Friday, January 22, 2010

What is Not Being Addressed in the Health Care Debate....written by Greg Gann

I remember the days when you intimately knew your family doctor, and the same doctor treated you for many, many years. There is great contention and debate today in the U.S. and the rest of the world over how to fix healthcare. Unfortunately, much of the focus and strategies have been based on political ideology and party affiliation. Whether this country shifts from a private pay system to a government sponsored or quasi-government health coverage, there are real healthcare crises that are not even making the radar, but are clearly affecting me personally and most likely you as well. The crisis deals with the tremendous challenges associated with finding a family care practitioner today. Two years ago, my internist left private practice to join as a staff member of a hospital. He could no longer practice medicine the way he wanted and to be able to provide basic support for his family. It wasn’t that he wasn’t “successful”. He already had such abundance that he stopped accepting new patients. He complained that lawyers get paid anytime a client calls seeking professional advice. Yet his time spent in this way remained completely uncompensated. Also, the reimbursements from private health insurance companies and Medicare were so astoundingly low that they literally would not cover his overhead. Malpractice insurance, staff, rent and other office expenses don’t adjust lower just because the reimbursements continually get cut each year. While the medical specialists complain about income cuts put on them from the health insurance industry and the government, they at least can still cover their overhead and maintain a relatively high lifestyle. Having said that, the one specialty that is having a hard time making ends meet is obstetrics, where malpractice insurance alone can cost well over $100,000 per year.

I’m grateful we had our kids when we did because I don’t know who would deliver them if they were being born today. And this is my point. The real health crisis that is not making the debate, and to me is the most fundamental, is that at the rate we are going, few of us are going to have the privilege of selecting our own doctor because there just aren’t enough family doctors or certain specialty doctors left.

When my family doctor quit his practice to join the hospital medical staff, I called about six or seven internists, only to learn that none of them was accepting new patients. I felt like I was seeking membership to an exclusive country club into which I just could not break. On the eighth office rejection, I happened to mention in passing to the doctor’s assistant how disappointed I was that the doctor would not take me as a new patient because I knew from my father who is his patient how good a doctor he was. To this comment, she responded by saying that since I had an in through my father that she was sure that the doctor would relax his stated policy and let me in. Wow! I had made it to the country club at last. I have enjoyed this doctor very much and have a lot of confidence in him. This week the form letter from his office arrived that he was converting his practice to a model known as “VIP” or sometimes referred to as “concierge” medicine. With this model, the doctor who today most likely treats more than 2500 patients will be limiting his practice to the first 500 who sign on. For the privilege of maintaining him as my family doctor, I would have to fork over $2000 per year per family member who he’d treat. This is on top of my exorbitant medical insurance premiums, co-pays, and deductibles. Interestingly enough, his partner is not switching to this new model. However, he is not willing to treat any of his partner’s patients. Additionally, he is no longer willing to participate with insurance plans. So, he will collect from patients the full amount and not just the reimbursement amount of say Blue Cross / Blue Shield. He is shifting the burden of collection to his patients as well as the non-reimbursable amounts. The point is that while Washington is battling over who will pay for medical care, I’m finding it difficult just to find a doctor to whom I can pay because the ones I know have either given up on the entire concept of private practice and work for an institution, or they are not taking new patients, or they are now VIP only, or they will no longer participate with insurance plans. Are we already living in a time period where adequate healthcare is only available for the rich? Baltimore is no doubt one of the medical meccas in the world, so I’m thinking if it’s this difficult here, what’s it like in other parts of the country? I asked this very question of a colleague based in Seattle, and he said that the VIP model hadn’t made it to his coast yet, but knew it would be inevitable.

Spending on doctors, hospitals, drugs, and the like now consumes more than one of every six dollars that we earn. Atul Gawande in his June 1, 2009 New Yorker article entitled, ”The Cost Conundrum” reported that in 2006, doctors performed at least sixty million surgical procedures, which equates to one for every five Americans. No other country comes close to this statistic. And complications from surgery kill some hundred thousand people annually, which is far more than the number of car crash fatalities. Katherine Baicker and Amitabh Chandra, two economists working at Dartmouth, found that contrary to common sense, the more money spent per person on Medicare in a given state, the lower that state’s quality ranking was. Gawande goes on to compare traditional medical models to those of places such as the Mayo Clinic. At Mayo, the core tenet is “the needs of the patient come first”. In a traditional practice or hospital, payment is received based on the numbers of procedures ordered. He goes on to say that if a general contractor were paid based on the number of electrical outlets installed versus overseeing and coordinating the job, then due to that economic incentive, there would most likely be a lot of electrical outlets making their way to the jobsite through a myriad of justifications. Compensation at the Mayo Clinic has nothing to do with the number of procedures ordered. The quality of medical care is the mission, and this is not measured through quantity. An example is given about an internist at the Clinic escorting the patient personally to the cardiologist and consulting as a team. Gwande points out that the greatest challenges for the healthcare industry is modifying the orientation of physicians away from profit and quantity to payment based on quality, which to the author requires collaborative medicine practiced in a way like the Mayo Clinic. I agree with his concerns over procedural based compensation, but I truly believe that the greatest initial obstacle is finding a way for the family doctor, who after all is the first line of defense, to be able to make a living by just being the old-time family doctor that he or she set out to be. Irrespective of whether we are Democrats, Republicans, or Independents, this is where the healthcare debate needs to initiate if we are to cover more people more efficiently, and have a healthier nation as a result.