Healthcare Reform, from a Doctor's perspective.

I have been putting off doing this post given the politically charged environment we live in, but now feel I need to share my perspective as the finish line to the presidential election draws near. For obvious reasons, health care is a VERY IMPORTANT issue to me. I feel I offer a unique perspective as I have seen our health care at work from several different angles. I have been a patient in the system: I remember being a young 16 year old boy who suffered sudden onset hearing loss and being told by a doctor that I may have a type of brain cancer and needed to get an MRI right away to rule it out. Talk about scary(not to mention horrible bedside manner by the Dr, which deserves a blog post all on its own). I have worked in the field as a medical records clerk, a courier transporting blood back and forth between clinics and labs, an x-ray/lab technician, a medical student and now a resident doctor. I have seen our health care system at work across multiple different specialties and in very diverse patient populations across the country. Each area had its unique challenges and circumstances, but also many similarities. I am currently living in the epicenter(Dallas) of the worst West Nile virus breakout our country has ever seen! Kind of crazy and tragic to see first hand the effects of a fairly new and relatively unknown disease that does not yet have a treatment! But even more exciting is to see the passion and dedication of outstanding neurologists, researchers and public health officials who are spending long hours trying to figure out the best way to save lives and restore function during this viral outbreak that acts very similarly to polio. In any honest discussion on healthcare, most will say our system as whole is broken in some form. When examined from a purely economical point of view it is a very unique marketplace. I admit I am no economist but I will attempt anyway to articulate my understanding of our current system. What we have right now is essentially a third party payer system. In other words, the person offering the goods or services(doctors, other providers) are not directly paid from the person receiving those services(patients) but instead from a third party(insurance companies). Ideally, we(patients) all contribute a small monthly amount to these third parties(insurance) to "subsidize" the costs of healthcare as a community to cover the large expenses that would be difficult for the individual to cover alone. It gets a bit more complicated when we consider employers who also contribute partially or fully to pay for employees health insurance as they sort of also become a third party payer. I believe understanding the third party payer system is crucial to understanding why healthcare costs are such a big portion of the GDP. Unlike other markets where consumers are behooved to find and shop for the best and least expensive "deals", consumers(patients)do not worry about costs as long as the third party(insurance)will pay for it. This is a big reason why, for example, a pacemaker sold in the USA can cost 70,000 dollars and the same device in other countries(like Canada)cost 7,000. It should also be pointed out that diagnostic equipment(like MRI machines) are more expensive for hospitals to buy in the USA than other countries because the companies that build the machines know hospitals can charge more to pay for the scanner because of the third party payer system. And not too confuse things any more than I already have, but we also have two little government third party payer programs called Medicare and Medicaid that are a part of this system. Medicare of course being for those over 65 or disabled and Medicaid for low income consumers. And lastly, malpractice law suits and defensive medicine undoubtedly drive up medical costs in an already expensive marketplace. More on this later. Now, one of the more frustrating parts about the current system is that insurance companies and plans are not equal and premiums are all different based on a variety of factors. One of the most obvious factors is the exclusion of consumers(patients) because "pre-existing conditions". I agree wholeheartedly that this needs to be eliminated when considering whether someone be covered with insurance(although I do support requiring those who choose to use tobacco, drugs,or excessive alcohol be charged higher premiums as these are known to increase costs and the patient can do something to change it). For me as a doctor, the most frustrating part with the system at present is the fact that insurance companies very literally decide who will live and who will die. In other words, I can recommend a life saving treatment but the insurance company will have the final say if they will pay for it or not and ultimately if the patient will receive it or not. I hate to say it, but when considering treatment for patients we absolutely have to consider their insurance and may alter our treatment plan based on what type of insurance, if any, the patient has. Ok, is there anyone still with me after my very barbaric attempt to be an economist? I applaud you if you are. :) So, I have finally arrived at the reason for this post. Healthcare reform! If you made it through the post, you probably guessed I support reform. And you are right as I indeed support reform. I support getting rid of pre-existing conditions as exclusionary for insurance. I support creating more portability of insurance plans so if you lose your employment you still can have insurance. I actually support requiring everyone to have health insurance(it pains me to write this sentence as I HATE the government telling us what we HAVE to do, but people without insurance who can't pay drive up costs for everyone else, and for those who have assets but no insurance end up losing their house, retirement etc trying to pay which also hurts everyone else). BUT, I do NOT support Obamacare(Patient accessibility and affordable care act) as a whole. And here is why: 1)NO malpractice reform. Did you know there is not a single mention about malpractice reform in Obamacare? I am not sure if it is because he is an attorney himself or what but do not believe anybody who tells you malpractice and defensive medicine do not drive up costs. They absolutely do! Every day I order tests just to be on the safe side in case I get sued. I was trained when thinking about a diagnostic plan to order enough tests to show you thought about EVERYTHING. This absolutely drives up costs. Not to mention malpractice insurance can cost a doctor over 100,000 dollars/year! Just like any industry, that cost transfers over to the consumer. 2)No medical education reform. My education cost several 100,000's of dollars. It cost more for some. This is a big deal, especially when Obama wants to pay for the bill by CUTTING provider payments...which brings me to my next point. 3)Cutting provider payments. I am not sure why Obama keeps saying this is how he will pay for the bill, because cutting provider payments will NOT actually pay for his bill. He probably says this because so many people have this vision of mean, rich doctors that are overpaid and so he thinks it will win votes. I understand doctors pay only account for 8 - 15% of all healthcare costs! I acknowledge there are some specialties that do make too much money(ie orthopedic surgeons) but on the whole, many doctors struggle to keep their offices running and pay the bills as medicare payments are DECREASING every year and office costs such as paying staff, supplies, electricity and rent continue to rise. Most physicians I worked with haven't had a raise in their salary for YEARS. In fact, many have decreased. Can you imagine working in your chosen field, gaining more experience, being more efficient, and getting paid LESS as the years go by? That is what is happening to most doctors and here is why. When Medicare first began, a doctor could submit a bill for a service to medicare and expect to get 100% of what he billed back. Over time medicare started to realize that this model was unsustainable as they were paying out a lot more than the program was getting in. So it started developing ways to scale back payments to providers and standardized how much it would pay for different services to providers. One politician took it to the extreme and developed the sustainable growth rate(SGR) formula years ago which calls for a percentage of cuts to providers every year to keep the program sustainable. Sounds reasonable right? Its only Medicare, so whats the big deal? There are a lot of other insurance companies to pay doctors a lot of money, right? Well, not so much. Since Medicare was scaling back payments, all the other insurance companies decided it would also scale back payments and follow the payment schedules set by medicare. Despite the fact that most insurance companies were and CONTINUE to have record profits, they decrease there payments to providers based on what medicare does. That is why its a big deal. And this year with all the baby boomers, the SGR formula called for a 21% cut to providers to help pay. So that means across the board all insurance companies would cut payments, despite making record profits! And Obama wants to cut provider payments further to pay for the bill. Ouch! 4)Increasing taxes on successful insurance companies. There is language in the bill that calls for an increased tax by 2018 I believe on those insurance companies that are more successful than others. I don't have a lot of love for insurance companies, but it feels very UN-AMERICAN to tax a company a higher rate just because it is more successful. That is my view anyway. And lastly 5)Quality based measures for payment. By the year 2015, Providers will not be paid on the amount of patients they see but by the outcomes of the patients they see. Sounds great, right? Actually, I think its a bad idea, and here is why. Let's say I'm treating a patient with diabetes and I only get paid if the patient's Hemoglobin A1c(3 month average of blood sugar) gets down to a certain level. Now imagine, despite my best diet teaching and prescribing the correct amount of insulin, the patient decides to eat whatever he wants and doesn't follow the insulin regimen. His A1c is still high at the next visit. Which means I don't get paid. But I will likely give him one more chance to get his A1c down and if his A1c is still to high at the next visit, I will likely fire the patient(yes, doctors can fire patients). Then I will start to be VERY selective with who I will take as a patient, as will other doctors, leaving this patient who really needs care, to be left untreated. Since it doesn't matter how many patients I see a day, I will likely only see a few select patients day, thus making for very LONG waiting lists to get in to see me. And I will have no incentive to see my patients any faster during the day, so it will be long wait times if you did get an appointment. So, if you think you wait long at a Dr's office now, just wait. And lastly... 6)I fear obamacare will cause a downward spiral on the healthcare profession. This is my own conclusion based on conversations I've had with many currently practicing doctors and my own analysis based on what I have read. It is no surprise with the baby boomer population there will be more people than ever to be treated. But I have spoken with many doctors who say they will retire if the new healthcare bill goes in effect, thus further worsening the projected physician shortages. I also believe that with physician payments AND salaries decreasing, and medical school costs continually rising, we will lose many bright minds to other less rigorous and equally or more lucrative fields. In fact, we may lose so many potential doctors that it further adds to the predicted shortage. Which means for doctors like me who are in the field and could not possibly retire or switch fields, we will likely be overburdened with too many patients AND underpaid since it really won't matter how many patients we see. I believe that ultimately leads to poor care and worse outcomes when a doctor has responsibility over too many patients. As a result of decreasing enrollment, med schools will be forced to lower tuition, thereby lowering pay to their professors, and thus causing many of those top minds to seek other fields. This will further cause the downward spiral of a smaller force of poorly trained physicians. I do believe that the field will always attract those who are altruistic to the cause and simply want to take care of their fellow mankind. I feel it a great privilege to be in healthcare and and a great honor in the trust people put in me to take care of patients. And this brings us full circle to my story about the West Nile outbreak. I'm not sure in an Obamacare world we would find the cure, or at the very least, adequately treat the symptoms of the worst outbreak of west nile or any other potential outbreak of X,Y,Z disease. I believe patient care will suffer. And that ultimately is the reason why I don't support Obamacare. I also think it a mistake to completely repeal it. Unfortunately, there really is no easy solution. I think Mitt Romney is right to say he will keep parts of the bill and repeal others. And I don't consider this a flip flop. The question is, what will his bill look like and will it address my concerns? Will it be similar to his Massachusetts bill or will he truly defer to the states to develop their own reform? I sincerely hope we find out.