Health Care in America: Open Forum (Part Two)

The following is from Dr. Joel Brill MD, Chief Medical Officer of Predictive Health. I won't pollute his sage input with my significantly less educated perspective but I will link some of the lesser known medical terms to sources that define and describe them. A sincere thanks goes out to Dr. Brill for taking the time to put this together.

Strengths:

· We have access to pharmaceuticals and medical devices that have allowed us to prolong life expectancy.

· We have improved life expectancy, which has allowed people to live long and fruitful lives into their 8^th, 9^th decades and more

· We can keep people alive, whether on the battlefield, the ER or OR, with life saving technologies that we could have only dreamed about decades ago.

· We are on the verge of genetic technologies that will allow us to re-engineer genomes and enable us to treat costly / chronic conditions to improve life expectancies and decrease costly complications.

· We have caring [patient] care managers who use their talents to coordinate care, negotiate the patient’s way through a complex system, and make sure people get the care and services they need in the most appropriate setting.

Weaknesses:

· Highly regulated. Payment system based on Medicare; as physicians get frustrated they drop out of Medicare / insurance contracts. Result is a 3 tier system: those who can pay, those who have insurance / Medicare / Medicaid / TriCare, and those working poor making too much to qualify for Medicaid but otherwise not making enough to purchase reasonable health care coverage on their own.

· High costs of attending medical school ($200K+) prompts physicians to go into specialty care to pay off their debts; primary care not attracting enough people and they are further down on the economic scale. As a result, patients often complain they are rushed through an appointment. In response, patients are willing to go to retail / convenience clinics located inside pharmacies, staffed by nurse practitioners, in part because they are fast and convenient, but also because nurses might do better than doctors when it comes to listening to patients.

· Insurance companies make their profits by the difference between $1 of insurance premium and what they pay out in healthcare claims (professional services, hospital, facility, lab, xray, medications, etc.). Even after accounting for administrative costs, insurers are motivated to make profits for management and investors, which can lead to perverse incentives to withhold access to drugs / technologies because of costs, not because of outcomes.

· Insurance agents make a significant commission in the 1^st year they place a group with an insurer; thus they are motivated to churn the client to a new insurer every 3-4 years once the group has “experience” from claims and premiums rise. While their mantra is “we’re doing the best we can for the client”, their incentive is to maximize their commission.

· Flawed payment system. There are 200,000+ pharmacists who provide front-line care to patients, yet Medicare and most insurers fail to recognize their contributions to the health care system.

· We do not penalize smokers or drinkers who account for significant health care costs when they get sick with COPD, cirrhosis, or cancer. Yet, we penalize those who are obese by claiming their problems are “lifestyle” and refusing / limiting payment for obesity surgeries. Similarly, when we limit payments for behavioral health conditions, we pay for it in the long run.

· Healthcare is the only industry where the government sets the fee schedule, whether for doctors or hospitals. What do you think would happen if lawyers, accountants, or basketball players were paid according to a schedule set by the government?

· Perhaps 20-30% of care is unnecessary and represents over-ordering / duplication of tests. The trust factor between a doctor and patient has been replaced by CYA (“cover your ass”) medicine. We need real incentives to encourage physicians to adopt electronic health records, electronic prescribing, and inter-operability.

· We need malpractice reform, health courts, a limit on juries awarding unrealistic amounts for pain and suffering, and a limit on frivolous lawsuits – which is going to be difficult to achieve as long as we have a preponderance of lawyers in the US Senate.

· Consumer directed healthcare is part of the answer, but it can’t work without transparency when it comes to costs of goods and services. While people need to take greater responsibility for their actions, we aren’t helping people by creating ridiculously high co-pays for lifesaving medications for their diabetes and similar conditions. When people don’t take their medications because they can’t afford them, they wind up in the hospital or the ER, resulting in poorer outcomes and higher costs from a system perspective.

· We should be ashamed of how we have treated American Indians when it comes to funding their care under the Indian Health Service. While savvy tribes with casino revenues have been smart enough to spend dollars on improving health care services on the reservation, while other tribes are falling further and further behind. Even with casino revenues, one needs to go no further than to cross the freeway [here in the Phoenix metro area] to recognize that you have gone from the 1^st world (Phoenix) to the 3^rd world (Gila River, Salt River Pima-Maricopa communities) when it comes to health care.

Having said such, would I want to receive care in a regulated environment where people need to enter a queue to receive services, such as in Canada? Or where the government makes an arbitrary decision to limit care because of your age, such as with ESRD services in Great Britain? Or where the government sets your pay and vacations as in Germany, but 93% of physicians would come to the US for care of a serious medical condition? No. Socialism is not the answer.

Medicare isn’t such a bad deal. Beneficiaries get access to more services than do commercial patients; if you doubt it then look at the which commercial insurance companies cover vertebroplasty and kyphoplasty and compare it to the Medicare coverage policy. Medicare contractors do a good job of paying claims efficiently, promptly, and effectively. And, since more of the healthcare [costs] goes to paying for services, their administrative costs are lower than for commercial insurers. But that doesn’t mean that I am in favor of single payor, or government funded care, for I am a capitalist. Rather, if we strip out the otherwise hidden administrative costs of care from the premium dollar, there should be plenty of money available to pay for care for those who need it.