A physician "comes out"

What appears below is crossposted from Daily Kos, where it stimulated very lively discussion. I appreciate the invitation to post it here as well.

I was inspired yesterday by a diary on Daily Kos written by nyceve, an articulate and powerful advocate for single payer health care, to crystallize my thinking about health system reform in a direction that many other factors in my life have pushed me away from.

You see, I'm a physician, and a very close family member is a physician. I am a delegate to the AMA -- which, as you know, remains steadfastly opposed to a single-payer solution, although it has developed an extensive reform proposal based upon providing insurance to everyone via tax credits -- subsidized health insurance.

But I have come to the conclusion that our insurance based system is simply not reparable.

I've decided it was time to come out.


First, a few words about the AMA

(I must note up front that I do not represent the AMA, and what I am saying here in no way speaks for the AMA. I am simply one of hundreds of delegates representing physicians in constituent societies of the AMA. All my comments here are my own.)

To its great credit, the American Medical Association has made a huge effort to inform the public about the need to fix the huge and growing problem of people with no ability to get the health care that they need. The AMA has spent years developing policy and putting together a comprehensive health system reform proposal. There is much that is of great merit in the AMA's proposal. It is truly progressive in how it is financed, using an income-based sliding scale system of tax credits, all the way to fully paying for people who cannot afford to pay any premiums. It does away with the regressive employer tax exclusion -- yes, regressive, because it primarily benefits the people who least need the benefit.

But in the end, the AMA plan, like President Obama's plan, and Sen. Baucus's plan, is still based on the core of our present system: one that is run by, dominated by, and subservient to the health insurance industry, the hospital industry (especially those tied in to the insurance industry), and big pharma.

It is a system that has created an unfixable disconnect in the traditional concept of a market driven by supply and demand, in that the purchasers of health care are not those who are receiving the care. It is a system in which the basic idea of competition has been turned upside down, driven not by quality, value, service or convenience, but by the most self-serving deals that can be driven by the insurance industry.

Could insurance reform fix this incredibly distorted marketplace?

In theory, possibly. But the political reality is that the insurance industry will never permit Congress to pass meaningful insurance reform. The dynamics are no different than they were in 1965 when the insurance industry was able to insist that this new creation called Medicare had to be run by the insurance industry -- or they were not going to let it get passed. Congress of course caved.

Insurance profits are simply too great, and the insurance lobby too powerful. And without really meaningful insurance reform, it won't matter if we nominally get every person in the country some form of insurance. Insurance does not equate to access to needed care. Abuses will continue, the horror stories that we are all too familiar with will continue to mount, and the insurance companies will continue to rake their profits off the top of every health care dollar. And, the huge proportion of the health care industry that is devoted to fighting with insurance companies will continue to waste valuable resources that should be going to providing care.

Integrated Systems: The Modern Standard Oils of Health Care

Many markets -- like the one I live in -- are dominated by one or two extremely powerful "integrated systems" that combine an insurance company that owns a large percentage of covered lives in the community (or the entire state), ownership of hospital networks, and ownership of physician groups. Any physician or group practice that refuses to play ball on their terms is often forced out of business. These dominant systems often are able to launder their insurance profits by having their for-profit insurance divisions pay well above market value for hospital and physician services to their own hosptial and physician services divisions, thereby moving taxable profits into non-taxable "retained earnings" of their not-for-profit delivery divisions. It's important to note here that some of the most egregious abuses like this are committed by organizations that portray themselves to their communities as "non-profit".

(By the way, paying for physician services simply means moving money into their delivery arm, it does not necessarily mean that physicians get paid above market value -- altho sometimes they are, as a deliberate strategy to crush a competitor by breaking up competing groups.)

How do they get away with this? The dominance of these integrated systems is so great, that nobody in a community is ever willing to challenge them for anti-trust and anti-competitive behavior, or call into question their non-profit, tax exempt status, because such a challenge is always a career-ending move. These integrated systems have become the Standard Oils of 21st century health care. They are utterly ruthless, and they essentially terrorize anyone who dares to even hint of challenging them. They routinely are able to prevent non-subservient competitors they wish to crush from ever getting the contracts needed for them to have a prayer of staying in business. (Generally very discretely, of course. It's seldom necessary for them to have to do anything more than hint.) And they are money machines, generating huge profits and handsome executive salaries, that contribute nothing to improving the health care of those without access (and often crappy care to those who do have access) -- all of their pompous rhetoric notwithstanding.

Sadly, even Universities have been perverted by becoming integrated systems

competing with their own communities in the worst possible ways. Even tax-supported state universities, whose mission should be to improve the entire community that they serve, have all too often now become seduced into empire building, often with highly deceptive advertising campaigns, and even going out of state to set up national referral networks, often putting private practices out of business or forcing them to sell. And do these universities fulfill their mission to at least serve those people who have no other access to care? Well, disgustingly, no. Aside from the legal requirement that every hospital has to provide care for emergency patients, many universities have become bulwarks against electively serving uninsured patients. Just one example: the University of Texas famed MD Anderson Cancer Center. No insurance? If you've got $50K spare change in your pocket, you're welcome. Otherwise, find someplace else to get your cancer care. In the meantime, programs like these have no compunctions about putting the physicians who do provide care to the uninsured out of business. I don't mean to tar all universities with this brush. Many provide superb care, and truly serve their communities. But sadly, an increasing number see their mission as defined by their business model, not by service.

How About Medicare as a model?

Medicare was a deeply flawed system from the get-go because the insurance companies were able to force their will on Congress to make Medicare greatly dependent on the insurance industry -- most people do not realize that even plain ol' fee-for-service Medicare is administered by private contractors, who have been given a great deal of latitude in interpreting and implementing the regs put forward by the Centers for Medicare and Medicaid Services (CMS). And because Medicare only covers 80%, that still gives the insurance companies a large role in selling supplemental insurance for the other 20%; insurance that a significant minority of seniors cannot afford. Patients without a supplemental policy are almost never denied care, and it's providers who are stuck covering the difference. And of course, Medicare Advantage is simply managed care, except that for the insurance companies, it's EVEN MORE PROFITABLE -- in fact, under the current system, they are guaranteed huge profits, while providers are often in the red for every Medicare patient they see, and patients and their physicians have to put up with all the administrative burdens that are part and parcel of managed care.

There continues to be tremendous concern about the way Medicare is structured. Part A and Part B are financed entirely separately. Part A covers inpatient hospital care, and Part B covers outpatient care given by physicians, and has grown tremendously in recent years as outpatient care as taken over much of the care that formerly was done in hospitals. Yet, current law mandates budget neutrality for Part B (only), so that as the volume of care has grown, a very badly flawed formula called the Sustainable Growth Rate requires draconian cuts in physician reimbursement in the face of ever rising costs of providing care, causing an annual crisis in Medicare fudning. Congress to date has refused to fix this, as it's become a useful political football, and there is much hand-wringing about where-oh-where the money would come from. So, we have annual emergency fixes. In fact, average reimbursement for regular Medicare is currently slated to by slashed by 20.5% in January, 2010. Congress will almost certainly not allow this to happen -- it would destroy Medicare almost over night. But needing an annual emergency fix for cuts based on an obsolete formula that everyone agrees is wrong, but nobody will fix, is an insane way to run a health care system. I mention this primarily to explain perhaps the foremost source of physician apprehension about single payer -- if Congress cannot even muster the political will to fix SGR, how in the world can we rely on Congress to come up with a single payer system that works? But ...

Stories: patients

There are untold numbers of stories. One I heard just this morning, from a construction supervisor who is doing some work for me. His former employer went out of business. He has tried to convert his previous plan -- offered by the dominant, integrated system in our state -- into a family insurance policy. But this hard-working laborer has had two compressed vertebrae. Not even a chronic illness! So? Presto -- he's uninsurable. When he questioned this, he was told, "Sorry, that's our policy."

Stories: physicians

Physicians and their employees spend inordinate amounts of time fighting with multiple insurance companies, each of which has myriad sets of rules that vary with different policies. It is absolutely impossible for physicians to keep all of the rules and restrictions straight, even with computerized records. And patients wind up paying the price, when their care is denied "because your doctor didn't prescribe an approved medication" or "your doctor forgot to get prior authorization". Even incredibly conscientious physicians who try their best, and who are willing to fight with insurers on their own time, can't keep up with this.

So, Single Payer?

Single payer health care might mean the death of private medicine in this country. It would likely mean that the clinic that my family member spent an entire professional career proudly building using loans that the clinic's physician partners took out on their own risk, would go out of business, because unless reimbursement rates were substantially increased above current Medicare rates, medical practices, even successful group practices, that are not owned by huge corporations or integrated systems that can take advantage of tax scams like those described above and preferential pricing only available to hospital owned practices -- will not be able to stay in business.

But you know what? Private, independent medicine is being slaughtered now. It's going extinct. And with its loss, an important part of what in the past made American medicine so vital, so personal and of such high quality will disappear, too.

That may be the price we have to pay. I have concluded that it's time to get private insurance out of the business of running and paying for health care, even if we were able to get every man, woman and child a health insurance policy, especially when insurance is used, as it often is now, as a way for huge corporations to gain a stranglehold on markets, and take all choice away from patients. Even if it means that many of my colleagues, including in my own family, wind up having to sell (probably at a substantial loss) what they've spent their lives building.

You see, while I understand capitalism, I also firmly believe that in an enlightened, wealthy society, we really have to do what does the most good for the most people. And if we believe that health care is a right and not a privilege, polishing the edges of a system that is rotten at the core will never get there.

I say this knowing that the overwhelming majority of physicians whom I represent at the AMA are vehemently opposed to the concept of single payer health care. Some of the opposition is not rational, but much of it is. If single payer were implemented poorly, it could turn our current system into something even worse.

Coming Out

So, I'm "coming out". I will say it: We need a true single-payer system in this country, but unlike Medicare, it has to done right. If it's done via insurance contractors, with all the control given to powerful hospitals and integrated systems, we will continue to have a disaster, perhaps worse than the one we have now, with the same disconnect in the marketplace that we have now between purchasers and users of health care and all of the upside-down incentives and rewards that have so perverted our current system.

We have to copy the very best of successful systems elsewhere. We have to make sure that physicians who have invested their careers and risked their own finances in developing practices are not destroyed. As a country, the last thing we an afford is to force physicians in their 50s into early retirement -- we already have severe shortages in many specialties and geographic areas, so a "tough shit" attitude about physicians is in NOBODY'S best interests. We need the input from the people who actually understand and provide health care in designing and running the system.

IF single payer were done right, the extinction scenario for practices not owned by huge conglomerates might not come to pass. In fact, it's possible that the opposite would be true. But that would take a huge amount of political will. More political will than we have ever seen to date from the likes of Harry Reid and Max Baucus.

I can think of no better way of closing this essay than to mention Paul Krugman's column today on health system reform, entitled Keeping Them Honest. Two guesses on who "Them" refers to:

... let me offer Congress two pieces of advice:
    1.    Don’t trust the insurance industry.
    2.    Don’t trust the insurance industry.

No votes yet


It's hitting the news today. Here's an excerpt from coverage by Comcast:

The bill would provide subsidies to help poor people pay for care, guarantee patients the right to select any doctor they want and require everyone to purchase insurance, with exceptions for those who can't afford to.

Insurers would be supposed to offer a basic level of care and would be required to cover all comers, without turning people away because of pre-existing conditions or other reasons. Insurance companies' profits would be limited, and private companies would have to compete with a new public "affordable access" plan that would for the first time offer government-sponsored health care to Americans not eligible for Medicare, Medicaid or other programs.