my health care manifesto

So, I posted a story about a Canadian Premiere coming to the U.S. for his health care the other day. When talking to a colleague about health care reform he asked me ‘well, what would you do to fix it?’ I thought that was a fair question. So here are my thoughts about what is broke and some ideas on how to fix it.

The first question to ask is whether health care is a right? I do not think so. However, when you are in a country with the means to do so, I think that you need to be able to delivery some form of basic health care. Now you have to define who you want to cover when you talk about ‘universal health care’. I think that if you are a citizen, that you should qualify for basic health care. Next, you have to decide what type of health care coverage. I think that everyone should have a base level of health care that covers you for emergencies and for preventative medicine. After that, I think that you should have options, either through work plans or personally financed, to increase your coverage.

It is easy enough to say ‘everyone should have health care’. However, how will one pay for it? Another thing to contemplate is, just who is going to see the patients? We are in a time when we are short primary care providers in this country. If we increase the patient pool without increasing the number of primary care providers (which takes years to accomplish) then we overwhelm the system. I have some ideas of how we can address these issues.

The very first thing that must be done is medical tort reform. You need to limit how much in damages one can get through legit or perceived medical malpractice. Medicine is not an exact science and there will always be the chance of adverse outcomes and there will always be mistakes. However, people like John Edwards have made far too much money through ambulance chasing. The days of channeling dead babies in the courtroom should end. This is a tough one since most congressmen are lawyers, but it is a must, because once you cap medical malpractice payments it has more positive impacts.

If malpractice is limited, then malpractice insurance goes down as well which means that physicians do not have to charge as much (kind of a reverse trickle down effect). Some medical specialties have obscene monthly medical malpractice insurance rates.

Also, when there is a fear of malpractice suits then a primary care provider will quickly refer patients to a subspecialist to make sure they are not missing anything. Let me give you an example. A family practice doctor hears a murmur which he thinks is benign (okay). However, he does not want to miss something and get sued so he refers the patient to a cardiologist. The cardiologist says ‘well if he sends this patient to me, then I should do a full workup’. So the cardiologist gets a chest x-ray, EKG, echocardiogram for a full cardiologist evaluation. Most likely, the patient is told that their murmur is benign. So the cost for this patient just went up exponentially. This patient could have been followed by the family physician to see if any changes or symptoms developed prior to sending to a specialist. However, they did not because of the fear of being sued.

Let me now talk about health care insurance. We need to open up competition between insurance companies. In many states there are near monopolies for health insurance. There may only be two companies to choose from. If you allow competition of insurance companies between state lines then you have more companies competing for your business. It is a basic principle of supply and demand that if more companies are allowed to do business then the price of insurance will go down.

We also need programs like Medicare to pay out better. They basically dictate how much they will pay for a procedure or a doctor visit. Many times the doctor gets 70% what he or she bills. So what happens next? The doctor will have to see more patients and do more procedures to try and get enough compensation to account for what he or she is not reimbursed by Medicare. This leads to unnecessary procedures. It also means less time per patient by the doctor.

When a primary provider is getting slammed seeing more patients (to make enough money) they get frustrated that a) they are working overly hard b) they are not practicing the medicine they envisioned. Most primary care providers went into that area of medicine to spend time with their patients and do preventative and anticipatory care. That is one of the reasons I got out of pediatrics. I wanted to spend time with the family to develop a bond. I wanted to help with preventative counseling. It is impossible to do in a 10-15 minute appointment. So, what happens? They become a sub-specialist like I did. Why do you think we have a lack of primary care providers in this country?

So we have established that doctors get driven out of primary specialties due to fear of malpractice, dissatisfaction with compensation and frustration about type of medicine they are doing. I think that there is another reason as well. Most civilian doctors have a huge debt after medical school. You are talking hundreds of thousands of dollars in debt. They become doctors when they are about 26. Then they do internship for a year where they make probably 35 thousand. Then they go into residency for 2-4 years where they make maybe 40 thousand a year. So they are now in their 30’s, have a doctorate degree, have a huge debt still and have not yet made any money. So they go into fellowship to become a specialist because they know they will get paid better. Besides they have talked to enough primary care providers to know they do not want to go that route. Maybe we should subsidize some of medical school costs and pay residents a bit more money so they do not have such financial pressures. They work 80-100 hours a week when a resident, I think they deserve it.

Well, there you have it, my thoughts, whether you wanted them or not. I am happy as a military physician. I had a good time being a pediatrician and I am glad that I did an allergy/immunology fellowship. If I were to do it all again (and that is a huge if) then the only way I would do it would to go through the military again. I am really struggling with whether I would want to practice medicine as a civilian post my military career.