and is approved

• The relationship between medical societies and the pharmaceutical industry raises questions.

Over the past 10-15 years there has been a change in the parameters of our most common diseases (hypertension, obesity and high cholesterol ). For example, in the past normal blood pressure was 120/80, and now  it is 115/75. In fact,those with a blood pressure of 120/80 are now considered to be pre-hypertensive and are eligible for medication. The body mass index (BMI) number for obesity decreased from 40 to 30 while the parameters for being overweight have expanded from a BMI of 27.8 in 1995 to less than 25 today. High cholesterol (LDL) is now < 200 instead of the old parameter of  < 250. The change in parameters have meant both a dramatic increase in the number of people who meet criteria for treatment with prescription drugs along with a resultant rise in the cost of healthcare. The question that has yet to be answered - why are we less healthy despite taking ever increasing amounts of prescription medication? 

• There is a tight financial relationship between the pharmaceutical industry and the medical industry.

The AMA, medical education and the underwriting of medical research has given the pharmaceutical industry a great advantage in the shaping of medical opinion and by extension evidence-based medicine.  

• There is a revolving door between those who work for the FDA and those who have worked in the pharmaceutical industry. 

This cozy relationship raises the importance of Big Pharma and relegates natural/alternative methods to junk science. Inherently, this should make those of us who are critical thinkers question the statements that summarily denigrate the supplement industry which makes products, that in many cases are in direct competition with the drugs that are manufactured by pharmaceutical companies, but don’t need patents.

A more balanced approach to our healthcare system is necessary. If the same standard is applied to both alternative and conventional treatments, each will be given a level playing field to determine efficacy. This change would go a long way towards accomplishing the task of improving the health of Americans without bankrupting them.

Let’s try something new like  promoting prevention and wellness instead of just talking about it or actually giving  doctors and patients the freedom to choose how they approach health choices. No one can argue with the fact that a healthier population, will lead to a significant decrease in healthcare costs.  The current system clearly is not working.