We have seen the dozens and sometimes hundreds of people who have come out to “Town Hall” meetings about health care reform… some people who have formed opinions and spew hatred based on inaccurate information… some people who really care about what happens to the future of medical care in our country but don’t know what to do about the issue… and some people who think everything is fine right now…

Those of us who have jobs that provide insurance… are relatively healthy and rarely need to go to the doctor may not understand what the big deal is… but the truth is there is a segment of our population that many argue is terribly under-served… there are people who have jobs and work hard to support their families yet do not have the means to pay for health insurance… some people say, “tough…” others want to make drastic changes that seem to serve the uninsured while drastically changing the climate for those of us who already have health care coverage….

The issue has left many of us asking - What is going on and is there really a solution here that could benefit EVERYONE?

One of my 10 On Your Side Health Team experts - Oncologist Dr. Bill Fintel shared his views on the issue and has given me permission to share them with you - it is a very detailed proposal but worth the read:  I’d love to hear what you think of it.

Health Care Reform: 2009

Health Care in the United State can be likened to a luxury cruise ship on the ocean.  In the current system, the majority of Americans enjoy life on the cruise ship with almost every amenity provided on demand, and a chocolate bar at midnight.  In the water are floating, and drowning, millions who are either too poor to get on, or have some illness that prevents them from being allowed on the ship, or work in jobs that don’t offer a cruise ticket, or make enough money to book passage but choose to swim on their own, or they may not be Americans at all.

For those of us on the cruise ship, life is pretty good, but far from perfect.  More on imperfections later.  The message we are hearing about health care re-envisioning looks like this: build enough barges for every single person, herd all onto the barges, and sink the luxury ship!  Now, everyone would be safe and out of the water, but goods and services would be dramatically different.  No chocolate bar at midnight.

It is the thought of the loss of the luxury liner that is bringing out the vitriol when folks start to talk about change.  The cruise ship has been very, very good to many of us, and keeping everything as is, seems safe, sure and known.  Unfortunately, the ship is dangerously overcrowded, water coming up to the railings, and soon to sink under its own weighty passengers.  It simply cannot take on more people!

The imperfections on the ship are numerous and can be summed up into 5 (probably more) categories that need our prompt attention.

the passengers
the physicians
the suppliers  
the sellers
the lawyers

1.    Let’s take the passenger, or the American public.  To say we are indulgent of our bodies is kind.  We, as a society, eat and drink too much, love our fast foods, crave tobacco products, exercise too little, avoid important health screening events (like PAP smears, colonoscopies and mammograms) and then when the floor falls out from under us, we want a pill to fix it.  And we as a country will tolerate no side effects from our new pills.  We could begin by offering incentives to alter behavior and encourage screening that are known to save lives, like offering a coupon for a free physician visit when you have your colonoscopy.  Our very first line of defense, in terms of our own health, begins at home and in childhood with good health habits, regular physician visits, healthy diet and exercise.  This never stops until we die.

2.    Moving on to physicians.  Speaking as one, and as the father of a medical student, we have created a medical education system that is the envy of the world.  Our hospitals and towns are full of doctors from every country who recognize this wonderful fact.  Unfortunately, the process is long, and competitive, and most new grads are under immense debt. They spend their twenties with little or no income while their peers are buying cars and houses, or hiking the Appalachian Trail.  When that first job appears, we are looking for the big payoff, and reward.  I can only imagine the effect of a debt-free medical degree on the expectation of that first salary.  Wouldn’t primary care in a small town look more attractive if the new doctor could emerge from training without that burden?  Could we reform medical education, and how we fund it?  A second motivator of more cost-effective health care is the trend to pay for care that is evidence based, value-added and aligns physician payments with appropriate utilization of resources. This is a very promising move in the right direction.  The majority of us are more than willing to make the vital changes needed to keep the ship a float. While greed has been around a long time, and we physicians are not immune, but the vast majority of doctors that I have the privilege of working with, work very long hours, are devoted to patient’s lives and health, and do not practice to make a lot of money, rather they make a lot of money because they practice this art.  My colleagues regularly discuss how we can be part of the solution, but we feel disenfranchised when it comes to a seat at the table of change. 

3.    How about the suppliers of goods and technology?  Pharmaceutical companies and owners of medical gadget patents have been holding patients hostage under the banner of “research and development.”  The third-party payer system buffers the effect on a patient’s wallet, so the sky-rocketing costs don’t affect the individual, but communally we all feel it in our monthly premium payment.  As far as I know there is no regulatory agency that tries to attach a price increase for new technology/goods to the degree of value added by this new drug/device. While the price for bread and milk has gone up steadily, the prices for new cancer drugs, for instance, have gone crazy.  It is not uncommon for me to write a prescription for a medication that is fifty times the cost of my office visit for that day.  Twenty years ago, it was unusual to see a prescription that was 5 times the cost of an office visit.  Some of these new drugs are monumental achievements, and others are ho-hum.  Yet, the price for almost any new medication lately has been exorbitant.  I, frankly, don’t know how to attach a price increase to added value of a new product, but I’d like to see someone try.

4.    The sellers are the folks who sell tickets to the ship, or the insurance companies.  In America, we started third-party payer system decades ago and put an unrealistic buffer between providers of care and the patients who seek it.  Very few of us shop around for price.  We simply expect our insurer to pay for what we want.  These are both private and public (like Medicare and Medicaid) and we have allowed them powers beyond their scope, and intellect.  Not only that, but we both give them control over the money, and let them set the rules on how it should be spent.  That is an incentive that cannot continue to exist.  Imagine a health care system in which a physician gets paid more if you die, than if you live.  Would you trust him or her to always be looking out for your interest?  Similarly, in a health system where the insurers holds the cash, and disperse it as they see fit, the incentive to not pay for services is much greater than the opposite.  We cannot continue to give the power to control where money is spent to the insurers, and expect anything but the mess of senseless rules that I live with now.  Furthermore, unless some of the buying power is put back in the patient’s hands, there will be very little incentive to appropriately price goods and services.  Health spending accounts is one mechanism to put power back where it belongs. 

5.    The lawyers, and yes, I saved this for last.  Also on the ship are members of the legal profession who add to the problem, more than they improve.  Yes, there are patients who are harmed by reckless, and hurried and incompetent practitioners.  Medical Societies, hospital safety committees, and malpractice insurance carriers work very hard to minimize these horrible events.  Appropriate compensation for errors of commission and omission are needed. But, let us stop the incentive to bring massive law suits, by making illegal the practice of sharing the spoils of a successful suit with your malpractice lawyer.  Let lawyers get paid for services rendered, an hourly wage, and let that hourly wage begin after the initial consultation.  Imagine your doctor approaching you about your life threatening illness and offering you no charge at all if you die, but should you live, he or she demands 40% of you lifelong earnings going forward!  Defensive medicine is the term for the ordering of tests with little merit in order to prevent a future suit.  Remove the threat of frivolous lawsuits, and physicians would feel emboldened to speak more forthrightly to patients and often family members who are insisting on care that is of little or no value, or just plain wasteful.  The way it is now, we live in a culture of fear, so that turning down an unreasonable request for care is an invitation to a lawsuit down the road.  No tort reform means no real change in defensive medicine, and hence, no real cost savings for the American public.

There are so many things we can do to this luxury ship to make it leaner, float higher, and take on more people.  In fact, we spend so much money right now, and so much of it foolishly, that I strongly suspect that we do not need to spend a penny more than we do, but rather fix the above issues, and watch the prices find their true mark.  Sinking the ship and building government run barges will provide basic care to all.  Sadly, this will be just when I reach the age where I will start needing it.

Bill Fintel   Oncologist, Pulaski, Virginia