Monday, September 21, 2009

A Tale of Two Presidents

The media is abuzz about President Obama's "unprecedented" presence yesterday on five network and cable interviews to make his case for health reform, to be followed tonight with an interview on the David Letterman show. As President Obama continues to make his case to the American people, might I be so bold as to suggest that he take note of an op-ed that appears today in the Atlanta Journal Constitution, written by ACP's own President, Joe Stubbs, MD? I am biased, but I think Joe makes as good a case as anyone, on why reform is imperative. He writes:

"I take care of patients in a general internal medicine practice in Albany, as I have done for the past 27 years. I take enormous professional pride and satisfaction in keeping my patients healthy, helping to heal them and providing comfort and relief when they are nearing the end of their life. I also share their frustrations with a health care system that is stacked against us both; a system that is unacceptable and unsustainable. Examples readily come to mind to support this point. By 2017, an average middle-income family will spend $4 out of every $10 they earn on health care alone, putting it out of reach for most. Just three years later, the number of uninsured is expected to climb from today's 46 million to 60 million, which is about one in five of our population. And, those with insurance will not be able to find a primary care doctor because of a growing primary care physician shortage of tens of thousands ...

Within our grasp is the achievement of health reform legislation that makes coverage affordable by building upon and improving our current employer-based system, providing incentives for young doctors to go into primary care, reforming and improving Medicare physician payments, and reducing the costs associated with our broken medical liability system. Let's not let the opportunity slip away."

If Joe is right that rising costs will exceed the ability of families to afford coverage - and I have no doubt that he is - then why does the public not seem to have the same sense of urgency? Ezra Klein writes in yesterday's Washington Post that the cost of health care to individuals and families is masked by the fact that employers pick up (most) of the tab. But when employers pay more for health care, they pay their employees less in wages. Health care costs arguably may be the biggest cause of decades of wage stagnation for middle and lower class families.

The political dilemma is that since the public doesn't readily see the impact of rising health care costs on their livelihood - unless they are among the unfortunate millions who have no health insurance coverage or have experienced personal bankruptcy because of a personal health care catastrophe - they don't want to hear about the need to control costs. When even relatively mild ideas to control costs are proposed - like funding research on the comparative effectiveness of different treatments, or reimbursing doctors and patients to sit down together to discuss advance directives - they are demagogued as "rationing" by some politicians.

This is why the political debate is shifting to things that are relatively popular with the public - like prohibiting insurers from turning them down if they have a pre-existing condition or cancelling their insurance if they get sick - instead of controlling costs. The idea seems to be to sell the public on the gain from insurance that can't be taken away, while postponing a discussion of the pain involved in controlling costs. Even though, as Joe Stubbs wrote, the cost of the current system is not sustainable for his patients and their families.

Today's questions: What do you think of the views expressed by Dr. Stubbs? How would you recommend engaging the public in a discussion of the cost of health care?


Steve Lucas said...

Dr. Stubbs has a balanced and realistic approach to the current and future problem's facing health reform. Unfortunately for a vast number of the public, they look at reform as an insurance issue only, and one that involves others, not themselves.

Two recent conversations highlight the problem. A couple of weeks ago a friend and I were discussing this topic and the argument ended when he stated that the President had stated he could keep his policy, so there was no issue, other than insuring others.

Saturday night I was at dinner with a large group and health reform was brought up. When I raised the questioned of cost control and doctor compensation I was asked: What does this have to do with health care reform? Again, once everyone had insurance, everything was right with the world.

Sadly many of the players will benefit from an insurance only reform agenda. The insurance companies, drug and device companies, hospitals, and even some medical societies will all gain if no cost controls are put in place, and we continue with our current lack of transparency.

This will leave only those with little or no conflict of interest to put forth an alternative view. Front line doctors, corporations paying for coverage, and medical societies with no financial gain in promoting an insurance only solution, will need to step forward and shoulder the difficult task of informing the public. The realistic result of this position will be condemnation, for the very things we need to do to control cost, are the very things already misunderstood and vilified in the press.

Reduced testing, branded vs generic drugs, and even end of life planning are first steps in controlling cost, but are subjects that are off limits. Add to this changing doctor compensation from a fee for service head count system, to one based on needed care and the public is primed for calls of rationing.

The results will be much the same as I suffered Saturday - stony silence.

Steve Lucas

Jay Larson MD said...

Since 80% of U.S. citizens don't have chronic disease, they are not affected by the dysfunctional health care system. Once they become one of the 20% chronically ill persons that consume 80% of health care resources, they will have a different attitude.

Sadly with the American lifestyle, more people are developing chronic disease. Once this burden of more chronic disease is compounded by an increasing elderly population, you know what will hit the fan. Americans will be singing a different tune.

Health care reform has to be about delivery reform in addition to insurance reform. The cost of pharmaceuticals and diagnositics has to be reeled in also. Adding more money to a dysfunctional system will not improve the system, nor make it less expensive.
It will be throwing good money after bad.

If this opportunity for meaningful reform slips away, it more than likely resurface in about 10 years. By that time, there will be no primary care providers. NP and PAs will have figured out that focusing on a speciality is more appealing and rewarding.

By that time, health insurance premiums will be so outrageous that even those who are healthy will demand that the burden of health premiums be relieved.

It would be interesting for Steve Lucas to have the same conversation with the same group in 10 years. I bet there would not be stony silence.

Arvind said...

Why is it that this is such an eye-opening moment for you Bob? It has been evident from the beginning that anyone that gets a high priced service for a relatively small fee (co-pay) will never realize the true value of the service. Hence the vast majority of the population with employer-sponsored health insurance never see the true cost of their demand for endless medical services.

The lack of transparency in financial transactions in medical care is to blame here. If every individual and/or family were to purchase their own health coverage without involvement of their employers, this would never happen. In addition, they would not be wedded to their jobs only to maintain their health coverage. Besides, coverage is almost never appropriate if someone else picks it for you.

Unfortunately, the same President who proposes "reform" refuses to delink work from health insurance, and wants to strengthen it. We look to the problem (third-party payer) as the solution and expect to succeed! How could that happen?

We don't need external inducements to make students pick a primary care career - simply allow primary care physicians (all physicians in fact) to compete in an open marketplace where the best can thrive and the worst perish, and provide appropriate financial rewards for great service and talent without price-fixing; and you will see not only high quality care but lower cost and more selective patients.

Currently, the main players in health care - patients and physicians - have no stake in it because they don't have any control over the financial transaction (which occurs between employer & insurer). Hence the unsustainable growth in spending. Make the financial transaction part and parcel of the medical transaction by eliminating CPT codes and price-fixed third party payers; and you will have your answers.

Rich Neubauer MD said...

The eloquent discussion from ACP President Joe Stubbs is right on the mark. If we stay on the current course, health care costs will continue to rise, and we will continue to ration care in the most cruel and arbitrary fashion: by denying meaningful access to a large and growing population of the country; those who lack health care insurance coverage. In addition, even those who have coverage will increasingly find themselves in jeopardy of being swallowed by health care bills not covered by their insurance. Finally, if the decline of primary care is not dealt with aggressively, our system which is already top heavy with sub-specialists will increasingly bewilder those trying to find their way in a technologically sophisticated but often undecipherable system that treats diseases but not always the person with the disease.

How best to engage the public in a discussion of the cost of health care? One probably needs to enumerate the public’s fears and misperceptions to know the answer. One fear that is prevalent is that what “I” have can only be less if we spend money to insure others who currently can’t afford or otherwise don’t have coverage. This gets to the rationing fear. An associated fear is that if we as a country are already spending twice as much as other countries on health care, how can we possibly add 46 million more to be covered without bankrupting the country. Finally, if we already have access problems, what will happen when more people are lapping at the door wanting to see “the doctor”. One misperception is that if “the government” gets involved in medical decisions, it will be all downhill (ignoring that insurance beaurocrats may be crueler judges of medical necessity and that government already is heavily involved and pays for some 40% of health care costs in the country). Another misconception is that we have the best health care in the world while the evidence shows that we rank poorly compared with other countries in many basic measures of quality and performance.

The recent ACP position paper entitled “CONTROLLING HEALTH CARE COSTS WHILE PROMOTING THE BEST POSSIBLE HEALTH OUTCOMES” ( enumerates no less than 47 major strategies for cost control that would require a national commitment from patients, physicians, and the health care “industry”. As I read and re-read this paper, I am convinced that the only way that these strategies can be seriously addressed is for our nation to make a moral decision to cover everyone first. Only then, when everyone has skin in the game, can we have a serious discussion about achieving cost control. The fact that we spend twice as much per capita as every other nation on health care while achieving inferior results in many important measures and to boot fail to cover 46 million of our citizens can mean only one thing: we can do better by spending our money differently, and we can cover everyone in the process.

I believe that a national decision to cover all our citizens with health insurance is the key to unlocking a serious but undoubtedly difficult public discussion of cost control.

Unknown said...

Dr. Stubbs,

The private Insurance companies are not the problem...the problem is the government regulations on the Insurance Co. See, if they could compete for my business the cost of premiums would go down, instead they operate in a jungle of regulations at the federal and state level! Those regulations mandate the insurance to cover for absurdities like sex exchange surgery...or fertility work up and treatments...or flatly encouraging price fixing, unfortunately this results in increased premiums for everybody! Health care insurance cannot insure that you are going to be healthy! Insurance only insures risk that comes from medical expenses. We all could insure for catastrophic events and pay as we go for routine doctors visits. Your car insurance does not cover your oil change...or regular maintenance. Health care is a privilege and not a right like the communists of the United Nations want you to believe! Basic needs of humans, like food and shelter, are not provided by government bureaucrats or should they? Americans are the most self reliant people in the world we need no government to provide and unfortunately restrict our personal freedoms!

From somebody who worked in the health system for 29 years. I worked in the health systems of Italy, England and Australia and finally landed on the Land of the Brave and the Free only to find out that deranged politicians and Hollywood shysters believe that Cuba has a better health system than ours.

God help us!!!!

ACP Member...will resign

Arvind said...

Well said, Cowboy. Unfortunately, the ACP is not listening to you. I feel that its best to stay wage the fight. If you state the truth often enough, even the liberals in the ACP will get it eventually.