If universal healthcare as currently sanctioned by the administration and congress extends and institutionalizes the status quo, the medical insurance companies will become even more powerful and the last vestiges of a physician's ability to practice medicine free of corporate manipulation will end. The only thing that will NOT change is the profit margin of the medical insurance industry, big Pharma and hospitals.

 

Do we really know what we are getting into? I am terrified that my days of practicing quality medicine are numbered. I had a conversation with a colleague who recently retired from medicine in Canada about their system and I was astounded by what I learned. Under the Canadian system physicians have a choice to either participate in the government run healthcare system or stay in the private sector. They cannot participate in both. Because most patients want to stay within the government system there are not enough patients for doctors outside of it so there is an economic pressure to stay within the government run system. It sounds fine until I learned how they keep the medical costs low in Canada.

 

The physician’s reimbursements are capped. The costs shift so that one year an internist may make more than a pediatrician, the following year their reimbursements will drop in favor of another specialty and so on. If the physician bills more than the capped amount he or she will not be paid for the work they performed. In addition, each physician has a profile and is compared to their counterparts. Those who have numbers that fall outside the average (i.e., you do more procedures or order more tests etc...) will be investigated. The morale of the physicians is non existent. The pressure is to want to see the healthy patients, do the absolute minimum and when you reach your cap leave Canada and practice part time somewhere else like the US. It explains why the waiting list for elective surgery is so long. Those patients with money simply leave Canada. The physicians in Canada are the only professionals who are told how much they can make. Yes, the patients are universally covered, and it works well as long as you are basically healthy and just need a cold or sinus infection treated, but what if you are a diabetic with kidney disease and need open heart surgery? What if you have a premature baby that requires neonatal intensive care? Who decides what happens to these patients when treatment may not be cost effective? Furthermore, what is it like to receive medical care from a professional who is treated like dirt and is counting the minutes to the end of the day or looking forward to leaving for their other job? The Canadian system is not profit driven because it is run by the government, but it is designed to provide minimal coverage by any means necessary. The physicians have been easy targets despite the fact that they have a union.

 

It has already been happening here. I spoke to another colleague in Puerto Rico who sees a lot of Medicare patients. Medicare advantage is a program that is run by a private insurance company (and there has been a big push to sign up physicians all over the country). When doctors in PR signed up they were told that they would be paid 110% of Medicare rates and that the rates would stay above the Medicare allowed amount. Now that they have been operating for a couple of years and they have most patients and physicians on their panel the reimbursements have dropped to as low as 80% of Medicare and the rates can continue to drop. This is how the private insurance industry operates and it is not new. If protections are not put in place, the only thing that will change is the exponential increase in the amount of people who will be paying them premiums. Let us not kid ourselves, the system will still be skewed towards limiting access and payments in favor of the almightily profit margin. The insurance company cannot be trusted to police itself.

 

If we pass universal healthcare in its present form the same thing will happen throughout the private insurance industry. They will simply continue to drop physician reimbursement rates in the name of ‘controlling health costs’. The floor will continue to be lowered, but under the new system doctors will have no choice but to accept it because there will be few patients who are 'outside' of the system and are self pay fee-for-service. Why would anyone want to practice medicine in that kind of environment?

 

There are long term consequences since the logical extension would mean less people going to medical school and less people practicing in rural underserved areas. To accommodate the change more patients will be seen at Wal-Mart clinics and more patients will be seen by allied health professionals. Without a public option this is the future that we are driving towards. In short, outsourcing medicine to corporate run clinics where patients have most of their medical care provided by non-physicians. When that day comes I will leave and go practice medicine elsewhere, and I am sure I will not be alone.

 

This problem was set into motion years ago. Most patients have no idea about the incestuous relationship between the medical insurance industry, big Pharma, and hospitals. It is important to not be fooled by their recent talk of altruism. The carefully orchestrated dance between the administration, those in Congress advocating taking the public option off the table, and these corporate players is Kabuki Theater. The fact is each of them has carved out their piece of the healthcare dollar pie and they are loath to give it up. The health insurance companies, big Pharma and hospitals have done a masterful job of actually increasing healthcare costs and limiting care while making the physician the scapegoat. The mantra from Washington, the insurance and big Pharma shills has remained the same: "the rising healthcare costs have been driven by the rising demand for technology as well as the doctors' reckless desire to perform unnecessary procedures and tests". It has worked beautifully. The truth is that doctors are getting paid less for doing surgery and procedures so that is not contributing to the raising costs. Insurance companies have already limited the over use of high priced procedures because they ALL need to be pre-certified. For example if you look at the cost of a CT scan of the sinuses it was approximately 800$ a few years ago now it is $350. There have been similar downward pressures on MRIs, sleep studies etc... The misperception of what is causing the rising costs has been cultivated by the medical insurance industry. If you add in the complicity of the AMA, and those in Congress taking money from their lobbyists, the insurance companies have been given free reign to reap a windfall of profits like a slot machine rigged to pay out every time the lever is pulled.

 

Let's really take a hard look at the claims vs. the reality of the rising healthcare costs. The medical insurance industry has been unregulated and has been allowed to make up the rules as they went along. At first glance the rules seem arbitrary and benign, but they have been designed to maximize profits for the companies and their shareholders. They have accomplished this by: 1) increasing premiums for patients; 2) shifting more up front costs from the insurance company to the patient in the form of increasingly higher deductibles, co-insurance and carve-outs that are not covered; and 3) decreasing reimbursements to physicians.

 

In the past 10 years there has been an inexorable decline in reimbursements to physicians. This has taken many forms. They range from setting arbitrary "usual and customary" rates that are not based on the rising cost of doing business, to denying claims that extend the payment process by at least 30 days, to asking the physician to provide information that they already have before the claim will even be considered, to 'losing claims' that then have to be re-submitted, to applying multiple procedure discounts that actually limit the amount of reimbursement by as much as 90%, to denying claims after they have been previously approved. These practices have increased the physician’s cost of doing business and have led to a significant delay in payment sometimes up to one year. In some cases it has meant a loss in revenue. More importantly these practices have allowed the insurance companies to reap a profit of over 80k for each day a payment is delayed. These companies have no idea what temperance or fairness mean. As the meeting with President Obama and their dealings with the Clinton administration clearly have shown, this cabal will say anything to delay the implementation of real change. It is all about profit and patient care be damned. The back peddling insurance companies are doing now is only a taste of what is to come. How can anyone seriously believe that it is fair that reimbursements have continued to decline while the cost of medical supplies, labor costs, malpractice insurance premiums have steadily gone up?

 

Big Pharma is doing double duty. Not only are they bent on making money off of chronic disease, but when that doesn't work they gin up demand for their products by a relentless campaign of direct marketing to a vulnerable public (even my mother would watch commercials for rosacea and believe that she had it). They have long made a habit of re-branding slightly altered drugs that are essentially the same as the old product to extend patents and keep profits high. They have also marketed drugs with little effectiveness and some that were even dangerous all in the name of profit. The most recent blow to healthcare costs was their role in passing the Medicare prescription drug benefit plan that locked the government into high priced drugs thereby dooming Medicare to an even faster slide towards insolvency. The tactic of inflaming the fear that drugs from Canada or Mexico were unsafe when in fact they are made by the same drug companies under the same guidelines (but available at discount rates) was unconscionable.

 

I understand that the hospitals have taken a hit from providing care for those who come to their ERs without insurance. However, they certainly have made money on other aspects of providing medical care. How else can they explain the rash of new construction, build outs and upgrades of their physical plants and operating rooms. For example, as surgeons, my colleagues and I have made a sizeable contribution to their bottom line of hospitals. We take ER call without receiving pay, and treat uninsured patients for free. These patients are a majority of who we see when we are on call. When I think about how much I am reimbursed for a surgery and what the hospital makes for the case that I did, I have little sympathy for them. I have been paid $900 (taking a 90% discount) for a case while the hospital received over 30K. They have even begun to play hard ball by advocating legislation to limit the amount of outpatient surgery centers near them because surgeons have been increasingly using them instead of taking patients to the hospital. Not only are the outpatient centers more efficient, they are lower cost for the patient. Fair play and competition are not something they want to entertain when they can't win. They are like a child who is losing so stops the game, picks up their toys and goes home.

 

It probably could have been avoided if the physicians had an advocate that was looking out for the interests of the doctor and the patient. I no longer belong to the American Medical Association because they do not represent my interests as a physician. They at best have been negligent and at worse have been complicit in this fiasco. They have been silent while entities like Wal-Mart and allied health professionals like nurse practitioners and physician assistants have enlarged their scope of practice thereby leading to a distance between the patient and the physician.

 

We as physicians also need be held accountable for ceding the field. We let the fear of losing patients and wanting to keep them at any cost empower the insurance companies; we allowed the AMA to sell us out without making them pay a price by leaving; we have given nurse practitioners and physician assistants the motivation and the license to step into the breech that we left because of the need to see more patients per day in order to stay in business. If physicians as a whole had discovered their backbone and stood up to the insurance companies from the beginning things would look a lot different today. At this point medical care has largely been reduced to practitioners who are frustrated in their attempts to take good care of their patients. Somehow, the perception of the physician as a wealthy, money hungry, ethically challenged, soulless creature who is bent on doing more unnecessary procedures is a caricature nurtured and popularized both by the insurance industry and those in congress who would like to further empower and cement the status quo. This has only accelerated the distance between the doctor and the patient. In fact, it has become somewhat adversarial; and I would argue that there is a direct correlation with medical malpractice litigation and the damage done to the fundamental frame work of the doctor patient relationship. We as physicians need to acknowledge and take responsibility for our part in allowing this to happen.

 

Do we really want to reward the current corporate healthcare players like we have done for the banking industry and Wall Street? They have squeezed all that they can from the physician AND the patient. The result has been a healthcare system on the brink of disaster. I don't think they deserve to be rewarded for their behavior by being given an unlimited amount of patients who will pay premiums. We cannot rely on President Obama or Congress to look out for us. Both patients and physicians must start demanding real change not lip service. We have to believe that we actually do have the power to bring it about. In my opinion a public option is essential to providing the first step in taking back that power so that we can stop being victims.