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Sunday, October 25, 2009

Physicians Are Talking About: What to Do to Reform Healthcare

Nancy R. Terry
Authors and Disclosures
Published: 08/07/2009
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As the healthcare debate heats up, the only point on which all parties agree is that the present healthcare system does not work.

An estimated 50 million Americans are uninsured, and the number continues to rise as more people lose both their jobs and their health insurance. Americans spend more than $2 trillion a year on healthcare, which is, by some estimates, 40% more per person than the next most costly country. President Barack Obama and Congress are mobilizing to reform healthcare. Yet, change alone does not guarantee improvement.

In a flurry of postings on Medscape's Physician Connect (MPC), a physician-only discussion board, doctors debate what reform measures would salvage US healthcare. Many physicians are as wary of increased government intervention as they are frustrated by the bureaucratic, profit-driven excesses of private insurance companies.

"As someone who has lived with illness (a congenital immune deficiency) for longer than I have been a doctor, I know first hand how broken our system is," says a dermatologist. "I live in fear of losing my health insurance since I know I am uninsurable through any private program. A public option is the only way to go."

"What would a greatly expanded role for the federal government mean for healthcare in this country?" asks an anesthesiologist. "Rationing for patients, with fewer treatment options and increased difficulty visiting a physician." An infectious disease physician agrees, "Obama's thrust to mandate a Medicare-for-all, single-payer [program] will ultimately lead to healthcare rationing of services -- not for the young and healthy but rather for the elderly, who are the sickest and most vulnerable among us."

The rationing of medical services is frequently cited by a number of physicians as an alarming but predictable component of a national healthcare plan. Yet, other physicians contend that rationing of services already exists. "The private, for-profit insurance carriers have contributed to the healthcare crisis by cherry picking the insureds," says an orthopedic surgeon. "To have a different premium price for those with preexisting illness denies insurance to those who need it most," adds an emergency medicine physician. Another MPC contributor comments, "Instead of making people wait, we just deny elective procedures altogether to people who don't have insurance. That's American rationing."

Advocates of free enterprise favor maintaining a system of multiple insurance providers because, they argue, free enterprise ensures maximum efficiency. In contrast, other physicians claim the exorbitant cost of healthcare can be largely attributed to profit-maximizing insurance companies. "Insurance companies are responsible for the high cost of healthcare," says an MPC contributor. "THEY set the premiums, and the reimbursement and the schemes that are squeezing everyone. All in the interest of profit -- not healthcare."

A national healthcare plan, according to other physicians, would afford no greater efficiency than the current system. "Already doctors aren't accepting Medicaid because of dwindling payments, hassling paper work, confounding delays, long waits, impersonal attention -- medicine DMV [department of motor vehicles] style," quips a pediatrician. "So, everyone will have insurance. Just not that many will have doctors."

Still others see little difference between the options of private and public insurance plans. "The schism between private health insurers and government is a ruse," says a general surgeon. "Medicare is already outsourced to private health insurers. Medicare-for-all will be a big boon for health insurers. Their volume will go up as will their profit margins as government-sponsored cost-effectiveness research demonstrates how much of the expensive medical treatments are "ineffective." Another win-win for government and health insurers. It's all a numbers game -- shift to preventative healthcare and the healthy are happy and the sick are shoved under the carpet."

Obviously, there is no easy solution. The best option, according to some MPC physicians, is to keep open as many options as possible. "Most of the primary care societies and academies favor a one-payer system," comments an MPC contributor. "If we are to give at least basic healthcare benefits to our citizens, we need it [a public plan]. It is not the perfect system, but at present it is the best option available. If a person wants concierge care, he should buy it."

"Will someone please explain what is wrong with a 2-tiered system?" asks an MPC contributor. "A basic plan with some basic coverage for those who cannot contribute and the premier plan for those who do contribute. The water analogy...everyone can drink tap water, but if you want bottled water, you gotta pay."

"Sounds OK to me," responds another contributor. "Coverage for treatments for which there is good efficacy data (not just statistical significance but clinical significance) and everything else, well, if you want it, feel free to buy it."

Few physicians are comfortable with a proposal favored by Congress that participation in a public plan be mandatory for all physicians who accept Medicare patients, although a nephrologist is "okay with mandatory participation for 1 to 2 years to support the government effort, but the mandatory participation should expire automatically afterwards."

Healthcare reform, however, is not simply a question of the number of insurance plans available. Recognizing that any insurance option must coexist with a reform agenda, physicians offer a range of proposals how a more equitable, efficient healthcare system might be achieved.
Hold the insurance companies accountable to insure patients who have a preexisting illness.
Set one premium level for all insurance participants, with varying deductible and copayment amounts.

Establish a fund, patterned after Alaska's Permanent Fund, to cover the cost of insurance for those who cannot afford it. The fund could be built up by taxing commodities and activities that increase the risk for illness, such as tobacco and alcohol use.

Incentivize preventive medicine, especially in the management of lifestyle diseases, such as diabetes and hypertension.

Reduce redundant and defensive testing.

Reform the tort system and eliminate malpractice insurance.

Initiate a national campaign to promote fitness programs, improved nutrition, self-care programs, and disease prevention.

Establish national licensure for nurses and doctors to decrease the costs of multistate practice.

Eliminate state-by-state variations in insurance laws to unify the method of determining eligibility for healthcare insurance.

Eliminate the fee-for-service model, and put doctors on salary.

Physicians, according to an MPC contributor, are in the best position to offer practical, constructive solutions for healthcare reform. "We need to stop coming to the table primarily motivated by protecting our incomes," said an emergency medicine physician. "Instead we should come to the table as citizens who have insight into why our healthcare system is so sick."

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