Saturday, September 19, 2009

Real Support

Just a brief note this time. Previously, I mentioned that I thought the National Physicians Alliance (NPA) represented my views better than the American Medical Association (AMA). Each day that goes by, I feel more and more strongly about this.

As you probably guessed, I believe that real, hones, meaningful healthcare reform is important and that we are in a critical time for reform. Whatever happens, good or bad, the decisions made now will determine the nature of healthcare for the next 15 years or so.

The AMA has signed on to the reform effort, and currently support HR 3200--which includes a public health insurance option. However, my perception is that their support is lukewarm at best and that the public insurance option makes them very nervous.

On the other hand, the NPA has stood up firmly in support of reform including a public option. They have videos like these two describing the situation (one here, the other here), informative links like this one discussing a poll in which health care leaders show a 70% support for reform including a public option and this one which compares the 3 current bills side-by-side. Useful stuff, no?

So: the NPA is again the stronger patient advocate and the better advocate for reform than the AMA. I'm glad the AMA is supporting HR 3200 because it allows the process to move forward. I just wish their support was deeper and more outspoken.

Wednesday, September 16, 2009

Physicians Support Health Reform With A Public Option

We've already seen that multiple physician groups support healthcare reform, including HR 3200, that includes a public option. We've also seen many, many loud/frantic opponents who would like to stop the process and eliminate any discussion of a public option.

Now, the New England Journal of Medicine publishes the result of a new survey in which most physicians (approximately 3/4) support health reform that includes a public option. This includes physicians of all specialties, though those that have less patient contact supported public options a little less than other clinicians.

In a related note, approximately 3/4 of physicians believe that physicians believe that addressing societal health policy issues is within the scope of their profession and that physicians are obligated to care for the uninsured and under-insured.

So: physicians, those with the most direct and meaningful interactions between patients and healthcare systems, believe that a public option is a valuable part of healthcare reform, and that advocating for this is within our vocation's calling.

So we need to speak up for our patients and we need to support reform that includes a public option. We cannot be silent about this.

Saturday, September 12, 2009


I saw pictures from the "conservatives" march on DC today. Some were carrying versions of the old colonial "Join or Die" flag.

I personally find this ironic. This implies solidarity between people and efforts to improve the common good. The irony is that these are the same people opposing efforts to expand healthcare to the marginalized and underprivileged citizens in our nation.

Do they really not see the disconnect? Their flag should read "leave me alone and stay out of my business".

The GOP Reform Plan

So, I'm reading over the GOP health reform plan from June 2009. Some thoughts:

--Tax savings for those who provide their own health insurance will not help if you cannot pay for your own health insurance.

--Will providing tax credits really be enough to account for the full cost of health insurance? If not, then the tax credits may have no impact on the availability of coverage.

--If insurance companies are allowed to pool their insured customers across state lines, which state's rules apply? Each state has an Insurance Commissioner who decides what coverage and obligations are required. If an insurer has a product that is sold in multiple states, will they be able to use the least restrictive rules? In that case, will there be a race to the bottom in which the only affordable insurance plans available are those that offer the fewest benefits and the least coverage?

--I agree that medical liability and tort reform would be nice. As a physician, I would be very happy not to be burdened by ever-increasing malpractice costs. Medical malpractice caps do limit the malpractice costs for physicians, but there is little/no evidence that it stops physicians from over-ordering tests or that the cost savings are passed along to patients or to the system as a whole. So--malpractice and tort reform would be great, but will not really fix the system. Including this reform might be best used to help get physicians on board, but not to remedy any real problems. [The way to stop over-ordering might be to allow physicians to see fewer patients and spend more time with each patient--a good history and physical exam could save a lot of tests--without going broke or out of business.]

--I do not see how health savings accounts (HSA) will help people who are too poor to save money. No-one has yet explained to me how patients whose incomes are used up by their bills and other obligations are supposed to benefit from access to an HSA unless someone is putting the money in on their behalf.

--Making health insurance portable and guaranteeing health insurance to all regardless of preexisting conditions: both already in the proposed legislation.

--Has the GOP paid any attention to the fact that health insurance costs are severely limiting business's ability to compete in the global marketplace? Are the proposed tax credits going to be enough to balance this out?

--Expanding SCHIP programs and allowing minors to stay on their parents insurance plans for a longer time: already in the proposed legislation.

--Enhancing incentives to enter primary care and promoting community health centers as an accessible model of care: already in proposed legislation.

So, one big missing piece: nowhere do I see any mechanism for controlling insurance costs. In the the current proposals, the public option would provide a means for controlling insurance costs. Under the GOP plan, is this supposed to magically appear as a gesture of goodwill on the part of the insurers? Or is a health insurance exchange going to help moderate costs (you know--like the exchange in the currently proposed legislation)?

I don't see how the GOP plan actually expands care to those who lack access now and I don't see how it makes health insurance more affordable.

It's a little like Medicare Part D (the drug coverage plan passed in the Bush years). This plan specifically restricted the government Medicare program from negotiating prices with drug companies. So, as a result, the program has been tremendously expensive for Medicare and a windfall for big pharmaceutical manufacturers while not providing maximal benefits to patients. The GOP healthcare refomr proposal would give patients and businesses tax credits to buy private insurance, in effect rewarding the very same companies that have failed us thus far.

Passing along public money to improve private companies' bottom lines. We've seen this show before, and it never ends well for us.

The Real Reasons We Need Health Reform

Over the last few months, many people (including me) have been making the point that health care reform / health insurance reform is necessary and urgent. I've tried to make the point by giving examples of patients who have suffered under the system, the additional fees and costs incurred by uninsured patients, the challenge to finding useful and affordable health insurance, etc. These are all valid reasons, but I don't know if they are the REAL reasons why we need healthcare reform.

In medical school, we took a class in medical ethics. As part of the class, we were taught the 4 key principles of medical ethics:


In more detail:

Beneficence: the requirement to do good for your patients; the obligation to provide benefits to those in need.

Non-maleficence: the obligation not to cause harm (primum non nocere); the obligation to prevent injury to our patients.

Autonomy: patients must have the personal rule of the self while remaining free of controlling interests by others and by personal limitations. This is patient autonomy, not autonomy in the restricted "conservative" sense of "hands off my property." I am referring to autonomy in the sense that without good health we cannot be in control of our lives and that harmful actions by any outside influences (including multinational corporations and the insurance companies) need to be avoided.

Justice: giving to each his due; equals must be treated equally, but unequals need to be treated unequally--if you have greater needs, you might require more resources.

If we value all human life (and "conservatives" claim to value human life more than anyone else), then we should hope that all people have the chance to flourish and to maximize their capabilities. In our economy and government, we do not guarantee equality of results. We do, however, claim equality of OPPORTUNITY. The classic American story is the individual who comes from poor beginnings and reaches great heights. This potential, this opportunity, is greatly restricted or lost altogether if one is in poor health.

Our current health care system violates all 4 principles of medical ethics. It does not allow for beneficence--insurance companies restrict access to care and the costs keep millions from accessing the system at all. It does not allow physicians to prevent harm: patients may not get follow-up tests or visits because of cost or access issues. It does not allow for patient autonomy in any meaningful form--the final decision is oftentimes not really the patients' decision. Finally, the system is evidently and fundamentally unjust. This system also negates any premise or claim we might make of truly valuing other people.

To me, these are the real reasons we need healthcare reform. Physicians and other healthcare professionals must stand behind reform that will make our system effective and ethical.

Sunday, September 6, 2009

Uninsured Patients Pay More For The Same Care

So: when last in the Dominican Republic, I was hit in the head with a pistol when 3 men tried to rob our group. 2 months I was still having a little dizziness, so I had an MRI of my brain with intravenous contrast to check things out. Last week I received my bill for the MRI. It cost $3,922.00.

Now, here is where things get a little odd and where uninsured patients get an even worse deal than you would expect. The hospital where I had my MRI participates with Anthem, who provides our health insurance coverage. In order to sign on to participate with Anthem (something that you pretty much have to do in Richmond, as the company is a huge player in the area) health care providers have to agree to accept Anthem's "discount". In this case, Anthem writes off $1,500.55 of the bill and determines that only $2,421.45 are actually allowed. So: Anthem determines automatically that 38% of the charges are not permissible.

Now, I pay my co-pay on the lower cost ($2,421.45). However, if you have no insurance, you do not qualify for Anthem's discount, and you are going to be charged the whole $3,922.00. This means that, if you are not able to afford coverage (or are one of the relatively few who chooses not to buy coverage) you pay a lot more. When you consider that most of the uninsured are also the working poor, you can see how quickly costs add up and threaten to crush families' chances of improving their lives.

To summarize: if you cannot afford health insurance, you will pay more for any health care services than you would if you had health insurance. And not just because you're paying for the charge instead of paying a copay--the actual charge is significantly higher.

[As an aside: for all those critics of health insurance reform who feel that young, healthy people may decide that they do not need insurance, this sort of incident shows why everyone should have some level of coverage. Remember that the hospital fees are increased in order to make up for the money lost on those who cannot pay for the care. I certainly didn't ask to be pistol whipped, in the same way that a 20 year old does not ask to be in an automobile accident or a 40 year old farmer does not ask to be mauled by her hogs. If we all contribute to the common good, then all can be protected and helped. At some point we will all need health care, and I think we should all be contributing to provide that care.]