BackgroundI am a human being, like all humans beings, fragile and sometimes ill. I am also a family doctor. I graduated from the University of Virginia Medical School. After my family practice residency training, I was part of a private practice in Connecticut for two years prior to taking my current position as a University Physician at a major Pennsylvania university. My perspective is from that of a caring family doctor who believes patient care is paramount in the healthcare industry. We cannot afford our current healthcare system because it’s broken. This essay examines the problems I see and provides some tangible solutions. I just want what will work best for my patients and as many Americans as possible.
1) Insurance company profitsTo make money, insurance companies charge as much as they can. To save money, they pay for as little as possible. They charge your employer first, who pays a percentage. Then they charge you, deducted from your pay. Then they charge you a co-pay. Then they charge a deductible. Then there’s a maximum spending limit. You pay at every step of the way. It’s only fair that you pay for some of care you receive, but you are paying too much. Then by hiring a secretary to deny your MRI, making your doctor jump through hoops to get it approved for you, they make incrementally more money for the one MRI they successfully deny. Meanwhile, your doctor has to pay another secretary to deal with the insurance company's paperwork. They negotiate deals with your doctor to pay your doctor less when they participate with your insurance. They stop covering some medications. They force you to try generics before paying for a brand name.
Where does the extra money go? It goes to shareholders of the insurance companies, to the managers, and to the employees. If you are covered by United Healthcare, then you are paying them 50% more than necessary. Suppose you spend $100 a month on health insurance. You are giving $22 to the company’s profit. You give $12 to the employees, many of which are paid to deny you coverage and generate paperwork. Almost $1 may go to the CEO as compensation. $65 is actually used to pay for your health care. In contrast, Medicare’s administrative costs are $3, so $97 would go to pay for your healthcare.
The major difference I see between health insurance and car insurance is that the health insurance has evolved to pay for all aspects of our medical care. It’s not a safety net in the traditional sense of being an insurance. It’s a healthcare program that you are buying. In contrast, you still pay for oil changes, tire rotations and other maintenance work on your car. Car insurance doesn’t kick in until you have an accident. With health insurance, the point is not for accident coverage, but for overall health maintenance so you reduce those accidents and catastrophes. A flu shot is an oil change; a complete physical is a tune-up. A heart attack is an accident. Health maintenance is a completely different goal than accident coverage. To allow for some individuals to profit from the denying of health maintenance to someone else is sick.
By taking profit-making out of the equation, most of the money paid into the healthcare system would actually be used to pay for health.
2) The Food Industry AKA Corn SubsidiesHealthcare costs more because unhealthy people cost more. People are less healthy because of the foods they eat. A brand of apple sauce with standard packaging is easy to market. But you can’t market an apple. The fresh food is almost always healthier than any processed packaged version of that food. There is just no substitute for real food, but the food industry is able to spin their packaged food as being healthy or even health-promoting when it’s far from the truth. Their goal is to make money by selling something edible. So they will add vitamins to nutrient poor bleached flour, extract fat but add sugar, or increase salt but not fry to convince you that something bad is somehow now good for you. By promoting the eating of real food (something not from a cardboard package), Americans will be healthier.
Corn is a major problem. Everything from cereal to sausages to cheesecake can contain some form or derivative of corn. Government subsidized corn creates cheap food. But then we pay for it later in medical costs. Corn farm subsidies were started in the 1970’s, and consequently, our incidence of diabetes has increased dramatically, in part due to the cheap availability of calories and sugar from corn. At the current rate, diabetes will eventually be more expensive to treat than heart disease or cancer. To slow that rate down, we need to stop subsidizing these empty meaningless harmful calories. By reducing the corn farm subsidies or redirecting those subsidies to teach farmers to produce other types of food, we’ll have a more balanced nutrition plan for our citizens. It’s not enough to tell people to not eat it when it tastes good and is cheap. If it’s more expensive, people will stop eating it. That will help people be healthier and reduce the increasing costs of the obesity epidemic.
Increasing the costs of corn will also increase the costs of beef, decreasing the demand. That is not only good for the environment by saving water and reducing greenhouse gases from raising cows, it’s also better for the public health. Eating less beef means eating less fat. The beef will be more grass fed and leaner. Perhaps cheaper vegetables and more expensive meats will help to encourage Americans to eat a healthier, leaner, vegetable-based diet. The health benefits from a better dietary profile are limitless.
3) Redundancy and inefficiency in medical recordsHave you ever tried to get your medical records? Did your physician keep a paper chart with illegible handwriting? Some medical offices charge patients to get a copy of their chart. Here in Pennsylvania, a doctor’s office can charge you up to $33 plus shipping for 20 pages of a medical chart. When you change doctors, if the new doctor doesn’t have access to a legible organized copy of the major and minor issues regarding your health from your previous doctor, they would have to start from scratch. Your medical history is often quite subtle with many important details of which you may not be aware. I can’t possibly explain to you every little medical tidbit I gleam from your records. Even if you think you know your medical history, the medical chart still contains valuable information. It needs to be easily accessible.
Hospitalizations are especially inefficient. Your cholesterol profile may have just been checked by your family doctor, but when you have chest pain after the doctor’s office closes, the emergency room doctor won’t have access to those numbers and may repeat that test. During the hospitalization, your cholesterol medication switches from your regular Lipitor to generic Zocor, because the hospital pharmacy only carries Zocor. So when you leave, the doctor writing your hospital discharge medication list has you taking Zocor instead of Lipitor. And maybe you don’t know that they do the same thing so you take both when you leave the hospital and overdose on the medications until you follow up with your family doctor. But perhaps your family doctor still hasn’t received a copy of the hospital chart at your follow up appointment, so it’s impossible to tell which little yellow pill you are describing. Eventually, your medications are straightened out.
Now, your EKG looks a little abnormal, but it always looks that way, so it’s really okay. Your doctor might even tell you that, but you don’t know just how abnormal abnormal looks. When you’re out-of-town on a Sunday attending your niece’s graduation, you fall ill and go to a different hospital. There, they do an EKG and it’s abnormal. But your regular doctor’s office is closed, and the hospital won’t release your medical records to the other hospital unless you sign a form, and then maybe they’ll get to it on Monday. Meanwhile, the ER doctor thinks you’re having a heart attack and pulls all of the stops because of the abnormal EKG. Instead of sending you home, you end up staying in the hospital getting unnecessary tests that end up costing $5,000, lots of bruises from needles, and costing sick days for you, your husband, your sister, and her husband to take care of you while you’re in the hospital.
Do you have your immunization records? Unless you got them from your pediatrician, your family doctor probably doesn’t have the complete set. I frequently have to obtain disease titers (like for measles) or give extra vaccines because patients do not know when their last tetanus booster was or if they received their second Hepatitis A shot after their trip to Cancun (Mexico).
Numerous inefficiencies and redundant care can be corrected with easily accessed electronic medical records that talk across all types of health care (clinic, office, hospital, ER, rehab, physical therapy, mental health, specialists, primary care, and pharmacies). Currently, it’s as frustrating for physicians as it is for patients to not have everyone on the same page. I think that patient privacy can still be well protected while easier access is achieved. It involves having a common health record platform. There is no incentive for private industry to create software that communicates well with other software. A government-sponsored software standard is necessary.
4) Drug companiesFrom a patient’s perspective, I’m glad that there has been reform of the drug industry’s ability to give physicians gifts. From a physician’s perspective, I’m disappointed that I missed out on the paid Caribbean cruises, European chateau vacations, and club seat tickets to professional sporting events. Now I just get pens, notepads, and an occasional in-office lunch. So that’s not a major cost in your prescription drugs anymore.
I don’t even mind the magazine advertising and commercials. The companies need to make money to have the capital to develop more products.
What I’m disappointed with is that private drug companies make more money by selling you a treatment than they do by developing a prevention. For example, if the company gives you a one-time $200 HIV vaccine, then it won’t make $2000 a month selling antiviral drugs to you for 20 years. There is little incentive for them to develop cures either. If they develop stem cells to cure diabetes, then the huge profits from routinely medicating 8% of the entire US population are gone. If the private drug companies had more incentive to develop cures and preventions, then overall healthcare costs would decrease.
5) MalpracticeWell, there are actually many aspects to this. First, there is the actual cost of buying malpractice insurance for doctors, who then pass on this cost to their patients. Second, there are the frivolous malpractice cases, which tax the entire system. Tort reform probably benefits the insurance companies the most – not patients in general. Lastly, but most importantly, all doctors practice defensive medicine to prevent lawsuits. This is from personal experience, and it’s the real cost of malpractice. With proper reform, overall costs can be decreased.
Doctors can’t practice medicine without malpractice insurance. It’s like you’re not supposed to drive without car insurance. Well, hospitals and clinics won’t take doctors without insurance. So doctors must buy malpractice insurance to practice medicine. Malpractice insurers are private companies trying to make money for their shareholders, employees, and managers. They, like healthcare insurers, try to minimize the insurance payouts in all the ways they can, and maximize their charges.
I’m extremely low risk. I’ve never been sued before, I don’t see a ridiculous number of patients a day, and I don’t do surgery or deliver babies. It cost me over $20,000 dollars to buy “tail” insurance when I left my previous practice where I was for 2 years so that I would be covered if someone were to sue me. The irony was, while I was practicing there, the office had already paid $10,000 a year for my malpractice insurance. But it only covers the years I worked there. To be covered for those patients, I had to buy my own “tail” coverage. My new job’s malpractice carrier cannot cover me for those patients. “Nose” coverage exists, but is extremely rare. These costs are ridiculously high because they know we can’t practice without it, and there are no standards regulating their profit margins. Some doctors have had their policies increase in price by 50% a year, which makes it unaffordable. Many areas of the country lack obstetricians because of malpractice insurance problems. That’s dangerous for patients who are unable to get the routine prenatal care they need and to reach a hospital in time for a delivery by an obstetrician. By regulating the malpractice insurance industry, both physicians and patients will benefit.
Tort reform was pushed a few years ago as a solution to the malpractice problem. It certainly does not benefit patients who have been subject to egregious malpractice. It doesn’t even reduce the number of frivolous lawsuits physicians and the legal system may face. I think tort reform mostly just benefits the malpractice insurance companies who would not have to pay extraordinary sums of money. The solution lies in screening out the frivolous cases and reviewing the ambulance-chasing attorneys.
But that’s not the real problem with malpractice either. It’s the common practice of defensive medicine. That’s when your doctor is afraid you’ll sue him so he orders extra tests and gives you extra medicines.
“Well, I really don’t think you have cancer because you’ve been coughing for 2 weeks. But since you are so worried about it, let’s do a chest X-ray just to be sure. Plus, I really don’t think you need that $120 antibiotic course for that cough, but because your father died of pneumonia and you’re worried about it, we’ll treat you just in case.”
If the doctor can have more confidence that the patient will follow up if the cough doesn’t improve, then the doctor would not have to go overboard with testing and treatment. A patient whose health insurance policy covers these routine visits will be much more likely to return in follow up. If the doctor has more confidence that the patient won’t sue him for being diagnosed with cancer 1 month later, then he would not have to order a chest x-ray for the other 999 people who have a 2 week cough and don’t have cancer. By reducing frivolous lawsuits, the practice of defensive medicine will decrease. Overall health costs will also decrease.
6) Physician PayI’m a family physician, a primary care specialist. I have not yet made a six-figure income as a doctor, so I’m not that golf-playing social elite. I had to attend and pay for college and medical school. I’m still paying back my student loans. An average medical student graduates $155,000 in debt. They have not been making any money from age 18-age 26. Then they go into residency training making about $50,000 a year having to pay back loans, work 80-100 hours a week, and try to maintain their humanity. That’s from age 26-29 for a primary care doctor (family doctor, internist, or pediatrician), or from age 26-31 for a general surgeon or cardiologist. Okay. Let’s do the math.
Family Doctor at age 40:
8 years x $0 + 3 years x $50,000 + 11 years x $100,000 = $1,250,000 = lifetime pay
With monthly investments of 10% of salary at 8% interest, the doctor would have $216,080 in investments saved up.
But then the student loan costs $1110 a month for 20 years at 6% interest = $266,400.
Plumber at age 40:
22 yrs x $40,000 = 880,000 = lifetime pay
With monthly investments of 10% of salary at 8% interest, the plumber would have $238,926 in investments.
At age 40, the doctor is only about $80,000 richer than the plumber. And believe me, the doctor works harder. Most doctors work 60-80 hours a week. A plumber works 40 hours a week. Both take calls at night for emergencies.
But wait, aren’t I arguing that physicians pay is too much rather than too little? Well, the primary care doctor is paid too little. Specialists are paid too much. That’s why the more financially conscious medical students may choose dermatology or allergy rather than pediatrics, for example. There is a shortage of primary care specialists, especially in rural areas. With the proper incentives, more medical students will choose primary care and better serve the preventive medicine needs of communities.
How is physician pay determined? In large part, it’s because of CPT coding. If you’ve ever looked closely at your medical bills, there would a code for your visit to the doctor and codes for any procedures. A visit to the doctor is expensive, but it’s the least of your worries. It’s the labs, the wart that was frozen off, and the X-rays that really adds to the costs. The pay rate is heavily skewed for procedures. Here’s a scenario. At age 50, your family doctor refers you to the gastroenterologist for a routine screening colonoscopy. He has the physician assistant see you for the initial visit to schedule the colonoscopy. Meanwhile, he’s busy doing colonoscopies. He makes a lot more per hour doing your colonoscopy than he does by seeing you in the office. That’s why he has his assistant see you instead. Primary care doctors do much fewer procedures than specialists. They mostly just see you in an office, which doesn’t pay well.
Who writes the CPT codes? The AMA publishes these codes every year. That’s actually how they make their money. The governance in the AMA is skewed, predictably, to the specialties. Percentage-wise, specialties have more representation than primary care. So the code book they publish with the standard reimbursement rates tends to pay specialists much more. Why aren’t family doctors trying to change that? Some are, but 70% of physicians are not part of the AMA. The membership in the AMA is largely old, white, and male. As a medical student, I went to a national conference in Chicago to see if I can change the organization from the inside by joining. They treated me as if I was an affirmative action baby. I was disgusted with the good old boys fraternity that alienates anyone who’s not a country club white male. I don’t trust them. The AMA protects the interests of doctors, not the public. They don’t emphasize prevention because treatment of diseases makes most doctors more money. For example, it was only in the past few years that physicians could bill for smoking cessation counseling. Medicare was the first the pay for that code. The insurance industry reluctantly followed. If doctors are paid for helping someone quit smoking, then perhaps doctors would spend the time to do so. To direct emphasis to prevention, the reimbursement schedule needs to be adjusted to reward patient education and prevention in any government plans.
7) Patient demands26% of Medicare dollars are spent on the elderly in their last year of life. 78% of that is spent in the last month. Much of the time, the elderly doesn’t have a living will to tell their family that they don’t want everything done, so their family request for the ICU physicians to do everything for their 90 year old grandmother when she really would not have wanted all of that torture anyway.
If you’ve never been in an ICU, you’ve never seen the torture and lack of patient dignity. That’s not a critique of the people working in an ICU. It’s just the reality of the necessary medical care in the ICU to keep people in critical condition alive. It’s an unnatural process, and the environment and treatment is thus highly unnatural. Most patients are purposefully sedated to keep them calm through the entire stay in the ICU because it’s so traumatic. Imagine a loud machine next to your uncomfortable bed blowing air into your lungs every 6 seconds 24 hours a day. After you defecate into your bed, the nurses come to turn you sideways so they can wipe your bottom and clean the sheets. It often happens a few times a day because your stomach can’t handle the 3 different IV antibiotics you’re getting. You have a tube inserted into your penis or urethra to collect your urine. You have a thick IV tube sutured into the skin of your neck giving you up to 3 medications at once directly to the heart. Sometimes it’s used to feed you if your bowels aren’t working. If your bowels are working, then you have a long tube going down from your nose to your stomach delivering liquid nutrition. Sometimes that tube gets clogged, your stomach gets too full, or your have bad acid reflux. That food accidentally gets into your lungs and you develop a bad pneumonia from that. Because you aren’t moving, you’re at risk for blood clots. So you have these leg pumps that inflate and deflate every few minutes to help blood circulate in your legs. Within 1 week of an ICU stay, you lose 15% of muscle mass and will likely need physical therapy especially if you are older. If you have a heart condition or are simply older, your brain will not be as sharp afterwards. You will likely have suffered tiny strokes from lack of oxygen to the brain at some point during your ICU stay. It’s a pretty horrible way to go. And if you make it, then you’ll have permanent bodily scars of your stay there. Ask any doctor or nurse, and more than 90% will tell you that they’d rather not be revived when they are elderly and dying anyway.
Look, let’s be realistic. Quality of life versus quantity of life – which would you prefer? Let your loved ones know so they can help choose treatments when you are unable to speak for yourself.
Medicine is not magic. Sometimes the miracle of an easy appendectomy or the cure of a strep throat with antibiotics may make it seem like anything is possible. But a full body MRI scan will likely not improve your health overall. Neither will an expensive heart catheterization. An experimental cancer treatment is just that – experimental. Some costs are well worth the benefits like fixing a heart in a baby or transfusing 10 units of blood and doing emergency surgeries on a young mother in a car accident. But doing CPR and subsequent ICU care on an 80-year-old frail cancer patient is probably not going to benefit anyone. That is very much a judgment call and subject to religious recommendations. That should be respected, but a well-developed public education campaign of standards in routine medical care is helpful to dispel myths learned from TV shows.
8) Healthcare for the uninsuredIf you have a sore throat and think you may have strep throat, you should see a doctor to get an antibiotic. When you call a doctor’s office to make an appointment, they will ask you for your health insurance information. If you don’t have insurance, they may not give you an appointment. That’s the reality of private practice. If you go to the emergency room, they are required by law to see you, regardless of your insurance status. So instead of going to the doctor who costs $100, you go to the hospital that charges $500 for the same treatment. Hospital and emergency room care costs much more than a doctor’s office because they are specially equipped and prepared to handle emergencies. They have the room set up for doing CPR and heart monitors. It’s really unnecessary for a simple strep throat. Whether or not you are able to pay that money back, you have cost the healthcare system $400 more than necessary. That’s part of the out-of-control expenses.
Well, you know you can’t afford the emergency room, and the doctor won’t see you. So you just tough it out. A month later, you continue to run fevers and now you’re feeling so weak you can’t work. So finally you go to the emergency room and you find out that now you have rheumatic fever, where the strep has permanently damaged your heart valves. You have to take antibiotics for years and you have to see the heart specialist regularly. Or perhaps you have diabetes and you can’t afford to see a doctor. So you don’t take medications and show up at the emergency room with a rotting foot that needs to be cut off. Not only does your health suffer from not having regular medical care, it also costs the healthcare system many times more. Preventative, routine, and regular healthcare costs less than emergency last-minute care. Without adequate health insurance, patients do not receive the care they deserve.
In conclusion, I think healthcare reform is mandatory. The currently system is unsustainable and will end up worsening the health of everyone if it does not change. The Health Insurance Consumer Protections in the current plan are a helpful first step. I want the changes made now and in the future to always be in the interest of patients. Hopefully this analysis contributes positively to the reform.
Major points are as follows:1) Healthcare insurance companies should be non-profit organizations with the goal of providing excellent healthcare, not making a profit.
2) Change the government incentives from cheap corn production to a more balanced variety of vegetables to feed the nation.
3) Standardize medical record software across all platforms to enhance communication and record keeping.
4) Give drug companies incentives to develop cures and preventions rather than treatments.
5) Regulate the malpractice insurance industry. Free market for malpractice insurance is not working.
6) Raise primary care physician pay rates while reducing the specialist pay rates to compensate. This will place more emphasis on prevention and less on treatment.
7) Encourage living wills and promote more realistic patient expectations.
8) Provide cheap easy access to routine healthcare for all.
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